Factors associated with uptake of voluntary medical male circumcision among University of Botswana undergraduate male students

Abstract

Background: The human immunodeficiency virus (HIV)/AIDS prevalence in Botswana of 18.4% is the third highest in the world. Thus, the Voluntary Medical Male Circumcision strategy was rolled out with a target of 80% uptake by year 2016. The programme targets mainly young people (15–24 years) as they account for 40% of all new adult infections. We, therefore, aimed at identifying the factors associated with uptake of voluntary medical male circumcision among University of Botswana undergraduate male students as well as to establish the male circumcision prevalence among the same group so as measure the success of the male circumcision (MC) strategy. Methods: A cross-sectional study was conducted amongst 303 undergraduate male students. Data were collected through self-administered questionnaires using stratified sampling. Data were captured and analysed using Statistical Package for the Social Sciences version 23, where adjusted odds ratios and p-values were calculated. Results: Uptake of male circumcision was 47.9%. Respondents’ knowledge on male circumcision was high (88%). However, a large majority of those uncircumcised (52.1%) indicated unwillingness to get circumcised although they were knowledgeable about the benefits MC. Believing that there are no risks in MC surgery [AOR:1.02; 95% CI: 1.004–1.037] and knowing that an injection is given before undergoing surgery (AOR: 1.072; 95% CI: 1.057–1.087) were positively associated with circumcision status. The main reasons stated for being circumcised were hygiene (49.7%) and protection from HIV (22.1%). Conclusions: There is need for a combination of factors to induce motivation for students to be circumcised. Referent others need to be targeted as well as they are role models and able to positively influence their peers and children.

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Factors associated with uptake of voluntary
medical male circumcision among University of
Botswana undergraduate male students
Roy Tapera, Tlhongbotho Kebofe, Tshephang Tumoyagae & James January
To cite this article: Roy Tapera, Tlhongbotho Kebofe, Tshephang Tumoyagae & James January
(2017): Factors associated with uptake of voluntary medical male circumcision among University of
Botswana undergraduate male students, International Journal of Health Promotion and Education,
DOI: 10.1080/14635240.2017.1394796
To link to this article: http://dx.doi.org/10.1080/14635240.2017.1394796
Published online: 28 Oct 2017.
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INTERNATIONAL JOURNAL OF HEALTH PROMOTION AND EDUCATION, 2017
https://doi.org/10.1080/14635240.2017.1394796
Factors associated with uptake of voluntary medical male
circumcision among University of Botswana undergraduate
male students
RoyTaperaa, TlhongbothoKebofea, TshephangTumoyagaea and JamesJanuaryb
aDepartment of Environmental Health, School of Public Health, Faculty of Health Sciences, University of
Botswana, Gaborone, Botswana; bDepartment of Community Medicine, College of Health Sciences, University
of Zimbabwe, Harare, Zimbabwe
ABSTRACT
Background: The human immunodeciency virus (HIV)/AIDS
prevalence in Botswana of 18.4% is the third highest in the world. Thus,
the Voluntary Medical Male Circumcision strategy was rolled out with
a target of 80% uptake by year 2016. The programme targets mainly
young people (15–24years) as they account for 40% of all new adult
infections. We, therefore, aimed at identifying the factors associated
with uptake of voluntary medical male circumcision among University
of Botswana undergraduate male students as well as to establish the
male circumcision prevalence among the same group so as measure
the success of the male circumcision (MC) strategy. Methods: A
cross-sectional study was conducted amongst 303 undergraduate
male students. Data were collected through self-administered
questionnaires using stratied sampling. Data were captured and
analysed using Statistical Package for the Social Sciences version 23,
where adjustedodds ratios and p-values were calculated. Results:
Uptake of male circumcision was 47.9%. Respondents’ knowledge on
male circumcision was high (88%). However, a large majority of those
uncircumcised (52.1%) indicated unwillingness to get circumcised
although they were knowledgeable about the benets MC. Believing
that there are no risks in MC surgery [AOR:1.02; 95% CI: 1.004–1.037]
and knowing that an injection is given before undergoing surgery
(AOR: 1.072; 95% CI: 1.057–1.087) were positively associated with
circumcision status. The main reasons stated for being circumcised
were hygiene (49.7%) and protection from HIV (22.1%). Conclusions:
There is need for a combination of factors to induce motivation for
students to be circumcised. Referent others need to be targeted as
well as they are role models and able to positively inuence their
peers and children.
