Medical male circumcision (MMC) has become a significant dimension of HIV prevention interventions, after the results of three randomised controlled trials in Uganda, South Africa and Kenya demonstrated that circumcision has a protective effect against contracting HIV of up to 60%. Following recommendations by the World Health Organization, Zimbabwe in 2009 adopted voluntary MMC as an additional HIV prevention strategy to the existing ABC behaviour change model.
The purpose of this study is thus to investigate the factors contributing to the low uptake of MMC.
The study was a quantitative cross-sectional survey conducted in Mutare rural district, Zimbabwe. Questionnaires with open- and closed-ended questions were administered to the eligible respondents. The target population were male participants aged 15–29 who met the inclusion criteria. The households were systematically selected with a sample size of 234. Statistical Package for the Social Sciences was used to analyse the data.
Socioculturally, circumcised men are viewed as worthless (37%), shameful (30%) and are tainted as promiscuous (20%), psychological factors reported were infection and delayed healing (39%), being ashamed and dehumanised (58%), stigmatised and discriminated (40.2%) and fear of having an erection during treatment period (89.7%) whilst socio-economic factors were not having time, as it will take their time from work (58%) and complications may arise leading to spending money on treatment (84%).
Knowledge deficits regarding male medical circumcision lead to low uptake, education on male medical circumcision and its benefits. Comprehensive sexual health education should target men and dispel negative attitudes related to the use of health services.
Male circumcision is one of the oldest and most common surgical procedures worldwide and is undertaken for many reasons, such as religious, cultural, social and medical. In Zimbabwe, male circumcision has been a practice amongst the social groups Shangani in Chiredzi and Mwenezi districts and the Varemba in Gutu and Mberengwa districts for traditional purposes. It has also been predominantly practiced by the Chewa and Muslim people for religious purposes.
Zimbabwe has a projected population of 12.7 million people and is amongst the countries in Sub-Saharan Africa worst affected by the HIV and AIDS epidemic.
In 2007, World Health Organization (WHO)
Furthermore, WHO
Following the recommendations of the WHO, Zimbabwe introduced the male circumcision programme in November 2009 as an additional HIV prevention strategy to the existing ABC behaviour change model. According to the Ministry of Health,
To investigate the factors contributing to the low uptake of MMC in Mutare rural district.
The results provided the nation with information with regards to why men in rural areas are reluctant to engage and partake in this programme despite its protective effect. The information acquired is of use to the National AIDS Council (NAC) and the Ministry of Health and Child Welfare in helping to develop an awareness programme. Furthermore, the results of the study provide baseline information that will assist health planners to design effective strategies directed towards dealing with factors that are hindering uptake of MMC in rural areas.
The study used a descriptive cross-sectional survey, which describes a phenomenon at one point in time. Its focus is to observe, describe and document aspects of a situation as it naturally occurs.
According to Babbie and Mouton,
The findings are presented and discussed according to the following sections: demographic information, sociocultural, psychological and socio-economic factors leading to the low uptake of MMC (
Biographic data.
Variable | % | |
---|---|---|
18–29 | 129 | 55 |
30–40 | 84 | 36 |
41–49 | 19 | 9 |
Grade 1–7 | 111 | 52 |
Secondary education | 52 | 25 |
No formal education | 50 | 24 |
Employed | 103 | 44 |
Unemployed | 131 | 56 |
Married | 105 | 45 |
Single | 70 | 30 |
Divorced | 33 | 14 |
Widow | 26 | 11 |
Christian | 129 | 55 |
Islam | 96 | 41 |
Baha I’ Faith | 7 | 3 |
Findings revealed that 18 (17%) were circumcised, and 216 (83%) were not circumcised. The reasons given were reduced risks of STIs 48%, reduces HIV infection (41%), and minority (6%) gives status in society, 8% sexual pleasure and 5% for religious purpose. For the uncircumcised, reasons given were unsatisfactory sexual performance 70 (30%), fear of pain 63 (27%), ancestors’ permission 44 (19%), being shunned by the community 42 (18%) and fear of the unknown 16 (7%).
Furthermore, 61 (26%) indicated removal of foreskin, 70 (30%) removal of head of the penis, 68 (29%) preparation for manhood and 5 (15%) had no idea.
