Socio-demographic characteristics.
Table 1: Socio-demographic characteristics of the participants
Variable
|
Category
|
Frequency
n=378
|
Percentage
%
|
Age
|
15-16 years
17-18 years
19-20 years
21-22 years
23-24 years
|
102
148
61
33
34
|
27.0
39.2
16.1
8.7
9.0
|
Level of Education
|
Primary
Secondary
Tertiary
|
184
182
12
|
48.7
48.1
3.2
|
Years spent in this camp
|
<2 years
2-5 years
>5 years
|
44
273
61
|
11.6
72.2
16.1
|
Marital status
|
Single or never married
Married
|
349
29
|
92.3
7.7
|
Religious affiliation
|
Catholic
Pentecostal/Anglican
Moslem
|
77
280
21
|
20.4
74.1
5.6
|
In reference to Table 1, majority (39.2%) of the participants were in the age group of 17-18 years, while the least were in the age group of 21- 22. Most of the respondents (48.7%) had primary education while the least (3.2%) had attained tertiary level of education. On the duration spent in the Rhino camp Refugee Settlement, majority, 72.2% of the participants had spent 2-5 years in the camp, majority (92.3%) of the participants were single or never married. Almost 3 out of 4 (74.1%) of the participants were affiliated to Pentecostal or Anglican by religion.
Uptake of safe male circumcision
Figure 1 shows that 159/378 (42.1%) of the participants had undergone safe male circumcision while the majority 219/378 (57.9%) had not undergone safe male circumcision.
Perceived risks and uptake of safe male circumcision services
Table 2: perceived risks associated with uptake of safe male circumcision services
Variable
|
Category
|
Frequency
n=378
|
Percentage
%
|
I fear that SMC may cause my penis to be amputated accidentally.
|
Strongly disagree
Disagree
Neutral
Agree
Strongly agree
|
66
110
26
130
46
|
17.5
29.1
6.9
34.4
12.2
|
I fear excessive removal of foreskin
|
Strongly disagree
Disagree
Neutral
Agree
Strongly agree
|
56
92
22
133
75
|
14.8
24.3
5.8
35.2
19.8
|
There is a possibility that I may develop adhesions when circumcised.
|
Strongly disagree
Disagree
Neutral
Agree
Strongly agree
|
71
115
53
100
39
|
18.8
30.4
14.0
26.5
10.3
|
I worry a lot about developing cysts after SMC.
|
Strongly disagree
Disagree
Neutral
Agree
Strongly agree
|
71
108
39
117
43
|
18.8
28.6
10.3
31.0
11.4
|
Majority (34.4%) of the participants agreed that they feared that SMC might cause their penis to be amputated, (35.2%) of the participants agreed that they feared excessive removal of foreskin. Three in every ten (30.4%) of the participants disagreed that there is possibility that they may develop adhesions when circumcised and 117/378 (31.0%) agreed that they worried a lot about developing cysts after SMC as indicated in Table 2.
Table 3: Perceived risk factors associated with uptake of safe male circumcision services at bivariate analysis.
Variable
|
Category
|
SMC uptake
|
COR (95% CI)
|
p-value
|
Yes (%)
|
No (%)
|
I fear SMC that my penis will be amputated.
|
Strongly disagree
Disagree
Neutral
Agree
Strongly agree
|
18(11.3%)
55(34.6%)
6(3.8%)
58(36.5%)
22(13.8%)
|
48(21.9%)
55(25.1%)
20(9.1%)
72(32.9%)
24(11.0%)
|
1.0
.375(.194-.724)
1.250(.433-3.612)
.466(.245-.885)
.409(.185-.904)
|
.003*
.680
.020*
.027*
|
I fear excessive removal of foreskin
|
Strongly disagree
Disagree
Neutral
Agree
Strongly agree
|
18(11.3%)
41(25.8%)
4(2.5%)
58(36.5%)
38(23.9%)
|
38(17.4%)
51(23.3%)
18(8.2%)
75(34.2%)
37(16.9%)
|
1.0
.589(.294-1.181)
2.132(.629-7.220)
.613(.317-1.182)
.461(.224-.948)
|
.136
.224
.144
.035
|
There is a possibility that I may develop adhesions when circumcised.
