CHAPTER ONE: INTRODUCTION

1.1 Background
Impact Research and Development Organization (IRDO) through its Research arm
have successfully completed training on soon to be launched Voluntary Medical Male
Circumcision (VMMC) demand creation study called TASCO (an acronym for Target,
Speed and Coverage).
The study is a two-year project that will be rolled out in phases; the first phase of
about 2 months will involve household listing of randomly selected villages in the 45
study Locations and a qualitative formative study to confirm barriers and facilitators
specific to older men, and to identifying intervention messages and preferred delivery
days/times by the target population. The next phase shall involve actual
implementation of the study intervention as well as sub-studies.
The main objective of the study is to evaluate the impact of two interventions - InterPersonal Communication [IPC] and Dedicated Service Outlets [DSOs] - in recruiting
men aged 25-39 years for VMMC services. According to the Principal Investigators
Dr. Kawango Agot and Mr. Jonathan Grund, there are several barriers that make the
uptake

of

VMMC

so

low

among

the

older

men

25

years).

The study aims at addressing some of these barriers associated with the low uptake of
VMMC among the older men and advice the Government and other stakeholders
further, on effective ways of increasing uptake of VMMC among this group.
The secondary objective of the study is to examine the level of involvement of female
sexual partners in the decisions and activities before, during and after circumcision,
and determine the association between the level of partner involvement in
circumcision decision-making and the length of post-surgical sexual abstinence.
The training began on 22/4/2014 to 26/4/2014 and involved the following personnel:
Research Assistants who will be in charge of data collection at the field, data staff and
Coordinators who will coordinate and oversee the Research Activities.
1

The workshop aimed at providing requisite skills that the personnel shall require
during the scope of the study. A final de-briefing before the study staff head off to the
field was held on May 3, 2014.
Present during the training period were; study Principal Investigator Dr. Kawango
Agot, Co-PI Mr. Jonathan Grund, head of Research and study Co-Investigator, Dr.
Eunice Omanga and Study Coordinator and Co-Investigator Mr. Jacob Onyango, who
also organized and coordinated the whole training.

1.2 Objectives of the study

a. Assess the uptake of VMMC by men 25 39 years exposed to two
interventions: interpersonal communication and dedicated VMMC service
outlets
b. Determine HIV prevalence, through anonymous testing of samples from
excised foreskin, in men declining pre-operative HTC (sub-study).
c. Determine the cost of implementing the interventions separately and together
(sub-study)
d. Evaluate the impact of involving female partners on time to resumption of sex
post-op and uptake of MC (sub-study)
.
1.3 Justification
When barriers and facilitators to VMMC are addressed, people tend to develop interest
to go for Male Circumcision. This is because most people tend to have wrong
perceptions concerning Male Circumcision but some of these myths and misconceptions
are addressed during intervention.
By trying to address the barriers and facilitators to VMMC, this study will give a basis of
addressing some of the challenges and this will further influence VMMC uptake in the
selected study areas. It will also provide a platform of awareness creation about the
2

existence of these problems and possible solutions to the challenges, and identifying key
stakeholders in any planned change.
1.4 Objectives of Internship Training
Internships provide an opportunity for students to link theory with practice and fur there
serve as a bonus work force to those organizations that have committed to participate in
the internship program. The department fulfils its mission of training the students for
significant professional and managerial positions in the real working environment at the
same time benefiting from the work done the students. Among my internship training
objectives are as follows;
To enable me as a student to compare theoretical ideas learned in the classroom
to that of the real world experience regarding their specializing.
To provide me as a student with experience in an actual work environment before
entering the job market. Such experience not o n l y increases Students jo b
prospects , but also teaches what is expected in terms of professional behavior .
To permit me as a student to apply the principals and technical skills learned in
the classroom to real - life problem solving situation.
To provide me as a student with the opportunity to test their interest in a
particular career before permanent commitments are made.
To help me as a student to get prepared to enter into full - time employment in

their area of specialization upon graduation.

To ensure students like me develop employment records/references that will enhance
employment opportunities.
1.5 Limitations of the study
The study findings have limited generalizability to the larger population in Kenya
because study participants were conveniently sampled from four randomly selected sites,
that is, Kisumu, Homabay, Migori and Siaya Counties.
The target Group involved may be too small to draw generalizations. The target group
consisted of only adults and issues surrounding children/teenagers were not observed.
The overall impact is to reduce HIV transmission and if that is so, the study should target
all age groups because HIV/AIDs is a generalized pandemic i.e. it affects all age groups
in the society. Another limitation or challenge is that the target group mainly constitute
3

the family bread winners and this meant that finding some of the participants was not
an easy task and this might in way or the other affected the quality of data that was
collected.
1.6 Organizational Structure
Impact Research and Development Organization which has its headquarters in Kisumu
has a centralized system of management with major decisions being made by the top
most management. The organizational structure is Hierarchical in that every entity in the
organization, except one, is subordinate to a single other entity. This arrangement is a
form of a hierarchy.

