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The World Bank shall not be liable for any content or error in its translation. All queries on rights and licenses should be addressed to the Office of the Publisher, The World Bank, 1818 H Street NW, Washington DC, 20433, USA; fax: 202-522-2625; email: pubrights@worldbank.org. Impact Evaluation on improving voluntary medical male circumcision demand in Malawi through the use of incentives IMPACT EVALUATION RESULTS March 2017 National AIDS Commission authors: Joel Suzi, Blackson Matatiyo, Christopher Teleka, James Njobvuyalema, Andrina Mwansambo Ministry of Health authors: Henry Chimbali, Ella Chamanga, Simeon Lijenje, Stephano Mjuweni, Stanley Ngoma, Fredson Ministry of Education, Science and Technology authors: Victor Mhoni, Albert Saka. World Bank authors: Andrew Longosz, Fadzai Chikwava, Jed Friedman, Marelize Gorgens, Molly de Marcellus, Rosalia Rodriguez-Garcia and Theo Hawkins This page is left blank for collation purposes TABLE OF CONTENTS Abbreviations ...................................................................................................................................... x Acknowledgements ...........................................................................................................................xiii Executive Summary ............................................................................................................................xv 1 BACKGROUND AND CONTEXT..................................................................................................... 1 1.1 HIV Epidemic in Malawi .............................................................................................................................. 1 2 Impact Evaluation Hypotheses and Intervention Parameters ..................................................... 3 2.1 Impact Evaluation Hypothesis .................................................................................................................. 3 2.2 Intended Intervention ................................................................................................................................... 4 2.3 Actual Intervention ........................................................................................................................................ 6 3 Impact Evaluation Site Selection ................................................................................................. 6 4 Impact Evaluation Methodology ................................................................................................. 7 4.1 Intended Design ............................................................................................................................................... 7 4.2 Actual Design .................................................................................................................................................... 7 4.3 Sampling Strategy at Baseline and Endline ....................................................................................... 7 5 Impact Evaluation Data Analysis Approach ................................................................................. 8 5.1 Quantitative Analytical Approach .......................................................................................................... 8 5.2 Qualitative Analytical Approach ...........................................................................................................10 6 Data Collection Tools, ETHICS and LIMITATIONS ....................................................................... 11 6.1 Data Collection Tools ..................................................................................................................................11 6.2 Ethics Compliance ........................................................................................................................................12 6.3 Study Limitations .......................................................................................................................................... 12 7 Implementation of the Intervention ......................................................................................... 13 v 8 Results from the Impact Evaluation .......................................................................................... 17 8.1 Primary Research Question: Do incentives significantly increase VMMC uptake among in-school and out-of-school boys and young men aged 10 to 34 in Malawi?....................17 8.2 Secondary Research Question: Does a school-based VMMC demand generation strategy have relevant spill-over effects that increase VMMC uptake in the school- boys' households (brothers and parents)? ........................................................................................ 36 8.3 Secondary Research Questions: Effect of intervention on women, and women on VMMC rates......................................................................................................................................................40 8.4 Secondary Research Questions: Do school heads recruit more males for VMMC than do the Mothers’ Groups, or vice versa? ......................................................................................................42 8.5 Secondary Research Question: What is the role of young men’s informal social networks (peers, family and guardians) in increasing VMMC uptake? ...............................43 9 Conclusions ............................................................................................................................... 45 10 References ................................................................................................................................ 48 11 Annexures ................................................................................................................................. 49 Annexure I: Vouchers ............................................................................................................................................... 49 Annexure II: Endline Sampling Strategy ........................................................................................................52 Annexure III: Data collection tool for VMMC Circumcision Endline Questionnaire -2016 ....54 Annexure IV: Questionnaire for in-depth interviews ................................................................................55 FIGURES 1 Map of Malawi: ('Study') Districts .....................................................Error! Bookmark not defined. 2 Circumcision rate, by month, for Rumphi and its synthetic control .................................................. 20 3 Circumcision rate, by month, for Mchinji and its synthetic control .................................................. 20 4 Treatment effect for Rumphi and simulated effects for comparator districts............................... 22 5 Treatment effect for Mchinji and simulated effects for comparator districts ............................... 22 6 VMMC uptake in Mchinji from voucher impact evalution.................................................................... 42 7 VMMC uptake in Mchinji from voucher impact evalution ........................................................ 43 TABLES – In Main Report Table 1 Impact evaluation questions, outcomes and analytical approach.................................... 3 Table 2 Target population and sample size for key informants’interviews................................. 10 Table 3 Target population and estimated sample size for focus groups discussions* ................ 11 Table 4 Number of Voucher Booklets Distributed, and Handed out to Potential VMMC Clients in Rumphi and Mchinji ........................................................................................................ 13 Table 5 VMMC Procedures Performed in Rumphi and Mchinji During the Intervention Period (Dec 2015 – April 2016) ................................................................................................... 13 Table 6 Voucher Redemption Rates in Rumphi ........................................................................... 14 Table 7 Voucher Redemption Rates in Mchinji............................................................................ 15 Table 8 Ratio of pre-intervention/post-intervention MSPE for Rumphi district and 17 possible comparators .................................................................................................................... 23 Table 9 Ratio of pre-intervention/post-intervention MSPE for Mchinji district and 17 possible comparators .................................................................................................................... 23 Table 10 Demographic characteristics ........................................................................................... 24 Table 11 Intention to get circumcised among uncircumcised men ............................................... 27 Table 12 Circumcision and HIV knowledge .................................................................................... 31 Table 13 Factors associated with VMMC uptake among men in Mchinji and Rumphi districts ... 35 Table 14 Ratio of VMMC procedure vouchers redeemed, compared to‘friends’ and ‘guardians of friends’ vouchers in Mchinji and Rumphi districts ......................................................... 37 Table 15 Source of Vouchers for those who Redeemed Vouchers, in Mchinji and Rumphi ......... 38 Table 16 Heard of and seen vouchers by distance from district hospital, in Rumphi and Mchinji 39 Table 17 Persons given vouchers by distance from district hospital, in Rumphi and Mchinji ...... 39 Table 18 Number of Vouchers Redeemed by VMMC Clients compared to Nuimber of Vouchers Redeemed by Guardians of VMMC Clients, in Rumphi and Mchinji............................... 44 vii TABLES – In Annexures A1 Key Informants Interview Questions Guide ............................................................................ 99 A2 Focus Groups Discussion Guide ............................................................................................ 102 A3 Endline household selection listing ...................................................................................... 106 A3 1 Impact evaluation questions, outcomes and analytical approach ....................................... 106 A3 2 Target population and sample size for key informants interviews ...................................... 108 A3 3 Target population and estimated sample size for focus groups discussions*...................... 108 A3 4 Ratio of pre-intervention/post-intervention MSPE for Rumphi district and 17 possible comparators .......................................................................................................................... 108 A3 5 Ratio of pre-intervention/post-intervention MSPE for Mchinji district and 17 possible comparators .......................................................................................................................... 109 A3 6 Demographic characteristics ................................................................................................ 109 A3 7 Intention to get circumcised among uncircumcised men .................................................... 112 A3 8 Intention to get circumcised cont’ ........................................................................................ 113 A3 9 Circumcision and HIV knowledge ......................................................................................... 115 A3 10 Circumcision and HIV knowledge cont’ ................................................................................ 118 A3 11 Factors Associated with VMMC Uptake among men in Mchinji and Rumphi Districts ........ 119 A3 12 Heard of vouchers by distance from district hospital ........................................................... 120 A3 13 Seen vouchers by distance from district hospital ................................................................. 120 A3 14 Given vouchers by distance from district hospital................................................................ 122 A3 15 Used vouchers by distance from district hospital................................................................. 122 A3 16 Sources of information about MC and HIV ........................................................................... 122 A3 17 Community discussions about VMMC: Reasons why other men/boys/ family thought VMMC is not a good idea ........................................................................................ 124 A3 18 Community discussions about VMMC: Reasons why other men/boys/ family thought VMMC is a good idea ................................................................................... 125 A3 19 Beliefs about MC and HIV ..................................................................................................... 126 A3 20 Self-Reported circumcision status ........................................................................................ 130 A3 21 Reasons for circumcision ...................................................................................................... 132 A3 22 Main reason for circumcision ............................................................................................... 133 A3 23 Reasons for not getting circumcised..................................................................................... 134 A3 24 Main reason for not getting circumcised .............................................................................. 136 A3 25 Access to vouchers for MC.................................................................................................... 138 A3 26 Factors associated with correct knowledge about VMMC among uncircumcised men in Mchinji and Rumphi districts ............................................................ 141 A3 27 Factors associated with intention to get circumcised among uncircumcised men in Mchinji district .......................................................................................................... 141 A3 28 Factors associated with Intention to get circumcised among uncircumcised men in Rumphi district ................................................................................. 142 A3 29 Factors associated with voucher exposure (ever heard about MC vouchers) among men in Mchinji and Rumphi districts ........................................................................ 143 A3 30 Factors associated with voucher exposure (ever seen MC vouchers) among men in Mchinji and Rumphi districts ........................................................................ 145 A3 31 District weights assigned to synthetic control for Rumphi district ....................................... 146 A3 32 District weights assigned to synthetic control for Mchinji district ....................................... 146 A3 33 Characteristics of Rumphi district and its synthetic control ................................................. 148 A3 34 Characteristics of Mchinji district and its synthetic control ................................................. 148 A3 35 Districts used for synthetic control analysis ......................................................................... 148 A3 36 Circumcision and HIV knowledge ......................................................................................... 149 ix This page is left blank for collation purposes ABBREVIATIONS AIDS Acquired Immune Deficiency Syndrome AOR Adjusted Odds Ratio ART Anti-Retroviral Therapy CCAP Church of Central Africa Presbyterian DFID Department for International Development FGD Focus Group Discussion GOM Government of Malawi HES Health Education Services HIV Human Immunodeficiency Virus IKI Invest in Knowledge KII Key Informant Interview MC Male Circumcision MG Mothers‘ Group MoEST Ministry of Education, Science and Technology MoH Ministry of Health MSPE Mean Squared Prediction Error MWK Malawi Kwacha NAC National AIDS Commission NSP National HIV and AIDS Strategic Plan OR Odds Ratio PEPFAR President's Emergency Plan for AIDS Relief PLHIV People Living with HIV and AIDS SB School Based SD Standard Deviation STI Sexually Transmitted Infection TA Traditional Authority UNAIDS Joint United Nations Program on HIV/AIDS VMMC Voluntary Medical Male Circumcision USD United States Dollars WHO World Health Organization xi This page is left blank for collation purposes xii ACKNOWLEDGEMENTS ACKNOWLEDGEMENTS This study was led by the National AIDS Commission of Malawi. The following teams of people contributed to the development of this publication: National AIDS Commission (NAC), Ministry of Health (MoH), Ministry of Education, Science and Technology (MoEST), district offices, the World Bank and its contractor (Invest in Knowledge (IKI)). This evaluation was possible due to the significant contributions of these teams that were each integral to the evaluation’s success, contributing to the launch, implementation of the Voluntary Medical Male Circumcision (VMMC) Demand Generation programme, the baseline and endline qualitative and quantitative evaluations, and providing valuable intervention and evaluation insights. The study was led by a VMMC Study Team established by NAC, and was technically and financially supported by the World Bank and the United Kingdom’s Department for International Development (DFID). The VMMC study team oversight to ensure the successful implementation of the national VMMC programme, and support to MoH for planning and implementation for VMMC demand generation activities in the two study districts of Rumphi and Mchinji. They were in charge of procurement of all VMMC study commodities including the transport vouchers and they provided financial and material resources for the incentivized component of the study. The following officials were involved as members of the study team: NAC: Joel Suzi, Blackson Matatiyo, Christopher Teleka, James Njobvuyalema, Andrina Mwansambo. MoH: Henry Chimbali, Ella Chamanga, Simeon Lijenje, Stephano Mjuweni, Stanley Ngoma, Fredson Kamcira. MoEST: Victor Mhoni, Albert Saka. The MoH officials at national and district level was responsible for demand generation in the districts and providing VMMC services during the implementation of the study. The MoH Health Education Services (HES) conducted mass demand generation campaigns in the two study districts and created Mothers’ Groups to distribute vouchers to out of school males in the community. The MoH HIV & AIDS Department delivered VMMC services in the study district hospitals. District officials planned services in the districts and administered the voucher scheme through district study teams led by District Medical Officers: Dr. Juliana Kanyengambeta (Mchinji) and Dr. Stephen Macheso (Rumphi). The following World Bank team was involved in providing coordination, technical, data management, analytical, formatting, and editing support: Rosalia Rodriguez-Garcia (consultant), Marelize Gorgens (World Bank), Jed Friedman (World Bank), Fadzai Chikwava (consultant), Andrew Longosz (consultant), Molly de Marcellus (consultant), and Theo Hawkins (consultant). The contractor that the World Bank appointed, IKI, conducted fieldwork supervision, baseline and endline data collection, data entry and management: Abdullah Chilungo, Sydney Lungu, James Mkandawire, and Hastings Honde. We would also like to thank the MoEST staff, all head teachers, and mothers for distributing the vouchers and participating in the qualitative interviews. We thank all of the young men and women who took part in the study and in some cases, shared their opinions and thoughts with us in longer interviews. xiii This page is left blank for collation purposes xiv EXECUTIVE SUMMARY Rationale for improving demand for male circumcision in Malawi In Malawi, with its high HIV prevalence, averting every possible new HIV infection by whichever scientifically proven means, is a national priority. Male circumcision has proven over 60% effective in reducing the risk of HIV acquisition by HIV negative men. In demonstrating its commitment to ‘zero new HIV infections, ‘the Malawian Government has adopted a male circumcision policy and launched a national program for it. But, uptake has been slow and several barriers to the demand for circumcision have been identified. Perceived barriers towards VMMC uptake, including lack of knowledge about VMMC and its benefits, will affect the individual’s decision to seek VMMC services. Society, culture, religion, peer networks and family play a role in an individual’s decision and motivation to go for VMMC, as does exposure to VMMC related messages. Additional factors that influence perceived barriers to VMMC uptake include costs, transportation limitations, and opportunity to get circumcised. As part of the process of figuring out innovative ways to addressing these barriers, the Government of Malawi and the World Bank decided to undertake a study to measure the effect of incentives on improving VMMC demand. Theory of Change: In the Health Belief Model, the theory of change that formed the basis of the intervention design, it is hypothesised that health services-seeking behaviour is a process of decision-making influenced by health information and a number of individual and socio-cultural factors that moves a person along the continuum prior to contemplating the action (getting circumcised) to being circumcised. In this impact evaluation, the hypothesis that incentives will have a higher likelihood of ‘moving’ a person from contemplating circumcision to being circumcised, than just receiving information about circumcision will result in, as illustrated below. xv IMPACT EVALUATION ON IMPROVING VMMC DEMAND IN MALAWI THROUGH THE USE OF INCENTIVES Impact Evaluation Objective and Research Questions The objective of this impact evaluation was to evaluate the effect of incentives on improving the uptake of Voluntary Medical Male Circumcision (VMMC) in two districts in Malawi. Primary Research Question: 1. Do incentives significantly increase VMMC uptake among in-school and out-of-school boys and young men aged 10 to 34 in Malawi? Secondary Research Questions: 2. Did the intervention have spill-over effects that increased VMMC uptake in the study participants‘ households (brothers and parents) or communities? 3. Are attitudes towards VMMC among school girls changed by the intervention? 4. Are women effective in motivating young men to seek VMMC? 5. Do school heads recruit more males for VMMC than do the Mothers’ Groups, or vice versa? 6. What is the role of young men’s informal social networks in increasing VMMC uptake? The planned intervention The intervention consisted of two types of incentives. Part A of the intervention were collective incentives (e.g., whiteboards, football equipment) – distributed monthly – to institutions that met the following criteria: (i) to intervention schools when 20 or more students to whom vouchers were provided, underwent VMMC that month, and (ii) to Mothers’ Groups when 20 or more boys and young men to whom they provided vouchers, underwent VMMC that month. Part B of the intervention consisted of individual vouchers that could be redeemed by the person getting circumcised and his caregiver during three events at the district hospital: the VMMC procedure itself, the first follow-up visit (two days after the VMMC procedure) and the second follow-up visit (seven days after the procedure). If the participants were in- school, the voucher booklets would be distributed to the study participants of head teachers of the intervention schools. If participants were out-of-school, Mothers’ Groups would distribute the vouchers. Participants who received the vouchers, were also provided with voucher booklets that they could distribute to their uncirucmcised male family members or friends, and their caregivers. The study was initiated through orientation sessions with schools (head teachers and teachers) and with school-linked Mothers’ Groups in the intervention arm. Over and above these incentives, the Ministry of Health implemented the country’s national VMMC demand generation communications effort (which did not include any reference to incentives) in the communities where the study was taken place. xvi EXECUTIVE SUMMARY Evaluation Methodology and Planned Data Collection To answer the research questions, a cluster randomised control trial was designed with every school and its associated Mothers‘ Group/s being a cluster. Each cluster was randomly assigned to either the treatment arm or the control arm. The study population at schools and with Mothers’ Groups in the control arm were to receive only the “standard” VMMC demand generation campaign as implemented by the MoH. The study population at schools and with Mothers’ Groups in the intervention arm were to receive the “standard” MoH VMMC demand generation campaign, and the intervention as described above. A difference-in-difference analysis was proposed to identify the additional VMMC uptake (and changes in VMMC-related attitudes and knowledge) that would have resulted from the intervention, with controls for baseline factors and other programmes that include exposure to the “standard” VMMC demand generation campaign. To support this evaluation design, the following data were planned to be collected: Qualitative baseline data collection at baseline: In early 2015, a qualitative analysis provided useful information for the implementation of the impact evaluation intervention and to shape VMMC demand generation approaches. A desk review of journal articles and official documents provided the basis for selecting six districts and eight ethnic groups for qualitative data gathering. This selection was not meant to be nationally representative, but rather to reflect the perceptions of a variety of ethnic groups, both those that are predominantly Christian and those that are predominantly Muslim. Evidence from the College of Medicine study suggested overwhelmingly that a weak demand for VMMC was a key factor for the low uptake of VMMC in Malawi (Mfutso-Bengo et al, 2010). Three methods of qualitative data collection were used: Ethnography done by participant observers, Focus Group Discussions (FGDs) and Key Informant Interviews (KIIs). The major recommendations of this qualitative analysis into the barriers and facilitators of VMMC in Malawi pointed to the need to: (1) work with traditional and community leaders as change agents, (2) engage women more actively in VMMC demand creation, and (3) ensure that (i) VMMC services were available when needed, (ii) no one was sent away without the services they sought, and (iii) follow-up visits were encouraged to avoid post-intervention complications. These findings informed the design of the intervention. Quantitative baseline and endline data collection: At baseline, data were collected from 3,034 randomly selected young people and children aged 10 to 34 in the area that was 0-10 km around the district hospital in each of the two study districts. 70% of the sampled individuals were males and 30% were female ages 10- 34 years. A similar survey amongst the same participants were planned for endline. xvii IMPACT EVALUATION ON IMPROVING VMMC DEMAND IN MALAWI THROUGH THE USE OF INCENTIVES Changes to intervention during implementation and their implications Changes between intervention as-planned and as-implemented: The intervention was not implemented entirely as planned. (a) The intended study population in the intervention group who were in school were able to receive vouchers from the Mothers’ Groups and head teachers. (b) Unlike how the Ministry of Health (MoH)‘s VMMC demand generation campaign was rolled out in other districts in Malawi, the campaign that was ubiquitously rolled out in the two districts, unfortunately included messages about the incentives. Because of the contents of the communication campaign in the two study districts, it created demand for the vouchers amongst participants in the control group. (c) These control arm participants – who were not meant to either know about, be able to access or redeem the vouchers – were, in fact, able to do so. They were able to access the vouchers through the Mothers‘ Groups linked to the intervention schools, and redeemed the vouchers once they got circumcised at the district hospital. (d) Finally, due to procurement challenges, the collective incentives to Mothers’ Groups and schools, which was meant to be paid at the end of every month, was only paid after the study ended. It is, however, important to note that even as the design of the impact evaluation was not followed, the spirit of the hypothesis being tested, remained. Implications: These variations between how the intervention was planned and how it was implemented affected the randomisation scheme and our ability to answer all the research questions; however, the primary research question could still be answered. The intervention implementation challenges meant that the planned difference-in-difference analytical approach was no longer feasible. It further limited the potential impact of collective incentives on VMMC uptake. And, finally, it necessitated an additional data analysis strategy and additional data collection efforts, as described below: (a) Expansion of endline data analysis efforts: 1. It was agreed that the primary research question would be answered through three analytical approaches: (i) before-after analysis in the two study districts; (ii) comparing circumcision rates in the two study districts to the other 18 districts before, during and after the intervention, and (ii) synthetic control analysis to create a synthetic control group against which to compare the results in the two study districts, respectively. 2. For all three of these analyses, the number of circumcisions performed in Rumphi and Mchinji before, during and after the intervention would be analysed. This would require that all the circumcisions performed in the two study districts and the total number of vouchers used for VMMC within each district would be used in the analysis, irrespective of whether an individual was in the control arm. 3. Since a difference-in-difference analysis was no longer possible, a synthetic control analysis was executed to estimate the uptake of VMMC attributable to the intervention. This analysis entailed comparing the circumcisions in the two study districts to circumcisions performed during the same time in the other 18 districts in Malawi that also received the MoH ’standard‘ VMMC demand creation campaign. However, one district, Balaka, had significantly higher male circumcision rates xviii EXECUTIVE SUMMARY (>20 times higher) than any of the other districts. The reason for such high rates in Balaka were due to a heightened use of outreach programs during July to Sept 2016, and also it being the traditional circumcision season in Balaka. Therefore, Balaka was dropped for analytical purposes leaving 17 other districts to be included in the analysis. 4. A distance analysis was also employed to determine any differences between the persons who did and did not receive the intervention (i.e., persons in the 0-10km and in the 10-20 km radius from the district hospital). (b) Expanded data collection at endline: Because of the expansion of the data analysis approach, data collection also needed to be expanded: 1. Expanded endline quantitative survey: Instead of interviewing just 2,000 persons (70% boys and 30% girls) within the 0–10 km radius of each district hospital, 3,000 individuals were selected for the quantitative endline survey using stratified random sampling, split equally between Rumphi and Mchinji. The expanded sample size included the original 1,000 persons per district, and had 500 additional respondents who lived 10-20km from the district hospital. The endline survey had a total sample size of 3,034 respondents. For the sampling frame, a cross-section of all eligible individuals within the given age range, were included in the randomization, instead of surveying of only those who were part of the intervention. This enabled the ability to assess knowledge, attitudes and the general uptake of the intervention in a randomised manner and thus improve the external validity of the analysis. 2. Qualitative endline data collection: The qualitative endline data collection effort was designed to complement the quantitative endline survey with qualitative data collection and analysis–albeit limited-to help understand the “how” and “why” of findings and to draw valuable lessons from the implementation of the study intervention. Qualitative interviews in the form of key informant interviews and focus groups discussions were conducted with head teachers, clinical service providers, community leaders, Mothers’ Group members, in and out-of-school study population members, parents and guardians. Qualitative findings were used to provide deeper meaning and rich exploratory analysis on the impact of perceptions, attitudes and behaviours towards VMMC by these target groups. All interviews were conducted in Chichewa, recorded and subsequently transcribed into English. 