This study was conducted in three provinces of Zambia namely Lusaka, Copperbelt and Muchinga. The two latter areas were selected because one province had the highest VMMC uptake rate (Copperbelt province) while the other one had the lowest VMMC rates (Muchinga province). Lusaka province is the country’s headquarters and had relatively high VMMC uptake rates. An earlier version of this article can be found on Research square ( https://doi.org/10.21203/rs.3.rs-295480/v1).

A qualitative case study approach was used for developing the community engagement plan for the maintenance phase of VMMC ( Gibbs, 2007). The case study methodology is an empirical approach that investigates contemporary phenomena within a real-life context, where the boundaries between phenomena and context are not clearly evident and in which multiple sources of evidence are used ( Zulu et al., 2018). The case study approach was considered as appropriate for this study because the CHA strategy was developed within a complex context, which involved social interactions, and dependent on multiple local contexts. The study adopted the consolidated criteria for reporting qualitative research (COREQ) checklist in framing the study design and analysis plan.

Data collection was conducted from August to September 2019. We held meetings with national implementers of VMMC from Ministry of Health and CHAI to shortlist actors involved in the demand creation of VMMC in Zambia at community level. The district and health facility coordinators assisted the research team to recruit eligible participants into the study. To be eligible- for the study, one needed to have been involved in the implementation of VMMC or should have accessed the services and or helped the child access services. Purposive sampling was used to select study participants who were appropriate given the study objectives and outcomes. Data were collected using Key Informant Interviews (KIIs) and Focus Group Discussions (FGDs) with community stakeholders such as chiefs, health centre committees, counsellors, headmen, teachers, health workers, community-based volunteers as well as parents/caregivers. We conducted a total of 72 interviews, 36 were FGDs consisting of at least 6 individuals (12 per province), while 36 were KIIs (12 per province) as shown in Table 1 below. A total of 35 KIIs were conducted (12 per province). Twelve interviews and FGDs were conducted per province in order to take into account a wide variety of stakeholders such as neighbourhood health committees (NHCs), community health workers (CHWs), traditional leaders, church leaders, health workers, teachers and parents. Transport refund compensation of K50 was provided to the participants. The Power/Interest Matrix stakeholder analysis tool by n Newcombe (2003) guided the mapping and ranking processes. The paper aimed to outline the type of stakeholders available at community level, their roles, power, interest as well as strategies in the transition/sustainability phase of the VMMC programme.

The data collection process started with a review of key documents on VMMC in Zambia. These documents included published papers on VMMC, the Zambia VMMC National Operational Plan [2016–2020] ( MoH, 2017), and the 2019 Transition and Sustainability Plan for the Zambia VMMC Programme ( MoH, 2019). Given that the focus was on Zambia, we targeted the Ministry of Health website as the main source of published documents on VMMC ( https://www.moh.gov.zm). Additional documents were obtained from VMMC coordinating office at the Ministry of Health. No search terms were used as there are few published documents on VMMC in Zambia, and also because documentary review was the secondary source of data.

All the interviews were conducted with the stakeholders in the district at various primary health care centres, locally called health facilities (clinics) or health posts and community settings (at traditional leaders’) separately by either the fourth (TFLM), fifth (JM), sixth (MK)and last authors (MPC), all had training and experience in conducting qualitative research. The authors had diverse backgrounds and qualifications (in anthropology, medicine and public health) which helped in improving credibility of data. The three authors held at least a master’s in public health, and one had a bachelor’s in demography and population studies. The lead Investigator had a PhD in anthropology and public health. Some researchers knew some key stakeholders, a new situation which facilitated good rapport and trust with the community.

We conducted interviews using a semi structured interviews. Respondents were asked to state their role in promoting sustainability of community driven VMMC activities, who to be engaged during the transition/sustainability phase of the VMMC, nature of the reporting process and feedback process, and monitoring mechanism of the plan. The interview guide can be found as extended data ( Chavula, 2022).