Decision making regarding circumcision was made by fathers in 95 (40.5%) respondents, 86 (36.7%) made the decision themselves, 42 (17.9%) took the help of extended family members and 8 (3.4%) indicated grandparents to have made the decision. Regarding their views, 87 (37%) reported that circumcision is viewed as worthless, 30% as shameful, 20% attached it with promiscuity, 23 (10%) viewed it as honourable, whilst 3% felt it is defied by the gods.
Of the respondents, 71% feared surgical operation, pain, bleeding and other complications; 74% had fear of infection and delayed wound healing; 145 (62%) felt circumcision dehumanises; 54 (23%) were not sure and 10% did not feel ashamed or dehumanised. Regarding stigma and discrimination, 159 (68%) felt it would lead to stigma, 26 (11%) had no fear of stigma and discrimination whilst 21% indicated it no impact on them. Participants were in disagreement (150 [64%]) that circumcision gives a false sense of security, 73 (31%) were unsure and 9 (4%) agreed that it does. Concerning HIV testing, prior circumcision was considered as an obstacle by 121 (51.7%) whilst 72 (30.7%) were not certain and 48 (20.5%) felt that it was not an obstacle. Pertaining to women’s preferences of circumcised men, 157 (67%) disagreed, 19 (8%) agreed and 59 (25%) were not sure. The majority (168 [72%]) reported that ‘it reduces penis size whilst did not agree, 136 (58%) indicated fear of losing a partner during wound healing time, whilst 98 (42%) did not’. Ninety-five percent reported fear of loss of erection as compared to 12 (5%) and 204 (87%), who agreed that it diminished sexual pleasure whilst 30 (13%) disagreed. Regarding preferences of women with circumcised men, 154 (66%) disagreed, 70 (30%) agreed and 9 (4%) were not sure
One hundred and sixty-eight (72%) agreed to not having time, 28 (12%) disagreed and 37 (16%) were not sure. Furthermore, 211 (95%) reported absence from work whilst 5% said it was not an issue and 115 (49%) were uncertain if persistent pain may result in job loss; 69 (29%) disagreed and 12 (5%) agreed. Regarding transport money to health service, 211 (95%) disagreed and only 9 (4%) agreed that it is a barrier.
Circumcision is a sociocultural issue and needs concerted effort in improving its uptake as majority of participants held different views that prevented them from using circumcision services. When curbing the scourge of HIV, adolescents are the most targeted group and older men are excluded from prevention strategies. The findings indicated that the age category 18–29 years had the highest rate of participants with 129 (55%), followed by the middle aged at 84 (36%) and lastly the 41- to 49-year category at 21 (9%). The analysis by the Ministry of Health and Child Welfare and the NAC
The high rate of unemployment could be attributed to the fact that in this study most respondents are in the age category 18–29 and more likely to be currently unemployed than their counterparts in older age groups as they are still pursuing their education. Religious and cultural beliefs were observed as barriers contributing to low uptake; this is asserted by the fact that Zimbabwe is mainly constituted of people with traditional beliefs and Christians as reflected by the views of 129 (55%) and 96 (41%) respondents, respectively. The Islum, baha’I faith constitutes a small fraction of the population. Religious affiliation has an influence on one’s decision to undergo circumcision or not. According to Salem,
Other personal and ethnic factors can hinder the decision of male circumcision.
Type of circumcision undertaken and the best place and age for circumcision.
Type of circumcision | % | Best place for circumcision | % | Best age for circumcision | % | ||
---|---|---|---|---|---|---|---|
Medical | 49 | 21 | Clinic/hospital | 16 | New born baby | 87 | 37 |
Traditional | 138 | 59 | Home | 10 | 2–6 years | 5 | 12 |
Religious | 33 | 14 | Traditional setting | 24 | 7–13 years | 9 | 4 |
None of the above | 14 | 6 | Church | 20 | Above 20 years | 56 | 24 |
Not acceptable | 30 | Unsure | 55 | 23 |
Almost three-quarters of the population defined circumcision wrongly, some indicated that they did not know what it is, while others viewed it as removal of the penis head and had sociocultural perceptions that circumcision is a sinful act and that nobody has the power to change what God has created. Bailey
In addition, statistics have shown low uptake of MMC in rural areas than in urban areas, which coincides with the present study. A comparison of the reasons for getting circumcised and not getting circumcised was made. The findings reflect that those who are circumcised had knowledge on the benefits that circumcision has as most of them stated it reduces HIV transmission by 60% and that it reduces the risk of HIV infection. This is supported by a study finding of Mhangara,
Those who had not been circumcised opined that circumcision will lead to unsatisfactory sexual performance and pain and thus preferred to avoid it. Hargreave
Participants had other psychological factors related to anxiety about fear of surgical operations; pain, bleeding and other complications are the reasons for not undergoing MMC as reflected in
Levels of agreement on psychological factors.
