The Effects of Providing Fixed Compensation and Lottery-Based Rewards on Uptake of Medical Male Circumcision in Kenya: A Randomized Trial

Background:Effective demand creation strategies are needed to increase uptake of medical male circumcision and reduce new HIV infections in eastern and southern Africa. Building on insights from behavioral economics, we assessed whether providing compensation for opportunity costs of time or lottery-based rewards can increase male circumcision uptake in Kenya. Methods:Uncircumcised men aged 21–39 years were randomized in 1:1:1 ratio to 2 intervention groups or a control group. One intervention group was offered compensation of US $12.50 conditional on circumcision uptake. Compensation was provided in the form of food vouchers. A second intervention group was offered the opportunity to participate in a lottery with high-value prizes on undergoing circumcision. The primary outcome was circumcision uptake within 3 months. Results:Among 903 participants enrolled, the group that received compensation of US $12.50 had the highest circumcision uptake (8.4%, 26/308), followed by the lottery-based rewards group (3.3%, 10/302), and the control group (1.3%, 4/299). Logistic regression analysis showed that compared with the control group, the fixed compensation group had significantly higher circumcision uptake [adjusted odds ratio 7.1; 95% CI: 2.4 to 20.8]. The lottery-based rewards group did not have significantly higher circumcision uptake than the control group (adjusted odds ratio 2.5; 95% CI: 0.8 to 8.1). Conclusions:Providing compensation was effective in increasing circumcision uptake among men over a short period. The results are consistent with studies showing that such interventions can modify health behaviors by addressing economic barriers and behavioral biases in decision making. Contrary to findings from studies of other health behaviors, lottery-based rewards did not significantly increase circumcision uptake. Trial Registration:Registry for International Development Impact Evaluations: RIDIE-STUDY-ID-530e60df56107.

[1]  K. Agot,et al.  Use of Economic Compensation to Increase Demand for Voluntary Medical Male Circumcision in Kenya: Qualitative Interviews With Male Participants in a Randomized Controlled Trial and Their Partners , 2016, Journal of acquired immune deficiency syndromes.

[2]  K. Agot,et al.  Effect of providing conditional economic compensation on uptake of voluntary medical male circumcision in Kenya: a randomized clinical trial. , 2014, JAMA.

[3]  S. Sgaier,et al.  Achieving the HIV Prevention Impact of Voluntary Medical Male Circumcision: Lessons and Challenges for Managing Programs , 2014, PLoS medicine.

[4]  G. Rutherford,et al.  Status of Voluntary Medical Male Circumcision in Kenya: Findings From 2 Nationally Representative Surveys in Kenya, 2007 and 2012 , 2014, Journal of acquired immune deficiency syndromes.

[5]  P. Dolan,et al.  Vouchers versus Lotteries: What works best in promoting Chlamydia screening? A cluster randomised controlled trial. , 2014, Applied economic perspectives and policy.

[6]  R. Gray,et al.  Programme science research on medical male circumcision scale-up in sub-Saharan Africa , 2013, Sexually Transmitted Infections.

[7]  R. Gray,et al.  Contextual Barriers and Motivators to Adult Male Medical Circumcision in Rakai, Uganda , 2013, Qualitative health research.

[8]  A. London,et al.  Improving Ethical Review of Research Involving Incentives for Health Promotion , 2012, PLoS medicine.

[9]  C. Hankins,et al.  Voluntary Medical Male Circumcision: An Introduction to the Cost, Impact, and Challenges of Accelerated Scaling Up , 2011, PLoS medicine.

[10]  C. Hankins,et al.  Voluntary Medical Male Circumcision: Modeling the Impact and Cost of Expanding Male Circumcision for HIV Prevention in Eastern and Southern Africa , 2011, PLoS medicine.

[11]  P. Cherutich,et al.  Voluntary Medical Male Circumcision: Translating Research into the Rapid Expansion of Services in Kenya, 2008–2011 , 2011, PLoS medicine.

[12]  R. Bailey,et al.  Acceptability of Medical Male Circumcision Among Uncircumcised Men in Kenya One Year After the Launch of the National Male Circumcision Program , 2011, PloS one.

[13]  R. Bailey,et al.  Implementing Voluntary Medical Male Circumcision for HIV Prevention in Nyanza Province, Kenya: Lessons Learned during the First Year , 2011, PloS one.

[14]  A. Banerjee,et al.  Improving immunisation coverage in rural India: clustered randomised controlled evaluation of immunisation campaigns with and without incentives , 2010, BMJ : British Medical Journal.

[15]  Lynnette M Neufeld,et al.  10-year effect of Oportunidades, Mexico's conditional cash transfer programme, on child growth, cognition, language, and behaviour: a longitudinal follow-up study , 2009, The Lancet.

[16]  E. Schouten,et al.  Community health workers for ART in sub-Saharan Africa: learning from experience – capitalizing on new opportunities , 2009, Human resources for health.

[17]  Kevin G Volpp,et al.  A test of financial incentives to improve warfarin adherence , 2008, BMC health services research.

[18]  T. Brennan,et al.  Asymmetric paternalism to improve health behaviors. , 2007, JAMA.

[19]  A. Haines,et al.  Conditional cash transfers for improving uptake of health interventions in low- and middle-income countries: a systematic review. , 2007, JAMA.

[20]  Stephen Moses,et al.  Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomised controlled trial , 2007, The Lancet.

[21]  Oliver Laeyendecker,et al.  Male circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial , 2007, The Lancet.

[22]  R. Bailey,et al.  Acceptability of Male Circumcision for Prevention of HIV/AIDS in Sub-Saharan Africa: A Review , 2006, AIDS and Behavior.

[23]  Emmanuel Lagarde,et al.  Randomized, Controlled Intervention Trial of Male Circumcision for Reduction of HIV Infection Risk: The ANRS 1265 Trial , 2005, PLoS medicine.

[24]  G. Chapman,et al.  Playing for peanuts: Why is risk seeking more common for low-stakes gambles? , 2005 .

[25]  T. Schultz.  SCHOOL SUBSIDIES FOR THE POOR: EVALUATING THE MEXICAN PROGRESA POVERTY PROGRAM , 2012 .

[26]  Ted O’Donoghue,et al.  Doing It Now or Later , 1999 .

[27]  K. Agot,et al.  Effect of Providing Conditional Economic Compensation on Uptake of VoluntaryMedical Male Circumcision in Kenya , 2014 .

[28]  A. Tversky,et al.  Prospect theory: analysis of decision under risk , 1979 .