Most of the interviews were conducted in local languages namely, Nyanja and Bemba as respondents were conversant with the language. Interviews conducted in local language were transcribed and translated in English. An average interview lasted for about 1:55 hours. Interviews were recorded using a voice recorder. The notes were also taken by during the interviews, and these were extensively reviewed and discussed.

The analysis and writing process of the engagement plans started with transcribing data from the audio interviews from the field and consultative/ stakeholder analysis meetings. Data was familiarised by multiple readings of the transcribed interviews while paying attention to patterns and occurrence. The code framework was generated by two researchers working on the study (MPC & JMC). The framework was revised several times after agreeing with the research team which themes represented the majority views. The code and transcripts were then exported into a qualitative software (Nvivo plus 12, RRID:SCR_014802) for data management and analysis. Coding involved identifying a passage in the text or other data items, searching and identifying concepts and finding relations between them ( Gibbs, 2007). Four researchers were involved in coding data into respective themes (MPC, JM, MK & TM). A workshop was held in Kabwe district on 1 ^st November 2019 to validate the data with participants drawn from all the study sites. In addition, officials from the Ministry of Health Headquarters attended the validation workshop.

Ethical approval to conduct the study was granted by the Excellence in Research Ethics and Science Converge (ERES), REF.No.2019-May-033 and the National Health Research Authority. Written and verbal informed consent was sought from all participants and high levels of confidentiality were observed throughout the stakeholder engagement process. To ensure confidentiality, the names of the respondents including any possible identifiers were removed during the report writing and dissemination process.

The main actors at community level who were involved in VMMC activities included the neighbourhood health committees (NHCs), community health workers (CHWs), traditional leaders, church leaders and teachers. In Zambia, these actors operate as part of the community health system structured at the lowest level of service delivery and utilises health centres and health posts and make up the highest proportion of health facilities. These structures work together with different committees such as the Health Centre Committees (HCC) and NHCs to provide health services in the community. The NHCs also work with community leaders such as traditional leaders, religious leaders, and political leaders through Ward Development Committee (WDC).

Data revealed that different stakeholders in urban and rural districts are of primary importance. Figure 1 and Figure 2 provide ranking of different stakeholders in terms of interest and power/influence. Stakeholders farther to the right have higher power/influence, and those farther up on the graph have higher interest, revealing that those stakeholders in the highest right quadrant have the most interest and power/influence according to the FGDs.

The first category of stakeholders. In the urban setting, all FGDs ranked neighbourhood health committees (NHCs), health workers, drama groups, community health workers (CHWs) and radio/TVs as having high power/influence and interest ( Chavula, 2022). In the rural setting, all FGDs ranked club leaders, health workers and radio/TVs as having high power/influence and interest. Thus, from these rankings, drama groups were only rated as having high power/interest in the urban area while club leaders were only rated as having high power/interest in the rural settings. While all FGDs in the urban area ranked CHWs as having high power and interest, differences were noted in the rural area. Analysis of FGDs showed that rural areas ranked CHWs as having high interest while only about 85% rated them to have high power.

The second category of stakeholders. The second category of stakeholders namely, teachers, traditional leaders, religious leaders- and male circumcision (MC) champions in the urban areas were rated to have high interest by around 60%– 80% percentage points. These stakeholders were also rated by more than 80% of the FGDs in urban sites as having high power. The second category of stakeholders also included youths, NHCs and parents in the rural areas. While the majority of the FGDs (100%) in the urban sites rated these stakeholders as having high power/influence, fewer FGDs (less than 60%) rated them as having high interest in VMMC.

Third rank/ category of stakeholders. The third and lowest category of stakeholders included musicians/ artists, civic leaders, ward chairpersons and private sector managers. While the majority of the FGDs (100%) for example in the urban sites rated these stakeholders as having high power/influence, fewer FGDs (less than 60%) rated these stakeholders as having high interest in VMMC. These were rated as having high power because they usually have access to financial resources and that they lead or have many people who follow them. However, their interest in circumcision maybe low due to limited knowledge.

