Conceived and designed the experiments: WM KH SML JS BRT CM LFL GH FMC. Performed the experiments: BRT CM WM. Analyzed the data: BRT CM WM. Contributed reagents/materials/analysis tools: WM KH SML JS BRT CM LFL GH FMC. Wrote the paper: WM KH SML JS BRT CM LFL GH FMC.
The authors have declared that no competing interests exist.
Early infant male circumcision (EIMC) is simpler, safer and more cost-effective than adult circumcision. In sub-Saharan Africa, there are concerns about acceptability of EIMC which could affect uptake. In 2009 a quantitative survey of 2,746 rural Zimbabweans (aged 18–44) indicated that 60% of women and 58% of men would be willing to have their newborn son circumcised. Willingness was associated with knowledge of HIV and male circumcision. This qualitative study was conducted to better understand this issue.
In 2010, 24 group discussions were held across Zimbabwe with participants from seven ethnic groups. Additionally, key informant interviews were held with private paediatricians who offer EIMC (n = 2) plus one traditional leader. Discussions were audio-recorded, transcribed, translated into English (where necessary), coded using NVivo 8 and analysed using grounded theory principles.
Knowledge of the procedure was poor. Despite this, acceptability of EIMC was high among parents from most ethnic groups. Discussions suggested that fathers would make the ultimate decision regarding EIMC although mothers and extended family can have (often covert) influence. Participants' concerns centred on: safety, motive behind free service provision plus handling and disposal of the discarded foreskin. Older men from the dominant traditionally circumcising population strongly opposed EIMC, arguing that it separates circumcision from adolescent initiation, as well as allowing women (mothers) to nurse the wound, considered taboo.
EIMC is likely to be an acceptable HIV prevention intervention for most populations in Zimbabwe, if barriers to uptake are appropriately addressed and fathers are specifically targeted by the programme.
Randomised trials suggest that male circumcision (MC) reduces a man's risk of acquiring HIV through heterosexual sex by 51–60% over an 18–24 months period
Although EIMC's effects on HIV will take longer to realize, infant circumcision is likely to ultimately be more effective at preventing HIV acquisition than adult MC as the procedure is carried out long before the individual becomes sexually active, negating the risk associated with sex during the healing period
Since 2009, Zimbabwe has provided circumcision to adult and adolescent men through a collaborative effort between the government and technical agencies. The programme aims to reach 1.2 million 15–29 year-olds by 2015
In a 2009 representative household survey of 2,746 rural Zimbabweans (aged 18–44), 60% of women and 58% of men reported willingness to have their son circumcised; willingness was associated with increased HIV and MC knowledge
The qualitative study was conducted between June and October 2010 with rural and urban participants in five of Zimbabwe's ten provinces: Bulawayo, Harare, Mashonaland West, Masvingo and Matebeleland North. Twenty-four gender-specific focus group discussions (FGDs) were held with expectant mothers (n = 6 groups), expectant fathers (n = 5 groups), grandmothers/mothers-in-law (n = 6 groups) and grandfathers/fathers-in-law (n = 7 groups) from seven ethnicities.
Key informant interviews (KIIs) were held with private paediatricians who offer EIMC (n = 2). An additional KII was held with a traditional leader from a traditionally circumcising ethnic group (Shangaan).
FGDs were conducted in either Shona or Ndebele, Zimbabwe's dominant indigenous languages, also spoken and understood by smaller ethnic groups. KIIs were conducted in English and Shona. Prior to group discussions, facilitators defined EIMC and presented basic information about the procedure, including the fact that it is quicker and safer than adult MC. Discussions then focused on issues such as perceptions of EIMC, willingness to have son undergo circumcision if it prevented HIV, barriers and motivating factors to EIMC and perceived acceptability of the intervention. Theme saturation - a situation where qualitative data collection reaches a point where no new issues emerge
Audio-recorded data were transcribed and translated verbatim into English (where necessary). Names and other personal identifiers were removed from transcripts before they were entered into NVivo 8 (QSR International, Melbourne, Australia), a qualitative data storage and retrieval program. Two researchers (CM and RBT) coded each transcription separately. Discrepancies were resolved by discussion with the senior social scientist (WM), who also independently coded all transcripts. Codes were grouped into categories and emerging themes were then identified iteratively following the general principles of grounded theory
Ethics approval was given by the Medical Research Council of Zimbabwe and the ethics board of University College London. Written informed consent was obtained on the day of the interview/discussion.