Introduction
Male circumcision (MC) is one of the oldest and most common surgical procedures world-
wide, and is undertaken for many reasons: religious, cultural, social and medical (Rennie et al.
KEYWORDS
VMMC; undergraduate
students; Botswana
ARTICLE HISTORY
Received 28 May 2017
Accepted17 October 2017
© 2017 Institute of Health Promotion and Education
CONTACT Roy Tapera ztapera@gmail.com, taperar@ub.ac.bw
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2 R. TAPERA ET AL.
2015). According to World Health Organisation (WHO 2017a), studies show that circum-
cised men have a signicantly lower risk of becoming infected with the human immunode-
ciency virus (HIV). Apart from lowering the risks of HIV infection, male circumcision also
protects against several diseases, including urinary tract infections, syphilis, chancroid and
invasive penile cancer (Dévieux et al. 2015; Ministry of Health and Child Care, Zimbabwe
(2013) cited in Rupfutse et al. 2014). Studies done in the Dominican Republic revealed
that post circumcision, men felt more masculine, had more potent erections and reported
increased ability to satisfy their partners (Fleming et al. 2017). However, this procedure
may cause adverse health eects such as bleeding, haematoma or sepsis, especially among
adolescents, but these can be treated when undertaken in a clinical setting with experienced
providers. In contrast, circumcision undertaken by inexperienced providers with inadequate
instruments, or with poor aer-care, can result in serious complications.
World Health Organization and Joint United Nations Programme on HIV/AIDS (2007)
showed that approximately 30% of males are estimated to be circumcised globally, of whom
an estimated two-thirds are Muslim. Recently, there has been increasing demand for male
circumcision in southern Africa. is calls for a need to integrate circumcision services
within comprehensive HIV prevention programming, including informed consent and
risk-reduction counselling for those willing to undertake the procedure, as well as their
partners, if any. According to Gray et al. (2007), during three randomised clinical trials
carried in Africa, in particular, Kisumu, Kenya; Rakai District, Uganda; and Orange Farm,
South Africa, a 50–60% reduction in risk of female-to-male HIV transmission among men
randomized to receive circumcision compared to uncircumcised controls was achieved. is
evidence is supported by long-standing ecologic and observational data (Padian et al. 2011).
In Botswana, the former President Festus Mogae lobbied for the addition of male cir-
cumcision to Botswana’s HIV/AIDS prevention approach in November 2007. is led to the
development of a ve-year strategy by the Ministry of Health which aimed at reaching 80%
circumcision coverage. e 80% was based on a mathematical model used to calculate the
public health impact of large-scale male circumcision for HIV prevention (Nagelkerke et
al. 2007). Aer calculating the results showed that a programme with MC uptake of (80%)
of at risk of HIV males over a 10year period would reduce male HIV prevalence from 30%
to around 10% and for females from 40% to about 20%, respectively.
WHO and UNAIDS recommend that VMMC for HIV prevention is cost eective. Recent
modelling studies found that reaching 80% coverage among men 15 - 49years old in 14
priority countries in Southern and Eastern Africa by performing approximately 20 million
circumcisions, would cost US$1.5 billion and would result in net savings of US$16.5 billion
by 2025 due to averted treatment and care costs. Achieving and maintaining 80% coverage
through 2025 would avert 3.4 million new HIV infections (WHO 2012).
According to Dickson et al. (2011), less than 20% of males in Botswana had access to
male circumcision services in 2010. Despite this, there is paucity of research on knowledge,
attitudes and male circumcision prevalence among young men in the country. Undeniably,
some attempts have been made to investigate a number of issues pertaining to male cir-
cumcision in Botswana.
For instance, Kebaabetswe et al.(2003) assessed the acceptability of male circumcision
in Botswana as well as the preferred age and setting for male circumcision. Sabone et al.
(2013, 2015), evaluated the male circumcision communication strategy for HIV prevention
in Botswana and impediments for the uptake of Botswana Government’s male circumcision
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INTERNATIONAL JOURNAL OF HEALTH PROMOTION AND EDUCATION 3
initiative for HIV prevention. Furthermore, Katisi and Daniel (2015) explored responses to
safe male circumcision in relation to circumcision as part of traditional initiation practices.
Keetile and Rakgoasi (2014), Keetile and Bowelo (2016) and Jayeoba et al. (2012) investi-
gated on willingness to undergo safe circumcision and HIV risk behaviours among men in
Botswana, the factors associated with acceptability of child circumcision in Botswana and
acceptability of male circumcision among adolescent boys and their parents, respectively.
