The education of religious leaders had a substantial effect on uptake of medical male circumcision and should be considered as part of such programmes in other sub-Saharan African countries, found a mixed-methods study in Tanzania.
Incident HIV infections reflect the inadequacy of prevention strategies, and the failure to adequately use proven effective interventions. Following compelling evidence from three independent community trials in South Africa, Uganda and Kenya, the World Health Organisation (WHO) and the Joint UN Programme on HIV/AIDS (UNAIDS) recommended that voluntary medical male circumcision (VMMC) should be part of a comprehensive HIV prevention strategy for heterosexually acquired infection among men. The eastern, central, and southern African countries have been prioritised for scaling up this intervention because of the high HIV burden and low prevalence of male circumcision in these countries. However, they have fallen short of their expected targets because of inadequate uptake of VMMC among men aged 15–49 years.
Several research groups in sub-Saharan Africa are experimenting with different approaches to substantially increase demand for VMMC. Jennifer Downs at the Centre for Global Health, department of medicine, Weill Cornell Medical College, New York and the department of medicine, Bugando Medical Centre, Mwanza, Tanzania and colleagues report a successful mixed-methods study in Tanzania that focused on educating religious leaders. They did a community cluster randomised trial in 16 villages, paired by proximity, and all received VMMC delivered by workers from the Tanzanian Ministry of Health services. Eight villages were randomly assigned to receive an education intervention for religious leaders in scientific, religious, and cultural aspects of male circumcision. The remaining villages (controls) did not receive the education intervention.
Following completion of the randomised trial, focus group interviews were conducted with religious leaders in all villages. In the intervention villages, 52·8% (30 889 of 58 536) of men were circumcised compared with 29·5% (25 484 of 86 492) in the control villages (odds ratio 3·2 [95% CI 1·4–7·3]; p=0·006). In the intervention villages, 30·8% of men undertook VMMC because of church discussions, compared with 0·7% in control villages (p<0·0001). The interviews showed that religious leaders recognised the strong influence they had on their followers' behaviour.
The study had limitations, for example, it did not collect baseline data on circumcision status and religion in the study villages but relied on the country's 2012 national census data, and it was assumed that the paired study villages had similar baseline characteristics. However, we are reassured that, despite the study limitations, the sensitivity analysis showed that the results were robust.
Additional support for the positive outcome of a significantly higher prevalence of circumcision in intervention than in control villages comes from the secondary qualitative findings that religious leaders from the intervention villages felt empowered to teach their congregations about male circumcision after the educational seminars, and that many of the leaders described that more members of their congregations were seeking VMMC after church discussions of the topic. Additionally, wives and girlfriends in intervention villages were more likely to encourage their male partners to seek circumcision than those in the control villages (p=0·001).
By contrast, people from the control villages had many negative opinions of circumcision, and misinformation and suspicion persisted in the control communities. The primary and secondary outcomes of this study suggest that social and structural determinants of behaviour can be influenced by incorporating religious leaders – including those opposed to the programme – as an integral part of community mobilisation in circumcision campaigns. Downs and colleagues estimated that their intervention strategy has the potential to encourage a million additional circumcisions, and potentially prevent 65,000–200,000 HIV infections in Tanzania, calling for worldwide attention to the innovative strategy used in this trial.
Some characteristics of the study by Downs and colleagues should be noted. First, this is a pragmatic cluster randomised controlled trial embedded within a routine health-service delivery system. The trial used data collected by practitioners during routine care. Although the study costs and cost-effectiveness data were not reported, the pragmatic trial approach has great potential to substantially reduce research costs, since the investigation procedures, intervention, and data collection are integrated into routine health-service delivery.
Second, on the basis of the structural barriers to VMMC – including social, cultural, and religious barriers – identified in earlier work in Malawi, Tanzania and Rwanda, the authors designed an education intervention to target religious leaders, who are important community gatekeepers and are often underused in health promotion or service delivery.
However, we acknowledge that religious leaders can sometimes hinder efforts to increase uptake of some health interventions – the rejection of polio vaccines in northern Nigeria.
Third, the use of religious leaders to increase uptake of VMMC is an example of an approach that is simple to adopt for use with existing community resources, and culturally acceptable. By examining the cultural context within which social life is sustained, culturally acceptable resources for health promotion and disease prevention and care can be identified.
By adapting the interventions used elsewhere to the cultural norms, values, and beliefs of the community, researchers developed sustainable health interventions.
A hallmark of VMMC, as in some other modern medicine interventions, is the foreign nature of the intervention to the community where it is implemented – they are usually designed outside of the intervention community, and thus based on different cultural norms. Drawing from the biomedical model, VMMC follows a top-down approach in which the user is prescribed an intervention, usually with scarce consideration of other structural factors, such as religious views, which create barriers to effective use of the service. Uptake might therefore be partly restricted because interventions do not adapt and respond to communities' broader structural or intersectoral challenges, such as health illiteracy. Approaches that emerge from community-based, culturally acceptable resources stand a good chance of enhancing health service recipient ownership and buy-in of the interventions.
Questions remain regarding the effectiveness of education of religious leaders in different contexts in which the target population engages in practices that religious leaders might be opposed to on a religious basis. Examples of such opposition include condom use for HIV prevention among men who have sex with men, commercial sex activities, and the use of routine immunisation. Religious institutions have a strong influence on the beliefs, cultures, and behaviours of large populations across Africa and other parts of the world. Further research is therefore required to explore and assess innovative religion-based approaches to promote healthy behaviour in religious communities.
Summary
Background: Male circumcision is being widely deployed as an HIV prevention strategy in countries with high HIV incidence, but its uptake in sub-Saharan Africa has been below targets. We did a study to establish whether educating religious leaders about male circumcision would increase uptake in their village.
Methods: In this cluster randomised trial in northwest Tanzania, eligible villages were paired by proximity ( Findings: Between June 15, 2014, and Dec 10, 2015, we provided education for church leaders in eight intervention villages and compared the outcomes with those in eight control villages. In the intervention villages, 52·8% (30 889 of 58 536) of men were circumcised compared with 29·5% (25 484 of 86 492) of men in the eight control villages (odds ratio 3·2 [95% CI, 1·4–7·3]; p=0·006).
Interpretation: Education of religious leaders had a substantial effect on uptake of male circumcision, and should be considered as part of male circumcision programmes in other sub-Saharan African countries. This study was conducted in one region in Tanzania; however, we believe that our intervention is generalisable. We equipped church leaders with knowledge and tools, and ultimately each leader established the most culturally-appropriate way to promote male circumcision. Therefore, we think that the process of working through religious leaders can serve as an innovative model to promote healthy behaviour, leading to HIV prevention and other clinically relevant outcomes, in a variety of settings.
Authors
Jennifer A Downs, Agrey H Mwakisole, Alphonce B Chandika, Shibide Lugoba, Rehema Kassim, Evarist Laizer, Kinanga A Magambo, Myung Hee Lee, Samuel E Kalluvya, David J Downs, Daniel W Fitzgerald
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