aIncludes the listing of men as well as the subsequent random selection of men, which allowed for more than 1 man per household.
bTwo sublocations were subsequently subdivided since the 2009 Kenya Population and Housing Census, resulting in 9 sublocations from which participants were selected.
cParticipants received the voucher upon the condition of undergoing voluntary medical male circumcision (VMMC). Because of varying exchange rates, US dollar conversions (from Kenya shillings) are approximate.
eAppendix. Trial Protocol: Compensation for Transport Costs and Lost Wages Associated With VMMC Uptake: an Intervention to Increase VMMC Demand Among Older Men in Nyanza Province
Thirumurthy H, Masters SH, Rao S, Bronson MA, Lanham M, Omanga E, Evens E, Agot K. Effect of Providing Conditional Economic Compensation on Uptake of Voluntary Medical Male Circumcision in KenyaA Randomized Clinical Trial. JAMA. 2014;312(7):703-711. doi:10.1001/jama.2014.9087
Novel strategies are needed to increase the uptake of voluntary medical male circumcision (VMMC) in sub-Saharan Africa and enhance the effectiveness of male circumcision as an HIV prevention strategy.
To determine whether small economic incentives could increase circumcision prevalence by addressing reported economic barriers to VMMC and behavioral factors such as present-biased decision making.
Design, Setting, and Participants
Randomized clinical trial conducted between June 22, 2013, and February 4, 2014, among 1504 uncircumcised men aged 25 to 49 years in Nyanza region, Kenya. VMMC services were provided free of charge and participants were randomized to 1 of 3 intervention groups or a control group.
Participants in the 3 intervention groups received varying amounts of compensation conditional on undergoing circumcision at 1 of 9 study clinics within 2 months of enrollment. Compensation took the form of food vouchers worth 200 Kenya shillings (≈US $2.50), 700 Kenya shillings (≈US $8.75), or 1200 Kenya shillings (≈US $15.00), which reflected a portion of transportation costs and lost wages associated with getting circumcised. The control group received no compensation.
Main Outcomes and Measures
VMMC uptake within 2 months.
Analysis of data for 1502 participants with complete data showed that VMMC uptake within 2 months was higher in the US $8.75 group (6.6%; 95% CI, 4.3%-9.5% [25 of 381]) and the US $15.00 group (9.0%; 95% CI, 6.3%-12.4% [34 of 377]) than in the US $2.50 group (1.9%; 95% CI, 0.8%-3.8% [7 of 374]) and the control group (1.6%; 95% CI, 0.6%-3.5% [6 of 370]). In logistic regression analysis, the US $8.75 group had significantly higher VMMC uptake than the control group (adjusted odds ratio [AOR] 4.3; 95% CI, 1.7-10.7), as did the US $15.00 group (AOR 6.2; 95% CI, 2.6-15.0). Effect sizes for the US $8.75 and US $15.00 groups did not differ significantly (P = .20).
Conclusions and Relevance
Among uncircumcised men in Kenya, compensation in the form of food vouchers worth approximately US $8.75 or US $15.00, compared with lesser or no compensation, resulted in a modest increase in the prevalence of circumcision after 2 months. The effects of more intense promotion or longer implementation require further investigation.
