The World Health Organization recommends medical male circumcision (MMC) to prevent human immunodeficiency virus (HIV). More research is needed in South Africa on factors influencing the uptake of MMC.
To evaluate factors associated with uptake of MMC.
Diepsloot, Johannesburg, South Africa.
An observational case-control study. Cases (men attending a private general practice (GP) offering free MMC) were compared to controls (uncircumcised men attending a local shopping mall) for a variety of demographic, sociocultural and financial factors. Factors were analysed using bivariate and multiple-variable binary forward logistic regression with the Statistical Package for Social Sciences.
There were 350 cases and 350 controls. Four factors were associated with the uptake of MMC: being a student (adjusted odds ratio [AOR]: 6.29, 95% confidence interval [CI]: 2.29–17.26), attending a mainline Christian denomination (AOR 2.85, 95% CI: 1.39–5.78), speaking an African language other than Zulu (range of AORs: 2.5–6.8,
Disease prevention initiatives should take note of the factors associated with MMC in this community. Further qualitative studies should explore issues behind the factors identified and provide further insights.
This study helps to identify factors that health services should address when implementing medical male circumcision.
Human immunodeficiency virus (HIV) is one of the major health problems in low- and middle-income countries, with over 38 million people infected worldwide.
Studies conducted in the United States of America and Israel, where circumcision rates are high and HIV burden is relatively low, show an inverse association between circumcision and HIV acquisition.
The majority of HIV infections (at least 70%) in sub-Saharan Africa are thought to be a result of penetrative sexual intercourse.
The introduction and expansion of highly active antiretroviral therapy (HAART) was associated with a sustained and profound population-level decrease in morbidity and mortality from HIV, as well as reduced transmission.
The United Nations report that 37% of men are circumcised globally.
To date, little research has been conducted to identify the demographic, sociocultural and financial factors that may contribute to an individual’s decision to have MMC.
This was an analytical observational case-control study that compared cases (men with MMC) and controls (men without MMC) and identified the factors associated with a decision to have MMC.
This study was conducted in Diepsloot, a densely populated and impoverished township in the north of Johannesburg, South Africa. The population of the township was 138 329 as per 2011 census with the following population groups: black people (98%), mixed race people (0.2%), Asian people (0.1%), white people (0.2%) and other (1.5%).
The local clinics manage acute and chronic medical conditions. Emergency services are provided by the nearby public hospital. There is also provision for antenatal care and immunisation programmes. The private sector also manages acute and chronic cases, although chronic cases are less common as patients receive free services in the public sector. The private doctors refer cash patients to the nearby government hospitals and insured patients to the private hospitals.
Medical male circumcision is included in the service in both the public and private sectors. It is free in the government clinics, but it incurs a fee for service in the private sector. However, one private practice offered free MMC to the community as part of the government initiative.
This study was conducted with men between the ages of 18 and 55 years living in Diepsloot, as this was the target group for MMC. Men who did not live in Diepsloot or had a traditional circumcision were excluded from the study.
Sample size for an unmatched case-control study was calculated using Epi Info. The following assumptions were made:
95% confidence intervals
80% power
ratio of cases : controls 1:1
expected odds ratio 1.7 with 31% of controls and 43% of cases exposed (based on those passing matriculation as a key educational factor
Using the Kelsey method, this gave a sample size of 243 in each group or 486 in total. It was assumed that five variables would be compared for their association with outcomes in the final multivariable analysis, and therefore an additional 10% was needed for each variable. This gave a final sample size of 364 cases and 364 controls, totalling 728 cases.
Cases were recruited from a local private practice, run by a local general practitioner, who offered free MMC to the community as part of the government initiative. This practice circumcised 50 people per day in the winter and 20 per day in the summer. People were recruited on a consecutive basis until the sample size was obtained, and only 11 men refused to consent.
Controls were recruited from the local shopping mall, which was used by all community members. Three research assistants were invited to help recruit controls, and the mall also provided a private more secluded space to obtain consent and complete the questionnaire. People meeting the inclusion and exclusion criteria were recruited on a random systematic basis as they entered the mall, whereby every third person was invited to participate until the sample size was obtained. All men who consented were then asked about their circumcision status, and those who were not circumcised were allocated to the controls. The exact ratio (i.e. every
The research focused on demographic, sociocultural and financial factors (
Factors measured in the study.
