A STUDY TO ASSESS AWARENESS AND ATTITUDE OF ADULTS ON MALE CIRCUMCISION AS A PREVENTION STRATEGY FOR HIV/AIDS TRANSMISSION IN WAKISO

DISTRICT: CASE STUDY KASANGATI HEALTH CENTER IV

BY

LWASAMPIJJA BAKER

A RESERCH REPORT SUBMITTED IN PARTIAL FULFILMENT AS A REQUIREMENT FOR THE AWARD OF A DIPLOMA IN PHARMACY OF THE MINISTRY OF EDUCATION AND SPORTS

JUNE 2008

Declaration I LWASAMPIJJA BAKER, declare that the content in this dissertation is original and has never been submitted to any institution for any award. Any quotations are thereby indicated.

…………………………… LWASAMPIJJA BAKER AUTHOR

Date……………………………

……………………………… Mr. OJAKI MIKLOTH SUPERVISOR

Date

…… …………………

i

Dedication. I dedicate this book to my brothers Sam, Musa, John, Fahd and my three sisters Habibah, Aidah, and Shadia.

I love you all.

ii

Acknowledgement This is the first publication I have made and it has been very difficult to come the end of it. It needed lots of support and guidance from many people.

My most sincere thanks go to Mr. Ojaki Mikloth my Principal Tutor and Supervisor, for his tireless efforts in guidance and supervision towards this publication.

Heart felt appreciation goes to my father Mr. Lukyamuzi Abdurashid for all his effort to make sure that I stay in school and providing for my whole family, and me may Allah bless you.

Special gratitude goes to all the people who filled the questionnaire during the study, as this book would not be possible without their contribution and to the Medical Superintendent of Kasangati Health center IV for allowing me to carry out research at this Unit.

A vote of thanks goes to my friends who have helped me with this research and throughout the course of study, friends like Lubyayi Sammy, Lwanga Jimmy, Namutebi Gladys, Kiiza Daniel and Naluuma Juliet. May Allah bless you all.

iii

Table of contents Declaration…………………………………………………………………….i Dedication……………………………………………………………………..ii Acknowledgement…………………………………………………………….iii List of tables ………………………………………………………………….vii List of figures……………………………………………….……………...…viii List of acronyms…………………………………………………………....…ix List of operation definitions…………………………………………………..x Abstract……………………………………………………………………….xi

CHAPTER ONE 1.0 INTRODUCTION ………………….…………………………………….1 1.1 Background ……………………………………………………………….1 1.2 Statement of the problem………………………………………………….4 1.3 Scope of the study ………………………………………………………...5 1.4.1 General objectives ………………………………………………………5 1.4.2 Specific objectives ……………………………………………………...5 1.5 Research questions ………………………………………………………..5 1.6 Significance of the study ………………………………………………….5

CHAPTER TWO 2.0 LITERATURE REVIEW …………………………………...…………….6 2.1 Introduction………………………………………………………………..6 2.2 Awareness and knowledge about circumcision……………………………7 2.3 Acceptability of male circumcision………………………………………..7 2.4 Age at circumcision………………………………………………………..9 2.5 Attitudes towards male circumcision……………………………………...10 CHAPTER THREE 3.0 METHODOLOGY ………………………..……………………………....11 3.1 Study area ………………………………….………………………………11 3.2 Study design ……………………………………………………………….11

iv

3.3 Study variables …………………………………………………………….11 3.4 Study population …………………………………………………………..12 3.5 Sample size ………………………………………………………………..12 3.6 Sampling technique……………………………………………………..…12 3.7 Data collection tools……………………………………………...………..12 3.8 Pre-test ….………………………………………………………………….12 3.9 Data collection method………………………….……………………….…13 3.10 Data processing, analysis and presentation ……….……………………...13 3.11 Ethical consideration …………………………………….……………….13 3.12 Study limitations………………………………………………...………..13 3.13 Dissemination of results…………………………………………………..13 CHAPTER FOUR 4.0 PRESENTATION OF RESULTS …………………………..……………..14 4.1 Introduction ………………………………………………………………..14 4.2 Social demographic characteristics ………………………………………..14 4.3 Awareness on male circumcision as an HIV/AIDS prevention strategy…..18 4.4 Attitude on male circumcision as an HIV/AIDS prevention strategy ……..21

CHAPTER FIVE 5.0 DISCUSSION ………………………..………………..……..…………….24 5.1 Introduction …………………………………………….………...………...24 5.2 Socio-demographic information ………………………….……………...…24 5.3 Level of knowledge of adults about male circumcision…………………….25 5.4 Reasons for carrying out MC………………………………………………..25 5.5 The age preferred for carrying out MC……………………………………...26 5.6 Response in carrying out male circumcision………………………………...27 5.7 Conclusions and recommendations ………………………………………....29 5.7.1 Conclusions ……………………………………………………………….29 5.7.2 Recommendations …………….…………………………………………..30

References

v

Appendices Questionnaires for respondents Letter of authorization Map of Uganda Map of Wakiso district Map of Kasangati

vi

List of tables Table 1: Variables…………………………………………………………………..11 Table 2: Summary of age, sex and marital status…………………………………...15 Table 3: Sources of information on male circumcision……………………………..19 Table 4: How long people were aware of male circumcision……………………….20 Table 5: Reasons for carrying out male circumcision……………………………….21 Table 6: Females’ preference for having a circumcised partner…………………….22 Table 7: Number of people who carried out male circumcision…………………….23

vii

List of figures Figure 1: Distribution of patients by religion………………………………………..16 Figure 2: Distribution by education………………………………………………….17 Figure 3: Awareness on male circumcision………………………………………….18 Figure 4: Preferred age for carrying out male circumcision…………………………21 Figure 5: Reasons for preferring a circumcised husband………………………….…21 Figure 6: Recommendation to carry out male circumcision…………………………23

viii

List of acronyms ABC Abstinence, be faithful, use condoms AIDS Acquired immune deficient syndrome ARV Antiretroviral CI Confidence interval DHS Demographic and health survey HIV Human immunodeficiency virus HPV Human papilloma virus MC Male circumcision MoH Ministry of health NHDS National Hospital Discharge Survey NGO Non-governmental organisation NIH National Institutes of Health (U.S.) RCT Randomized controlled trial PLWH/A Person/people living with HIV/AIDS PMTCT Prevention of mother-to-child transmission (of HIV) STI Sexually transmitted infection UNAIDS Joint United Nations Programme on HIV/AIDS USAID United States Agency for International Development VCT Voluntary counseling and testing WHO World Health Organization

ix

Operation definitions 1. Adult- This refers to a mature, fully-grown person who has attained the age of Majority which is age 18 and above in Uganda.

