Abstract

Definition and concepts:  Male Circumcision is simply defined as the removal of a fold of loose skin (the foreskin or prepuce) that covers the glans of the flaccid penis. It has been practiced as a religious rite since time immemorial, which has been commonly  practiced by all African societies among all religious denominations, especially by the Ethiopian Coptic Church. 

Motivation and Objectives:  Circumcision is recommended as a global efforts to combat the prevalence of the HIV/AIDS pandemic, for it has been widely believed to be important intervention strategy to tackle the scourge since 2007. 

Data Sources: In 2008, Botswana AIDS Impact Survey Programme (BAIS- III) was conducted, based on two stages stratified sampling design.The study covered 8275 households, systematically drawn from selected Primary Sampling Units PSU’s), known as Enumeration Areas (EA’s). 

Methodolgy: Using the SPSS Package Programme,  the  target  group  was screened to constitute 5647 males within the 10-49 age bracket, consisting of about 622(11%) circumcised  and 5025 (89 %) uncircumcised. However, the number of the uncircumcised males who responded willing to undergo Safe Male Circumcision(SMC) were 3046 (61%) and those not willing were 1979(39%). 

Analytical Approaches: The appropriate statistical analytical models of analysis include the univariate frequency distribution, bivariate chi-squares (X²) technique and the Logistic Regression Model.

Introduction

According to Rain-Taljaard etal ( 2003), circumcision is the removal of a fold of loose skin (the foreskin or prepuce) that covers the head (glans) of the flaccid male penis. This procedure has been practiced as a religious rite from time immemorial, popularly quoted during Abraham and Herodotus’ time. For example, Doyle ( 2005) said that the Children of Israel used to had been circumcised during their captivity in Egypt around 1200 BC The ancient Semitic peoples, including Egyptians and Jews, used to had been practiced circumcising their children dating as far back as around 2300 Before Christ (WHO and UNAIDS, 2007; and Doye, 2005).

Although Male circumcision had been commnly practiced in many African societies for cultural reasons, it was gradually stopped among many African ethnic groups, such as Botswana, southern Zimbabwe and parts of South Africa and Malawi due to the influence of some European Missionaries & Colonial Administrators (WHO and UNAIDS, 2007).

However, randomized controlled studies in Africa have provided compelling evidence for the protective effect of male circumcision against the HIV acquisition in heterosexual men,

with a 51% to 61% risk reduction ((Gray et al. ( 2007), Bailey et al. ( 2007) and Auvert et al. ( 2005), as cited inTieu et al. ( 2010)),

Recently, several studies on acceptability of safe male circumcision (SMC) have been undertaken in many parts of Sub-Saharan Africa (SSA). Accordingly, almost all studies revealed that both men and women were in favour of the procedure. For example, about 51% of uncircumcised men among rural Zulu population ( South Africa), reported that they would like to undergo the procedure if it is conducted safely with little pain and at low cost ( Scott, et al..2005).

Similarly, Gasasira et al., ( 2012) revealed that half of the participants in Rwanda were willing to get circumcised and 79% of men would accept circumcision for their sons.

The 2008 Botswana AIDS Impact Survey (BAIS III) results revealed that the incidence and prevalence rates of HIV stood at 2.9% and 17.6%, respectively. Furthermore, the 2010 Botswana progress report on the national response to the 2001 declaration of commitment on HIV/AIDS, highlighted that the spread of the VIRUS was caused by multiple and concurrent sexual partnerships, alcohol and high risk sex, gender violence and sexual abuse, high population mobility and adolescent intergenerational sex.

It should be noted that Male Circumcision (MC) is not a new phenomenon in Botswana. According to National Strategy on Safe Male Circumcision ( 2009), the history of male circumcision practice of the country is documented as far back as 1874. This adopted strategy focuses on increasing SMC prevalence among the HIV negative males of 10-49 years from 20% in 2009 to 80% by 2016, among others. However, Botswana remained one of the countries with very low prevalence of Safe Male Circumcision.

Accordingly, the focus of this study is to establish the factors which influence male’s willingness to circumcise in Botswana through the operationalization of the Health Belief Model (HBM), which is a psychological model that attempts to explain and predict health behaviors, by focusing on the attitudes and believes of individuals, based on the outcome of the 2008 BAIS III data set.