Demographic | Sociocultural | Financial |
---|---|---|
Age | Home language | Education |
Gender | Religion | Employment |
Marital status | Nationality | Income |
Location or municipal ward | Beliefs and attitudes towards circumcision | - |
A questionnaire was developed to measure these factors. Demographic and financial questions were derived from established questionnaires used in South Africa,
The questionnaire was translated by the Language Centre of Stellenbosch University and piloted with community members to ensure that it was easily understood in the local community. The languages were IsiZulu, IsiXhosa, Setswana and Tsonga.
Data were collected in 2021. The respondents completed the questionnaire in a private area of the general practice (GP). The research assistant took consent and was available to assist with the questionnaire if necessary. The questionnaire was completed by the respondents before having the circumcision, as the pain experienced after circumcision made it difficult to complete the questionnaire. In the mall, the research assistants took potential participants to a private and secluded area where they completed the questionnaire in a similar process. The researcher was assisted by three trained male research assistants. One assistant was a clinical associate from the researcher’s practice, and the other two assistants were contracted. They were all trained and held at least a basic degree and were proficient in the local languages.
Data were captured in an Excel spreadsheet and checked for errors or omissions. The data were then analysed using Statistical Package for Social Sciences version 25. The supervisor, with support from the statistician at Stellenbosch University, assisted the researcher to perform the analysis.
Data were analysed by descriptive statistics with means and standard deviations (numerical data) or frequencies and percentages (categorical data). If not normally distributed, numerical data were described using medians and interquartile ranges (IQR).
Each independent variable was then tested for an association with cases or controls in a bivariate binary logistic regression. Associations with
Ethical approval to conduct the study was obtained from the Health Research Ethics Committee of Stellenbosch University (ref. no. HREC2-2020-11877). Permission to conduct the research was obtained from the private GP and shopping mall (ref. no. S19/10/276).
Characteristics of the study sample (
Variables | % | |
---|---|---|
South Africa | 411 | 58.7 |
Zimbabwe | 126 | 18.0 |
Malawi | 44 | 6.3 |
Lesotho | 41 | 5.9 |
Eswatini | 15 | 2.1 |
Mozambique | 25 | 3.6 |
Botswana | 22 | 3.1 |
Namibia | 15 | 2.1 |
Unknown | 1 | 0.0 |
Single | 449 | 64.6 |
Partner | 181 | 26.0 |
Married | 41 | 5.9 |
Divorced | 23 | 3.3 |
Unknown | 6 | 0.2 |
None or some primary school | 99 | 14.2 |
Completed primary school | 153 | 21.9 |
Some high school | 169 | 24.2 |
Completed high school | 218 | 31.2 |
Certificate or diploma | 51 | 7.3 |
Degree | 9 | 1.3 |
Unknown | 1 | 0.0 |
None | 574 | 83.9 |
Catholic | 63 | 9.2 |
Protestant | 2 | 0.3 |
Zionist | 39 | 5.7 |
Muslim | 5 | 0.7 |
Unknown | 17 | 2.4 |
Unemployed | 290 | 41.8 |
Employed | 224 | 32.3 |
Self-employed | 73 | 10.4 |
Informal | 47 | 6.7 |
Student | 54 | 7.7 |
Other | 5 | 0.7 |
Unknown | 7 | 0.1 |
Zulu | 153 | 21.9 |
Xhosa | 76 | 10.9 |
Ndebele | 143 | 20.5 |
Siswati | 41 | 5.9 |
Sepedi | 57 | 8.2 |
Setswana | 40 | 5.7 |
Sotho | 44 | 6.3 |
Tonga | 37 | 5.3 |
Venda | 23 | 3.3 |
Other | 86 | 12.3 |
Extension 1 | 97 | 13.9 |
Extension 2 | 165 | 23.6 |
Extension 3 | 54 | 7.7 |
Extension 4 | 85 | 12.2 |
Extension 5 | 43 | 6.2 |
Extension 6 | 49 | 7.0 |
Extension 7 | 41 | 5.9 |
Extension 8 | 55 | 7.9 |
Extension 9 | 32 | 4.6 |
Extension 10 | 29 | 4.2 |
Extension 11 | 20 | 2.9 |
Extension 12 | 13 | 1.9 |
Extension 13 | 15 | 2.1 |
Age distribution of the study sample.