2. Attitude- This is a relatively stable characteristics that predisposes an individual to male circumcision or a directed behavior towards the practice of male circumcision.

3. Awareness- This used to refer to adults showing realization or knowledge on the practice of male circumcision.

4. Circumcision- For males, circumcision involves removal of the foreskin of the penis. For females, it is the excision of all or part of the external genitalia, and is commonly referred to as clitodectomy or female genital mutilation.

5. Herd immunity is defined as the resistance of a group to attack by a disease due to the immunity achieved in a large proportion of the members.

6. Male circumcision refers to the surgical removal of all or part of the prepuce (foreskin) of the penis; may be practices as part of a religious ritual performed shortly after birth, a traditional "come of age" ritual practiced after puberty in certain or medical procedure related to infections injury or anomalies of the fore skin.

7. Prevention of HIV/AIDS is the act of keeping from happening or arising the spread of HIV/AIDS.

8. Transmission is used to refer to an incident in which HIV/AIDS is spread.

x

Abstract The study was conducted in Wakiso using a representative sample of 30 adults in Kasangati Health center IV to assess the awareness and attitude of adults towards male circumcision as a preventive strategy for HIV/AIDS transmission, knowledge, reasons as well as the preferred age for carrying out male circumcision.

The study was mainly to assess the awareness and attitude of adults on male circumcision as an HIV/AIDS prevention strategy. Also, to find out the level of knowledge of adults about male circumcision as an HIV prevention strategy, determining reasons for carrying out male circumcision, age preferred for caring out circumcision and people’s response in carrying out male circumcision.

A descriptive and non-interventional study was carried out and the information was obtained using standardized questionnaires after an informational session outlining benefits of male circumcision and the study to individuals to be interviewed.

The study was successfully completed with most participants (88%) feeling that the ideal age for circumcision is before one month to one year old, that 87% felt that they would circumcise their male child if MC was offered for free in a hospital setting and carried out by qualified medical personnel. 73% of women favored male circumcision for their partners and 93% of population felt that they would recommend some one to carry out male circumcision in order to reduce the risk of acquiring HIV/AIDS.

In conclusion, results from the study indicates that the majority of the population are aware and have a positive attitude towards male circumcision would be highly acceptable to reduce the risk of acquiring HIV/AIDS.

It is recommended here that further feasibility studies on MC should be conducted; public information campaigns and training of more health workers by the MoH should be considered for effective and safe practice of MC.

xi

CHAPTER ONE 1.0 INTRODUCTION 1.1 Background As we enter a third decade of living with HIV/AIDS, there is still no cure, and no vaccine to provide either full or partial immunity against the virus that has infected more than 39 million people (of which 24.7 million live in Sub-Saharan Africa) since it was first recognized in the early 1980s. It is therefore urgent that we immediately address the cultural, economic, social, ethical, moral, and political challenges related to Male Circumcision (MC) as an HIV prevention strategy.

MC is the surgical removal of all or part of the prepuce (fore skin) of the penis; may be practiced as part of a religious ritual performed shortly after birth, a traditional "come of age" ritual practiced after puberty in certain or medical procedure related to infections injury or anomalies of the fore skin. MC is increasingly being considered as a preventive medical procedure to reduce the acquisition of sexually transmitted HIV-infection.

Historical perspective. Circumcision precedes recorded history. The oldest evidence for circumcision comes from Egypt. Artwork on tombs from the Sixth Dynasty (2345–2181 BC) depicts men with circumcised penises. Stone engravings showing the actual act of circumcision were found in the Temple of Khonspekhrod, Luxor dating back to the dynasty of Amenhotep III in1360 BC. Circumcision was very commonly practiced among ancient nations. The book of Jeremiah, written in the 6th century BC listed Egyptians, Edomites, Ammonites and Moabites as circumcising nations. Herodotus, a 5th century BC scholar, added Colchians, Ethiopians, Syrians and Phoenicians to the list (wikipedia.org).

Religiously, the obligation to circumcise was disclosed to Abraham (Gen 17:2-14). Jews adamantly continue to circumcise their newborn boys on the eighth day of life, thereby strictly observing the biblical instructions. In Christianity, Circumcision is not obligatory, although Jesus was circumcised (Luke 2:21). Early Christians, politically oppressed by

-1-

the Roman Empire that opposed circumcision, kept their foreskins intact to maintain their social acceptance. This Christian attitude towards circumcision was later expressed as a papal bull at the Council of Florence in 1442, which condemned circumcision (ewtn.com). This reflected the anti-Jewish feelings in the Roman Catholic Church at that time and a political challenge to the Coptic Christians who practiced circumcision.

In Islam, circumcision is highly recommended and considered a ‘sunnah’ (a deed to get Allah’s blessings) and a perpetuation of the Abrahamian heritage, although the timing of performing it on the eighth day is not necessary. Aside from religion, societal drives worldwide promote circumcision. Tribes in East and Central Africa, e.g. the Meru, Kisii and Kikuyu tribes of Kenya, the Maasai people of Tanzania and the Bagisu of Uganda, perform ceremonies for circumcision as a ritual of passage from childhood to adulthood and, despite a gradual loss of tribal ceremonies in modern life, circumcision remains as a ritual that is still performed and is crucial to personal identity and pride.

Medically, MC has been cited to reduce transmission of Urinary tract infection, Zoon’s plasma balanitis, lichen sclerosis, dermatological conditions of the glans penis, chronic idiopathic penile edema, penile cancer, STIs and finally HIV/AIDS is a new justification (answers.com). In conclusion, circumcision has stood the test of time and is backed up by historical, religious and societal and medical acceptance.