Principal Investigators
IRDO (Kenya) & CDC (USA)

Co-Investigators

Research Officer
Co-investigator

Study Investigator

Data Manager
Study Accountant

County Study
Coordinator

Data Officers
Team Leaders
4

Research Assistants

Accounts Clerk

Data Clerks

1.6.1 Vision
To create, develop and sustain empowered and healthy individuals and communities.
1.6.2 Mission
To improve community health and development gains by promoting local research and
implementing evidence-based public health and development programs that respect and
leverage community resources.
1.6.3 Core Values
In the conduct of its business and in the delivery of its services at wherever place and at
whatever time, IRDO shall be guided by and shall endeavor to promote and maintain the
following core values:

Supremacy of human rights, particularly gender equality.

Community support and community participation.
Accountability, transparency, efficiency and responsiveness.
Commitment and professionalism.
Partnership with other agencies through collaborative decision making.
Environmental friendliness.
Non-partisan (non-political) approach to development.

1.6.4 Governance
IRDO is managed by a Board of Directors consisting of ten directors whose members are
drawn from diverse academic, social and professional backgrounds (including medicine,
public health, law, social science, communications, and finance). The board meets semiannually and whenever necessary to give programmatic and financial direction of all
studies and programs carried out under the auspices of the organization. The executive
secretary to the board serves as IRDO Director and who with the help of Program
Coordinators, Human Resources Manager and the Finance Officer manages the
organization and oversees its activities on day-to-day basis.

CHAPTER TWO: LITERATURE REVIEW

2.1. HIV/AIDS in Kenya, Nyanza Province.
According to 2007 Kenya AIDS Indicator Survey (KAIS), national HIV prevalence was
estimated to be 7.1% among adults aged 15 - 64 years. Nyanza province had the highest
prevalence among both rural (14.9%) and urban residents (13.9%) compared to other
provinces. Knowledge of HIV status was low only 16.4% of HIV-infected respondents
knew they had HIV. Knowledge of partners HIV status was also low. Among those
respondents who reported one or more sexual partners in the past 12 months, their
partners had been tested for HIV and disclosed their status to the respondent in only
22.2% of partnerships reported in the year prior to the survey.

2.2 Why TASCO study Targets older men?

The main goal of Voluntary Medical Male Circumcision can be categorized into three,
that is, the immediate, medium and long term goals.
Immediate goal

The immediate goal of Voluntary Male Circumcision is to target currently sexually active
HIV uninfected men.
Medium Goal
The medium goal of voluntary Medical Male Circumcision is to target adolescents (presexual activity).
Long term
The Long term goal is target infant male circumcision.
According to modeling by Hankins et al, it indicated that to impact HIV incidence, we
should;
Circumcise men aged 25-34 years for high level impact.
Circumcise men aged 15-24 years and 35-49 for modest impact and,
Circumcise men aged 50 years and above for little impact.
Thus three things matter;
Target What is the population we are targeting?
Speed What numbers are we reaching?
Coverage At what percentage coverage do we expect to see the impact?
Thus according to the TASCO study, from 25yrs onwards, Men decision-making
dynamics change and;
Men get into sexual relationships so decisions of partners matter.
Men start to fend for self.
Men move into own house and men start to form families hence responsibilities
increase.

2.3 Phases of the main study.

The main study has four phases, that is, phase 1, phase 2, phase 3 and phase 4. There
were also other sub-studies nested to the main study.
7

2.3.1 Phase 1: Household Enumeration (Establishing the Denominator)

Household listing was done to identify those with men 25-39 years.
Research Assistants collected the following information from the participants:
Names and telephone numbers of men aged 25-39 years.
Locator information of households with men aged 25-39 years.
Compile a list with potentially eligible men.

2.3.2 Phase 2: Establishing Baseline VMMC Prevalence and Proportion of Eligible

Men
This involves revisiting of households with men aged 25-39 years. Behavioral
questionnaire is conducted. Physical verification of male circumcision status is also done
to identify households with uncircumcised men aged 25-39 years.