3. Routine data about VMMC uptake in 18 other districts in Malawi: To enable the synthetic control analyses to be done, routine data about the uptake of VMMC in all other 18 districts in Malawi (i.e. district in Malawi that are not the eight districts where PEPFAR has focused its large scale VMMC efforts) was also collected from health facilities. This was done by the NAC, using data auditing processes and was done for the period January 2015 to June 2016. xix IMPACT EVALUATION ON IMPROVING VMMC DEMAND IN MALAWI THROUGH THE USE OF INCENTIVES Where and when was it evaluated: the evaluation locations and timeframes This impact evaluation was conducted in the Rumphi district (predominantly non-circumcising Tumbuka ethnic group) and in the Mchinji district (predominantly non-circumcising Chewa ethnic group). The intervention was implemented in the area 0 – 10 km around these hospitals and endline data were collected in a radius of 20 km around each district hospital. The impact evaluation (planning, execution, and analysis) took place between January 2015 to December 2016, whilst the intervention itself was implemented from December 2015 to April 2016. Intervention Implementation To observe the intervention‘s implementation, three key indicators were observed: (a) the number of booklets printed, distributed to schools and Mothers’ Groups, and the number handed out to potential VMMC clients; (b) number of circumcisions performed, in total and as a result of the voucher scheme; (c) the voucher redemption rates. (a) A larger proportion of booklets intended for Mothers’ Groups were distributed than those intended for school based distribution. (b) 93% of redeemed vouchers reached the intended targets stipulated by the country’s VMMC policy (10 – 34 year olds), and only 27 of the 2,241 circumcisions performed during the intervention implementation period in the two study districts, did not involve the redemption of a VMMC voucher. (c) Voucher redemption rates were high. Overall, voucher redemption rates in Mchinji were higher than in Rumphi (40% vs 26%, P<0.01). Key Research Findings RESEARCH QUESTION 1: Do incentives significantly increase VMMC uptake among in-school and out-of- school boys and young men aged 10 to 34 in Malawi? All three impact analyses confirmed that the incentives, together with the MoH communications campaign on VMMC that included references to the vouchers, did significantly increase VMMC uptake among students in the two study districts in Malawi. (a) According to the before-after analysis, VMMC rates dramatically increased in the two study districts during the months of the intervention and rapidly declined the minute that the intervention ended – see Figure 1. xx EXECUTIVE SUMMARY Figure1. Number of VMMC procedures in (a) Mchinji and (b) Rumphi before, during and after incentive intervention a) Mchinji b) Rumphi Sep_2016 Sep_2016 Aug_2016 NGO-run VMMC campaign Aug_2016 July_2016 July_2016 Jun_2016 Jun_2016 May_2016 May_2016 Apr_2016 Apr_2016 Mar_2016 Mar_2016 VMMC incentives Feb_2016 Feb_2016 study Jan_2016 Jan_2016 Dec_2015 Dec_2015 Nov_2015 Nov_2015 Oct_2015 Oct_2015 Sep_2015 Sep_2015 Aug_2015 Aug_2015 Govt communications efforts and July_2015 July_2015 campaign-based VMMC Jun_2015 Jun_2015 May_2015 May_2015 Apr_2015 Apr_2015 Mar_2015 Mar_2015 Feb_2015 Feb_2015 Jan_2015 Jan_2015 Dec_2014 Dec_2014 Nov_2014 Nov_2014 Oct_2014 Oct_2014 Sep_2014 Sep_2014 Aug_2014 Aug_2014 July_2014 July_2014 Jun_2014 Jun_2014 May_2014 May_2014 Apr_2014 Apr_2014 Mar_2014 Mar_2014 Feb_2014 Feb_2014 Jan_2014 Jan_2014 0 200 400 600 800 0 100 200 300 400 Source: Routine circumcision data provided by the Malawi Ministry of Health and Social Welfare (b) When comparing circumcision rates in the 17 districts to that of the study districts, the pattern is as stark: In the 23 months leading up to the intervention, the average male circumcision monthly rate in Mchinji was 0.24 (standard deviation (SD): 0.79) male circumcisions per 1,000 adult males (>15 years of age). It increased to 2.61 (SD: 2.16) male circumcisions per 1,000 adult males during the 4 month intervention. In Rumphi, the rate prior to the intervention was 0.48 (SD: 0.74) male circumcisions per 1,000 adult males, and it increased to 3.78 (SD: 1.74) male circumcisions per 1,000 adult male – see Figure 2. In the two months following the end of the impact evaluation the monthly average male circumcision rate in Mchinji fell to 0 male circumcisions per 1,000 adults males, and 1.34 (SD: 0.55) male circumcisions per 1,000 adult males in Rumphi. In the other 17 districts in Malawi (excluding the 8 PEPFAR priority districts and Balaka), the average monthly male circumcision rate before, during and after the impact evaluation intervention was 0.63, 0.45 and 0.40 male circumcisions per 1,000 adult males respectively. xxi IMPACT EVALUATION ON IMPROVING VMMC DEMAND IN MALAWI THROUGH THE USE OF INCENTIVES Figure 1 Circumcision rate, by month, for Rumphi and its synthetic control Source: Authors’ synthetic control analyses (c) While the before and after figures of VMMC uptake illustrate an increase in the uptake of VMMC, the synthetic control analysis provided statistically significant proof that the voucher intervention caused a dramatic increase in VMMC uptake. The intervention led to an additional 16.05 male circumcisions per 1,000 adult males in Rumphi, and an additional 9.15 male circumcisions per 1,000 adult males in Mchinji. The impact evaluation was able to increase VMMC uptake among males in Rumphi and Mchinji where an individual who received a voucher was 7 times more likely to be circumcised than someone who had not received a voucher [OR: 7.32 (3.55, 15.32), P<0.001]. RESEARCH QUESTION 2: Did the intervention have spill-over effects that increased VMMC uptake in the study participants‘ households (brothers and parents) or communities? First, because of the voucher booklet design and according to the voucher distribution and redemption data, the same amount of vouchers for friends and family were distributed (i.e. to secondary voucher recipients) as vouchers for a VMMC procedure (i.e. primary voucher recipients). Primary voucher recipients indicated that they gave vouchers to their relatives and parents (25%) or brothers (27%). Second, according to the information about the source of the voucher there were two types of spillover. The first kind of spillover was as intended in the intervention design – ‘social network spillover’. The second kind xxii EXECUTIVE SUMMARY of spillover was unintended and unplanned for and involved wholesale distribution of the entire voucher booklet itself to other persons Spill-over from study participants to their social networks was a positive output and intended in the design of the intervention. This spill-over allowed for the expansion of voucher uptake within social networks that were not reached directly by head teachers and Mothers‘ Groups, and thus expanded the intervention reach by 31%. There was some evidence, albeith limited, of spillover of knowledge about the vouchers in the non-intervention area (areas outside the 0-10 km radius). It is worth noting that, in general, while general knowledge of the voucher spilled across the distance threshold (10km from the district hospital), the endline data suggests that the person interviewed and who used the vouchers, were concentrated among those individuals residing closer to the point-of-service. RESEARCH QUESTION 3: Are attitudes towards VMMC among school girls changed by the intervention? The impact evaluation was not able to explicitly answer if the attitudes of school girls changed by the intervention, but the endline survey was able to examine common beliefs, and the level of VMMC knowledge among males and females at the end of the impact evaluation. More than 52% of the female population surveyed at endline could correctly explain what male circumcision was, and knew the benefits of male circumcision. However, even with more than half of the women surveyed at endline knowing the procedure of male circumcision and its benefits, males were more knowledgeable of the procedure and health benefits. This was to be expected because the impact evaluation’s main objective was to increase VMMC. In order to achieve this objective, informal networks were examined (interactions between males and females), but the males themselves needed to decide if circumcision was right for them, and this required additional focus on the male participants. RESEARCH QUESTION 4: Are women effective in motivating young men to seek VMMC? Women in the Mothers‘ Groups seem to have been more effective than head teachers in motivating young men to seek VMMC. Some of the self-reported contributing factors to Mothers’ Groups’ effectiveness in young men to seek VMMC included reach, training and orientation and trust. Mothers’ Groups were able to reach both out-of-school and in-school study population. While the impact evaluation was not designed for this to happen, Mothers’ Groups reaching both in-school and out-of-school boys was beneficial. Young boys and their parents were hesitant to receive vouchers from head teachers, and were more comfortable receiving vouchers from Mothers’ Groups. Mothers’ Groups increased their initial level of knowledge and became positive advocates of VMMC within the community who both dispersed the vouchers, and spread knowledge of the benefits of VMMC. Qualitative data suggests that women were also effective facilitators of the intervention. They were able to provide personal attention to both young boys and parents. xxiii IMPACT EVALUATION ON IMPROVING VMMC DEMAND IN MALAWI THROUGH THE USE OF INCENTIVES RESEARCH QUESTION 5: Do school heads recruit more males for VMMC than do the Mothers’ Groups, or vice versa? Overall, in both districts, VMMC uptake due to Mothers’ Groups vouchers was higher than VMM cuptake due to vouchers distributed by head teachers. Voucher redemption rates of MG-distributed vouchers were higher, in all cases, than the SB vouchers (33% vs 18% in Rumphi and 58% vs 34% in Mchinji), despite the fact that many more and a higher proportion of intended booklets were distributed to MGs than schools. In Mchinji, for every kind of voucher, the voucher redemption rate for MG-distributed vouchers was between 1.1 and 2.8 times higher than the voucher redemption rate for vouchers distributed by head teachers. In Rumphi, the voucher redemption rate for MG-distributed vouchers was between 1.6 and 3.2 times higher than VMMC uptake due to head teachers across three months of the impact evaluation.The data, however, also suggests that there are some important temporal differences: Because head teachers did not want circumcisions to take place during the school year, the VMMC uptake from vouchers distributed by head teachers was much higher in December 2015 and April 2016 (school holidays) than during the other months of the year. RESEARCH QUESTION 6: What is the role of young men’s informal social networks in increasing VMMC uptake? The attitudes and beliefs held about VMMC are affected by the social influence from peers, parents and other community members. Throughout the impact evaluation there was both positive and negative feelings for VMMC. Negative peer feelings were one of the largest obstacles discouraging males to get circumcised. There were numerous rumours started within these groups to dissuade male circumcision where Mothers’ Groups and head teachers stepped in and explained on multiple occasions why these were untrue. A young man’s family was a deciding factor for if a young man should go to get circumcised, and there was often conflicting opinions within the family as fathers were more supportive and mothers less supportive. Additionally, cultural norms added an additional level of complexity. Mothers’ Groups acted as an important mediator to bridge differences, and beliefs toward male circumcision. Caregivers played an important role as a supportive faction when a young male went for circumcision. There was some concern that caregivers would encourage those with vouchers to go for circumcision. Nevertheless, Mothers’ Groups and head teachers played a role in educating different members of the study population’s networks to increase knowledge of and demand for VMMC. Conclusions Incentives in the form of vouchers for VMMC work. Incentives had a significant impact on driving the demand for VMMC among males aged 10–34 years in the two study districts in Malawi by increasing the odds of getting circumcised in Mchinji or Rumphi, if one had a voucher, 7.32 times. Secondary distribution by voucher recipients show potential to informally increase distribution networks without increasing costs.There was some evidence of spill-over to relatives: approximately 31% xxiv EXECUTIVE SUMMARY of participants in both study districts who had been given vouchers reported that they gave vouchers to their relatives and parents (25%) or brothers (27%). Using the participants’ own social networks had the result of expanding the reach of the intervention by 31% without increasing distribution costs or other costs to the intervention, per se. Community-involvement was essential to make it happen. Women in the Mothers‘ Groups seem to have been more effective than head teachers in motivating young men to seek VMMC. Some of the self-reported contributing factors to the effectiveness of Mothers’ Groups’ in young men to seek VMMC included reach, training and orientation and trust. The attitudes and beliefs held about VMMC are affected by the social influence from peers, parents and other community members. There are some implementation challenges that would need to be overcome in the case of national roll out of the intervention. There were also implementation challenges – including voucher control and the redemption by guardians -- that would need to be overcome should this programme be rolled out. Benefit Cost analysis will be useful to help make the case for national roll out. As a final analytical step, a cost-benefit analysis is needed before a decision about national roll out can be made. A cost-benefit analysis will estimate the full economic cost per additional VMMC performed as a result of the intervention over the course of the impact evaluation and compare that to the monetary value of the benefits incurred because of these additional circumcisions performed. Given the results of the impact evaluation presented, it would be prudent to run such an analysis to determine if benefits outweighed costs in an attempt to increase VMMC uptake through the use of incentives. Also, a cost benefit analysis will be done to assess whether benefits still outweighted costs even after measures were put in place to address the implementation challenges. This information would be a valuable input to the Government of Malawi as the national VMMC programme is scaled up and implemented throughout Malawi. xxv 1 BACKGROUND AND CONTEXT 1.1 HIV Epidemic in Malawi Malawi has a generalised HIV epidemic. According to Spectrum, the adult (15-49 years) HIV prevalence in 2013 was estimated to be 10.3%, a reduction from 16.4% in 1999. The number of People Living with HIV and AIDS (PLHIV) is estimated at about 1,065,491 (Spectrum, 2015). That said, there are still 34,000 new HIV infections occurring every year (Spectrum, 2015), and continued vigilance in HIV prevention is essential. Voluntary Medical Male Circumcision (VMMC) is an effective HIV prevention practice. Three randomized control trials conducted in the past found that male circumcision reduced HIV transmission from women to men by approximately 60% (Auvert et al., 2005 in South Africa, Gray et al., 2007 in Uganda, Bailey et al., 2007 in Kenya). In addition, an ongoing follow-up study in Kenya found that this protective effect was sustained over 42 months, reducing men’s chances of becoming infected with HIV by 64% (Bailey et al., 2008). Malawi has been identified as a priority country for VMMC. Given Malawi’s high HIV prevalence and low prevalence of male circumcision (according to the Malawi AIDS Response Progress Report, 2015, only 27.5% of Malawian men are circumcised). Malawi has been identified by the World Health Organization (WHO) and the Joint United Nations Programme on HIV/AIDS (WHO, UNAIDS: Joint strategic action framework (2011)) as one of 14 global priority countries for scaling up VMMC for HIV prevention purposes. The Malawian government has responded to the need for VMMC uptake by initiating a VMMC campaign and communication strategy. In 2012, the National Voluntary Medical Male Circumcision Program was formally launched in Malawi. Additionally, the National Communication Strategy for Voluntary Medical Male Circumcision was created. The overall goal of the communication strategy, which primarily focuses on behaviour change communication, was to increase demand for VMMC services in the country from 2012 – 2016. In 2014, the government of Malawi launched the 2015-2020 National HIV and AIDS Strategic Plan (NSP). This NSP aims to translate the National HIV and AIDS Policy into action and provide a new framework for the implementation of HIV and AIDS interventions to meet UNAIDS 90-90-90 targets. The Malawian government is now targeting males aged 10-34 years old. Malawi’s Voluntary Medical Male Circumcision Strategy and National Operations Plan for Scale Up 2015-2020 proposes new VMMC scale-up plans for the country to now focus on scaling up VMMC to 60% coverage among males aged 10-34 years old in 14 of the 28 districts. Scaling up coverage to 60% of males aged 10-34 years old in the rest of the country is planned to occur by 2025 (2015-2020 National HIV and AIDS Strategic Plan). Over a 15-year period, circumcising males aged 10-29 years old would avert 75% of HIV infections, and circumcising males aged 10-34 would avert 88% of infections when compared to the previous strategy of circumcising males 1 IMPACT EVALUATION ON IMPROVING VMMC DEMAND IN MALAWI THROUGH THE USE OF INCENTIVES aged 15-49 (Kripke et al. 2016). Focusing Malawi’s VMMC operational plan to 10-34 year olds allows for a focused plan to reduce HIV infections. Despite efforts to scale-up VMMC in Malawi, uptake of VMMC has been slower than expected. The cumulative number of VMMCs performed from 2011 to 2014 was 150,000 less than needed to reach 80% coverage (Malawi AIDS Response Progress Report, 2015). As a reflection of the slow implementation of the VMMC programme, the prevalence of all types of male circumcision in the general population increased only marginally from 21.5% in 2010 to 27.5% in 2014 (Malawi AIDS Response Progress Report, 2015). Additional reasons for slow uptake of VMMC include concern of culture loss, and supply & demand challenges. There appears to be very little motivation for male circumcision and considerable concern about loss of ethic/religious identity and side effects of the procedure, such as pain, infection and the abstinence required following the procedure (Malawi AIDS Response Progress Report, 2015). In addition to delays in policy adoption and planning around VMMC, implementation has faced a number of challenges both on the supply and demand sides (Malawi AIDS Response Progress Report, 2015). On the supply side, constraints have included healthcare worker capacity and the amount of time that trained staff is able to dedicate to VMMC, leading to variable subpopulation coverage (Malawi AIDS Response Progress Report, 2015). Other supply-side challenges are limited funding, limited infrastructure and few implementing partners (Malawi AIDS Response Progress Report, 2015). Both the United States President’s Emergency Plan for AIDS Relief (PEPFAR) and the World Bank are prioritizing different districts to help support VMMC uptake. PEPFAR is currently supporting 8 high HIV disease burden districts (Blantyre, Lilongwe, Zomba, Thyolo, Mulanje, Chikwawa, Chiradzulu and Phalombe) to achieve 80% coverage over the next four years (Malawi Operational Plan COP16, 2016). Some of the key PEPFAR activities include: implementation of VMMC delivery on global guidance and the procurement of VMMC supplies and training (Malawi Operational Plan COP16, 2016). The World Bank has provided a grant to Malawi to support male circumcision roll-out in the other 20 districts. The aim of this grant is to build supply side capacity in public health facilities with the goal of circumcising over 260,000 men in four years. Progress has been slow to reach the goal of 60% coverage among males aged 10-34 years old in 14 of the 28 districts, thus requiring innovative solutions to increase VMMC uptake. In 2016 average VMMC coverage in the 8 priority PEPFAR districts was under 31%, and the expected 2017 average coverage is expected to grow to just 34%. Nationally, VMMC coverage in 2016 was 13%, and coverage is expected to grow too just 14% in 2017. Therefore, innovative solutions such as the voucher scheme evaluated in this study are needed to reenergize the VMMC programme and to reach the VMMC coverage targets over the next four years. 2 2 IMPACT EVALUATION HYPOTHESES AND INTERVENTION PARAMETERS 2.1 Impact Evaluation Hypothesis The impact evaluation was designed to test the following hypotheses; corresponding outcome measures and analysis approaches are summarised in Table 1 below. Table 1 Impact evaluation questions, outcomes and analytical approach Research question to be answered Outcome Measure Analysis approach/es Primary 1. Do incentives significantly a. Comparison of VMMC uptake in two study i. Before and After Research increase VMMC uptake districts before, during and after intervention ii. Synthetic Control Question among in-school and out- b. Comparison of VMMC uptake in Rumphi and iii. Descriptive findings of-school boys and young Mchinji to those in other Malawian districts iv. Distance Analysis men aged 10 to 34 in v. Logistic regression c. Proportion of study population who became Malawi? vi. Focus Group medically circumcised during the course of the Discussion evaluation vii. Key Informant d. Characteristics that increase the uptake of Interviews VMMC Secondary 2. Did the intervention have spill- e. “Friends” vouchers redeemed i. Descriptive Findings Research over effects that increased ii. FGDs Questions VMMC uptake in the study iii. KIIs participants‘ households (brothers and parents) or communities? 3. Are attitudes towards VMMC f. Knowledge, attitudes and perceptions about iv. Descriptive Findings among school girls changed by VMMC among females v. FGDs the intervention? vi. KIIs 4. Are women effective in g. Knowledge, attitudes and perceptions about vii. FGDs motivating young men to seek VMMC among females viii. KIIs VMMC? 5. Do school heads recruit more h. Proportion and overall number of vouchers from ix. Descriptive Findings males for VMMC than do the Mothers’ Groups and Head Teachers that have x. Routine data analysis Mothers’ Groups, or vice versa? been redeemed 6. What is the role of young men’s i. Qualitative evidence of diffusion of VMMC xi. FGDs informal social networks in through the informal social networks xii. KIIs increasing VMMC uptake? 3 IMPACT EVALUATION ON IMPROVING VMMC DEMAND IN MALAWI THROUGH THE USE OF INCENTIVES 2.2 Intended Intervention 2.2.1 Intended Intervention Part A: Part A involved collective incentives (e.g. whiteboards, football equipment) for the intervention schools for every month between December 2015 and April 2016 in which 20 or more students went for VMMC at their District Hospital. Collective incentives, as above, were available to the Mothers’ Groups in the intervention schools for every month between December 2015 and April 2016 in which 20 or more out-of-school young males underwent VMMC at their district hospital. The incentives were intended to be awarded monthly, rather than at the end of the study, in order to ensure the motivation of the school heads and the Mothers’ Groups. 2.2.2 Intended Intervention Part B Vouchers for VMMC were to be provided to the intervention arm of the impact evaluation. Vouchers were to reduce the burden of costs associated with traveling to/from a district hospital for VMMC and other costs associated with lost labour as a result of the circumcision procedure. These vouchers were to be handed out to boys in the intervention arm attending primary and secondary schools by head teachers. For those in the intervention arm of the impact evaluation who were out-of-school, Mothers’ Groups were to hand out the vouchers for VMMC. Booklets: Vouchers were distributed as booklets where every booklet contained a set of colour coded vouchers. Each different colour voucher had a different purpose: not only were vouchers for the potential VMMC client and his caregiver for the actual procedure included, but also vouchers for follow up vists (the national VMMC protocol states that 2 follow up visits are needed: one 3 days after the procedure and another 7 days after the procedure), and vouchers for the person to give to his friends and their caregivers, as follows: Voucher Number of vouchers Voucher in VMMC Booklet Colour per booklet Vouchers for primary 1. Voucher for VMMC Procedure Green 1 booklet recipient and 2. Guardian of Student for VMMC Procedure Skyblue 1 his guardian 3. Student follow up Voucher Yellow 2 4. Guardian for Student follow up Voucher White 2 Vouchers for secondary 5. Friends of Student Voucher for VMMC Procedure Maroon 1 voucher recipient 6. Guardian of Friends of Student Voucher for Procedure Dark Blue 1 (friends / family of primary recipient, and 7. Friends of Student follow up Voucher Grey 2 their guardians) 8. Guardian of Friends of Student follow up Voucher Red 2 TOTAL vouchers per booklet 12 NOTE TO TABLE: For yellow, white, red and gray vouchers, 2 vouchers per booklet were distributed as there are 2 follow up visits required per every one VMMC procedure performed. 4 The value of each voucher, which was based on the average cost of a round trip within a 10 km radius from the district hospital, was MWK 2000 or approximately US$2.86. 1 These vouchers were redeemed after the VMMC procedure was conducted or follow up visit completed at the health facility, after verification and quality assurance, as illustrated below. Three reasons served as a rationale for the chosen intervention: 1. A school-based approach proved to be a successful strategy for increasing the number of circumcisions in Kenya and South Africa (Montague C et al., 2014). 2. Circumcising males when they are younger may reduce the likelihood of acquiring HIV when they become sexually active. 3. As more male adolescents and young men become circumcised, VMMC demand is likely to increase, and could become “self-sustained” through diffusion and social interactions. 1 Using a June 2016 exchange rate of MWK 0.00143 to the US dollar 5 IMPACT EVALUATION ON IMPROVING VMMC DEMAND IN MALAWI THROUGH THE USE OF INCENTIVES 2.3 Actual Intervention Changes between intervention as-intended and as-implemented: The intervention was not implemented entirely as planned, in the following ways: a) The intended study population in the intervention group who were in school got voucher booklets from the Mothers’ Groups and head teachers (Mothers’ Groups were only supposed to hand them out to out of school youth. b) Unlike how the Ministry of Health‘s VMMC demand generation campaign was rolled out in other districts in Malawi, the MoH campaign in the two study districts unfortunately included messages about the incentives. Because of the contents and ubiquitous roll-out of the communication campaign in the two study districts, it created demand for the vouchers amongst participants in the control group. c) The control arm participants – who were not meant to either know about, be able to access or redeem the vouchers – were, in fact, able to do so. They were able to access the vouchers through the Mothers‘ Groups, and redeemed the vouchers once they got circumcised at the district hospital, similar to the intervention group participants. d) Finally, due to procurement challenges, the collective incentives to Mothers’ Groups and schools, which was meant to be paid at the end of every month, was only paid after the study ended. It is, however, important to note that even as the design of the impact evaluation was not followed, the spirit of the hypothesis being tested, remained. 3 IMPACT EVALUATION SITE SELECTION The impact evaluation was conducted in two Malawian districts: Rumphi in the Northern region and Mchinji in the Central Region. The two study districts were chosen because of the 20 districts selected by the Ministry of Health for VMMC rollout in 2015, eight were districts in which PEPFAR partners have been conducting VMMC since 2012; these were not to be included in the impact evaluation. Two Traditional Authorities (TAs) were selected in each selected district (Rumphi and Mchinji); the criterion for selection was that one of the TAs included the District Hospital, where VMMC services would be rolled out first. The two targeted TAs were Chikulamayembe in Rumphi, and Zulu in Mchinji. Most interviews at endline were also conducted in Mlonyeni and Nyoka TA’s in Mchinji district and Jalavikuwa and Chisovya TA’s in Rumphi district. Of the remaining 12 districts, seven were classified by 6 the Government of Malawi (GOM) as low priority. Of the five remaining, two (Chiradzulu and Machinga) have substantial populations of circumcising ethnicities. This left two appropriate districts: Mchinji, populated primarily by non-circumcising Chewa, and Rumphi, populated primarily by non-circumcising Tumbuka. This permits a comparison of responses to the study interventions by ethnicity. 4 IMPACT EVALUATION METHODOLOGY 4.1 Intended Design The impact evaluation was designed as a cluster randomised control trial, where schools and their associated Mothers’ Groups were randomly assigned to either the intervention arm or the control arm. Schools and Mothers’ Groups in the control arm of the impact evaluation were to receive only the “standard” campaign conducted by the Ministry of Health (MoH). Schools and Mothers’ Groups assigned to the intervention arm were to receive the “standard” campaign conducted by the MoH, and the additional two part incentive consisting of collective incentives and vouchers for VMMC. 4.2 Actual Design The afirementioned variations between how the intervention was planned and implemented resulted in the randomisation scheme failing and an inability to answer all the study research questions; however, the primary research question could still be answered. The intervention implementation challenges meant that the planned difference-in-difference analytical approach was no longer feasible. It further limited the potential impact of collective incentives on VMMC uptake. And, finally, it necessitated an additional mixed- methods data analysis strategy and additional data collection efforts, as described later in the report. 4.3 Sampling Strategy at Baseline and Endline At baseline the distance a school was from a district hospital served as the first point of stratification. It was determined that an individual would not be willing to travel back from a VMMC procedure by bike taxi if his school was more than 10km from the district hospital where the VMMC was performed. In Mchinji, there were 13 primary schools and 12 secondary schools within the 10 km radius; in Rumphi there were 10 primary schools and 6 secondary schools. The National Statistics Office showed that there were a total of 4,459 students in the selected Mchinji schools and 2,866 students in the selected Rumphi schools. In each district, approximately half of the students were male, and half female. Rather than selecting schools randomly and drawing the sample population from it, schools we selected purposefully to ensure comparability in intervention and control schools because of different school sizes. Schools were paired by similar sizes and then randomly selected as intervention or control. From these selected schools and with the aid of a household listing 2,200 males (1,100 from Mchinji and 1,100 from Rumphi) aged 15-24 and 800 (400 from Mchinji and 400 from Rumphi) females aged 15-24 were selected for the impact evaluation at baseline. 7 IMPACT EVALUATION ON IMPROVING VMMC DEMAND IN MALAWI THROUGH THE USE OF INCENTIVES 5 IMPACT EVALUATION DATA ANALYSIS APPROACH 5.1 Quantitative Analytical Approach 5.1.1 Planned Analysis The planned outcomes of interest for the evaluation were VMMC status among school-boys and VMMC-related attitudes and knowledge among school-boys and girls, as well as VMMC uptake among non-school-attending young males. These outcomes were to be measured in both the baseline and follow-up school survey. The comparison of baseline and follow-up survey was planned to identify VMMC uptake and changes in VMMC-related attitudes and knowledge. The analysis was also planned to focus on the comparison of changes in VMMC uptake (or changes in VMMC-related attitudes and knowledge) among uncircumcised boys in schools that received the VMMC demand generation intervention with the changes in schools that did not receive that treatment. A difference-in-difference analysis was proposed to identify the additional VMMC uptake (or changes in VMMC-related attitudes and knowledge) from the vouchers. A difference-in- difference analysis strategy relies on three specific assumptions: (a) non-random attrition across treatments, (b) random assignment into treatment so that there is not contamination due to national VMMC campaigns or other factors that may affect VMMC uptake, and (c) parallel time trends across treatment groups. In addition, descriptive analyses were to be performed to characterize the study population, and geospatial analyses to describe the relationship between VMMC uptake and distance-to-clinic from school/household. 5.1.2 Expanded Analysis The analysis as planned, needed to be adjusted and expanded because of the challenges stated previously. The primary outcome of interest, the proportion of school boys who became circumcised during the course of the evaluation, could not be estimated because assumption (b) failed, and thus required a different and expanded approach including synthetic controls to properly evaluate impact. Expansion of endline data analysis efforts entailed the following: (a) It was agreed that the primary research question would be answered through three analytical approaches: (i) before-after analysis in the two study districts; (ii) comparing circumcision rates in the 2 study districts compared to the other 18 districts before, during and after the intervention, and (ii) synthetic control analysis to create a synthetic control against which to compare the results in the 2 study districts, respectively. (b) For all three of these analyses, the number of circumcisions performed in Rumphi and Mchinji before, during and after the intervention would be analysed. This would require that all the circumcisions performed in the two study districts and the total number of vouchers used for 8 RESULTS FROM THE IMPACT EVALUATION VMMC within each district would be used in the analysis, irrespective of whether an individual was in the control arm. (c) Since a difference-in-difference analysis was no longer possible, a synthetic control analysis was executed to estimate the uptake of VMMC attributable to the intervention. This analysis entailed comparing the circumcisions in the two study districts to circumcisions performed during the same time in the other 18 districts in Malawi that also received the MoH ’standard‘ VMMC demand creation campaign. (d) A distance analysis was also employed to determine any differences between the persons who did and did not receive the intervention (i.e. persons in the 0-10km and in the 10-20 km radius from the district hospital). 5.1.3 Before and After Analysis Collected data from the two study districts and from the National AIDS Commission about circumcision in all district hospitals allowed for the comparison of time series data that enabled one to compare circumcision rates in the two study districts, and in other non-PEPFAR study districts before, during and after the intervention. It enabled an analysis of the extent to which circumcisions increased during and decreased after the intervention ended. 5.1.4 Synthetic Control Analysis This method of analysis was used to provide a more robust evaluation of the intervention as the analysis looked at data trends before and after the start of the impact evaluation. Trend changes before and after the impact evaluation were compared with the average VMMC uptake of all other hospitals in the 18 other districts. The synthetic control method allows for these effects to change over time, by re-weighting the control group so that it has similar pre-intervention characteristics to the exposed group. The “treatment” district hospitals (Mchinji and Rumphi) are compared with a “synthetic” counterfactual composed of a weighted average of district hospitals in the other 18 districts. This method seeked to construct a suitable comparator to the study districts from a linear combination of untreated districts as formalized by Abadie et al. (2010). The synthetic control approach determined the optimal weights for a population of comparator districts in order to best approximate the characteristics of either Mchinji or Rumphi district over the pre-campaign period (before December 2015). The post-intervention trend in outcomes for this synthetic control was then compared to the treated districts‘ outcomes post-intervention, and any difference, was attributed to the effects of integration. The synthetic control method was a variant of the more familiar difference-in-difference estimator which was originally proposed for this impact evaluation, with covariate balancing in the pre-intervention period improved through a minimum-distance matching estimator. As such, the identifying assumptions for the synthetic control were the same for any difference-in-difference: the post-intervention trends for the synthetic control represent the trends that either district would have experienced if not for the circumcision campaign. A further 9 IMPACT EVALUATION ON IMPROVING VMMC DEMAND IN MALAWI THROUGH THE USE OF INCENTIVES assumption was that the circumcision campaign only affects outcomes in the treated districts and not the outcomes in comparator districts, a seemingly benign assumption in this setting. 