Evidence based facts on circumcision. Male circumcision may offer a powerful advantage over other HIV prevention strategies in that it involves a one-time surgery that does not require ongoing behavioral modification in order to work. The protection afforded by MC is temporally separate from the risk behavior. Once it is done safely, it is completed and the person does not need to exert any further actions in order to achieve the protection that circumcision affords. This may have significant implications in resource-poor settings where routine access and distribution of technologies that require ongoing use (condoms, Antiretrovirals (ARVs), diaphragms, etc) may present operational hurdles that diminish efficacy.

-2-

The mechanism thought to be responsible for reduced risk of incident HIV-1 infection in circumcised males is the presence of a significantly higher concentration of Langerhans cells, which are target cells for HIV-1 in the mucosal layer of the foreskin (Patterson et al, 2002). Additionally, keratin is believed to provide a protective barrier against HIV-1 infection (Vincenzi et al, 1994). The penile shaft and outer foreskin surface are well keratinized, while the inner mucosal layer of the foreskin is not (McCoombe, 2006). It is also argued that the sensitive foreskin may be more susceptible to micro-abrasion during sexual intercourse, which could provide an entry for STIs and HIV (Szabo, 2000).

Nonetheless, MC presents challenges. The cost associated with population-level MC may exceed a country’s financial resources and health care infrastructure capacity. Furthermore, people may develop the perception that circumcision provides complete protection, when in fact protection is far less than ideal (based on the recent clinical trials, approximately a 65% protective benefit under ideal circumstances at the time of vaginal intercourse). Experts also cautioned that circumcision is no cure-all. It only lessens the chances that a man will catch the virus in a heterosexual relationship, it is expensive compared to condoms and abstinence or other methods, and the surgery has serious risks if performed by folk healers using dirty blades, as often happens in rural Africa. Circumcision is "not a magic bullet, but a potentially important intervention," said Dr Kevin M. De Cock, director of HIV/AIDS for the World Health Organization (UNAIDS, 2006).

-3-

1.2 Statement of the problem. There is very little experience concerning the awareness, practicality, feasibility, acceptability, and cost-effectiveness of male circumcision as an HIV intervention. Since there is increased advocacy for MC, there is a danger that this increased demand will be filled by unqualified practitioners causing unnecessary adverse events.

In Uganda, non-medical MC is performed by people who learn how to circumcise on the job or inherit the role. Much as MC looks simple, it poses some complications, especially when done on adults, where blood vessels are bigger leading to over bleeding, infection and in some cases injured penis head (glans). Sometimes the skin is cut too short and not stitched to the base. In children, especially with fat ones, the penis may retract inside as the skin heals, sealing off the head and the person cannot urinate, and this needing surgery, which is a big complication.

1.3 Scope of the study. The study was limited to Kasangati Health Center IV, Kasangati town in Wakiso district. The study was carried out on adult patients, their caretakers receiving treatment and some of the healthcare providers at the center with in a period of one month starting from mid February to mid March 2008. The study was focused in determining the awareness and attitude of adults on MC as a preventive strategy for HIV/AIDS transmission.

-4-

1.4.0 Objectives of the study. 1.4.1 General objective. To assess the awareness and attitude of adults on male circumcision as an HIV/AIDS prevention strategy. 1.4.2 Specific objectives. i. To find out the level of knowledge of adults about male circumcision as an HIV prevention strategy. ii. iii. iv. To determine the reasons for carrying out male circumcision. To find out the age preferred for caring out circumcision. To assess people’s response in carrying out male circumcision.

1.5 Research questions. i. What is the level of knowledge of adults about male circumcision as an HIV prevention strategy? ii. iii. iv. Why do people carry out male circumcision? At what age would people prefer to carry out male circumcision? What do people respond towards the practice male circumcision?

1.6 Significance of the study. The study findings and recommendations were to define the loopholes and supplement to the already available information on MC. It also created awareness to those who are unfamiliar with the concept as the process of obtaining data required explaining to individuals about MC enabling them to make informed decisions as this could greatly reduce the risk of acquiring the infection and later contributing to Herd immunity. The study also promoted the skills of the researcher in proposal and research report writing.

-5-

CHAPTER TWO 2.0 LITERATURE REVIEW. 2.1 Introduction. Routine male circumcision could reduce a man's risk of HIV infection through heterosexual sex by 65%, according to final data from two NIH-funded studies conducted in Kenya and Uganda published in the Feb. 23 issue of the journal Lancet, the New York Times reports (McNeil, 2007). Early data from the two studies released in December 2006 indicated that circumcision reduced a man's risk of HIV infection by 50%. For the studies, researchers monitored 4,996 men ages 15 to 49 living in Uganda and 2,784 men ages 18 to 24 living in Kenya -- half of whom were randomly assigned to be circumcised and the other half served as a control group -- to determine if circumcision reduced HIV infection. All participants in both studies received counseling on HIV risk reduction and were advised to use condoms. The Uganda study found 43 cases of HIV among the uncircumcised men, compared with 22 among the circumcised men -- a 48% reduction of HIV transmission. The Kenya study found 47 cases of HIV among uncircumcised men, compared with 22 among the circumcised men -- a 53% reduction. The results of the studies were so overwhelming that NIH stopped the trials early and offered circumcision to all participants. The results of the Uganda and Kenya studies mirrored similar results of a study conducted in South Africa in 2005 (Kaiser, 2006). The combined the results of the Kenya and Uganda trials with the South Africa trial and found that male circumcision might reduce a man's risk of HIV infection through sexual intercourse by 65% (New York Times, 2/23). Kevin de Cock, director of the World Health Organization's HIV/AIDS Department, called the results an "extraordinary development," adding, "Circumcision is the most potent intervention in HIV prevention that has been described." , (WHO, 2006). If practiced by dully authorized medical practitioners, male circumcision could reduce

the risk of acquiring HIV infection through sexual intercourse as proved by the studies as mentioned above.

