| dc.description.abstract | Introduction and significance: Safe male circumcision (SMC) is a biomedical HIV prevention intervention recommended especially for countries with high HIV prevalence and low SMC coverage. In order for a country to achieve public health benefit from SMC, it is estimated that 80% of its eligible males must be circumcised. Despite many innovations to scale-up SMC coverage in Uganda, the national SMC coverage is still low (42.2%) and exceptionally low (13.1%) in the traditionally non-circumcising district of Gulu, Acholi sub-region mid northern Uganda.
Objectives: To assess comprehensive knowledge of MoH approved SMC messages among SMC service providers, males and married women; to determine the relationship between men’s knowledge about SMC and their circumcision status, and married women’s knowledge about SMC in relation to their sexual partner’s circumcision status; to explore sociocultural and contextual factors that may enhance or hinder uptake of SMC services; and determine SMC clients’ perception of increased risk of HIV infection, explore preferred choice of circumcision method, providers’ demographics and mode of SMC service delivery.
Methodology: A mixed methods cross sectional study assessing the comprehensive knowledge of approved MoH SMC messages among 32 service providers and548 men and married women. The respondents were sampled from three communities (clusters), within 5 km of four SMC static sites that were providing SMC services. These sites included Awach HCIV in Achwa county, Lalogi HCIV in Omoro county, Gulu regional referral Hospital and Lacor Hospital in Gulu municipality. A sampling frame of households was obtained from the VHTs who had just finished distributing bed nets. Sample of households were proportionately distributed in the 3 communities. Within each community, systematic sampling was applied to obtain the required number of households. In all sampled households, members were listed, and randomly selected one eligible participant using the KISH grid. A quantitative tool was administered and data collected on social demographics, health indicators including circumcision status (for male), and knowledge of the approved MOH SMC messages. Qualitative data were collected from nineteen focus group discussions, 9 in-depth interviews and 11 key informant interviews among men, women, cultural and religious leaders in the selected cluster to explore sociocultural and contextual factors that may enhance or hinder uptake of SMC services, as well as client’s preferred choice of circumcision method, providers’ demographics and mode of service delivery.
For the analysis, adequate comprehensive knowledge (CK) was defined as “1=yes” if the participants scored at least 80% of the items in the 5 domains of the approved MOH messages, else “0=no”. Adequate CK was ascertained as proportion of all participants with a cut-off of 80%. The associations of adequate CK and participants’ characteristics were determined using prevalence ratios (PR) as a measure of association with corresponding 95% confidence interval obtained via the modified Poisson model. Statistical significant was attained at p<5%. Qualitative interviews were analyzed thematically using both inductive and deductive approaches based on the socio- ecological model that provides for individual, household, community and district levels. Qualitative methods were used to explore sociocultural and contextual factors that may enhance or hinder uptake of SMC services, preferred choice of circumcision method, providers’ demographics and mode of service delivery.
Results: A total 488/548 (94.1%) participants responded to the study. Overall, CK was 85%(75-90); higher in male, 85% (75-93), compared to married women 80% (65-88) and was universal among SMC service providers. After dichotomizing CK into adequate and inadequate, 76.1% of males adequate CK while 64.4% of married women. Factors associated with adequate CK among males were tribe, location and level of education. In the adjusted analysis, the adequate CK of males who belonged to other tribes was 17% (adj. PR=1.17, 95% CI: 1.00,1.36, p=0.038) higher as than the Acholi while the adequate CK of the Langi was 1% (adj PR=0.99, 95%CI: 0.82,1.19, p=0.925) lower than the males belonging to Acholi tribe. Adequate CK of Males in the urban municipality was 26% (adj PR= 1.27, 95% CI: 1.06, 1.49, p=0.008) higher than the males in rural Awach and the difference was statistically significant. Also adequate CK of males in Lalogi (peri-urban) was 27% (adj PR=1.27, 95%CI: 1.06,1.54, p=0.12) higher than the males in Awach but this difference was not statistically different. Adequate CK of males with tertiary/ university education was 45% (adj PR= 1.45, 95%CI: 0.95 2.25, p=0.086) higher than that of males with no education. Males with primary education had adequate knowledge that was 25% (adj PR=1.25, 95% CI: 0.81,1.93, p=0.317) higher than those with none and males with secondary education had adequate CK that was 23% (adj PR=1.23, 95%CI: 0.80,1.90, p=0.334) higher than those with none.
The prevalence of circumcision among males was only 27.1%, and was 30.2% among the sexual partners of the married women. Male circumcision was significantly lower in males who rejected the misconception that SMC reduces sexual performance (PR = 0.58, 95% CI 0.38–0.89, p = 0.012), among male sexual partners of females who failed to reject the same misconception (PR = 0.22, 95% CI = 0.07–0.76, p = 0.016), and in males who failed to reject the misconception that SMC increases a man’s desire for more sexual partners i.e. promiscuity (PR = 0.65, 95% CI = 0.46–0.92, p = 0.014).
Enhancers for SMC included adequate knowledge about MC services, being young and never-married, partner involvement, peer influence, perceived increased libido after MC, and availability of free and high quality of MC services. Barriers included sexual abstinence during wound healing, penile appearance after MC, Christian religion, culture, myths and beliefs. The participants in Gulu perceived themselves to be at increased risk for HIV infection and they preferred device to conventional surgery while mobile services were preferred to static services. However, there were divergent views regarding circumcision service providers’ socio-demographics and these were influenced mainly by age, level of education and location in the community.
Conclusion: Adequate comprehensive knowledge of the approved MoH SMC messages was universal in service providers, but less than three quarters in males and married women. Misconceptions about poor sexual performance or low sexual drive were associated with lower circumcision uptake in this population, while knowledge of SMC benefits, risks and procedure were enhancers of male circumcision. Participants in Gulu perceived themselves to be at increased risk of HIV infection but uptake of male circumcision was low. Use of devices compared to conventional surgery was more preferred, so was use of mobile compared to static services. Optimizing Enhancers, addressing the barrier, and improving comprehensive knowledge of circumcision may increase uptake of MC services in these settings. | en_US |