While all these studies were notable and provided crucial information on MC in the coun-
try, they excluded young males especially those in tertiary institutions who are the most
aected by HIV pandemic. In addition, earlier studies tended to focus on mining commu-
nities. It is thus critical to focus on younger age groups as young men (15–24years) account
for 40% of all new adult infections globally (WHO 2010). ey also constitute the largest
demographic group in the priority countries (Botswana, Ethiopia, Kenya, Lesotho, Malawi,
Mozambique, Namibia, Rwanda, South Africa, Swaziland, Uganda, Tanzania, Zambia and
Zimbabwe) (WHO 2014). erefore, this gap needs to be urgently addressed in order to
come up with evidence to inform policy and interventions aimed at increasing MC uptake
among University of Botswana (UB) male students. is study, therefore, is designed to
investigate knowledge and attitudes of circumcision among UB undergraduate male stu-
dents. UB undergraduate male students were chosen because the majority of them (90%) are
in the (15–24years) age group which has the highest HIV new infections. UB is a tertiary
institution which makes the target group well informed and more educated on health issues
compared to the rest of the population. e group may be considered as future role models
for the entire country. Establishing factors associated with VMMC from this group will be
instrumental in designing interventions to encourage VMMC.
Methods
A cross-sectional study was conducted among University of Botswana male students who
were aged between 18 and 32years. At the time of the study in 2016, there were 7376 UB
male students registered in six faculties in the university. Using the population size of
n=7376 and a 95% condence level, the required sample size for the study was 381. e
students were selected using multi-stage sampling technique. Firstly, degree programmes
from each faculty of the University were considered as strata. en, from each programme,
a number of students were selected based on the proportion of students who were studying
for dierent degree programmes in the faculties according to the year of study. Research
assistants went into dierent classrooms aer lectures were completed and collected data
aer prior consultation with the respective lecturers. ose who were present in the class-
room were asked to complete the questionnaire. Written informed consent was obtained
from participants at the time of completing the questionnaire. e survey was self-admin-
istered and anonymous and completed surveys were returned to research assistants. e
dependant variable was being circumcised or not while the independent variables were
categorised into demographic variables, knowledge levels on male circumcision, attitudes
and practices about male circumcision. e study was approved by the ethical review board
of the University of Botswana Oce of Research and Development (ORD), (permit number
Ref: X-REF: UB/RES/ETHI/07).
Data were analysed using Statistical Package for the Social Sciences Version 24.
Associations of MC and willingness to circumcise were identied using binary logistic
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4 R. TAPERA ET AL.
regression analysis. Adjusted odds ratios and their condence intervals were calculated.
All analyses were done at the 5% level of signicance.
Results
Of the 381 questionnaires distributed, only 303 were returned, amounting to a 79.5%
response rate. From the data obtained, it was found that 88% students were Christian, 97%
were single and 30% were in rst year. Furthermore, the mean age of the respondents was
21years (SD2.4). Demographic details of participants are summarised in Table 1.
e mean age at which respondents were circumcised was 16years (SD 3.2). Furthermore,
the median age was 17, the minimum age at which a male was circumcised was 9years
whereas the maximum age was 25years.
Prevalence of male circumcision among UB undergraduate male students
A total of 145 (47.9%) were circumcised (126 Christians, 5 Muslims, 10 African Traditional
Religion, and 4 no religion). Among these, all the Muslims were circumcised, 47.2% of
Christians and 55.6% of African traditional Religion(ATR). On the other hand, of the 158
males who reported that they are uncircumcised, most (89.2%) were Christians.
Table 1.Demographic characteristics of respondents.
Characteristics 
Mean age 21
Standard deviation 2.4
 NO. (%)
Marital status 
Married 8(2.6)
Single 294(97)
Divorced 1(0.3)
Total 303(100)
Year of study 
1 91(30)
2 54(17.8)
3 64(21.1)
4 64(21.1)
5 29(9.6)
Total 303(100)
Religious denomination 
Christianity 267(88.1)
Islam 5(1.7)
ATR 18(5.9)
None 13(4.3)
Total 303(100)
Faculty 
Business 51(16.8)
Humanity 49(16.2)
Education 50(16.5)
Science 52(17.2)
Engineering & technology 52(17.2)
Social science 49(16.2)
Total 303(100)
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INTERNATIONAL JOURNAL OF HEALTH PROMOTION AND EDUCATION 5
Prediction of male circumcision
According to Table 2, the odds of being circumcised were 1.072; 95% CI: 1.057–1.087), when
one knew that injections are given before undergoing MC surgery. Additionally, Table 2
shows that there is a signicant relationship between being circumcised and believing that
there are no risks in MC surgery (p<0.05). However, the ndings indicated that there was
no signicant relationship between believing that when you are circumcised there is no
need to use condom and being circumcised. ere was no statistical association between
knowing whether MC reduces chances of getting penile cancer and being circumcised.