-6-

2.2 Awareness and Knowledge about circumcision. Circumcision is widely practiced in Korea, but little is known regarding the public's attitude towards circumcision. A study was designed to evaluate the knowledge and the general opinion of Korean adult males towards circumcision(S-Joh et al; 2004). Fifteen hundred self-completion questionnaires were distributed to adult males in five decadal age groups ranging from 10 to 59 year old. Questions concerning opinions regarding the necessity, reasons, potential benefits and disadvantages of circumcision, as well as the role of peer pressure upon the decision to circumcise were included. Completed questionnaires were collected and analyzed statistically. The achieved response rate was 73% believed that circumcision is necessary, while 7% believed it is not necessary. The principal reason for circumcision was to improve penile hygiene (77.9%). 68.7% did not prefer neonatal circumcision regardless of the respondent's age. The major reason was fear of pain (36.9%). Peer pressure was one of the most influential factors when deciding upon circumcision: 60.8% believed that they might be ridiculed by their peer group unless circumcised, and the younger the age of the respondent, the more frequently this opinion was held 62.7% thought that circumcision would prevent genital tract infection of the sexual partner. Respondents with older age tended to emphasize improved sexual potency. Conclusions: This study indicates that common beliefs of adult males about circumcision in Korea are relatively homogeneous. 2.3 Acceptability of male circumcision. There are still questions whether the introduction of male circumcision in traditionally non-circumcising regions is acceptable? Male circumcision is generally embedded in a complex web of cultural and religious beliefs and practices, and is seldom seen as a simple health matter. Yet there is growing evidence that male circumcision is increasing in traditionally non circumcising areas as people associate it with reduced risk of HIV and STI. (Bailey et al, 2002). The 13 studies identified from nine countries that include investigation of the acceptability of MC in traditionally non-circumcising regions in sub-Saharan Africa.

-7-

The level of acceptability across the nine countries appears greater than might be expected, considering that, all thirteen communities where the studies were performed were all traditionally non-circumcising. The lowest level of acceptability by uncircumcised men (29%) was reported from eastern Uganda in a study conducted Bailey et al 1999, before MC became well recognized as possibly being associated with STIs and HIV. In all the studies carried out, more than half of men in the regions studied appear to be receptive, if not eager, to become circumcised. However, the level of acceptability in Uganda in relation to other districts is not known as there are no studies of this kind carried out to address the issue. Cost, fear of pain, and concern for safety were the three most consistent barriers to acceptability of MC. In communities where circumcision is the norm families expect to incur the obligatory circumcision expenses negating the importance of cost. In noncircumcising communities circumcision is regarded as a voluntary procedure that may be unlikely to take over competing needs. (Bailey, Unpublished report to AIDSMARK, 2002). According to Green et al, 1993; cultural norms, ethnic identity, and religious affiliation were viewed as central factors in acceptability of circumcision. Circumcision was associated with specific traditionally circumcising communities and with Muslims and members of a few minority Christian and animist sects. It will likely be important that confidentiality is maintained by circumcision practitioners, since stigmatization for being circumcised is a possibility in non-circumcising communities. An important conclusion reached by several studies was that circumcision was increasingly an issue of personal choice rather than ethnic identity (Rain-Taljaard et al., 2003). Urbanization, ethnic mixing, and exposure to other cultures and religions are conducive to higher acceptability of circumcision in traditionally non-circumcising ethnic groups.

-8-

2.4 Age at circumcision. The age at circumcision varies across societies and across individuals within societies. In most developed countries and in communities following Islam or Judaism and some minority Christian sects, circumcisions are done normally within days or weeks after birth. In many other communities, particularly in East and Southern Africa most MCs are done between ages 8 and 21 and the preferences for age at circumcision found in studies are consistent with these practices. However, a large enough proportion of people, especially mothers, preferred infant circumcision to consider making infant circumcision an available option. This should be an important consideration in designing MC interventions (Kelly et al, 1999).

There is little information available concerning the relation between risk of HIV acquisition in men and age at circumcision. It seems biologically plausible that, as long as it occurs before HIV exposure (and after full wound healing), circumcision would offer the same degree of protection against HIV and STIs regardless of the age at which it was done. Curiously, one study conducted in Tanzania when found that the protective effect of circumcision was restricted to those circumcised at age 15 years or more. However, Kiwanuka et al, 1999; found in a multivariate analysis of cross-sectional data from a Ugandan population that in adult men who were circumcised before age 13. The protective effect of circumcision was 0·39 (95% CI 0·29–0·53); for those circumcised at ages 13 to 20, the protective effect was similar, 0·46 (95% CI 0·28–0·77); and for those circumcised after age 20, the protective effect was 0·78 (95% CI 0·43–1·43), and did not attain statistical significance (there was limited statistical power in analyzing this latter group with only 76 men in it). This suggested to the authors that circumcision before age 21 years had a greater protective effect than after age 20 years. However, it is important to recognize that men who choose to circumcise as adults, after the onset of sexual relations, may be exposed to and infected by HIV before circumcision.

In conclusion, most of the studies, it is suggested and preferred to carry out male circumcision at a relatively lower age i.e. in infants’ months old to 2 years.

-9-

2.5 Attitudes towards male circumcision Attitudes toward circumcision assessed by early studies (Bailey et al., 1999; Nnko et al., 2001) may have changed since the time of the study. All studies attempted to assess peoples' beliefs and attitudes toward circumcision and their willingness to be circumcised under some hypothetical conditions sometime in the future. We cannot know from these studies what the actual uptake of circumcision would be if it were found to be protective in three clinical trials and was actively promoted. We have only one example of an introduction of MC services in a traditionally non-circumcising community (Bailey, Unpublished report to AIDSMARK, 2002), and this was at a time when circumcision could not be actively promoted, but could only be made available. Results from that intervention were instructive in that demand for safe circumcision was robust, but depended very much upon price. Quantitative and qualitative acceptability studies conducted in preparation for the Kenya, South Africa, and Uganda RCTs, and at least half a dozen other studies in these and four other African countries indicate that many men as well as women show favorable attitudes towards MC. For example, of over 800 people, both men and women interviewed in Botswana, 68 percent expressed interest in having their male child circumcised, and a similar proportion of uncircumcised men expressed interest in becoming circumcised (Kebaabetswe et al, 2003). In Zambia, where MC is relatively uncommon (and where USAID is planning to support the development of pilot MC services), preliminary qualitative data indicate there is widespread interest as well (Green et al, 1993). In conclusion, as suggested by the above studies, peoples attitude on many aspects vary especially after being educated. Therefore, the recent attitudes on male circumcision are discussed in chapter five.