Rationale of the Study:

The 2010 WHO report states that data from a range of epidemiological studies, conducted since the mid-1980s, indicated that circumcised men have a lower prevalence of HIV infection than for uncircumcised men. Three randomized controlled trials were also conducted in Orange Farm( South Africa); Kisumu( Kenya); and Rakai District( Uganda) and showed that following circumcision, the incidence of HIV infection in men was reduced by more than half.

Although the SMC procedure has applied in both private and public hospitals in Botswana, the performance has been fairly low. Some of the core challenges outlined by the country’s SMC National Strategy include ensuring that the population gets the right messages about male circumcision and does not lead to behavior inhibition as well as reducing stigma associated with HIV testing and male circumcision status.

Problem Statement:

Despite the amount of focus put on HIV intervention strategies in Botswana, the scourge continues to spread among the general population. For this reason, safe male circumcision (SMC) was introduced in the country in 2009 as an added value to the National HIV interventions, targeting on HIV negative males, aged 10-49 years. These together with other factors, like shortage of skilled manpower and relevant physical resources necessary for implementation of the programmes, have a great potential in influencing acceptability of safe male circumcision

Objectives of the study:

The main objectives of the study include as follows:

1. establish factors which influence males’ willingness to circumcise through the operationalization of the Health Belief Model (HBM);
2. understand the socio-demographic characteristics of circumcised males in Botswana;
3. determine factors associated with males’ willingness to circumcise; and Explore factors influencing males’ willingness to circumcise.

Literature Review:

A study by Busang et al.( 2011) revealed that fear for pain/complication/deaths, lack of time and inadequate information about SMC, remained to be the main barriers to getting circumcised.

According to Ndwapi et al.( 2012), Botswana’s national Safe Male Circumcision (SMC) Program aimed at reaching circumcision prevalence rate of 80% among HIV-negative males aged 10-49 years by 2016. WHO & UNAIDS ( 2010) reported that the national male circumcision prevalence in Botswana stood at 11.2%, while for other countries, like Kenya, Malawi, Tanzania, Mozambique and Namibia, it was 85%, 21%, 70%, 56% and 21%, respectively.

WHO ( 2011) has also revealed that in 2011 alone, 4.2% of the targeted males in Botswana underwent the procedure, raising a bit from about 2% in 2009, which accounted for 25,858 targeted males circumcised at national level to date. This low turn out of the targeted males calls for the need to further unpack socio-demographic factors which influence the males’ willingness to undergo MC procedure in Botswana, because curbing HIV transmission remains a priority for the country as vital programs which could add to the increase of the expectation of life of the population.

HIV/AIDS still remains a major global health concern for almost three decades. Sub-Saharan Africa is highly affected by the scourge, with observed large scale social and economic consequences. In 2010, about 68% of all persons living with HIV incidence worldwide, were reported in Sub-Saharan Africa, a region with only 12% of the global population ( UNAIDS 2011). According to Lau and Muula ( 2004), the pandemic is responsible for escalating poverty and hunger, making a large number of children orphaned, stigma and discrimination and contributing to the decline in life expectancy.

Global efforts in combating the scourge remain a priority by introducing antiretroviral drugs which appeared to manage HIV mutation, ultimately reducing many incidences of morbidity and mortality in the whole world, including in many sub-Saharan African countries. The challenge that remains is the observed new HIV incidence rates registered by many of these countries.

According to UNAIDS report ( 2011), about 34 million people were estimated to have been living with HIV worldwide. In recent years, the continued war against HIV/AIDS has seen the introduction of Safe Male Circumcision (SMC) as additional HIV prevention strategy among other existing controlling programs, like condom use, reduction in sexual partners and antiretroviral therapy. Several randomized controlled studies and/or trials have yielded findings that safe male circumcision significantly reduces acquisition of heterosexually HIV infection among men.

In the same vein, Westercamp and Bailey ( 2007) reviewed thirteen acceptability studies from nine sub-Saharan African countries to assess factors that will influence uptake for circumcision in traditionally non-circumcising populations. Accordingly, cross-sectional studies indicated that about 65% of uncircumcised men expressed willingness to become circumcised; 69%. of women favored circumcision for their partners and about 71% of men and 81% of women were willing to circumcise their sons.

