Development and testing of an m-Health platform to reduce post-operative penetrative sex in recipients of voluntary medical male circumcision

Background: The widespread roll-out of voluntary medical male circumcision (VMMC) has been accompanied by reports of VMMC recipients, particularly men who are married or cohabiting, resuming sexual intercourse before the recommended healing period of six weeks. This behaviour carries an increased risk of transmission of STIs and HIV, particularly for the female partner. At the same time, it is unrealistic to assume that an already over-burdened health system will be able to provide repeated, intense messaging that recent recipients of VMMC may need to help them navigate the post-operative period sexually. There is an urgent need to develop culturally appropriate messages and innovative delivery strategies for behaviour modification in the post-operative period and the longer term for medically circumcised men. Methods: As a step to better understand the behaviour of the VMMC patients during the six-week recovery period, we conducted eight single-gender focus groups with males who had undergone VMMC in the previous six months and their partners. (Study 1) Armed with this information, we strove to create a contextually-relevant message regime by using a staggered qualitative methodology: (1) focus group discussions with 52 recently circumcised men and their partners to develop initial voice messages (2) thematic analysis and expert consultation to select the final messages for pilot testing, and (3) cognitive interviews with 12 recent VMMC patients to judge message comprehension and rank the messages. The message content and phasing were guided by the theory of planned behaviour, the health action process approach and the action research approach. (Study 2) For the next two years, this intervention was evaluated using a two-armed, randomized, single-blind, controlled design. This sample was collected at 12 clinics in urban areas in Western Cape Province, South Africa. Patients were followed up at 42 days after enrolment. (Study 3) As a final measure, the usability of the platform was evaluated. At follow-up, 597 participants completed questionnaires regarding the usability and user experience of the mobile audio platform. Usability was measured with the System Usability Scale (SUS). Five focus groups with a total of 25 patients were also conducted. The scale’s multidimensionality was shown with the emergence of three trends that explained more than 65% of the total variance of the scale. (Study 4) Results: The primary motivation to VMMC uptake included religious injunction and hygiene reasons and protection against sexually transmitted infections not necessarily HIV. Both men and women felt that sex was important to maintain the relationship. (Study 1) We received 245 messages with 42 themes. Expert review and cognitive interviews with more patients resulted in 42 messages with a clear division in terms of needs and expectations between the initial wound-healing recovery phase (weeks 1–3) and the adjustment phase (weeks 4–6). Participants were more positive and salutogenic than public health experts were. (Study 2) The randomised controlled trial found a slightly larger positive effect in the Intervention Group (28.0%) than in the Control Group (32.3%)) bot not significant (p=0.071). (Study 3) Participants gave the platform an overall usability score of 62.80 (SD 13.41). Most of them were positive about the messages. (Study 4) Conclusions: VMMC counselling needs to take into account the real-life factors of the circumcised men. Due to systematic, social and cultural factors, there is a real risk that men in this population may initiate sex before complete healing has occurred. (Study 1) Consultation with potential mHealth recipients and using classic behavioural theories are vital to the success of a programme. (Study 2) Early resumption of sex after VMMC is common, warranting better counselling. M-Health technology is a potential tool but it should be complemented by other methods. (Study 3) The results suggest that the audio messaging system has good usability, user experience and user acceptance.