5.2 Qualitative Analytical Approach At baseline in early 2015, a qualitative analysis provided useful information for the implementation of the impact evaluation and to shape VMMC demand generation messages. The qualitative selection was not meant to be nationally representative, but rather reflect the perceptions of a variety of ethnic groups, both those that were predominantly Christian and those that were predominantly Muslim. Three methods of qualitative data collection were used: Ethnography done by participant observers, Focus Group Discussions (FGDs) and Key Informant Interviews (KIIs). Interviews focused on the barriers and facilitators of VMMC in Malawi: (1) use of traditional and community leaders as change agents, (2) engagement of women, and (3) ensure that (i) services were available when needed, (ii) no one was sent away without the services they sought, and (iii) that follow-up visits were encouraged to avoid post-intervention complications. At endline, qualitative data collection allowed for the understanding of the “how” and “why” findings occurred. Additionally, findings allowed for drawing valuable lessons from the implementation of the study intervention. Two methods of qualitative data collection were used at endline: 1. KIIs with (a) school heads/teachers, (b) clinical service providers/hospital staff, and (c) community leaders/chiefs; and 2. FGDs with (a) Mothers’ Groups, (b) in-schools males, (c) out-of-schools males, and (d) parents. Some of these populations overlapped in the FGDs. In addition, three informal FGDs apart from the arranged FGDs were held. See Table 2 and Table 3 below for the number and characteristics of KIIs and FGDs. Content analysis was used to classify findings. The meanings of the data were gauged by identifying patterns and themes, using a process of inductive qualitative content coding analysis. Table 2 Target population and sample size for key informants’interviews Target Population Mchinji Rumphi Total Males Females Males Females 1. School heads/teachers 3 1 4 0 8 2. Hospital clinical VMMC providers 4 0 5 1 10 3. Community leaders/chiefs 2 0 2 1 5 TOTAL 9 1 11 2 23 10 RESULTS FROM THE IMPACT EVALUATION Table 3 Target population and estimated sample size for focus groups discussions* Target Population Mchinji Rumphi Total Average Average Average Number of number of number of Number of number of focus participants in Number of participants focus participants groups each FGD focus groups in each FGD groups in each FGD 1. Mothers groups 2 9 2 8 4 9 2. In-school males 1 10 2 6 3 5 3. Out-of-school males 1 9 1 5 2 7 4.Parents and guardians 2 9 2 10 4 10 5. Informal 1 n/a 2 n/a 3 n/a TOTAL 7 9* 9 7* 16 8* Note: *Average number of participants for those categories for which numbers were available. 6 DATA COLLECTION TOOLS, ETHICS AND LIMITATIONS 6.1 Data Collection Tools Because of the expansion of the data analysis approach, data collection also needed to be expanded from what was originally intended: (a) Expanded endline quantitative survey: Instead of interviewing just 2,000 persons (70% boys and 30% girls) within the 0–10 km radius of each district hospital, 3,000 individuals were selected for the quantitative endline survey using stratified random sampling, split equally between Rumphi and Mchinji. The expanded sample size included the original 1,000 persons per district, and had 500 additional respondents who lived 10-20km from the district hospital. The endline survey had a total sample size of 3,034 respondents. For the sampling frame, a cross-section of all eligible individuals within the given age range, were included in the randomization, instead of surveying of only those who were part of the intervention. This enabled the ability to assess knowledge, attitudes and the general uptake of the intervention in a randomized manner and thus improve the external validity of the analysis. (b) Qualitative endline data collection: The qualitative endline data collection effort was designed to complement the quantitative endline survey with qualitative data collection and analysis–albeit limited- to help understand the “how” and “why” of findings and to draw valuable lessons from the implementation of the study intervention. Qualitative interviews in the form of key informant interviews and focus groups discussions were conducted with head teachers, clinical service providers, community leaders, Mothers’ Group members, in and out-of-school study population members, parents 11 IMPACT EVALUATION ON IMPROVING VMMC DEMAND IN MALAWI THROUGH THE USE OF INCENTIVES and guardians. Qualitative findings were used to provide deeper meaning and rich exploratory analysis on the impact of perceptions, attitudes and behaviours towards VMMC by these target groups. All interviews were conducted in Chichewa, recorded and subsequently transcribed into English. (c) Routine data about VMMC uptake in 18 other districts in Malawi: To enable the synthetic control analyses to be done, routine data about the uptake of VMMC in all other 18 districts in Malawi (i.e. district in Malawi that are not the eight districts where PEPFAR has focused its large scale VMMC efforts) was also collected from health facilities. This was done by the National AIDS Commission, using data auditing processes and was done for the period January 2015 to June 2016. The following tools were designed to collect data on the baseline and endline surveys. A complete set of qualitative and quantitative data collection tools used is as shown in Annexure II. • Household listing Questionnaire for Endline • Baseline Questionnaire • Endline Questionnaire • Qualitative Interview Tools for In-Depth Interviews and Focus Group Discussions 6.2 Ethics Compliance The impact evaluation protocol was reviewed and approved by the National Health Sciences Research Ethics Committee (Protocol Number 1409), ascent and parental consent to participate in the baseline and endline surveys was required from to those aged under 18 years, while those aged 18 years and above provided their consent to participate. 6.3 Study Limitations It was anticipated that the baseline would be conducted in the schools; however, there were delays at several stages of implementation, where data were collected during the school holidays, when students were at their homes (some boarding students lived in districts which were not their school districts). Also due to high mobility, some students dropped out of school while others were new enrollees in some of the schools. The school heads also acknowledged that some of their records were not up-to-date. The field supervisors had to rely on a combination of the names of students from the school registers and the names as given by students. In some locations, participants refused to participate in the impact evaluation due to rumours that participation meant that one would be forced to get circumcised. The impact evaluation team met with chiefs, religious leaders and other members of the community to explain that the team was only conducting interviews, and that circumcision was completely voluntary. As mentioned previously, the intervention was not implemented as initially planned with consequences already described. 12 RESULTS FROM THE IMPACT EVALUATION 7 IMPLEMENTATION OF THE INTERVENTION In terms of intervention implementation, Tables 4, 5, 6 and 7 summarise, respectively: (a) the number of booklets printed, distributed schools and Mothers’ Groups, and the number handed out to potential VMMC clients; (b) number of circumcisions performed, in total and as a result of the voucher scheme; (c) the voucher redemption rates in Rumphi; and (d) voucher redemption rates in Mchinji. Table 4 Number of Voucher Booklets Distributed, and Handed out to Potential VMMC Clients in Rumphi and Mchinji Rumphi Mchinji School Mothers' School Mothers' Voucher booklets based Groups TOTAL based Groups TOTAL Booklets allocated for printing 1523 762 2285 2791 1396 4187 Booklets distributed to venue (school / MG) 774 720 1494 1407 813 2220 % printed booklets distributed 51% 95% 65% 50% 58% 53% Booklets handed out 527 558 1085 955 488 1443 % of distributed booklets handed out to 68% 78% 73% 68% 60% 65% potential VMMC clients Table 4 shows that a larger proportion of booklets intended for Mothers’ Groups were distributed than those intended for school based distribution. Reasons included that headteachers did not want to accept as many voucher booklets. Table 5 VMMC Procedures Performed in Rumphi and Mchinji During the Intervention Period (Dec 2015 – April 2016) Circumcision by age band Rumphi Mchinji TOTAL Younger than 10 3 4 7 10-15 253 693 946 16-18 153 267 420 19-24 203 349 552 25-29 77 27 104 30 -34 72 0 72 35-39 46 1 47 40 and older 47 0 47 Age details not captured 6 15 19 Total VMMC procedures for which vouchers were redeemed 858 1356 2214 Total VMMC procedures performed for which no vouchers were redeemed 10 17 27 Total VMMC procedures performed 868 1373 2241 Table 5 shows that 93% of redeemed vouchers reached the intended targets stipulated by the country’s VMMC policy (10 – 34 year olds), and that only 27 of the 2241 circumcisions performed during the period, did not involve the redemption of a VMMC voucher. Table 5 also show that more males over the age of 34 (outside the study population age range) in Rumphi (93) compared to Mchinji (1) went for VMMC. 13 Table 6 Voucher Redemption Rates in Rumphi Voucher Total Vouchers Vouchers Vouchers Voucher Vouchers Vouchers Vouchers redemp Voucher vouchers distributed by distributed by distributed to redemp- Voucher type redeemed redeemed redeemed -tion redemption distributed SB to potential MG to potential potential VMMC tion rate - SB - MG - TOTAL rate rate - TOTAL to venues VMMC clients VMMC clients clients - TOTAL from MG from SB Voucher for VMMC Procedure 1494 527 558 1085 203 349 552 39% 63% 51% Guardian of VMMC client for VMMC 1494 527 558 1085 197 352 549 37% 63% 51% Procedure Student follow up Voucher - TOTAL 2988 1054 1116 2170 363 653 1016 34% 59% 47% Student follow up Voucher - 1st follow up 1494 527 558 1085 188 331 519 36% 59% 48% Student follow up Voucher - 2nd follow up 1494 527 558 1085 175 322 497 33% 58% 46% Guardian for Student follow ups Voucher - 2988 1054 1116 2170 352 719 1071 33% 64% 49% TOTAL Guardian for Student follow ups Voucher - 1494 527 558 1085 178 362 540 34% 65% 50% 1st follow up Guardian for Student follow ups Voucher - 1494 527 558 1085 174 357 531 33% 64% 49% 2nd follow up Friends of Student Voucher for VMMC 1494 527 558 1085 106 200 306 20% 36% 28% Procedure Guardians of friends Student Voucher for 1494 527 558 1085 99 220 319 19% 39% 29% VMMC Procedure Friends of Student follow up Voucher 2988 1054 1116 2170 198 396 594 19% 35% 27% Friend of Student follow up Voucher - 1st 1494 527 558 1085 118 208 326 22% 37% 30% follow up Friend of Student follow up Voucher - 2nd 1494 527 558 1085 80 188 268 15% 34% 25% follow up Guardians of Friends of Student follow up 2988 1054 1116 2170 160 428 588 15% 38% 27% Voucher Guardian of Friend of Student follow up 1494 527 558 1085 97 316 413 18% 57% 38% Voucher - 1st follow up Guardian of Friend of Student follow up 1494 527 558 1085 63 112 175 12% 20% 16% Voucher - 2nd follow up TOTAL 26892 9486 10044 19530 1678 3317 4995 18% 33% 26% NOTE: SB = Vouchers that were ‘school-based‘ in the sense that headteachers distributed them. MG = Mothers‘ Group distribution 14 RESULTS FROM THE IMPACT EVALUATION Table 7 Voucher Redemption Rates in Mchinji Voucher Total Vouchers Vouchers Vouchers Voucher Vouchers Vouchers Vouchers redemp Voucher vouchers distributed by distributed by distributed to redemp- Voucher type redeemed redeemed redeemed -tion redemption distributed SB to potential MG to potential potential VMMC tion rate - SB - MG - TOTAL rate rate - TOTAL to venues VMMC clients VMMC clients clients - TOTAL from MG from SB Voucher for VMMC Procedure 2220 955 488 1443 478 421 899 50% 86% 62% Guardian of VMMC client for VMMC 2220 955 488 1443 456 382 838 48% 78% 58% Procedure Student follow up Voucher - TOTAL 4440 1910 976 2886 798 661 1459 42% 68% 51% Student follow up Voucher - 1st follow up 2220 955 488 1443 440 356 796 46% 73% 55% Student follow up Voucher - 2nd follow up 2220 955 488 1443 358 305 663 37% 63% 46% Guardian for Student follow ups Voucher - 4440 1910 976 2886 737 646 1383 39% 66% 48% TOTAL Guardian for Student follow ups Voucher - 2220 955 488 1443 391 340 731 41% 70% 51% 1st follow up Guardian for Student follow ups Voucher - 2220 955 488 1443 346 306 652 36% 63% 45% 2nd follow up Friends of Student Voucher for VMMC 2220 955 488 1443 257 200 457 27% 41% 32% Procedure Guardians of friends Student Voucher for 2220 955 488 1443 250 196 446 26% 40% 31% VMMC Procedure Friends of Student follow up Voucher 4440 1910 976 2886 370 350 720 19% 36% 25% Friend of Student follow up Voucher - 1st 2220 955 488 1443 202 250 452 21% 51% 31% follow up Friend of Student follow up Voucher - 2nd 2220 955 488 1443 168 100 268 18% 20% 19% follow up Guardians of Friends of Student follow up 4440 1910 976 2886 366 362 728 19% 37% 25% Voucher Guardian of Friend of Student follow up 2220 955 488 1443 259 210 469 27% 43% 33% Voucher - 1st follow up Guardian of Friend of Student follow up 2220 955 488 1443 107 152 259 11% 31% 18% Voucher - 2nd follow up TOTAL 26,640 11,460 5,856 17,316 3,712 3,218 6,930 32% 55% 40% NOTE: SB = Vouchers that were ‘school-based‘ in the sense that headteachers distributed them. MG = Mothers‘ Group distribution 15 Tables 6 and 7 paint an interesting picture concerning voucher redemption rates: (a) Overall, voucher redemption rates in Mchinji was higher than in Rumphi (40% vs 26%, P<0.01). (b) Voucher redemption rates of MG-distributed vouchers were higher, in all cases, than the SB vouchers (33% vs 18% in Rumphi and 58% vs 34% in Mchinji), despite the fact that many more and a higher proportion of intended booklets were distributed to MGs than schools. (c) Most VMMC clients went for their first follow up visit (94% in Rumphi and 90% in Mchinji), and fewer went for their second follow up visit (88% in Rumphi and 74% in Mchinji). (d) For ‘primary’ booklet recipients (i.e. VMMC clients who received their vouchers from headteachers or MGs), voucher redemption rates (i.e. redemption rates of the frist two types of vouchers, green and skyblue) were higher than for the VMMC clients who received their vouchers through friends (i.e. gray and maroon vouchers). (e) Guardians who received vouchers from ‘primary’ booklet reciepients had a higher voucher redemption rate (both first follow-up and second follow-up) than guardians of VMMC clients who received their vouchers through friends. Specific implementation lessons that were learned through the process, are as follows: (a) Balancing supply and demand. Multiple delays during implementation occurred causing times where there were insufficient coordination of program activities, a shortage of supplies, and a lack of “readiness” when VMMC demand significantly increased due to the vouchers. This evaluation provides evidence for the need of engaging and accurately estimating possible demand before implementation. Collaboration between evaluation partners and estimating the proper funds to implement an effective implementation are key ingredients to consider for future implementation of a similar program.The evaluation would have benefitted by estimating a priori how many circumcisions might occur in a given month within each district. There was not enough space in district hospitals to accommodate all the individuals going for VMMC during particular months (February and April). This was especially true in Mchinji. Tents were used to alleviate this problem allowing for additional theaters to conduct circumcisions. Tents could have been used at the start of the study to allow for district hospitals to meet demand in a more efficient manner. (b) Voucher distribution. Head teachers and Mothers’ Groups reported difficulties making reconciliations for the total number of vouchers they received against the total number they distributed. Mothers’ Groups and head teachers could have benefitted from additional training to support voucher handout. (c) Voucher redemption. Payments for vouchers were slow for clients. This created congestion during voucher redemption. There were frequent cash shortages that left some VMMC clients waiting until late at night or even multiple days to collect payment for vouchers. 16 RESULTS FROM THE IMPACT EVALUATION 8 RESULTS FROM THE IMPACT EVALUATION The results from the impact evaluation are presented to answer the study hypotheses, starting with the primary research question. To answer this question, required a mixed method approach, as described earlier. After the primary research question was answered, secondary research questions were answered including. All of these questions are answered using a combination of descriptive statistics, logistic regressions and qualitative insights. All the tables presented/referenced in the written report and additional tables on the analyses are provided in Annexure III. 8.1 Primary Research Question: Do incentives significantly increase VMMC uptake among in-school and out-of-school boys and young men aged 10 to 34 in Malawi? 8.1.1 Before and After Results National Malawian VMMC program data provided by NAC and MoH allowed for the comparison of VMMC rates in Rumphi and Mchinji before, during and after the voucher intervention implementation. As Figure 4 shows, there were very few male circumcisions occurring in both Mchinji and Rumphi before the incentives (voucher) intervention. In the prior 23 months leading up to the intervention, the average male circumcision monthly rate in Mchinji was 0.24 (standard deviation (SD): 0.79) male circumcisions per 1,000 adult males (>15 years of age). The average male circumcision rate in Rumphi was slightly higher at 0.48 (SD: 0.74) male circumcisions per 1,000 adult males. During the 4 month incentives (voucher) intervention implementation period in Mchinji, the average monthly male circumcision rate increased to 2.61 (SD: 2.16) male circumcisions per 1,000 adult males, and increased to 3.78 (SD: 1.74) male circumcisions per 1,000 adult males in Rumphi. In the two months following the end of the impact evaluation the monthly average male circumcision rate in Mchinji fell to 0 male circumcisions per 1,000 adults males, and 1.34 (SD: 0.55) male circumcisions per 1,000 adult males in Rumphi. 17 IMPACT EVALUATION ON IMPROVING VMMC DEMAND IN MALAWI THROUGH THE USE OF INCENTIVES Figure 4. Number of VMMC procedures in (a) Mchinji and (b) Rumphi before, during and after incentive intervention Source: Routine circumcision data provided by the Malawi Ministry of Health and Social Welfare Both Mchinji and Rumphi had similar male circumcision rates within the 23 months prior to the intervention, a much higher rate during the 4 month intervention and slightly higher rates two months after the intervention when compared to the other districts in Malawi excluding the 8 PEPFAR priority districts (Blantyre, Lilongwe, Zomba, Thyolo, Mulanje, Chikwawa, Chiradzulu and Phalombe) and Balaka. Balaka had significantly higher male circumcision rates (>20 times higher) than any of the other districts. In the prior 23 months leading up to the intervention, the average male circumcision monthly rate in the other districts was 0.63 (SD: 1.86) male circumcisions per 1,000 adult males (>15 years of age). The reason for such high rates in Balaka were due to a heightened use of outreach programs during Q3, and also Q3 includes the traditional circumcision season. During the 4 month impact evaluation in the other districts, the average monthly male circumcision rate stayed roughly the same at 0.45 (SD: 1.01) male circumcisions per 1,000 adult males. In the two months following the end of the impact evaluation the monthly average male 18 RESULTS FROM THE IMPACT EVALUATION circumcision rate in the other districts remained roughly the same at 0.40 (SD: 0.94) male circumcisions per 1,000 adults males. These circumcision rates demonstrate an increase in male circumcision rates within both Rumphi and Mchinji compared to the other districts which did not take place in the intervention. However, these results do not provide statistical evidence that the impact evaluation had a direct impact in the increase of male circumcision rates within these districts. The synthetic control results which follow indicate the magnitude of impact vouchers had on the uptake of VMMC within Rumphi and Mchinji. 8.1.2 Synthetic Control Results As described previously, Balaka had much higher circumcision rates and was excluded from the analysis. Therefore, a total of 17 districts were selected to create an effective control using the synthetic control methods. These 17 districts were considered possible controls for the intervention districts as they were not part of the present intervention, and were not among the Malawian NAC chosen intervention districts for PEPFAR to provide VMMC support. Additionally, Mzimba has been recently separated into Mzimba North and Mzimba South, but the existing administrative dataset did not account for this separation. Therefore, for this analysis the two Mzimba districts will be treated as one unit. Nkhata Bay and Likoma have been combined into one variable in order to use VMMC demand data. To create an effective control using these 17 districts, 5 district level characteristics were compared in addition to the male circumcision rate, the main outcome of interest. These characteristics include the adult population within each district, the number of outpatient visits per district, the ratio of people living with HIV to ART recipients within each district, the estimated demand of male circumcision within each district, and the geographical region in which a district was located (e.g., central, northern or southern). Each of the 17 districts and its relevant inputs were observed over the course of 30 months (January 2014 to June 2016) to establish temporal trends for each district. The minimum distance estimator generated district level weights to construct the synthetic control, applied separately for each treated district (Rumphi or Mchinji). Both Rumphi and its synthetic control had the same baseline (before the intervention) monthly male circumcision rate per 1,000 adult males (aged >15 years), 0.48 (Figure 5). The high rate of circumcisions between August and October 2015 seen in Figure 5 and Figure 6 were due to long school breaks that occur from July to August where boys are out-of- school and are able to go for VMMC services. Additionally, Salima, Mangochi, Balaka and Machinga districts had their season of initiation ceremonies where linkages are established with traditional circumcisers and brought to clinics for services. 19 IMPACT EVALUATION ON IMPROVING VMMC DEMAND IN MALAWI THROUGH THE USE OF INCENTIVES Figure 5 Circumcision rate, by month, for Rumphi and its synthetic control Both Mchinji and its synthetic control also had the same baseline (before the intervention) monthly male circumcision rate per 1,000 adult males of 0.24 (Figure 6). The similarity between characteristics in the treatment district and its counterfactual, lends confidence to this method of measuring the impact of the intervention, as it appears the synthetic control is a very close match to each of the study districts. Figure 6 Circumcision rate, by month, for Mchinji and its synthetic control 20 RESULTS FROM THE IMPACT EVALUATION Over the course of the intervention (December 2015 to April 2016), there was a substantial increase in the rate of circumcisions in the study districts. In Rumphi the circumcision rate varied from 1.02 to 5.62 male circumcisions per 1,000 adult males over this period (Figure 5). Summing over the months of the intervention, the total impact of the intervention in Rumphi comes to 17.01 male circumcisions per 1,000 adult males, compared to 0.96 male circumcisions per 1,000 adult males in the synthetic control. Therefore, the intervention led to an additional 16.05 male circumcisions per 1,000 male population in Rumphi. This translates into an additional 867 male circumcisions from December 2015 to April 2016 due to the intervention. In Mchinji the circumcision rate varied from 0.00 to 5.29 male circumcisions per 1,000 adult males over the 4 month intervention (Figure 4). The total impact of the intervention in Mchinji was 10.43 male circumcisions per 1,000 adult males, compared to 1.28 male circumcisions per 1,000 adult males in the synthetic control. Therefore, the intervention led to an additional 9.15 male circumcisions per 1,000 adult males. This translates into an additional 1,342 male circumcisions from December 2015 to April 2016 due to the intervention. This number is close to the reported VMMC figure of 1,373 in Mchinji. Given the nature of the synthetic control method, there are no formal tests of statistical significance for these impact estimates. However the robustness of the findings can be explored through sensitivity analysis of placebo impact estimates. This process “re-estimates” the impact of the intervention as if it was implemented in each of the 17 comparator districts. If the intervention did result in real impact in the treated district, then we would expect to see the largest divergences post-implementation in the outcome between treated and synthetic control precisely for the actual treated district. Figure 7 (for Rumphi) and Figure 8 (for Mchinji) relay the estimated net effect of the intervention in each of the 17 control districts as well as the treated district. In each case the response of the indicator to the intervention is readily apparent only in the district that actually received the intervention. These graphical patterns strengthen the confidence in the conclusion that VMMC incentives really did achieve an increase in the targeted outcomes (VMMC uptake) over the implementation period. 21 IMPACT EVALUATION ON IMPROVING VMMC DEMAND IN MALAWI THROUGH THE USE OF INCENTIVES Figure 7 Treatment effect for Rumphi and simulated effects for comparator districts Figure 8 Treatment effect for Mchinji and simulated effects for comparator districts More formally, for the treated districts as well as the placebo permutations, we can calculate the ratio of the mean squared prediction error (MSPE) for the post-intervention period (in the numerator of the ratio) and the pre-intervention period (in the denominator). If the intervention had a real impact on the populations of Mchinji or Rumphi, then we would expect to observe a relatively high ratio for those districts in relation to all possible placebo districts. Table 8 and Table 22 RESULTS FROM THE IMPACT EVALUATION 9 convey these MSPEs. In the case of Rumphi, the MSPE is substantially higher than all other districts, by greater than an order of magnitude. This is further evidence that the rise in circumcisions attributable to the intervention is an actual consequence of the intervention and not a statistical artefact. The MSPE for Mchinji is also the highest of all possible comparator districts, although closer in magnitude to the placebo estimates. While not as definitive as with Rumphi, these results also would led us to conclude that the increase in circumcisions can be attributed to the intervention. Table 8 Ratio of pre-intervention/post-intervention MSPE for Rumphi district and 17 possible comparators District MSPE if district is "treated" District MSPE if district is "treated" Balaka 0.416 Mzimba 0.261 Chitipa 2.524 Neno 0.230 Dedza 0.322 Nkhata Bay and Likoma 0.208 Dowa 0.074 Nkhotakota 0.229 Karonga 0.293 Nsanje 0.129 Kasungu 0.790 Ntcheu 0.133 Machinga 0.342 Ntchisi 0.047 Mangochi 0.211 Salima 0.227 Mwanza 0.214 Rumphi 100.633 Table 9 Ratio of pre-intervention/post-intervention MSPE for Mchinji district and 17 possible comparators District MSPE if district is "treated" District MSPE if district is "treated" Balaka 0.439 Mzimba 0.261 Chitipa 0.269 Neno 0.138 Dedza 0.341 Nkhata Bay and Likoma 0.686 Dowa 3.316 Nkhotakota 0.136 Karonga 0.286 Nsanje 0.106 Kasungu 2.551 Ntcheu 0.977 Machinga 0.337 Ntchisi 0.211 Mangochi 0.242 Salima 0.189 Mwanza 0.206 Mchinji 3.785 8.1.3 Description of the Endline Survey Sample The total sample for the endline survey was 3,034. The sample was equally split between Mchinji (50%) and Rumphi (50%) districts. By design, both districts had approximately 31% females and 69% males, and 67% lived within 10km of each respective district hospital, while 33% lived 10- 23 IMPACT EVALUATION ON IMPROVING VMMC DEMAND IN MALAWI THROUGH THE USE OF INCENTIVES 20km from the district hospital (Table 10). About 40% of the total sample was below the age of 18 years. The mean age and standard deviation for each district was 20.4 years (SD. 6.8) for Mchinji and 20.0 years (SD. 7.0) for Rumphi. There was no statistical difference in the age of the respondents in the two districts. Table 10 Demographic characteristics Mchinji (N=1,517) Rumphi (N=1,517) P- P- Within Within TOTAL value)2 value)3 Factor 10km4 10-20km5 10km 10-20km Sex Female 309 (30.6%) 156 (30.7%) 306 (30.3%) 155 (30.6%) 926 (30.5%) Male 701 (69.4%) 351 (69.2%) 0.94 705 (69.7%) 351 (69.4%) 0.88 2,108 (69.5%) Age 10-14 237 (23.5%) 122 (24.1%) 252 (24.9%) 167 (33%) 778 (25.6%) 15-19 296 (29.3%) 119 (23.5%) 287 (28.4%) 131 (25.9%) 833 (27.5%) 20-24 193 (19.1%) 119 (23.5%) 201 (19.9%) 67 (13.2%) 580 (19.1%) 25-29 142 (14.1%) 76 (15%) 129 (12.8%) 65 (12.8%) 412 (13.6%) 30-34 142 (14.1%) 71 (14%) 0.11 142 (14%) 76 (15%) 0.002 431 (14.2%) Mean age (SD) 20.4 (6.8) 20.5 (6.9) 0.806 20.2 (6.8) 19.5 (7.3) 0.067 20.2 (6.9) Education Not attending school 494 (48.9%) 293 (57.8%) 0.001 466 (46.1%) 223 (44.1%) 0.46 1,476 (48.7%) Primary 338 (33.5%) 178 (35.1%) 0.52 331 (32.7%) 224 (44.3%) <0.001 1,071 (35.3%) Secondary & above 178 (17.6%) 36 (7.1%) <0.001 214 (21.2%) 59 (11.7%) <0.001 487 (16.1%) Marital Not Married 669 (66.2%) 294 (58%) 686 (67.9%) 338 (66.8%) 1,987 (65.5%) Status Married 341 (33.8%) 213 (42%) 0.002 325 (32.2%) 168 (33.2%) 0.68 1,047 (34.5%) 2 Test for significant difference between the two groups of respondents living within 10km and those within 20km from the hospital in Mchinji District (if p<0.05, there is a significant difference in the observed %) 3 Test for significant difference between the two groups of respondents living within 10km and those within 20km from the hospital in Rumphi District (if p<0.05, there is a significant difference in the observed %) 4 Distance from Hospital 5 Distance from hospital 6T-test for difference in mean age (years) for respondents living within 10km and those within 20km from the hospital in Mchinji District (if p<0.05, there is a significant difference in the mean age) 7 T-test for difference in mean age (years) for respondents living within 10km and those within 20km from the hospital in Rumphi District (if p<0.05, there is a significant difference in the mean age) 24 RESULTS FROM THE IMPACT EVALUATION Mchinji (N=1,517) Rumphi (N=1,517) P- P- Within Within TOTAL value)2 value)3 Factor 10km4 10-20km5 10km 10-20km Rural 690 (68.3%) 466 (91.9%) 575 (56.9%) 471 (93.1%) 2,202 (72.6%) Area <0.001 <0.001 Urban 320 (31.7%) 41 (8.1%) 436 (43.1%) 35 (6.9%) 832 (27.4%) Employment Not employed 805 (79.7%) 413 (81.5%) 805 (79.6%) 430 (85%) 2,453 (80.8%) 0.42 0.01 Status Employed 205 (20.3%) 94 (18.5%) 206 (20.4%) 76 (15%) 581 (19.2%) Catholic 578 (57.2%) 331 (65.3%) 0.003 243 (24%) 122 (24.1%) 0.97 1,274 (41.1%) CCAP 137 (13.6%) 47 (9.3%) 0.02 256 (25.3%) 128 (25.3%) 0.99 568 (18.7%) Anglican 9 (0.9%) 5 (1%) 0.86 10 (1%) 6 (1.2%) 0.72 30 (1.0%) Religion Muslim 22 (2.2%) 2 (0.4%) 0.009 7 (0.7%) 2 (0.4%) 0.48 33 (1.1%) Adventist/Baptist 55 (5.5%) 9 (1.8%) 0.001 95 (9.4%) 43 (8.5%) 0.57 202 (6.7%) Other8 204 (20.2%) 110 (21.7%) - 397 (39.3%) 205 (40.5%) - 916 (30.2%) Refused to answer 1 (0.1%) 0 (0.0%) - - - - 1 (0.0%) Chewa 503 (49.8%) 387 (76.3%) <0.001 64 (6.3%) 23 (4.5%) 0.16 977 (32.2%) Yao 25 (2.5%) 1 (0.2%) 0.001 7 (0.7%) 1 (0.2%) 0.21 34 (1.1%) Ethnic Tumbuka 20 (2%) 4 (0.8%) 0.08 759 (75.1%) 437 (86.4%) <0.001 1,220 (40.2%) Group Ngoni 392 (38.8%) 106 (20.9%) <0.001 82 (8.1%) 19 (3.8%) 0.001 599 (19.7%) Nkhonde - - - 41 (4.1%) 6 (1.2%) 0.002 47 (1.5%) Other 45 (4.5%) 6 (1.2%) - 35 (3.5%) 10 (2%) 96 (3.2%) Can Read Letter in 574 (56.8%) 199 (39.2%) <0.001 724 (71.6%) 275 (54.3%) <0.001 1,772 (58.4%) English Literacy Can Read Letter 880 (87.1%) 391 (77.1%) <0.001 947 (93.7%) 418 (82.6%) <0.001 2,636 (86.9%) in Chichewa Most respondents were not married (65%). There was a significantly higher proportion of unmarried people living within 10km (66%) of Mchinji district hospital compared to those living 10-20km (58%) from the hospital (P=0.002). Most respondents were not employed (81%), significantly so among respondents living 10-20km (85%) from Rumphi district hospital compared to those who lived within 10km (80%) from the hospital (P=0.01). There was no significant difference in employment status by distance from hospital among respondents living in Mchinji. Most respondents were from rural areas more so among those who lived 10-20km from the district hospital compared to 8 Largely Apostolic Faith, African National Church, Church of Christ, Assemblies of God, Jehovah’s witness 25 IMPACT EVALUATION ON IMPROVING VMMC DEMAND IN MALAWI THROUGH THE USE OF INCENTIVES those who lived within 10km from the hospital (92% vs. 62% in Mchinji and 93% vs. 57% in Rumphi) (P<0.001). The main religion in Mchinji was Catholic (60% [909/1,517]) while in Rumphi the main religion was both Catholic (24% [365/1,517]) and Church of Central Africa Presbyterian (25% [384/1,517]). There were significantly more Muslim (P=0.009) respondents living within 10km from the district hospital compared to those living 10-20km from the hospital in Mchinji. In Rumphi there were no differences by religion in the two locations. Chewa (59%) and Ngoni (33%) were the main ethnic groups in Mchinji, while Tumbuka (79%) was more prevalent in Rumphi district. There were significantly more Chewa in Mchinji living 10-20km (76%) from the hospital compared to those living with 10km (50%) from the hospital (P<0.001) and also among the Ngoni ethnic groups (39% vs. 21%, P<0.001). In Rumphi there were significantly more Tumbuka living 10-20km (86%) from the hospital compared to those who lived 0-10km (75%) from the hospital (P<0.001). The majority of the respondents mentioned that they were not in school (49%), while 35% were in primary school, and 16% were in secondary school or higher education. There were significantly more people not in school in Mchinji living 10-20km (58%) from the hospital compared to those who lived within 10km (49%) from the hospital (P<0.001). There were higher education levels among respondents living within 10km from the hospitals in both districts compared to those who lived 10-20km from the hospital (18% vs. 7% in Mchinji and 21% vs. 12% in Rumphi, P<0.001 in both cases). 8.1.4 Characteristics that Increase VMMC uptake Intention to Get Circumcised About 51% of the total sample of uncircumcised study population expressed an interest to get circumcised in the future. 