Another study conducted by Gasasira et.al,( 2012) in Rwanda showed that most male participants were willing to get circumcised to prevent STI/HIV infection as well as for hygienic improvement. The findings revealed that the willingness to circumcise was significantly associated with younger ages, marital status (cohabiting & single/living alone), and the knowledge of the preventive role of circumcision. The same Author further elaborated that the prevalence of men’s circumcision in Rwanda was higher for those who attended universities and secondary schools with 82% and 41%, respectively.

Tieu et al. ( 2010) also found out that in Thailand, willingness to be circumcised increased from low baseline of 14.2% to 24.9% after men were educated about circumcision, thereby altering perceptions about the risks and benefits of the procedure. In this connection, counseling, information dissemination and education on SMC are crucial as they inform the intended target population about the benefits of the procedure, ultimately eroding negative perceptions that may be entrenched to interference.

Similarly, Lukobo and Bailey ( 2007) in their study on acceptability of male circumcision for HIV prevention in Zambia, found out that nearly all the participants in non-circumcising districts expressed willingness to be circumcised or have their son circumcised, if the benefits of male circumcision were clear and the procedure were offered at no or minimal cost. The same scholars also noted certain barriers to circumcision in Zambia being painful and the healing process of length of time for healing, cost and identification of the procedure with certain ethnic and religious groups. However, their study was mainly qualitative and hence did not look into and/or establish the statistical relationship between willingness to circumcise and the chosen variables.

The results of another study undertaken in Nyanza Province ( Kenya) by Mattson et al. ( 2005), indicated that the majority of men (60%) and women (69%) reported that they would welcome male circumcision services if they were safe and affordable. The acceptance was generally associated with penile hygiene and minimal chances of acquiring STIs and HIV infections. These findings are also consistent with Mavhu et al. ( 2011) study in Zimbabwe which revealed that women were more likely to favour adult SMC if they were informed about its health benefits.

The gaps identified in Mattson et al. ( 2005) study included a small sample size of 217 (107 men and 110 women) as well as the adoption of the convenience sampling method which has a very low likelihood of sample being representative of the total population. On the other hand, Mavhu studied a large sample size of 2746 individuals but did not investigate how other important socio-demographic variables, like place of residence, age and religion relate to and/or influence willingness to circumcise among men.

Pelzer and Mlambo ( 2012) study findings in South Africa have noted that generally there is a tendency for many young people in that country to undergo medical rather than traditional male circumcision, with acceptability positively associated with its better knowledge. This is corroborated by a study by Yang et al., ( 2012) in China, which revealed that young men below 25 years were more willing to accept MC than those aged over 35 years, and this was attributed to the fact that young men are more knowledgeable about MC and its sexual health benefits.

The same authors notably reported that prevention of penile inflammation and cancer, as well as sexual hygiene and sexual health are as the benefits of the procedure. Their study also identified long foreskin, residing in Xinjiang province, knowing hazards of redundant foreskin and having a friend who underwent circumcision as other factors influencing men’s willingness to undergo the procedure in China. Gasasira et al, ( 2012), also found out that young adults and adolescents in Rwanda were more willing to be circumcised, although they reported that they were afraid of pain, particularly those less than 19 years old (42%). However, Pelzer and Mlambo ( 2012) study targeted persons aged 18-24 years only, leaving those in other groups and/or ages, who are sexually active and hence prone/vulnerable to HIV transmission.

On the other hand, National Institute for Medical Research and Ministry of Health and Social Welfare ( 2009), found out (in rural and urban areas of Mara, Kagera & Mbeya regions - Tanzania) that males’ willingness to circumcise was influenced by adherence to traditional customs, social desirability (e.g. forces of modernity brought by schooling), religion ( Muslims & Christians), awareness about circumcision acquired through various channels including mass media, availability of facilities providing circumcision services in urban areas and social stigma.

Although there are indications of acceptability of MC, questions remain on psychological and socio-cultural underpinnings to adopting the practice as an HIV preventive measure among traditionally non-circumcising communities ( Obure, Nyambeda, Oindo, Kodero, 2009). However, circumcision prevalence in Ethiopia is universally high (93%) but men are most likely to be circumcised if they are in a higher wealth quintile, have at least secondary education and live in an urban area (WHO & UNAIDS, 2007). With respect to religion, National Institute for Medical Research and Ministry of Health & Social Welfare ( 2009) states that Muslims are the largest religious group to practice circumcision in Tanzania. The 2003/04 DHS data in Tanzania showed that 96.8% of Muslim, 60-70% Christians and 25% of men with indigenous beliefs were circumcised. Muslims practice circumcision as a confirmation of their relationship with Allah/God .

