MedicalResearch.com Interview with:
Jennifer A. Downs, M.D., Ph.D.
Assistant Professor of Medicine and Microbiology & Immunology
Department of Medicine
Weill Cornell Medicine
Center for Global Health
New York, NY 10065
MedicalResearch.com: What is the background for this study? What are the main findings?
Response: Between 2002 and 2006, three large randomized controlled trials in sub-Saharan Africa demonstrated that male circumcision reduces new HIV infections in men by approximately 60%. Based on these findings, the World Health Organization recommended male circumcision as an HIV prevention strategy in countries with high levels of HIV and a low prevalence of male circumcision. This led to prioritization of 14 countries in Eastern and Southern Africa for massive scale-up of male circumcision beginning in 2011.
In many of these countries, the uptake of male circumcision was lower than expected. In northwest Tanzania, where we work, there are a number of barriers to male circumcision. Some of these barriers are cultural, tribal, economic, and religious. We conducted focus group interviews in 2012 that showed that many Christian church leaders and church attenders in our region in Tanzania had major concerns about whether male circumcision was compatible with their religious beliefs. This led us to hypothesize that the uptake of male circumcision could be increased when religious leaders were taught about male circumcision, with the goal that they would then be equipped to discuss this issue with their congregations.
MedicalResearch.com: How did you test this hypothesis? What are the main findings?
Response: To conduct our study, we worked with male circumcision outreach campaigns from the Tanzanian Ministry of Health. These outreach campaigns would arrive in a village and provide male circumcision at the village’s local health center for several weeks to months. The Ministry of Health campaign provided drama and open-air announcements about male circumcision, but did not specifically educate religious leaders. We worked with the Ministry of Health to identify 16 villages that would receive this circumcision campaign. All villages received the standard teaching from the Ministry of Health. Then, in addition, in 8 of these villages, we provided an educational seminar for religious leaders from all Christian denominations during which we discussed the religious, cultural, and historical aspects of male circumcision. The church leaders themselves then decided how to bring this education back to their congregations.
In all 16 villages, we determined the total number of men who sought circumcision during the time of the outreach campaign. We found that, in the 8 villages in which the religious leaders did not receive the educational seminar, 29.5% of the total male population sought circumcision. In the villages in which the religious leaders did receive the educational seminar, 53.8% of the total male population sought circumcision. In addition, in the villages that received the educational seminar, 30.8% of men who sought circumcision stated that they had heard discussions of male circumcision in church. In contrast, less than 1% of men stated that they had heard this topic discussed in their churches in the villages that did not receive the educational seminar.
If we were to expand our work to the entire country of Tanzania, we estimate that our strategy would lead to 1.4 million more circumcisions and would therefore prevent 65,000 to 200,000 new HIV infections in men in Tanzania alone.
MedicalResearch.com: What should readers take away from your report?
Response: Our work shows that, in a setting in which people are strongly committed to their religious beliefs, healthy behavior can be promoted by working with a community’s religious leaders. The Pew Research Center conducted a large survey in 19 countries in sub-Saharan Africa in 2010 that showed that most people in sub-Saharan Africa are devoutly committed to their religious faith, with 80-90% in most countries describing religion as “very important” in their lives and attending services at least weekly. This situation is extremely different than it is in many Western countries. The longer that I work in Tanzania, the more I become aware that the Western impulse to separate religion from medicine does not make sense in Tanzania because almost the entire population is deeply committed to their religious faith and practice.
I think that our study proves the validity of the concept that a cross-disciplinary collaboration that strives to educate and equip religious leaders is a powerful way to promote healthy behavior. We worked closely with our Tanzanian colleagues to design and implement an educational seminar that would be relevant in our setting. There would likely need to be some adjustments to make this relevant and appropriate for other settings, but the concept would not change: addressing people’s health behavior by reaching them through their religious leaders can be an effective way to impact health-related behavior.
MedicalResearch.com: What recommendations do you have for future research as a result of this study?
Response: We hope very much that our study will inspire other investigators to study the applicability of our findings in other countries, among other religious groups, and with a focus on other health topics. We are beginning to do this in our setting by moving beyond Christian communities to look at health care interventions among Muslim groups and to work to address other health-related behaviors.
The other essential research priority, which is highlighted by the work we did for this project, will be to learn to build cross-disciplinary collaborations to achieve effective health interventions. Our study team included not only physicians and public health officials, but also religious leaders, regional community leaders, and educators. Each member of our team was vitally important to the success of our project. I hope that our work will encourage similar interdisciplinary work in other settings.
We are grateful to the Bill & Melinda Gates Foundation, the National Institutes of Health, and the Mulago Foundation for their financial support of this project.
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