|
Strongly disagree
Disagree
Neutral
Agree
Strongly agree
|
26(16.4%)
52(32.7%)
18(11.3%)
47(29.6%)
16(10.1%)
|
45(20.5%)
63(28.8%)
35(16.0%)
53(24.2%)
23(10.5%)
|
1.0
.700(.382-1.284)
1.123(.533-2.368)
.652(.350-1.214)
.831(.373-1.849)
|
.249
.760
.177
.649
|
I worry a lot about developing cysts after SMC.
|
Strongly disagree
Disagree
Neutral
Agree
Strongly agree
|
26(16.4%)
47(29.6%)
19(11.9%)
50(31.4%)
17(10.7%)
|
45(20.5%)
61(27.9%)
20(9.1%)
67(30.6%)
26(11.9%)
|
1.0
.750(.406-1.387)
.608(.275-1.343)
.774(.422-1.419)
.884(.405-1.926)
|
.359
.219
.408
.756
|
Participants who disagreed to the fear of SMC causing amputation of the penis were 62.5% likely to have SMC (Crude OR = 0.375, 95%, CI 0.194 - 0.724) and this was statistically significant with a p-value of 0.003. Those who strongly feared (strongly agreed) that it would result in amputation of the penis were 43.4% likely to have SMC (Crude OR = 0.566, 95% CI 0.245 - 0.885). Concerning fear of excessive removal of foreskin, those who strongly disagreed were 41.1% likely to have SMC (Crude OR = 0.589, 95% CI 0.294-1.181). However, the participants who agreed to fear of excessive removal of foreskin were 38.7% likely to have SMC (Crude OR = 0.613, 95% CI 0.317-1.182). Participants who strongly believed that there was a possibility of developing adhesions when circumcised were 16.9% likely to have SMC (Crude OR = 0.831, 95% CI 0.373-1.849). Participants who worried a lot (strongly agreed) about developing cysts after SMC were 11.6% likely to have SMC (Crude OR = 0.884, 95% CI 0.405-1.926). The rest of the variables were not statistically significant as indicated in Table 3.
Perceived severity and uptake of safe male circumcision services
Table 4: Perceived severity and its influence on the utilization of safe male circumcision services at Univariate Analysis
Variable
|
Category
|
Frequency
n=378
|
Percentage
%
|
I fear bleeding and infection after SMC.
|
Strongly disagree
Disagree
Neutral
Agree
Strongly agree
|
93
110
20
89
66
|
24.6
29.1
5.3
23.5
17.5
|
SMC may result to irritation of the glands.
|
Strongly disagree
Disagree
Neutral
Agree
Strongly agree
|
68
131
41
88
50
|
18.0
34.7
10.8
23.3
13.2
|
I fear injury to the penis during the procedure.
|
Strongly disagree
Disagree
Neutral
Agree
Strongly agree
|
76
143
32
69
58
|
20.1
37.8
8.5
18.3
15.3
|
I fear increased risk of meatitis (inflammation of the glans penis)
|
Strongly disagree
Disagree
Neutral
Agree
Strongly agree
|
90
112
33
99
44
|
23.8
29.6
8.7
26.2
11.6
|
Majority 143/378 (37.8%) disagreed that they feared injury to the penis during the procedure while 131/378 (34.7%) disagreed that SMC may result into irritation of the penis. A good number 112/378 (29.6%) disagreed that they feared the risk of meatitis while 110/378 (29.1%) disagreed that they feared bleeding and infection after SMC as indicated in Table 4.
Table 5: Perceived severity factors associated with uptake of safe male circumcision services at bivariate analysis.