clinicaltrials.gov Identifier: NCT01857700
Following 3 randomized trials demonstrating that medical male circumcision reduces men’s risk of HIV acquisition by 50% to 60%,1- 3 in 2007 UNAIDS and the World Health Organization recommended the scale-up of voluntary medical male circumcision (VMMC) in 14 countries in eastern and southern Africa.4 To achieve 80% circumcision prevalence among HIV-uninfected men aged 15 to 49 years, a total of 20.3 million and 8.4 million circumcisions will need to be performed in these countries between 2011-2015 and 2016-2025, respectively.5 Despite considerable scale-up efforts, most countries are far short of the targets associated with 80% circumcision prevalence.6 Although Kenya is one of few countries where circumcision prevalence has risen substantially, uptake has been highest among adolescents and lowest among men aged 25 to 49 years.7 Novel strategies are needed to increase VMMC uptake. To date, no trials of interventions to increase demand for VMMC have been conducted and recent reviews have identified this as a priority for implementation science research.6,8
Although VMMC is generally acceptable in noncircumcising communities in sub-Saharan Africa,9 numerous barriers to VMMC uptake have also been documented.9- 11 Concern about lost wages during and after the circumcision procedure has been one commonly reported barrier. Low circumcision uptake may be further explained by the behavioral economics concept of present-biased preferences, which posits that individuals place greater emphasis on costs and benefits that are immediate rather than those that are delayed.12,13 To address these barriers, this study tested an intervention to increase demand for VMMC among older men in Kenya, based on prior research showing that incentives can modify health behaviors.14,15
We conducted a randomized clinical trial in Kenya that examined whether the provision of small amounts of conditional economic compensation could increase VMMC uptake among men aged 25 to 49 years.
The study took place within 3 districts in the Nyanza region of western Kenya. Adult HIV prevalence in the region is 15.1%,16 and primary occupations include subsistence farming, fishing, wage labor, and various forms of skilled and casual wage labor. The study was conducted in collaboration with Impact Research and Development Organization (IRDO), the largest VMMC service delivery organization in Kenya and primary provider of VMMC services in the study area.
The study received approval from the Office of Human Research Ethics at the University of North Carolina at Chapel Hill and the ethics and research committee at Kenyatta National Hospital, University of Nairobi (trial protocol is provided in the Supplement). Seven of 76 sublocations in the study area were first randomly selected using selection probabilities proportional to each sublocation’s population (Figure). Two of these sublocations were subsequently determined to have been subdivided since the 2009 Kenya Population and Housing Census, resulting in a total of 9 sublocations from which study participants were selected. Trained research assistants conducted a listing of households in the study sublocations from March 2013 through April 2013 and recorded names of all male household members aged 25 to 49 years.
A random sample of men who were listed was then selected for home visits by research assistants, which took place from June 22, 2013, to December 4, 2013. Initially a random sample of 2100 men was selected and subsequently additional men were randomly selected to serve as replacements until the study had enrolled the target number of men who met eligibility criteria. Research assistants attempted to contact the randomly selected men and recruit those who met eligibility criteria: self-reported age between 25 and 49 years, self-reported to be uncircumcised, and with no intention to leave the study area in the next 3 months. The trained research assistants, who were fluent in Kiswahili and Dholuo (the 2 languages that are spoken in the study region), obtained written informed consent from the participants. Afterwards, the eligible participants were administered a brief questionnaire, provided with general information about the risks and benefits of VMMC, and then randomized in a 1:1:1:1 ratio to 1 of the 4 study groups. Randomization was performed using computer-generated scratch cards and balanced block randomization (block size, 100). Scratch cards were offered to participants sequentially and revealed the study group assignment to the participant and research assistant at the same time. The cards also served as referrals for undergoing circumcision so that VMMC uptake could be recorded at clinics. Unless participants voluntarily chose to seek VMMC services at IRDO clinics in the study area, they had no further contact with research assistants after the enrollment visit.
All participants received information about 9 IRDO clinics in the study area where VMMC services were available free of charge, as is the case in most of Kenya. Participants in the control group received no economic compensation if they underwent circumcision at one of the clinics. Participants randomized to the 3 intervention groups were informed that they would receive food vouchers worth 200 Kenya shillings (≈US $2.50), 700 Kenya shillings (≈US $8.75), or 1200 Kenya shillings (≈US $15.00) if they underwent circumcision at one of the clinics within 2 months. These amounts approximated transportation costs from participants’ homes to a clinic or dispensary (≈US $2.50); transportation costs plus 1 to 2 days’ wages for most men based on the interquartile range (IQR) of study participants’ daily wages (≈US $8.75); and transportation costs plus 2 to 3 days’ wages for most men based on the IQR of study participants’ daily wages (≈US $15.00). Importantly, the largest food voucher amount was comparable to likely costs associated with circumcision in order to minimize the risk of coercion. The duration of time that the compensation offer remained valid was 2 months because this study sought to rapidly determine the acceptability, feasibility, and short-term effectiveness of the interventions. Food vouchers were selected as the form of compensation because of concerns about the potential for social harms that could result from distributing cash. The food vouchers listed 12 shops in the study area where they could be redeemed.
