Experimental Design Details
In an effort to investigate factors behind the low uptake of VMMC in South Africa, this pilot study will employ a randomised control field experiment design in Soweto, Gauteng. The experiment involves the hand-delivery of postcards containing social marketing messages and/or vouchers to compensate participants for transport associated with travelling to the VMMC site, as well as some of the time they spend on the study. By randomising which households receive a particular message, voucher, or combination thereof and comparing uptake across these groups, we will be able to measure the relative effectiveness of each message and the transport voucher in increasing the uptake of VMMC.
We will evaluate the impact on uptake of VMMC of three different postcard-based VMMC recruitment mechanisms relative to a basic VMMC postcard (which will contain basic information about the participating VMMC facilities). The three main VMMC recruitment mechanisms are:
(i) A transport voucher for R100 conditional upon completing a VMMC consultation at one of the listed participating VMMC facilities,
(ii) Information that ‘2 out of 3 partners of uncircumcised men prefer circumcised men’, and
(iii) The statement, “Are you tough enough?”
All postcards, including the basic VMMC postcard, will include a voucher for light refreshments, conditional on completing a VMMC consultation. This provides an incentive for participants to bring in their postcard if they choose to visit a participating VMMC clinic, which will allow us to measure the effect of each type of postcard on take-up of the VMMC consultation relative to the basic VMMC postcard. All postcards will include a list of participating VMMC facilities (CHAPS has VMMC clinics in 75% of health facilities in the area, thus the list should provide a facility that is accessible to all postcard recipients).
An overlapping design will be implemented, such that there will be six unique postcards:
Postcard 1: Basic information about clinics and HIV prevention benefits of VMMC + Refreshments (conditional on completing VMMC consultation)
Postcard 2: Basic information about clinics and HIV prevention benefits of VMMC + R100 transport voucher (conditional on completing VMMC consultation) + Refreshments (conditional on completing VMMC consultation)
Postcard 3: Information that 2 out of 3 partners of uncircumcised men prefer circumcised men + Basic information + Refreshments (conditional on completing VMMC consultation)
Postcard 4: Information that 2 out of 3 partners of uncircumcised men prefer circumcised men + Basic information + R100 transport voucher (conditional on completing VMMC consultation) + Refreshments (conditional on completing VMMC consultation)
Postcard 5: A challenge, “Are you tough enough?” + Basic information + Refreshments (conditional on completing VMMC consultation)
Postcard 6: A challenge, “Are you tough enough?” + Basic information + R100 transport voucher (conditional on completing VMMC consultation) + Refreshments (conditional on completing VMMC consultation)
One thousand postcards per treatment arm, and thus 6000 postcards in total (across all 6 arms) will be hand-distributed by CHAPS outreach workers to households in Soweto, Gauteng, with random assignment of each type of postcard to households based on a random-walk sampling algorithm.
In addition to the aforementioned details, all postcards will contain a phone number and instructions for sending a SMS to the specified number should recipients want to receive more information from an advice nurse, who will make a follow-up call within 2 days of receiving the SMS (the postcard will inform recipients that they will receive a follow-up call from an advice nurse within 2 days of sending their message). The phone number will be different for each group, in order to track which postcards generate the most initial interest.
Project staff in each listed facility will record each clinic visit made by an individual with a postcard, as well as whether they received the postcard from a CHAPS outreach worker or a family member or friend. It is believed that the light refreshments provides a small incentive for bringing the card into the facility, which will encourage postcard recipients to provide us with evidence (that is, the actual postcard) indicating which treatment they received. This will allow us to measure which of the postcards most effectively encourages uptake of the VMMC consultation and uptake of the VMMC procedure. Project staff will also record the number of postcard recipients that complete a VMMC consultation, and the number of postcard recipients that complete the VMMC procedure.
Further, in an effort to assess which individuals are most at risk for HIV infection, a short survey will be conducted both with males that SMS the listed phone numbers for information, and males that visit the VMMC facilities, either for a consultation or to have the procedure done, or both. The cost-effectiveness of this intervention depends critically upon the relative risk profile of individuals who are encouraged to get circumcised. That is, if males most at risk of HIV infection choose to get circumcised, the effectiveness of this intervention is dramatically larger than if those who are least at risk choose to get circumcised. The survey will collect information about basic demographic characteristics, self-reported risky sexual behaviour, and other factors related to risk of HIV infection. The survey will be administered in two ways: (1) for SMS users, the survey will be conducted telephonically by the advice nurse, a few weeks after they have sent a SMS, in order to provide time to seek VMMC services. These individuals will be contacted using the phone numbers from their SMSes and asked for consent to administer the survey, after which the survey will be administered telephonically or (2) for men that attend the VMMC facility, project staff will obtain consent from the men to administer the survey and will complete it using an interview technique. The survey will include questions about whether the individual sent a SMS to the VMMC hotline on the postcard and whether they completed the phone survey in order to avoid duplication. Project staff will also request permission to record the results of the STI and HIV tests (standard in VMMC consultations) for these men, in addition to the survey.