Ayaan Abukar

9 september 2016



marjolein-hekelaarMarjolijn Hekelaar works at Impact Centre Erasmus (ICE) where she advises organizations on evidence-based programming. In a series of six blogs for ViceVersa, ICE shares lessons learned and puts evaluation in the spotlight. In this first one, inspired by the circumcision song, Marjolijn scrutinizes the way we make decisions about the effectiveness of programs based on gut feelings and advocates to use evidence instead.

It is the year 2013 and I am sitting in the back of a taxi that’s speeding through the capital of Zimbabwe, discussing local politics with the driver. While he is running red lights and enlightening me with his critical reflections on the causes of petty corruption, I hear a very catchy song on the radio: the “circumcision song”[1]. What catches my attention is not the Southern-African inspired rhythm or the fact that it is sung by a very famous local singer, but the message being conveyed on Zimbabwe’s number one radio station: “Let’s circumcise!”. I am intrigued and start digging into the why and how of this male circumcision campaign.

I don’t know how I had missed it up until that moment; you could spot articles featuring pictures of broadly smiling ‘circumcision ambassadors’[2] in every major newspaper and there were television commercials[3] on the topic as well as several other kinds of radio broadcasts. These were all aimed at motivating young men to get circumcised in order to reduce the spread of STI’s such as HIV. The campaign (led by the USAID funded NGO Population Services International), had not succeeded in gaining my sympathy. In fact, I couldn’t get my head around the large amounts of money being invested in a program that I was sure was not at all effective. I was convinced that although promoting this surgical measure would maybe marginally decrease chances of transmission, it would also mean that no one would feel the need to use the still necessary condom, hereby cancelling out the allegedly positive effect of men being circumcised.

I was wrong. I made two major errors in my judgment. First,  rather than a marginal reduction in transmission, evidence – from multiple randomized controlled trials, such as this one[4] – shows that male circumcision reduces the risk of female to male HIV transmission by approximately 60%[5]. In 2007 the WHO[6] and UNAIDS[7] therefore emphasized that male circumcision should be considered an effective intervention for HIV prevention in countries with predominantly heterosexual transmission, high HIV and low male circumcision prevalence; such as Zimbabwe. By being so effective, male circumcision has the potential to greatly increase general public health: if there were 80% coverage of voluntary male circumcision, a whopping 3.4 million new HIV infections could be prevented[8]. Plus, this would mean saving up to US$16.5 in costs by 2025[9] by averting HIV infections and therefore reducing the number of people who need HIV treatment and care.

Let’s call out my second big mistake: I presumed that condom distribution combined with proper sexual education results in people using condoms and reducing the spread of infections. Unfortunately (for all the dollars wasted), that presumption doesn’t hold [10],[11]. The reason comprehensive sexuality education programs[12] combined with condom distribution show no effect is that they depend on people to practice reflective, deliberate decision-making. Most of our decisions, however, aren’t made by careful reflection on which course of action would be optimal[13]. Especially when it comes to sex: in the heat of the moment we are not really in the mood for reflective decision making (such as: ‘If I use a condom then I will prevent the odds of transmitting STI’s, which could have short or long-term negative consequences’). In other words, many decisions are made based on automatic thinking that we are often not even aware of. The best way to change behavior patterns, therefore, is to nudge[14] people to do the right thing without them necessarily being aware that they are being influenced. This makes providing information far from an ideal method. Using multi-media to convey well-thought out messages[15] and exposing people to role models that showcase positive behavior promises to be a lot more effective.

Good to know – but what can we conclude from all this? I’d say at least three things:

  1. Increasing male circumcision coverage is effective as a means of HIV prevention
  2. Condom distribution programs (combined with education) have no detectable effect on STIs/HIV
  3. People change most behaviors sub-consciously, by constantly being exposed to it or by following role models

This makes PSI’s efforts in Zimbabwe[16] to reduce HIV transmission by promoting male circumcision – through multi-media campaigns and using public figures as role models – a promising social program. My outrage should be redirected from PSI’s radio spots to organizations that still spend their money on doing what doesn’t work, such as those still focusing on comprehensive sexuality education combined with condom distribution.

We all rely too much on our gut feeling. This results in us dismissing effective projects, and (arguably even worse) promoting ineffective ones. I overestimated my ability to judge what has impact and what doesn’t, based on assumptions that were incorrect and/or had no scientific foundation. Due to this realization, I took away a lot more from this experience than solely the knowledge on why men should remove their foreskins in order to reduce the spread of HIV. It has been a life changer for me personally, as it made me realize the importance of taking into account evidence in judging the effectiveness of programs.

To those living in a context with HIV: if you are a champion, get circumcised! To those living in any context: don’t rely on your gut feeling to make vital judgement calls, seek out evidence.

This is the first in a series of six blogs in which Impact Centre Erasmus shares lessons learned in working on evidence-based programming. Next up, we dive deeper into the practical steps we can take to think deeply about our impact. 

















Marjolijn Hekelaar

Marjolijn Hekelaar works at Impact Centre Erasmus (ICE) where she advises organizations on evidence-based programming.

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