Man, what took you so long?: Social and Individual Factors Affecting Adult Attendance at Voluntary Medical Male Circumcision Services in Tanzania

This 9-page journal article summarises the findings of a study to identify potential barriers and facilitators to voluntary medical male circumcision (VMMC) among older men in Tanzania. According to the article, VMMC has been shown to be a safe and effective method of reducing female-to-male HIV transmission by about 60% in randomised controlled trials and by up to 73% in post-trial observation. The article discusses HIV and MC rates in Tanzania and the strategies for increasing VMMC in the population, especially where there is the highest rate of HIV and the lowest rate of MC.

The study used focused discussion groups with 142 people, about half men, stratified by age and sex in the districts of Iringa and Njombe.  While both men and women had good attitudes about VMMC, there were social and personal barriers for adult men such as:

• Shame associated with seeking services in the same place as younger boys;
• Perceived inappropriateness of VMMC after puberty, marriage, or having children by both men and women - (traditional MC is a traditional rite of passage conducted before puberty and for Tanzanian Muslims, MC is a religious ceremony performed during infancy) - most participants thought that VMMC clients in their 20s or 30s would be harassed or should control their sexuality and maintain their status; and
• Concerns about partner infidelity during post-surgical abstinence period, loss of income, and pain.

Participants were aware of the HIV-prevention benefit and “perceptions of cleanliness and enhanced attractiveness to women.”  Nearly all participants knew that VMMC was the removal of the foreskin, and many mentioned HIV prevention and good hygiene, women’s preferences, and peer pressure as motivating factors. For example, younger men perceive that circumcised men have a higher status than their non-circumcised counterparts.

Communication strategies and ongoing barriers

In the two regions studied, the VMMC programmes use a variety of communication strategies to create a demand and communicate need including radio coverage, billboards, and experiential media. Messages are focused on adult men while conveying the importance for of VMMC for everyone. Interestingly, in spite of the messages, a mere 6% of clients are 25 or older, while 85% of VMMC clients are under 20 years old.

These results are reflected in the five stages of Rogers diffusion of innovation theory about how new ideas are adopted and at what rate - based on people’s perceptions about the new behaviour, how easy it is to practice, and what risks it entails. As stated here, it would appear that VMMC has been adopted quite well by the easier audiences - and that future campaigns should focus on the “late majority” and “laggards”.

• Educational materials and other means of creating demand will be adapted in accordance with study findings - addressing the concerns of older men, partners, and community leaders;
• Some service delivery sites will segregate clients by age in the hopes of bringing in older men who are married and men who are parents;
• Some permanent sites will devote their service to older men rather than use resources in campaigns that tend to attract younger clients;and
• Messages and approaches from here on out will attempt to reflect concerns shared by older men; they will also attempt to change “ingrained social norms” that may be inhibiting VMMC uptake, even when those social norms are held by secondary audiences - partners and community leaders;

Further research on why cohabitating partners tend to resume sexual activity prior to the six-week waiting period is also suggested. The study also recommends “formative qualitative assessment of attitudes, care-seeking practices, and social norms related to VMMC, particularly the appropriate age and life stage to get VMMC, to help guide this process. The findings also highlighted the need to address concerns and misconceptions around erections during the post-circumcision healing period.”