What if the pathway to a medical procedure that could prevent HIV infections started on a soccer pitch? With a long-term objective of eradicating HIV in Zimbabwe, Grassroot Soccer initiated a series of trials utilizing its Make The Cut (MTC) curriculum to prompt young men in Zimbabwe to undergo voluntary medical male circumcision (VMMC). Through soccer drills and activities, the program teaches these men about the benefits of VMMC, which has proven to reduce the transmission of HIV (Auvert B et al, Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk, 2005).
Currently, there are very few programs acting to drive demand for VMMC. This is hindering Zimbabwe from reaching its goal of 80% VMMC coverage among males ages 15-29 by 2015 (WHO. Progress in scaling up voluntary medical male circumcision for HIV prevention in East and Southern Africa, 2011). GRS’s Male Circumcision Uptake Through Soccer (MCUTS) trials show that with the education and encouragement the curriculum provides, these men are more likely to receive the procedure.
The Pathway of Change
According to social learning theory, observation and modeling of one another’s attitudes and behaviors in a social context provide the optimal environment for learning (Bandura, Social Learning Theory, 1977). Grassroot Soccer’s approach to VMMC demand creation incorporates five individual and community-level enablers. Through education on HIV and STI risk reduction, information on improved sexual performance and/or hygiene, encouragement from coaches, peer support, and soccer-based incentives, MCUTS teaches Zimbabwean men what’s to gain from VMMC. GRS’s Caring Coaches, some of whom are professional soccer players, have become role models and have successfully created a safe space in which young men can ask questions, express fears, and get answers.
What We Observed
Myths about VMMC and general lack of knowledge are some of the greatest obstacles that coaches are faced with, which is why generating an environment that is conducive to open dialogue is so critical. The common language of soccer helps to create this open environment. During the first round of trials, 736 men on Zimbabwean soccer teams participated in the study over the course of 6 months. Participants were encouraged to undergo VMMC at free clinics in Bulawayo.
Results from the initial trial suggest an absolute increase in VMMC uptake of about 4.6% among the men on soccer teams who participated in the study. This is a 9X increase in circumcision uptake compared to the control group. Interviews and focus group discussions taught us that younger participants, between 15-19 years old, were more open to learning about VMMC through soccer drills as compared to their older counterparts. Coaches found that follow-up and soccer-related incentives might drive even more demand.
What We’ll Do Next
Inspired by the findings from the initial trial, GRS is now in a secondary phase trial (MCUTS II), teaching the MTC curriculum in secondary schools in Bulawayo, targeting 15-19 year olds. Coaches speak to worries about pain, HIV tests, and healing time by sharing their own experiences. After the session is over, coaches foster their relationship with students by calling them directly and encouraging them to follow through with the procedure. Prizes such as t-shirts and tickets to soccer matches incentivize some participants who receive the procedure. Preliminary results from the second trial indicate that the response has been positive, and these tactics are contributing to a higher uptake rate.
By using soccer as a tool to attract vulnerable youth, GRS is able to access youth that are otherwise difficult to reach. GRS has proven that its innovative education programs increase the resiliency skills of participants and improve attitudes of stigma and discrimination (Clark et al, AIDS and Behavior, 2006). Combined with the low cost of implementation and its unique ability to demonstrate the benefits of VMMC, MCUTS is a promising solution. If the MCUTS program can generate demand for VMMC through a game of soccer, let’s play.
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To learn more about Grassroot Soccer, click here. To learn more about the Gates Foundation's HIV Strategy, click here.