Qualitative process evaluation of SKILLZ to promote voluntary medical male circumcision among men and adolescent boys in Zimbabwe

DETAILED SUMMARY

Importance

• Voluntary medical male circumcision (VMMC) can reduce the risk of female-to-male HIV transmission by 50–60%, and UNAIDS and the World Health Organization have stressed the importance of increasing VMMC uptake among adolescent males, identifying schools and sports as two possible intervention vehicles.
• Despite this urgency, Zimbabwe was falling short of its national VMMC coverage target, and few studies had examined the effects of sport-based educational programming on VMMC uptake.

Objective

• To conduct a process evaluation of two sport-based VMMC demand-creation interventions, Make The Cut and Make The Cut+, investigating perceptions of program impact, intervention components, program delivery, participants’ understanding of intervention content, and factors related to uptake.

Study details

• Study design: Qualitative study (no control group), conducted as a process evaluation alongside two cluster randomized controlled trials
• Data collection tools: In-depth interviews and focus group discussions with Coaches and circumcised/uncircumcised participants; structured observation of program implementation
• Participants: Men ages 18–30 on soccer teams (Make The Cut) and secondary school boys ages 14–19 (Make The Cut+); 46 in-depth interviews and 2 focus group discussions conducted with Coaches and participants, alongside 42 implementation observations
• Implementation setting: Bulawayo, Zimbabwe (urban)
• Study period: 2012–2014

Intervention

• Make The Cut (MTC): A 60-minute soccer-themed educational session for men ages 18–30 on soccer teams, led by circumcised Coaches ages 18–30, including a soccer-based activity (“Cut and Cover”), a personal narrative from the Coach about his VMMC experience (“Coach’s Story”), and a question-and-answer period, with SMS follow-up messaging.
• Make The Cut+ (MTC+): The same 60-minute curriculum adapted for secondary school boys ages 14–19, with follow-up phone calls, Coach accompaniment to the VMMC clinic, and soccer-based incentives for VMMC completion.

Results

• Findings demonstrated high program acceptability for both interventions, with the Coach-participant relationship identified as a key factor associated with VMMC uptake.
• Participants valued Coaches’ openness in discussing their personal VMMC experiences and their accompaniment to the VMMC clinic.
• A related cluster RCT evaluating MTC found weak statistical evidence of an effect on uptake (4.8% among intervention participants vs. 0.5% among controls; OR = 9.81, 95% CI: 0.93–103.2, p = 0.06), while a related RCT evaluating MTC+ found strong evidence of an effect (12.2% vs. 4.6%; OR = 2.65, 95% CI: 1.19–5.86, p = 0.02).
• Within MTC, younger participants (ages 18–29) had higher VMMC uptake (5.1%) than participants over age 30 (1.1%), and older men were generally perceived as less engaged with the program’s content and messaging.
• Follow-up SMS messaging received mixed reactions and was often not recalled by participants, while personalized phone follow-up and clinic accompaniment in MTC+ were described as more motivating.
• Soccer-based incentives were associated with somewhat higher, though not statistically significant, uptake (15.4% among participants offered incentives vs. 9.5% among those not offered incentives; OR = 1.88, 95% CI: 0.68–5.23).

Conclusions and implications

• Sport-based VMMC demand-creation interventions delivered by circumcised near-peer Coaches were highly acceptable and showed promise in increasing VMMC uptake, particularly among adolescent boys.
• The Coach-participant relationship, including personal storytelling and clinic accompaniment, appeared central to motivating uptake; further research is needed to adapt engagement strategies for older men and to clarify the role of incentives.