The attitudes and beliefs of respondents (
Statements | Strongly disagree |
Disagree |
Agree |
Strongly agree |
Unknown |
|||||
---|---|---|---|---|---|---|---|---|---|---|
% | % | % | % | % | ||||||
Getting circumcised makes me feel good because it means that I take care of my health. | 10 | 1.4 | 178 | 25.4 | 400 | 57.1 | 107 | 15.3 | 5 | 0.7 |
Failing to get circumcised can increase my risk of getting HIV. | 14 | 2.0 | 173 | 24.7 | 369 | 52.7 | 140 | 20.0 | 4 | 0.6 |
Failing to get circumcised can increase my risk of getting HPV. | 18 | 2.6 | 172 | 24.6 | 417 | 59.6 | 87 | 12.4 | 6 | 0.9 |
Circumcision goes against my culture. | 57 | 8.1 | 464 | 66.3 | 159 | 22.7 | 16 | 2.3 | 4 | 0.6 |
Getting circumcised will negatively affect my sexual performance. | 101 | 14.6 | 447 | 64.4 | 115 | 16.6 | 31 | 4.5 | 6 | 0.9 |
Getting circumcised is painful. | 18 | 2.6 | 175 | 25.2 | 409 | 58.9 | 91 | 13.1 | 7 | 1.0 |
Getting circumcised helps to protect me against disease even if I have unprotected sex. | 23 | 3.3 | 182 | 26.2 | 384 | 54.9 | 106 | 15.3 | 5 | 0.7 |
Circumcision can prevent other serious health problems. | 19 | 2.7 | 200 | 28.8 | 373 | 53.3 | 103 | 14.7 | 5 | 0.7 |
Getting circumcised is expensive. | 64 | 9.2 | 434 | 62.4 | 158 | 22.7 | 39 | 5.6 | 5 | 0.7 |
Getting circumcised is embarrassing for me. | 123 | 17.8 | 524 | 75.7 | 35 | 5.1 | 10 | 1.4 | 8 | 1.1 |
Getting circumcised might make potential sexual partners reluctant to have sex with me. | 100 | 14.3 | 446 | 64.4 | 131 | 18.9 | 16 | 2.3 | 7 | 1.0 |
I do not have information about where to go to get a circumcision. | 103 | 14.9 | 512 | 73.9 | 64 | 9.2 | 14 | 2.0 | 7 | 1.0 |
Getting circumcision is a good investment of my time for my health. | 23 | 3.3 | 226 | 32.6 | 343 | 49.4 | 102 | 14.7 | 6 | 0.9 |
I do not know at what age it is necessary to have a circumcision. | 75 | 10.8 | 521 | 75.2 | 88 | 12.7 | 9 | 1.3 | 7 | 1.0 |
I have not had a circumcision because when I go, I need to wait a long time to be seen. | 136 | 19.6 | 521 | 75.1 | 31 | 4.5 | 6 | 0.9 | 6 | 0.9 |
My partner wants me to get a circumcision. | 19 | 2.7 | 249 | 35.8 | 375 | 54.0 | 52 | 7.5 | 5 | 0.7 |
Circumcision can save my life. | 11 | 1.6 | 195 | 28.1 | 362 | 52.1 | 127 | 18.3 | 5 | 0.7 |
I have not had a circumcision because I am afraid to attend a health centre that might advise me that I have another sexually transmitted disease. | 38 | 6.3 | 444 | 74.0 | 102 | 17.0 | 16 | 2.7 | 100 | 14.3 |
I have not had circumcision because the health care centre is only open during hours when I cannot go. | 66 | 9.5 | 597 | 86.1 | 27 | 3.9 | 3 | 0.4 | 7 | 1.0 |
I have not been circumcised because I am embarrassed to have a genital procedure. | 60 | 8.7 | 520 | 75.3 | 104 | 15.1 | 7 | 1.0 | 9 | 1.3 |
Being circumcised does not protect me from getting HIV. | 86 | 12.4 | 439 | 63.3 | 143 | 20.6 | 25 | 3.6 | 7 | 1.0 |
Circumcision exposes my foreskin to more infection. | 97 | 14.0 | 532 | 76.8 | 57 | 8.2 | 7 | 1.0 | 7 | 1.0 |
I am not at risk for contracting HIV. | 90 | 13.0 | 449 | 65.1 | 126 | 18.3 | 25 | 3.6 | 10 | 1.4 |
As I do not have a history of sexually transmitted diseases, it is very unlikely that I will get HIV. | 90 | 13.0 | 479 | 69.2 | 93 | 13.4 | 29 | 4.2 | 9 | 1.3 |
If I am sterilised, I do not need a circumcision. | 105 | 15.2 | 456 | 66.0 | 96 | 13.9 | 34 | 4.9 | 9 | 1.3 |
If I do not have symptoms of an STI, I do not need a circumcision. | 86 | 12.4 | 474 | 68.4 | 98 | 14.1 | 35 | 5.1 | 7 | 1.0 |
If I do not have intercourse, I do not need a circumcision. | 84 | 12.1 | 471 | 68.0 | 104 | 15.0 | 34 | 4.9 | 7 | 1.0 |
HIV, human immunodeficiency virus; HPV, human papilloma virus; STI, sexually transmitted infection.
