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Original Investigation |

Effect of Providing Conditional Economic Compensation on Uptake of Voluntary Medical Male Circumcision in Kenya:  A Randomized Clinical Trial

Harsha Thirumurthy, PhD1,2; Samuel H. Masters, MPH1; Samwel Rao, MPH3; Megan A. Bronson, MPH2; Michele Lanham, MPH4; Eunice Omanga, PhD3; Emily Evens, PhD4; Kawango Agot, PhD3
[+] Author Affiliations
1Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill
2Carolina Population Center, University of North Carolina at Chapel Hill
3Impact Research and Development Organization, Kisumu, Kenya
4FHI 360, Durham, North Carolina
JAMA. 2014;312(7):703-711. doi:10.1001/jama.2014.9087.
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Importance  Novel strategies are needed to increase the uptake of voluntary medical male circumcision (VMMC) in sub-Saharan Africa and enhance the effectiveness of male circumcision as an HIV prevention strategy.

Objective  To determine whether small economic incentives could increase circumcision prevalence by addressing reported economic barriers to VMMC and behavioral factors such as present-biased decision making.

Design, Setting, and Participants  Randomized clinical trial conducted between June 22, 2013, and February 4, 2014, among 1504 uncircumcised men aged 25 to 49 years in Nyanza region, Kenya. VMMC services were provided free of charge and participants were randomized to 1 of 3 intervention groups or a control group.

Interventions  Participants in the 3 intervention groups received varying amounts of compensation conditional on undergoing circumcision at 1 of 9 study clinics within 2 months of enrollment. Compensation took the form of food vouchers worth 200 Kenya shillings (≈US $2.50), 700 Kenya shillings (≈US $8.75), or 1200 Kenya shillings (≈US $15.00), which reflected a portion of transportation costs and lost wages associated with getting circumcised. The control group received no compensation.

Main Outcomes and Measures  VMMC uptake within 2 months.

Results  Analysis of data for 1502 participants with complete data showed that VMMC uptake within 2 months was higher in the US $8.75 group (6.6%; 95% CI, 4.3%-9.5% [25 of 381]) and the US $15.00 group (9.0%; 95% CI, 6.3%-12.4% [34 of 377]) than in the US $2.50 group (1.9%; 95% CI, 0.8%-3.8% [7 of 374]) and the control group (1.6%; 95% CI, 0.6%-3.5% [6 of 370]). In logistic regression analysis, the US $8.75 group had significantly higher VMMC uptake than the control group (adjusted odds ratio [AOR] 4.3; 95% CI, 1.7-10.7), as did the US $15.00 group (AOR 6.2; 95% CI, 2.6-15.0). Effect sizes for the US $8.75 and US $15.00 groups did not differ significantly (P = .20).

Conclusions and Relevance  Among uncircumcised men in Kenya, compensation in the form of food vouchers worth approximately US $8.75 or US $15.00, compared with lesser or no compensation, resulted in a modest increase in the prevalence of circumcision after 2 months. The effects of more intense promotion or longer implementation require further investigation.

Trial Registration  clinicaltrials.gov Identifier: NCT01857700

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Figure.
Flow of Study Participants for Voluntary Medical Male Circumcision

aIncludes the listing of men as well as the subsequent random selection of men, which allowed for more than 1 man per household.

bTwo sublocations were subsequently subdivided since the 2009 Kenya Population and Housing Census, resulting in 9 sublocations from which participants were selected.

cParticipants received the voucher upon the condition of undergoing voluntary medical male circumcision (VMMC). Because of varying exchange rates, US dollar conversions (from Kenya shillings) are approximate.

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