Behavioral design for uptake of voluntary medical male circumcision among fisherfolks - PowerPoint Presentation

1. Behavioral design for uptake of voluntary medical male circumcision among fisherfolks in TanzaniaIntroductionVoluntary medical male circumcision (VMMC) is highly effective and among PEPFAR’s highest HIV prevention priorities. HIV prevalence among fisherfolks in Tanzania’s Lake Zone Region is estimated at 14%, three times higher than national HIV prevalence; 70% of adult men in the region are uncircumcised. VMMC outreach approaches that have succeeded among the general population have not been as effective among fisherfolks; thus, nonconventional multidisciplinary solutions are needed to reach this segment of the population. Behavioral design (BD) leverages insights from social psychology, economics, and neuroscience to understand individuals’ decisions and actions. Through participation in BD workshops led by ideas42, IntraHealth International used BD to create tools to increase VMMC uptake among fisherfolks. Carolina Mejia1, Zaynab Lweno2; Msafiri Swai2, Emily Zimmerman3, Ely McElwee3, Rahin Khandker3, Lucy Mphuru21 IntraHealth International, Chapel Hill, North Carolina, USA2 IntraHealth International, Dar es Salaam, Tanzania3 ideas42, New York, USAContact: Lucy MphuruProject Director, IntraHealth International Plot#.446, Golf Street, Kawe areaDar es Salaam – TanzaniaTel: +255 22 0383/+255 22 278 0683Email: lmphuru@intrahealth.orgAcknowledgments: The training and coaching of the behavioral design team were funded by the William and Flora Hewlett Foundation in collaboration with the Tohara Plus project led by IntraHealth International.Lessons Learned Behavioral design can be employed to address cognitive biases and other behavioral tendencies contributing to low uptake of VMMC among priority populations. Solutions can reframe choices to allay fears about sexual performance, provide identity cues that show accessing VMMC as consistent with strength and masculinity, reduce immediate costs, and connect VMMC to salient, immediate benefits.DescriptionBehavioral design occurred in four-phases: problem definition, diagnosis, design, and testing. Conclusions/Next StepsImplementers and researchers must understand the context of service provision and learn directly from priority populations what drives their behavior so that behaviorally informed interventions can be harnessed to achieve HIV prevention goals. Moving forward, we will finalize our prototypes based on feedback from the community influencers and VMMC providers. Once updated, we will train providers and influencers on the correct and consistent use of these job aids and pilot test the prototypes with the fisherfolk communities for finalization. We generated over 100 hypotheses about behavioral drivers of VMMC uptake, which were investigated through interviews with providers, clients, and community members. Confirmed common behavioral drivers included:Time inconsistent preferences: immediate costs of VMMC related to lost wages and wait times outweigh longer-term benefits.Zero risk bias: men’s motivation to avoid any risk of jeopardizing sexual performance, even if they perceive that risk to be remote.Descriptive social norms: men perceive circumcision to be uncommon among peers and conform to this norm. Availability heuristic: vivid stories of fears or complications related to VMMC come easily to mind, leading men to overestimate risks.We designed four protypes (job aids) for community health workers to support them in addressing these and other behavioral drivers through outreach and sensitization activities. Prototypes were user-tested within fishing communities, including health workers— VMMC service providers and community influencers (VMMC champions and home-based care workers)—in June 2020. Community influencers recommended the development of a planning (VIP) card to address men’s concerns around anticipated loss in wages and time post-procedure and the financial costs. This appointment card allows men the ability to 1) schedule services at their convenience and select the gender of their VMMC provider, and 2) plan transportation needs and anticipate the amount of funds needed to cover the time not working. Both the VMMC providers and community influencers provided feedback that anticipated shame was the first major barrier. The development of the job aid below was intended to address Shame and Pride issues that might prevent fisherfolks from choosing circumcision.POINTS TO CONSIDEROVERCOME SHAME AND BE PROUD AFTER CIRCUMCISION PICTURE  1.WALKING TO THE SITEYou can arrange times and days convenient to you to come to the siteSites are arranged to assure privacy when walking in You have the right to go to any of the sites 2. AT REGISTRATION You can choose the day and time that fits your needs, the time that you feel comfortable to come to the clinic 3.DURING PROCEDUREService providers will always ensure procedure is done in adequate visual and audio privacy Providers will ensure your privacy is observed throughout the procedureYou have the right to select either a female or male service provider to serve you  4. POST PROCEDURE You will be allowed to sit in a private room so that the providers can observe your condition before you go home  5. WALKING BACK HOMEYou will be able to walk back home normally Providers will show you how to position your penis so that you don’t feel much pain during walking 6. DURING HEALING You will be able to do some work provided it does not cause pain at the site of operationYou will be given instruction on how to care for the wound so that healing is achieved without problems 7.DRESSING AFTER PROCEDURE You will be able to dress normally in the same clothes you came with before the procedure and people will not notice that you have been circumcisedSTAGE OF PAIN  EXPLANATION PAIN ANALOGY WHAT SHOULD YOU DO The injection You will get a numbing injection in the base of the penis to numb the area. The purpose is to make sure you can’t feel the area.The injection can feel like a small thorn prick.The pain will be brief; try to think about other things, or focus on how the injection will ensure you don’t feel any pain during the actual procedure.Procedure After the numbing injection the health care provider will begin the procedure.There won’t be any pain at this stage.While the numbing injection is working, you should not feel any pain. If there is pain, let the doctor know so they can give you more numbing medication.First two days The wound will remain wrapped in the bandage.Generally, pain at this stage can feel like a mild headache.Make sure to rest around the house and take the pain­killers as directed.Bandage removal You will need to come back to the health facility on day two to have the bandage removed.Bandage removal feels like removing a plaster bandage.This pain will be brief and minimal. Think about other things and focus on the fact that after this the worst pain is over.Erection During the first 1-2 weeks, getting an erection with stitches will be a painful part of the healing process.Erections during the first 1-2 weeks feel like a throbbing headache but won’t last long.You will be able to take paracetamol and should also drink lots of water so that if you get an erection, you can urinate to relieve the pain.Keep it clean It is important to regularly clean the area, and if you are gentle, the pain here is mild.Keeping it clean can feel like the burn­ing sensation after eating chilies when the soap meets the wound.Make sure to clean the wound gently with lukewarm or cold water. Doing this regularly will decrease the pain and help the stitches dissolve faster.1-2 wks post procedure The wound will heal between one and two weeks after the procedure.There won’t be any pain at this stage.Even though you won’t be in any pain, it’s important to refrain from sexual activity and make sure to go back to the clinic for your 7 day and 6 week check-ups.Prototypes address behavioral barriers to VMMCDuring the interviews, some of the VMMC providers admitted to not providing adequate information to clients about all the pain points a clients experiences during and after VMMC, which may be a barrier to the client in making an informed decision to get circumcised and prevent providers from being good VMMC ambassadors. Providers indicated that the prototype for addressing pain should be focused on describing the pain points by intensity categories.DEFINEDIAGNOSEDESIGNTESTACTIONABLE BARRIERSSCALABLEINTERVENTIONDEFINEDPROBLEM