This section explains how and why the respondents ranked stockholders being in the first or second, or third categories in terms of the sustainability phase of VMMC. Table 2 below provides a summary of the rankings of the stakeholders.

The main forms or sources of power that emerged in the interviews included technical expertise, local authority, financial resources, community health settings, and relational power. As shown in the table above, some stakeholders such as health workers, teachers, CHWs, traditional leaders, religious leaders had more sources of power than others like parents and private sector managers. Table 3 provides more details on the forms or sources of power.

Health care workers. The participants ranked health care providers with high power and interest because they have technical expertise to conduct medical circumcision. Further, health workers have a socially recognised setting or base from which they perform their roles. They were rated as having high interest because despite the shortages in human resources for health, they still attend to clients undergoing VMMC. Health care workers also work in collaboration with various structures or stakeholders such as traditional leaders, NHCs, CHWs, and religious leaders to create demand for VMMC.

“The health professionals who are responsible in circumcising the people have a lot of interest – and power as their major task is to provide circumcision services” (FGD, Community Based Volunteers, Chongwe District).

Neighbourhood health committees and community health workers. It was noted that the NHCs and CHWs have power because they are knowledgeable/ skilled as they were trained to sensitise and refer people for circumcision. Furthermore, they also have recognised community spaces or settings from where they hold meetings to educate the people on circumcision. Being members of the community and having close relations/bonds with community members, they have an interest to ensure that their community is healthy.

“ The role of community health workers and NHC is that if they get information here at the clinic on circumcision - they take it to the community. They are the link between the community and health facility” (FGD, NHC, Chongwe District).

Radio/TV/ social media platforms. Radio/TV/ social media communication platforms were ranked high because they are important for community health settings as a means of disseminating health information about circumcision. Some stakeholders argued that although the media is extremely important in creating demand, radio and TV may not be accessible to all people especially to those living in rural areas. In addition, the language barrier is another challenge which might affect many others from accessing information because they may not understand the information.

Club leaders. Leaders of community groups such as clubs for women, sports and farmers were identified as other key groups that would be essential to involve during the transition phase for VMMC. The leaders are key because they have influence over their members. They further noted that use of these channels or community health settings would be compatible with the community practices as such groups have been previously used to communicate health messages in the community.

Teachers. Teachers were viewed as powerful because they have formal platforms or community health settings (schools) for providing health education, including on VMMC. Teachers were further ranked to have high power and interest given the amount of time pupils spend at school than at home. In addition, teachers are also viewed by learners as role models and opinion leaders and can thus influence behaviour change for learners under their portfolio.

“Teachers can spread the information in the community through school going children. As learners always look up to teachers, they can easily take up messages on circumcision once taught” (FGD, Women, Chongwe District).

Traditional leaders. Most participants indicated that traditional leaders had high power and interest because the community is more likely to listen or obey them as they are custodians of all the traditions, norms, and practices in the community. Further, traditional leaders have power interest because they hold community meetings in community spaces/ settings to provide health education. Power is also exercised through giving penalties (local authority) to those who do not adhere to instructions from the traditional leaders.

“Headmen and chiefs are powerful, because when chiefs talk, people will have that fear, and thus follow as it will be considered as tradition which should be done. For example, in North-western province, circumcision is just a tradition which has to be done whether you like it or not as long as you are a man. They have powers because they have influence over people, - they can easily control people or have the powers to enforce an activity in the community” (FGD, Young men, Mpika District).

Religious leaders. Several reasons guided the ranking of religious leaders. Zambia is considered a Christian nation, and as such respondents revealed that religious leaders (mostly Christians) are powerful as they able to educate their congregants on the benefits of men undergoing circumcision through the existing religious programmes. In addition, respondents indicated that religious leaders have a lot of influence and interest as they can use religious community settings (churches) and authority in the form of religious rituals on circumcision to sensitise the community on the importance of VMMC.

“The church has power because they have the examples from the Bible (on male circumcision), this helps them to encourage their members to access circumcision with authority”(FGD, Community Members, Chinsali District).

Youth champions. The rating of youth/ VMMC champions was based on the assessment that young people have opportunities to meet in safe spaces or community settings where they are able to discuss health related issues freely and should therefore be the key target for VMMC. Some communities that have engaged young people and made them understand the importance of VMMC have recorded increased involvement of young people in educating and influencing their fellow young people to access VMMC services.

“Some young people work as champions, so we visit those who are not yet circumcised and inform them on the benefits of VMMC, and once we have convinced them to participate in this programme, they also easily get other young people on board as young people easily attract the attention of other young people” (FGD, Community Members, Chinsali District).

Parents. Respondents reported that some parents have been supporting VMMC uptake. Particularly, this has been through decision making on behalf of their children. Thus, if a parent were informed, they would hold more influence over the decisions they make for their children, and that children usually listen to their parents. However, some participants argued that parents needed to be ranked lower than other stakeholders because parents are traditionally not comfortable to openly discuss issues of sexuality and VMMC with their children irrespective of whether it is in a rural or urban setup.

“At the moment, we even see more parents taking their children for circumcision and the number of children getting circumcised is more than other age groups. Furthermore, parents are even the ones who assent for their children to get circumcised, if they do not have interest for their children to get circumcised, they cannot bring them” (FGD, CHWs, Lusaka).

The third and lowest category of stakeholders included musicians/ artists, chairpersons ward (civic leaders), private sector managers and farmers. While the majority of the FGDs for example in the urban sites rated these stakeholders as having high power/influence, fewer FGDs (less than 60%) rated these stakeholders as having high interest in VMMC. These were rated as having high power because they usually have access to financial resources (managers and farmers), that they lead or have many people who follow them and have access to community health settings or spaces (musicians/ artists), and that they have political authority. However, their interest in circumcision maybe low due to limited knowledge.

“ Like musicians, they have a lot of influence in the community because people follow their music but may not be interested in circumcision activities because of lack of knowledge, thus if they can ---be sensitised on the importance of circumcision, then they can motivate many people who follow them to accept circumcision” (FGD, Young Men, Chongwe District).

This section presents the roles and strategies for facilitating community engagement in the transition/ sustainability of phase of VMMC. In each sub section, we begin by outlining the key role and then the strategies for achieving the role.

Integrating VMMC into primary health care was one of the roles that was mentioned in the interviews. Strategies for facilitating this role were making VMMC as part of the normal working routine at health facilities and building the capacity of different stakeholders in the community.

Making VMMC as part of normal working routine at health facilities. Developing strategies that would make VMMC health education a component of routine activities at health facilities was widely recommended. Study participants stated that integration is vital as it would make VMMC a point of discussion in almost all departments at health facilities, thus triggering improved appreciation and uptake of VMMC services. It was noted that integrating VMMC activities into ongoing community health outreach activities such as family planning talks, growth monitoring and promotion and under-five talks is sustainable as these activities do not require new funding.

“I think like even integration with other services can help improve uptake of VMMC-- usually, we have the community members who work as volunteers, and when they are conducting like these other programmes in the area of maternal and child health, like community growth monitoring, I think they can also integrate VMMC – and this can be helpful”l (KII, Sister in Charge. Kitwe District).

Building the capacity of different stakeholders in the community. To facilitate service provision, it was suggested that capacity building of community members needs to be prioritised. Training various stakeholders such as volunteers, community leaders and NHCs on the importance of the VMMC, including how to conduct community mobilisation, skills in monitoring and evaluation and project management can make these stakeholders gain understanding, competencies, and courage to communicate and promote VMMC in the community.

“It’s important to involve community, by training a few community members so they can go in the field, and they can talk about it to the other community members. Maybe, if they see it come from their fellow community members, maybe they can even welcome it (circumcision)” (KII, Female, Class teacher, Lufwanyama District).