When developing the interventions, researchers for this study consulted with various community stakeholders and national and provincial VMMC task forces. Support was also obtained from the local Ministry of Health officials and a community advisory board.
VMMC uptake was monitored at study clinics until February 4, 2014. All participants were asked to present their scratch cards to a study research assistant at the IRDO clinics if they decided to uptake VMMC within 2 months of enrollment. Participants in the 3 intervention groups were offered the food vouchers by study research assistants immediately after the circumcision procedure, which the research assistants verified by consulting with surgeons at the clinic. Research assistants also verified the participants’ identity with national identification cards or another form of identification. VMMC uptake was also verified at the end of the study by comparing names of participants with names appearing on official VMMC registers maintained by IRDO. No discrepancies in VMMC uptake were found in this comparison.
The primary, prespecified outcome was VMMC uptake within 2 months of enrollment. The outcome was coded as a binary variable equal to 1 if the participant underwent circumcision at study clinics within 2 months of enrollment and 0 if the participant did not. The primary analysis compared VMMC uptake in each intervention group to the control group using logistic regression. A Wald test was performed to compare the coefficients for the US $8.75 and US $15.00 groups. The analysis also estimated logistic regression models that adjusted for participants’ age, educational attainment, marital status, and wealth. Age was defined as a categorical variable with 5-year age categories (using age 25-29 years as the reference standard); and education was defined as a categorical variable indicating different levels of school completion (using less primary school attainment as the reference standard). Marital status was defined as a binary variable to indicate whether the participant was married. Participants’ wealth was measured by an asset index defined as the sum of affirmative responses to ownership of 11 household items. Participants with missing information on these covariates were excluded from the analyses.
In secondary analyses, VMMC uptake among participants in the US $8.75 and US $15.00 groups (those receiving high compensation) was compared with uptake among participants in the control and US $2.50 groups (low compensation) using logistic regression. Subgroup analyses were conducted to determine the effects of providing high compensation to participants with certain demographic and socioeconomic characteristics, self-reported sexual behavior or HIV risk, and attitudes toward circumcision. Subgroup analyses included significance testing of the subgroup-intervention interaction term in logistic regression models that also adjusted for the covariates described above. All statistical tests were 2-sided and significance was set at a P value of less than .05. Statistical analyses were performed using Stata version 13.1 (StataCorp).
The planned sample size for the trial was 1500, with 375 participants in each study group. Power calculations indicated that with a sample size of 375 per study group and 10% VMMC uptake in the control group, there would be 90% power to detect a difference in uptake as small as 9% and 80% power to detect a difference in uptake as small as 7%. At the time that power calculations were performed, there were no data available to our knowledge on the incidence of VMMC uptake among 25- to 49-year-old men in the study region. This study was powered to detect a 7% to 9% difference in circumcision uptake because it was thought that this would constitute a large enough increase to be significant from a policy standpoint. Informal discussions with VMMC implementing organizations and policy makers led authors for this study to believe that such an effect size within a 2-month period would warrant consideration for scale-up of the intervention.
