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Title
Adaptive social and behavior change communication strategies achieve modification in social norms around uptake of voluntary medical male circumcision services in traditionally non-circumcising communities in three regions of Tanzania
Presenter
Maende Makokha
Authors
M. Makokha1, A. Christensen1, A. Hellar1, M. Machaku1, C. Francis1, S. Tesha1, P. Massawe1, K. Curran2, Z. Mwandi3, M. Carrasco4, V. Kiggundu4, E. Mlanga5, G. Lija6, G. Msalale6, P. Luvanda6, E. Kessy6
Institutions
1Jhpiego, AIDSFree, Dar es Salaam, Tanzania, United Republic of, 2Jhpiego, Washington, United States, 3Jhpiego, AIDSFree, Nairobi, Kenya, 4U.S. Agency for International Development (USAID), Washington, United States, 5USAID, Dar es Salaam, Tanzania, United Republic of, 6Ministry of Health, Community Development, Gender, Elderly and Children (MOHCDGEC), Dar es Salaam, Tanzania, United Republic of

Background: In 2009, Jhpiego collaborated with the Tanzania Ministry of Health to start offering voluntary medical male circumcision (VMMC) for HIV prevention to males ages 10 years and older in Iringa, later expanding to Njombe and Tabora regions. At inception, male circumcision (MC) prevalence in Iringa, Njombe, and Tabora (all traditionally non-circumcising regions) was 29%, 29%, and 38%, respectively, compared to 67% nationally. As of September 2017, the program had performed 721,444 VMMCs, contributing to an MC prevalence of 80%, 62%, and 67%, respectively, in the three regions, compared to 80% nationally.
Description: Social and behavior change communication (SBCC) strategies were developed to support three VMMC implementation phases: a scale-up phase focusing on normalizing VMMC in traditionally non-circumcising communities, implemented at the beginning when coverage was low among all age groups; a catch-up phase mobilizing female partners to influence VMMC uptake among older youth and men, implemented as the program expanded VMMC in all communities in the three regions; and a sustainability phase leveraging parental advocacy to cultivate future demand for infant and adolescent VMMC services, implemented as coverage reached 80% among males ages 15-29 years. The program used experiential learning approaches backed by independent operational research on motivational incentives, message dissemination and timing options, service environment, and the role of community-owned resource persons as drivers of VMMC uptake. The main SBCC strategies corresponding to each phase were mass media campaigns promoting self-reinforcing messages; community mobilization at village level incorporating social routines and schedules; and setting-based one-to-one interactions to address individual needs and support linkage to services.
Lessons learned: SBCC strategies responsive to context factors and incremental service coverage, augmented by experiential learning and operational research, helped VMMC to evolve from a cultural novelty to a normative practice in these communities. Figure 1 shows how SBCC strategies adapted as VMMC evolved in the program.

Figure 1: How SBCC adapted as VMMC evolved in the program
[Figure 1: How SBCC adapted as VMMC evolved in the program]


Conclusions/Next steps: The program is working to integrate VMMC into routine facility-based health services. SBCC''s new challenge is to promote and maintain peer-to-peer advocacy among VMMC adopters, friends, and networks to make future demand for VMMC self-sustaining.

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