Food vouchers as an incentive for male circumcision in Kenya

Effect of providing conditional economic compensation on uptake of voluntary medical male circumcision in Kenya: a randomized clinical trial


Thirumurthy H, Masters SH, Rao S, Bronson MA, Lanham M, Omanga E, Evens E, Agot K. JAMA. 2014 Aug 20;312(7):703-11. doi: 10.1001/jama.2014.9087.Epub 20 July 2014.

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 1 504 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 (approximately US $2.50), 700 Kenya shillings (approximately US $8.75), or 1 200 Kenya shillings (approximately 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 1 502 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.

Abstract access  [1]

Editor’s notes: Despite considerable scale-up of voluntary medical male circumcision (VMMC), most countries are short of their targets of 80% circumcision prevalence, and novel demand-creation strategies are needed. This study is the first randomised controlled trial to evaluate the effectiveness of a conditional economic compensation on VMMC, and found that incentives were effective in increasing VMMC uptake in this population. The compensation was given in the form of food vouchers of a value approximating transportation costs plus up to about three days’ wages.  The voucher was given if the participant underwent circumcision at one of the study clinics within two months.  The programme was particularly effective among married and older participants, and men at higher risk of acquiring HIV – these are priority groups for scale-up but have been relatively hard to reach in many settings.  The trial shows that such economic incentives are promising for VMMC by addressing economic barriers to uptake. Further rigorous evaluation of these economic-based activities, and the exploration of innovative ways to use economic incentives, for HIV-related behaviours such as HIV-testing and linkage/retention in care should be considered.

Africa [5]
Kenya [6]
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