- 10 -

CHAPTER THREE. 3.0 METHODOLOGY. This section out lines the study area, study design, sample size, research data collection methods and tools that were be employed for this research.

3.1 Study area. The study was conducted in Kasangati Health Center IV, located in Wakiso district, located on Gayaza road in Kasangati town. The hospital receives patients ranging from medical, mental and labor. Since the area is basically rural, most people indulge in subsistence farming and operating small scale retail shops.

3.2 Study type. The study was descriptive and non-interventional

3.3 Study variables. Table 1: The study variables. Specific objective. Variable. Indicator(s). -Primary. -Secondary. -Tertiary To determine the reasons for -Reasons. carrying out M C. -Religion. -Medical. -Traditional. To determine the preferred -Preferred age. age for carrying out M C. -Infant. -Middle age. -Adult. To assess people’ response -People’s response. towards M C. -Low turn-up -.High turn-up

To find out the level of -Level of knowledge. knowledge of adults on M C

- 11 -

3.4 Study population. The study population included all adult patients and their care takers seeking treatment and some of the healthcare providers at Kasangati Health center during the period of the study from 8: am to 5: pm. The center receives about 70 patients daily totaling to about 210 patients a month. Both in-patients and out-patients were included in the study.

3.5 Sample size. Due to the limited time and inadequate resources available, a representative sample of 30 people from the study population available on the days of the study was interviewed.

3.6 Sampling technique. The study employed simple random sampling to select the sample. This technique was used as it selects those who happen to be there on the first come first serve basis. It is used to collect data at that moment and takes advantage of those who happen to be there.

3.7 Data collection tools. Questionnaires with open and closed ended questions were used as a main tool for collecting data. The selection of the tools was guided by the nature of data to be collected, the time available as well as the objectives of the study. Questionnaires were used since the study was concerned mainly with variables that cannot be directly observed such as awareness, views, opinions and attitudes of the respondents, such information is best collected through questionnaires and the target population was largely literate and is unlikely to have difficulties responding to questionnaire items.

3.8 Pre-test. This was carried out amongst 10 patients in the nearby Health center- Kira Health center III. This enabled the Researcher to detect ambiguous questions and also discover some important questions omitted in questionnaires which improved on the questionnaire.

- 12 -

3.9 Data collection method This was done by the researcher who distributed the questionnaires to the participants on the basis of "first come first serve" and collected them after being filled.

3.10 Data processing Data was processed manually with aid of a scientific calculator and a computer. Frequency distribution tables, pie charts and graphs were drawn. Interpretation of results from percentages and averages were determined. 3.11 Ethical consideration The study was conducted after receiving a letter of permission from the Principal Tutor of Pharmacy- Paramedical Training Schools, Mulago. The permission to carry out research at the Health center was received from the In-charge Kasangati Health Center. Consent was sought from each interviewee and the information obtained from respondents was kept with utmost confidentiality.

3.12 Study limitations. • Some of the interviewees never returned the questionnaires and this created an anticipated gap in the results. • There was limited co-operation from some patients as they considered some information personal.

3.12 Dissemination of results Results of the study were disseminated as follows; Two hard cover copies to the Pharmacy School- Mulago, a copy to the in-charge Kasangati Health center IV, supervisor and the researcher.

- 13 -

CHAPTER FOUR 4.0 PRESENTATION OF RESULTS AND ANALYSIS 4.1 Introduction This chapter presents the findings of the study according to the analysis of data. The data represented in this section was collected on the social demographic characteristics, knowledge and attitude of adults about the male circumcision strategy in prevention of HIV/AIDS.

- 14 -

4.2 Social demographic characteristics

Table 2: Summary of sex, marital status and age groups.

Age group

Sex

Male

Female

Total

Marital status

Marital status

Single

Married

Single

Married

No.

%

No.

%

No.

%

No.

%

No.

%

18 – 20

3

10

1

3

4

13

-

-

8

26

21 - 25

4

13

-

-

4

13

2

7

10

33

26 – 35

5

17

-

-

-

-

2

7

7

24

36-45

-

-

3

10

-

-

2

7

5

17

Total

12

40

4

13

8

26

6

21

30

100

In this study, the representative sample size was 30 of which 53% (16) were males and 47% (14) females. Majority of the people interviewed (10) were in the age groups 21-25 years of age. Majority (73%) were married.

- 15 -

4.2.1 Religion Figure 1: The distribution of patients by religion

45 40 35
40

30
Percentage (%)

25 20 15 10 5
17 13

7

20

3

0 Cat Mos Prot
Religion

SDA

T.A

Pent

Key: Cat = Catholic Mos = Moslem Prot = Protestant SDA = Seventh day Adventists T.A = Traditional African Pent = Pentecostals/ saved

According to the study, the majority of the population were Moslems (40%) followed by Seventh Day Adventists.

- 16 -

4.2.2 Patients level of education Figure 2: Distribution by education

Primary 13%

Tertiary 50%

Secondary 37%

The majority (50%) reached tertiary level of education and least number (13%) were at least primary level dropouts.

- 17 -

4.3 Awareness on male circumcision as an HIV/AIDS prevention strategy Figure 3: Awareness of participants on male circumcision being pointed out as an HIV/AIDS prevention strategy.

Not sure 17%

No 13%

Yes 67%

The greatest number (67%) agreed to the questions, 13% did not agree well as 17% of the participants were not sure whether male circumcision could reduce the risk of acquiring HIV/AIDS.

