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.

…………………………… Date……………………………
LWASAMPIJJA BAKER
AUTHOR

……………………………… Date …… …………………

Mr. OJAKI MIKLOTH
SUPERVISOR

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

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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.

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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).

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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.

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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. To determine the reasons for carrying out male circumcision.
iii. To find out the age preferred for caring out circumcision.
iv. 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. Why do people carry out male circumcision?

iii. At what age would people prefer to carry out male circumcision?

iv. 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.

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 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.

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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.

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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 non-
circumcising 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.

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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.

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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.

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 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).
To find out the level of -Level of knowledge. -Primary.
knowledge of adults on M C -Secondary.
-Tertiary
To determine the reasons for -Reasons. -Religion.
carrying out M C. -Medical.
-Traditional.
To determine the preferred -Preferred age. -Infant.
age for carrying out M C. -Middle age.
-Adult.
To assess people’ response -People’s response. -Low turn-up
towards M C. -.High turn-up

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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.

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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.

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 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.

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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.

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4.2.1 Religion
Figure 1: The distribution of patients by religion

45

40

35
40
30
Percentage (%)

25 7
13
20

15 17 20

10

5
3
0
Cat Mos Prot SDA T.A Pent
Religion

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.

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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.

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

Source Frequency Percentage (%)

News papers 11 23

Radio 11 23

Television 9 18

Friend 6 13

Internet 1 2

Sex education 2 4

Personal experience 2 4

None 2 13

Total 48 100

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

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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.

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Table 5: Reasons for carrying out male circumcision

Reason Cumulative frequency Percentage (%)

Religion 13 25

Good hygiene 10 18

Cultural roles 14 26

Prevent STDs/HIV 13 25

To look smart 1 2
Enhance Sexual pleasure 2 4
Total 53 100

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%).

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

Table 6: Females’ preference for having a circumcised partner

Response Frequency Percentage (%)

Yes 11 79

No 3 21

Total 14 100

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.

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

Number Frequency Percentage (%)

1-5 8 27

6-10 3 10

11-20 7 23

None 12 40

Total 30 100

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,93.00%
Yes 93%

No
No,7.00%
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; socio-
demographic 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%

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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-Ancient-
world.

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

Kaiser Daily HIV/AIDS report, 2006

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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 International Conference
on AIDS: Durban, South Africa; August, 2000; 195

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.

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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

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 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 ii) 21-25
iii) 26-35 iv) 36-45

3. Religion
i) Catholic ii) Moslem
iii) Protestant iv) SDA
V) Traditional African vi) Other (specify) ………………….

4. Marital status.
i) Single ii) Married
iii) Widow(er) iv) Other (specify) ………………….

5. Level of education.
i) Primary ii) Secondary
iii) Tertiary 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.

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- 36 -
WAKISO

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