49% of the sample expressed no intention to get circumcised or were not sure whether they would get circumcised. Among the respondents who had intentions to get circumcised, male family members were the most influential on the choice of circumcision. Other individuals in the community were also influential, but not as influential as uncles and fathers. Importantly participants mentioned they would get circumcised (43%) if vouchers were available. The majority of those who expressed interest in getting circumcised in the future knew that a government hospital (81%) and a Health Center (4%) would be the places where they could go for circumcision (Table 11). This result was significantly higher among respondents who lived 0-10km from the district hospital compared to respondents who lived 10-20km from the hospital in both districts (84% vs. 74% in Mchinji, P<0.001 and 90% vs. 68% in Rumphi, P<0.001). Various means of transportation to undergo VMMC at district hospitals would be used. These included a minibus (38%), bike taxi (21%), 26 RESULTS FROM THE IMPACT EVALUATION bicycle (21%), walking (22%) and a taxi (13%). Most participants would incur transport costs (74%), and, as expected, those who lived closer to the hospital (0-10km), would incur on average less than 1500MK compared to those who lived 10-20km. Table 11 Intention to get circumcised among uncircumcised men Mchinji Rumphi Chi- Chi- square square Within (p- Within (p- FACTOR 10km 10-20km value)9 10km 10-20km value)10 TOTAL Intend to get No 283 271 122 840 circumcised (47.5%) 164 (48.8%) (42.5%) (36.0%) (44.0%) Yes 277 341 194 966 (46.5%) 154 (45.8%) (53.5%) (57.2%) (50.6%) Neither Yes/No 25 23 102 36 (6.0%) 18 (5.4%) 0.96 (3.9%) (6.8%) 0.001 (6.3%) Would you Father/grandfather/ 265 338 235 986 consider getting uncle (44.5%) 148 (44.1%) 0.98 (53.1%) (69.3%) <0.001 (51.7%) circumcised if Mother/grandmothe 232 296 209 866 encouraged by r/aunt (38.9%) 129 (38.4%) 0.47 (46.5%) (61.7%) <0.001 (45.4% Wife/partner 228 301 211 879 (38.3%) 139 (41.4%) 0.57 (47.3%) (62.2%) <0.001 (46.1%) Traditional leader 204 258 200 791 (34.2%) 129 (38.4%) 0.29 (40.5%) (59%) <0.001 (41.5%) Religious leader 220 278 200 829 (36.9%) 131 (39.0%) 0.75 (43.6%) (59%) <0.001 (43.4%) Government 234 313 225 909 (39.3%) 137 (40.8%) 0.23 (49.1%) (66.4%) <0.001 (47.6%) Doctor/nurse/HSA 273 333 230 1,004 (45.8%) 168 (50%) 0.54 (52.3%) (67.9%) <0.001 (52.6%) Teacher 212 256 193 780 (35.6%) 119 (35.4%) 0.87 (40.2%) (56.9%) <0.001 (40.9%) Transport vouchers 233 268 191 825 (39.1%) 133 (39.6%) 0.98 (42.1%) (56.3%) <0.001 (43.2%) Parents 247 335 225 (41.4%) 147 (43.7%) 0.13 (52.6%) (66.4%) <0.001 954 (50%) 9 Test for significant difference between the two groups of respondents living within 10km and those within 20km from the hospital in Mchinji district (if p<0.05, there is a significant difference in the observed %) 10 Test for significant difference between the two groups of respondents living within 10km and those within 20km from the hospital in Rumphi district (if p<0.05, there is a significant difference in the observed %) 27 IMPACT EVALUATION ON IMPROVING VMMC DEMAND IN MALAWI THROUGH THE USE OF INCENTIVES Table 11 Intention to get circumcised among uncircumcised men (continued) Mchinji Rumphi Chi- Chi- square square Within (p- Within (p- FACTOR 10km 10-20km value)11 10km 10-20km value)12 TOTAL Would you Brothers/ cousins 255 157 311 950 consider getting (42.8%) (46.7%) 0.20 (48.8%) 227 (67%) <0.001 (49.8%) circumcised Best friends 259 151 320 221 951 if........gets (43.5%) (44.9%) 0.83 (50.2%) (65.2%) <0.001 (49.8%) circumcised Most friends in 248 151 318 220 937 village (41.6%) (44.9%) 0.36 (49.9%) (64.9%) <0.001 (49.1%) Most friends in 227 120 285 832 school (38.1%) (35.7%) 0.57 (44.7%) 200 (59%) <0.001 (43.6%) A political leader 182 107 219 184 692 (30.5%) (31.8%) 0.49 (34.4%) (54.3%) <0.001 (36.3%) A pop culture star 178 106 210 179 673 (29.9%) (31.5%) 0.86 (33%) (52.8%) <0.001 (35.3%) I am paid money to 181 111 218 168 678 get circumcised (30.4%) (33.0%) 0.41 (34.2%) (49.6%) <0.001 (35.5%) Celebrity get 182 114 215 180 691 circumcised (30.5%) (33.9%) 0.43 (33.8%) (53.1%) <0.001 (36.2%) I am given vouchers 194 153 334 206 887 to get circumcised (32.5%) (45.5%) <0.001 (52.4%) (60.8%) <0.001 (46.5%) Circumcision Intentions Where would one CHAM 2 (0.3%) 9 (2.7%) 0.001 2 (0.3%) 4 (1.2%) 0.10 17 (0.9%) go for circumcision Government 500 248 570 232 1,550 hospital (83.9%) (73.8%) <0.001 (89.5%) (68.4%) <0.001 (81.2%) 50 Health Center 5 (0.8%) 12 (3.6%) 0.003 5 (0.8%) (14.8%) <0.001 72 (3.8%) Traditional circumciser 4 (0.7%) 1 (0.3%) 0.45 1 (0.2%) 1 (0.3%) 0.65 7 (0.4%) Private 24 (4.0%) 9 (2.7%) 0.28 26 (4.1%) 10 (2.9%) 0.37 69 (3.6%) Other 27 (4.5%) 11 (3.3%) - 6 (0.9%) 2 (0.6%) - 46 (2.4%) 40 147 Don’t know 34 (5.7%) 46 (13.7%) <0.001 27 (4.2%) (11.8%) <0.001 (7.7%) 11 Test for significant difference between the two groups of respondents living within 10km and those within 20km from the hospital in Mchinji district (if p<0.05, there is a significant difference in the observed %) 12 Test for significant difference between the two groups of respondents living within 10km and those within 20km from the hospital in Rumphi district (if p<0.05, there is a significant difference in the observed %) Table 11 Intention to get circumcised among uncircumcised men (continued) Mchinji Rumphi Within Chi-square Chi-square 10km 10-20km (p-value) 13 Within 10km 10-20km (p-value) 14 TOTAL Is circumcision Yes 509 (95.1%) 265 (95.0% 578 (95.7%) 268 (90.2%) 1,620 (94.5%) place conveniently 0.92 0.001 located No 26 (4.9%) 14 (5.0%) 26 (4.3%) 29 (9.8%) 95 (5.5%) If one decided to Walk 112 (18.8%) 20 (5.9%) 0.001 230 (36.1%) 50 (14.7%) <0.001 412 (21.6%) get circumcised Bicycle 103 (17.3%) 94 (28.0%) 0.001 130 (20.4%) 73 (21.5%) 0.68 400 (21.0%) transportation to be used Bike taxi 152 (25.5%) 63 (18.8%) 0.02 134 (21.0%) 54 (15.9%) 0.05 403 (21.1%) Minibus 189 (31.7%) 91 (27.1%) 0.14 251 (39.4%) 189 (55.8%) <0.001 720 (37.7%) Taxi 74 (12.4%) 52 (15.5%) 0.19 77 (12.1%) 35 (10.3%) 0.41 238 (12.5%) Own 4 (0.7%) 1 (0.3%) 0.54 12 (1.9%) 3 (0.9%) 0.23 20 (1.1%) Would you incur Yes 385 (72.0%) 186 (66.7%) 450 (74.5%) 247 (83.2%) 1,268 (73.9%) Transportation 0.12 0.001 costs No 150 (28.0%) 93 (33.3%) 154 (25.5%) 50 (16.8%) 447 (26.1%) If one decided to 0-500 109 (28.3%) 6 (3.2%) <0.001 120 (26.7%) 10 (4.1%) <0.001 245 (19.3%) get circumcised, 500-1000 184 (47.8%) 58 (31.2%) <0.001 138(30.7%) 38 (15.4%) <0.001 418 (33.0%) Cost of transportation 1000-1500 39 (10.1%) 32 (17.2%) 0.02 67 (14.9%) 45 (18.2%) 0.25 183 (14.4%) (MK) would be... 1500-2000 21 (5.5%) 40 (21.5%) <0.001 62 (13.8%) 60 (24.3%) <0.001 183 (14.4%) 2000-4000 32 (8.3%) 50 (26.9%) <0.001 63 (14.0%) 94 (38.1%) <0.001 239 (18.8%) If one decided to Yes 302 (50.7%) 141 (42.0%) 294 (46.1%) 113 (33.3%) 850 (44.5%) get circumcised would losing time 0.01 <0.001 from school be a No 294 (49.3%) 195 (58.0%) 343 (53.8%) 226 (66.7%) 1,058 (55.5%) significant problem Knowledge about Vouchers The MoH sensitization messages, schools, Mothers’ Groups, and word-of-mouth were the most commonly cited ways that people heard about the vouchers (Table 12). In-school respondents were familiar with various sensitization methods of the MoH campaign and students from the two FGDs held in Rumphi were able to describe the sensitization that occurred at their schools in detail. Some of the students in Mchinji, had heard sensitization messages on the radio. However, they did not fully understand the intention of the vouchers. Multiple individuals in the FGDs did not know that the 13 Test for significant difference between the two groups of respondents living within 10km and those within 20km from the hospital in Mchinji district (if p<0.05, there is a significant difference in the observed %) 14 Test for significant difference between the two groups of respondents living within 10km and those within 20km from the hospital in Rumphi district (if p<0.05, there is a significant difference in the observed %) rationale behind providing the vouchers was to reduce the burden of transportation cost for VMMC. Students in Rumphi had a better understanding of how the vouchers were intended to be used. Out-of-school males in Mchinji and Rumphi understood the intervention, and indicated that they felt that Mothers’ Groups were able to articulate how the intervention was to contribute to increased VMMC uptake. Voucher Distribution and Use Distribution. In-school survey respondents expressed that everyone who wanted a voucher could get one, and could then go for VMMC as they wished. The students in Mchinji received their vouchers from the head teachers. They mentioned that out-of- school members of the study population were receiving vouchers from the Mothers’ Groups, however, students were incorrectly given back the vouchers for the out-of- school members of the study population and vice versa. Students in Rumphi received their vouchers from a variety of sources (head teachers, Mothers’ Groups, and relatives [usually mothers who had collected the vouchers for them]). Some of the students from Chozoli Primary, for example, had their mothers request vouchers from the head teachers who usually declined because they were not in the intervention arm of the impact evaluation and did not want the students to miss school. Mothers making voucher requests were usually able to get vouchers from Mothers’ Groups if head teachers declined. Out-of-school members of the study population in Mchinji received their vouchers from Mothers’ Groups, but in Rumphi, vouchers were received not only from Mothers’ Groups but also from district hospitals. There was a common perception on the part of students, out-of-school males, and parents that parents were the driving factor behind younger school-age children (fourteen and younger) receiving VMMC, whether because of the health benefits for the children or because of the money received from the vouchers, is unclear. Almost half of the respondents in the endline survey had heard about the vouchers (47%). In both districts, significantly more people who lived within 10km from the district hospital had heard about the vouchers compared to those who lived 10-20km from the district hospital (53% vs. 29%, P<0.001 in Mchinji and 62% vs. 27%, P<0.001 in Rumphi). Among those who had heard about the vouchers, 33% had seen the vouchers, more among those who lived within 10km from the district hospital compared to those who lived 10-20km from each district hospital (45% vs. 10%, P<0.001 in Mchinji and 31% vs. 14%, P=0.003 in Rumphi) p<0.001). About 87% of those who had seen the vouchers mentioned that their friends obtained the vouchers (significantly more among respondents who lived within 10km (87%) from the district hospital in Rumphi compared to those who lived 10-20km (77%) from the hospital (P<0.001). Only 96 out of the 2,107 total sample (5%) had received the vouchers themselves and almost half (48%) of these respondents mentioned that the vouchers changed their minds about circumcision. Use. The vouchers were used to pay for transport for circumcision (56%), and for first (93%) and second (87%) follow-up visits. Voucher money was also used for purchasing food and household groceries, “That money helped people in the way that this year there was so much hunger so it was helping people. When the child gets circumcised they were buying food, use it for milling, buying salt. The money was helping.” (Rumphi - Parents - FGD) “We did not know any procedures - and thought that the voucher money was for transport and buying food stuffs. (Rumphi – Young men - FGD) and personal products for post-operation care such as soap, hydrating drinks and painkillers. Table 12 Circumcision and HIV knowledge Mchinji Rumphi P- Females Males value15 Females Males P-value16 TOTAL Have you been Yes 234 (50.3%) 343 (32.6%) 215 (46.6%) 448 (42.4%) 1,240 (40.9%) to a healthcare provider in the No 231 (49.7%) 708 (67.3%) 246 (53.4%) 608 (57.6%) 1,793 (59.1%) last year Refused to Answer 0 (0.0%) 1 (0.1%) <0.001 - - 0.13 1 (0.0%) Did Provider Yes 131 (56.0%) 205 (59.8%) 138 (64.2%) 243 (54.2%) 717 (57.8%) talk about HIV No 103 (44.0%) 138 (40.2%) 0.37 77 (35.8%) 205 (45.8%) 0.02 523 (42.2%) Did Provider Yes 51 (21.8%) 136 (39.6%) <0.001 74 (34.4%) 141 (31.5% 0.45 402 (32.4%) talk about MC No 183 (78.2%) 207 (60.3%) 141 (65.6%) 307 (68.5%) 838 (67.6%) 15 Test for significant difference between males and females in Mchinji District (if p<0.05, there is a significant difference in the observed %) 16 Test for significant difference between males and females in Rumphi District (if p<0.05, there is a significant difference in the observed %) Table 12 Circumcision and HIV knowledge (continued) Mchinji Rumphi Chi- square (p- value) Chi-square 17 FACTOR Females Males Females Males (p-value) 18 TOTAL Removal of the entire 1,664 foreskin19 203 (43.4%) 595 (56.6%) <0.001 251 (54.4%) 615 (58.2%) 0.17 (54.9%) Removal of the Describe what foreskin, but not you think entire foreskin 71 (15.3%) 169 (16.1%) 0.69 73 (15.8%) 194 (18.4%) 0.23 507 (16.7%) male Removal of the penis 13 (2.8%) 34 (3.2%) 0.65 16 (3.5%) 40 (3.8% 0.76 103 (3.4%) circumcision is Other 16 (3.4%) 18 (1.7%) - 5 (1.1%) 22 (2.1% - 61 (2.0%) Don’t know 20 154 (33.1%) 219 (20.8%) <0.001 107 (23.2%) 180 (17.1%) 0.01 660 (21.8%) Refused to answer 8 (1.8%) 17 (1.6%) - 9 (1.9%) 5 (0.5%) - 39 (1.3%) How likely are More likely 72 (15.5%) 183 (17.4%) 0.36 39 (8.5%) 68 (6.4%) 0.16 362 (11.9%) circumcised 2,224 men to get Less likely 330 (71.0%) 685 (65.1%) 0.03 367 (79.6%) 842 (79.7%) 0.95 (73.3%) infected with HIV compared About the same 24 (5.2%) 98 (9.3%) 0.01 22 (4.8%) 78 (7.4%) 0.06 222 (7.3%) to uncircumcised men Don’t know 39 (8.4%) 86 (8.2%) 0.89 33 (7.2%) 68 (6.4%) 0.60 226 (7.5%) Knows health facility where 2,523 someone can be circumcised 380 (81.7%) 891 (84.7%) 0.15 369 (80.0%) 883 (83.6%) 0.10 (83.2%) Knows someone personally who has 1,775 been circumcised 242 (52.0%) 714 (67.9%) <0.001 203 (44.0%) 616 (58.3%) <0.001 (58.5%) Yes 2,083 <0.001 Would you 321 (69.0%) 616 (58.5%) 354 (76.8%) 792 (75.0%) 0.35 (68.7%) recommend No 113 (24.3%) 374 (35.6%) 92 (20.0%) 234 (22.2%) 813 (26.8%) MC to others Neither Yes/ No 31 (6.7%) 62 (5.9%) 15 (3.2%) 30 (2.8% 138 (4.5%) 17 Test for significant difference between males and females in Mchinji District (if p<0.05, there is a significant difference in the observed %) 18 Test for significant difference between males and females in Rumphi District (if p<0.05, there is a significant difference in the observed %) 19 Significantly associated with circumcision status: 54.1% among uncircumcised men vs 88.1% among circumcised men (p<0.001) 20 Significantly associated with circumcision status: 20.8% among uncircumcised men vs 1% among circumcised men (p<0.001) Table 12 Circumcision and HIV knowledge (continued) Mchinji Rumphi Chi- Chi- square square (p- (p- Females Males value)21 Females Males value)22 TOTAL Medical 24 (5.2%) 71 (6.8%) 0.24 22 (4.8%) 64 (6.1%) 0.32 181 (6.0%) To protect against HIV & other STIs 386 (83.0%) 898 (85.4%) 0.24 418 (90.7%) 953 (90.2%) 0.8 2,655 (87.5%) Ethnicity/Religion 62 (13.3%) 147 (14.0%) 0.74 44 (9.5%) 125 (11.8%) 0.19 378 (12.5%) Why do you think Hygiene/Cleanliness 153 (32.9%) 338 (32.1%) 0.77 77 (16.7%) 228 (21.6%) 0.03 796 (26.2%) circumcision is Social Desirability 10 (2.2%) 18 (1.7%) 0.58 8 (1.7%) 33 (3.1%) 0.12 69 (2.3%) carried out Perceived Health Benefits 52 (11.2%) 96 (9.1%) 0.21 30 (6.5%) 74 (7.0%) 0.72 252 (8.3%) Perceived sexual benefits 26 (5.6%) 64 (6.1%) 0.71 20 (4.3%) 48 (4.5%) 0.86 158 (5.2%) Cosmetics 3 (0.7%) 8 (0.8%) 0.81 1 (0.2%) 7 (0.7%) 0.27 19 (0.6%) Socio-economic status 1 (0.2%) 2 (0.2%) 0.92 0 (0%) 13 (1.2%) 0.02 16 (0.5%) Its associated with one’s ethnicity 0 (0%) 5 (0.8%) 0.11 3 (0.8%) 1 (0.1%) 0.05 9 (0.4%) It’s associated with being 16 (5.0%) 21 (3.4%) 0.24 2 (0.6%) 6 (0.8%) 0.72 45 (2.2%) religious Sex sweet for man 18 (5.6%) 57 (9.2%) 0.05 19 (5.4%) 41 (5.2%) 0.89 135 (6.5%) Sex sweet partner 22 (6.8%) 60 (9.7%) 0.14 24 (6.8%) 50 (6.3%) 0.77 156 (7.5%) Reasons for recommending Reduces chance of HIV 300 (93.5%) 557 (90.4%) 0.11 325 (91.8%) 720 (90.9%) 0.62 1,902 (91.3%) MC to others23 Reduces chance of other STIs 214 (66.7%) 423 (68.7%) 0.53 284 (80.2%) 617 (77.9%) 0.38 1,538 (73.8%) Health in general will be better 55 (17.1%) 101 (16.4%) 0.77 47 (13.3%) 115 (14.5%) 0.58 318 (15.3%) It is cleaner 152 (47.3%) 307 (49.8%) 0.47 82 (23.2%) 214 (27.0%) 0.17 755 (36.3%) No need to use a condom 4 (1.2%) 5 (0.8%) 0.52 0 (0%) 1 (0.1%) 0.50 10 (0.5%) Won't be embarrassed at being 2 (0.6%) 6 (1.0%) 0.58 1 (0.3%) 1 (0.1%) 0.56 10 (0.5%) circumcised 21 Test for significant difference between males and females in Mchinji District (if p<0.05, there is a significant difference in the observed %) 22 Test for significant difference between males and females in Rumphi District (if p<0.05, there is a significant difference in the observed %) 23 Other reason mentioned included that MC helps to prevent the partner from getting cervical cancer IMPACT EVALUATION ON IMPROVING VMMC DEMAND IN MALAWI THROUGH THE USE OF INCENTIVE Factors Associated with VMMC Uptake Within both Mchinji and Rumphi after controlling for all covariates, only a few factors were associated with VMMC uptake: (a) An individual who had received a voucher was 7 times more likely to be circumcised than someone who had not received a voucher [OR: 7.32 (3.55, 15.32), P<0.001]. (b) Respondents who had correct knowledge about circumcision were 9 times more likely to be circumcised compared to those who had incorrect knowledge [OR: 9.20 (2.41, 35.11), P<0.001]. (c) Respondents who had received circumcision information from the TV [OR: 2.19 (1.03, 4.68), P=0.04], were more likely to be circumcised than those not exposed to TV. (d) Respondents from Ngoni ethnic group [OR: 0.20 (0.05, 0.80) P=0.02] were less likely to be circumcised than respondents from Tumbuka ethnic group (Table 13). After controlling for all covariates in Mchinji, those who had seen the vouchers before were more likely to get circumcised [OR 2.28 (1.31, 3.96), p=0.003]. Those with a secondary education and above were more likely to consider getting circumcised in the future [OR 2.21 (1.06, 4.62), p=0.04] compared to those who were not currently in a school. It was also interesting to note that those who lived 10-20km from the hospital were more likely to get circumcised than those who lived within 10km from the district hospital [OR 2.49 (1.37, 4.52), p=0.003]. This result is surprising because the intervention was targeted just within 10km of the district hospital, but this result shows that there was a positive impact of spill-over from the intervention which will be covered in one of the subsequent secondary research questions. A similar result to Mchinji was obtained for Rumphi district, except that exposure to vouchers did not make an impact in influencing someone to get circumcised. This is also reflected in the number of vouchers disseminated and redeemed (see Tables 4,5, 6 and 7) and the age band of circumcised participants. Intention to get circumcised was less likely for someone who lived in an urban area compared to someone who lived in a rural area [OR: 0.67 (0.47, 0.93), p=0.02]. Those who lived 10- 20km from the district hospital were more likely to be circumcised than those who lived within 10km from the district hospital [OR: 1.81 (1.30, 2.54), p=0.001]. Also one was more likely to express and interest to get circumcised if they had received information about circumcision from a person who was circumcised [OR: 1.66 (1.15, 2.40), p=0.01], from mobile campaigns [OR: 1.79 (1.29, 2.49), p=0.001] or knew someone who had been circumcised [OR: 1.63 (1.11, 2.40, p=0.01)]. 34 Table 13 Factors associated with VMMC uptake among men in Mchinji and Rumphi districts Factors Circumcised Men OR (95% CI) p-value aOR (95% CI) p-value Were you given some No 16.9% (38/225) 1 - 1 - vouchers yourself Yes 62.5% (60/96) 8.20 (4.78, 14.08) <0.001 7.32 (3.55, 15.12) <0.001 Age (years) 10 - 17 7.2% (63/875) 1 - 1 - 18 - 34 11.0% (136/1,232) 1.59 (1.17, 2.18) <0.001 1.75 (0.57, 5.33) 0.33 Education Not in school 9.2% (86/938) 1 - 1 - Primary 7.8% (62/799) 0.83 (0.59, 1.17) 0.30 1.14 (0.25, 5.20) 0.87 Secondary & above 13.8% (51/370) 1.58 (1.09, 2.29) 0.01 0.91 (0.30, 2.71) 0.86 Marital Status Not Married 9.8% (146/1,495) 1 - 1 - Married 8.7% (53/612) 0.88 (0.63, 1.21) 0.43 0.45 (0.14, 1.44) 0.18 Locality Rural 7.4% (115/1,556) 1 - 1 - Urban 15.3% (84/551) 2.25 (1.67, 3.04) <0.001 0.84 (0.40, 1.77) 0.65 Employment Status Not employed 9.3% (150/1,621) 1 - 1 - Employed 10.1% (49/486) 1.10 (0.78, 1.54) 0.58 0.57 (0.23, 1.38) 0.21 District Mchinji 11.4% (120/1,052) 1 - 1 - Rumphi 7.5% (79/1,055) 0.63 ( 0.47, 0.85) 0.002 0.32 (0.09, 1.21) 0.09 Distance from Within 10km 12.3% (173/1,406) 1 - 1 - Hospital 10-20km 3.7% (26/701) 0.27 (0.18, 0.42) <0.001 0.89 (0.22, 3.55) 0.87 Knowledge about Incorrect Knowledge24 3.0% (13/437) 1 - 1 - Circumcision Correct Knowledge 14.5% (176/1,210) 5.55 (3.12, 9.86) <0.001 9.20 (2.41, 35.11) <0.001 Ethnic Group Tumbuka 6.6% (56/849) 1 - 1 - Chewa 11.2% (75/671) 1.78 (1.24, 2.56) 0.002 0.67 (0.17, 2.75) 0.58 Ngoni 7.0% (30/431) 1.06 (0.67, 1.68) 0.81 0.20 (0.05, 0.80) 0.02 Received MC No 5.9% (79/1,338) 1 - 1 - information from TV Yes 15.5% (119/766) 2.93 (2.17, 3.95) <0.001 2.19 (1.03, 4.68) 0.04 Reasons for not getting circumcised The main reasons for not getting circumcised were fear of pain (43%) and injury that could be experienced during circumcision (36%) Significantly more people who lived within 10km from Mchinji district hospital mentioned fear of pain (50%) compared to those who lived 10-20km (43%) from Mchinji district hospital (P=0.04). Some participants in FGDs held the perception that circumcision was associated with Islam and others were worried they would be inadvertently converted to Islam due to circumcision. 55% of respondents highlighted that losing time from school would be a significant problem for them if they decided to get circumcised. Other barriers to circumcision mentioned included abstaining for too long after circumcision (8%). (Circumcised men are required to abstain from sex for six weeks 24 Removal of the foreskin but not the entire foreskin or removal of the penis IMPACT EVALUATION ON IMPROVING VMMC DEMAND IN MALAWI THROUGH THE USE OF INCENTIVES post circumcision) or that their parents/ other relatives did not want them to be circumcised). A large number of respondents (32%) mentioned various other reasons as the main reason why they were not circumcised. Some of these reasons included fear of death, fear of becoming barren, long healing process, lack of time/ opportunity costs to go for circumcision and lack of correct knowledge about circumcision and its benefits. 8.2 Secondary Research Question: Does a school-based VMMC demand generation strategy have relevant spill- over effects that increase VMMC uptake in the school- boys' households (brothers and parents)? In the context of this research, the first kind of spillover – which was encouraged and promoted in that participants who received the vouchers, were asked to also give their friends and family (the voucher booklet contained specific vouchers, in a different colour, for friends/family and caregivers of friends/family) – was to encourage voucher distribution through a person’s local social network. Two sources of data were available to determine the extent to which these ‘friends’ vouchers were distributed and used: (a) the voucher distribution and redemption rates from intervention implementation database; and (b) information about the source of the voucher, also from the intervention implementation database. The second kind of spillover involves knowledge about and use of vouchers by persons who were not in the intended 0 – 10 km radius of the district hospital. Because the endline survey also collected data from persons in the 10-20 km area, spillover into this expanded geographic area could also be measured. First, according to the voucher distribution and redemption data and because of the booklet design, the same amount of vouchers for friends and family were distributed as vouchers for a VMMC procedure. Of these, the median ratio between the redemption of vouchers for the person to get circumcised (and their guardian) and redemption of vouchers for their friends/family to get circumcised was 1.87 – see Table 14. That said, from Tables 6 and 7, it is clear that the voucher redemption rate for friends/family vouchers were in the 30% range, thus showing that these vouchers were redeemed and used. This is corroborated by endline survey data: according to the endline survey data, about 31% of the total number of endline survey respondents who had obtained vouchers had given the vouchers to their relative or parents or brothers. Within 10km of the Mchinji district hospital 25% of respondents gave vouchers to their brothers compared to 36% in Rumphi. Within 10km of the Mchinji district hospital 25% of respondents gave a vouchers to uncles or parents compared to 0% in Rumphi. 36 Using the participants’ own social networks had the result of expanding the reach of the intervention by approximately 31% without increasing distribution costs or other costs to the intervention, per se. Table 14 Ratio of VMMC procedure vouchers redeemed, compared to‘friends’ and ‘guardians of friends’ vouchers in Mchinji and Rumphi districts Rumphi Mchinji Ratio - SB Ratio - MG Ratio - Ratio - SB Ratio - MG Ratio - vouchers vouchers overall vouchers vouchers overall Voucher for VMMC Procedure 1.92 1.75 1.80 1.86 2.11 1.97 Voucher for Guardian of VMMC client for 1.99 1.60 1.72 1.82 1.95 1.88 VMMC Procedure Follow-up voucher for VMMC client 1.83 1.65 1.71 2.16 1.89 2.03 Follow-up voucher for caregiver of VMMC 2.20 1.68 1.82 2.01 1.78 1.90 client Second, according to the information about the source of the voucher (which was recorded of all participants who redeemed the vouchers), there were two types of onward distribution of the vouchers (‘social spillover’ from the participant to other persons to whom the vouchers were not directly given). (a) The first kind of spillover was as intended in the intervention design – ‘social network spillover’: persons who received the voucher booklets, tore out the maroon, dark blue, gray and maroon vouchers intended for friends/family and their caregivers (vouchers for the VMMC procedure and follow up) and gave it to friends/family, as they were requested to do when they received the vouchers. Tables 6 and 7 quantifies the extent to which vouchers intended for the friends / family of the primary recipient of the incentives voucher booklet (vouchers 5 – 8), were distributed to them, and suggests that the vouchers intended for those in the social network of the primary booklet recipient, were redeemeded at a rate approximately half that of the redemption of vouchers for primary booklet recipients. (b) The second kind of spillover was unintended and unplanned for and involved wholesale distribution of the entire voucher booklet itself to other persons. Table 15 documents the extent to which this occurred. The data in Table 15 originates from the intervention implementation database. Specifically, when a voucher was redeemed, the person redeeming it was asked where they received the vouchers from. If only the social network spillover effects described in (a) took place, then voucher types 1 to 4 would have all been received from head teachers and mothers’ groups and voucher types 5 to 8 would have been received from friends. However, in a small number of cases, voucher types 1 to 4 were documented to have been received from friends, suggesting that wholesale ‘secondary’ distribution of the booklet itself to the primary booklet recipient’s friends / family, took place. Although not intended, this is further evidence of the positive spillover IMPACT EVALUATION ON IMPROVING VMMC DEMAND IN MALAWI THROUGH THE USE OF INCENTIVES and ‘secondary distribution’ effects of these booklets, which ultimately reduces the distribution costs within a network. Table 15 Source of Vouchers for those who Redeemed Vouchers, in Mchinji and Rumphi Rumphi: Voucher received from…. Mchinji: Voucher received from…. Head Mothers’ Mothers’ Voucher Type Teacher Group Friend TOTAL Head Teacher Group Friend TOTAL 1. Voucher for VMMC Procedure 201 349 2 552 478 410 11 899 2. Guardian of VMMC client for VMMC 196 352 1 549 456 363 19 838 Procedure 3. Student follow up Voucher for 1st and 361 653 2 1016 798 647 14 1459 2nd follow-up visits 4. Guardian of student follow up Voucher for 1st and 2nd follow-up 349 719 3 1071 737 613 33 1383 visits 5. Friends of Student Voucher for 9 23 274 306 10 8 439 457 VMMC Procedure 6. Guardians of friends Student Voucher 6 13 300 319 15 8 423 446 for VMMC Procedure 7. Friends of Student follow up Voucher 17 13 564 594 15 13 692 720 for 1st and 2nd follow-up visits 8. Guardians of Friends of Student follow up Voucher for 1st and 2nd 8 7 573 588 20 18 690 728 follow-up visits Total 1147 2129 1719 4995 2529 2080 2321 6930 Third, according to the endline survey data, there was some evidence, albeith limited, of spillover of knowledge about the vouchers in the non-intervention area (areas outside the 0- 10 km radius). Most participants (>60%) who lived within 2 km from the district hospital in both Rumphi and Mchinji had heard of the vouchers (Table 16). However, as participants lived further from the district hospital, fewer had heard about the vouchers. Within the 10km of the district hospital the largest drop-off of having heard about the vouchers occurred between 9 and 10km for Mchinji and for Rumphi. There was, however, a clear pattern regarding access to and use of vouchers dramatically dropping after the 10km radius ‘cut-off’ point. In both Rumphi and Mchinji there was a steep drop-off between those who have heard versus those who have seen the vouchers (Table 16). There was a difference of 17% (174/1,020) between those who had heard of the vouchers versus those who had seen the vouchers in Mchinji. There was even a larger difference seen in Rumphi of 28% (147/528). Again those closest to the district hospital were more likely to have seen the vouchers in both districts. Many of the individuals who were living within 4km of the district hospital were both given (71%]) and used (84%) the vouchers in Mchinji (Table 17). Similarly in Rumphi, the majority of the individuals who were living within 4km of the district hospital were both given (75%) and used (66%) the vouchers. Two individuals who lived more than 10km from 38 the district hospital used the vouchers to get circumcised in Mchinji, while no one outside of 10km in Rumphi used the vouchers to get circumcised. Table 16 Heard of and seen vouchers by distance from district hospital, in Rumphi and Mchinji Distance from Heard of vouchers - Heard of vouchers - Seen vouchers - Seen vouchers - District Hospital Mchinji Rumphi Mchinji Rumphi 0-2km 66% (128/194) 70% (245/352) 40% (79/199) 27% (96/352) 2-4km 60% (94/156) 51% (23/45) 23% (37/161) 13% (6/45) 4-6km 51% (32/63) 84% (26/31) 23% (16/70) 19% (6/31) 6-8km 43% (43/99) 58% (66/114) 9% (9/102) 9% (10/114) 8-10km 44% (58/131) 50% (64/129) 13% (17/133) 10% (13/129) 10-12km 34% (31/91) 41% (34/82) 6% (6/93) 7% (6/82) 12-14km 20% (8/41) 34% (31/92) 5% (2/41) 5% (5/94) 14-16km 29% (20/68) 25% (18/71) 1% (1/69) 4% (3/73) 16-18km 33% (33/100) 22% (11/49) 5% (5/104) 0% (0/49) 18-20km 22% (13/59) 11% (7/63) 2% (1/62) 2% (1/64) 20-22km 29% (2/7) 6% (1/17) 0% (0/7) 0% (0/18) >22km 64% (7/11) 50% (2/4) 9% (1/11) 25% (1/4) Table 17 Persons given vouchers by distance from district hospital, in Rumphi and Mchinji Distance from District Given vouchers - Given vouchers - Used vouchers - Used vouchers - Hospital Mchinji Rumphi Mchinji Rumphi 0-2km 13% (26/199) 8% (28/352) 8% (15/199) 5%(17/352) 2-4km 7% (11/161) 11% (5/45) 4% (6/161) 4% (2/45) 4-6km 3% (2/70) 6% (2/31) 1% (1/70) 6% (2/31) 6-8km 3% (3/102) 1% (1/114) 1% (1/102) 1% (1/114) 8-10km 2% (2/133) 5% (6/129) 0% (0/133) 4% (5/129) 10-12km 3% (3/93) 0% (0/82) 0% (0/93) 0% (0/82) 12-14km 0% (0/41) 2% (2/94) 0% (0/41) 2% (2/94) 14-16km 1% (1/69) 0% (0/73) 0% (0/69) 0% (0/73) 16-18km 2% (2/104) 0% (0/49) 1% (1/104) 0% (0/49) 18-20km 2% (1/62) 0% (0/64) 2% (1/62) 0% (0/64) 20-22km 0% (0/7) 0% (0/18) 0% (0/7) 0% (0/18) >22km 9% (1/11) 0% (0/4) 0% (0/11) 0% (0/4) IMPACT EVALUATION ON IMPROVING VMMC DEMAND IN MALAWI THROUGH THE USE OF INCENTIVES 8.3 Secondary Research Questions: Effect of intervention on women, and women on VMMC rates 8.3.1 Attitudes towards VMMC among young women The impact evaluation was not able to explicitly answer if the attitudes of young women were changed by the intervention itself, but the endline survey was able to demonstrate some of the commonly-held beliefs, and the level of VMMC knowledge among males and females at the end of the impact evaluation. There were mixed beliefs about whether circumcised men or partners of circumcised men would have more or less sexual pleasure than uncircumcised men. Significantly more women (40% in Mchinji and 46% in Rumphi) than men (32% in Mchinji and 36% in Rumphi) did not know whether sexual pleasure increased or decreased due to circumcision in both districts (P<0.001). Significantly more men (36%) than women (31%) in Mchinji believed that partners of circumcised men would get more sexual pleasure than partners of uncircumcised men (P=0.03), while significantly more men (32%) than women (24%) in Rumphi district felt the sexual pleasure for partners would be the same after circumcision. Significantly more women (46%) than men (35%) in Rumphi did not know the effect of circumcision on sexual pleasure for partners (P<0.001). Almost half (48%) of the respondents believed that circumcised men would have about the same number of sexual partners. This result was significantly higher among men (48%) than women (40%) in Mchinji district (P=0.002). Most people had faith in the medical sector, as 89% (98% circumcised vs. 88% uncircumcised men) believed that the circumcision procedure was safe when carried out by a medical practitioner. Sixty two percent expressed the desire to have all men circumcised in their districts, significantly more among women (72% in Mchinji and 62% in Rumphi) than men (66% in Mchinji and 54% in Rumphi) in both locations (P=0.03 in Mchinji and P=0.003 in Rumphi). About 76% believed that the likelihood of getting HIV if circumcised would be reduced, while a worrisome 8% thought the likelihood of getting HIV if circumcised would increase. There was a significantly higher proportion (48%) of all respondents in both districts who did not know what male circumcision was. Significantly more women than men did not know what male circumcision was ((Mchinji (Women (57%) vs. men (43%), P<0.001) and Rumphi (Women (46%) vs. men (42%), P=0.01)). In comparison to the baseline results among 10-24 year old males, there was an increase in the knowledge of circumcision from baseline. 52% of male respondents at baseline did not accurately describe or know what male circumcision was compared to 43% of respondents at endline, P<0.001. There was a significant increase in female 40 knowledge of male circumcision. 61% of female respondents at baseline did not accurately describe or know what male circumcision was compared to 52% of respondents at endline, P<0.001. 8.3.2 Effectiveness of Women Motivating Young Men to Seek VMMC Survey data and qualitative data suggest that women are effective in motivating young men to seek VMMC. According to qualitative findings, some of the contributing factors to mothers’ groups’ effectiveness were (i) training and orientation, (ii) outreach and (iii) trust. Training and Orientation. Mothers’ Groups mentioned that they enjoyed the training they received, and indicated they felt well prepared to pass their knowledge on to people in the community. Their initial level of knowledge had been low and their perceptions of VMMC, negative. After training, their thinking and attitudes evolved from resistance to acceptance of VMMC. Women indicated they would like even more training, as it was not completely clear why the study was designed to have males not receive the vouchers (e.g., what is the purpose of the control arm of the impact evaluation) and what was the benefit of such a design. However, training and orientation allowed women to better understand the health benefits of VMMC and provided women with the tools to counter rumours about why vouchers were being provided. The women of the Chapanama Mothers’ Group were aggressive in countering rumours that foreskins were sold. Similarly, in Ng’onga, women countered rumours that VMMC and the intervention getting were linked to Islam and emphatically insisted that in no way did getting circumcised mean that one had unwittingly converted to another religion. Overall, women who participated in the intervention felt that their role in the intervention helped start a positive chain reaction towards greater uptake of VMMC and they enjoyed educating others. Reach. While the target audience for Mothers’ Groups was out-of-school males, vouchers from Mothers’ Groups were also distributed to in-school males. In Bumba, women noted that they were freely giving vouchers to students: “if “that person is willing can we refuse him? And we were giving them the vouchers.” They also pointed out that sometimes voucher seekers “were pretending to be school leavers, and you don’t know if he is a school leaver or student can you deny him?” While the intention of the impact evaluation was to not have Mothers’ Groups providing vouchers to in- school males, this likely did allow for a more robust uptake of VMMC. Trust. Women were effective facilitators of the intervention because it was seen that they were able to provide more personal attention to males. Initially, those women who travelled to villages at the beginning of the campaign and sensitized community members were viewed with suspicion. However, as the impact evaluation progressed having Mothers’ Groups passed out vouchers allowed for boys who were ashamed to get vouchers from head teachers to get them from another source. A head teacher IMPACT EVALUATION ON IMPROVING VMMC DEMAND IN MALAWI THROUGH THE USE OF INCENTIVES corroborated this perception saying that parents were more comfortable approaching a woman from the Mothers’ Groups than the head teacher. Even after the impact evaluation ended, women continued to encourage youths to go for VMMC. While many individuals did not go for VMMC after the end of the impact evaluation because of economic and other social reasons, their encouragement continued a more positive outlook on VMMC in the communities. 8.4 Secondary Research Questions: Do school heads recruit more males for VMMC than do the Mothers’ Groups, or vice versa? Overall, VMMC uptake due to Mothers’ Groups vouchers was higher than school heads in both districts, but there were temporal differences. Data in Tables 6 and 7 show these differences. In Mchinji, 51% (5,856/11,460) of total vouchers were distributed by MGs to potential VMMC clients, and 47% (421/899) of the total VMMC procedures in the district was as a result of a booklet given to a MG for distribution. In Rumphi, a similar pattern emerged: only 51% (10,044/19,530) of total vouchers were distributed to MGs for further distribution, and 63% (349/552) of redeemed vouchers came from a booklet given to a MG for distribution. In Mchinji, for every kind of voucher, the voucher redemption rate for MG-distributed vouchers was between 1.1 and 2.8 times higher than the voucher redemption rate for vouchers distributed by head teachers. In Rumphi, the voucher redemption rate for MG-distributed vouchers was between 1.6 and 3.2 times higher than VMMC uptake due to head teachers across three months of the impact evaluation (January, February and March 2016). Figure 2 VMMC uptake in Mchinji as a result of intervention School based voucher Mother groups voucher No voucher 600 492 500 400 336 300 205 196 200 86 100 37 7 2 8 1 3 0 0 Dec 21st-31st Jan Feb Mar (1st-8th) Note to Figure 6: In Mchinji, the NAC dispensed all funds by the end of Feb 2016, so few circumcisions in return for voucher redemption took place after that. 42 Figure 3 VMMC uptake in Rumphi as a result of intervention School Based voucher Mother groups voucher No voucher 600 500 400 300 250 198 200 143 100 29 17 43 35 47 56 40 6 0 1 1 0 0 Dec 21st-31st Jan Feb Mar April 8.5 Secondary Research Question: What is the role of young men’s informal social networks (peers, family and guardians) in increasing VMMC uptake? The attitudes and beliefs held about VMMC are affected by the social influence from peers, parents and other community members. Conversations held during FGDs showed the degree to which young men talk about VMMC and the vouchers. 8.5.1 The Role of Peers The most direct positive influence that young males had on each other was encouragement. Throughout the FGDs there were twenty-one mentions of positive encouragement to go for VMMC. A mother in Mlongoti said that her son, who was circumcised through the intervention, “is campaigning for others to get circumcised.” Inversely, according to the FGDs, negative accounts or discouragement from peers are still important barriers to VMMC. Some young men felt that some of the negative accounts omitted key details in order to paint a darker picture or were expressly crafted to discourage peers from going for VMMC. One of the two rumours was that foreskins were sold. Another rumour was that Boko Haram had an association with acquiring foreskins from the impact evaluation. The FGDs suggested that these rumours were present in Mchinji and Rumphi. During the FGDs, one young man in Mchinji and one young man in Rumphi mentioned that their peers ostracized them after they had undergone VMMC. 8.5.2 The Role of Family Another component of a young man’s informal social network is his family. Because of the vouchers given to guardians (parents), parents generally had a sound IMPACT EVALUATION ON IMPROVING VMMC DEMAND IN MALAWI THROUGH THE USE OF INCENTIVES understanding of VMMC and its benefits, though for cultural reasons they tended to view VMMC with reservations. One of their main concerns was young men were undergoing VMMC for the wrong reasons. The FGDs suggested that fathers were generally identified as the one in the family who decided whether sons should go for VMMC. Mothers were generally more resistant to the notion of VMMC than fathers, but not exclusively. A sense of detachment and resignation about VMMC and the activities of their sons came through in some of the FGDs, while in others, women emphatically expressed their opposition to VMMC. Six key informants (all from Rumphi) emphasized how culturally sensitive the issue of circumcision is among the Tumbuka, in particular, because matters of an intimate nature are simply not discussed among family members. Additionally, parents in Chikalamba expressed discomfort with the campaign because they found the material too graphic for children. As one key informant explained, “it would have been better if this thing should be done in a confidential way, they should not mix children and adults, this is supposed to be a confidential matter but it was spoken publicly, so this really made us uncomfortable and it was the reason why some adults were not participating or asking any questions.” 8.5.3 The Role of Guardians Guardians were involved throughout the VMMC uptake process. Guardians often were family members such as parents, older brothers, uncles or a trusted family friend (as intended by the program design). The redemption rate of guardian vouchers was closely matched to that of the persons who they were accompanying. This is appropriate, given that at least 61% of VMMC clients who redeemed vouchers (see Table 5) were younger than 18 and needed adult accompaniment for medical procedures to be performed. Voucher redemption data from Tables 6 and 7, summarised in Table 18 overleaf, suggest that in Mchinji, guardian vouchers were redeemed almost in the same quantities than VMMC client vouchers and that in Rumphi, more guardian vouchers than VMMC client vouchers were redeemed. Table 18 Number of Vouchers Redeemed by VMMC Clients compared to Nuimber of Vouchers Redeemed by Guardians of VMMC Clients, in Rumphi and Mchinji Rumphi Mchinji Participant Guardian Difference Participant Guardian Difference Vouchers for VMMC 10 more guardians 72 more participants 858 868 1356 1284 procedure itself than participants than guardians Vouchers for 2 follow-up 49 more guardians 68 more participants 1,610 1,659 2179 2111 visits per VMMC procedure than participants than guardians 44 There were some intervention implementation concerns concerning the redemption of guardian vouchers. First, fact that in Rumphi, more guardian vouchers than VMMC client vouchers were redeemed, suggests that either some guardians who did not accompany any person, redeemed a voucher or that a VMMC client had more than one guardian – neither of which was allowed according to the intervention roll-out manual. Also, in one of the FGDs, there were some reported cases in which VMMC clients were accompanied by older guardians who took the VMMC client’s voucher money (this is not necessarily a problem since these clients were under 18 and the guardians could legitimately have decided to use the money for transport or other household items). Then, in one other FGD, there was a concern that persons ‘posed’ as guardians so as to enable under-18 participants to undertake the procedure. Parents in Chibwana village, for example, described how young men who were not known by the boys seeking VMMC, became their ‘guardians’: “when you go to the hospital there were some youths aged twenty something years old that they were not for the male medical circumcision. When they see a boy without a guardian they were calling him. ‘Come here, who is with you?’ so when he say ‘I am alone’ they said ‘I will be your parents don’t worry, understood?’ so the boy accepted it. […] So instead of giving some money to the boy, he did what, he took the whole money to himself.” 9 CONCLUSIONS It is possible to increase demand for circumcision using incentives and effective communications program accompanying it. This impact evaluation demonstrated that incentives were able to have a significant impact on driving the demand for VMMC among males aged 15-34 years. Before and after the impact evaluation male circumcision within Rumphi and Mchinji was close to 0.5 male circumcisions per 1,000 adult males per month. During the course of the intervention this rate increased to peaks of 5.62 and 5.29 male circumcisions per 1,000 adult males per month in Rumphi and Mchinji respectively. The impact evaluation led to an additional 16.05 male circumcisions per 1,000 adult males in Rumphi, and an additional 9.15 male circumcisions per 1,000 adult males in Mchinji. This evaluation also proves effectiveness of using community groups and structures in mobilizing clients as well as distribution of incentives. Significant VMMC uptake was due to the efforts of both Mothers’ Groups and head teachers. Main success factors for generating such large demand for VMMC included strong planned orientations to district leaders and providers, schools, and school-linked Mothers’ Groups. Mothers’ Groups proved to be particularly effective with meaningful community outreach and by establishing trust in the communities and among young males, thereby producing societal benefits ranging from increasing VMMC knowledge for both males and females, to refocusing social networks on the IMPACT EVALUATION ON IMPROVING VMMC DEMAND IN MALAWI THROUGH THE USE OF INCENTIVES benefits of VMMC. Additionally, vouchers increased demand for VMMC by providing enough of an incentive to reduce the financial burden of going to a district hospital for VMMC. The impact evaluation was able to address concerns about male circumcision through improved communication messages. Communication from Mothers’ Groups and head teachers were clear and constructive to building VMMC demand. Messages were positively reinforced within the communities even as cultures within these districts were not receptive to VMMC in the past. There was significant uptake of VMMC within Rumphi and Mchinji, and there were both social and cultural benefits that came from the impact evaluation. Communities were more receptive to VMMC, and previous rumours and negative attitudes about VMMC were largely overcome. That said, there are still some knowledge gaps that were not completely filled by the impact evaluation, but those living within these two districts have made VMMC knowledge gains (e.g., know what VMMC is and what the benefits of VMMC are). Building on this momentum will be an effective way forward for the MoH’s messaging campaigns. However, it also revealed a need for continuity in communication and messaging at the community level. Just like any other new intervention being rolled out, there were some implementation challenges, which the team had to overcome and accommodate. (a) The intervention that was planned differed from the intervention that was implemented. This was due in great part to challenging operational and procurement issues which can surface when implementing an impact evaluation in a real-life situation. This challenge could be mitigated in the future with additional field supervision and by working closely with communities and the MoH to create better formulated and more focused messaging. (b) There were some miscommunications and some confusion around messages related to the voucher redemption process. Proper training and messaging throughout the course of an intervention needs to be consistent and continuous. (c) The redemption of guardian incenitves, in the case of person 18 and older, need to be considered and better implementation checks are needed to ensure that vouchers are only redeemed to those who qualify. Also, how some guardians acted during the VMMC uptake process will need to be taken into account and additional safeguards should be put in place to make sure under-18 participants are getting the support they need from their guardians. (d) In light of some logistical challenges observed, it is recommended that further considerations be made to understand the capacity to which the administration of a voucher scheme can be feasible across districts in Malawi. Regardless of the challenges, the goal of the evaluation was achieved and significant demand for VMMC was generated. Provided that implementation challenges are discussed and can be overcome, the expansion of the intervention to other districts and as a national programme should be considered. This impact evaluation has amply demonstrated the significant role of vouchers in VMMC demand creation resulting in remarkable VMMC uptake.Given the sizable effects of 46 the vouchers in generating VMMC demand as demonstrated by this impact evaluation, the GOM may wish to consider a voucher-type mechanism as one robust way to reach the national VMMC targets. To support this decision, as a next step to determine the benefits of implementing a voucher mechanism in Malawi, it would be appropriate to conduct a cost- benefit analysis. A cost-benefit analysis determines the costs and the health effects attributable to providing vouchers to generate VMMC demand. This analysis should estimate both the marginal cost per additional VMMC procedure over the course of the intervention implementation period, and then calculate the ratio of the marginal benefits generated by the increase in VMMC procedures because of the intervention. This analysis would provide critical data to support national decision-makers as they consider if the use of vouchers is a fiscally feasible approach in the current context of Malawi, and whether they provide enough benefits to overcome the costs. 10 REFERENCES 1. Abadie A, Diamond A, and Hainmueller J. Synthetic Control Methods for Comparative Case Studies: Estimating the Effect of California’s Tobacco Control Program. Journal of the American Statistical Association, Vol 105 , ISS. 490. (2010) 2. Auvert B et al. Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: the ANRS 1265 trial. PLoS Med, 2:e298. (2005) 3. Bailey RC et al. Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomized controlled trial. Lancet, 369:643–656. (2007) 4. Bailey RC et al. The protective effect of male circumcision is sustained for at least 42 months: results from the Kisumu, Kenya Trial [THAC0501]; Presented at: XVII International AIDS Conference; Mexico City, Mexico. August 3–8, 2008. 5. Gray RH et al. Male circumcision for HIV prevention in men in Rakai, Uganda: a randomized trial. Lancet, 369:657–666. (2007) 6. Government of Malawi. National AIDS Commission (NAC). Malawi National HIV Prevention Strategy, 2015-2020. Lilongwe, Malawi: National AIDS Commission (2014). 7. Kripke, K. et al. (2016). Voluntary medical male circumcision for HIV prevention in Malawi: Modeling the impact and cost of focusing the program by client age and geography. PLoS One, 11(7), e0156521. 8. Mills et al. Male circumcision for the prevention of heterosexually acquired HIV infection: a meta- analysis of randomized trials involving 11 050 men. HIV Medicine, 9: 332–335 (2008) 9. National Statistical Office (NSO) and ICF Macro. Malawi Demographic and Health Survey 2010. Zomba, Malawi, and Calverton, Maryland, USA: National Statistical Office and ICF Macro (2011) 10. National Statistical Office (NSO) and ICF Macro. Malawi Demographic and Health Survey (Key Indicators Report) 2015-2016. Zomba, Malawi, and Calverton, Maryland, USA: National Statistical Office and ICF Macro (2016) 11. Study Protocol Document: Prospective Impact Evaluation of Incentivized VMMC Demand- Generation Strategies for Younger Men in Malawi (2015) 12. WHO/UNAIDS, Joint Strategic Action Framework to Accelerate the Scale-Up of Voluntary Medical Male Circumcision for HIV Prevention in Eastern and Southern Africa. Geneva. (2011) 13. Joint United Nations Program on HIV/AIDS (UNAIDS). (2015) Malawi: May 2014 HIV estimates 14. National AIDS Commission. (2014) National HIV Prevention Strategy 2015-2020 15. National AIDS Commission. (2015) Malawi AIDS Response Progress Report 16. PEPFAR. (2016) Malawi Operational Plan CO16: Strategic Direction Summary 48 ANNEXURE ANNEXURES Annexure I: Vouchers Impact Evaluation on improving voluntary medical male circumcision demand in Malawi through the use of incentives Vouchers This evaluation asked: Do incentives significantly increase voluntary medical male circumcision (VMMC) uptake among in-school and out-of-school boys and young men aged 10 to 34 in Malawi? The hypothesis was that incentives would have a higher likelihood of influencing a male’s decision to be circumcised, than providing information about VMMC only. The incentive of choice was individual vouchers to be used for transportation to and from the hospital for the procedure and two follow up visits. The value of each voucher, based on a round trip within a 10 km radius from the district hospital, was estimated at 2000 Kwacha each, received ony after the procedure was conducted. Each male received one booklet of 3 vouchers for himself and another booklet of 3 vouchers for the parent or guardian, if a minor. The underlying principle of the voucher scheme was that circumcision uptake should not entail additional costs for the interested males. The vouchers were designed, distributed and redeemed in a purposeful and systematic manner to faciliate verification and ensure accountability. (See illustrative graphic of a voucher below) IMPACT EVALUATION ON IMPROVING VMMC DEMAND IN MALAWI THROUGH THE USE OF INCENTIVES Characteristics of Vouchers. Vouchers were designed with a unique serial number to allow for tracking the vouchers from the printer through redemption at the two district hospitals, making it possible to associate the client with his guardian/parent (as needed). The vouchers were also color coded in order to distinguish between vouchers distributed by school heads of the intervention schools and those distributed by Mothers’ Groups; as well as between vouchers redeemed by males undergoing VMMC and vouchers of their guardians. The process of distribution and redemption of vouchers followed the study operational procedures from the design and printing stage to their distribution to males, through schools heads and Mothers’ Groups, to their collection once they were redeemed for money, after the VMMC procedure. Following school-based information and motivational sessions, the same amount of vouchers were given to schools heads and Mothers’ Group at each school. The guidance provided to males encouraged them to take a bike taxi from their residence to the hospital and back at a negotiated (by them) charge. After the procedure and once the voucher was redeemed for cash by the (study) accountant the client paid the bike taxi driver the agreed amount. The driver then completed the fare taking the male client back to his residence. Thus, the bike taxi driver was expected to wait for the client at the hospital. This approach was deemed appropriate because it discouraged the males to walk back home after the circumcision. This was important for safety and health reasons. Special attention was paid to vouchers verification and accounting. In addition to planned supervisory observations, just-in-time problem solving and random visits contributed to quality control. 50 ANNEXURE The impact analyses confirmed that these incentives, together with the MoH communications campaign on VMMC that included references to the vouchers, did significantly increase VMMC uptake in the 2 study districts of Mchinji and Rumphi. IMPACT EVALUATION ON IMPROVING VMMC DEMAND IN MALAWI THROUGH THE USE OF INCENTIVES Annexure II: Endline Sampling Strategy Random Selection of individuals 10 km from Rumphi District Hospital and 10 km from Mchinji District Hospital Items used for random selection: 1) village boundary maps, 2) spreadsheet with a list of all the villages within 10 km of Rumphi District Hospital and Mchinji District Hospital containing the number of individuals who are 10-34 and their sex within each village, and 3) household listing spreadsheet which contains village, household head, name of the individual, and age of individual. Randomization procedure 1. Using Census data and census growth estimates, the population density was calculated in each village of boys/men aged 10 to 34, and girls/young women aged 10 to 34 within 10 km from the Rumphi District Hospital within the borders of Malawi 2. Using Census data and census growth estimates, the population density was calculated in each village of boys/men aged 10 to 34, and girls/young women aged 10 to 34 within 10 km from the Mchinji District Hospital within the borders of Malawi 3. Villages with a population density of fewer than 50 boys/young men aged 10 to 34, or fewer than 50 girls/young women aged 10 to 34 were dropped 4. 700 boys aged 10 to 34 years were randomly selected from high (>50 boys/young men aged 10 to 34) density villages using baseline generated household listings from both Mchinji and Rumphi (1400 total), and an additional 200 boys were randomly selected from both Mchinji and Rumphi (400 total) to account for any boys who could not be found during data collection 5. 300 girls in Rumphi and Mchinji (600 total) aged 10 to 34 years were randomly selected from the same villages in step 4. Household listings from both Mchinji and Rumphi were used, and an additional 60 girls were randomly selected from both Mchinji and Rumphi (120 total) to account for any girls who could not be found during data collection Random Selection of individuals 10-20 km from Rumphi District Hospital and 10-20 km from Mchinji District Hospital Items to be used for random selection: 1) village boundary maps, and 2) household listing spreadsheet with all the villages and individuals within 10 to 20 km of Rumphi District Hospital and Mchinji District Hospital containing the number of individuals who are 10-34 years old and their sex Randomization procedure 52 ANNEXURE 1. Household listings of all homes within 10 to 20 km of the Mchinji and Rumphi district hospitals were completed before the randomization of participants selected within 10 to 20 km of the Mchinji and Rumphi district hospitals 2. 350 boys aged 10 to 34 years were randomly selected from both Mchinji and Rumphi (700 total) from the household listings with an additional 10 boys selected to account for any boys who were not able to be found during data collection 3. 150 girls aged 10 to 34 years were randomly selected from the same villages in step 4. Household listings from both Mchinji and Rumphi were used, and an additional 30 girls were randomly selected from both Mchinji and Rumphi (60 total) to account for any girls who could not be found during data collection Household selection listing and list of intervention and control schools are shown in Annexure V and VI respectively. IMPACT EVALUATION ON IMPROVING VMMC DEMAND IN MALAWI THROUGH THE USE OF INCENTIVES Annexure III: Data collection tool for VMMC Circumcision Endline Questionnaire -2016 Q0: DATE OF INTERVIEW A1: DISTRICT NAME 1=Rumphi 2=Mchinji A2: TRADITIONAL AUTHORITY NAME: 1=T/A Zulu 2=T/A Chikulamayembe 77= other A3a: VILLAGE NAME A3b: URBAN/RURAL 1=urban 2=Rural A4: ENUMERATOR NAME A6: SEX OF RESPONDENT 1=Male 2=Female A7: NAME OF RESPONDENT A8: ARE YOU ABOVE 18 YEARS OF AGE? 1=Yes-Above 18 2=No-Below 18 INTERVIEWER INSTRUCTION: READ CONSET SRIPTS. [Refer to the paper printed forms] A9: WAS CONSENT GIVEN( FOR THOSE AGED 18 AND ABOVE) 1=Yes 2=No A10: WAS PARENTAL CONSENT GIVEN ( FOR THOSE AGED UNDER 18 YEARS) 1=Yes 2=No INTERVIWER INSTRUCTION: READ ASCENT SRIPTS. [Refer to the paper printed forms] A11: WAS ASCENT GIVEN ( FOR THOSE AGED UNDER 18 YEARS 1=Yes 2=No 54 ANNEXURE Annexure IV: Questionnaire for in-depth interviews Attitudes towards male circumcision Today I’m going to ask you about male circumcision. In Malawi, some people practice traditional circumcision. The male circumcision I’m talking about is different—it is done in health facilities, such as a hospital or a health center or a private clinic--and may be done any time from birth onwards. Many boys and men have become circumcised at a health facility, but many have not. Recently, there was a campaign to encourage Voluntary Male Medical Circumcision in hospitals. The questions I am going to ask you now concerns the VMMC that took place recently in health facilities. ------------------------------------BOYS & GIRLS ------------------------------------ --- SECTION A A1a BOYS. There is a lot of talk these days about male circumcision. Have you heard other men/boys talk about it? A1b GIRLS: There is a lot of talk these days about male circumcision. Have you heard friends or family talk about it? Matsiku anu, anthu ambiri akukambirana zokhuza mdulidwe waabambowu. Kodi inu munayamba mwamvako azibambo kapena anyamata akukambirana zokhuza mdulidwewu? Madazi ghano wanthu wanandi wakudumbilananga za kukhwafyana na kukotoleka. Kasi imwe muli kupulikapo wanyamata panji wazidada wakudumbilanapo za kukhwafyana na za kukotoleka? Yes→2 no→ [Skip to section B] A2a BOYS. If Yes: What did they say about why it is Not a good idea? (If no, skip to next question) Ngati inde: Kodi anati ndi chifukwa chiyani chomwe amati ichi sichinthu chabwino? Usange enya: kasi ntchifukwa uli icho wakuyowoyela kuti kukotoleka nkhuwemi yayi? IMPACT EVALUATION ON IMPROVING VMMC DEMAND IN MALAWI THROUGH THE USE OF INCENTIVES A2b GIRLS. If Yes: What did you hear they say about why it is not a good idea? Interviewer: do not read list, multiple answers possible. Probe for any reasons on the list that he didn’t mention. For example, many will first answer something like “it’s against my ethnicity”, but you should then go on and ask about the other issues. (Select Multiple Response) Ethnicity 1 Religion 2 Pain 3 Fear of injury or impotence 4 Sex isn’t good for the man 5 Sex isn’t good for his partner 6 Their girlfriends/partners prefer uncircumcised men 7 Their mothers/grandmothers/aunts don’t want them to be circumcised 8 Their fathers/grandfathers/uncles don't want them to be circumcised 9 Have to abstain too long afterwards 10 Don’t like going to a health facility 11 Have to get an HIV test, don’t want to know their status 12 Circumcision is not 100%, so why bother 13 Have to use a condom anyway 14 Embarrassment/shame at being circumcised 15 Early Infant Male Medical circumcision 16 Other (specify) 77 A3a BOYS. What did you hear other boys/men say about why circumcision is a good idea? Ndi chiyani chomwe munamva kuchokera kwa anyamata kapena azibambo kunena kuti mdulidwe ndi chinthu chabwino? kasi mukapulika vichi kufumila ku wanyamata/wazidada ivyo wakayowoya vyakuti kukotoleka nkhuwemi? 56 ANNEXURE A3b GIRLS. What did you hear they say about why circumcision is a good idea? Interviewer: As above, multiple answers are possible. After 1st response, probe for the reasons he did not mention. (Select Multiple Response) Ethnicity 1 Religion 2 Sex is sweeter for the man 3 Sex is sweeter for my partner 4 My girlfriend/partner wants me to be circumcised 5 My mother/grandmother/aunt wants me to be circumcised 6 My father/grandfather/uncle wants me to be circumcised 7 Reduces my chances of getting HIV 8 Reduces my chances of getting other diseases like gonorrhea and syphilis 9 My health in general will be better 10 It’s cleaner 11 Don't have to use a condom 12 Embarrassment/shame at being uncircumcised 13 Early Infant Male Medical circumcision 14 Other (specify) 77 ----------------------------------------BOYS ONLY------------------------------- SECTION B Now I’d like to ask you about yourself. Tsopano ndikufunsani mafunso okhudza inuyo. sono nimufumbaninge mafumbo yakukhwafyana na imwe B1. Are you circumcised? Kodi inuyo munapanga mdulidwe? Kasi muli wakukotoleka? Yes→1 No →2 [SKIP B6] IMPACT EVALUATION ON IMPROVING VMMC DEMAND IN MALAWI THROUGH THE USE OF INCENTIVES B2. How old were you when you were circumcised? Munali ndi zaka zingati pamene inu munapangidwa mdulidwe? Kasi mukawa na vyaka vilinga apo mukakotolekanga? Birth – 1 Year old 1 1 Year old 2 2 Years old 3 3 Years old 4 4 Years old 5 5 Years old 6 6 Years old 7 7 Years old 8 8 Years old 9 9 Years old 10 10 Years old 11 11 Years old 12 12 Years old 13 13 Years old 14 14 Years old 15 15 Years old 16 16 Years old 17 17 Years old 18 18 Years old 19 19 Years old 20 20 Years old 21 21 Years old 22 58 ANNEXURE 22 Years old 23 23 Years old 24 24 Years old 25 25 Years old 26 26 Years old 27 27 Years old 28 27 Years old 29 29 Years old 30 30 Years old 31 31 Years old 32 32 Years old 33 33 Years old 34 34 Years old 35 No best age 36 Don’t know 88 B3. In what setting were you circumcised? Kodi inu munapangitsa mdulidwewu kuti? Kasi mukakotoleska kochi? (1) CHAM hospital 1 (2) Government Hospital/Clinic/ 2 (3) Private clinic 3 (4) Traditional village setting 4 (5) Other (specify) 77 IMPACT EVALUATION ON IMPROVING VMMC DEMAND IN MALAWI THROUGH THE USE OF INCENTIVES B4. Why did you decide to get circumcised? Ndichifukwa chiyani munasankha kukapanga mdulidwe? ntchivichi icho chikamupangiskani kuti mukotoleske? Interviewer: do not read list, multiple answers possible; probe for any that weren’t mentioned. (Select Multiple Response) Ethnicity 1 Religion 2 Sex is sweeter for the man 3 Sex is sweeter for my partner 4 My girlfriend/partner wants me to be circumcised 5 My mother/grandmother/aunt wants me to be circumcised 6 My father/grandfather/uncle wants me to be circumcised 7 Reduces my chances of getting HIV 8 Reduces my chances of getting other diseases like gonorrhea and syphilis 9 My health in general will be better r 10 It’s cleaner 11 Don't have to use a condom 12 Embarrassment/shame at being uncircumcised 13 Friends 14 Early Infant Male Medical circumcision 15 Money/Voucher 16 Other (specify) 77 Refused to Answer 99 B5. What is the main reason you decided to get circumcised? Ndi chifukwa chiyani chenicheni chimene chinakupangitsani kukapanga mdulidwe? chifukwa ntchini chomene icho chikamupangiskani kuti mukotoleke? Ethnicity 1 Religion 2 Sex is sweeter for the man 3 60 ANNEXURE Sex is sweeter for my girlfriend/partner 4 My girlfriend/partner encouraged me to get circumcised 5 My mother/grandmother/aunt encouraged me to be circumcised 6 My father/grandfather/uncle encouraged me to be circumcised 7 Reduces my chances of getting HIV 8 Reduces my chances of getting other diseases like gonorrhea and syphilis 9 My health in general will be better 10 It’s cleaner 11 Don't have to use a condom 12 Embarrassment/shame at being uncircumcised 13 Friends 14 Early Infant Male Medical circumcision 15 Money/Voucher 16 Other (specify) 77 Refused 99 Don’t know 88 B6. If No, ask Why did you decide not to get circumcised? Ndichifukwa chiyani chimene chinakupangitsani kuti musasankhe mdulidwe? Usange yayi: Ntchifukwa wuli icho chikamupangiskani kuti muleke kukotoleska? Interviewer: As above, multiple answers are possible. After lst response, probe for the reasons he did not mention. (Select Multiple Response) Ethnicity 1 Religion 2 Pain 3 Fear of injury /impotence 4 Sex wouldn’t be as sweet for me 5 Sex wouldn’t be as sweet for my partner 6 My girlfriend/partner prefers uncircumcised men 7 My mother/grandmother/aunt doesn’t want me be circumcised 8 IMPACT EVALUATION ON IMPROVING VMMC DEMAND IN MALAWI THROUGH THE USE OF INCENTIVES My father/grandfather/uncle doesn’t t want me to be circumcised 9 Have to abstain too long afterwards 10 Don’t like going to a health facility 11 Have to get an HIV test, don’t want to know status 12 Circumcision is not 100%, so why bother 13 Have to use a condom anyway 14 Embarrassment/shame at being circumcised 15 Didn’t receive Voucher 16 No pain killers 17 Other (specify) 77 B7. What was the main reason you decided not to get circumcised? Ndichifukwa chanji chachikulu chimene chinakupangitsani kuti musakapange mdulidwe? ntchifukwa uli chikulu icho chikamupangiskani kuti muleke kukotoleska? Ethnicity 1 Religion 2 Pain 3 Fear of injury /impotence 4 Sex wouldn’t be as sweet for me 5 Sex wouldn’t be as sweet for my partner 6 My girlfriend/partner prefers uncircumcised men 7 My mother/grandmother/aunt doesn’t want me be circumcised 8 My father/grandfather/uncle doesn’t t want me to be circumcised 9 Have to abstain too long afterwards 10 Don’t like going to a health facility 11 Have to get an HIV test, don’t want to know status 12 Circumcision is not 100%, so why bother 13 Have to use a condom anyway 14 Embarrassment/shame at being circumcised 15 62 ANNEXURE Didn’t receive Voucher 16 No pain killers 17 Other (specify) 77 IMPACT EVALUATION ON IMPROVING VMMC DEMAND IN MALAWI THROUGH THE USE OF INCENTIVES -----------------------------------BOYS & GIRLS -------------------------------- B8. Please describe what you think male circumcision is Chonde, ndilongosoloreni mmaganizo anu kuti mdulidwe wa abambo ndi chiyani? Chonde nilongosolerani, mumaghanoghano yinu kuti kasi kukotoleka ntchivichi? Listen to what the respondent says and tick and / or fill in the options below. Do not show or describe the options to the respondent. Removal of the entire foreskin (the skin that can be rolled forward or back over the head of the penis 1 Removal of the foreskin but not necessarily the entire foreskin 2 Removal of the penis 3 Other (specify) 77 Don’t know 88 Refused to answer 99 ------------------------------------BOYS ONLY----------------------------------- SECTION C Once the question has been answered, please explain that: Male circumcision is the surgical removal of the entire foreskin, which is the skin that can be rolled forward or back over the head of the penis. If less than the entire foreskin has been removed, this is not "full" circumcision. Recently people from the district hospital had a campaign to encourage men to go for circumcision in the hospital. There was a truck with a PA system and a football game outside the District hospital. Did you watch the football game? Did you see posters? If yes, did it change your mind about getting circumcised? If no, did you hear about it from someone? Mdulidwe wa abambo ndikudula kachikopa kakutsogolo kwa chida cha abambo. Aka ndi kachikopa kamene kamavindikira chida cha abambo. Ngati kachikopaka sikachotsedwa konse, ndiye kuti Mdulidwe siunathe. Onani pachithunzichi pomwe pakusonyeza mdulidwe wopangika bwinobwino ndi mdulidwe woti siunathe. Kukotoleka kwa wadada nkhukudumula kachipapa ka kunthanzi kwa nkhule ya wadada, aka nkhachipapa kakubenekelera nkhule, usange kachipapa aka kandadumulike kose ndiko kuti kukotoleka kundachitika makola, awonani pachithuzi, apa pakuwoneska kukotoleka kwakuchitika makola ku chipatala, na kukotoleka kwakuti kundamale 64 ANNEXURE IMPACT EVALUATION ON IMPROVING VMMC DEMAND IN MALAWI THROUGH THE USE OF INCENTIVES C1. Now that I have told you what circumcision is, let me ask you again Are you circumcised? Tsopano ndakuwuzani kuti mdulidwe wa abambo ndi chiyani,ndikufunsaninso kachiwiri, Kodi inu munapangitsa mdulidwe Namuphalirani kuti kukotoleka nivichi, Nimufumbaningiso kuti kasi ndimwe wakukotoleka? 1 = Yes 1 2 = No 2 [ Skip to C3] 3 = Don’t know 88 C2. Are you pleased that you are circumcised? Kodi inu ndi wosangalala kuti munapanga mdulidwe? Kasi ndimwe wakukondwa kuti muli kukotoleka? 1 = Strongly No 1 2 = No 2 3 = Neither No or Yes 3 4 = Yes 4 5 = Strongly Yes 5 [Any answer skip to C11] C3. Would you consider being circumcised? Kodi mukhoza kuganizira chisankho chochita mdulidwe? Kasi mungasankha kuti mukakotoleske? Interviewer: Give the interviewee the choice of the following options 1 = Strongly ‘no’ 1 2 = No 2 3 = Neither Yes or No 3 4 = Yes 4 5 = Strongly Yes 5 66 ANNEXURE C4. Would you consider getting circumcised if you get encourage to do so by any of the following?: (Check all that applies) Kodi inu mungalore kuchita mdulidwe m’modzi mwa anthu awa atakulimbikitsani? kasi mungasankha kuti mukotoleske usange mwa wanthu awa: C4a. My parents/grandfather/uncle encouraged me to be circumcised 1 yes 2 no C4b. My mother/grandmother/aunt encouraged me to be circumcised 1 yes 2 no C4c. My wife/partner encouraged me to be circumcised 1 yes 2 no C4d. A traditional leader (TA, GVH or headman) encouraged me to get circumcised 1 yes 2 no C4e. A religious leader encouraged me to get circumcised 1 yes 2 no C4f. The government encouraged me to get circumcised 1 yes 2 no C4g. A doctor/nurse/HSA encouraged me to get circumcised 1 yes 2 no C4h. A teacher encouraged me to get circumcised 1 yes 2 no C4i. Study vouchers motivated me to get circumcised 1 yes 2 no C4j. My Parents encouraged me to be circumcised 1 yes 2 no C5. Would you consider getting circumcised if (Check all that applies): Kodi mungalore kuchita mdulidwe ngati: kasi mungasankha kuti mukotoleke usange: C5a My brothers/cousins get circumcised 1 yes 2 no C5b. My best friend gets circumcised 1 yes 2 no C5c. Most of my friends in the village get circumcised 1 yes 2 no C5d. Most of my friends at school get circumcised 1 yes 2 no IMPACT EVALUATION ON IMPROVING VMMC DEMAND IN MALAWI THROUGH THE USE OF INCENTIVES C5e. A political leader gets circumcised 1 yes 2 no C5f. A pop culture star gets circumcised 1 yes 2 no C5g. I am paid money to get circumcised 1 yes 2 no 68 ANNEXURE C5h. Celebrity 1 yes 2 no C5f. I am given vouchers to get circumcised 1 yes 2 no C6. If you decide to become circumcised, where would you go to be circumcised? Mutati mwapanga chisankho chokapanga mdulidwe waabambo, kodi mungapite kuti kuti mukapange mdulidwe? usange mungakhumba kukotoleska, mungakakotoleskera kochi? CHAM 1 Government hospital 2 Health Center 3 Traditional circumciser 4 Private 5 Other: ________________ 77 [skip to c10] 88 DON’T KNOW [skip to c10] C7. Is this place where you can get circumcised conveniently located? Kodi kumalo amene mungakapangitseko mdulidwe, ali malo abwino kwa inu? Ku malo agho mwazunula, kasi ngakuti mungayafikira kwambula suzgo? Yes 1 No 2 C8. If you decide to become circumcised, what transportation would you use to get a circumcision? Ngati mungapange chisankho chokapangitsa mdulidwe, mungagwiritse ntchito njira yanji ya mayendedwe kukafika ku malo amene kukupangidwe mdulidweko? kasi ni mendelo wuli agho mungagwiliska ntchito usange mungasankha kukotoleska? (Select Multiple Response) (1) Walk 1 (2) your own bicycle 2 (3) bike taxi 3 (4) Minibus 4 IMPACT EVALUATION ON IMPROVING VMMC DEMAND IN MALAWI THROUGH THE USE OF INCENTIVES (5) Taxi 5 (6) your own car 6 (7) Other: 77 C9a. What is the round trip cost of this transportation? INTERVIWER: Include for both trip(Round trip/To and from) Kodi mumalipira ndalama zingati pamayendedwe? Mukulipilanga ndalama zilinga zakwendela? Cost 1 No cost 2 → Skip to C10 C9b. How Much? Ndi ndalama zingati? Makopala ghalinga? 1 0- MK500 2 MK500-MK1000 3 MK1000-MK1500 4 MK1000-MK1500 5 MK2000-MK2500 6 MK2500-MK3000 7 MK3000-MK3500 8 MK3500-MK4000 C10. If you decide to be circumcised, would losing time from school be a significant problem? Ngati mungapange chisankho chosankha mdulidwe, kodi kutaya nthawi yamaphunziro lingakhale vuto kwainu? Usange mungasankha kukotoleska, kasi kutaya nyengo ya kusukulu lingawa suzgo likulu? Yes 1 No 2 70 ANNEXURE -----------------------------------BOYS & GIRLS --------------------------- C11. In your opinion, how likely are circumcised men to get infected with HIV compared to uncircumcised men? Are they …? M’maganizo anu, kodi pali mpata wotani woti amuna amene anapanga mdulidwe atha kutenga kachilombo koyambitsa matenda a edzi (HIV) poyerekeza ndi amene sanapange mdulidwe? Kodi ndi …….? Mumaghanoghano ghinu, kasi pali mpata wuli wakuti wanalume wakukotoleka wangamanya kutola kachibungu kakwambiska matenda gha EDZI mwakuyelezgela na awo wambula kukotoleka? More likely 1 Less likely 2 About the same 3 Don’t know 77 C12 Do you know any health facility where someone can get circumcised? Kodi mukudziwapo chipatala china chilichonse chimene mamuna/mnyamata angakapangitseko mdulidwe? Kasi mukumanyapo chipatala chilichose icho munthu wangakakotolekelako? Yes 1 No 2 C13. Do you know someone personally who has been circumcised? Kodi mukudziwapo munthu wina wake amene anakapangitsako mdulidwe? Kasi mukumanyapo waliyose uyo wali kukotoleska? Yes 1 No 2 [skip to C15] C14. If yes to above questions, what is your relationship to the circumcised person? Ngati inde pa funso lapamwambali, kodi pali ubale wotani ndi munthu amene anadulidwayo? Usange inya: kasi pali ubale wuli na munthu uyo? (Select Multiple Response) Father/grandfather 1 Brother 2 IMPACT EVALUATION ON IMPROVING VMMC DEMAND IN MALAWI THROUGH THE USE OF INCENTIVES Cousin 3 Family friends 4 Personal (best) friend my age 5 Village headman 6 School principal/teacher 7 Other 77 C15. Why do you think male circumcision is carried out? Kodi mukuganiza kuti mdulidwe wa abambo umapangika chifukwa chiyani? kasi mukuyanayana kuti kukotoleka kukuchitika chifukwa cha vichi? Listen to what the respondent says and tick and fill in the options below. Do not show or describe the options to the respondent. (Select Multiple Response) Medical 1 To protect against HIV and other infections such as gonorrhea and syphilis 2 Religion/Ethnicity 3 Hygiene/cleanliness 4 Social desirability 5 Perceived health benefits 6 Perceived sexual benefits 7 Cosmetics 8 Socio-economic status 9 Other specify 77 Don’t know 88 C16. Would you recommend male circumcision to others? Kodi inu mungathandize kupanga chisankho kwa anthu ena kuti akapangitse mdulidwe? 72 ANNEXURE Kasi mungaphalilako wanyinu kuti wakakotoleske? 1 Strongly No 1 2 No 2 3 Neither No or Yes 3 4 Yes 4 5 Strongly Yes 5 C17. If “Neither No or Yes” “Yes”, “Strongly Yes,” : What reasons would you give in your recommendation? Ngati inde, ndi zifukwa ziti zimene mungapereke kuti mzanu apange chisankhochi? nivifukwa uli ivyo mungaphalilako wanyinu kuti wakakotoleske? (Select Multiple Response) Ethnicity 1 Religion 2 Sex is sweeter for the man 3 Sex is sweeter for man’s partner 4 Reduces chances of getting HIV 5 Reduces chances of getting other diseases like gonorrhea and syphilis 6 Health in general will be better 7 It’s cleaner 8 Don't have to use a condom 9 Won’t be embarrassed/mocked at being uncircumcised 10 Other (specify) 77 IMPACT EVALUATION ON IMPROVING VMMC DEMAND IN MALAWI THROUGH THE USE OF INCENTIVES -----------------------------------BOYS & GIRLS -------------------------------- SECTION D Now I’m going to find out about your beliefs about HIV and MC. I want to find out if your ideas about HIV are changing now that MC is being made available in your community. Tsopano ndifuna ndidziwe za maganizo anu pankhani ya HIV ndi Mdulidwe. Ndikufuna ndidziwe ngati maganizo anu pankhani ya HIV akusintha panthawi ino imene achipatala akufikitsa mdulidwe mmadera anu. Sono nkhukhumba nimanye maghanoghano ghinu pa nkhani ya EZI na kukotoleka, nkhukhumba nimanye usange maghanoghano yinu pa nkhani gha HIV yakusintha pa nyengo iyi apo wachipatala wiza na kukotoleka mchigawa chino I will read you some statements. Please respond disagree, unsure, or agree for each statement. There are no right or wrong answers to these statements. We just want to find out what you think. Tsopano ndikuwerengerani ziganizo izi. Chonde ndiuzeni ngati simukugwirizana nazo, simukutsimikidza, kapena mukugwirizana ndi ziganizo zonse. Palibe mayankho olondola kapena olakwika. Tikungofuna tidziwe zimene inuyo mukuganiza. Nimuwelengelaninge viganizo ivi, chonde niphalirani usange mukukolerana navyo, kususka, panji kukayikira. Palije zgolo launenesko panyakhe la utesi? Agree Disagree Unsure 1 2 3 D1. Now that MC is available, condom use during sex is less necessary. Tsopano poti mdulidwe ukupezeka, makondomu panthawi yogonana kufunikira kwake kwachepa. pakuti kukotoleska kulipo, kondomu njakukhumbikwila viwi yayi panyengo ya kugonana D2. Now that MC is available, I am more likely to have more than one sexual partner. Panthawi ino imene mdulidwe ukupezeka, pali mpata waukulu wakuti nditha kukhala ndi anthu ogonana nawo oposera mmodzi. sono pakuti kukotoleska kulipo, nili na mwawi ukulu wakuti ningawa na 74 ANNEXURE Agree Disagree Unsure 1 2 3 wanakazi wakujumpha umoza wakugonana nawo D3. Now that MC is available, HIV is a less serious threat than it used to be. Panthawi ino imene mdulidwe ukupezeka, Kachilombo koyambitsa matend a edzi sichiopsezonso ngati mmene zinalili kale. Pakuti kuli kukotoleska, HIV njakofya chomene yayi ngati umo yikawila D4. Now that MC is available, people do not need to be as concerned about becoming HIV-positive. Panthawi ino imene mdulidwe ukupezeka, anthu sayeneranso kukhuzidwa ndikuli akhala ndi kachilombo koyambitsa matenda a edzi. Sono Pakuti kuli kukotoleska, wanthu wakwenela kukhwafyika viwi chomene yayi na vyakuti wangawa na HIV D5. Now that MC is available, it is more important for people to know their HIV status. Panthawi ino imene mdulidwe ukupezeka, ndikofunika kwambiri kuti anthu adzidziwa ngati ali ndi kachilombo koyambitsa matenda a edzi kapena ayi. Sono Pakuti kuli kukotoleska,ntchakukhumbikwa chomene kuti wanthu wamanye umo walili mwakuyana na HIV D6. Now that MC is available, I am less worried about HIV infection. Panthawi ino imene mdulidwe ukupezeka, ndilibe nkhawa ina iliyonse kuti nditha kutenga kachilombo koyambitsa matenda a edzi. Pakuti kuli kukotoleska, Nili wakudandaula yayi Kuti ningatola kachibungu ka HIV. IMPACT EVALUATION ON IMPROVING VMMC DEMAND IN MALAWI THROUGH THE USE OF INCENTIVES Agree Disagree Unsure 1 2 3 D7. Now that MC is available, I am somewhat more willing to take a chance of getting infected or infecting someone else with HIV. Panthawi ino imene mdulidwe ukupezeka, ndili ndi chikhumbokhumbo chachikulu kupedza mwayi wotenga kapena kupatsira wina kachilombo koyambitsa matenda a edzi. Sono Pakuti kuli kukotoleska, nili wakunweka chomene kuti ningatola panji kupeleka ka chibungu ka HIV D8. Now that MC is available, someone who is HIV positive doesn’t need to worry as much about condom use. Panthawi ino imene mdulidwe ukupezeka, munthu wina amene ali ndi Kachilombo koyambitsa matenda a edzi safunikanso kudandaula kenakalikonse pankhani yogwiritsa ntchito makondomu. Pakuti kuli kukotoleska, munthu uyo wali na kachibungu ka HIV wangadandaulanga viwi yayi na kugwiliska ntchito kondomu D9. Now that MC is available, I am more likely to have sex without a condom. Panthawi ino imene mdulidwe ukupezeka, pali mpata waukulu woti ndingagone ndi mkazi osagwiritsa ntchito Kondomu. Pakuti kuli kukotoleska, pali mpata wukulu wakuti ningagonana na mwanakazi kwambula kugwiliska ntchito kondomu D10. Circumcised men have more, less, about the same sexual pleasure than uncircumcised men. Amuna a mdulidwe amanva kukoma kwambiri, pang’ono kapena chimodzimodzi pogonana poyelekeza ndi amuna amene sanapange mdulidwe? Mwanalume uyo wali kukotoleska wakupulika kunowa chomene, pachoko panji vikuyana waka pala wakugonana na mwanakazi kupambana na wambula kukotoleska? More 1 Less 2 About the Same 3 Unsure 4 RA 99 76 ANNEXURE D11. The partners of circumcised men get more, less, about the same sexual pleasure than the partners of uncircumcised men. Abwenzi a amuna amene anapanga mdulidwe amanva kukoma kwambiri, pang’ono kapena chimodzimodzi pogonana poyelekeza ndi amuna amene sanapange mdulidwe? Wanakazi awo wakugonana na wanalume awo wali kukotoleska wakupulika kunowa chomene, pachoko panji vikuyana waka pala wakugonana, panji vikupambana na wanakazi na wanakazi awo wakugonana na wanalume wambula kukotoleska? More 1 Less 2 About the Same 3 Unsure 4 RA 99 D12. Circumcision changes the sensitivity of a man’s penis. Sensitivity… Mdulidwe umasinthitsa mamvekedwe/makomedwe a chida cha abambo. Mamvekedwe/makomedwe….. Kukotoleska kukusintha kapulikiro panji kunowa kwa nkhule ya wanalume. Kanowelo/kapulikiro ka: (1) Decreases 1 (2) Increases 2 (3) Remains about the same 3 (4) Unsure 4 (5) RA 99 D13. Circumcised men have more, less, or about the same number of sexual partners than uncircumcised men. Amuna odulidwa amakhala ndi ogonana nawo ambiri, ochepa, kapana chimodzimodzi ndi amuna oti sanapange mdulidwe? Wanalume wakukotoleska wakuwanga na wanakazi wakugonana nawo wanandi, wachoko panji wakuyana waka na wanalume wambula kukotoleska? More Less About the same Unsure RA IMPACT EVALUATION ON IMPROVING VMMC DEMAND IN MALAWI THROUGH THE USE OF INCENTIVES D14. The best age to circumcise a male is Zaka zoyenera kupanga mdulidwe waamuna ndivyaka vyakwenela kuti mwanalume wakotoleske ni Birth – 1 Year old 1 1 Year old 2 2 Years old 3 3 Years old 4 4 Years old 5 5 Years old 6 6 Years old 7 7 Years old 8 8 Years old 9 9 Years old 10 10 Years old 11 11 Years old 12 12 Years old 13 13 Years old 14 14 Years old 15 15 Years old 16 16 Years old 17 17 Years old 18 18 Years old 19 19 Years old 20 78 ANNEXURE 20 Years old 21 21 Years old 22 22 Years old 23 23 Years old 24 24 Years old 25 25 Years old 26 26 Years old 27 27 Years old 28 27 Years old 29 29 Years old 30 30 Years old 31 31 Years old 32 32 Years old 33 33 Years old 34 34 Years old 35 No best age 36 Don’t know 88 D15. The circumcision procedure is safe when carried out by a medical practitioner. Mdulidwe umakhala otetezeka ngati wapangidwa ndi achipatala? Kukotoleska kukuwa makola pala kwachitika na munthu wa chipatala Agree 1 Disagree 2 Unsure 3 RA 4 D16. If I had my way, all men in Mchinji/Rumphi district would be circumcised. IMPACT EVALUATION ON IMPROVING VMMC DEMAND IN MALAWI THROUGH THE USE OF INCENTIVES Ndinakakhala ndi kuthekera, amuna onse aku Mchinji/Rumphi) atha kupanga mdulidwe. Niwenge na mazaza, wanalume wose waku Mchinji/Rumphi wati wakotoleskenge Agree 1 skip→D18 Disagree 2 D17. If I had my way, all men in Mchinji/Rumphi district would be uncircumcised. Ndinakakhala ndi kuthekera, amuna onse aku Mchinji/Rumphi) atha kukhala osapanga mdulidwe. Niwenge na mazaza, wanalume wose waku Mchinji/Rumphi wati wawe wambula kukotoleska Agree 1 Disagree 2 D18. What is the likelihood of getting HIV if you are circumcised (rather than uncircumcised) Pali mpata waukulu bwanji oti munthu utha kutenga kachilombo koyambitsa matenda a edzi (HIV) ngati unapanga mdulidwe (Kusiyana ndi osapanga mdulidwe) Kasi pali mpata ukulu wuli wakuti munthu wangatola kachibungu ka HIV pala wakotoleska (na pala wandakotoleske) 1.Increased 1.Decreased 2 .Same 3 88. Don't know 80 ANNEXURE SECTION E Sources of information about HIV and Male Circumcision E1. Now I’m going to ask you how you have learned about MC. Have you received information about MC from…? Tsopano ndikufunsani mafunso a mmene inuyo munamvera za mdulidwe wa amuna. Kodi munamva za mdulidwe wa amuna kuchokera kwa….[May choose more than one] a. A person who is circumcised Yes No Munthu amene anapanga mdulidwe Munthu uyo walikukotoleska b. A sexual partner Yes No Bwenzi logonana nalo Bwenzi/mwanakazi wakugonana naye c. Radio Yes No Pawayilesi d. Newspaper/Magazines Yes No Panyuzi kapena magazine Mumanyuzi panji magazini e. TV Yes No Pawayilesi yakanema f. Billboards/posters Yes No Kuchokera pama bilubodi/maposita ma bilubodi/maposita g. Community organizations/meetings Yes No Kumabungwe amdera/misonkhano Mabungwe ya ku dela/maungano IMPACT EVALUATION ON IMPROVING VMMC DEMAND IN MALAWI THROUGH THE USE OF INCENTIVES h. Mobile campaigns/Road shows Yes No Makampeni oyendayenda/kapena zionetsero za mmiseu Makampeni wakwendakwenda/viwoneskelo vya mumsewu Teacher/someone at school Yes No Mphunzitsi/munthu wina kusukulu Wasambizgi/munthu munyakhe kusukulu j. VCT center Yes No Kumalo opereka uphungu ndi kuyedzetsa magazi Kumalo yakupimila ndopa nakupelekera uphungu k. Health facility Yes No Kuchipatala Kuchipatala l Other [kwina] kunyakhe Yes No E2. Have you been to a health care provider in the last year? Kodi mwapitako kwa munthu amene amapereka chithandizo chazaumoyo mchaka chapitachi? Muchaka chamala ichi, mwalutapo kukakumana na munthu wa vyaumoyo? Yes=1 No =2 [if boys SKIP TO e5] [if girls SKIP TO SECTION f] Refuse to answer=99 [if boys SKIP TO e5] [if girls SKIP TO SECTION f] E3. At your last visit to a health care provider, did the provider talk to you or ask you about HIV? Paulendo omaliza umene munakakumana ndi munthu wazaumoyowu, kodi anakukambiraniko kapena kukufunsaniko za kachilombo koyambitsa matenda a edzi? Paulendo winu waumalilo kukakumana na wavyaumoyo, kasi wakakudumbilanipo panji kukufumbani vyakukhwafya kachibungu ka HIV? Yes 1 No 2 Refuse to answer 99 82 ANNEXURE E4. At your last visit, did the provider talk to you or ask you about male circumcision? Paulendo omaliza umene munakakumana ndi munthu wazaumoyowu, kodi wazaumoyowu kapena kukufunsaniko za mdulidwe? Paulendo winu waumalilo, kasi wavyaumoyo wakakudumbilanipo panji kukufumbani vyakukhwafyana na kukotoleska? Yes 1 No 2 Refuse to answer 99 ---------------------------------BOYS ONLY-------------------------------------- E5. Do you know where to go to get circumcised? Yes 1 No 2 Refuse to answer 99 E6. If YES to E5, where is that? Name: E7. Have you ever heard about vouchers to make it easier to go to the district hospital for circumcision? If No, skip to F1a, otherwise continue here Yes 1 No 2 Refuse to answer 99 E8. Have you ever seen these vouchers? If No< skip to F1, otherwise continue here Yes 1 No 2 Refuse to answer 99 E9. Did any of your friends have any of these vouchers? Yes 1 No 2 Refuse to answer 99 E10. Were you given some of these vouchers yourself? If No< skip to E21, otherwise continue here Yes 1 No 2 Refuse to answer 99 E11. Did the voucher change your mind about circumcision? Yes 1 No 2 Refuse to answer 99 IMPACT EVALUATION ON IMPROVING VMMC DEMAND IN MALAWI THROUGH THE USE OF INCENTIVES E12. Where did you get the vouchers? School 1 Mother group 2 Friend. 3 Bought 4 Other Specify 5 E13 If you received vouchers, did you get some only for yourself? If YES< skip to E17, otherwise continue here Yes 1 No 2 Refuse to answer 99 E14. For who else did you get vouchers? (Select Multiple Response) Brother 1 Other Relative 2 Friends 3 Other 4 E15. Did you give it to them? If NO< skip to E17, otherwise continue here Yes 1 No 2 Refuse to answer 99 E16. Do you know if they used it? Yes 1 No 2. Don’t Know 3. Refuse to answer 99 E17. Did you use the voucher to pay for transport to have the circumcision procedure done? If No< skip to E21, otherwise continue here Yes 1 No 2 E18. Did you use the voucher to pay for transport for the 1st follow up visit? Yes 1 No 2 E19. Did you use the voucher to pay for transport for the 2nd follow up visit? Yes 1 No 2 E20. What was your experience in redeeming the vouchers? 84 ANNEXURE IMPACT EVALUATION ON IMPROVING VMMC DEMAND IN MALAWI THROUGH THE USE OF INCENTIVES E21. What did your friends say about the vouchers? --------------------------------------BOYS & GIRLS ----------------------------- SECTION F Demographics and background characteristics F1. In what month and year were you born? Kodi munabadwa mwezi wanji, chaka chiti? Kasi mukababika mwezi na chaka uli? MONTH YEAR 1 January 1 1981 2 February 2 1982 3 March 3 1983 4 April 4 1984 5 May 5 1985 6 June 6 1986 7 July 7 1987 8 August 8 1988 9 September 9 1989 10 October 10 1990 11 November 11 1991 12 December 12 1992 88 Don’t know 13 1993 14 1994 15 1995 16 1996 17 1997 18 1998 19 1999 20 2000 21 2001 22 2002 23 2003 24 2004 25 2005 88 Don’t know 86 ANNEXURE F2. How old were you at your last birthday? Patsiku lokumbukira kubadwa lanu lomaliza, munali ndi zaka zingati? Pa zuwa lakukumbukira kubabikwa kwinu lajumpha, Kasi mukawa na vyaka vilinga? F3. Are you currently married? Pakadali pano, kodi muli pabanja? Kasi muli pa nthengwa? Yes 1 No 2 F4. What is your religion? Kodi ndinu achipembedzo chanji? Kasi ndimwe wachipembezo uli? Catholic= 1 CCAP =2 Anglican =3 Muslim=4 No religion=5 Adventist/Baptist =6 Refuse to answer=99 Other (specify) = 77 F5. What is your ethnic group/tribe? Kodi ndinu a mtundu wanji? Kasi ndimwe wa mtundu uli? 1 = Chewa 2 = Yao 3 = Tumbuka 4 = Lomwe 5= Sena 6= Ngoni 7= Tonga 8= Amang’anja/Nyanja] 9= Nkhonde 77= Other (specify……… 99=Refuse to answer IMPACT EVALUATION ON IMPROVING VMMC DEMAND IN MALAWI THROUGH THE USE OF INCENTIVES 88 ANNEXURE F6. Which language did you speak as a child? Muli mwana wamn’gono, kodi mumalankhula chilankhulo chanji? Apo mukawa mwana muchoko, kasi mukayowoyanga chiyowoyelo uli? Chichewa 1 Chiyao 2 Chitumbuka 3 Chilomwe 4 Chisena 5 Chingoni 6 Chitonga 7 Chimang’anja 8 Chinkhonde 9 English 10 Other Specify 77 F7. What other languages can you speak well enough to have a conversation? Kodi ndi ziyankhulo zina ziti zimene mumatha kuyankhula bwinobwino mpaka kucheza ndi munthu kasi ni viyowoyelo wuli vinyakhe ivyo mukuyowoya na kuchezga na munthu? (Select Multiple Response) English 1 Chichewa 2 Tumbuka 3 None 4 Other 77 IMPACT EVALUATION ON IMPROVING VMMC DEMAND IN MALAWI THROUGH THE USE OF INCENTIVES F8 What languages can you read well? (Select Multiple Response) Kodi ndi ziyankhulo ziti zimene mungawelenge bwino? Kasi ni viyowoyelo wuli ivyo mungayowoya makola? English 1 Chichewa 2 Tumbuka 3 None 4 Other 77 F9a Are you currently attending School? Yes 1 No 2 If No Skip to F11 F9. Which school are you currently attending? Pakadali pano mukuphunzira sukulu iti? Panyengo ya sono mukusambila sukulu njini? Name of School zina la sukulu 1 Bua Community Day Secondary School 2 Fair View Private Secondary School 3 Home of Hope Secondary School 4 Kapasa Private Secondary School 5 Mchinji Mission Community Day Secondary 6 Mchinji Secondary School 7 Mthunzi Private Secondary School 8 Kholoni Community Day Secondary School 9 Magawa Secondary 10 Ludzi CDSS 11 Ludzi Girls Secondary 12 Bua Primary School 13 Chapanama Primary School 14 Dole Primary School 15 Kamuzu Primary School 16 St Dominic Primary School 90 ANNEXURE Name of School zina la sukulu 17 Mzura Primary School 18 Mtondo Primary School 19 Tikoliwe Primary School 20 Tiwonge Primary 21 Zulu Primary School 22 Kabira Primary School 23 Mchinji Mission Primary School 24 Jane Glaves Primary School 25 Mayera Primary School 26 Kamwazonde Primary School 27 Kamwendo Primary School 28 Kakoma 11 Primary School 29 Ludzi Boys Primary 30 Ludzi Girls Primary 31 St theresa pvt 32 St Anthony pvt 33 Tenthere Primary School 34 Chankhomi Primary School 35 Chirambo Primary 36 Chirambo Secondary 37 Bolero CDSS 38 Bolero Primary 39 Kawaza Primary 40 Kanyerere Primary 41 Luwarwe Primary 42 Jandang'ombe Primary 43 Chanyoli Primary 44 Kakoloha Primary 45 Mkombezi Primary 46 Mkombezi CDSS 47 Chinyolo Primary 48 Pachichi Private Sec 49 Mzokoto Primary 50 Phwezi Boys Private 51 Chivungulu Primary 52 Maranatha Private Secondary 53 Ng'onga Primary 54 Msikizi Junior Primary 55 Chilulu Primary IMPACT EVALUATION ON IMPROVING VMMC DEMAND IN MALAWI THROUGH THE USE OF INCENTIVES Name of School zina la sukulu 56 Henga Private Secondary 57 Lubagha (St Martin) Primary 58 Mhuju CDSS 59 Mhuju Primary 60 Bethel Private Primary 61 Our Future Private Primary F10. What class are you in? Kodi muli mukalasi yanji? Kasi muli kalasi uli? 1 Std 1 1 2 Std 2 2 3 Std 3 3 4 Std 4 4 5 Std 5 5 6 Std 6 6 7 Std 7 7 8 Std 8 8 9 Form 1 9 10 Form 2 10 11 Form 3 11 12 Form 4 12 University or more 13 F11. Can you read a letter written in: Mutha kuwerenga kalata yolembendwa mu kasi mungawelenga kalata yakulembeka mu: A. Chichewa? Yes 1 No 2 92 ANNEXURE B. English? Yes 2 No 2 F12. Can you write a letter in: Mutha kulemba kalata muchi kasi mungalemba kalata mu: A. Chichewa? Yes 1 No 1 B. English? Yes 1 No 2 IMPACT EVALUATION ON IMPROVING VMMC DEMAND IN MALAWI THROUGH THE USE OF INCENTIVES F13. Have you ever worked for pay? Kasi muli kugwilako ntchito yakulipilika? Kodi munagwirapo ntchito kuti mulipidwe? F14. Are you now working for pay, for example when school is not in session? Pakadali pano mukugwira ntchito yoti mulipidwe, monga nthawi yoti simuli pasukulu? Panyengo yasono, kasi mukugwila ntchito yakulipilika munyengo yakuti muli pa sukulu yayi Yes 1 No 2 --------------------------------GIRLS ONLY----------------------------------- H1: Do you have any of the following kinds of males in your life? (tick all options) Dad Boyfriend Son Brother Uncle None H2: For every type of male in H1 that was ticked, ask the following questions Is he circumcised? Yes 1 No 2 Refuse to answer 99 If no, would you want for him to be circumcised? (and then skip to H3) Yes 1 No 2 Refuse to answer 99 If yes, was he recently circumcised? Yes 1 No 2 Refuse to answer 99 94 ANNEXURE IMPACT EVALUATION ON IMPROVING VMMC DEMAND IN MALAWI THROUGH THE USE OF INCENTIVES If yes, did he get circumcised because of the recent voucher program? Yes 1 No 2 Refuse to answer 99 H3. Did you have a son who was circumcised as part of the voucher program? Yes 1 No 2 Refuse to answer 99 H4: If the respondent had a son who was circumcised as part of the voucher program, did you accompany him to the facility? Yes 1 No 2 Refuse to answer 99 H5: What do you think could be done to motivate more boys to get circumcised? ** END OF INTERVIEW ** This is the end of the interview. Thank you very much for your cooperation. The information you provided is very helpful. Do you have any final questions or comments about the interview that you would like to share with me? 96 ANNEXURE SECTION G Interviewer’s observations (to be filled in after completing interview) How would you rate the overall quality of the interview? Excellent 1 Good 2 Fair 3 Poor 4 How cooperative was the participant? Very cooperative 1 Somewhat cooperative 2 Somewhat uncooperative 3 Very uncooperative 4 In your opinion, how truthful did the participant appear? Very truthful 1 Somewhat truthful 2 Somewhat untruthful 3 Very untruthful 4 Difficult to judge 5 Is this Respondent within 10km radius or 20km radius 10 Kilometers 1 20 Kilometers 2 If 10 kilometers: What is the baseline ID: ______________________ If 20 kilometers: What is his/her individuals"______________________________ IMPACT EVALUATION ON IMPROVING VMMC DEMAND IN MALAWI THROUGH THE USE OF INCENTIVES General Comments: GPS Readings: END 98 ANNEXURE Table A 1 Key Informants Interview Questions Guide Population targets: (A) school heads/faculty, (B) clinical service providers, and (C) community leaders. Estimated total number of interviews: 24 (12 per district-4 per category) Sample of convenience within those categories. For each respondent, indicate, sex and age or age-range; their affiliation and location. Target Questions Participants A. School 1. Would you describe your experience with the just ended VMMC campaign? Heads and/or 2. How were you involved in the campaign? 3. Did you like your role? Why and why not? senior 4. Is VMMC still a sensitive issue in your area? Why? Among whom? What can you teachers from do/or have done about it? study schools 5. What is your view on circumcision? 6. Were you directly involved in the transport voucher effort? How? 7. What do you think of the transport vouchers effort? Could it be improved? 8. Do you see any negative aspects in the transport voucher for VMMC program? 9. How did the boys in your school get to hear about the vouchers, and how did you distribute them? 10. Did the voucher effort affect the school? In which way? The students, the teachers? 11. Were there any complaints to the voucher scheme? By teachers, by students, by parents, by religious groups? by the community at large? How were they handled? 12. How did most people access the vouchers? 13. Of the methods used to distribute vouchers, which ones do you think were the most effective and the least effective? 14. Which other methods do you think can be used to better distribution of vouchers in the future? 15. Were there any complaints from the boys who got circumcised about their care givers? 16. Are you aware of any situation when the transport vouchers were misused? Please explain how and what happened? 17. What is the feeling in the school now that the voucher for VMMC effort has ended? 18. Are there stories that you know or have heard concerning vouchers that you can share? 19. What happened after the story? 20. If a campaign was launched again in the future would you accept for your school to participate? Why and How 21. If it were you making decision regarding vouchers what would you have done differently? 22. In your opinion, who was key in decision making for a child or someone to access VMMC? IMPACT EVALUATION ON IMPROVING VMMC DEMAND IN MALAWI THROUGH THE USE OF INCENTIVES Target Questions Participants 23. Vouchers were like money? What do you think this money was used for? 24. What is your opinion of VMMC? 25. Would you encourage your family or someone to get circumcised with or without vouchers? Why and why not? 26. How do you compare sexual behavior before circumcision and after circumcision in your community? Why, how B. Clinical 1. Is VMMC still a sensitive issue in your area? Why? Among whom? What can services you do/or have done about it? 2. What is your view on circumcision? providers 3. Were you directly involved in the transport voucher effort? How? 4. What do you think of the transport vouchers effort? Could it be improved? 5. Do you see any negative aspects in the transport voucher for VMMC program? 6. How did most people access the vouchers? 7. Of the methods used to distribute vouchers, which ones do you think were the most effective and the least effective? 8. Which other methods do you think can be used to better distribution of vouchers in the future? 9. Have you been trained to performed male circumcision? How many circumcisions have you conducted since the training? 10. What has been your personal experience with circumcisions? Too many to do? 11. How would you describe the physical space adequate? 12. Tell me about the clinical supplies that you needed?, were they adequate, did they come in time 13. What were the most common problems you encountered during the transport vouchers for VMMC effort 14. What is the feeling in the hospital now that the voucher effort has ended? Are the hospitals freer now? 15. How can you describe demand generation? Was it adequate, what challenges do you know? 16. What do people say about their experiences at the hospital? 17. What is the common thing that they complained about? 18. What is the common thing they liked? 19. What challenges did people talk about the most? 20. Was the community happy about the service delivery? Why, why not? 21. If the campaign was to be done again in future, what would you like to be done differently from how the just ended campaign? 22. Vouchers were like money? What do you think this money was used for? 23. What is your opinion of VMMC? 24. Would you encourage your family or someone to get circumcised with or without vouchers? Why and why not? 100 ANNEXURE Target Questions Participants 25. Would please about challenges that you faced during the whole campaign? C. Community 1. Is VMMC still a sensitive issue in your area? Why? Among whom? What can leaders you do/or have done about it? 2. What is your view on circumcision? (include 3. How would describe the campaign, like what was involved? (if they don’t religious mention vouchers prompt if they heard about vouchers, how did they leaders if hear about them, how they were supposed to be done) possible) 4. Were you directly involved in the transport voucher effort? How? 5. What do you think of the transport vouchers effort? What are the benefits? Could it be improved? How can it be improved 6. Do you see any negative aspects in the transport voucher for VMMC program? 7. How did the community hear about the vouchers? 8. Who benefited the most from the transport voucher effort for VMMC? 9. Were there any complaints to the voucher scheme? By men and women in the community? by religious groups? 10. How did most people access the vouchers? 11. Of the methods used to distribute vouchers, which ones do you think were the most effective and the least effective? 12. Which other methods do you think can be used to better distribution of vouchers in the future? 13. Are you aware of any situation when the transport vouchers were misused? Please explain how and what happened? How did you learned about it? 14. Would you support a transport voucher effort for VMMC again? Please explain. 15. What is the feeling in the community now that the voucher effort has ended? 16. In your opinion, who was key in decision making for a child or someone to access VMMC? 17. Vouchers were like money? What do you think this money was used for? 18. If it were you making decision regarding vouchers what would you have done differently? 