Introduction
Methods
Study design
Characteristic | Low amount | High amount | Total | ||||
---|---|---|---|---|---|---|---|
Fixed | Loss aversion | Lottery | Fixed | Loss aversion | Lottery | ||
N | 10 | 10 | 10 | 10 | 10 | 10 | 60 |
Age [n (%)] | |||||||
18–24 | 3 (30) | 5 (50) | 4 (40) | 4 (40) | 7 (70) | 3 (30) | 26 (43) |
25–44 | 5 (50) | 3 (30) | 2 (20) | 4 (40) | 2 (20) | 5 (50) | 21 (35) |
45+ | 2 (20) | 2 (20) | 4 (40) | 2 (20) | 1 (10) | 2 (20) | 13 (27) |
Parish [n (%)] | |||||||
Mabira | 5 (50) | 2 (20) | 5 (50) | 2 (20) | 3 (30) | 1 (10) | 18 (30) |
Katyazo | 4 (40) | 4 (40) | 3 (30) | 5 (50) | 7 (70) | 5 (50) | 28 (47) |
Ruhunga | 1 (10) | 3 (30) | 1 (10) | 3 (30) | 0 (0) | 2 (20) | 10 (17) |
Itara | 0 (0) | 1 (10) | 1 (10) | 0 (0) | 0 (0) | 2 (20) | 4 (7) |
HTC [n (%)] | 5 (50) | 5 (50) | 5 (50) | 5 (50) | 5 (50) | 5 (50) | 30 (50) |
Data collection and analysis
Ethical approvals
Results
Structural barriers and motivators to testing, and the role of incentives
“Every other time, I had to get money for transport to go to [the nearest health center] where I would at times spend a day without a meal. Now the service was brought closer in addition, gifts [incentives] were to be given. I would not miss the chance to attend [...]” (25–44 year-old, participated in HIV testing and counseling [HTC], fixed, low).
“I had spent a long time without testing because am always busy looking for money so one would not get time even to go to [nearest health center] get tested. So when I got the chance to get tested in addition to getting a gift [incentive], I said it was a must to attend, I also called the other workers so we went to get tested.” (25–44, HTC, fixed, low).
“The gift did motivate me but mostly was that services were brought nearer to us and the gift made my decision easier to go test.” (44+, HTC, fixed, low).
“[...] Since I was using money for transport to get tested together with her [his wife], I was not going to miss a chance of testing for free nearby. So that is why we decided to get tested.” (25–44, HTC, fixed, high).
“There was nothing much [to lose] since these were not expensive prizes that it would hurt a lot if you missed. The prizes were of a low value.”(25–44, non-HTC, fixed, low).
“I had won a bicycle but I got busy and never tested. A bicycle looked like a small prize, I thought there would be cars, cows and other expensive prizes but the prizes were of low-value. Since I had a lot of work to do and I would get more money, I went with the better deal.” (25–44, non-HTC, lottery, high).
Interpersonal barriers and motivators to testing, and effect of incentives on these barriers
“When women know that we [men] are HIV-positive, problems start. Even mine [wife] tells me that if am found sick, she can kill me or separate from me. I also ask if it were them [women] sick, not me, what would happen? That is why men fear. Rather stay without knowing.” (25–44, HTC, fixed, high).
“Some [men] fear telling their wives of positive results. That is why they want their wives to go test first. Or others, after testing and they’re positive, they hide the results from the wife and start taking medication from somewhere else but not home [closest health center].”(25–44, HTC, fixed, low).
“If one goes to a health facility, there are many kinds of people— even those from your village— and they may spread rumors that so-and-so is HIV-positive, even when you may not be sick.” (25–44, non-HTC, loss aversion, high).
“My wife and I decided that we would test for HIV and get the results.”(25–44, HTC, lottery, low).
“When you and your wife decide, you go because if you don’t your wife may start questioning why you never go to test. When one goes with the wife for the checkup, you test together and she doesn’t ask many questions.”(45+, HCT, loss aversion, low).