Odds of medical male circumcision if you agree with the statement.
Variables | OR | 95% CI | |
---|---|---|---|
Getting circumcised makes me feel good because it means that I take care of my health. | 62.9 | 27.3–144.8 | < 0.001 |
Failing to get circumcised can increase my risk of getting HIV. | 45.0 | 21.6–93.6 | < 0.001 |
Failing to get circumcised can increase my risk of getting HPV. | 22.5 | 12.9–39.4 | < 0.001 |
Circumcision can save my life. | 17.8 | 10.9–28.9 | < 0.001 |
Getting circumcised might make potential sexual partners reluctant to have sex with me. | 15.9 | 8.82–28.9 | < 0.001 |
Getting circumcised helps to protect me against disease even when I have unprotected sex. | 13.2 | 8.40–20.7 | < 0.001 |
Circumcision can prevent other serious health problems. | 10.5 | 6.99–15.9 | < 0.001 |
Getting circumcision is a good investment of my time for my health. | 8.35 | 5.78–12.1 | < 0.001 |
Being circumcised does not protect me from getting HIV. | 3.05 | 2.10–4.43 | < 0.001 |
My partner wants me to get a circumcision. | 2.94 | 2.14–4.04 | < 0.001 |
Getting circumcised is painful. | 2.89 | 2.04–4.11 | < 0.001 |
I have not had a circumcision because when I go, I need to wait a long time to be seen. | 1.49 | 0.76–2.92 | 0.247 |
I am not at risk of contracting HIV. | 1.38 | 0.96–1.99 | 0.08 |
Getting circumcised is expensive. | 1.27 | 0.91–1.77 | < 0.001 |
Getting circumcised will negatively affect my sexual performance. | 1.23 | 0.85–1.78 | 0.264 |
I do not know at what age it is necessary to have a circumcision. | 0.69 | 0.45–1.06 | 0.093 |
Circumcision goes against my culture. | 0.55 | 0.39–0.78 | < 0.001 |
I do not have information about where to go to get a circumcision. | 0.55 | 0.34–0.89 | 0.016 |
Getting circumcised is embarrassing for me. | 0.52 | 0.28–0.99 | 0.046 |
I have not been circumcised because the health care centre is only open during hour when I cannot go. | 0.48 | 0.22–1.05 | 0.066 |
Circumcision exposes my foreskin to more infection. | 0.25 | 0.14–0.46 | < 0.001 |
As I do not have a history of sexually transmitted diseases, it is very unlikely that I will get HIV. | 0.15 | 0.09–0.24 | < 0.001 |
I have not been circumcised because I am embarrassed to have a genital procedure. | 0.10 | 0.05–0.18 | < 0.001 |
If I am sterilised, I do not need a circumcision. | 0.06 | 0.03–0.11 | < 0.001 |
If I do not have intercourse, I do not need a circumcision. | 0.06 | 0.03–0.12 | < 0.001 |
If I do not have symptoms of an STI, I do not need a circumcision. | 0.05 | 0.03–01.1 | < 0.001 |
HIV, human immunodeficiency virus; OR, odds ratio, CI, confidence interval; HPV, human papilloma virus; STI, sexually transmitted infection.
People who had not had MMC were less informed and were more likely to see it as against their culture. They felt less at risk from Sexually transmitted infections (STIs) and thought that if they had no symptoms of STIs they did not need an MMC. They also felt less risk if they were sexually inactive and believed that if they were sterilised they did not need MMC. They were more likely to see it as embarrassing and to put them at risk of complications, such as infection of their foreskin.
Bivariate and multivariable analysis of factors associated with medical male circumcision.