2.3.3 Phase 3: Conducting Rapid Formative Study

This involves conducting a systematic review of published barriers and facilitators to
male circumcision, including womens role in Voluntary Medical Male Circumcision. It
also involves identification of Independent reviewers & retrieval of all relevant studies
(80 articles reviewed, 59 included).
At this phase, Drafting of VMMC Demand Creation Toolkit (messages to be used in IPC
and DSO sites) is also done. Focus Group Discussions (FGDs and IDIs) and In-depth
interviews are conducted with with circumcised men aged 25-39 to explore why they
8

went to Male circumcision and with uncircumcised men why they have not gone for the
cut. Merging of information from systematic review and IDIs is also done to guide
development of VMMC Demand Creation Toolkit.

2.3.4 Phase 4: Describing IPC intervention.

Guiding Principle: Target audience heterogeneous, hence tailor messages to address
unique contexts.
This Involved door-to-door mobilization of households with eligible men to mainly;
Engage them as individuals or couples, as appropriate
Discuss what they like about VMMC (facilitators)
Here the Toolkit is used to reinforce ONLY facilitators mentioned by the
participant.
Discuss why they have not gone for VMMC despite the facilitators (barriers)
Here the Toolkit is used to address ONLY barriers identified/mentioned by the
participant.
If spouse present, also address her barriers and facilitators
Give men referral coupons with list of clinics within the Location; encourage
them to carry coupons to the clinic.

2.3.5 Phase 4: Describing the DSO Intervention

Special clinics/spaces are set up within clinics dedicated to providing services
only to men age 25 years
It involves providing age-appropriate environment with the following features:
Flexible visiting days and hours; that provides services over the
weekends/during public holidays, in the evenings/moonlight and
collaborate with private health facilities
9

 Service provision by peers; by male service providers only and

within/close to the same age bracket as clients.
Ensures discretion and privacy to the clientele
Household mobilization is also done to direct men to DSOs (Dedicate Service
Outlets).

2.3.6 Phase 4: Describing control Locations

Routine mobilization activities are conducted. The activities include;
Satisfied clients are engaged to make referrals if need be.
Local mobilizers are engaged to conduct one on one and small group meetings
to sell VMMC.
IEC materials are distributed.
Visits to social venues to discuss VMMC (men/women/youth groups,
churches, markets etc.
2.3.7 Phase 4: End-line Survey
All households with eligible men will be visited again to administer questionnaire
and verify male circumcision status. This will help assess impact of the
interventions.
Physical verification is compared with clinic records (which will be extracted
from the Theater Register) as well as documentation on Participant Log during
enrollment and at the clinic.

2.4 Staffs Key responsibilities and duties.

At the main office, we have the data officer, data clerk, Accountants clerk and the
County Study Coordinator (CSC). They have different responsibilities. The data
officer collects and verifies field data from team leader (TLs) and checks for data
10

consistency then hands it over to the data clerk to enter it to the database. The data
officer also collects study tools from the study headquarters and distributes them to
the team leaders who later hands them over to the Research assistants.
The data clerk is responsible for the orderly maintenance and security of data
including paper records with participants identifying information. He or she
also enters field data and submits it to the data officer. At the county office,
regular sorting and arrangement of files is done for easy referral and also to give
the monitors an easy task of checking through the data forms.
Adhoc analysis is done to the already entered data to address issues that arise from
time to time in the county. After the analysis, the already entered data is then
submitted to the study data manager by the data officer through an FTP service (File
Transfer Protocol), for example FileZilla. We interns also had some work to do in the
office. We helped in regular data entry and sorting out of data files and forms. We also
had the opportunity to interact with different Research Assistants both in the office
and at the Field. While at the field, we were able to interact with different participants
and also observed or witnessed various consenting and intervention sessions.
The Accounts clerk is responsible for regular disbursement of study funds within
designated study region. He/she also manages petty cash and make payments for all
study activities within designated study region. At the county office, the accounts
clerk prepare weekly reports and submits them to the project/study accountant.
The County study Coordinator Oversees the coordination of study activities in the
designated County as per the study Protocol, Provide leadership, supervision and
support to the data collection team, Review collected data and typed transcripts and
provide feedback, Monitor participant accrual and maintain the data log logging
each data collection event conducted into a log to keep track, Serve as a liaison person
between the IRDO, staff, study participants and the general community in the study
region and Prepare and submit progress reports at required intervals. He/she is also
11

responsible for regular supervision of interns and ensures all tasks assigned to the
interns are done in the right order and as per the study protocol.