- 18 -

Table 3: The list of sources where participants got the information concerning male circumcision and HIV prevention

Source News papers Radio Television Friend Internet Sex education Personal experience None Total

Frequency 11 11 9 6 1 2 2 2 48

Percentage (%) 23 23 18 13 2 4 4 13 100

There are two main sources where the participants got their information i.e. from reading newspapers and listening to radios both at 23%

- 19 -

Table 4: The length participants were aware of male circumcision as an HIV prevention strategy (n=30)

Period

Cumulative Frequency

Percentage (%)

One day

2

7

Six months

4

13

Over a year

13

43

Over five years

6

20

Never heard of it

5

17

Total

30

100

According to the study, the idea of male circumcision to reduce the risk of acquiring HIV was not new in that the majority (43%) knew about this concept over a year. On the other hand 17% of the population never heard of the subject.

- 20 -

Table 5: Reasons for carrying out male circumcision Reason Religion Good hygiene Cultural roles Prevent STDs/HIV To look smart Enhance Sexual pleasure Total Cumulative frequency 13 10 14 13 1 2 53 Percentage (%) 25 18 26 25 2 4 100

Prevention of HIV/AIDS (25%), prevention of HIV/STDs (25%) and cultural roles (26%), according to the study are the major reasons

Figure 4: Preferred age for carrying out male circumcision
18 and above 10% 1-7 year 10%

1 month-1 year 80%

Most people according to the study prefer to carry out male circumcision on children from one month to one year of age (80%).

- 21 -

4.4 Attitude on male circumcision as an HIV/AIDS prevention strategy

Table 6: Females’ preference for having a circumcised partner Response Yes No Total Frequency 11 3 14 Percentage (%) 79 21 100

73% of females preferred their male partners circumcised, 7% did not prefer the act while 20% had no comment on the matter.

Figure 5: Reasons for preferring a circumcised husband

45 40 35

Percentage(%)

30 25 20 15 10 5 0
Prevent STDs Hygiene Religion None Culture Medical reasons

Reason

Females in the study prefer circumcised males mainly because of cleanliness (40%) and to prevent the spread of STDs.

- 22 -

Table 7: Number of people who carried out circumcision to reduce the risk of acquiring HIV/AIDS.

Number 1-5 6-10 11-20 None Total

Frequency 8 3 7 12 30

Percentage (%) 27 10 23 40 100

The majority of the study population (40%) has never seen any one carrying out male circumcision to reduce the risk of acquiring HIV/AIDS while 27% have at least seen 1-5 people being circumcised for the cause.

Figure 6: Recommendation to carry out male circumcision

Yes, 93% Yes 93.00%

No 7.00% No, 7%

Almost all people (93%) agreed that they would recommend some one to carry out male circumcision.

- 23 -

CHAPTER FIVE 5.0 DISCUSSION 5.1 Introduction

The results of the study are hereby discussed under the following headings; sociodemographic information, awareness and attitude on MC as an HIV prevention strategy.

5.2 Socio-demographic Information

Social, cultural and religious factors played a great role on the awareness and attitude of adults towards male circumcision as a preventive strategy in reducing the risk of acquiring HIV infection. From a total of 30 who were involved in the study, the majority were predominantly young (21-25 years for both males and females) and single (75% of men, 57% of women), and were mostly Moslems (Figure I). One of the strengths of this study was the use of random sampling to generate a representative group of adults and healthcare providers from the target population. Comparing the demographics of this study population to urban populations described in the Uganda Demographic and Health Survey (DHS) conducted in 2000–2001, there were notable differences. The great proportion of adults (50%) completing at least tertiary institution was comparable with that reported for urban Ugandan Adults; however, literacy was slightly higher. In addition, this study population had much greater access to education facilities and sources of information (table 2) than the majority of the Ugandan population living in rural areas.

5.3 Level of knowledge of adults about male circumcision as an HIV prevention strategy.

From the results of the study, the greatest number of participants (67%) agreed that male circumcision could reducing the risk of acquiring HIV/AIDS, 13% did not agree well as 17% of the participants were not sure whether this is a fact or fiction. There were two main sources where the participants got their information i.e. from reading newspapers and listening to radios both at 23%

- 24 -

According to the study, the idea of male circumcision to reduce the risk of acquiring HIV was not new in that the majority of the participants (43%) knew about this concept over a year. On the other hand, 17% of the participants never heard of the subject.

The study findings are particularly important within a context whereby although most people are aware of the protective effect of condoms; condom uptake remains worryingly low, emphasizing an urgent need for alternative strategies to help curb the HIV epidemic. The research results suggest that male circumcision might provide a useful HIV intervention within Wakiso and Uganda at large in the future, as it has already been indicated that such an intervention does reduce incidence of HIV infection in men by more than 60%.

5.4 Reasons for carrying out male circumcision.

Results of the study indicate that prevention of HIV/STDs (25%) and cultural roles (26%), according to the study are the major reasons as to why one would carry out MC. This suggests that MC may generally be more acceptable than believed prior to these studies. The lowest level of acceptability by uncircumcised men (29%) was reported from eastern Uganda in a study conducted in 1997, before MC became well recognized as possibly being associated with STIs and HIV (Bailey et al., 1999).

The study results show that, as found elsewhere in sub-Saharan Africa, circumcision decisions are becoming more a matter of individual and family preference than of cultural identity. Therefore, culture might not be a significant barrier in the promotion of male circumcision. The important conclusion reached by several studies was that circumcision was increasingly an issue of personal choice rather than ethnic identity (Rain-Taljaard et al., 2003). Urbanization, ethnic mixing, and exposure to other cultures and religions are conducive to higher acceptability of circumcision in traditionally non-circumcising ethnic group (Scott et al., 2005).

Around half the uncircumcised men show that they would be circumcised if the procedure could be conducted safely with little pain and at low cost. Seventy three

- 25 -

percent of women would like their primary partners to be circumcised. There is a higher preference for male circumcision among those with higher educational levels. Men who do have particular beliefs regarding health or sexual aspects of circumcision are least likely to be circumcised. This suggests that appropriate educational messages might further increase levels of acceptability in this community.

There was little association between willingness to be circumcised and beliefs about health aspects of circumcision (keeping the penis clean, catching STIs/HIV, pain during intercourse), although when questioned to give reasons as to why they would be circumcised, 25% included reduced risk of STI among their responses than any other reason. As compared in previous studies, the main reasons for favoring male circumcision were prevention of STIs, including HIV, and beliefs surrounding the likelihood of pain and/or enhanced pleasure during intercourse and circumcision status (Bailey et at 2002; Taljaard et at 2000; Varga et al 1998) which in a more perspective agree to the results of the study.