Variables | OR | 95% CI | AOR | 95% CI | ||
---|---|---|---|---|---|---|
0.98 | 0.97–1.00 | 0.062 | - | - | - | |
- | - | - | ||||
Divorced | Reference | - | - | - | ||
Single | 3.04 | 1.18–7.85 | 0.022 | - | - | - |
Partner | 2.20 | 0.83–5.82 | 0.114 | - | - | - |
Married or widowed | 7.08 | 2.25–22.29 | 0.028 | - | - | - |
- | - | - | ||||
Not South African | Reference | Reference | ||||
South Africa | 2.2 | 1.6–3.0 | < 0.001 | 2.50 | 1.58–3.96 | < 0.001 |
None or some primary | Reference | - | - | - | ||
Primary | 0.85 | 0.51–1.42 | 0.538 | - | - | - |
Some high school | 1.77 | 1.07–2.92 | 0.026 | - | - | - |
High school | 1.41 | 0.87–2.27 | 0.160 | - | - | - |
Higher education | 1.17 | 0.62–2.22 | 0.633 | - | - | - |
None | Reference | Reference | ||||
Mainline Christian | 4.67 | 2.49–8.77 | < 0.001 | 2.83 | 1.39–5.78 | 0.004 |
Zionist | 1.36 | 0.71–2.62 | 0.349 | 0.84 | 0.41–1.73 | 0.632 |
Not Christian | 5.85 | 0.68–50.3 | 0.108 | 4.15 | 0.44–38.9 | 0.213 |
Unemployed | Reference | Reference | ||||
Employed | 0.93 | 0.66–1.32 | 0.68 | 0.91 | 0.62–1.32 | 0.612 |
Self-employed | 0.76 | 0.46–1.28 | 0.31 | 0.91 | 0.52–1.59 | 0.732 |
Informal | 0.55 | 0.30–1.01 | 0.55 | 0.68 | 0.34–1.31 | 0.237 |
Student | 10.1 | 3.93–26.2 | < 0.001 | 6.29 | 2.29–17.26 | < 0.001 |
Zulu | Reference | Reference | ||||
Xhosa | 4.84 | 2.67–8.77 | < 0.001 | 4.48 | 2.42–8.29 | < 0.001 |
Ndebele | 2.07 | 1.29–3.31 | 0.002 | 3.70 | 2.08–6.59 | < 0.001 |
Siswati | 2.68 | 1.33–5.42 | 0.06 | 3.47 | 1.65–7.28 | < 0.001 |
Sepedi | 7.88 | 3.83–16.2 | < 0.001 | 6.82 | 3.14–14.8 | < 0.001 |
Setswana | 2.32 | 1.15–4.70 | 0.02 | 4.10 | 1.85–9.10 | < 0.001 |
Sotho | 1.75 | 0.86–3.46 | 0.108 | 3.14 | 1.39–7.09 | 0.006 |
Tonga | 3.88 | 1.82–8.24 | 0.001 | 3.52 | 1.61–7.70 | 0.002 |
Venda | 3.94 | 1.57–9.90 | 0.004 | 3.36 | 1.26–8.95 | 0.015 |
Other | 1.05 | 0.60–1.85 | 0.866 | 2.50 | 1.23–5.09 | 0.011 |
Extension 13 | Reference | |||||
Extension 1 | 2.09 | 1.25–3.47 | 0.005 | - | - | - |
Extension 2 | 0.63 | 0.13–1.26 | 0.188 | - | - | - |
Extension 3 | 1.48 | 0.83–2.66 | 0.189 | - | - | - |
Extension 4 | 1.09 | 0.53–2.25 | 0.811 | - | - | - |
Extension 5 | 1.42 | 0.71–2.83 | 0.319 | - | - | - |
Extension 6 | 0.89 | 0.43–1.86 | 0.756 | - | - | - |
Extension 7 | 1.05 | 0.54–2.04 | 0.893 | - | - | - |
Extension 8 | 0.75 | 0.33–1.71 | 0.499 | - | - | - |
Extension 9 | 1.78 | 0.77–4.12 | 0.179 | - | - | - |
Extension 10 | 1.03 | 0.39–2.70 | 0.519 | - | - | - |
Extension 11 | 1.46 | 0.46–4.68 | 0.519 | - | - | - |
Extension 12 | 1.20 | 0.37–3.27 | 0.865 | - | - | - |
OR, odds ratio; CI, confidence interval; AOR, adjusted odds ratio.
The findings of the study are summarised using the health belief model in
Summary of key findings in the health belief model.
One key modifying factor was language, which is closely linked to culture. A survey, conducted in South Africa in 2008, also found that Zulus were the least likely to be circumcised.
In this study, 41% of the men enrolled were foreign nationals, which illustrates the importance of this group in HIV prevention. The decreased chance of foreign nationals being circumcised may also be because of cultural issues. The largest group was from Zimbabwe, where it seems that attitudes are also against circumcision. A study from Mashonaland reported that circumcised men were perceived as ‘half a man’ and saw themselves as emasculated by the loss of their foreskins.