Methodology:

1. Conceptual framework: 1 Conceptual framework:

The conceptual analytical framework for this study is constructed by modifying the Health Believe Model (HBM) of Janz and Becker ( 1984), as presented in Figure 1. The model attempts

to reflect the factors that influence male’s willingness to undergo circumcision. The HBM is a psychological model that attempts to explain and predict health behaviors by focusing on the attitudes and believes of individuals. This study assumes that male’s perceived threat, which is the central indicator of behavioral motivation, is HV/AIDS and other debilitating diseases (refer to figure 1).

This conceptual model tries to address the individual’s perceptions of the threat posed by a health problem (susceptibility, severity), the benefits of avoiding the threat, and the factors influencing the decision to act on the barriers, cues to action and self-efficacy (US Department of Health & Human Services, 2005; Masuri et al. , 2012). Perceived susceptibility to disease is when an individual (or a male in this case) becomes conscious and/or aware of contracting a disease or condition. In this case, the framework was modeled to show that a man will show willingness to circumcise if he perceives himself to be susceptible to HIV/AIDS, and also has a positive expectation by undergoing the procedure.

Figure 1. Modified Health Belief Model

According to Redding et al (2000), an individual is more likely to take action to prevent cancer if she/he believes that possible negative physical, psychological, and/or social effects resulting from developing the disease pose serious consequences (e.g., altered social relationships, reduced independence, pain, suffering, disability, or even death). Furthermore, individuals who are not convinced that there is a causal relationship between smoking and cancer, are unlikely to quit smoking because they believe that quitting will not protect against the disease . In this case, if males do not see the benefits of male circumcision, then they won’t show willingness to circumcise, resulting in few targeted beneficiaries coming forth to consume the service.

On the other hand, perceived barriers to preventive action are potential individual’s perceptions detrimental to undertaking recommended healthy behavior. A study by Lukobo and Bailey ( 2007) in Zambia revealed that the biggest barriers to circumcision in study communities were identification of the procedure with certain ethnic and religious groups, pain, healing process, length of time for healing and cost. Furthermore, perceived susceptibility to disease and perceived seriousness (severity) of disease are influenced by socio-demographic variables, like level of education, religion, place of residence, age and marital status. Kenyon et.al( 2010) stated thatsex, race/ethnicity, age, education, class and sexual orientation are some of the categories which influence people’s experience and understanding of disease. For instance, educated males are more likely to possess knowledge about the benefits of circumcising and would thus probably show willingness to undergo the procedure, compared to those who are less or not educated. The possessed knowledge translates into perceived benefits such as HIV prevention, penile hygiene and optimal sex enjoyment.

Another proxy models are cues to actionwhich defines initiatives and/or strategies in place acting as stimulus to influencing health actions or decision making. According to this model, people make a rational cost-benefit analysis when trying to decide whether to adopt preventive behavior or not. Actual changes in behavior may then be stimulated by cues to action such as educational messages or learning that someone they know has AIDS ( Hingson et al., 1990). In this case HIV/AIDS information could be disseminated to the people through education (sex education in the formal school environment, campaigns), various forms of media (radio, print etc.) as well as from other individuals they interact with in their respective communities, among others.

1. It should be noted that the recent formulations of the HBM have added another key construct, namely self-efficacy, which basically states that individuals are ready to act if they are confident in their ability to successfully perform an action. Self-efficacy is influenced by mediating variables and in turn influences expectations ( Redding et al. 2000). Males who are willing to circumcise are ready to adopt any available measure in place aimed at preventing HIV transmission as they are confident that such would indeed protect them from HIV/AIDS. It should be noted that the recent formulations of the HBM have added another key construct, namely self-efficacy, which basically states that individuals are ready to act if they are confident in their ability to successfully perform an action. Self-efficacy is influenced by mediating variables and in turn influences expectations ( Redding et al. 2000). Males who are willing to circumcise are ready to adopt any available measure in place aimed at preventing HIV transmission as they are confident that such would indeed protect them from HIV/AIDS.
2. The Sampling Procedure2. The Sampling Procedure
3. Measurement of variables: Independent and Dependent Variables:3. Measurement of variables: Independent and Dependent Variables:
4. Analysis of Results:4. Analysis of Results:

Since health motivation is its central focus, the HBM is a good fit for addressing problem behaviors that evoke health concerns (e.g. high risk sexual behavior and the possibility of contracting HIV) (US Department of Health & Human Services, 2005 ).