19. Had you had to deal with dispute arising from the campaign? What were the common disputes, from who and how did you handle them? 20. How do you compare sexual behavior before circumcision and after circumcision in your community? Why, how Note: Questions in blue color are used in all interviews. IMPACT EVALUATION ON IMPROVING VMMC DEMAND IN MALAWI THROUGH THE USE OF INCENTIVES Table A 2 Focus Groups Discussion Guide Population Targets: (A) Mothers groups, (B) In-school males who got circumcised, (C) Out-of-school males who got circumcised because they received the incentives, and parents. Sample of convenience within these categories. Estimated number of FGD: 6 in each district with 6-12 participants each. For each respondent, indicate, sex and age or age-range; their affiliation and location. Respondents Questions A. Mothers 1. Is VMMC still a sensitive issue in your area? Why? Among whom? What can groups you do/or have done about it? 2. What is your view on circumcision? 3. What are some of your thoughts about the VMMC transport voucher program? 4. Are you pleased to have been part of this program? Why / why not? 5. Did you distribute vouchers? If yes, to whom? 6. How would you describe the distribution process? 7. Would you share with us some of the strategies you used to distribute the vouchers? 8. How did you decide in how many vouchers to distribute? 9. How did you decide who should receive the vouchers? 10. If you could change anything in the vouchers distribution effort, what would that be? 11. How did most people access the vouchers? 12. Of the methods used to distribute vouchers, which ones do you think were the most effective and the least effective? 13. Which other methods do you think can be used to better distribution of vouchers in the future? 14. What's going on now that there are no transport vouchers, as far as you know? Do males seek circumcision? 15. Do you think the transport vouchers for VMMC should continue? Why and why not? 16. Some people have said that in some instances there was money involved in the distribution of vouchers. Do you agree with this? How do you feel about that? 17. Did you observe anything like this in your area? Do you have some thoughts on this? 18. Does any of you have some additional thoughts on the issues of transport vouchers for VMMC? 19. What is the feeling in the community now that the voucher effort for VMMC has ended? 20. Did you attend any of the demand generation meetings? 21. What messages were said at the function? 22. How different was this campaign from the previous campaigns? 23. What were the aspects of demand generation you did not like? Why? 102 ANNEXURE Respondents Questions 24. What were the aspects of demand generation you really liked? Why? 25. How would you have done things differently 26. How do you compare sexual behavior before circumcision and after circumcision in your community? Why, how B. In-school 1. Is VMMC a sensitive issue in your school? Why? Among whom? What can males you do/or have done about it? 2. What is your view on circumcision? 3. Did you attend any of the demand generation meetings? 4. What messages were said at the function? 5. How different was this campaign from the previous campaigns? 6. What were the aspects of demand generation you did not like? Why? 7. What were the aspects of demand generation you really liked? Why? 8. How would you have done things differently 9. Are you aware of the transport voucher effort for VMMC in your school? 10. Who benefited the most from the transport voucher effort for VMMC? 11. Did the transport barrier remove barriers to circumcision more broadly? How? 12. What are other barriers that still need to be addressed? 13. How did you get the transport vouchers? From Whom? 14. Did you give transport vouchers to friends or family? 15. How was the experience in the clinic? 16. What does your family and friends think about your getting circumcised (or not?) 17. Do you see any negative aspects in the transport voucher for VMMC program? 18. Are you aware of any situation when the transport vouchers were misused? Please explain how and what happened? 19. Have you heard of any comments or reaction by others in the school or among students to the transport vouchers to encourage circumcision? 20. How did most people access the vouchers? 21. Of the methods used to distribute vouchers, which ones do you think were the most effective and the least effective? 22. Which other methods do you think can be used to better distribution of vouchers in the future? 23. What is the feeling among students now that the voucher effort for VMMC has ended? 24. What do people say about their experiences at the hospital? 25. What is the common thing that they complained about? 26. What is the common thing they liked? 27. What challenges did people talk about the most? 28. Was the community happy about the service delivery? Why, why not 29. In your opinion, who was key in decision making for a child or someone to access VMMC? 30. Vouchers were like money? What do you think this money was used for? 31. If it were you making decision regarding vouchers what would you have done differently? IMPACT EVALUATION ON IMPROVING VMMC DEMAND IN MALAWI THROUGH THE USE OF INCENTIVES Respondents Questions 32. How do you compare sexual behavior before circumcision and after circumcision in your community? Why, how C. Out-of-school 1. Is VMMC still a sensitive issue in your area? Why? Among whom? What males can you do/or have done about it? 2. What is your view on circumcision? 3. Are you aware of the transport voucher effort for VMMC in your community? 4. Did the transport barrier remove barriers to circumcision more broadly? How? 5. What are other barriers that still need to be addressed? 6. How did you get the transport vouchers? From Whom? 7. Do you think people shared transport vouchers to friends or family? 8. What does your family and friends think about your getting circumcised (or not?) 9. Do you see any negative aspects in the transport voucher for VMMC program? 10. Are you aware of any situation when the transport vouchers were misused? Please explain how and what happened? 11. Have you heard of any comments or reaction by others in the community or among your friends to the transport vouchers to encourage circumcision? 12. How did most people access the vouchers? 13. Of the methods used to distribute vouchers, which ones do you think were the most effective and the least effective? 14. Which other methods do you think can be used to better distribution of vouchers in the future? 15. What is the feeling in your community among your friends and family now that the voucher effort for VMMC has ended? 16. What do people say about their experiences at the hospital? 17. What is the common thing that they complained about? 18. What is the common thing they liked? 19. What challenges did people talk about the most? 20. Was the community happy about the service delivery? Why, why not 21. In your opinion, who was key in decision making for a child or someone to access VMMC? 22. Vouchers were like money? What do you think this money was used for? 23. If it were you making decision regarding vouchers what would you have done differently? 24. How do you compare sexual behavior before circumcision and after circumcision in your community? Why, how 104 ANNEXURE Respondents Questions D. Parents and Demand Generation : Guardians and other groups 1. Is VMMC still a sensitive issue in your area? Why? Among whom? What can you do/or have done about it? 2. What is your view on circumcision? 3. Were you directly involved in the transport voucher effort? How? 4. What do you think of the transport vouchers effort? Could it be improved? 5. Do you see any negative aspects in the transport voucher for VMMC program? 6. What were the most common problems you encountered during the transport vouchers for VMMC effort 7. Vouchers were like money? What do you think this money was used for? 8. How did most people access the vouchers? 9. Of the methods used to distribute vouchers, which ones do you think were the most effective and the least effective? 10. Which other methods do you think can be used to better distribution of vouchers in the future? 11. What is the feeling in the hospital now that the voucher effort has ended? Are the hospitals freer now? 12. How can you describe demand generation? Was it adequate, what challenges do you know? 13. How would you describe the physical space at the VMMC center? 14. What do people say about their experiences at the hospital? 15. What is the common thing that people complained about? 16. What is the common thing they liked? 17. What challenges did people talk about the most? 18. Was the community happy about the service delivery? Why, why not? 19. How would you describe the demand generation campaign 20. What was the response from the community? Who mainly attended? What feedback did you receive? 21. What messages were in the campaign? 22. Explain some of the strategies that you used? 23. Were you satisfied with how demand generation was done? Why or why not? 24. If the campaign was to be done again in future, what would you like to be done differently from how the just ended campaign? 25. What do you think the voucher money was used for? Note: Questions in blue colour were used in all interviews. IMPACT EVALUATION ON IMPROVING VMMC DEMAND IN MALAWI THROUGH THE USE OF INCENTIVES Table A 3 Endline household selection listing This page is for collation purposes 11 ANNEXURE III: TABLES Table A3 1 Impact evaluation questions, outcomes and analytical approach Research question to be Outcome Measure Analysis approach/es answered Primary 1. Does a school-based demand a) Comparison of VMMC Uptake i.Before and After Research generation strategy significantly in Rumphi and Mchinji to ii.Synthetic Control Question increase VMMC uptake among those in other Malawian iii.Descriptive findings students? districts iv. Logistic regression b) Proportion of in-school and v. Focus Group out-of-school boys who Discussion became medically circumcised vi. Key Informant during the course of the Interviews evaluation c) Characteristics that increase the uptake of VMMC (including knowledge & attitudes towards VMMC) Secondary 2. Does a school-based VMMC d) VMMC uptake by male i. Descriptive Research demand generation strategy members’ households (e.g. Findings Questions have relevant spill-over effects brothers, father, uncles); ii. Focus Group that increase VMMC uptake in Discussions the school-boys' households iii. Key Informant (brothers and parents)? Interviews 3. Are attitudes towards VMMC e) Knowledge, attitudes and i. Descriptive Findings among school girls changed by a perceptions about VMMC ii. Focus Group school-based VMMC demand among females Discussions generation? iii. Key Informant Interviews 4. Are women effective in b) Knowledge, attitudes and i. Focus Group motivating young men to seek perceptions about VMMC Discussions VMMC? among females i. Key Informant Interviews 5. Do school heads recruit more c) Proportion of in-school and i. Descriptive Findings males for VMMC than do the out-of-school boys who Mothers’ Groups, or vice versa? became medically circumcised during the course of the evaluation 106 ANNEXURE Research question to be Outcome Measure Analysis approach/es answered 6. What is the role of young men’s f) Evidence of diffusion of VMMC i. Focus Group informal social networks in through the informal social Discussions increasing VMMC uptake? networks i. Key Informant Interviews 107 IMPACT EVALUATION ON IMPROVING VMMC DEMAND IN MALAWI THROUGH THE USE OF INCENTIVE Table A3 2 Target population and sample size for key informants interviews Target Population Mchinji Rumphi Total Males Females Males Females 1. School heads/teachers 3 1 4 0 8 2. Hospital clinical VMMC providers 4 0 5 1 10 3. Community leaders/chiefs 2 0 2 1 5 TOTAL 9 1 11 2 23 Table A3 3 Target population and estimated sample size for focus groups discussions* Target Population Mchinji Rumphi Total Number of Average Number of Average Number of Average focus number of focus number of focus number of groups participants in groups participants in groups participants in each FGD each FGD each FGD 1. Mothers groups 2 9 2 8 4 9 2. In-school males 1 10 2 6 3 5 3. Out-of-school males 1 9 1 5 2 7 4.Parents and guardians 2 9 2 10 4 10 5. Informal 1 n/a 2 n/a 3 n/a TOTAL 7 9* 9 7* 16 8* Note: *Average number of participants for those categories for which numbers were available. Table A3 4 Ratio of pre-intervention/post-intervention MSPE for Rumphi district and 17 possible comparators District MSPE if district is "treated" Balaka 0.416 Chitipa 2.524 Dedza 0.322 Dowa 0.074 Karonga 0.293 Kasungu 0.790 Machinga 0.342 Mangochi 0.211 Mwanza 0.214 Mzimba 0.261 Neno 0.230 Nkhata Bay and Likoma 0.208 Nkhotakota 0.229 Nsanje 0.129 Ntcheu 0.133 108 ANNEXURE Ntchisi 0.047 Salima 0.227 Rumphi 100.633 Table A3 5 Ratio of pre-intervention/post-intervention MSPE for Mchinji district and 17 possible comparators District MSPE if district is "treated" Balaka 0.439 Chitipa 0.269 Dedza 0.341 Dowa 3.316 Karonga 0.286 Kasungu 2.551 Machinga 0.337 Mangochi 0.242 Mwanza 0.206 Mzimba 0.261 Neno 0.138 Nkhata Bay and Likoma 0.686 Nkhotakota 0.136 Nsanje 0.106 Ntcheu 0.977 Ntchisi 0.211 Salima 0.189 Mchinji 3.785 Table A3 6 Demographic characteristics 109 110 Chi- squar e (p- value) 26 Mchinji (N=1,517) Chi- Rumphi (N=1,517) 10- square 20km (p- Within TOTA Factor Within 10km 27 28 value)25 10km 10-20km L 156 926 (30.7 306 155 (30.5 Female 309 (30.6%) %) (30.3%) (30.6%) %) Sex 0.94 0.88 351 2,108 (69.2 705 351 (69.5 Male 701 (69.4%) %) (69.7%) (69.4%) %) 122 778 (24.1 252 (25.6 10-14 237 (23.5%) %) (24.9%) 167 (33%) %) 119 833 (23.5 287 131 (27.5 15-19 296 (29.3%) %) (28.4%) (25.9%) %) 119 580 Age (23.5 0.11 201 67 0.002 (19.1 20-24 193 (19.1%) %) (19.9%) (13.2%) %) 412 76 129 65 (13.6 25-29 142 (14.1%) (15%) (12.8%) (12.8%) %) 431 71 (14.2 30-34 142 (14.1%) (14%) 142 (14%) 76 (15%) %) Mean 20.2 age 20.5 0.8029 20.2 (6.8) 19.5 (7.3) 0.0630 (6.9) (SD) 20.4 (6.8) (6.9) 25 Test for significant difference between the two groups of respondents living within 10km and those within 20km from the hospital in Mchinji District (if p<0.05, there is a significant difference in the observed %) 26 Test for significant difference between the two groups of respondents living within 10km and those within 20km from the hospital in Rumphi District (if p<0.05, there is a significant difference in the observed %) 27 Distance from Hospital 28 Distance from hospital 29T-test for difference in mean age (years) for respondents living within 10km and those within 20km from the hospital in Mchinji District (if p<0.05, there is a significant difference in the mean age) 30 T-test for difference in mean age (years) for respondents living within 10km and those within 20km from the hospital in Rumphi District (if p<0.05, there is a significant difference in the mean age) Table A3 6 Demographic characteristics Chi- TOTA Chi- squar L square Factor e (p- (p- value) value)31 32 Mchinji (N=1,517) Rumphi (N=1,517) 10- 20km Within Within 10km 33 34 10km 10-20km Not 1,476 attendi 293 (48.7 0.001 0.46 ng (57.8 466 223 %) school 494 (48.9%) %) (46.1%) (44.1%) 178 1,071 Education (35.1 0.52 331 224 <0.001 (35.3 Primary 338 (33.5%) %) (32.7%) (44.3%) %) Second 487 ary & 36 <0.001 214 59 <0.001 (16.1 above 178 (17.6%) (7.1%) (21.2%) (11.7%) %) 1,987 Not 294 686 338 (65.5 Marital Married 669 (66.2%) (58%) (67.9%) (66.8%) %) 0.002 0.68 Status 1,047 213 325 168 (34.5 Married 341 (33.8%) (42%) (32.2%) (33.2%) %) 466 2,202 (91.9 575 471 (72.6 Rural 690 (68.3%) %) (56.9%) (93.1%) %) Area <0.001 <0.001 832 41 436 (27.4 Urban 320 (31.7%) (8.1%) (43.1%) 35 (6.9%) %) Not 413 2,453 111 employ (81.5 805 (80.8 Employme ed 805 (79.7%) %) (79.6%) 430 (85%) %) 0.42 0.01 nt Status 94 581 Employ (18.5 206 (19.2 ed 205 (20.3%) %) (20.4%) 76 (15%) %) 31 Test for significant difference between the two groups of respondents living within 10km and those within 20km from the hospital in Mchinji District (if p<0.05, there is a significant difference in the observed %) 32 Test for significant difference between the two groups of respondents living within 10km and those within 20km from the hospital in ANNEXURE Rumphi District (if p<0.05, there is a significant difference in the observed %) 33 Distance from Hospital 34 Distance from hospital 112 Table A3 7 Intention to get circumcised among uncircumcised men Mchinji Rumphi Chi- Ch FACTOR Within square Within sq 10-20km 10-20km 10km (p- 10km (p value)35 va 283 (47.5%) 164 (48.8%) 271 (42.5%) 122 (36.0%) No Intend to get 277 (46.5%) 154 (45.8%) 0.96 341 (53.5%) 194 (57.2%) 0. Yes circumcised 36 (6.0%) 18 (5.4%) 25 (3.9%) 23 (6.8%) Neither Yes/No 265 (44.5%) 148 (44.1%) 0.98 338 (53.1%) 235 (69.3%) <0 Father/grandfather/uncle 232 (38.9%) 129 (38.4%) 0.47 296 (46.5%) 209 (61.7%) <0 Mother/grandmother/aunt 228 (38.3%) 139 (41.4%) 0.57 301 (47.3%) 211 (62.2%) <0 Wife/partner Would you 204 (34.2%) 129 (38.4%) 0.29 258 (40.5%) 200 (59%) <0 Traditional leader consider getting 220 (36.9%) 131 (39.0%) 0.75 278 (43.6%) 200 (59%) <0 Religious leader circumcised if 234 (39.3%) 137 (40.8%) 0.23 313 (49.1%) 225 (66.4%) <0 encouraged Government by 273 (45.8%) 168 (50%) 0.54 333 (52.3%) 230 (67.9%) <0 Doctor/nurse/HSA 212 (35.6%) 119 (35.4%) 0.87 256 (40.2%) 193 (56.9%) <0 Teacher 233 (39.1%) 133 (39.6%) 0.98 268 (42.1%) 191 (56.3%) <0 Transport vouchers 247 (41.4%) 147 (43.7%) 0.13 335 (52.6%) 225 (66.4%) <0 Parents Brothers/ cousins 255 (42.8%) 157 (46.7%) 0.20 311 (48.8%) 227 (67%) <0 Would you consider Best friends 259 (43.5%) 151 (44.9%) 0.83 320 (50.2%) 221 (65.2%) <0 getting circumcised if........gets Most friends in village 248 (41.6%) 151 (44.9%) 0.36 318 (49.9%) 220 (64.9%) <0 circumcised Most friends in school 227 (38.1%) 120 (35.7%) 0.57 285 (44.7%) 200 (59%) <0 35 Test for significant difference between the two groups of respondents living within 10km and those within 20km from the hospital in Mchinji district (if p<0.05, there is a significant difference in the observed %) 36 Test for significant difference between the two groups of respondents living within 10km and those within 20km from the hospital in Rumphi district (if p<0.05, there is a significant difference in the observed %) A political leader 182 (30.5%) 107 (31.8%) 0.49 219 (34.4%) 184 (54.3%) <0 A pop culture star 178 (29.9%) 106 (31.5%) 0.86 210 (33%) 179 (52.8%) <0 I am paid money to get circumcised 181 (30.4%) 111 (33.0%) 0.41 218 (34.2%) 168 (49.6%) <0 Celebrity get circumcised 182 (30.5%) 114 (33.9%) 0.43 215 (33.8%) 180 (53.1%) <0 I am given transport vouchers to get circumcised 194 (32.5%) 153 (45.5%) <0.001 334 (52.4%) 206 (60.8%) <0 Table A3 8 Intention to get circumcised cont’ Mchinji Rumphi Chi- Chi- squar squar TOTA Circumcision Intentions Within Within 10-20km e (p- 10-20km e (p- L 10km 10km value value ) ) 17 2 (0.3%) 9 (2.7%) 0.001 2 (0.3%) 4 (1.2%) 0.10 CHAM (0.9%) 1,550 500 248 <0.00 570 232 <0.00 Government (81.2 (83.9%) (73.8%) 1 (89.5%) (68.4%) 1 hospital %) 50 <0.00 72 Where 5 (0.8%) 12 (3.6%) 0.003 5 (0.8%) Health Center (14.8%) 1 (3.8%) would one Traditional 7 go for 4 (0.7%) 1 (0.3%) 0.45 1 (0.2%) 1 (0.3%) 0.65 circumciser (0.4%) circumcision 69 24 (4.0%) 9 (2.7%) 0.28 26 (4.1%) 10 (2.9%) 0.37 Private (3.6%) 46 27 (4.5%) 11 (3.3%) - 6 (0.9%) 2 (0.6%) - Other (2.4%) 46 <0.00 40 <0.00 147 113 34 (5.7%) 27 (4.2%) Don’t know (13.7%) 1 (11.8%) 1 (7.7%) Is 1,620 509 265 578 268 circumcision (94.5 (95.1%) (95.0% (95.7%) (90.2%) place Yes 0.92 0.001 %) convenientl 95 y located 26 (4.9%) 14 (5.0%) 26 (4.3%) 29 (9.8%) No (5.5%) 412 If one 112 230 50 <0.00 20 (5.9%) 0.001 (21.6 decided to (18.8%) (36.1%) (14.7%) 1 Walk %) get 400 circumcised 103 94 130 73 0.001 0.68 (21.0 transportati (17.3%) (28.0%) (20.4%) (21.5%) Bicycle %) ANNEXURE 114 Mchinji Rumphi Chi- Chi- squar squar TOTA Circumcision Intentions Within Within 10-20km e (p- 10-20km e (p- L 10km 10km value value ) ) on to be 403 152 63 134 54 used 0.02 0.05 (21.1 (25.5%) (18.8%) (21.0%) (15.9%) Bike taxi %) 720 189 91 251 189 <0.00 0.14 (37.7 (31.7%) (27.1%) (39.4%) (55.8%) 1 Minibus %) 238 74 52 77 35 0.19 0.41 (12.5 (12.4%) (15.5%) (12.1%) (10.3%) Taxi %) 20 4 (0.7%) 1 (0.3%) 0.54 12 (1.9%) 3 (0.9%) 0.23 Own (1.1%) 1,268 385 186 450 247 Would you (73.9 (72.0%) (66.7%) (74.5%) (83.2%) incur Yes %) 0.12 0.001 Transportati 447 150 93 154 50 on costs (26.1 (28.0%) (33.3%) (25.5%) (16.8%) No %) 245 109 <0.00 120 <0.00 6 (3.2%) 10 (4.1%) (19.3 (28.3%) 1 (26.7%) 1 0-500 %) 418 If one 184 58 <0.00 138(30.7 38 <0.00 (33.0 decided to (47.8%) (31.2%) 1 %) (15.4%) 1 500-1000 %) get 183 circumcised, 39 32 67 45 0.02 0.25 (14.4 Cost of (10.1%) (17.2%) (14.9%) (18.2%) 1000-1500 %) transportati on (MK) 183 40 <0.00 62 60 <0.00 would be... 21 (5.5%) (14.4 (21.5%) 1 (13.8%) (24.3%) 1 1500-2000 %) 239 50 <0.00 63 94 <0.00 32 (8.3%) (18.8 (26.9%) 1 (14.0%) (38.1%) 1 2000-4000 %) If one 850 302 141 294 113 decided to Yes (44.5 (50.7%) (42.0%) (46.1%) (33.3%) get %) circumcised <0.00 0.01 would 1 1,058 294 195 343 226 losing time No (55.5 (49.3%) (58.0%) (53.8%) (66.7%) from school %) be a Mchinji Rumphi Chi- Chi- squar squar TOTA Circumcision Intentions Within Within 10-20km e (p- 10-20km e (p- L 10km 10km value value ) ) significant problem Table A3 9 Circumcision and HIV knowledge Mchinji Rumphi TOTA Chi- Chi- L FACTOR squar squar Females Males e (p- Females Males e (p- value value )37 )38 1,664 Removal of the entire 203 595 <0.00 251 615 0.17 (54.9 foreskin 39 (43.4%) (56.6%) 1 (54.4%) (58.2%) %) 507 Removal of the foreskin, 71 169 73 194 0.69 0.23 (16.7 but not entire foreskin (15.3%) (16.1%) (15.8%) (18.4%) %) 103 Describe 13 34 16 Removal of the penis 0.65 40 (3.8% 0.76 (3.4% what you (2.8%) (3.2%) (3.5%) ) think male circumcisi 61 16 18 on is Other - 5 (1.1%) 22 (2.1% - (2.0% (3.4%) (1.7%) ) 660 154 219 <0.00 107 180 Don’t know40 0.01 (21.8 (33.1%) (20.8%) 1 (23.2%) (17.1%) %) 115 39 17 Refused to answer 8 (1.8%) - 9 (1.9%) 5 (0.5%) - (1.3% (1.6%) ) How likely 362 72 183 39 68 are More likely 0.36 0.16 (11.9 (15.5%) (17.4%) (8.5%) (6.4%) circumcise %) d men to 2,224 330 685 367 842 get Less likely 0.03 0.95 (73.3 (71.0%) (65.1%) (79.6%) (79.7%) infected %) 37 Test for significant difference between males and females in Mchinji District (if p<0.05, there is a significant difference in the observed %) 38 Test for significant difference between males and females in Rumphi District (if p<0.05, there is a significant difference in the observed %) ANNEXURE 39 Significantly associated with circumcision status: 54.1% among uncircumcised men vs 88.1% among circumcised men (p<0.001) 40 Significantly associated with circumcision status: 20.8% among uncircumcised men vs 1% among circumcised men (p<0.001) 116 Mchinji Rumphi TOTA Chi- Chi- L FACTOR squar squar Females Males e (p- Females Males e (p- value value )37 )38 with HIV 222 24 98 22 78 compared About the same 0.01 0.06 (7.3% (5.2%) (9.3%) (4.8%) (7.4%) to ) uncircumc 226 ised men 39 86 33 68 Don’t know 0.89 0.60 (7.5% (8.4%) (8.2%) (7.2%) (6.4%) ) 2,523 Knows health facility where someone 380 891 369 883 0.15 0.10 (83.2 can be circumcised (81.7%) (84.7%) (80.0%) (83.6%) %) 1,775 Knows someone personally who has 242 714 <0.00 203 616 <0.00 (58.5 been circumcised (52.0%) (67.9%) 1 (44.0%) (58.3%) 1 %) 181 24 71 22 64 Medical 0.24 0.32 (6.0% (5.2%) (6.8%) (4.8%) (6.1%) ) 2,655 To protect against HIV & 386 898 418 953 0.24 0.8 (87.5 other STIs (83.0%) (85.4%) (90.7%) (90.2%) %) 378 62 147 44 125 Ethnicity/Religion 0.74 0.19 (12.5 (13.3%) (14.0%) (9.5%) (11.8%) %) 796 153 338 77 228 Hygiene/Cleanliness 0.77 0.03 (26.2 (32.9%) (32.1%) (16.7%) (21.6%) Why do %) you think 69 10 18 33 circumcisio Social Desirability 0.58 8 (1.7%) 0.12 (2.3% (2.2%) (1.7%) (3.1%) n is carried ) out 252 52 96 30 74 Perceived Health Benefits 0.21 0.72 (8.3% (11.2%) (9.1%) (6.5%) (7.0%) ) 158 26 64 20 48 0.71 0.86 (5.2% (5.6%) (6.1%) (4.3%) (4.5%) Perceived sexual benefits ) 19 3 (0.7%) 8 (0.8%) 0.81 1 (0.2%) 7 (0.7%) 0.27 (0.6% Cosmetics ) 16 13 1 (0.2%) 2 (0.2%) 0.92 0 (0%) 0.02 (0.5% (1.2%) Socio-economic status ) ANNEXURE 117 118 Table A3 10 Circumcision and HIV knowledge cont’ Mchinji Rumphi Chi- Chi- squa squa TOTA FACTOR re re Females Males Females Males L (p- (p- valu valu e) e) 2,083 321 616 354 792 Would you (68.7 (69.0%) (58.5%) (76.8%) (75.0%) recommen Yes %) d MC to 813 113 374 <0.0 92 234 others 0.35 (26.8 (24.3%) (35.6%) 01 (20.0%) (22.2%) No %) 138 31 62 15 30 (2.8% (4.5% (6.7%) (5.9%) (3.2%) Neither Yes/ No ) 9 Its associated with one’s 0 (0%) 5 (0.8%) 0.11 3 (0.8%) 1 (0.1%) 0.05 (0.4% ethnicity ) 45 16 21 It’s associated with being 0.24 2 (0.6%) 6 (0.8%) 0.72 (2.2% (5.0%) (3.4%) religious ) 135 18 57 19 41 0.05 0.89 (6.5% (5.6%) (9.2%) (5.4%) (5.2%) Sex sweet for man ) 156 22 60 24 50 0.14 0.77 (7.5% (6.8%) (9.7%) (6.8%) (6.3%) Sex sweet partner ) Reasons for 1,902 recommen 300 557 325 720 0.11 0.62 (91.3 ding MC to (93.5%) (90.4%) (91.8%) (90.9%) Reduces chance of HIV %) others41 1,538 214 423 284 617 Reduces chance of other 0.53 0.38 (73.8 (66.7%) (68.7%) (80.2%) (77.9%) STIs %) 318 55 101 47 115 Health in general will be 0.77 0.58 (15.3 (17.1%) (16.4%) (13.3%) (14.5%) better %) 755 152 307 82 214 0.47 0.17 (36.3 (47.3%) (49.8%) (23.2%) (27.0%) It is cleaner %) 10 4 (1.2%) 5 (0.8%) 0.52 0 (0%) 1 (0.1%) 0.50 (0.5% No need to use a condom ) 10 Won't be embarrassed at 2 (0.6%) 6 (1.0%) 0.58 1 (0.3%) 1 (0.1%) 0.56 (0.5% being circumcised ) 41 Other reason mentioned included that MC helps to prevent the partner from getting cervical cancer Mchinji Rumphi Chi- Chi- squa squa TOTA FACTOR re re Females Males Females Males L (p- (p- valu valu e) e) 1,240 234 343 215 448 (40.9 Have you (50.3%) (32.6%) (46.6%) (42.4%) Yes %) been to a 1,793 healthcare 231 708 <0.0 246 608 0.13 (59.1 provider in (49.7%) (67.3%) 01 (53.4%) (57.6%) No %) the last 1 year 0 (0.0%) 1 (0.1%) - - (0.0% Refused to Answer ) 717 131 205 138 243 Did (57.8 (56.0%) (59.8%) (64.2%) (54.2%) Provider Yes %) 0.37 0.02 talk about 523 103 138 77 205 HIV (42.2 (44.0%) (40.2%) (35.8%) (45.8%) No %) 402 51 136 <0.0 74 141 0.45 (32.4 (21.8%) (39.6%) 01 (34.4%) (31.5% Did Yes %) Provider 838 183 207 141 307 talk about (67.6 (78.2%) (60.3%) (65.6%) (68.5%) MC No %) Table A3 11 Factors Associated with VMMC Uptake among men in Mchinji and Rumphi Districts Circumcised Factors OR (95% CI) p-value aOR (95% CI) p-value 42 Men 119 Were you given some No 16.9% (38/225) 1 - 1 - vouchers yourself (E10) Yes 62.5% (60/96) 8.20 (4.78, 14.08) <0.001 7.32 (3.55, 15.12) <0.001 Age (years) 10 - 17 7.2% (63/875) 1 - 1 - 18 - 34 11.0% 1.59 (1.17, 2.18) <0.001 1.75 (0.57, 5.33) 0.33 (136/1,232) Education Not in school 9.2% (86/938) 1 - 1 - Primary 7.8% (62/799) 0.83 (0.59, 1.17) 0.30 1.14 (0.25, 5.20) 0.87 Secondary & above 13.8% (51/370) 1.58 (1.09, 2.29) 0.01 0.91 (0.30, 2.71) 0.86 Marital Status Not Married 9.8% (146/1,495) 1 - 1 - Married 8.7% (53/612) 0.88 (0.63, 1.21) 0.43 0.45 (0.14, 1.44) 0.18 Locality Rural 7.4% (115/1,556) 1 - 1 - Urban 15.3% (84/551) 2.25 (1.67, 3.04) <0.001 0.84 (0.40, 1.77) 0.65 ANNEXURE 42 If p-value is <0.05 there is significant difference in voucher exposure at the 95% significance level 120 Employment Status Not employed 9.3% (150/1,621) 1 - 1 - Employed 10.1% (49/486) 1.10 (0.78, 1.54) 0.58 0.57 (0.23, 1.38) 0.21 District Mchinji 11.4% 1 - 1 - (120/1,052) Rumphi 7.5% (79/1,055) 0.63 ( 0.47, 0.85) 0.002 0.32 (0.09, 1.21) 0.09 Distance from Hospital Within 10km 12.3% 1 - 1 - (173/1,406) 10-20km 3.7% (26/701) 0.27 (0.18, 0.42) <0.001 0.89 (0.22, 3.55) 0.87 Knowledge about Incorrect Knowledge43 3.0% (13/437) 1 - 1 - Circumcision Correct Knowledge 14.5% 5.55 (3.12, 9.86) <0.001 (176/1,210) 9.20 (2.41, 35.11) <0.001 Ethnic Group Tumbuka 6.6% (56/849) 1 - 1 - Chewa 11.2% (75/671) 1.78 (1.24, 2.56) 0.002 0.67 (0.17, 2.75) 0.58 Ngoni 7.0% (30/431) 1.06 (0.67, 1.68) 0.81 0.20 (0.05, 0.80) 0.02 Received MC No 5.9% (79/1,338) 1 - 1 - information from TV Yes 15.5% (119/766) 2.93 (2.17, 3.95) <0.001 2.19 (1.03, 4.68) 0.04 Table A3 12 Heard of vouchers by distance from district hospital Distance from District Hospital Mchinji Rumphi 0-2km 66% (128/194) 70% (245/352) 2-4km 60% (94/156) 51% (23/45) 4-6km 51% (32/63) 84% (26/31) 6-8km 43% (43/99) 58% (66/114) 8-10km 44% (58/131) 50% (64/129) 10-12km 34% (31/91) 41% (34/82) 12-14km 20% (8/41) 34% (31/92) 14-16km 29% (20/68) 25% (18/71) 16-18km 33% (33/100) 22% (11/49) 18-20km 22% (13/59) 11% (7/63) 20-22km 29% (2/7) 6% (1/17) >22km 64% (7/11) 50% (2/4) Table A3 13 Seen vouchers by distance from district hospital Distance from District Hospital Mchinji Rumphi 0-2km 40% (79/199) 27% (96/352) 2-4km 23% (37/161) 13% (6/45) 4-6km 23% (16/70) 19% (6/31) 6-8km 9% (9/102) 9% (10/114) 43 Removal of the foreskin but not the entire foreskin or removal of the penis ANNEXURE 8-10km 13% (17/133) 10% (13/129) 10-12km 6% (6/93) 7% (6/82) 12-14km 5% (2/41) 5% (5/94) 14-16km 1% (1/69) 4% (3/73) 16-18km 5% (5/104) 0% (0/49) 18-20km 2% (1/62) 2% (1/64) 20-22km 0% (0/7) 0% (0/18) >22km 9% (1/11) 25% (1/4) 121 121 IMPACT EVALUATION ON IMPROVING VMMC DEMAND IN MALAWI THROUGH THE USE OF INCENTIVE Table A3 14 Given vouchers by distance from district hospital Distance from District Hospital Mchinji Rumphi 0-2km 13% (26/199) 8% (28/352) 2-4km 7% (11/161) 11% (5/45) 4-6km 3% (2/70) 6% (2/31) 6-8km 3% (3/102) 1% (1/114) 8-10km 2% (2/133) 5% (6/129) 10-12km 3% (3/93) 0% (0/82) 12-14km 0% (0/41) 2% (2/94) 14-16km 1% (1/69) 0% (0/73) 16-18km 2% (2/104) 0% (0/49) 18-20km 2% (1/62) 0% (0/64) 20-22km 0% (0/7) 0% (0/18) >22km 9% (1/11) 0% (0/4) Table A3 15 Used vouchers by distance from district hospital Distance from District Hospital Mchinji Rumphi 0-2km 8% (15/199) 5%(17/352) 2-4km 4% (6/161) 4% (2/45) 4-6km 1% (1/70) 6% (2/31) 6-8km 1% (1/102) 1% (1/114) 8-10km 0% (0/133) 4% (5/129) 10-12km 0% (0/93) 0% (0/82) 12-14km 0% (0/41) 2% (2/94) 14-16km 0% (0/69) 0% (0/73) 16-18km 1% (1/104) 0% (0/49) 18-20km 2% (1/62) 0% (0/64) 20-22km 0% (0/7) 0% (0/18) >22km 0% (0/11) 0% (0/4) Table A3 16 Sources of information about MC and HIV Mchinji Rumphi Schooling TOT Chi- AL Second Within 10- Within 10- No Primar squar ary & 10km 20km 10km 20km school y e44 above Source (p- 44 Test for significant difference among the groups of respondents in the three educational categories (if p<0.05, there is a significant difference among the observed %) 122 value ) 1,31 A person who is 562 157 458 135 635 391 286 2 <0.001 circumcised (55.6%) (31%) (45.3%) (26.7%) (43%) (36.5%) (58.7%) (43.2 %) 520 151 45 237 87 325 84 111 A sexual partner <0.001 (17.1 (14.9%) (8.9%) (23.4%) (17.2%) (22%) (7.8%) (22.8%) %) 2,40 870 357 805 368 1,276 687 437 0 Radio <0.001 (86.1%) (70.4%) (79.6%) (72.7%) (86.4%) (64.1%) (89.7%) (79.1 %) 1,07 Newspaper/ 406 106 424 135 586 205 280 1 <0.001 Magazines (40.2%) (20.9%) (41.9%) (26.7%) (39.7%) (19.1%) (57.5%) (35.3 %) 1,02 392 81 411 141 512 244 269 5 TV <0.001 (38.8%) (16%) (40.7%) (27.9%) (34.7%) (22.8%) (55.2%) (33.8 % 1,23 467 132 479 161 638 305 296 9 Billboards/ posters <0.001 (46.2%) (26%) (47.4%) (31.8%) (43.2%) (28.5%) (60.8%) (40.8 %) 1,39 Community 505 168 489 228 745 355 290 0 <0.001 meetings (50%) (33.1%) (48.4%) (45.1%) (50.5%) (33.1%) (59.5%) (45.8 %) 1,86 617 189 755 301 943 561 358 2 Mobile Campaigns <0.001 (61.1%) (37.3%) (74.7%) (59.5%) (63.9%) (52.4%) (73.5%) (61.4 %) 1,62 Teacher/ Someone 549 174 637 266 591 644 391 6 <0.001 at school (54.4%) (34.3%) (63%) (52.6%) (40%) (60.1%) (80.3%) (53.6 123 %) 1,16 455 152 391 162 671 226 263 0 VCT Center <0.001 (45%) (30%) (38.7%) (32%) (45.5%) (21.1%) (54%) (38.2 %) 1,74 609 218 634 288 968 429 352 9 Health Facility <0.001 (60.3%) (43%) (62.7%) (56.9%) (65.6%) (40.1%) (72.3%) (57.6 %) 273 111 73 59 30 151 71 51 Other45 - (9.0 (11%) (14.4%) (5.8%) (5.9%) (10.2%) (6.6%) (10.5%) %) ANNEXURE 45 Other sources include friends, relatives, football match, grandparents, churches/mosque, youth clubs, community members 124 Table A3 17 Community discussions about VMMC: Reasons why other men/boys/ family thought VMMC is not a good idea Females (N = 791) Males (N = 1, 878) Factor N % N % VMMC is associated with someone’s ethnic background 243 30.7 614 32.7 VMMC is associated with someone’s religious background 193 24.4 510 27.2 Fear of pain 509 64.4 1,355 72.2 Fear of injury 423 53.5 1,026 54.6 Fear that sex would not be as good for man 51 6.5 169 9.0 Fear that sex would not be as good for partner 57 7.2 130 6.9 Their girlfriend(s)/ partner(s) prefer uncircumcised men 46 5.8 116 6.2 My mother/aunt/grandmothers don’t want them circumcised 94 11.9 264 14.1 Father/grandfather/uncle don’t want them circumcised 93 11.8 270 14.4 Have to abstain for too long after the circumcision procedure 193 24.4 512 27.3 Don't like going to a health facility 50 6.3 181 9.6 Have to get an HIV Test before 73 9.2 236 12.6 Circumcision is not 100% effective in preventing HIV infection 111 14.0 277 14.8 Have to use a condom anyway 57 7.2 191 10.2 Embarrassment at being circumcised 109 13.8 303 16.1 Their mother made the decision to have them circumcised as a child 29 3.7 45 2.4 Table A3 18 Community discussions about VMMC: Reasons why other men/boys/ family thought VMMC is a good idea Females (N = 791) Males (N = 1, 878) Factor N % N % VMMC is associated with someone’s ethnic background 126 15.9 364 19.4 VMMC is associated with someone’s religious background 136 17.2 359 19.1 Sex would be sweet for man 132 16.7 398 21.2 Sex would be sweet for the partner 135 17.1 399 21.3 Their girlfriend/ partner wants them to be circumcised 53 6.7 152 8.1 Mother/aunt/grandmother wants them to be circumcised 62 7.8 170 9.1 Father/grandfather/uncle wants them to be circumcised 59 7.5 164 8.7 Reduces my chances of getting HIV 697 88.1 1,664 88.6 Reduces my chances of getting STIs 537 67.9 1,287 68.5 Health in general will be better 130 16.4 359 19.1 It is cleaner 345 43.6 915 48.7 Don't have to use condom 54 6.8 175 9.3 Embarrassment at being uncircumcised 36 4.6 87 4.6 Their mother made the decision to have them circumcised as a child 42 5.3 135 7.2 125 ANNEXURE 126 Table A3 19 Beliefs about MC and HIV Mchinji Rumphi TOTA Chi- Chi- L squar squar Females Males e (p- Females Males e (p- value) value) 46 47 Factor Condom use 539 110 216 83 130 during sex is 0.10 0.01 (17.8 (23.7%) (20.5%) (18.0%) (12.3%) less necessary %) I am more 411 likely to have 84 193 102 0.63 32 (6.9%) 0.07 (13.5 more than one (18.1%) (18.3%) (9.7%) %) partner HIV is a less 630 serious threat 120 248 80 182 0.29 0.36 (20.8 than it used to (25.8%) (23.6%) (17.3%) (17.2%) %) be People do not need to be as 598 concerned 87 198 96 217 0.90 0.99 (19.7 about (18.7%) (18.8%) (20.8%) (20.5%) %) becoming HIV positive Now that MC is It is more 2,436 available..... important for 394 863 359 820 0.34 0.006 (80.3 .. people to know (84.7%) (82.0%) (77.9%) (77.7%) %) their HIV status I am less 583 98 206 85 194 worried about 0.63 0.31 (19.2 (21.1%) (19.6%) (18.4%) (18.4%) HIV infection %) I am somewhat more willing to take a chance of getting 57 262 91 (8.7%) 0.09 25 (5.4%) 89 (8.4%) 0.03 infected/ (12.3%) (8.6%) infecting someone with HIV Someone who is HIV+ doesn't 400 80 156 53 111 need to worry 0.34 0.85 (13.2 (17.2%) (14.8%) (11.5%) (10.5%) about condom %) use 46 Test for significant difference between males and females in Mchinji District (if p<0.05, there is a significant difference in the observed %) 47 Test for significant difference between males and females in Rumphi District (if p<0.05, there is a significant difference in the observed %) Mchinji Rumphi TOTA Chi- Chi- L squar squar Females Males e (p- Females Males e (p- value) value) 46 47 Factor I am more 384 likely to have 72 156 113 0.91 43 (9.3%) 0.09 (12.7 sex without a (15.5%) (14.8%) (10.7%) %) condom 902 138 364 121 279 0.06 0.94 (29.7 (29.7%) (34.6%) (26.2%) (26.4%) More %) Circumcised 118 men have 18 (3.9%) 42 (4.0%) 0.91 16 (3.5%) 42 (4.0%) 0.64 Less (3.9%) more/less 828 sexual 107 278 106 337 About the 0.16 <0.001 (27.3 pleasure (23.0%) (26.4%) (23.0%) (31.9%) same %) than uncircumcis 1,110 188 335 210 377 ed men 0.001 <0.001 (36.6 (40.4%) (31.8%) (45.5%) (35.7%) Unsure %) Refused to 76 14 (3.0%) 33 (3.1%) - 8 (1.7%) 21 (2.0%) - answer (2.5%) Table A3 19 Beliefs about MC and HIV (continued) Mchinji Rumphi Chi- Chi- squar squar Females Males e (p- Females Males e (p- TOTAL value value Factor )48 )49 127 The 142 381 120 297 940 0.03 0.40 partners More (30.5%) (36.2%) (26.0%) (28.1%) (31.0%) of 21 45 12 35 113 circumcise 0.83 0.46 Less (4.5%) (4.3%) (2.6%) (3.3%) (3.7%) d men get 110 256 110 336 812 more, less, 0.78 0.002 About the same (23.7%) (24.3%) (23.9%) (31.8%) (26.8%) about the same 179 338 210 374 <0.00 1,101 0.02 sexual Unsure (38.5%) (32.1%) (45.5%) (35.4%) 1 (36.3%) pleasure than 13 32 14 - 9 (1.9%) - 68 (2.2%) partners (2.8%) (3.0%) (1.3%) of Refused to answer ANNEXURE 48 Test for significant difference between males and females in Mchinji District (if p<0.05, there is a significant difference in the observed %) 49 Test for significant difference between males and females in Rumphi District (if p<0.05, there is a significant difference in the observed %) 128 uncircumc ised men 27 45 14 39 125 Decrease 0.20 0.52 (5.8%) (4.3%) (3.0%) (3.7%) (4.1%) 148 383 112 271 914 Circumcisi Increase 0.08 0.57 (31.8%) (36.4%) (24.3%) (25.7%) (30.1%) on Remains about 96 237 107 337 777 changes 0.41 0.001 the same (20.7%) (22.5%) (23.2%) (31.9%) (25.6%) the sensitivity 88 183 155 289 715 Unsure 0.47 0.01 of a man's (18.9%) (17.4%) (33.6%) (27.4%) (23.6%) penis 104 196 72 108 480 Don’t know 0.09 0.003 (22.4%) (18.6%) (15.6%) (10.2%) (15.8%) 12 Refuse to Answer 2 (0.4%) 8 (0.8%) - 1 (0.2%) - 23 (0.8%) (1.1%) Circumcise 79 172 71 154 476 More 0.76 0.68 d men (17.0%) (16.3%) (15.4%) (14.6%) (15.7%) have 86 148 58 112 404 more, less, Less 0.03 0.26 (18.5%) (14.1%) (12.6%) (10.6%) (13.3%) about the 185 508 225 552 1,470 same About the same 0.002 0.21 (39.8%) (48.3%) (48.8%) (52.3%) (48.4%) number of 53 87 76 182 398 sexual Unsure 0.05 0.72 (11.4%) (8.3%) (16.5%) (17.2%) (13.1%) partners than 59 133 30 53 275 Don’t know 0.98 0.24 uncircumc (12.7%) (12.6%) (6.5%) (5.0%) (9.1%) ised men Refuse to Answer 3 (0.6%) 4 (0.4%) - 1 (0.2%) 3 (0.3%) - 11 (0.4%) Table A3 19 Beliefs about MC and HIV (continued) Mchinji Rumphi Chi- Chi- square square Females Males (p- Females Males (p- TOTAL value) value) 50 51 Factor Less than 5 133 132 81 (17.4%) 0.01 70 (15.2%) 0.16 416 (13.7%) yr (12.6%) (12.5%) Best Age 165 187 to 60 (12.9%) 0.16 62 (13.5%) 0.04 474 (15.6%) 5-9 years (15.7%) (17.7%) circumcis 181 422 189 455 1,247 e a male 0.66 0.45 10-14 years (38.9%) (40.1%) (41.0%) (43.1%) (41.1%) is 140 186 57 (12.3%) 0.57 91 (19.7%) 0.32 474 (15.6%) 15-19 years (13.3%) (17.6%) 50 Test for significant difference between males and females in Mchinji District (if p<0.05, there is a significant difference in the observed %) 51 Test for significant difference between males and females in Rumphi District (if p<0.05, there is a significant difference in the observed %) 20-35 years 31 (6.7%) 39 (3.7%) 0.01 20 (4.3%) 38 (3.6%) 0.49 128 (4.2%) No best age 3 (0.6%) 19 (1.8%) 0.08 3 (0.6%) 2 (0.2%) 0.15 27 (0.9%) 134 52 (11.2%) 0.39 26 (5.6%) 56 (5.3%) 0.79 268 (8.8%) Don’t know (12.7%) Circumcision Procedure 403 918 429 956 2,706 is safe when carried out 0.94 0.09 (80.7% (87.3%) (93.1%) (90.5%) (89.2%) by a medical practitioner If I had my way, all men 335 699 286 568 1,888 in Mchinji/ Rumphi 0.03 0.003 (72.0%) (66.4%) (62.0%) (53.8%) (62.2%) would be circumcised What is Increased 55 (11.8%) 100 (9.5%) 0.17 26 (5.6%) 55 (5.2%) 0.73 236 (7.8%) the 344 786 365 811 2,306 0.76 0.31 likelihood Decreased (74.0%) (74.7%) (79.2%) (76.8%) (76.0%) of getting 135 19 (4.1%) 77 (7.3%) 0.02 46 (10.0%) 0.12 277 (9.1%) HIV if you Same (12.8%) are circumcise Don’t 47 (10.1%) 89 (8.5%) 0.30 24 (5.2%) 55 (5.2%) 1.00 215 (7.1%) d know 129 ANNEXURE 130 Table A3 20 Self-Reported circumcision status Mchinji (N=1,052) Rumphi (N=1,056) Chi- Chi- FACTOR squar squar TOTAL Within Within 10-20km e (p- 10-20km e (p- 10km 10km value) value) 52 53 202 107 (9.6%) Are you Yes (15.3%) 15 (4.3%) 69 (9.8%) 11 (3.1%) 54 circumcise <0.001 <0.001 d 1,906 594 336 636 340 (90.4% No (84.7%) (95.7%) (90.2%) (96.9%) ) 13 0.73 0.70 Less than 5 years 6 (5.8%) 1 (8.3%) 5 (8.3%) 1 (12.5%) (7.1%) 20 13 0.19 0.01 (10.9% 5-9 years (12.6%) 0 (0%) 4 (6.7%) 3 (37.5%) ) 51 Age at 0.55 11 0.68 (27.9% circumcisi 10-14 years 34 (33%) 5 (41.7%) (18.3%) 1 (12.5%) ) on 63 0.25 26 0.09 (34.4% 15-19 years 34 (33%) 2 (16.7%) (43.3%) 1 (12.5%) ) 36 16 0.12 14 0.92 (19.7% 20-31 years (15.5%) 4 (33.3%) (23.3%) 2 (25%) ) Median Age (Years) 14 15 17 9.5 2 1 (0.9%) 1 (7.7%) 0.08 0 (0%) 0 (0%) - CHAM hospital (1.1%) 141 75 53 Government 6 (46.1%) 0.06 7 (77.8%) 0.55 (74.6% (71.4%) (85.5%) Hospital ) 8 5 (4.8%) 1 (7.7%) 0.65 2 (3.2%) 0 (0%) 0.58 Circumcisi Private clinic (4.2%) on Setting 31 20 5 (38.5%) 0.11 4 (6.4%) 2 (22.2%) 0.11 (16.4% (19.1%) Traditional village ) 3 2 (1.9%) 0 (0%) - 1 (1.6%) 0 (0%) - Other (1.6%) 4 Don’t know 0.62 0.58 2 (1.9%) 0 (0%) 2 (3.2%) 0 (0%) (2.1%) 52 Test for significant difference between the two groups of respondents living within 10km and those within 20km from the hospital in Mchinji District (if p<0.05, there is a significant difference in the observed %) 53 Test for significant difference between the two groups of respondents living within 10km and those within 20km from the hospital in Rumphi District (if p<0.05, there is a significant difference in the observed %) 54 DHS 2010 report, 8% and 3% of men aged 15-49 years old reported being circumcised in Mchinji and Rumphi districts respectively Pleased 190 103 13 64 10 that you Yes (95.5% (98.1%) (86.7%) (94.12%) (90.9%) were 0.04 0.67 ) circumcise No/ Neither Yes 9 2 (1.9%) 2 (13.3%) 4 (5.9%) 1 (9.1%) d nor No (4.5%) FACTOR Catholic CCAP Anglican Muslim No Adventist Other Refused Total religion to answer Are you 57 (6.5%) 46 0 (0.0%) 15 0 (0.0%) 27 57 (8.9%) 1 (0%) 202 (9.6%) circumcised Yes (11.6%) (65.2%) (18.7%) No 821 352 14 8 9 (100%) 117 584 1,906 (93.5%) (88.4%) (100%) (34.8%) (81.2%) (91.1%) (90.4%) 131 ANNEXURE 132 Table A3 21 Reasons for circumcision 5556 Mchinji Rumphi Chi- Chi- square squar Within (p- Within (p- Factor 10km 10-20km value)57 10km 10-20km value Circumcised due to my ethnic 59 background 18 (17.1%) 2 (15.4%) 0.87 5 (8.1%) 1 (11.1%) 0.76 Circumcised due to my religious60 background 15 (14.3%) 2 (15.4%) 0.91 0 (0%) 1 (11.1%) 0.01 My mother/aunt/grandmother wants me to be circumcised 12 (11.4%) 2 (15.4%) 0.68 5 (8.1%) 0 (0.0%) 0.38 Father/grandfather/uncle wants me to be circumcised 11 (10.5%) 2 (15.4%) 0.59 3 (4.8%) 0 (0.0%) 0.50 Reduces my chances of getting HIV 76 (72.4%) 5 (38.5%) 0.01 47 (75.8%) 6 (66.7%) 0.56 Reduces my chances of getting other diseases 57 (54.3%) 4 (30.8%) 0.11 43 (69.3%) 6 (66.7%) 0.87 My health in general will be better 23 (21.9%) 2 (15.4%) 0.59 8 (12.9%) 0 (0.0%) 0.25 It is cleaner 61 (58.1%) 7 (53.9%) 0.77 19 (30.7%) 1 (11.1%) 0.22 Don't have to use condom 2 (1.9%) 1 (7.7%) 0.21 1 (1.6%) 0 (0.0%) 0.70 Embarrassment at being circumcised 6 (5.7%) 0 (0.0%) 0.38 2 (3.2%) 0 (0.0%) 0.58 Most of my friends are circumcised 12 (11.4%) 3 (23.1%) 0.23 5 (8.1%) 0 (0.0%) 0.38 My mother made the decision to have me circumcised as a child61 7 (6.7%) 1 (7.7%) 0.89 3 (4.8%) 0 (0.0%) 0.50 Other62 16 (15.2%) 1 (7.7%) 0.46 12 (19.4%) 3 (33.3%) 0.34 Sex is sweet for man 10 (9.5%) 1 (7.8%) 0.83 5 (8.1%) 0 (0.0%) 0.38 Sex is sweet for the partner 13 (12.4%) 13 (11.0%) 0.18 2 (3.2%) 0 (0.0%) 0.58 55 Each factor is positively correlated with factor in community discussions about male circumcision, but correlation<0.50 56 Multiple response question 57 Test for significant difference between the two groups of respondents living within 10km and those within 20km from the hospital in Mchinji district (if p<0.05, there is a significant difference in the observed %) 58 Test for significant difference between the two groups of respondents living within 10km and those within 20km from the hospital in Rumphi district (if p<0.05, there is a significant difference in the observed %) 59 Mostly among Yao and Lomwe groups 60 Mostly Muslims 61 Checked for association with Muslim respondents: There was no association among Muslim respondents 62 Other reasons cited included prevention of cervical cancer, approval from friends/family My girlfriend wants me to be circumcised 4 (3.8%) 0 (0.0%) 0.47 2 (3.2%) 0 (0.0%) 0.58 I received a voucher/ money for transport to get circumcised 5 (4.8% 1 (7.7%) 0.65 3 (4.8%) 0 (0.0%) 0.50 Table A3 22 Main reason for circumcision 63 Mchinji Rumphi Within 10- Within 10- TOTAL Factor 10km 20km 10km 20km 2 1 17 Circumcised due to my ethnic background 10 (9.5%) (15.4%) 4 (6.5%) (11.1%) (9.0%) 1 6 Circumcised due to my religious background 5 (4.5%) 0 (0%) 0 (0%) (11.1%) (3.2%) My mother/aunt/grandmother wants me to be 5 circumcised 4 (3.8%) 0 (0%) 1 (1.6%) 0 (0%) (2.7%) 6 Father/grandfather/uncle wants me to be circumcised 4 (3.8%) 1 (7.7%) 1 (1.6%) 0 (0%) (3.2%) 79 41 33 4 (41.8 Reduces my chances of HIV (39.1%) 1 (7.7%) (53.2%) (44.4%) %) 1 13 Reduces my chances of getting other diseases 4 (3.8%) 0 (0%) 8 (12.9%) (11.1%) (6.9%) 4 My health in general will be better 3 (2.9%) 0 (0%) 1 (1.6%) 0 (0%) (2.1%) 24 18 3 (12.7 It is cleaner (17.1%) (23.1%) 3 (4.8%) 0 (0%) %) 1 Don't have to use condom 1(0.9%) 0 (0%) - - (0.5%) 2 Embarrassment at being uncircumcised 2 (1.9%) 0 (0%) - - (1.1%) 133 4 8 Most of my friends are circumcised 3 (2.9%) (30.8%) 1 (1.6%) 0 (0%) (4.2%) My mother made the decision to have me circumcised as 5 3 (2.9%) 1 (7.7%) 1 (1.6%) 0 (0%) a child (2.7%) 2 16 Other 7 (6.7%) 1 (7.7%) 6 (9.7%) (22.2%) (8.5%) 1 Sex is sweet for man - - 1 (1.6%) 0 (0%) (0.5%) I received a voucher/ money for transport to get 1 circumcised - - 1 (1.6%) 0 (0%) (0.5%) ANNEXURE 63 Single response only 134 Table A3 23 Reasons for not getting circumcised 6465 Mchinji Rumphi Chi- Chi- squar squar e (p- Withi e (p- Within 10- value n 10- value TOT Factor 10km 20km )66 10km 20km )67 AL 173 506 143 73 (26.7 117 (26.5 It is against my ethnic background (24.1%) (21.7%) 0.41 %) (34.6%) 0.01 %) 73 216 68 53 (11.4 22 (11.3 It is against my religious background (11.5%) (15.8%) 0.06 %) (6.5%) 0.01 %) 259 823 298 145 (40.3 121 (43.1 Fear of pain (50.2%) (43.1%) 0.04 %) (35.8%) 0.16 %) 252 689 239 92 <0.00 (39.2 358 (36.1 Fear of injury (40.3%) (27.4%) 1 %) (31.4%) 0.01 %) 30 11 8 (1.6 Sex would not be as sweet for me 7 (1.2%) (3.3%) 0.03 (1.2%) 4 (1.2%) 0.93 %) 16 3 (0.8 Sex would not be as sweet for my partner 5 (0.8%) 6 (1.8%) 0.20 (0.5%) 2 (0.6%) 0.79 %) 23 My girlfriend(s)/ partner(s) prefer 10 (1.2 uncircumcised men 7 (1.2%) 2 (0.6%) 0.83 (1.6%) 4 (1.2%) 0.64 %) 101 My mother/aunt/grandmother don’t want 35 13 30 15 (5.3 me circumcised (5.9%) (3.9%) 0.18 (5.9%) (4.4%) 0.33 %) 103 Father/grandfather/uncle don’t want me 35 11 43 14 (5.4 circumcised (5.9%) (3.3%) 0.08 (6.7%) (4.1%) 0.10 %) 157 58 31 51 17 (8.2 Have to abstain for too long (9.8%) (9.2%) 0.78 (7.9%) (5.0%) 0.09 %) 72 17 12 34 (3.8 Don't like going to a health facility (2.3%) (3.6%) 0.55 (5.3%) 9 (2.7%) 0.06 %) 64 Multiple response question 65 Each factor is positively correlated with factor in community discussions about male circumcision, but correlation<0.50 66 Test for significant difference between the two groups of respondents living within 10km and those within 20km from the hospital in Mchinji district (if p<0.05, there is a significant difference in the observed %) 67 Test for significant difference between the two groups of respondents living within 10km and those within 20km from the hospital in Rumphi district (if p<0.05, there is a significant difference in the observed %) 20 10 4 (1.1 Have to get an HIV Test (1.7%) 5 (1.5%) 0.82 (0.6%) 1 (0.3%) 0.49 %) 65 Circumcision is not 100% effective in 30 11 19 (3.4 preventing HIV infection (5.1%) (3.3%) 0.20 (3.0%) 5 (1.5%) 0.15 %) 30 14 6 (1.6 Have to use a condom anyway (2.4%) 9 (2.7%) 0.76 (0.9%) 1 (0.3%) 0.26 %) 95 26 17 31 21 (5.0 Embarrassment at being circumcised (4.4%) (5.1%) 0.64 (4.8%) (6.2%) 0.36 %) 37 Didn't receive a voucher for transport to get 17 9 (1.9 circumcised (2.9%) 9 (2.7%) 0.87 (1.4%) 2 (0.6%) 0.25 %) 135 ANNEXURE 136 Table A3 24 Main reason 68 for not getting circumcised Mchinji Rumphi TOTA Within Within L Factor 69 10km 10-20km 10km 10-20km 325 86 50 104 85 (17.0 (14.5%) (14.9%) (16.2%) (25.2%) It is against my ethnic background %) 67 24 (4.1%) 19 (5.6%) 20 (3.1%) 4 (1.2%) It is against my religious background (3.5%) 379 118 72 130 59 (19.8 (19.9%) (21.4%) (20.2%) (17.5%) Fear of pain %) 347 102 50 131 64 (18.2 (17.2%) (14.9%) (20.4%) (18.9%) Fear of injury %) 5 2 (0.3%) 1 (0.3%) 2 (0.3%) 0 (0.0%) Sex would not be as sweet for me (0.3%) My girlfriend(s)/ partner(s) prefer uncircumcised 7 3 (0.5%) 0 (0.0%) 3 (0.5%) 1 (0.3%) men (0.4%) My mother/aunt/grandmother don’t want me 18 10 (1.7%) 3 (0.9%) 1 (0.2%) 4 (1.2%) circumcised (0.9%) Father/grandfather/uncle don’t want me 43 16 (2.7%) 4 (1.2%) 21 (3.3%) 2 (0.6%) circumcised (2.2%) 39 4 (0.7%) 3 (0.9%) 26 (4.1%) 6 (1.8%) Don't like going to a health facility (2.0%) 4 2 (0.3%) 2 (0.6%) 16 (2.5%) 1 (0.3%) Have to get an HIV Test (0.2%) Circumcision is not 100% effective in preventing 19 7(1.2%) 3 (0.9%) 8 (1.3%) 1 (0.3%) HIV (1.0%) 1 - - 1 (0.2%) 0 (0.0%) Have to use a condom anyway (0.1%) 27 9(1.5%) 3 (0.9%) 9 (1.4%) 6 (1.8%) Embarrassment at being circumcised (1.4%) Didn't receive a voucher for transport to get 14 8(1.4%) 1 (0.3%) 4 (0.6%) 1 (0.3%) circumcised (0.7%) 1 1 (0.2%) 0 (0.0%) - - No pain killers (0.1%) 613 209 125 182 105 (32.1 70 (33.9%) (37.2%) (28.4%) (31.1%) Others %) 68 Single response only 69 Each factor is positively correlated with factor in community discussions about male circumcision, but correlation<0.50 70 Other reasons mentioned include: fear of death, fear of becoming baren, long healing process, lack of time to get circumcised, lack of information/knowledge about MC, circumcision was new to the community, distance from health facility, abstaining for too long ANNEXURE 137 138 Table A3 25 Access to vouchers for MC Mchinji Rumphi Chi- Chi- TOT Within 10- square Within 10- square AL 71 72 10km 20km (p- 10km 20km (p- FACTOR value) value) 1,743 Knows where to get 608 267 630 238 <0.001 <0.001 (82.7 circumcised (86.2%) (76.3%) (89.9%) (67.8%) %) 820 Mchinji District 610 210 <0.001 - - - (47.1 Hosp. (96.8%) (88.2%) %) 766 Where can one get Rumphi District 580 183 1 (0.2%) 2 (0.8%) 0.13 <0.001 (44.0 circumcised Hosp. (95.4% (68.5%) %) 157 19 26 28 84 Other - - (9.0% (3.0%) (10.9%) (4.6%) (31.5%) ) 997 Ever heard about 368 101 435 93 (47.3 transport vouchers (52.5%) (28.8%) <0.001 (61.7%) (26.6%) <0.001 %) 321 Ever seen transport 164 10 134 13 (32.2 vouchers (44.6%) (9.9%) <0.001 (30.8%) (14.0%) 0.003 %) 280 Any friends have the 146 116 10 (87.2 vouchers (89.0%) 8 (80%) 0.62 (86.6%) (76.9%) <0.001 %) 96 Were you given vouchers 48 42 2 (29.9 yourself (29.3%) 4 (40.0% 0.47 (31.3%) (15.4%) 0.23 %) 46 Voucher changed mind 23 3 19 (47.9 about circumcision (47.9%) (75.0%) 0.58 (45.2%) 1 (50%) 0.89 %) 60 33 23 (62.5 School (68.8%) 4 (100%) (54.8%) 0 (0%) %) 17 5 11 (17.7 Where did you get the Mother group (10.4%) 0 (0%) (26.2%) 1 (50%) %) vouchers 7 (7.3% Friends 3 (6.2%) 0 (0%) 3 (7.1%) 1 (50%) ) 0.13 12 7 0.62 (12.5 Other (14.6%) 0 (0%) (11.9%)5 0 (0%) %) 71 Test for significant difference between the two groups of respondents living within 10km and those 10-20km from the hospital in Mchinji district (if p<0.05, there is a significant difference in the observed %) 72 Test for significant difference between the two groups of respondents living within 10km and those 10-20km from the hospital in Rumphi district (if p<0.05, there is a significant difference in the observed %) 66 If vouchers received, only 28 (68.7 got for oneself 36 (75%) 2 (50%) 0.28 (66.7%) 0 (0%) 0.06 %) 139 ANNEXURE 140 Table A3 25 Access to vouchers for MC (continued) Mchinji Rumphi Chi- Chi- TOTAL Within 10- square 73 Within 10- square 74 FACTOR 10km 20km (p- 10km 20km (p- value) value) 5 8 Brother 3 (25%) 0 (0%) 0.42 (35.7%) 0 (0%) 0.31 (26.7%) 3 Who else did you give the Other relative 3 (25%) 0 (0%) 0.42 0 (0%) 0 (0%) - (10.0%) vouchers to or get the vouchers from? 4 10 2 18 Friends (33.3%) 2 (100%) 0.08 (71.4%) (100%) 0.38 (60.0%) Other/ Don’t 4 4 know (33.3%) 0 (0%) - - - - (13.3%) Gave the voucher to 11 14 2 28 brother/friends/other 1 (50%) 0.12 - (91.7%) (100%) (100%) (93.3%) relative Knows if they used the 10 14 2 27 1 (100%) 0.75 - voucher (90.9%) (100%) (100%) (96.4%) Used the voucher to pay for 24 27 2 54 1 (25%) 0.34 0.30 transport for circumcision (50%) (64.3%) (100%) (56.2%) Use voucher to pay for 22 25 2 50 transport for 1st follow up 1 (100%) 0.76 0.69 (91.7%) (92.6%) (100%) (92.6%) visit Used voucher to pay for 19 25 2 47 transport for 2nd follow up 1 (100%) 0.61 0.69 (79.2%) (92.6%) (100%) (87.0%) visit 73 Test for significant difference between the two groups of respondents living within 10km and those 10-20km from the hospital in Mchinji district (if p<0.05, there is a significant difference in the observed %) 74 Test for significant difference between the two groups of respondents living within 10km and those 10-20km from the hospital in Rumphi district (if p<0.05, there is a significant difference in the observed %) Table A3 26 Factors associated with correct knowledge about VMMC among uncircumcised men in Mchinji and Rumphi districts Factors Correct Knowledge OR (95% CI) p-value aOR (95% CI) p-value 75 about VMMC Age (years) 10 - 17 41.5% (327/787) 1 - 1 - 18 - 34 66.3% 2.76 (2.28, 3.34) <0.001 (707/1,067) 1.39 (0.96, 2.01) 0.08 Education Not in school 65.1% (539/828) 1 - 1 - Primary 38.4% (273/711) 0.33 (0.27, 0.41) <0.001 0.58 (0.39, 0.88) 0.01 Secondary & above 70.5% (222/315) 1.28 (0.97, 1.70) 0.08 1.40 (0.97, 2.01) 0.07 Marital Status Not Married 51.1% 1 - 1 - (670/1,312) Married 67.2% (364/542) 1.96 (1.59, 2.41) <0.001 1.23 (0.90, 1.67) 0.20 Locality Rural 52.9% 1 - 1 - (738/1,394) Urban 64.3% (296/460) 1.60 (1.29, 1.99) <0.001 1.16 (0.89, 1.50) 0.27 Employment Status Not employed 52.5% 1 - 1 - (749/1,427) Employed 66.7% (285/427) 1.82 (1.45, 2.28) <0.001 1.22 (0.94, 1.57) 0.14 District Mchinji 53.9% (487/903) 1 - 1 - Rumphi 57.5% (547/951) 1.16 (0.96, 1.39) 0.12 1.03 (0.67, 1.56) 0.90 Distance from Hospital Within 10km 60.1% 1 - 1 - (720/1,198) 10-20km 47.9% (314/656) 0.61 (0.50, 0.74) <0.001 0.80 (0.64, 1.01) 0.07 Ethnic Group Tumbuka 56.2% (434/772) 1 - 1 - Chewa 53.0% (307/579) 0.88 (0.71, 1.09) 0.24 0.90 (0.57, 1.40) 0.63 Ngoni 58.8% (227/386) 1.11 (0.87, 1.42) 0.40 0.95 (0.61, 1.47) 0.81 Received MC information No 48.3% (463/958) 1 - 1 - from a person who is Yes 63.9% (571/894) 1.89 (1.57, 2.28) <0.001 circumcised 1.46 (1.17, 1.81) 0.001 141 Received MC information No 36.5% (136/373) 1 - 1 - from the radio Yes 60.8% 2.70 (2.13, 3.41) <0.001 (898/1,478) 1.49 (1.13, 1.95) 0.004 Received MC information No 42.5% (309/727) 1 - 1 - from mobile campaigns/ Yes 64.4% road shows 2.45 (2.02, 2.97) <0.001 (725/1,125) 1.74 (1.39, 2.16) <0.001 Table A3 27 Factors associated with intention to get circumcised among uncircumcised men in Mchinji district Factors Intend to get OR (95% CI) p-value aOR (95% CI) p-value 76 circumcised No 52.5% (135/257) 1 - 1 - ANNEXURE 75 p-value is <0.05 there is significant difference in correct knowledge about VMMC at the 95% significance level 76 p-value is <0.05 there is significant difference in intention to get circumcised at the 95% significance level 142 Have you ever seen 65.5% (74/113) Yes 1.71 (1.08, 2.71) 0.02 vouchers 2.28 (1.31, 3.96) 0.003 Age (years) 10 – 17 38.0% (131/345) 1 - 1 - 18 – 34 56.3% (300/533) 2.10 (1.59, 2.77) <0.001 1.19 (0.55, 2.58) 0.66 Education Not in school 51.9% (217/418) 1 - 1 - Primary 36.9% (121/328) 0.54 (0.40, 0.72) <0.001 0.70 (0.30, 1.63) 0.41 Secondary & above 70.5% (93/132) 2.21 (1.45, 3.36) <0.001 2.21 (1.06, 4.62) 0.04 Marital Status Not Married 47.3% (291/615) 1 - 1 - Married 53.2% (140/263) 1.27 (0.95, 1.69) 0.11 1.37 (0.72, 2.63) 0.34 Locality Rural 46.8% (325/695) 1 - 1 - Urban 57.9% (106/183) 1.57 (1.13, 2.18) 0.01 1.17 (0.68, 2.01) 0.58 Employment Status Not employed 47.4% (315/665) 1 - 1 - Employed 54.5% (116/213) 1.33 (0.97, 1.81) 0.07 0.86 (0.50, 1.46) 0.57 Distance from Hospital Within 10km 49.5% (277/560) 1 - 1 - 10-20km 48.4% (154/318) 0.96 (0.73, 1.26) 0.77 2.49 (1.37, 4.52) 0.003 Received MC information No 38.1% (160/420) 1 - 1 - from a person who is Yes 59.3% (271/457) 2.37 (1.81, 3.10) 2.37 circumcised 1.26 (0.69, 2.28) 0.45 Received MC information No 45.9% (355/774) 1 - 1 - from a sexual partner Yes 75.0% (75/100) 3.54 (2.20, 5.69) <0.001 1.96 (0.94, 4.08) 0.07 Received MC information No 39.7% (198/499) 1 - 1 - from community Yes 61.8% (233/377) 2.46 (1.87, 3.24) <0.001 organizations 1.14 (0.69, 1.88) 0.60 Received MC information No 41.2% (188/456) 1 - 1 - from a teacher/ someone Yes 57.9% (243/420) 1.96 (1.50, 2.56) <0.001 at school 1.31 (0.80, 2.15) 0.28 Received MC information No 38.3% (161/420) 1 - 1 - from Mobile campaigns/ Yes 59.1% (270/457) 2.32 (1.77, 3.04) <0.001 road shows 1.65 (1.00, 2.74) 0.05 Knows someone who has No 32.9% (100/304) 1 - 1 - been circumcised Yes 57.7% (331/574) 2.78 (2.07, 3.72) <0.001 1.52 (0.73, 3.18) 0.26 Table A3 28 Factors associated with Intention to get circumcised among uncircumcised men in Rumphi district 77 Factors Intend to get OR (95% CI) p-value aOR (95% CI) p-value 78 circumcised Age (years) 10 – 17 47.0% (199/423) 1 - 1 - 18 – 34 66.5% (336/505) 2.24 (1.71, 2.92) <0.001 1.52 (0.94, 2.48) 0.09 Education Not in school 67.8% (257/379) 1 - 1 - Primary 46.9% (172/367) 0.42 (0.31, 0.56) <0.001 0.65 (0.36, 1.18) 0.16 Secondary & above 58.2% (106/182) 0.66 (0.46, 0.95) 0.03 0.61 (0.36, 1.02) 0.06 Marital Status Not Married 54.0% (360/667) 1 - 1 - Married 67.1% (175/261) 1.73 (1.29, 2.34) <0.001 0.87 (0.54, 1.40) 0.58 77 Voucher exposure not significant in the models for Rumphi District 78 p-value is <0.05 there is significant difference in intention to get circumcised at the 95% significance level Locality Rural 59.0% (392/664) 1 - 1 - Urban 54.2% (143/264) 0.82 (0.61, 1.09) 0.18 0.67 (0.47, 0.93) 0.02 Employment Status Not employed 55.1% (401/728) 1 - 1 - Employed 67.0% (134/200) 1.65 (1.19, 2.30) 0.00 1.25 (0.86, 1.82) 0.24 Distance from Hospital Within 10km 55.7% (341/612) 1 - 1 - 10-20km 61.4% (194/316) 1.26 (0.96, 1.67) 0.10 1.81 (1.30, 2.54) 0.001 Received MC information No 48.6% (250/514) 1 - 1 - from a person who is Yes 68.8% (285/414) 2.33 (1.78, 3.06) <0.001 circumcised 1.66 (1.15, 2.40) 0.01 Received MC information No 54.6% (399/731) 1 - 1 - from a sexual partner Yes 69.4% (136/196) 1.89 (1.35, 2.64) <0.001 1.19 (0.82, 1.73) 0.37 Received MC information No 47.8% (223/466) 1 - 1 - from community Yes 67.5% (312/462) 2.27 (1.74, 2.96) <0.001 organizations 1.33 (0.98, 1.80) 0.07 Received MC information No 52.1% (185/355) 1 - 1 - from a teacher/ someone Yes 61.0% (349/572) 1.44 (1.10, 1.88) 0.008 at school 1.32 (0.96, 1.80) 0.08 Received MC information No 43.5% (123/283) 1 - 1 - from Mobile campaigns/ Yes 63.9% (412/645) 2.30 (1.73, 3.06) <0.001 road shows 1.79 (1.29, 2.49) <0.001 Knows someone who has No 47.0% (189/402) 1 - 1 - been circumcised Yes 346/526 (65.8%) 2.17 (1.66, 2.83) <0.001 1.63 (1.11, 2.40) 0.01 Table A3 29 Factors associated with voucher exposure (ever heard about MC vouchers) among men in Mchinji and Rumphi districts Factors Ever heard about Transport OR (95% CI) p-value79 aOR (95% CI) p-value VOUCHERS No 45.5% (851/1,871) 1 - 1 - Are you circumcised Yes 73.7% (146/198) 3.36 (2.42, 4.68) <0.001 2.34 (1.58, 3.46) <0.001 10 - 17 45.3% (389/859) 1 - 1 - Age (years) 18 - 34 50.2% (608/1,210) 1.22 (1.02, 1.45) 0.03 0.84 (0.58, 1.21) 0.35 143 Not in school 47.0% (431/917) 1 - 1 - Education Primary 43.0% (337/783) 0.85 (0.70, 1.03) 0.10 0.90 (0.61, 1.32) 0.59 Secondary & above 62.1% (229/369) 1.84 (1.44, 2.36) <0.001 1.24 (0.91, 1.67) 0.17 Rural 42.5% (646/1,520) 1 - 1 - Locality Urban 63.9% (351/549) 2.40 (1.96, 2.93) <0.001 1.31 (1.03, 1.67) 0.03 Not employed 47.4% (751/1,584) 1 - 1 - Employment Status Employed 50.7% (246/485) 1.14 (0.93, 1.40) 0.20 1.03 (0.79, 1.30) 0.92 Mchinji 46.0% (469/1,020) 1 - 1 - District Rumphi 50.3% (528/1,049) 1.19 (1.00, 1.41) 0.05 1.03 (0.70, 1.52) 0.87 Distance from Within 10km 58.0% (803/1,384) 1 - 1 - Hospital 10-20km 28.3% (194/685) 0.29 (0.23, 0.35) <0.001 0.43 (0.35, 0.55) <0.001 Ethnic Group Tumbuka 47.9% (404/843) 1 - 1 - ANNEXURE 79 If p-value is <0.05 there is significant difference in voucher exposure at the 95% significance level 144 Chewa 44.1% (290, 658) 0.85 (0.70, 1.05) 0.14 0.95 (0.63, 1.43) 0.81 Ngoni 50.6% (209/413) 1.11 (0.88, 1.41) 0.37 0.99 (0.66, 1.49) 0.98 Received MC No 36.6% (379/1,035) 1 - 1 - information from a person who is Yes 59.8% (618/1,033) 2.58 (2.16, 3.08) <0.001 1.67 (1.35, 2.06) <0.001 circumcised Received MC No 45.3% (772/1,704) 1 - 1 - information from a sexual partner Yes 62.1% (224/361) 1.97 (1.56, 2.49) <0.001 1.37 (1.03, 1.81) 0.03 Table A3 29 Factors associated with voucher exposure (ever heard about MC vouchers) among men in Mchinji and Rumphi districts (continued) Received MC No 39.2% (456/1,162) 1 - 1 - information from billboards/ posters Yes 59.6% (539/904) 2.29 (1.91, 2.73) <0.001 1.23 (0.98, 1.54) 0.07 Received MC No 33.3% (258/775) 1 - 1 - information from mobile campaigns/ Yes 57.1% (739/1,293) 2.67 (2.20, 3.22) <0.001 1.89 (1.51, 2.37) <0.001 road shows Received MC No 38.6% (335/867) 1 - 1 - information from a health facility Yes 55.1% (662/1,201) 1.95 (1.63, 2.33) <0.001 1.23 (0.99, 1.54) 0.06 Received MC No 39.9% (359/900) 1 - 1 - information from a teacher/ someone at Yes 54.6% (637/1,166) 1.81 (1.52, 2.16) <0.001 1.11 (0.89, 1.38) 0.36 school Table A3 30 Factors associated with voucher exposure (ever seen MC vouchers) among men in Mchinji and Rumphi districts Factors Ever seen Transport OR (95% CI) p-value aOR (95% CI) p-value80 VOUCHERS No 26.3% (223/849) 1 - 1 - Are you circumcised Yes 67.1% (98/146) 5.73 (3.93, 8.36) <0.001 5.42 (3.43, 8.57) <0.001 10 - 17 38.9% (151/388) 1 - 1 - Age (years) 18 - 34 28.0% (170/607) 0.61 (0.46, 0.80) <0.001 0.78 (0.46, 1.35) 0.38 Not in school 22.3% (96/430) 1 - 1 - Education Primary 39.3% (132/336) 2.25 (1.64, 3.08) <0.001 2.48 (1.35, 4.53) 0.003 Secondary & above 40.6% (93/229) 2.38 (1.68, 3.37) <0.001 1.86 (1.19, 2.91) 0.007 Rural 25.2% (163/646) 1 - 1 - Locality Urban 45.3% (158/349) 2.45 (1.86, 3.22) <0.001 2.00 (1.42, 2.83) <0.001 Not employed 33.0% (247/749) 1 - 1 - 145 Employment Status Employed 30.1% (74/246) 0.87 (0.64, 1.19) 0.40 0.95 (0.64, 1.40) 0.78 Mchinji 37.1% (174/469) 1 - 1 - District Rumphi 28.0% (147/526) 0.66 (0.50, 0.86) 0.002 0.91 (0.54, 1.51) 0.71 ANNEXURE 80 If p-value is <0.05 there is significant difference in voucher exposure at the 95% significance level 146 Table A3 31 Factors associated with voucher exposure (ever seen MC vouchers) among men in Mchinji and Rumphi districts (continued) Within 10km 37.2% (298/802) 1 - 1 - Distance from Hospital 10-20km 11.9% (23/193) 0.23 (0.14, 0.36) <0.001 0.41 (0.25, 0.68) 0.001 Tumbuka 24.9% (100/402) 1 - 1 - Ethnic Group Chewa 34.1% (99/290) 1.56 (1.12, 2.18) 0.01 1.37 (0.77, 2.41) 0.28 Ngoni 40.2% (84/209) 2.03 (1.42, 2.90) <0.001 2.39 (1.39, 4.12) 0.002 Received MC No 22.5% (85/378) 1 - 1 - information from a person who is Yes 38.2% (236/617) 2.13 (1.59, 2.86) <0.001 1.52 (1.06, 2.16) 0.02 circumcised Received MC No 22.4% (75/335) 1 - 1 - information from a health facility Yes 37.3% (246/660) 2.06 (1.52, 2.78) <0.001 2.06 (1.42, 2.99) <0.001 Received MC No 24.4% (87/357) 1 - 1 - information from a teacher/ someone at Yes 36.7% (234/637) 1.80 (1.35, 2.41) <0.001 1.08 (0.75, 1.56) 0.67 school Table A3 31 District weights assigned to synthetic control for Rumphi district District Weight Balaka 0 Chitipa 0.635 Dedza 0 Dowa 0 Karonga 0 Kasungu 0 Machinga 0 Mangochi 0 Mwanza 0 Mzimba 0.162 Neno 0 Nkhata Bay and Likoma 0.04 Nkhotakota 0 Nsanje 0.163 Ntcheu 0 Ntchisi 0 Salima 0 Table A3 32 District weights assigned to synthetic control for Mchinji district District Weight Balaka 0.01 ANNEXURE Chitipa 0 Dedza 0 Dowa 0.25 Karonga 0 Kasungu 0.1 Machinga 0 Mangochi 0 Mwanza 0 Mzimba 0 Neno 0 Nkhata Bay and Likoma 0 Nkhotakota 0 Nsanje 0.117 Ntcheu 0.324 Ntchisi 0 Salima 0.199 147 IMPACT EVALUATION ON IMPROVING VMMC DEMAND IN MALAWI THROUGH THE USE OF INCENTIVE Table A3 33 Characteristics of Rumphi district and its synthetic control Rumphi Synthetic control Monthly male circumcision rate per 1000 men (pre-intervention) 0.48 0.48 Adult female population (> 15 years) 57110.0 58688.4 Adult male population (>15 years) 54032.0 53241.7 Outpatient visits per 1000 population 2873.0 2876.8 Ratio of PLHIV / ART recipients 0.71 0.94 Estimated demand of male circumcision (per 1000 men) 864.6 903.8 Region code (1=North, 2=Central, 3=South) 2.0 2.0 Table A3 34 Characteristics of Mchinji district and its synthetic control Mchinji Synthetic control Monthly male circumcision rate per 1000 men (pre-intervention) 0.24 0.24 Adult female population (> 15 years) 146992.0 153412.2 Adult male population (>15 years) 146621.0 141918.3 Outpatient visits per 1000 population 1803.0 2200.1 Ratio of PLHIV / ART recipients 1.89 1.46 Estimated demand of male circumcision (per 1000 men) 878.4 1047.6 Region code (1=North, 2=Central, 3=South) 3.0 2.7 Table A3 35 Districts used for synthetic control analysis District NAC Data Reason no data Balaka Y Chitipa Y Dedza Y Dowa Y Karonga Y Kasungu Y Machinga Y Mangochi Y Mchinji Y Mwanza Y Mzimba Y Neno Y Nkhata Bay and Likoma* Y Nkhotakota Y Nsanje Y Ntcheu Y Ntchisi Y Rumphi Y Salima Y Lilongwe N PEPFAR District Blantyre N PEPFAR District Chikwawa N PEPFAR District Chiradzulu N PEPFAR District Mulanje N PEPFAR District Thyolo N PEPFAR District 148 ANNEXURE Phalombe N PEPFAR District Zomba N PEPFAR District Note: *Nkhata Bay and Likoma have been combined into one variable in order to use the VMMC demand data because data was displayed in combination in that study Table A3 36 Circumcision and HIV knowledge Mchinji Rumphi TOTAL Chi- Chi- squa FACTOR squar Femal re Female Males Males e (p- es (p- s value valu )82 e)81 203 595 615 Removal of the entire <0.0 251 1,664 (43.4 (56.6 (58.2% 0.17 foreskin 83 01 (54.4%) (54.9%) %) %) ) 71 169 194 Removal of the foreskin, but 73 507 (15.3 (16.1 0.69 (18.4% 0.23 not entire foreskin (15.8%) (16.7%) Describe %) %) ) what you 13 34 16 40 103 Removal of the penis 0.65 0.76 think male (2.8%) (3.2%) (3.5%) (3.8% (3.4%) circumcision 16 18 22 61 is Other - 5 (1.1%) - (3.4%) (1.7%) (2.1% (2.0%) 154 219 180 <0.0 107 660 Don’t know84 (33.1 (20.8 (17.1% 0.01 01 (23.2%) (21.8%) %) %) ) 8 17 5 39 Refused to answer - 9 (1.9%) - (1.8%) (1.6%) (0.5%) (1.3%) 72 183 How likely 39 68 362 More likely (15.5 (17.4 0.36 0.16 are (8.5%) (6.4%) (11.9%) %) %) circumcised 330 685 842 men to get 367 2,224 Less likely (71.0 (65.1 0.03 (79.7% 0.95 infected (79.6%) (73.3%) %) %) ) with HIV compared to 24 98 22 78 222 About the same 0.01 0.06 uncircumcis (5.2%) (9.3%) (4.8%) (7.4%) (7.3%) ed men 39 86 33 68 226 Don’t know 0.89 0.60 (8.4%) (8.2%) (7.2%) (6.4%) (7.5%) 380 891 883 Knows health facility where someone can be 369 2,523 (81.7 (84.7 0.15 (83.6% 0.10 circumcised (80.0%) (83.2%) %) %) ) 81 Test for significant difference between males and females in Mchinji District (if p<0.05, there is a significant difference in the observed %) 82 Test for significant difference between males and females in Rumphi District (if p<0.05, there is a significant difference in the observed %) 83 Significantly associated with circumcision status: 54.1% among uncircumcised men vs 88.1% among circumcised men (p<0.001) 84 Significantly associated with circumcision status: 20.8% among uncircumcised men vs 1% among circumcised men (p<0.001) 149 150 242 714 616 Knows someone personally who has been <0.0 203 <0.00 1,775 (52.0 (67.9 (58.3% circumcised 01 (44.0%) 1 (58.5%) %) %) ) Table A3 36 Circumcision and HIV knowledge (continued) Mchinji Rumphi Chi- Chi- square square FACTOR Females Males Females Males TOTAL (p- (p- value)85 value)86 24 71 22 64 181 Medical 0.24 0.32 (5.2%) (6.8%) (4.8%) (6.1%) (6.0%) To protect against 386 898 418 953 2,655 0.24 0.8 HIV & other STIs (83.0%) (85.4%) (90.7%) (90.2%) (87.5%) 62 147 44 125 378 Ethnicity/Religion 0.74 0.19 (13.3%) (14.0%) (9.5%) (11.8%) (12.5%) 153 338 77 228 796 Hygiene/Cleanliness 0.77 0.03 Why do you (32.9%) (32.1%) (16.7%) (21.6%) (26.2%) think 10 18 33 69 Social Desirability 0.58 8 (1.7%) 0.12 circumcision is (2.2%) (1.7%) (3.1%) (2.3%) carried out Perceived Health 52 96 30 74 252 0.21 0.72 Benefits (11.2%) (9.1%) (6.5%) (7.0%) (8.3%) Perceived sexual 26 64 20 48 158 0.71 0.86 benefits (5.6%) (6.1%) (4.3%) (4.5%) (5.2%) 8 7 19 3 (0.7%) 0.81 1 (0.2%) 0.27 Cosmetics (0.8%) (0.7%) (0.6%) Socio-economic 2 13 16 1 (0.2%) 0.92 0 (0%) 0.02 status (0.2%) (1.2%) (0.5%) 85 Test for significant difference between males and females in Mchinji District (if p<0.05, there is a significant difference in the observed %) 86 Test for significant difference between males and females in Rumphi District (if p<0.05, there is a significant difference in the observed %) Table C3 36 Circumcision and HIV knowledge( continued) Mchinji Rumphi Chi- Chi- squa squa TOTA FACTOR re re Females Males Females Males L (p- (p- valu valu e) e) 2,083 321 616 354 792 Would you (68.7 (69.0%) (58.5%) (76.8%) (75.0%) recommen Yes %) d MC to 813 113 374 <0.0 92 234 others 0.35 (26.8 (24.3%) (35.6%) 01 (20.0%) (22.2%) No %) 138 31 62 15 30 (2.8% (4.5% (6.7%) (5.9%) (3.2%) Neither Yes/ No ) 9 Its associated with one’s 0 (0%) 5 (0.8%) 0.11 3 (0.8%) 1 (0.1%) 0.05 (0.4% ethnicity ) 45 16 21 It’s associated with being 0.24 2 (0.6%) 6 (0.8%) 0.72 (2.2% (5.0%) (3.4%) religious ) 135 18 57 19 41 0.05 0.89 (6.5% (5.6%) (9.2%) (5.4%) (5.2%) Sex sweet for man ) 156 22 60 24 50 0.14 0.77 (7.5% (6.8%) (9.7%) (6.8%) (6.3%) Sex sweet partner ) Reasons for 1,902 recommen 300 557 325 720 0.11 0.62 (91.3 ding MC to (93.5%) (90.4%) (91.8%) (90.9%) Reduces chance of HIV %) others87 1,538 151 214 423 284 617 Reduces chance of other 0.53 0.38 (73.8 (66.7%) (68.7%) (80.2%) (77.9%) STIs %) 318 55 101 47 115 Health in general will be 0.77 0.58 (15.3 (17.1%) (16.4%) (13.3%) (14.5%) better %) 755 152 307 82 214 0.47 0.17 (36.3 (47.3%) (49.8%) (23.2%) (27.0%) It is cleaner %) 10 4 (1.2%) 5 (0.8%) 0.52 0 (0%) 1 (0.1%) 0.50 (0.5% No need to use a condom ) 87 Other reason mentioned included that MC helps to prevent the partner from getting cervical cancer 152 10 Won't be embarrassed at 2 (0.6%) 6 (1.0%) 0.58 1 (0.3%) 1 (0.1%) 0.56 (0.5% being circumcised ) 1,240 234 343 215 448 (40.9 Have you (50.3%) (32.6%) (46.6%) (42.4%) Yes %) been to a 1,793 healthcare 231 708 <0.0 246 608 0.13 (59.1 provider in (49.7%) (67.3%) 01 (53.4%) (57.6%) No %) the last year 1 0 (0.0%) 1 (0.1%) - - (0.0% Refused to Answer ) 717 131 205 138 243 Did (57.8 (56.0%) (59.8%) (64.2%) (54.2%) Provider Yes %) 0.37 0.02 talk about 523 103 138 77 205 HIV (42.2 (44.0%) (40.2%) (35.8%) (45.8%) No %) 402 51 136 <0.0 74 141 0.45 (32.4 (21.8%) (39.6%) 01 (34.4%) (31.5% Did Yes %) Provider 838 183 207 141 307 talk about (67.6 (78.2%) (60.3%) (65.6%) (68.5%) MC No %)