Other studies have also shown that members of mainline churches are more in support of circumcision (53%) than African traditional religions (27%) or Islam (0%).
Previous studies from KwaZulu-Natal reported that men presenting for MMC were young, living in urban townships, single, employed, more educated and sexually active.
In a study from 2012, in four of nine provinces (Eastern Cape, Gauteng, KwaZulu-Natal and Mpumalanga) in South Africa, a high number of the participants (96%) had knowledge regarding MMC and found it acceptable (84%).
In our study, those who had MMC also held strong beliefs about the health benefits and prevention of infectious diseases such as HIV. On the other hand, those who had MMC were also more likely to believe that they were safe during unprotected sex. While MMC reduces transmission, it does not fully protect from HIV, HPV and other infections, and barrier methods such as condoms are still needed. This false sense of security among those with MMC also needs to be addressed in health education.
As this was a case-control study, factors are associated with the outcome, but a cause and effect relationship cannot be proven. Nevertheless, the relationship between factors can be logically attributed, even though not proven; for example, in those with MMC it is likely that the belief in the protective effect of MMC was instrumental in the decision to have the procedure.
The control group was selected from the shopping mall, and during the coronavirus disease 2019 (COVID-19) pandemic and lockdown, it is likely that unemployment led many people to shop locally and not travel to the mall. Two other malls were also available in the area. This could have introduced a selection bias, although employment versus unemployment was not found to be a significant factor. The case group was selected from a private practice offering free MMC sponsored by the government. Nevertheless, it is possible that those choosing to have the MMC at the private practice were different from those choosing to have it done at a public sector facility.
A few of the statements that participants responded to were worded in a way that implied which group the person should belong to. It would have been better to phrase all the statements more neutrally for both groups. For example, the statement ‘I have not been circumcised because I am embarrassed to have a genital procedure’ speaks more directly about the control group.
Diepsloot is a metropolitan township in Johannesburg, with a mix of different people typical of Gauteng. The mix of cultures, languages and population groups would however be very different from other provinces such as the Western Cape or KwaZulu-Natal. Likewise, the urban setting cannot be generalised to more rural areas. Hence, the results may not be generalised to other districts in South Africa, although it is likely that many of these factors would also be identified elsewhere.
The health belief model helps to focus attention on key issues that health promotion should focus on in this community. The perceived susceptibility to and seriousness of HIV infection should be addressed and, in particular, misinformation regarding the protection offered by sterilisation as well as the absence of risk if there are no symptoms of an STI. The value of MMC to reduce future risk, even if one is not currently sexually active, should also be addressed.
Culture and traditions can act as barriers to the acceptability of MMC.
Further attention should be given to understanding the perceptions of Zulu-speaking community members and what issues need to be addressed to overcome resistance to MMC. Attention may also need to be given to migrants in the community and barriers to MMC, such as the cost of the procedure and making health services more migrant-friendly.
Health promotion messages should be tailored to reach groups less likely to accept MMC, such as those attending Zionist and other Christian denominations. Engaging religious and faith-based leaders and understanding the theological issues involved may assist with this.
Therefore, qualitative studies could explore issues behind some of the factors identified and provide insights useful to health promotion. Factors such as being a student, attending a mainline Christian denomination, speaking Zulu and being a foreigner could be further explored.
People who had MMC were more likely to believe in the positive health benefits and protection from HIV and HPV. Culture and traditions were the factors against MMC. Being a student, attending a mainline Christian domination, speaking an African language other than Zulu and being a South African were associated with obtaining MMC.
The health belief model helps to focus attention on the key issues that health promotion and disease prevention should address in this community. The perceived susceptibility to and seriousness of HIV infection should be addressed and, in particular, misinformation regarding the protection offered by sterilisation as well as the absence of risk if there are no symptoms of an STI. Men with MMC believed that they were fully protected during unprotected sex, and this also needs to be addressed.
The authors acknowledge the contribution of the three research assistants towards data collection.
The authors have declared that no competing interests exist.
S.O.O. completed this research for a MPhil degree in Family Medicine and was responsible for all aspects of the work from conceptualisation, data collection, analysis to final manuscript writing. R.J.M. supervised S.O. and contributed towards conceptualisation, methods, data analysis and editing of the final manuscript.
This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
Data may be available upon reasonable request to the authors.
The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors.