Effect of Providing Conditional Economic Compensation on Uptake of Voluntary Medical Male Circumcision in Kenya: A Randomized Clinical Trial | Global Health | JAMA | JAMA Network
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Auvert  B, Taljaard  D, Lagarde  E, Sobngwi-Tambekou  J, Sitta  R, Puren  A.  Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: the ANRS 1265 Trial.  PLoS Med. 2005;2(11):e298.PubMedGoogle ScholarCrossref
Gray  RH, Kigozi  G, Serwadda  D,  et al.  Male circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial.  Lancet. 2007;369(9562):657-666.PubMedGoogle ScholarCrossref
Bailey  RC, Moses  S, Parker  CB,  et al.  Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomised controlled trial.  Lancet. 2007;369(9562):643-656.PubMedGoogle ScholarCrossref
World Health Organization and Joint United Nations Programme on HIV/AIDS.  New Data on Male Circumcision and HIV Prevention: Policy and Programme Implications. Geneva, Switzerland: World Health Organization; 2007.
World Health Organization.  Joint Strategic Action Framework to Accelerate the Scale-Up of Voluntary Medical Male Circumcision for HIV Prevention in Eastern and Southern Africa, 2012-2016. Geneva, Switzerland: World Health Organization; 2011.
Sgaier  SK, Reed  JB, Thomas  A, Njeuhmeli  E.  Achieving the HIV prevention impact of voluntary medical male circumcision: lessons and challenges for managing programs.  PLoS Med. 2014;11(5):e1001641.PubMedGoogle ScholarCrossref
Galbraith  JS, Ochieng  A, Mwalili  S,  et al; KAIS Study Group.  Status of voluntary medical male circumcision in Kenya: findings from 2 nationally representative surveys in Kenya, 2007 and 2012.  J Acquir Immune Defic Syndr. 2014;66(S1)(suppl 1):S37-S45.PubMedGoogle ScholarCrossref
Gray  RH, Wawer  MJ, Kigozi  G.  Programme science research on medical male circumcision scale-up in sub-Saharan Africa.  Sex Transm Infect. 2013;89(5):345-349.PubMedGoogle ScholarCrossref
Westercamp  N, Bailey  RC.  Acceptability of male circumcision for prevention of HIV/AIDS in sub-Saharan Africa: a review.  AIDS Behav. 2007;11(3):341-355.PubMedGoogle ScholarCrossref
Herman-Roloff  A, Otieno  N, Agot  K, Ndinya-Achola  J, Bailey  RC.  Acceptability of medical male circumcision among uncircumcised men in Kenya one year after the launch of the national male circumcision program.  PLoS One. 2011;6(5):e19814.PubMedGoogle ScholarCrossref
Evens  E, Lanham  M, Hart  C, Loolpapit  M, Oguma  I, Obiero  W.  Identifying and addressing barriers to uptake of voluntary medical male circumcision in Nyanza, Kenya among men 18-35: a qualitative study.  PLoS One. 2014;9(6):e98221.PubMedGoogle ScholarCrossref
Loewenstein  G, Brennan  T, Volpp  KG.  Asymmetric paternalism to improve health behaviors.  JAMA. 2007;298(20):2415-2417.PubMedGoogle ScholarCrossref
O’Donoghue  T, Rabin  M.  Doing it now or later.  Am Econ Rev. 1999;89(1):103-124. doi:10.1257/aer.89.1.103Google ScholarCrossref
Lagarde  M, Haines  A, Palmer  N.  Conditional cash transfers for improving uptake of health interventions in low- and middle-income countries: a systematic review.  JAMA. 2007;298(16):1900-1910.PubMedGoogle ScholarCrossref
Sindelar  JL.  Paying for performance: the power of incentives over habits.  Health Econ. 2008;17(4):449-451.PubMedGoogle ScholarCrossref
National AIDS and STI Control Programme.  Kenya AIDS Indicator Survey 2012: Preliminary Report. Nairobi, Kenya: Ministry of Health; 2013.
Hatzold  K, Mavhu  W, Jasi  P,  et al.  Barriers and motivators to voluntary medical male circumcision uptake among different age groups of men in Zimbabwe: results from a mixed methods study.  PLoS One. 2014;9(5):e85051.PubMedGoogle ScholarCrossref
Macintyre  K, Andrinopoulos  K, Moses  N,  et al.  Attitudes, perceptions and potential uptake of male circumcision among older men in Turkana County, Kenya using qualitative methods.  PLoS One. 2014;9(5):e83998.PubMedGoogle ScholarCrossref
Chinkhumba  J, Godlonton  S, Thornton  R.  The demand for medical male circumcision.  American Economic Journal: Applied Economics.2014;6(2):152-177. doi:10.1257/app.6.2.152Google ScholarCrossref