Psychological factors | Level of agreement (%) | ||||
---|---|---|---|---|---|
SD | D | U | A | SA | |
1. I fear surgical operation, pain, bleeding and other complications | 9.4 | 10.7 | 9.0 | 46.6 | 24.4 |
2. I fear that circumcision would lead to infection and wound will take too long to heal | 9.4 | 8.5 | 7.7 | 35.5 | 38.9 |
3. I feel ashamed and dehumanised due to circumcision | 3.0 | 6.8 | 22.6 | 9.4 | 58.1 |
4. I fear being stigmatised and discriminated | 6.0 | 4.7 | 20.9 | 28.2 | 40.2 |
5. Circumcision gives me a false sense of security | 1.3 | 63.2 | 31.2 | 0 | 4.3 |
6. HIV testing before the procedure prevents me from get circumcised | 13.7 | 6.8 | 30.8 | 9.0 | 39.7 |
7. I heard women do not like circumcised men | 38.5 | 27.8 | 25.2 | 5.1 | 3.4 |
8. Circumcision reduces penis size | 17.1 | 10.3 | 0 | 52.5 | 20.1 |
9. I fear losing my partner or wife during the waiting period | 32.9 | 8.5 | 0 | 47.0 | 11.5 |
10. I may lose the capability of having an erection and I am scared of having an erection during waiting period | 5.6 | 0 | 0 | 4.7 | 89.7 |
11. Sexual pleasure is diminished when a person is circumcised and I might end up losing my partner | 2.1 | 11.1 | 0 | 85.1 | 1.7 |
12. Women prefer to have sex with men who are circumcised | 29.5 | 36.8 | 4.3 | 18.8 | 10.7 |
Similar findings were noted by Herman-Roloff,
Regarding the notion that women do not like circumcised men, 157 (67%) of the respondents were in disagreement with it. Only 8% were in agreement with the notion that women do not like circumcised men, and 59 (25%) stated that they were unsure about women’s preference. Above half of the respondents shared sentiments of fear of losing a partner during waiting period, whilst 98 (42%) did not share the same sentiments. Khehla
Majority (204 [87%]) of the respondents were in agreement that circumcision diminished sexual pleasure and this would lead them to lose their partner. Thirteen percent of the respondents did not think it would diminish their sexual pleasure or lead them to losing their partner. Wilcken
Data analysed indicated reluctance by older men to engage in MMC as compared to younger men. Therefore, in order for MMC implementers and health planners to boost MMC uptake, more resources should be spent on circumcising younger men and more campaigns in schools and engaging MMC in their school curricula would be of more influence and older men should also be targeted.
Culture and religion were shown to have a great impact on decision making regarding MMC. Dissemination of information should be increased in the various religious and traditional groups as they are holding back on circumcision due to certain misconceptions. Leaders of these groups should be engaged as they have a great influence.
Misconceptions and myths on MMC remain high especially in rural areas as indicated in the study; therefore, provision of accurate information is of paramount importance in order to educate people on the benefits and risks associated with MMC. The Ministry of Health and Child Welfare should come up with more campaign strategies in order to increase the adoption of MMC.
The Ministry of Health and Child Welfare should come up with strategies to curb the following major barriers identified in the study: long healing time, pain, complications such as death, costs incurred before and after circumcision and also providing accurate information on MMC.
The methodological limitation of this study is that it used a small sample from Mutare District. Therefore, the results may not be generalised to the entire population, including men in other districts of Zimbabwe.
The survey indicates the need to improve the uptake of male circumcision so as to decrease the burden of AIDS in Sub-Saharan Africa in line with reducing the mortality and morbidity of HIV and/or AIDS. The health belief theory suggests that perceived susceptibility influenced change in behaviour. Intensive health education campaigns on the benefits of male circumcision, inclusion in the curricula, and a multi sectoral approach with community leaders and private sector to improve acceptability are required.
A big thanks to the community of Bambazonge Village and the traditional leadership who gave consent.
The authors have no financial disclosures or conflict of interest relevant to this research report.
I.O.C. conceived the study and designed, collected and collated data and then interpreted. D.U.R. was the project supervisor, provided conceptual guidance and wrote the article. N.S.M. sourced literature for the article.