“She [my wife] said that why are you afraid of testing and she encouraged me to go ahead and get tested. My wife is the one who supported me to test.” (45+, HTC, fixed, high).
“One goes to know his/her health status and my other friends were going too, so I got the motivation to go and test also.” (18–24, HTC, loss aversion, high).
“There is someone that won a bicycle and a phone, so they [the incentives] encouraged me to go for testing.” (25–44, HTC, fixed, low).
“When a person came with a gift [won an incentive], friends who had no time created [time] to go get tested; thus, I saw that the gift motivated many people to go get tested, but if it wasn’t for the gift, you know us men, we wouldn’t get time to go get tested.”(25–44, HTC, fixed, high).
“I could not leave people who had come for burial [at my home] and go to the campaign. I later heard you had gone to Runengo [CHC site] but there were other people coming at home. I hoped if it [CHC] came next time I would attend.” (44+, non-HTC, lottery, low).
“He [study team member] told me to come and test but unfortunately on the day of testing, we lost someone and I went to bury thus could not attend.” (25–44, non-HTC, lottery, low).
Individual level barriers and motivators to testing, and the role of incentives
“There should be an increase in the value of prizes [incentives] so that we know they can be used to earn, and in that we are motivated to attend the campaign” (25–44, non-HTC, lottery, high).
“I thought it was a lie [incentives], but I progressed and took the test, and when the doctor tested me, he told me to move somewhere and I received my gift and went home very happy”(25–44, HTC, loss aversion, low).
“I thought they were lying and just wanted people to get tested, but later it turned out they were telling the truth”(18–24, non-HTC, lottery, high).
“We did not talk much about the gifts because we doubted their availability and thus waited to speculate because once, we participated in some things way back, and they were not successful.” (18–24, non-HTC, lottery, high).
“I had no questions but thought that these people just wanted us to come and test, but I doubted the presence of the prizes. I could not imagine giving all people prizes because it would be expensive, but it happened and I know some who got big prizes like bicycles.”(18–24, non-HTC, lottery, high).
Other individual-level barriers to testing. Some men didn’t view CHC attendance and HIV testing as particularly urgent because they had previously tested for HIV, or they preferred the privacy of clinic-based testing. Therefore, they decided not to attend, as illustrated in the following quotes.“But also there were few bicycles to be won in the whole sub-county and so my chances of winning were less. I had some work to do and I was already late, and I knew my chances were less, so I was not motivated” (18-24, non-HTC, lottery, low)
Other individual-level barriers included more interest/concern about other diseases, low perceived severity of HIV, and fatalism related to HIV. Below, a man described being more interested in screening for other diseases than HIV, suggesting that though screening for other diseases (including hypertension and diabetes) was offered at the campaign, not all participants reported awareness of the multi-disease services available:“I also knew your mission was to test those men that do not like testing, but as for me, I have tested. And no need to go there for me, to go public, and I am forced to show people even when I do not want to tell you. That is why I go to Bwizibwera Health Centre where it is private” (18-24, non-HTC, lottery, high)
Perceptions of HIV as either a low-severity illness or a fatal condition, were both expressed as barriers to testing for HIV. Some young men expressed a perception of HIV as a low-severity illness due to the availability of efficacious antiretroviral treatment (ART). ART was perceived to improve health and help maintain daily routines, in the event of an HIV-positive diagnosis. A man describes how HIV is no longer seen to be a life-threatening condition since there is effective medication:“Those that had come from testing were telling me it was just HIV testing and to me that was not very important. I was more interested in testing for diabetes, pressure [hypertension], hepatitis B. Hepatitis is now common and it kills so I was much more interested in that.” (25-44, non-HTC, lottery, high)
“HIV is taken to be less frightening nowadays and a person can start medication when they feel like, and live […]” (18-24, non-HTC, lottery, high)
Yet, other men were reluctant to take up testing out of fear of dying after being diagnosed as HIV-positive:“Others say that they no longer fear, since there is medication” (25-44, non-HTC, lottery, low)
