Behavior change pathways to male circumcision narrative interviews with VMMC clients in Zambia J. Price 1, D. Mulenga 1, L. Phiri 1, P. Hewett 1, K. Hatzold 2, N. Shiliya 3, K. Bowa 4 July 1, Population Council/Zambia, 2 Population Services International/Zimbabwe, 3 Society for Family Health/Zambia, 4 Copperbelt University/Zambia

Objectives and Methods Objective Understand the behavior change process leading to MC-seeking Methods and theorized behavior change stages Narrative interviews with 40 clients (18 years old) waiting for surgical MC at two Lusaka clinics Context Zambia has experienced challenges in meeting VMMC targets in adult men CommitmentEarly actionContemplation Initial exposure and impressions Stage 1 Stage 2Stage 3 Stage 4

Empirically-Determined Behavior Change Stages Exposure and belief adjustment Personalizing benefits and norming pressures Conquering fears and taking charge of Self Taking action, seeking MC Stage 1 Stage 2Stage 3 Stage 4

Most Frequently Cited Sources of Information, Advantages, and Fears Sources of Information Perceived Advantages Major Fears (n=40)

I met a girl named Alice... Stage 1: Exposure & Belief Adjustment I met a girl named Alice. Shes the one who enticed me to do it. She came with a brochure and said, you know honey, theres something we can do to make our love more enjoyable.

I started to see it wasnt dangerous because even my best friend from the Copperbelt did it. He even showed me. I then talked to my wife and she said you can do it. MC is... safe for Christians too for all ethnic groups for adult men Main Beliefs Adjusted

This is an honest opinion, everyone around me has gone [for MC], so I feel different. Now I just feel like Im doing what a man is supposed to do. I was being left behind because everyone else has done it. I feel different... Stage 2: Personalization & Norming Pressures If I dont get circumcised Ill be... left behind missing out left out of the group different If I do get circumcised Ill be... responsible sexually appealing clean safe like other men

I told myself... just forget your fears no pain lasts forever all wounds eventually heal other men have done it its my... life health future Im ready now... Stage 3: Conquering Fears, Taking Charge Im ready now, I even feel desperate. Its like having a thirst. I need to drink water.

I wanted to go to X clinic but found it was a celebration of cancer day today. I went home and sat down in my chair. Then I thought to myself, since I decided that I should do this today, why don't I try Y? I woke up, had my breakfast, brushed my teeth, and came here... Stage 4: Commitment, MC Seeking First24 (60%) Second12 (30%) Third4 (10%) Number of attempts to obtain MC

Service-Side Access Barriers Encountered MC not offered that day 6 Lack of privacy, information4 Wait too long, too many people2 Came too late, turned away2 Too many people, turned away1 Female provider1 MC services canceled1 Clinic closed (Sunday)1 Second thoughts, doubted clinic1 Unclear from the interview1 First24 (60%) Second12 (30%) Third4 (10%) = 20 failed MC attempts in total Number of attempts to obtain MC

Implications and Recommendations Exposure and belief adjustment Personalizing benefits and norming pressures Conquering fears and taking charge of Self Taking action, seeking MC Stage 1 Stage 2Stage 3 Stage 4 1.Continue multi-media communications 2.But diversify messaging Target network members Emphasize secondary benefits Emphasize that MC is for EveryMAN 1.Use MC- experienced men (I did it, so can you) 2.Offer more places where men can get their specific questions answered 1.Advertise clinic hours, days 2.Introduce by- appointment- only scheduling 3.Improve processing efficiencies at the clinic