Variable
|
Category
|
SMC uptake
|
COR (95% CI)
|
p-value
|
Yes (%)
|
Yes (%)
|
I fear bleeding and infection after SMC.
|
Strongly disagree
Disagree
Neutral
Agree
Strongly agree
|
33(20.8%)
52(32.7%)
4(2.5%)
44(27.7%)
26(16.4%)
|
60(27.4%)
58(26.5%)
16(7.3%)
45(20.5%)
40(18.3%)
|
1.0
.613(.348-1.081)
2.200(.679-7.125)
.563(.310-1.019)
.846(.411-1.623)
|
.091
.188
.058
.615
|
SMC may result in irritation of the glans.
|
Strongly disagree
Disagree
Neutral
Agree
Strongly agree
|
30(18.9%)
58(36.5%)
14(8.8%)
35(22.0%)
22(13.8%)
|
38(17.4%)
73(33.3%)
27(12.3%)
53(24.2%)
28(12.8%)
|
1.0
.9940(.551-1.792)
1.523(.681-3.401)
1.195(.629-2.270)
1.005(.482-2.096)
|
.983
.305
.585
.990
|
I fear injury to the penis during the procedure.
|
Strongly disagree
Disagree
Neutral
Agree
Strongly agree
|
30(18.9%)
59(37.1%)
13(8.2%)
25(15.7%)
32(20.1%)
|
46(21.0%)
84(38.4%)
19(8.7%)
44(20.1%)
26(11.9%)
|
1.0
.929(.526-1.638)
.953(.411-2.213)
1.148.586-2.249
.530(.265-1.059)
|
.798
.911
.688
.072
|
I fear increased risk of meatitis (inflammation of the glans penis)
|
Strongly disagree
Disagree
Neutral
Agree
Strongly agree
|
28(17.6%)
53(33.3%)
15(9.4%)
43(27.0%)
20(12.6%)
|
62(28.3%)
59(26.9%)
189(8.2%)
56(25.6%)
24(11.0%)
|
1.0
.503(.281-.898)
.542(.239-1.228)
.588(.324-1.069)
.542(.258-1.139)
|
.020*
.142
.082
.106
|
As far as perception of fear of bleeding and infection after SMC was concerned, 38.7% of the participants were likely to have SMC (Crude OR = 0.613, 95% CI 0.348-1.081). Participants who strongly perceived that SMC would result in irritation of the glans were 0.6% likely to have SMC (Crude OR =0 .9940, 95% CI 0.551-1.792). Increased fear of Meatitis (Crude OR = 0.503, 95% CI .281-.898) was significantly associated with uptake of safe male circumcision at bivariate analysis as indicated in Table 5.
Table 6: Perceived risk, severity, and uptake of safe male circumcision services among young men aged 15-24 years at multivariate analysis
Variable
|
Category
|
Crude PR (95% CI)
|
p-value
|
Adjusted 0R (95% CI)
|
p-value
|
I fear increased risk of meatitis (inflammation of the glans penis)
|
Strongly disagree
Disagree
Neutral
Agree
Strongly agree
|
1.0
.503(.281-.898)
.542(.239-1.228)
.588(.324-1.069)
.542(.258-1.139)
|
.020*
.142
.082
.106
|
1.0
.726(.338- .959)
.636(.216- 1.872)
.741(.340- 1.615)
.932(.364- 2.388)
|
.012*
.412
.450
.883
|
SMC can prevent cervical cancer in my partner
|
Strongly disagree
Disagree
Neutral
Agree
Strongly agree
|
1.0
.815(.486-1.366)
.782(.409-1.497)
.559(.271-1.152)
.314(.127-.779)
|
.437
.458
.115
.012*
|
1.0
1.547(.779- 3.073)
1.729(.742- 4.028)
1.346(.524- 3.458)
2.455(1.278- 3.627)
|
.213
.204
.537
.004*
|
To me undergoing SMC is very painful and uncomfortable
|
Strongly disagree
Disagree
Neutral
Agree
Strongly agree
|
1.0
.458(.261-.802)
.686(.222-2.123)
.839(.444-1.586)
.458(.221-.946)
|
.006*
.514
.589
.035*
|
1.0
.976(.431- 2.213)
1.169(.289- 4.721)
2.649(1.100- 6.379)
.742(.279- 1.973)
|
.954
.827
.550
.030*
|
I cannot afford cost of doing SMC at most private health facilities
|
Strongly disagree
Disagree
Neutral
Agree
Strongly agree
|
1.0
.394(.216-.722)
.292(.120-.706)
.393(.201-.768)
.223(.104-.478)
|
.003*
.006*
.006*
.000*
|
1.0
.538(.240- 1.203)
.248(.080- .765)
.385(.156- .948)
.167(.058- .478)
|
.131
.015*
.038*
.001*
|
Fear of risk of meatitis, SMC preventing cervical cancer in partners, undergoing SMC being painful and uncomfortable, being unable to afford the cost of doing SMC at most private health facilities were found to be significantly associated with uptake of SMC services at multivariate analysis as indicated in Table 6.