Among those who were circumcised, the decision to undergo circumcision was mainly
made by self, 82 (56.9%) and parents 42 (29.2%).
Sources of information
Amongst those who were circumcised, the main information source on male circumcision
was the media (51.8%) which comprised of radio, television and billboards followed by
friends (26.6%)see Table 3.
Attitudes and practices of male circumcision
Table 4 shows that the odds of willing to circumcise in the next 6months wasmainly inu-
enced by how one had received information about MC(AOR:1.43;95 CI: 1.15 - 1.79), (p
value < 0.05).In this study most people received information through the media and friends.
Benets of male circumcision
Of the 158 uncircumcised males, 101 (33.3%) reported being aware that male circumcision
brings about health/ hygienic benets. A total of 13 (4.3%) of those who were uncircum-
cised mentioned sexual satisfaction as one of the benets of MC. When compared to the
protection of HIV, 4.6% of the respondents mentioned traditional/ cultural values as the
benet they are aware of.
Table 2.Knowledge levels about MC and association with MC prevalence.
Variables
Are you circumcised?
  95% CI
P-values Adjusted Odds Ratio Lower Upper
Injection given before MC surgery 0.001   
Yes 1.072 1.057 1.087
No 1.00 reference  
There is no risk in MC surgery 0.017   
Yes 1.02 1.004 1.037
No 1.00 reference  
There is no need to use condom when circumcised 0.999   
1.23 0.01 5.043
Yes 1.00 reference  
No
MC reduce chances of getting penile cancer 0.787   
Yes 1.004 0.976 1.033
No 1.00 reference  
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6 R. TAPERA ET AL.
Discussion
is study shows that circumcision prevalence is below the projected target of 80% by 2016
stated in the safe male circumcision programme introduced in Botswana in 2009. is is in
contrast to the ndings in Kenya and the Gambella region in Ethiopia that have achieved
over 85% of their targets e study shows that more still needs to be done to reach the
projected goal of 80%. Although male circumcision has been known to be practiced in
Botswana in the past by many tribes (Willoughby 1909), few males who reported to believe
in African Traditional Religion have reported to have been circumcised. Christianity, being
the dominant religion in this study, registered more circumcisions.
Attitudes and practices of male circumcision
One of the main obstacles to circumcision uptake highlighted in this study centres around
lack of knowledge on how male circumcision reduces HIV infection. Surprisingly, while
there have been eorts to ght the burden of HIV in the country, some University students
who are supposed to be enlightened still believe that there is no need to use condoms while
having sex if you are circumcised. is shows that health education needs to be intensied
at the University to dispel misconceptions associated with circumcision. All the time when
males are circumcised it must be emphasised that circumcision provides men life- long par-
tial protection against HIV as well as other sexually transmitted infections. It should always
be considered as part of a comprehensive HIV prevention package of services and used in
conjunction with other methods of prevention, such as females and male condoms (WHO
2012). However, this is insignicant in our study, given the probability value of greater than
0.05 for males with this belief. is practice is worrisome as this initiative of circumcision
was developed to curb the HIV prevalence across the world. It is disappointing to have found
that only about 13.7%of males in our study reported being aware of circumcision as another
HIV preventive method, given the abundant scientic evidence from both randomized
controlled clinical trials and case control studies demonstrating that male circumcision
Table 3.Sources of information.
Source of information Frequency Per cent
Friends 37 26.6
Community discussion forum 12 8.6
Relatives 6 4.3
Community leaders 12 8.6
Media (radio, TV, billboards) 72 51.8
Total 139 100
Table 4.Association of Male’s willingness to circumcise and their attitudes and practices towards MC.