The main strategies for enabling stakeholders effectively to participate in planning VMMC included developing community VMMC steering committees, broadening spaces for citizen engagement, mobilising existing community resources and prioritising gender inclusion in planning of VMMC.

Most respondents suggested that development of VMMC technical working groups to coordinate VMMC activities at community level and integrating them into existing community committees such as the NHCs is vital in promoting community participation, sustaining and scaling up VMMC. Formation of committees is key not only for coordination purposes but also co-production of VMMC services through collaborative planning processes. Involvement of community stakeholders in the planning process would help generate interest and subsequently power to drive VMMC activities at community level.

“If we can involve the church and community leaders, no funds will be required to conduct the activities as they can also go out there to sensitise other people using their normal platforms” (FGD, NHC, Members, Mpika District).

Broadening spaces for citizen engagement in planning process. There is a need to create public forums or spaces through which the community can participate in planning VMMC activities to generate more interest and support from the traditional leaders, youths, religious leaders and parents towards VMMC. This was noted as important because currently not all community members, such as youths, are involved in decision making processes. To achieve this, there is need for increased sensitisation by NGOs on the relevance of community participation in decision making.

“We need to have regular meetings, and in which many members of the community can meet to strategise and plan on how to proceed with activities on circumcision” (KII, Male Religious Leader, Lusaka District).

The other aspect of co-production was participation by the community in mobilising local resources. The respondents narrated that in case there is no funding from the Ministry of Health, the community can engage the private sector or businesses to disseminate printed information on VMMC to their customers through displaying such information in various shops and supermarkets. The community members cited examples of how in the past they have been able to contribute local resources towards infrastructure development such as construction of a maternity ward.

“At some point we never used to have water in the maternity ward, and we did everything possible to make sure that we bring water to the ward. So based on our previous experience, we believe that we can work together and mobilise resources for circumcision from different sources” (FGD, Community Based Volunteers, Lufwanyama District).

Key strategies for enhancing the provision of VMMC information using locally appropriate communication channels included use of locally recognised communication spaces and channels such as the school system (integrated science subjects) and use of spaces managed by community leaders to promote uptake of VMMC.

Integrating VMMC in the school system. Integrating VMMC into the schools was one of the suggested ways of facilitating increased participation of teachers in delivering and sustaining VMMC activities at community level. While schools have been used in some cases as platforms for sharing information on VMMC, it was noted that this has not been done in a standardised and comprehensive manner. One way of institutionalising VMMC within the school is through integrating VMMC into the school curriculum. To support the integration process, participants indicated that there is a need to train teachers in communicating information on VMMC. In addition to reaching out to a bigger audience within a short period, such integration would help in socialising young people at an early age. Further, integration in the school curriculum was viewed as effective as teachers are influential and highly respected in their communities.

“In schools they have to include male circumcision in the school curriculum because reproduction is there already, so even this one they should include it so that pupils can start learning about male circumcision” (FGD, CHW/Vs, Kitwe District).

Use of locally recognised communication spaces and channels. Stakeholders suggested that it was important to make use of the spaces and channels that are managed by community leaders such as traditional and religious leaders in disseminating information on VMMC. Such spaces include community meetings and traditional ceremonies. It was widely noted that traditional leaders have high influence in the community, and as such they had the power to impact VMMC activities positively. Traditional leaders, especially in rural areas, are usually the first contact persons that programme implementers meet or interact with before interacting with the wider community. They are seen to hold the key to high community participation in programmes.

“We will be calling the parents to attend awareness meetings on circumcision, and for those parents that will show lack of interest in coming to meetings and taking the children for circumcision, we call them and make them answerable” (KII, Male, Traditional Leader, Chinsali District).

It was further reported that involving traditional leaders would help the community view circumcision as a social phenomenon which is embedded in the local cultural practices. This was widely discussed as a few ethnic groupings in Zambia have male circumcision as part of their cultural practice.

