Environmental/Behavioral Factors Shaping Circumcision Decisions in Zimbabwe

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DESCRIPTION (provided by applicant): Male circumcision (MC) has been clearly demonstrated to substantially reduce female to male transmission of HIV, and there is evolving consensus that MC should be included as a strategy in comprehensive HIV prevention programs (WHO/UNAIDS, 2006; WHO/UNAIDS, 2007; MOHCW, 2007). International agencies, programs, and countries are considering how to implement broad-based MC programs. Experts recommend that the countries where implementation should have highest priority are those where HIV is hyperendemic (HIV prevalence > 15%), infection is spread mainly through heterosexual transmission, and where a large proportion of men (e.g., > 80%) are not circumcised. Zimbabwe is such a country and is considering development of an MC program. Critical to the success of such a program is research to determine factors affecting the implementation, while maintaining successful HIV prevention strategies. We propose to use a strong theoretical model as a framework to investigate environmental (capacity, structure, culture) and individual (attitude, normative, personal agency) factors influencing motivation regarding MC-related behaviors among four key groups in Zimbabwe: policy makers, clinicians, adolescent and adult men, and expectant parents and parents of adolescent boys. Applying a framework adapted from Jaccard, et al (2002) and the Integrated Behavioral Model (IBM) we will carry out the research in four main steps: 1) Qualitative interviews conducted with each group will be used to identify salient issues relevant to each construct in the model with respect to MC behaviors; 2) Quantitative surveys, designed based on qualitative results, will be administered to representative samples of each study group, and analyses will identify the most important factors affecting MC-related behavior motivation for each group; 3) Survey results will be used to design educational messages to motivate MC behavior for each study group, and message testing will be carried out to assess acceptability and impact on behavioral motivation; 4) Results provided to Zimbabwe policy-makers will serve as the basis for designing a comprehensive MC program that is likely to be effective. This research will be carried out by a team of investigators who have developed a collaborative research team in Zimbabwe. Data collection will be done in two urban and two rural areas, including both major ethnic groups, and thus will maximize inclusion of all perspectives of people who would be impacted by an MC program. If a policy decision is made to implement an MC program in Zimbabwe, this study will provide key information on how to motivate clinicians to encourage MC among their male patients and parents with adolescent boys. The research will assess the acceptability and potential demand for MC, and determine training needs. It will allow the Ministry of Health and Child Welfare (MOHCW) to prioritize the target groups for MC, based on MC acceptability and health system capacity. In sum, this research will provide vital information for the MOHCW in Zimbabwe to plan the roll out and dissemination of a MC program. PUBLIC HEALTH RELEVANCE: Male circumcision (MC) has been demonstrated to substantially reduce female to male transmission of HIV, so there is evolving consensus that MC should be implemented in countries where HIV is hyperendemic (HIV prevalence > 15%), infection is spread mainly through heterosexual transmission, and where a large proportion of men (e.g., > 80%) are not circumcised. The proposed research will investigate environmental and individual factors influencing motivation for or against MC-related behaviors among four key groups in Zimbabwe: policy makers, clinicians, adolescent and adult men, and expectant parents and parents of adolescent boys. Findings will provide vital information for Zimbabwe policy-makers to plan the roll out and dissemination of a MC program and maximize likelihood of success.