2.5 Study Monitoring and Evaluation

In order to monitor the performance and effectiveness of current programs, and to
improve the delivery of future projects, IRDO regularly conducts program
evaluations. In addition, it incorporates monitoring and evaluation components at the
program design stage to ensure that research and program activities produce useful
results. IRDO view planning an intervention and designing an evaluation strategy as
inseparable activities. IRDO recognizes collaboration between project designers and
local stakeholders in outlining processes which help to ensure the relevance,
sustainability and avoidance of duplication of evaluation activities.
After study monitoring, a brief meeting by the county study county coordinator is
usually held to discuss some of the major and minor issues raised by the monitors. For
instance, some of the issues raised by the monitors in their previous visit included
issues to do with inappropriate dating of Informed Consent forms (ICFs), Research
Assistants signing of for participants, overwriting and the question to do with whether
the participant consented or not.

2.5.1 VMMC Quality Assurance/Control and Training Team

IRDOs VMMC program has a Quality Assurance/Control and Training department
which is mandated to ensure that VMMC services at IRDO sites are provided under
WHO/UNAIDS Quality Assurance standards.

2.5.2 Training
The team is responsible for training Ministry of Health staff i.e. Medical Officers,
Clinical Officers, Nursing Officers, HTC Counsellors and Infection Prevention
12

Officers; on provision of safe VMMC services. In addition, the training team

enhances Sub County VMMC Service provision supervisors (Sub County Health
Management Teams) capacity, by training them on WHO/UNAIDS QA standards, to
provide support supervision at VMMC service delivery sites within their Sub
Counties.

2.5.3 Protocols development

The

QA/QC

and

Training

Team

develops

and

distributes

copies

of

SOPs/protocols/quality guidelines on provision of VMMC services according to the

WHO/UNAIDS standards, to all service provision sites; and ensure compliance to the
guidelines. Consumables management: The QA/QC and Training Team ensures
effective VMMC consumables management. They take stocks, and issue controls
where necessary, of all supplies and consumables meant for MC surgical procedures
in each of the 14 IRDO Sub County stores.

2.5.4 Data Quality

As a key concern in building an effective Health Management Information System,
the team ensures data quality by checking for correctness, completeness and
consistency of data generated at facility level.

2.6 Barriers addressed by the interventions

IPC:
Pain and other complications.
HIV testing and counseling.
Effect on sexual function, penile size and many others.
Long period of sexual abstinence.
13

 Cultural and religious barriers.

DSO:
Concern over queuing alongside young people.
Concern over female providers.
Inconvenient locations, opening hours, privacy.
Concern over long waiting time.
2.7 Status report and next steps
Desk review (systematic review completed) and VMMC Demand Creation Toolkit is
drafted and Institutional Review Board (IRB) Approval process is done;
CDC-DGHA Science Office - Technical review done and approval
obtained April, 2013
CDC Science Office submitted to their IRB; feedback received and
responses submitted. Awaiting their response.
KNH/UoN-ERC Approval granted.
Development of database starts and conversations with Data Manager
initiated.
Development of SOPs is done staff needs are identified, that is, some key staff on
board/identified and adverts to go up for remaining or unoccupied positions.

14

CHAPTER THREE: METHODOLOGY

3.1 Overview of methodology

This chapter examines the methodology used by the student to carry out the study. It
gives a brief description of the study area and study variables. Other areas to be covered
in this chapter include study design, data collection methods and tools as well as data
management and analysis. Ethical considerations is also examined in this chapter.

3.2 Study Design

A cluster randomized-controlled trial with 4 study arms was used. The four study arms
include;
Inter-Personal Communication(IPC)
Dedicated Service Outlets (DSO)
15

 Combined IPC and DSO

No intervention [routine demand creation services]
It was conducted in 45 administrative Locations (clusters) in 11 districts in Nyanza
Province (9 IRDO, 2 non-IRDO). The Study-wide sample size was 4,932 men taking up
male circumcision. Compared to no intervention, service uptake was expected to double
in single-intervention arms and triple in combined intervention arm.

Enumeration of all the Households in the 45 was done and participating Enumeration
Areas (EAs) per Location was based on estimated men aged 25-39 years per 100
Households. Participating EAs was randomly selected from each of the 45 Locations.

The study design facilitated collection of qualitative data through observation and
interviews to achieve the study objectives.