Presentation of the qualitative data from the FGDs
Facilitating factors for SMC uptake: Participants in all FGDs cited increased protection from HIV and other STIs as an advantage of SMC. Similarly, it was consistently reported that circumcised men are cleaner and more hygienic than those who are uncircumcised. The concept of cleanliness manifests itself in the FGDs in two disparate ways:
SMC improves general hygiene of the penis, including the reduction of foul odors. FDG 1
SMC reduces the transmission of STIs via improved cleanliness due to the removal of the foreskin. Most men can spend the entire day without showering. Such a man harbors a lot of dirt under the prepuce, unlike a circumcised man. Therefore, that is the source of syphilis, HIV and other STIs . . . it is easy to contract them, especially if the woman is not ready for sex. FDG 2
In FGDs, circumcision was described as protective against HIV acquisition because it reduced “bruising.” However, there were inconsistencies with the description of how bruising affected HIV transmission. When bruising was mentioned in the FGDs, participants reported that circumcision reduced bruising of the penis and subsequently, risk of HIV transmission.
“A circumcised person cannot easily get HIV. He penetrates into the vagina smoothly, but a person who is not circumcised can easily get infected. Since the foreskin keeps on moving up and down, he gets bruises and the blood mixes up, thus being infected with HIV if the woman is infected”. A participant in FDG 3.
However, when discussed in the FGDs, SMC was described as protective against HIV transmission through reduced bruising of the vagina:
The foreskin keeps a lot of dirt. After removing the foreskin, the woman does not get bruises so much. The bruises are caused by the small size of the woman’s entry point because the skin rubs so much on it if one is not circumcised. FDG 1
In several of the FGDs, participants connected SMC with cancer prevention. The mechanisms through which circumcision reduces the risk of cancer were described in varying manners.
A male participant explained the relationship between circumcision, pregnancy, and cancer:
“We were taught that the foreskin keeps germs, so if you have sex with a pregnant woman before circumcision, it may cause cancer. One is clean after circumcision to the partner, which helps her deliver with no problem”. Participant in FDG 2
The perceived advantages and disadvantages of Safe Male Circumcision
General fear of pain regarding circumcision was the concern mentioned most often. Young men expressed concern over pain specifically during the SMC procedure but they also feared pain during recovery due to potentially poor suturing or a surgical mishap resulting in a deformity. A few teenagers thought that pain could result from a lack of follow-up wound assessment by SMC health providers. Concern over pain during morning erections was another common concern. Some men and women feared that pain during recovery would cause a man to miss work and lose income.
“We are afraid because those who had gone for the circumcision were saying that it was very painful when the foreskin is cut, during suturing, and then after that you were unable to perform your normal duties as usual. Being a person with dependents, it was not appealing to me.” Said one of the male respondents. FDG 1
However, concern about pain was not universal; those who were not circumcised at the time of their interviews said that they were not concerned about pain.
“No, no, right now I am 23, and there is no pain I will feel when I become circumcised because I have endured painful things so there is none I will feel when I become circumcised”. A participant in FDG 3
Circumcised participants were asked about pain during the post-circumcision recovery period. All of the circumcised men reported that they managed their pain well during recovery by following the post-circumcision instructions given to them by their SMC providers primarily, taking prescribed painkillers and urinating when waking with a morning erection. They said their circumcision experiences were not as painful as they feared prior to the procedure.
“The provider who performed the circumcision gave me some pain killers, and I used them as prescribed to me. The drugs really helped me such that the pain was bearable…I did not have too much pain.” One of the respondents in FDG 1 aged 18 years.