Intrinsic motivations to test for HIV. Men also described their intrinsic motivations to test for HIV, and their positive attitudes towards health services in general. In particular, older men and men in local leadership roles discussed intrinsic motivations to test and their prior participation in HIV testing and other health-related activities. In these narratives, participants share that the incentives did not have a major role in influencing their decision to retest, further stating their desire to attend even in the absence of incentives, as shown in the following quotes.“Some [men] get involved while others fear because they think if I am found positive, I would die quickly. so they better go when they are already bedridden.” (25-44, non-HTC, fixed, low)
“I did not see the incentives as very important because I am aware that knowing my health status was more important.” (25-44, non-HTC, fixed, high)
Men expressed a desire to attend and confirm the veracity of the CHC and services offered, as well as the accuracy of the HIV tests, and to confirm their HIV status.“I was not much interested in the prizes but my health. I was negative which I was happy about though I never got a prize.” (45+, HTC, lottery, high)
“I came to see how this campaign operates, is conducted, whether good or bad and rate it; but I was very grateful for the way you operated entirely.” (25-44, HTC, lottery, low)
Among intrinsically-motivated men: incentives as “cue to action”. Among men who were intrinsically motivated to test, many described incentives as a secondary motivator for HIV testing. They discussed prior participation in health campaigns or efforts, and a general willingness to test. These men were already participating in other health efforts within the community, prior to the arrival of the CHCs, but were prompted to participate because of the incentives. A man discussed his prior testing experience and described the incentives as a secondary motivator that “sweetened the deal”:“I knew that I was positive and so I wanted to come and check and see if your machines do work.” (25-44, HTC, fixed, low)
“Now you are asking me how the gift motivated me to go for checkup. As for me, I had always gone for checkups, even that gift added on motivating me to check because I had spent time without going to the health center to know my health status. Getting HIV testing close by motivated me.” (25-44, HTC, fixed, high)
Emotional responses to incentives
“I felt very happy since I and my wife had both tested HIV negative and I had received the actual gift I had won. It felt like I had gone to work and returned with salary.” (45+, HTC, loss aversion, low)
Other participants described positive perception of incentives depending on incentive group: feelings and language of ownership were expressed among men in the loss-framed incentive groups, while men in the lottery groups expressed excitement upon winning a prize.“When I got the gift, I was happy because there are others that did not get any and my testing went well, I was motivated by the gift to test and get it. I did not want to miss because they would take it back.” (18-24, HTC, loss aversion, high)
“When the doctor tested me, he told me to move somewhere and I received my gift and went home very happy” (25-44, HTC, loss aversion, low).
A man in the lottery groups expresses the excitement he got on winning the reward:“ I knew I would get my hoe and I had to come from where I was to receive it, because I am not usually at home” (25-44, HTC, loss aversion, high)
Some described the usefulness of incentives in overcoming livelihood challenges and improving life. To these the usefulness rather than the value of the incentive was likely the more motivating factor. A man describes how the entire family utilizes the gum boots [incentive] whenever it rains:“[…..] after being tested and given a gift I got happy, too much excitement” (44+, HTC, lottery, low)
A man describes how his main focus in testing for HIV was the anticipated utilization of the incentive:“I feel proud. Now days it rains so am always putting on my boots while gardening. At times my wife and children put on the boots. I was very pleased with the gift.” (25-44, HTC, fixed, high)
Some men discussed the morale-boosting effect of the incentives, including men who did not attend the campaign but described witnessing the morale-boosting, and trust-building effect among other community members.“I had to be there to test and get my prize so my hoe would help me to dig. 'It looked good to me, I got my hoe because it does many things for me. I felt happy.” (25-44, HTC, loss aversion, high)
“Your gifts were powerful. They gave people morale […] I had two reasons [for attending]… I wanted to know my HIV status and also pick my gift since I had already won.” (25-44, HTC, fixed, low)
“Prizes entice people to get involved in government campaigns. Ugandans like being motivated. People would have been few at the campaign if prizes were not being given. If one wins boots, bicycle or radio, they go away happy.” (25-44, non-HTC, lottery, high)