“Some ethnic groups in Zambia have male circumcision in their traditions, and we can emphasise the cultural value; because if we link it so much to diseases, then it starts looking like it’s a medical issue” (FGD, WDC Chairpersons, Kitwe District).

While religious leaders have been involved in promoting VMMC, not all are participating currently. The use of churches was cited as important because Zambia is Christian nation and thus religious values, and doctrines shape the decisions and behaviour of many people in the country. It was also noted that currently churches are also engaged in providing health information on various issues such as HIV/AIDS, drug and substance abuse and general health issues, to mention but a few.

“We have to explain to them that it is custom of all Christians to be circumcised, and the scientific reason as to why it is like that is because of the dirty which is found in the foreskin which is later passed on to women who eventually get sick of cervical cancer” (FGD, Community Men, Lufwanyama District).

Integrating participatory approaches in VMMC health education. The community members suggested that it might be important to adopt and use more innovative approaches to health education. The main inventive approaches which were proposed are various media platforms, drama, and sporting activities. For such programmes to be locally relevant, it was noted that there is need for involvement of local people in developing health education including holding debates on VMMC. This can also include the development of local films which can be shown on local TV stations and plays aired on local radio stations.

“So, when we have some TVs in the OPD, we can ask the patients as they wait to watch some film or video on the benefits of circumcision” (KII, Sister in-charge, Female, Matero, Lusaka District).

Participants also recommended that more young people should be trained on how to integrate VMMC messages into drama (theatre). It was suggested that such approaches may help in reaching many people within a short period as drama performances may attract many people to come to one place.

“One way is to have at least a drama group which can be going out in the villages, as they do drama, people will come together, and then those in charge can now talk to the people about circumcision” (KII, Female, Traditional Leader, Lufwanyama District).

The key strategy for promoting ownership of VMMC processes included strengthening participation of local actors local monitoring and accountability processes.

Strengthening local monitoring and accountability processes. Most of the respondents reported that there is a need to integrate VMMC in the current monitoring and accountability processes. Strengthening VMMC community monitoring and accountability systems is important in documenting lessons learnt to inform the sustainability processes of VMMC programmes. Community based participatory evaluation is relevant as it can facilitate development of appropriate or locally relevant implementation processes since local communities lead the development process. Further, the participatory approach can, through iterative and inclusive dialogue at various levels of the research process, promote local capacity building geared towards a collective social change. The participants highlighted that there is a need to develop other tools to effectively capture community driven activities such as health education, distribution of information education counselling (IEC) materials, referrals, and community sensitisation.

“ It’s when we evaluate that you see and learn that it is true that this programme that we have started is working or not working. For circumcision, we need to make sure that the community is involved in capturing data on the progress of activities for promoting circumcision” (KII, Male, Treasurer, NHC, Lusaka District).

“As traditional leaders, we can also come up with stakeholder meetings and discuss issues about male circumcision including regularly checking on how these activities are being handled in the community and coming up with ways for improving uptake of circumcision services” (KII, Male, Traditional Leader, Mpika District).

The first limitations of this study are centered on generalizability, our study is context based, therefore it maybe difficult to replicate these findings elsewhere as it may be challenging to ensure consistency in data collection and interpretation across different contexts. Secondly, the study involved purposive sampling to select study participants, which could have been biased towards selecting participants who could possibly give positive responses. However, the generation of data from various stakeholders involved in the creation of VMMC programme enabled us to gather rich information on the subject. This also helped us to gain a better understanding of themes from different perspectives and sources. Furthermore, the research team comprised professionals from various academic backgrounds such us public health, social sciences and health sciences, which could have shaped the analysis and interpretation of results. However, there were also limitations to this study. We conducted this study in three provinces in Zambia. The results may not be a representative of the whole country perspectives, due to cultural and societal perceptions, values and norms around VMMC. We however attempted to address this limitation by including both rural and urban sites in the six districts that where sampled. The prolonged engagement and interaction between participants and researchers helped to gain a deeper understanding of the subject.