3.3 Study Area

There were four selected study areas i.e. Kisumu, Migori, Homabay and Migori
counties. The study region where I was attached to was Siaya County, which is about
89km kilometres from Kisumu city via Luanda (According to Google maps). It covers
an area of 2,350 square kilometers with a population of 842,304 people as per 2009
census. It is organized into six sub-counties (which are also constituencies): Ugunja,
Ugenya, Alego-Usonga, Gem, Bondo and Rarieda and is accessible by air, road, and
water.
The major urban centres include (in order of population size) Bondo, Siaya (the
capital), Usenge,Ugunja, Yala, Ukwala and Ndori. Notable geographical features in
the County include: part of LakeVictoria, the Worlds second largest fresh water lake;
Lake Kanyaboli, the second largest ox-bow lake in Africa; River Yala; River Nzoia
16

and numerous wells, dams, swamps and streams. Siaya County has numerous islands
such as Ndeda, Mageta, and mountainous ranges like Got Ramogi and Got Abiero.
The administrative boundaries are under the jurisdiction of assistant chiefs who work
with village elders. The study constituted 45 locations and 67 selected study villages.
In the health sector, the numbers of health facilities was 160. Of these, 12 were
hospitals; 40 were health centres; 4 were nursing homes, while there were 78
dispensaries and 26 clinics. HIV/AIDS prevalence rate was 24%, with 34 VCT
centres. The total bed capacity in the county was 657, while doctor/population ratio
was as follows: Bondo - 1:72,390; Siaya - 1:52, 000.
The major economic activity of the residents is farming, with the majority planting
maize, beans and sorghum among others which is reliant on rainfall. Those who
border the lake engage in fishing while the youth population operate bicycle and
motor cycle taxi (boda boda) business.

3.4 Methods of Data Collection

The study used qualitative data collection methods, these involves individual
observations and in-depth interviews with participants. It also involves Clinic based RAs
and health care workers within the health facilities offering HIV testing and counselling
services (HTC).

3.4.1 In-depth interviews.

In-depth interviews were developed to capture sensitive information from partners who
have gone through day 42 and are willing to take part in in-depth interview. The main
objective of in-depth interview is to understand why men resume or not resume sex
before complete wound heal.
17

3.5 Data Quality Control

The data tools were tested for reliability and validity by the Ethic and Review
Commission (ERC). The study teams were trained to ensure that they understood the
instruments/tools. The teams were always briefed after each stage to ensure data
accuracy and completeness.

3.6 Data Management and Analysis

At the study county office, the collected data is received by the data officer who
conducts a quality check then entered into the county study database. Adhoc analysis is
done to the already entered data to address issues that arise from time to time in the
county.

3.7 Ethical Consideration

This study was ethical approved by ethics and review commission (ERC). At the same
time each Research assistant was certified to conduct the study. To be certified, each
Research assistant was required to do an online ethics exam and receive an ethics
certificate from National Institute of health. Consent was sought from the respondents.
Confidentiality, anonymity and privacy were observed during the study.

18

4.0 CHAPTER FOUR: CONCLUSION AND RECOMMENDATIONS

Overview of summary, conclusions and recommendations

This chapter constitutes the conclusions, recommendations and suggestions for further
research.
4.1 Conclusions
This study provides important insights into the barriers and facilitators of clients
seeking medical circumcision services. The findings from both quantitative and
qualitative data sources suggest that circumcision for health, especially HIV and STI
prevention, is the predominant motivator for VMMC, and this continues to be an
effective message for promoting medical circumcision in settings where there is a
high burden of HIV. There are considerable barriers to circumcision, including fear of
pain, fear of HIV testing, and indirect costs associated with VMMC. However, these
barriers are not insurmountable as, evidently, study participants were able to
overcome them and ultimately seek medical circumcision. These findings can inform
the national VMMC program, which can build on what we have learned in this study
and develop mass communication messages that specifically addresses the fears and
concerns experienced by men who sought VMMC. However, additional research to
understand the impact of fear of HIV testing on VMMC uptake in Kenya region is
needed.

4.2 Recommendations
Creating sustained demand for VMMC is essential to the success of scale-up. Formative
research should be an integral part of VMMC programming to guide the design of
service delivery modalities that meet specific needs and desires of communities and
specific age groups of men to take up VMMC. Demand creation messages and
approaches need to be specifically tailored for different ages as there are important
19

disparities in motivators and barriers to VMMC uptake by age groups. Positioning

VMMC as a lifestyle choice with other health benefits rather than an HIV prevention
method might increase acceptance of the service by both older men (over 25 years of
age) and women. Service delivery modality and intensity through campaigns also is
important to generate demand, influencing uptake of services especially by younger age
groups such as adolescents. In most VMMC facilities as at now, high numbers of
adolescents (10-19 years) are accessing services during school holiday campaigns, which
is not the case for older men who have proven to be more challenging to reach. VMMC
programs need to explore underlying cultural preferences and barriers to effectively
target older clients. The barriers to VMMC demand in Kenya for older men included
stigma associated with VMMC, fear of pain, long healing period and the perception of
low risk for HIV for older men. Clearly, as programs scale up, it is essential to
understand and tailor both demand creation interventions and service delivery models to
the specific age groups of clients.

20

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