Variables
Willingness to circumcise in next 6months
P-values Odds Ratio
95% CI
Lower Upper
Have you received information about MC? 0.605 1.36 0.424 4.362
How did you receive information about MC? 0.002 1.432 1.147 1.788
Is MC practised in you tribe? 0.369 0.996 0.976 1.009
MC benefits one is aware of 0.198 0.835 0.635 1.099
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INTERNATIONAL JOURNAL OF HEALTH PROMOTION AND EDUCATION 7
signicantly reduces men’s risk of becoming infected with HIV through heterosexual sex.
is gap in knowledge was coupled by the fact that participants feared that there are risks
associated with MC. Such fears have been reported in other studies. For example, a study
on awareness, knowledge, attitudes and up-take of male circumcision as an HIV preven-
tion strategy among youth in Zambia done by Phiri (2012), the youths believed not only
that circumcision is painful but also that the operation can lead to negative reproductive
health consequences such as reduction in sexual pleasure during intercourse, impotence as
well as severe bleeding. Fear of pain and fear of wound healing were associated with being
uncircumcised in a study done in Mazowe, Zimbabwe and Mhondoro Ngezi, respectively
(Rupfutse et al. 2014 and Moyo et al. 2015). However, in a study carried out by Mshana et
al. (2011) among the Kurya of North-eastern Tanzania, initiates are expected to demon-
strate ability to withstand pain that is framed as a demonstration of bravery and courage,
an important attribute of male adulthood among the Kurya. Moreover, females in the same
study reported sexual satisfaction with circumcised males rather than with uncircumcised.
is demonstrates that MC does not negatively aect sexual satisfaction of males compared
to sexual pleasures before and aer circumcision. Given the high numbers of respondents
who had heard about male circumcision both as HIV prevention method and a way to
improve health and hygienic status as well as those who had been exposed to or received
information about MC, it was expected that equally high numbers were going to report
willingness to get circumcised. However, this was not the case in our study.
Benets of male circumcision
When asked about the benets of MC males are aware of, most of males indicated the health
and/or hygienic benets as one of the benets they are aware of. is is seconded by MC’s
ability to reduce chances to improve sexual satisfaction.
In this study, it was also observed that the information about male circumcision was
mainly obtained from the media (radio and television) as well as through friends. e media
must be complimented for reinforcing and enabling messages that have seen some students
practising wellness behaviours. It must also be a social marketing tool to dispel misconcep-
tions. On the other hand, others, especially those from ATR reported to have received this
information from community discussion forums as well as from the community leaders.
is trend was also observed in a study carried out by Phiri (2012), who reported that the
main source of information about MC was from friends of the respondents. From these
results therefore, it is not easy to relate the source of information to male circumcision prev-
alence, as they are not signicantly associated with each other. is is because the question
of whether to circumcise or not is mainly dependent on the person or male in question.
However, since the study showed that the way the males receive information serves as a
determinant on the willingness to circumcise, it is vital that the information given to males
regarding MC should be well tailored by health promotion and education practitioners.
Henceforth, disseminating information about this issue will serve as a basis for males who
are willing to circumcise and most importantly to their parents and/or partners, which in
some other cases are the ones who usually urge and inuence their male counterparts to
get circumcised based on the merits and demerits of the procedure.
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8 R. TAPERA ET AL.
Limitations
ere was risk of measurement bias for self-reported questions regarding circumcision
as it was not conrmed by physical examination. Self-report of circumcision status might
not result in accurate information, mainly because some students might be unsure of their
status and some might not recall because they might have been circumcised whilst they
were very young and they might have forgotten. is study is a cross-sectional snapshot
and the location from where the students were recruited may not be wholly representative
of the nation.
Conclusion
Although most of the uncircumcised students knew the benets of circumcision, it shows
that being knowledgeable alone does not always cause behavioural change. Knowledge
is a necessary but usually not a sucient factor in changing individual behaviour (Ajzen
and Fishbein 1980). Behaviour may not change immediately in response to knowledge or
awareness, but the cumulative eects of heightened awareness, increased understanding and
greater command of facts that seep into the system of beliefs, values, attitudes, intentions and
self-ecacy and eventually into behaviour (Green and Kreuter 2005). To those educating
and promoting circumcision, there is need of a combination of factors to motivate people
so that they circumcise. Circumcision programmes need to incorporate considerations of
masculine norms and male sexuality into their programming, as this has been found to
motivate males to be circumcised (Fleming et al. 2017). Social mobilisation and evaluation
is critical to successful MC campaign as well as continual assessment of local knowledge,
practices and attitudes towards circumcision. Advertisements by the media stating the
benets of circumcision must intensify. ere must also be programmes targeting peers
and parents as they are important referent others who have the ability to inuence their
peers and children.
Acknowledgements
We would like to thank all University of Botswana students who participated in the study.
Disclosure statement
No potential conict of interest was reported by the authors.
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