A total of 3717 men aged 25 to 49 years were listed in study sublocations and 3333 of these men were randomly sampled and assessed for eligibility and enrollment. Among the 3333 men, 1504 were enrolled and randomized to the 4 study groups (Figure). Enrollment of uncircumcised participants required considerable effort because many men did not meet eligibility criteria; 830 reported already being circumcised and 146 did not meet self-reported age and residential criteria. Because a period of 3 to 8 months elapsed between household listing and enrollment, a larger than expected number of men had left the study area by the time of enrollment (n = 410). Other reasons for nonenrollment included difficulty locating men at home (n = 209) and being busy or declining to participate (n = 119). Among the 2334 participants (1504 + 830) whose self-reported circumcision status was obtained, circumcision prevalence was 35.6% (830 of 2334). Two of the 1504 participants were excluded from the analyses due to missing information on covariates, resulting in an analysis sample of 1502 participants.
Participants in the 4 study groups generally had similar characteristics at baseline (Table 1). Nearly all participants were from the Luo ethnic group, the largest in the region and one that is traditionally noncircumcising. Participants reported being economically active; mean hours worked in the past week were 47.1 (SD, 19.8) and median daily earnings were US $5.00 (IQR, $3.80-$7.50). Participants’ self-reported sexual behavior and male circumcision attitudes were similar in all study groups (Table 2). The vast majority of participants (68%) reported the possibility of being unable to work temporarily as their greatest concern about getting circumcised, 15% reported fear of pain, and 16% reported other factors.
Table 3 shows that 2-month VMMC uptake was higher among participants randomized to receive compensation of approximately US $8.75 (6.6%; 95% CI, 4.3%-9.5% [25 of 381]) or approximately US $15.00 (9.0%; 95% CI, 6.3%-12.4% [34 of 377]). The VMMC uptake in the US $2.50 group (1.9%; 95% CI, 0.8%-3.8% [7 of 374]) was similar to uptake in the control group (1.6%; 95% CI, 0.6%-3.5% [6 of 370]). A mean of 26 days elapsed between enrollment in the study and VMMC uptake (SD, 23 days).
Logistic regression analysis of VMMC uptake (Table 3) indicated that compared with participants in the control group, those in the US $15.00 group were significantly more likely to get circumcised within 2 months (OR, 6.0; 95% CI, 2.5-14.5). Participants in the US $8.75 group were also significantly more likely to uptake VMMC (OR, 4.3; 95% CI, 1.7-10.5). Those enrolled in the US $2.50 group, however, were not significantly more likely to uptake VMMC (OR, 1.2; 95% CI, 0.4-3.5). The effect sizes of the US $8.75 and US $15.00 groups did not differ significantly (P = .21). Results from the adjusted logistic regression analysis were similar, with significant increases in the likelihood of VMMC uptake among those in the US $15.00 and US $8.75 groups (AOR, 6.2; 95% CI, 2.6-15.0 and AOR, 4.3; 95% CI, 1.7-10.7, respectively). There were no adverse events reported in any of the study groups. Examples of adverse events related to the study would have included cases in which participants felt coerced to undergo circumcision or negative rumors about the intervention that would have led to participants suffering social harm.
The results in Table 3 were used as the basis for combining participants receiving low compensation (control and US $2.50 groups, in which VMMC uptake was similar) or high compensation (US $8.75 and US $15.00 groups, in which VMMC uptake was higher and also similar) and then comparing the effectiveness of providing high compensation in participant subgroups that had different characteristics. Participants offered high compensation were significantly more likely to become circumcised than participants offered low compensation (Table 4; AOR, 5.0; 95% CI, 2.7-9.2). Among all subgroups examined in this study, provision of high compensation significantly increased the likelihood of getting circumcised. This included married participants (AOR, 4.5; 95% CI, 2.3-9.1), participants older than age 33 years (AOR, 7.9; 95% CI, 2.7-22.7), as well as participants who self-reported having any other sex partner besides the primary in the past year at baseline (AOR, 11.8; 95% CI, 1.4-98.7). The intervention also significantly increased the likelihood of circumcision among participants who self-reported a low likelihood of getting circumcised in the near future (AOR 7.8; 95% CI, 3.0-20.2). There were no statistically significant interactions within any of the analyzed subgroups (Table 4).
This study demonstrates that incentives were effective in increasing VMMC uptake because participants offered compensation in the form of food vouchers worth approximately US $15.00 and approximately US $8.75 were significantly more likely to become circumcised within 2 months than participants in the control group. There was also a significant increase in VMMC uptake among married and older participants, groups that have been harder to reach previously. The interventions also significantly increased the likelihood of circumcision uptake among participants at higher risk of acquiring HIV. This latter result is especially promising from an HIV-prevention standpoint. The overall increase in VMMC uptake within 2 months, as a result of providing compensation, was modest, with an increase of at most 7.4% in the US $15.00 group. This increased uptake was in a population with an estimated circumcision prevalence of 35.6%. Evaluation of scaled-up implementation of the intervention is needed to determine whether it will help achieve higher circumcision coverage over longer periods of time.
This study adds to an as yet small evidence base on effective strategies to create demand for male circumcision. Although a number of qualitative studies and a few quantitative studies have examined stated barriers to and facilitators of VMMC demand in sub-Saharan Africa,11,17,18 none have tested specific individual-level interventions to create demand. While one study has shown that prices for VMMC services may influence demand,19 the study reported herein is unique in testing the effect of economic incentives on demand for VMMC. In light of the fact that VMMC services are already provided free of charge in many priority countries in sub-Saharan Africa and that economic factors continue to be reported as a barrier to VMMC uptake, the intervention tested here is one that has considerable relevance and applicability for countries and programs seeking ways to increase circumcision prevalence. The study also strengthens our broader understanding of how economic incentives can promote HIV-related health behaviors by addressing economic barriers and decision-making errors identified in behavioral economics. Incentives have previously been used to promote various health and education behaviors in low-income countries,14,15,20 and recently their use has also been shown to reduce HIV and sexually transmitted infection prevalence.21 However, despite growing interest in using incentives to promote HIV-related behaviors such as HIV testing uptake, linkage to HIV care, and retention in care, evidence from randomized trials has been limited.22- 26 This study illustrates the strengths and limitations of using incentives as a strategy for modifying such behaviors and preventing new HIV infections.
From a policy standpoint, an appealing feature of the intervention implemented in this study is that most of the costs (the compensation amounts) would be incurred only if circumcision uptake occurs. While a cost-effectiveness analysis was beyond the scope of this study, the intervention is likely to be highly cost effective given estimates that 1 HIV infection can be averted for every 5 to 15 VMMCs performed and given lifetime HIV treatment costs.27- 29 The sustainability of the intervention is also enhanced because it is for a 1-time behavior rather than a recurring health behavior. The 1-time compensation amounts in the study, which equated to roughly 1 to 3 days of wages in the case of the US $8.75 and US $15.00 vouchers as well as transportation costs, compare favorably to the amounts used in other studies of incentives to modify health behavior. In high-income countries, comparable amounts, adjusting for relative income levels, have been used to promote behaviors such as smoking cessation (≈US $750 over 12 months).30 In low- and middle-income countries, considerably larger amounts of transfers have been used to incentivize children’s school attendance and health behaviors in conditional cash transfer programs, ranging from approximately 25% to 44% of poor households’ incomes in rural areas of Mexico (Progresa and Oportunidades programs) to approximately US $10.00 per household on a monthly basis in Malawi.21,31,32 Although it is difficult to draw comparisons across behaviors and settings, these examples provide context for the compensation amounts used in this study. Finally, there are multiple reasons why offering compensation amounts of approximately US $8.75 or approximately US $15.00 on a wider scale may result in larger effects on VMMC uptake than observed here. First, because this study aimed to rapidly ascertain whether the intervention was acceptable, feasible, and effective, a short VMMC uptake period of 2 months during which compensation was provided was intentionally chosen. It is plausible that a higher proportion of men would become circumcised if a scaled-up intervention offered compensation over a prolonged duration. Second, a scaled-up version of this intervention would presumably also include more promotion of it using mass media, which could in turn increase its effectiveness.
Despite these arguments, it remains possible that participants did not become circumcised because they faced other barriers to circumcision or found the compensation amounts to be inadequate in comparison to their costs associated with circumcision. The results provide some support for such explanations. At enrollment, barriers such as fear of pain or concern about female partners’ perceptions were stated by some participants. Moreover, the interventions were less effective among participants with above-median income and many participants initially recommended larger incentive amounts than US $15.00 for adequate compensation of costs associated with circumcision.
This study had several limitations. First, some men initially sampled as potential participants were not found at their homes or had migrated out of the study area. This was likely due to household listing of study sublocations occurring 3 to 8 months before enrollment, which means that our results may not apply to highly mobile men. Second, because of smaller sample sizes and limited statistical power, our comparisons of the interventions’ effect in different subgroups should be considered as exploratory. Third, the study did not examine whether alternative forms of conditional economic compensation (whether cash or noncash) could be equally or more effective in increasing VMMC uptake. Behavioral economics, for example, points to the potential for other forms of incentives—such as lottery-based rewards—to be more effective than small, fixed incentives.33,34 Additional testing of such strategies is needed. Finally, further testing is necessary to determine the generalizability of our intervention and results to settings outside Kenya. It is important to emphasize, for example, that the intervention would need to be accompanied by adequate supply of VMMC services and that a high background level of general knowledge and acceptability of VMMC, as was the case in our study setting due to prior efforts of the government and VMMC implementing organizations, may be required. To the extent that economic and behavioral barriers to VMMC uptake exist for many men, however, the results from this study should apply in these other settings.
Ethical considerations must also be taken into account when using economic incentives to promote health behaviors such as male circumcision. Although an exhaustive discussion of these issues falls outside the scope of this study, there are several reasons why the intervention in this study is ethically sound. First, based on participants’ reported wages, the modest amounts we used compensated participants for only part of the costs they would likely incur as a result of becoming circumcised. In fact, most men indicated that the appropriate voucher amounts to offset the economic costs associated with male circumcision were even higher than the amounts we offered. Second, in light of the health externality benefits of male circumcision such as secondary HIV prevention, the provision of modest incentives in this case has a more compelling rationale than it would for behaviors with no externality benefits.
Among uncircumcised men in Kenya, compensation in the form of food vouchers worth approximately US $8.75 or approximately US $15.00, compared with lesser or no compensation, resulted in a modest increase in the prevalence of circumcision after 2 months. The effects of more intense promotion or longer implementation require further investigation.
Corresponding Author: Harsha Thirumurthy, PhD, Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Dr, Campus Box 7411, Chapel Hill, NC 27599-7411 (firstname.lastname@example.org).
Published Online: July 20, 2014. doi:10.1001/jama.2014.9087.
Author Contributions: Dr Thirumurthy had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Thirumurthy, Lanham, Evens, Agot.
Acquisition, analysis, or interpretation of data: Thirumurthy, Masters, Rao, Bronson, Lanham, Omanga, Evens, Agot.
Drafting of the manuscript: Thirumurthy.
Critical revision of the manuscript for important intellectual content: Thirumurthy, Masters, Rao, Bronson, Lanham, Omanga, Evens, Agot.
Statistical analysis: Thirumurthy, Masters.
Obtained funding: Thirumurthy, Agot.
Administrative, technical, or material support: Thirumurthy, Rao, Lanham, Omanga, Evens, Agot.
Study supervision: Thirumurthy, Rao, Bronson, Omanga, Agot.
Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.
Funding/Support: The study was funded by the Bill and Melinda Gates Foundation (grant OPP1069673). Dr Thirumurthy reports receipt of support from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (grant K01HD061605).
Role of the Sponsors: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.