5.5 The age preferred for carrying out circumcision

Most people according to the study prefer to carry out male circumcision on children from one month to one year of age (80%).There appeared to be conflict between whether boys should be circumcised as babies when the procedure would be simpler and the boys unafraid, or as adults when they would be free to decide for themselves. Many people where noted saying that the reason as to why they preferred to carry out the procedure is because in this age group the pain can be tolerated with out much complaining and healing is quick

5.6 Response in carrying out male circumcision.

When asked whether they would have their male children circumcised as away of reducing the risk of acquiring HIV, 87% said yes, this was due to the fact that as the AIDS epidemic is continuing to spread, many parents are afraid that their children will contract the virus. Therefore if MC offers any protection, many would gladly carry it out for the safety of their children. 73% of females preferred their male partners circumcised,

- 26 -

this was mainly because of cleanliness of cleanliness (40%) since a circumcised penis is easy to clean and to prevent the spread of STDs.

‘What are the main reasons you would/would not accept to be circumcised?’ While the majority stated cultural roles, good hygiene, religion and protection from STIs, including HIV, than increased sexual pleasure as a reason for circumcision (Table 4), the results suggest that factors concerning beliefs about sexual pleasure may actually be more influential. It is possible that people stated protection from STIs as the primary motivator for circumcision more frequently than enhanced sexual pleasure believing that this is what the researcher wanted to hear or because they did not wish to admit to their primary motivation.

The majority of the study population (40%) has never seen any one carrying out male circumcision to reduce the risk of acquiring HIV/AIDS while 27% have at least seen 1-5 people being circumcised for the cause. This is majorly because the practice has not yet been fully implemented in Kasangati where the study was carried out.

Almost all respondents (93%) agreed that they would recommend some one to carry out male circumcision. From a health promotion perspective, it is worth noting the differences between factors statistically associated with willingness to be circumcised, and the answer to the question:

However, while this strategy would build upon the beliefs of the population rather than ‘health education’, it could adversely affect sexual practice and the impact of other HIV prevention campaigns. Information campaigns may be effective in increasing acceptability of MC. This was found to be true in Botswana and South Africa (Kebaabetswe et al., 2003; Scott et al., 2005). In any event, education campaigns must emphasize that male circumcision cannot afford total protection from STIs and HIV, a minority of participants believing it could.

- 27 -

The study highlights this (Figure 4), women volunteering that while they may wish their partners to be circumcised, men would be unlikely to respond to their wishes. Thus, the impact of women’s preference for male circumcision may be limited. However, there may be some influence of women’s views within health promotion targeting men, as believing that women enjoyed sex more with circumcised men than their uncircumcised counterparts was significantly associated with an increased willingness of men to be circumcised.

The fact that this study focused mainly on awareness and attitude of male circumcision rather than feasibility, one identified barrier to the promotion of male circumcision in Wakiso is that, theoretically, only hospital doctors can carry out the procedure. This raises problems of logistics and costs for the men, as well as the risk of diverting medical resources from other areas where they are needed.

While it may prove cost-effective to promote male circumcision to reduce the burden of STIs and HIV in Wakiso, the burden of reduced resources would fall upon nurses who are unable to perform circumcision and an increased burden would fall upon already stretched hospital clinicians. Further, while around half the men said that they would choose to be circumcised, it is not known how many would actually take up the service if it were offered to them, making it difficult to estimate the Male circumcision as an HIV prevention strategy in the health system.

- 28 -

5.7 Conclusions and recommendations 5.7.1 Conclusions

The following conclusions were drawn from the research results; Majority displayed knowledge that male circumcision is a strategy in reducing the risk of acquiring HIV/AIDS and has known this fact for over a year. Cultural, religious and prevention of STDs and AIDS are the main reasons as to why people carry out male circumcision. Most adults felt that the best age for circumcision is birth to 1 year. Majority of the population are aware of male circumcision as an HIV/AIDS prevention strategy. Almost all people would recommend one to carry out male circumcision showing a positive attitude towards the practice. Safe circumcision services in Wakiso could provide an effective, available, permanent, and affordable means to reduce the incidence of HIV in the next generation of children.

- 29 -

5.7.2 Recommendations

1. In the meantime, Wakiso district should carry out further feasibility studies so that if the time for circumcision promotion comes the health system will be ready.

2. Widespread public information, campaigns, broad dissemination of this and similar monographs should be encouraged by the Central Government that describes the risks and benefits of male circumcision to the public.

3. A number of births in the Wakiso occur at the health centers, therefore training physicians and nurses at these locations by the Ministry of Health could implement circumcision services with existing resources.

4. Studies that shed light on peoples understanding of the protection offered by male circumcision for both males and females will be essential if undertaken by the Ministry of Health. It will be important to repeat these over time as events change.

- 30 -

REFERENCES:

Auvert B, Taljaard D, Lagarde E, Sobngwi-Tambekou J, Siita R, Puren A. Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: the ANRS 1265 Trial. PLoS medicine. 2005 Nov; 2(11):e298.

Bailey R, Neema S, Othieno R. Sexual behaviors and other HIV risk

Factors in

circumcised and uncircumcised men in Uganda. J Acquir Immune Defici Syndr 1999; 22: 294–301.

Bailey RC, Muga R, Poulussen R, Albright H. The acceptability of male Circumcision to reduce HIV infection in Nyanza province, Kenya, AIDS press.(In press). 2002.

Bailey RC, Muga R, Poulussen R. Trial intervention introducing male circumcision to reduce HIV/STD infections in Nyanza Province, Kenya: baseline results. XIII International Conference on AIDS; Durban, South Africa; August 2000. MoOrC196.

Camlin, C. S., & Chimbwete, C. E. (2003). Does knowing someone with AIDS affect condom use? An analysis from South Africa. AIDS Education and Prevention, 15(3), 231_/244. de Vincenzi I, Mertens T. Male circumcision: a role in HIV prevention? AIDS London, England). 1994 Feb; 8(2): 153-60.