Banerjee  AV, Duflo  E, Glennerster  R, Kothari  D.  Improving immunisation coverage in rural India: clustered randomised controlled evaluation of immunisation campaigns with and without incentives.  BMJ. 2010;340:c2220.PubMedGoogle ScholarCrossref
Baird  SJ, Garfein  RS, McIntosh  CT, Ozler  B.  Effect of a cash transfer programme for schooling on prevalence of HIV and herpes simplex type 2 in Malawi: a cluster randomised trial.  Lancet. 2012;379(9823):1320-1329.PubMedGoogle ScholarCrossref
Lee  R, Cui  RR, Muessig  KE, Thirumurthy  H, Tucker  JD.  Incentivizing HIV/STI testing: a systematic review of the literature.  AIDS Behav. 2014;18(5):905-912.PubMedGoogle ScholarCrossref
Thornton  RL.  The demand for, and impact of, learning HIV status.  Am Econ Rev. 2008;98(5):1829-1863.PubMedGoogle ScholarCrossref
Bjorkman-Nyqvist  M, Corno  L, De Walque  D, Svensson  J.  Evaluating the impact of short term financial incentives on HIV and STI incidence among youth in Lesotho: a randomized trial. In: Proceedings from the 7th IAS Conference on HIV Pathogenesis, Treatment, and Prevention; June 30-July 3, 2013; Kuala Lumpur, Malaysia.
Operario  D, Kuo  C, Sosa-Rubí  SG, Gálarraga  O.  Conditional economic incentives for reducing HIV risk behaviors: integration of psychology and behavioral economics.  Health Psychol. 2013;32(9):932-940.PubMedGoogle ScholarCrossref
de Walque  D, Dow  WH, Nathan  R,  et al.  Incentivising safe sex: a randomised trial of conditional cash transfers for HIV and sexually transmitted infection prevention in rural Tanzania.  BMJ Open. 2012;2:e000747.PubMedGoogle ScholarCrossref
UNAIDS/WHO/SACEMA Expert Group on Modelling the Impact and Cost of Male Circumcision for HIV Prevention.  Male circumcision for HIV prevention in high HIV prevalence settings: what can mathematical modelling contribute to informed decision making?  PLoS Med. 2009;6(9):e1000109.PubMedGoogle ScholarCrossref
Njeuhmeli  E, Forsythe  S, Reed  J,  et al.  Voluntary medical male circumcision: modeling the impact and cost of expanding male circumcision for HIV prevention in eastern and southern Africa [published online November 29, 2011].  PLoS Med. 2011;8(11):e1001132. doi:10.1371/journal.pmed.1001132.PubMedGoogle ScholarCrossref
Auvert  B, Marseille  E, Korenromp  EL,  et al.  Estimating the resources needed and savings anticipated from roll-out of adult male circumcision in Sub-Saharan Africa.  PLoS One. 2008;3(8):e2679.PubMedGoogle ScholarCrossref
Volpp  KG, Troxel  AB, Pauly  MV,  et al.  A randomized, controlled trial of financial incentives for smoking cessation.  N Engl J Med. 2009;360(7):699-709.PubMedGoogle ScholarCrossref
Schultz  TP.  School Subsidies for the Poor: Evaluating the Mexican Progresa Poverty Program.  J Dev Econ. 2004;74(1):199-250. doi:10.1016/j.jdeveco.2003.12.009Google ScholarCrossref
Levy  S.  Progress Against Poverty: Sustaining Mexico’s Progresa-Oportunidades Program. Washington, DC: Brookings Institution; 2006.
Loewenstein  GF, Weber  EU, Hsee  CK, Welch  N.  Risk as feelings.  Psychol Bull. 2001;127(2):267-286.PubMedGoogle ScholarCrossref
Volpp  KG, John  LK, Troxel  AB, Norton  L, Fassbender  J, Loewenstein  G.  Financial incentive-based approaches for weight loss: a randomized trial.  JAMA. 2008;300(22):2631-2637.PubMedGoogle ScholarCrossref
Original Investigation
August 20, 2014

Effect of Providing Conditional Economic Compensation on Uptake of Voluntary Medical Male Circumcision in Kenya: A Randomized Clinical Trial

Author Affiliations
  • 1Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill
  • 2Carolina Population Center, University of North Carolina at Chapel Hill
  • 3Impact Research and Development Organization, Kisumu, Kenya
  • 4FHI 360, Durham, North Carolina
JAMA. 2014;312(7):703-711. doi:10.1001/jama.2014.9087

Importance  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.

Objective  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.

Interventions  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.

Results  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.

Trial Registration  clinicaltrials.gov Identifier: NCT01857700