New look at circumcision

What is 60% protection?

Amos Zikusooka, a Health Communication expert says while the low VMMC numbers might have been caused by many other reasons, the initial message that focused on the `60% protective effect’ of safe male circumcision was complicated for the target audience.

“Many never made sense of it at all,” he says.

Zikusooka says some men went for the circumcision and, thereafter, engaged in unprotected sexual activity in the false belief that they were now immune to HIV.

In an interview with The Independent on May 18, he advised the VMMC implementers to craft effective communication campaigns, based on studies and understanding of the kind of audience they are communicating to. The medically-based messages, according to him, have been a loser.

He said: “Most behavioral choices are made basing on emotional rather than rational appeals. Messages designed using slang, culture of the audience become more successful than those based on scientific evidence. Emotion wins most of the time.”

He says a man may not go for circumcision even if they know of the medical importance but will easily get circumcised because their wife loves it.

Zikusooka, who is the innovator of Uganda’s biggest health campaign ‘Obulamu’ says campaigns like `Mwami Mulembe’ can work for the illiterate rural dwellers but not for the urban elite. He says the elite have all the information at their disposal and only need to be given options; they need to choose from.

“People have been looking at the doctors to solve the HIV puzzle but what are the people who are affected doing? In my campaign for the elite, I am taking the discussion back to them,” he says.  One such message targeting the elite offers a variety of options. One says: “I got circumcised to reduce my chances of acquiring HIV. What about you?”  Another says: “circumcision has made making love fun and safer. How is your love life?”

Zikusooka says, however, the HIV prevention message design process is complicated by the numerous and sometimes conflicting demands of their clients.

“Communicators are torn between designing the message that donors want, that politicians want, and what will benefit the audience.

“Technical words have not helped us achieve results; audiences need a simple specific message,” he says.

The simplistic messages, however, also pose new challenges. The health communicators suddenly have taken a route many advertisers take; of selling a product basing on false pretenses or making promises that are too good to be true. But, don’t the audience soon see through them and stops biting the bait?

Mugambe says, VMMC implementers do continuous audience research regarding the message and change it when it is shorn of its novelty.

Tetanus scare

Away from the message, the VMMC campaign has faced numerous practical complications. It is faced with fear and suspicions surrounding the procedure and political leaders, including President Yoweri Museveni, undoing their efforts by either scoffing at the message or discouraging men from the procedure.

Even clients who opt to be circumcised, have questions about how best to get circumcised – whether to go traditional, medical, and if medical whether to go surgical or non-surgical.

The RHSP and the Makerere University Walter Reed Project trains VMMC implementers on how to use the two circumcising methods. But they have to battle skeptics who say traditionalist circumcisers, such as the Bakonzo and Bamasaba, do it better. Such perceptions according to Dr. Freddie Ssengooba of the Makerere University School of Public Health point to gaps in the VMMC policy that were never considered initially.

Dr. Henry Mafabi Gizamba, a surgeon at Mulago National Referral Hospital in Kampala, literally straddles both worlds.  He belongs to the Bamasaba community and was circumcised by a tradition surgeon.  As a medical surgeon, however, he can see the advantages and disadvantages of either method. He says while the medical removes the foreskin alone and one gets stitched, the traditional way gets rid of both the inner and fore skin which makes the traditional one more comfortable but less safe. In the end, he says, it is hard for people who are used to the traditional method to go for VMMC.

A meeting of circumcision implementers at Silver Springs Hotel in Kampala on May 13 brought out an even more but very controversial issue.  Since the VMMC programme was rolled out in the country, 13 people have died of tetanus as a result of the procedure.

Fearing such incidents, the ministry of Health announced guidelines for every man opting for circumcision to be vaccinated for tetanus (TT) first. The procedure is such that at first visit one gets a shot and another one at 28 days when he returns for the circumcision procedure. But the directive appears to have delivered a double blow to the VMMC campaign; after getting the TT vaccine, the men do not come back to be circumcised. Linking circumcision to tetanus has also scared away clients.

Annet Kagoro, the officer in charge of the VMMC clinic at Fort Portal Regional Referral hospital in western Uganda, has experienced the duo effects first hand.

Her facility handles five districts of Kabarole, Kyenjojo, Kamwenge, Bundibugyo and Ntoroko. But when The Independent visited in early April, she said the clinic had not had a single client in three weeks. In some cases, the men who get the TT vaccine claim they do not return because they do not have transport. Kagoro says, as a result, it is easier to get men circumcised during outreaches; when a team goes out and circumcise the men wherever they find them.

But she added:  “The turnout is low because of TT”.

And the Ministry says it is not about to scrap the directive on tetanus.

“Not many men are dying of tetanus (but) they need the vaccines. Everyone needs to be vaccinated,” says Nanteza. She points out that 75% of all the people who contract tetanus end up dying.

Dr. Ssengooba says the link between circumcision and tetanus deaths “has been blown out of proportion”. He is one of the early advocates for the procedure and says initially when designing the first messages they decided to ignore such ‘rare events’ as tetanus for fear of scaring away possible clients but “now the ministry’s guideline is more of a scare than what advocates would have made”.

In reality, says Kigozi of RHSP, the tetanus vaccination requirement kills one major feature of the decision to get circumcised – spontaneity.

“For some people, the decision is spontaneous,” says Kigozi, “TT limits us with only 45% of the people given a shot coming back a month later.”

As one drives away from Rakai, the future of the VMMC seems uncertain. But a combination of right message and more outreach interventions hold the promise of success.