Green EC, Zokwe B, Dupree JD. Indigenous African healers promote male circumcision for prevention of sexually transmitted diseases. Trop Doct 1993;23: 182–83.

http://en.wikipedia.org/wiki/History-of-male-circumcision#circumcision-in-the-Ancientworld.

http://www.answers.com/circumcisionDefinition/htm.

Kaiser Daily HIV/AIDS report, 2006

- 31 -

Kebaabetswe, P., Lockman, S., Mogwe, W., & Thoir, I. (2003). Male circumcision: an acceptable strategy for HIV intervention in Botswana? Sexually Transmitted Infections , 79, 214_/219. Kelly R, Kiwanuka N, Wawer M, et al. Age of male circumcision and risk of prevalent HIV infection in rural Uganda. AIDS 1999; 13: 399–405.

Mc Neil, 2007.Jounal Lancet, The New York times Feb. Pg 23

McCoombe SG, Short RV. Potential HIV-1 target cells in the human penis. AIDS (London, England). 2006 July 13; 20(11):1491-5.

Nnko S, Washija R, Urassa M, Boerma JT. Dynamics of male circumcision practices in northwest Tanzania. Sex Transm Dis 2001; 28: 214–18.

Patterson BK, Landay A, Seigel JN, Flener Z, Pessis D, Chaviano A, et al. Susceptibility to human immunodeficiency virus-1 infection of human fore skin and cervical tissue grown in explant culture. The American Journal of Pathology. 2002 Sept; 161(3): 867-73.

Pope Eugenius IV. Eamenical council of Florence: Bull of Union with the Copts. Session II-February 1442. Available at: http://www.ewtn.com/library/COUNCILS/FLORENCE.htm#5.

Rain-Taljaard, Taljaard D, Auvert B, Neilssen G. Cutting it fine, male circumcision practices and the transmission of STDs in Carletonville. XIII on AIDS: Durban, South Africa; August, 2000; 195 International Conference

Scott BE, Weiss HA and Viljo JI: The acceptability of male circumcision as an HIV intervention among a rural Zulu population, KwaZulu-Natal, South Africa. AIDS care, April 2005: 17(3):304-313.

- 32 -

S-Joh, T. Kim, D.J Lim, H. Choi. Knowledge of attitude towards of adult Korean males by age. Acta paediatrica Volume 93 issue II page 1530-33, November 2004.

Szabo R, Short RV. How does male circumcision protect against HIV infection? BMJ (Clinical research ed. 2000 Jun 10; 3207249): 386-91.

The Bible. Genesis 17: 2- 14.

The Bible. Luke 2: 21.

Tyndall M, Ronald A, Agoki E, et al. Increased risk for infection with the human Immunodeficiency virus type-1 among uncircumcised men presenting with genital ulcer disease in Kenya. Clin Infect Dis 1996; 23: 449–53.

UNAIDS. Global summary of AIDS epidemic: December 2006: Joint United Nations programme on HIV/AIDS; 2006. Varga, C. A. (1998). Sexual decision-making and negotiation in the midst of AIDS: youth in KwaZulu-Natal, South Africa. Health Transition Review, 7(Suppl. 3), 45_/67

- 33 -

Q/No: A QUESIONNAIRE TO DETERMINE AWARENESS AND ATTITUDE OF ADULTS ON MALE CIRCUMCISION AS A PREVENTIVE STRATEGY FOR HIV/AIDS IN WAKISO DISTRICT: CASE STUDY KASANGATI HEALTH CENTER IV.

Introduction:This survey is being carried out to assess the awareness and attitude of adults on male circumcision as an HIV/AIDS prevention strategy. Please feel free to respond genuinely; the information collected will be treated with utmost confidentiality. Return the questionnaire to the person who gave it to you. Thank you for your co-operation. Instructions: Please put a tick (√) in the box corresponding to your answer of choice or fill in the blank spaces as applicable.
a) Social demographic characteristics. 1. Sex. i) Male

ii) Female

2. Age i) 18-20 iii) 26-35 3. Religion i) Catholic iii) Protestant V) Traditional African 4. Marital status. i) Single iii) Widow(er) 5. Level of education. i) Primary iii) Tertiary

ii) 21-25 iv) 36-45

ii) Moslem iv) SDA vi) Other (specify) ………………….

ii) Married iv) Other (specify) ………………….

ii) Secondary iv) Other (specify) ………………….

b) Awareness on male circumcision as an HIV/AIDS prevention strategy.

6(a) Male circumcision has been pointed out as an HIV/AIDS prevention strategy. Do you agree to this? Yes No Not sure

- 34 -

(b) If yes, how did you know this (i) Reading news papers. (ii) Heard from a radio. (iii) By watching T.V (iv) From a friend. (v) Other (specify) ………………………………………………………………………… © For how long have you known? (i)Over a year. (ii) Six months. (iii)One month (iv) Just today. (v) Other (specify) …………………………………………………………………………. 7. People carry out male circumcision for other reasons apart from the one in 6 (a) above. What are the other reasons? (List as many as you can.) ……………………………………………………………………………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………………… 8. What age do you think is appropriate for carrying out male circumcision? (i) Birth -1 year (ii) 2-7 years (iii) 8-18 years (iv) 18 and above
c) Attitude on male circumcision as an HIV/AIDS prevention strategy. 9(a) If you have children, would you have your male child circumcised as a way of reducing the risks of acquiring HIV/AIDS? Yes. No. (b) If male, would you accept to be circumcised? Yes. No. Give a reason(s) for your answer. ……………………………………………………………………………………………… ………………………………………………………………………………………………

© If female, would you prefer your husband circumcised? Yes. No. Give one or two reasons or your answer. ……………………………………………………………………………………………… ……………………………………………………………………………………………… 10. How many people do you know that have carried out male circumcision in order to reduce the risk of acquiring HIV/AIDS? (i) 1-5 (ii) 6-10 (iii) 11-20 (iv) None 11. Would you recommend some one to carry out male circumcision? Yes No THE END, THANK YOU.

- 35 -

- 36 -

WAKISO

- 37 -

Sign up to vote on this title
UsefulNot useful