Promoting voluntary medical male circumcision through soccer: how evidence influenced global practices
Context
In the mid-2000s, studies found male circumcision to be effective in reducing female-to-male sexual transmission of HIV by 60 per cent. VMMC is identified as the only one-off intervention that reduces the risk of HIV whilst being cost-effective. The World Health Organization and UNAIDS both recommend VMMC as a key method to reduce HIV in countries with high prevalence.
In Zimbabwe, the Ministry of Health and Child Welfare launched VMMC in 2009. Population Services International and USAID provided technical and financial support to the ministry. The country aimed to reach 80 per cent of 13- to 29-year-old males in Zimbabwe by 2015. However, the gap between VMMC adoption and targeted numbers underlined a need to devise innovative demand-generating interventions.
In 2013, 3ie supported a collaboration between non-profit Grassroot Soccer, researchers from the London School of Hygiene & Tropical Medicine, and the Zimbabwe-based National University of Science and Technology to evaluate Grassroot Soccer’s soccer-based MTC+ programme.
MTC+ aimed to increase demand for VMMC amongst adolescent students (aged 15 to 19 years) in secondary schools in Bulawayo through a combination of initiatives led by a circumcision coach. Intervention components included a 60-minute, soccer-themed educational session including the coach’s story, during which they shared personal experiences and addressed fears of HIV testing, referrals and phone-based follow-up with interested participants.
Cluster-randomised controlled trials were conducted in 26 schools of Bulawayo; 1,226 male students participated in the trials. Qualitative interviews and group discussions were conducted to comprehend the experiences, opinions, and feelings of the coaches and student participants.
Evidence
The study found the MTC+ intervention to be effective in increasing VMMC uptake. The intervention cost-effectively increased uptake approximately 2.5-fold, or about 7.5 percentage points. The qualitative analysis revealed perceptions of high acceptability amongst coaches and student participants. The ‘coach’s story’ component, in particular, generated discussions around VMMC, with participants exploring the pros and cons of the practice with their coaches.
Evidence impacts
‘So in 2014 … when we did the [randomised controlled trial] with 3ie … we found the really encouraging evidence that we needed to convince partners and government and donors that this is something feasible, something cost-effective. [That’s] when we were able to work with a number of partners in Eswatini, Tanzania and Uganda, and then … our own programs in South Africa and Zambia.’
Type of impact: Inform the design of other programmes
Where findings from the evaluation or review inform the design of a programme(s) other than the one(s) evaluated.
This is one of 3ie’s seven types of evidence use. Impact types are based on what we find in the monitoring data for an evaluation or review. Due to the nature of evidence-informed decision-making and action, 3ie looks for verifiable contributions that our evidence makes, not attribution.
Read our complete evidence impact typology and verification approach here.
Close windowThe study provided evidence of large impact and cost-effectiveness of MTC+ on increasing VMMC uptake in Bulawayo secondary schools. The positive results led Grassroot Soccer to pilot a similar programme in Uganda, in collaboration with the Uganda Virus Research Institute and evaluated by the London School of Hygiene & Tropical Medicine. The 3ie-funded evaluation helped Grassroot Soccer refine the programme design, especially the components around the training of coaches, phone-based follow-up, accompanying participants to the clinic, and establishing rapport between coaches and participants.
Type of impact: Inform the design of other programmes
Where findings from the evaluation or review inform the design of a programme(s) other than the one(s) evaluated.
This is one of 3ie’s seven types of evidence use. Impact types are based on what we find in the monitoring data for an evaluation or review. Due to the nature of evidence-informed decision-making and action, 3ie looks for verifiable contributions that our evidence makes, not attribution.
Read our complete evidence impact typology and verification approach here.
Close windowGrassroot Soccer also collaborated with the South Africa-based Centre for HIV and AIDS Prevention Studies on a project in Eswatini to train outreach workers to deliver the MTC+ curriculum. The intervention was nested within a larger project, supported by USAID, that involved a variety of actors supporting Eswatini’s Ministry of Health to implement a national strategic plan to increase the demand for VMMC.
The Soka Soccer Challenge designed and implemented by the Centre for HIV and AIDS Prevention Studies and the ministry was heavily informed by the Grassroot Soccer pilot in Zimbabwe. Under the intervention, sessions were carried out to explain difficult epidemiological concepts like risks. The challenge was endorsed by Dennis Yuki Masina, the ace footballer of Eswatini, who also became the Soka Soccer Challenge captain.
Type of impact: Inform global guidelines and policy discussions
When findings from an evaluation or review can be traced to discussions or actions. Examples include governments or multilateral or bilateral donors’ mentioning the findings to inform policy or programming. To date, we have only one case of an individual impact evaluation informing global health guidelines. WHO guidelines require that the guidance is based on randomised evaluation evidence.
This is one of 3ie’s seven types of evidence use. Impact types are based on what we find in the monitoring data for an evaluation or review. Due to the nature of evidence-informed decision-making and action, 3ie looks for verifiable contributions that our evidence makes, not attribution.
Read our complete evidence impact typology and verification approach here.
Close windowPEPFAR’s 2017 Country/Regional Operational Planning Guidance cited evaluation findings and highlighted Grassroot Soccer’s MTC+ soccer-based intervention as a best practice to increase the demand for VMMC. Working in 50 countries, PEPFAR is one of the US government’s largest initiatives to address the global HIV/AIDS epidemic. The 2017 operational planning guidance document highlights intervention examples from different PEPFAR-supported countries to inform planning and enhance the impact and sustainability of programmes aiming to control HIV/AIDS.
Type of impact: Inform the design of other programmes
Where findings from the evaluation or review inform the design of a programme(s) other than the one(s) evaluated.
This is one of 3ie’s seven types of evidence use. Impact types are based on what we find in the monitoring data for an evaluation or review. Due to the nature of evidence-informed decision-making and action, 3ie looks for verifiable contributions that our evidence makes, not attribution.
Read our complete evidence impact typology and verification approach here.
Close windowIn 2018, evidence from the 3ie-supported evaluation and subsequent studies prompted USAID AIDSFree and Jhpiego to collaborate with Grassroot Soccer to design a new soccer-based VMMC intervention under Tanzania’s VMMC programme, Timu Ya Ushindi, which was piloted in two regions of the country. Grassroot Soccer’s MTC+ intervention was adapted to target boys aged 10–14 years to increase the knowledge around VMMC, whilst Grassroot Soccer and Jhpiego added a new component of HPV routine service delivery to adolescent girls under the age of 14.
Suggested citation
International Initiative for Impact Evaluation (3ie), 2020. Promoting voluntary medical male circumcision through soccer: how evidence influenced global practices [online summary], Evidence Impact Summaries. New Delhi: 3ie.
Evidence impact summaries aim to demonstrate and encourage the use of evidence to inform programming and policymaking. These reflect the information available to 3ie at the time of posting. Since several factors influence policymaking, the summaries highlight contributions of evidence rather than endorsing a policy or decision or claiming that it can be attributed solely to evidence. If you have any suggestions or updates to improve this summary, please write to influence@3ieimpact.org
Last updated on 13th November 2020