The 2008Botswana AIDS Impact Survey (BAIS-III) was based on two stages stratified sampling design. The study covered 8275 households, systematically drawn from selected Primary Sampling Units (PSU’s), known as Enumeration Areas (EA’s). These households constituted 24 962 persons, aged between 10-64 years, with a total response rate of 82%. During the survey, a sample of 6302 males in the age group 10-64 years were asked whether or not they were circumcised. Accordingly, a total of 5821 males aged 10-49 years were targeted for the SMC program in Botswana. But, due to the non-response errors and/or missing values, only 5647 in the age group 10-49 were asked if they would be willing to undergo circumcision. Those already circumcised were about 622 (11%), while the number of those not circumcised stood at about 5025 (89%). Those willing to undergo Safe Male Circumcision were about 3046 (61%0 and unwilling were 1979 (39%).

Reference could be made for details to the conceptual frame work ( Figure 1). The basic main independent variables were operationalized to include a ge ; level of education; marital status; place of residence; religion; perceived susceptibility to disease; perceived seriousness (severity) of disease; perceived benefits of preventive action; p erceived barriers to preventive action; cues to action; .s elf-efficacy etc. Each main variable will be split into categorical variables. For example, education as main variable is categorized as: “no-education”, “primary”,

“secondary”, and “higher /teritial educational levels.

On the other hand , “willingness” to undergo SMC is considered dependent variable, coded as Yes= 1 or No=0 to the question of Circumcision.

Analytical Methods

Applying the SPSS Package Programme, the analytical techniques include univariate descriptive frequency distributions; Pearson’s chi-square statistic (x²) and binary logistic regression models

The univariate c ross-tabulation analysis is simply expressing the percentage and absolute distribution of the sample target males to be circumcised,constructed in contingency tabular form. Accordingly, we compare the share of each categorical variable out of the categories of a given main variable and observe the distributional pattern/level in the designed Table.

In the case of the bivariate analysis, the Pearson’s chi-square statistics (2) are applied to assess the association between male’s willingness to circumcise against the selected categorical variables, say, religion, place of residence, age, marital status and level of education and other HBM proxies. The Chi-Square Test is carried out to examine the association of the proportional distribution of the categorical independent variables against the dependent variables. The level of significance of associations is established at 95% and the level of significance of the association is defined to be 5 % or 0.05 .

Accordingly, the formula of the Pearson Chi-square test of association is defined as follows:

χ c 2 = ∑ i = 0 3 ( O i − E i ) 2 E i

where; 2 = computed Chi-squares;

 = sigma notation/ summation sign;

Oi = observed frequencies where i=1,2, 3, etc

Ei = expected frequencies where i= 1,2,3,etc

The decision criteria is based on the stated Null-Hypothesis. Normally, the H0 (Null-Hypothesis) is stated as: “there is no difference in the association between selected categorical variables of each main independent variable against any categorical variables of a dependent variable”. The decision criterion is that If the computed 2 is higher than the one picked from the standard Pearson’s chi-squares table, under a given degree of freedom (df) , then the Ho is rejected, implying that there are differences among the given categorical variables in the distribution of the target population ( ie., males responding to the question of willingness to circumcise)

In order to examine the differentials in the degree of impact among the categorical variables of a main variable, we select a Reference Category from among the group of the categorical variables of the same main variable and apply the Logistic Regression Model which is appropriate for our analysis (Refer to Sarkar and Midi,2010: Binary Logistic Model).

The magnitude of the influence of each independent variable “X” on the dependent variable “willingness to circumcise” is expressed as “Odds Ratio”, which signifies the importance of each categorical variable of the main variable in relation to the appropriately designated “Reference Category” in the model. The formula of Odds Ratio is expressed as follows:

Odds Ratio = exp(