Journal Article

Acceptability, feasibility and appropriateness of intensified health education, SMS/phone tracing and transport reimbursement for uptake of voluntary medical male circumcision in a sexually transmitted infections clinic in Malawi: A mixed methods study

Bonongwe, Naomi, Kudowa, Evaristar, Mathiya, Esther, Jere, Edward, Jewett, Sara, Kamtambe, Blessings, Tseka, Jennifer, Tsidya, Mercy, Ndalama, Beatrice, Hosseinipour, Mina C., Yatina, Dumbo, Chasela, Charles S., Matoga, Mitch M.

2025

Overview

Uptake of voluntary medical male circumcision (VMMC) remains a challenge in many settings. Innovative implementation strategies are required to scale-up VMMC uptake. RITe was a multi-faceted intervention comprising transport reimbursement (R), intensified health education (IHE) and SMS/Telephone tracing (Te), which increased the uptake of VMMC among uncircumcised men with sexually transmitted infections (STIs) in Malawi. Using a concurrent exploratory mixed-method approach, we assessed the intervention's acceptability, feasibility and appropriateness among men with STIs and healthcare workers (HCWs) at Bwaila District Hospital. Participants completed Likert scale surveys and participated in-depth interviews (IDIs) and focus group discussions (FGDs). We calculated percentages of responses to survey items and summarized common themes using thematic analysis. Median scores and interquartile ranges (IQR) were calculated for acceptability, feasibility and appropriateness of each strategy at baseline and end-line and compared using the Wilcoxon signed rank test. A total of 300 surveys, 17 IDIs and 4 FGDs were conducted with men and HCWs between baseline and end-line. The mean age for men in the survey was 29 years (SD ±8) and most were married/cohabiting (59.3%). Mean age for HCWs was 38.5 years (SD ±7), and most were female (59.1%). For acceptability, participants agreed that RITe was welcome, approvable, and likable. Despite participants agreeing that RITe was a good idea, fit and suitability influenced appropriateness, particularly at baseline, which improved at end-line for Te and R. For feasibility, HCWs agreed that RITe was easy to implement, but expressed concerns that R (end-line median = 4, IQR: 2, 4) and Te (end-line median = 4, IQR: 4, 4), were unsustainable. Interviews corroborated the survey results. Participants reported that IHE provided important information, Te was a good reminder and R was attractive, but they reported barriers to R and Te such as electricity, limited access to phones and distrust in the government. The RITe intervention was acceptable, feasible and appropriate. However, culture/religion and structural barriers affected perceptions of appropriateness and feasibility, respectively. Continued awareness raising on VMMC and addressing setting-specific structural factors are required to overcome barriers that impede demand-creation interventions for VMMC.

• Publisher: Public Library of Science,Public Library of Science (PLoS)
• Subject: Abstinence / Acceptability / Acquired immune deficiency syndrome / Adult / AIDS / Circumcision / Circumcision, Male - economics / Circumcision, Male - statistics & numerical data / Clinics / Demographic aspects / Disease prevention / Education / Evaluation / Feasibility / Feasibility Studies / Health aspects / Health education / Health Education - methods / Health facilities / HIV / Hospitals / Human immunodeficiency virus / Humans / Infections / Intervention / Malawi / Male / Medical innovations / Medical personnel / Medicine and Health Sciences / Men / Methods / Mixed methods research / Patient Acceptance of Health Care / People and Places / Polls & surveys / Prevention / Public opinion / Qualitative research / Rank tests / Reimbursement / Research and Analysis Methods / Sexually transmitted diseases / Sexually Transmitted Diseases - epidemiology / Social Sciences / STD / Surveys / Surveys and Questionnaires / Text Messaging / Tracing / Wound healing / Young Adult