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Modifying the health system to maximize voluntary medical male circumcision uptake: a qualitative study in Botswana

Thursday, 11th of January 2018 Print

Abstract below; full text is athttps://www.dovepress.com/modifying-the-health-system-to-maximize-voluntary-medical-male-circumc-peer-reviewed-article-HIV


HIV AIDS (Auckl). 2017 Dec 18;10:1-8. doi: 10.2147/HIV.S144407. eCollection 2018.

Modifying the health system to maximize voluntary medical male circumcision uptake: a qualitative study in Botswana

Semo BW1,2Wirth KE1,2,3,4Ntsuape C5Barnhart S1Kleinman NJ1,2,6Ramabu N2Broz J2Ledikwe JH1,2.


1 Department of Global Health, University of Washington, Seattle, WA, USA.

2 Botswana International Training and Education Center for Health (I-TECH), Gaborone, Botswana.

3 Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA.

4 Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, MA, USA.

5 Department of HIV/AIDS Prevention and Care, Botswana Ministry of Health, Gaborone, Botswana.

6 NJK Consulting, Seattle, WA, USA.



In 2007, the World Health Organization and the Joint United Nations Programme on HIV/AIDS endorsed voluntary medical male circumcision (VMMC) as an add-on HIV-prevention strategy. Similar to many other sub-Saharan countries, VMMC uptake in Botswana has been low; as of February 2016, only 42.7% of the program target had been achieved. Previous work has examined how individual-level factors, such as knowledge and attitudes, influence the update of VMMC. This paper examines how factors related to the health system can be leveraged to maximize uptake of circumcision services, with a focus on demand creation, access to services, and service delivery.


Twenty-seven focus group discussions with 238 participants were conducted in four communities in Botswana among men (stratified by circumcision status and age), women (stratified by age), and community leaders. A semi-structured guide was used by a trained same-gender interviewer to facilitate discussions, which were audio recorded, transcribed, translated to English, and analyzed using an inductive analytic approach.


Participants felt demand creation activities utilizing age- and gender-appropriate mobilizers and community leaders were more effective than mass media campaigns. Participants felt improved access to VMMC clinics would facilitate service uptake, as would designated mens clinics with male-friendly providers for VMMC service delivery. Additionally, providing comprehensive pre-procedure counseling and education, outlining the benefits and disadvantages of the surgical procedure, and explaining the differences between the surgical and non-surgical procedures, were suggested by participants to increase understanding and uptake of VMMC.


Cultural acceptability of circumcision services can be improved by engaging age- and gender-appropriate community mobilizers. Involving influential community leaders, providing a forum for men to discuss health issues, and bringing services closer to people can increase VMMC utilization. Service delivery can be improved by communicating the pros and cons of the procedure to the clients for informed decision-making.