The PSI BCC Blog

Male Circumcision: Not So Simple, After All

The BBC reported on Friday that elders of Kenya's Luo ethnic group have refused to endorse a government plan to promote male circumcision to prevent HIV, saying that the practice is "against the community's culture." The Luo, who comprise 2.5 million of Kenya's 32 million people, do not traditionally practice circumcision. The elders, while acknowledging that circumcision is an individual decision, cited concerns about behavioral disinhibition following circumcision and the efficacy of the surgery in reducing the risk of HIV transmission. The BBC notes that the council of elders holds substantial sway among Luo, a fact that is likely to herald problems for the government's efforts to take medical circumcision services to scale. A similar situation is currently playing out in Lesotho, where traditional circumcizers have reportedly blocked efforts to launch a national circumcision initiative.

At the end of the day, is male circumcision really so different from any other health service that we promote? Maybe. In many of the cultures where it is traditionally practiced, circumcision signifies the transition from boyhood to manhood. Circumcision status is, in some settings, intimately connected to conceptions of masculinity, as well beliefs about sexuality, sexual prowess, and pleasure. Circumcision has traditionally been an important ethnic identifier, a point of belonging not only in terms of the physical act itself, but the many rituals that often accompany it. So can we really reduce all this to an individual decision about a surgical procedure? Again, the answer is maybe - but with due analysis of and consideration for the broader context.

PSI's male circumcision initiatives have chosen to address the question of culture in a variety of ways. In Zambia, a substantial minority of men undergo traditional circumcision, participating in camps where they are circumcized and instructed about adult life. Men need not belong to one of the groups that traditionally circumcise to attend the camps, and young men have the option of being circumcized in a medical setting but attending the camp for purposes of instruction. Rates of adverse events from circumcisions performed in the camps are apparently relatively low. PSI's formative research indicated that the medicalization of circumcision (and awareness of the surgery's potential health benefits) meant that many men no longer viewed it as a tradition linked to specific ethnic groups. Program staff reached out to traditional circumcizers, who were invited to visit PSI facilities and offer input on the initiative. Those were participated  were generally supportive of the launch of medical circumcision services, and opportunities for further coordination and/or collaboration are being discussed.

In South Africa, where PSI provides communication support to the Bophelo Pele male circumcision pilot at Orange Farm, a very different conclusion has been reached. There, circumcision is strongly associated with certain ethnic groups and is still considered a key marker of ethnic identity. Moreover, the existence of amateur circumcizers (not to be confused with trained traditional circumcizers, many of whom are highly skilled professionals) has resulted in a number of grisly adverse events, inspiring a certain amount of anxiety around the procedure. Given this context, project partners concluded that addressing culture or tradition in any way was likely to be perceived as divisive or off-putting to potential clients.

So, how best to proceed when planning and implementing medical circumcision interventions? Carefully, and with the knowledge that it's rarely simple after all.

BBC Kenya story: http://news.bbc.co.uk/2/hi/africa/7514431.stm.

The Kids Are Alright: Using Youth to Monitor Mass Media Programming

While providing TA recently in Haiti, I met with staff to discuss a mass media monitoring approach they are currently piloting. Faced with enormous costs when they contract creative agencies or consultants to monitor mass media campaigns, and unable to use their own staff in the interest of objectivity, PSI/Haiti is going to train local youth to conduct monitoring activities. The approach, which has been used to a limited extent in other PSI country platforms in the past, will be piloted during a three-day radio teaser campaign, which will air in Port au Prince in conjunction with national Malaria Day activities. If all goes well, PSI hopes to replicate the approach for longer and/or national campaigns in the future.

During the pilot, teams of three young people will use a simple form to monitor broadcasts on each of three participating radio stations. Having multiple monitors for each station will help ensure reporting accuracy, which will be further enhanced by periodic confirmation checks by a supervisor.

Participating young people, who are already affiliated with one of PSI’s youth programs, will be provided with some compensation (the specifics of which have yet to be decided).

If the pilot is expanded for national use in the future, PSI may elect to work with local partners in the regions, using these organizations’ peer educators and supervisors to conduct the monitoring rather than maintaining a separate cadre of PSI monitors in areas with limited human resources. Given the enormous rates of unemployment among Haitian young people, these monitoring activities may provide an opportunity for youth-serving organizations to motivate exceptional peer educators with the promise of small compensation and the development of additional professional skills.

A second potential adaptation that we discussed was the possibility of having monitors collect basic qualitative tracking data from members of the intended audience in addition to information on airtime. While this would require additional training for monitors and more elaborate systems for data entry and analysis, it would provide valuable information on audience comprehension and perception, allowing for mid-course corrections or compensation through IPC or community mobilization.

Against All Odds: Promoting Behavior Change in Angola

Guest blogger bio: In a new PSI BCC Blog feature, investigative blogger (and PSI Intern), Daniel Weil seeks out health communication staff in the field to discuss their programs, challenges, and lessons learned. Born in Brazil, Daniel graduated in May 2007 from Boston University's School of Communication. Daniel joined PSI in February of this year and is currently working for the HIV department.

In this first feature, I talked with Luis Martinez. Director of Marketing and Communications for PSI/Angola. Luis oversees the research, IEC and IPC components of PSI/Angola's BCC and marketing efforts.

Could you briefly describe PSI/Angola’s BCC (behavior change communication) efforts? (e.g. who are your target groups, what kinds of channels do you use, what types of activities do you implement?

PSI/Angola has two major BCC efforts. The first targets high-risk groups, mostly CSWs and truck drivers. We target truck drivers because they usually have money, are often away from home and engage in sexual behavior with SWs. Recently, this program has included policemen who do not "officially" engage in sexual behavior with SWs, but who often "overlook" the illegal activities of SWs in exchange for sexual favors.

The second program, Jango Juvenil (Jango Youth), is geared towards youth aged 13 to 25. This program appeals to youth by providing life skills and formal training in a variety of fields, such as Information Technology as many Angolans were prevented from completing their education due to the many years of war the country has endured. While youth attend these training courses they are exposed to information on the risk of HIV and STIs and learn about healthy behavior through discussions and videos. Once they attain this knowledge, many join outreach programs that visit public places such as soccer fields, schools, and market places to inform others about safer sexual behavior.

Tell me a bit about Angola and whether its social/political context was conducive to BCC campaigns.

Angola was at war for 30 years, then independence came, then civil war. Then communists tried to take power so it has only been for 6 years that peace has settled in Angola. Many areas have had to be completely rebuilt. Those who made a living through agriculture still cannot farm from the widespread danger of landmines in rural areas. So a lot of money has gone into rebuilding and restructuring, leaving little funds for social marketing.

For the full interview: Download luis_martinez_interview.pdf