A total of 240 participants took part in FGDs; an additional three key informants were interviewed. EIMC knowledge was generally poor. Despite low knowledge, EIMC acceptability was high among participants from most ethnic groups. Older men from one traditionally circumcising population, who circumcise during adolescence, were strongly opposed to EIMC. Paediatricians reported a recent increase in parents requesting EIMC. Participants raised several concerns that have implications for circumcision roll-out. We present these themes in more depth below.
Male circumcision knowledge in general and EIMC knowledge, in particular, is poor among the general population and especially among traditionally non-circumcising groups. Several participants, particularly (and understandably) females, did not know what the procedure involves save to say,
When asked to give their opinions on timing of EIMC, participants generally felt that it should be done three to six months after birth.
Despite low levels of infant MC knowledge, discussions suggested high willingness to have son circumcised in most ethnic groups – providing MC was an effective HIV prevention method.
Paediatricians reported a recent increase in the number of infant circumcisions being conducted privately as well as the number of Zimbabwean parents requesting EIMC, something previously uncommon.
Study findings highlighted importance of the father in the decision-making process.
Discussions with traditionally circumcising tribes in Zimbabwe including the Xhosa, Chewa, Venda and Remba suggested that these groups are not opposed to EIMC. However, they felt that they would prefer the procedure to be performed by someone who was themselves circumcised and of the same tribe. Some Muslim participants (mostly the Chewa of Malawian origin) preferred it to be done by someone of the same religion.
However, older men from the dominant traditionally circumcising population in Zimbabwe, the Shangaan, were strongly opposed to EIMC for two reasons. Firstly, they mentioned that circumcision is just one part of a comprehensive ‘rites of passage’ ritual and should therefore not be undertaken separately.
Despite high levels of acceptability, community members raised several key questions discussed below.
Community members questioned the safety of EIMC. As previously stated, safety-related concerns were based on the assumption that the newborn infant's penis is too fragile to be circumcised, leading participants to feel that, to maximise safety, the procedure should only be performed by highly-trained doctors.
Customarily, Zimbabweans are worried about disposal of body fluids/tissues as they fear that these may be used by ‘witches’ to cause subsequent harm. For example, people burn shaved hair and nail clippings in case these end up in the wrong hands. With infants, disposal of the umbilical stump is a culturally-sensitive issue which involves mothers-in-law/grandmothers. Unilateral disposal of the umbilical stump by a young couple/mother can have serious implications. Community members were therefore anxious about the fate of the amputated foreskin:
Some participants felt that parents should be given the foreskins in order that they would be able to dispose of them themselves, drawing parallels with the common practice of obtaining the infant umbilical stump from health-care workers.
A few participants questioned why MC in general and EIMC specifically, is being or will be provided free of charge.
Data from this qualitative study corroborate some of the quantitative findings from our population-based survey, namely that EIMC was seen as widely acceptable. However, given the very low levels of knowledge or experience of EIMC, it is not clear whether this hypothetical acceptability will translate into actual acceptability once EIMC roll-out begins. It is clear though that participants were very interested in the intervention as described, that is, one that could protect their sons against future HIV.
This qualitative study additionally identified new issues which have implications for EIMC implementation. Firstly, given the low levels of knowledge about the procedure, it will be important to provide information at a community level to enhance the procedure's acceptability. These qualitative findings reinforce the need for multi-faceted awareness campaigns (e.g. community mobilisation, road shows) to ensure that everyone in the community is reached and not just those in contact with clinical services
Education needs to include both women and men; it should also target multiple generations. While reinforcing the crucial role fathers play in EIMC decision-making shown elsewhere
Participants raised concerns around the safety of EIMC. Similar concerns have also been observed in other studies across the region
Participants strongly felt that safe EIMC can only be provided by highly-trained doctors. However, in practice, it is likely that EIMC will largely be performed by midwives/nurses since it is an uncomplicated procedure
Study findings support the now well-recognised notion that cultural beliefs are integral to successful MC provision
These findings have at least three implications for rolling-out circumcision, in general and EIMC, specifically. Firstly, implementers will need to recognise and understand cultural and religious beliefs attached to MC among certain groups
This study has several strengths. Firstly, this research was conducted with participants representing the majority of ethnic groups, and in half of Zimbabwe's ten provinces. Secondly, our sample size was large for a qualitative study. The sample was purposively selected to ensure a wide range of views were heard from a diverse population. Thirdly, we managed to achieve theme saturation, an important component of qualitative research.
There were some limitations to this study. Firstly, although EIMC was defined prior to group discussions, some participants still discussed neonatal circumcision and had to be reminded that they needed to focus on infant circumcision. Secondly, we explored EIMC acceptability in the absence of widely-available services or any communication campaign that specifically provides information about infant circumcision. Hypothetical acceptability may be quite different from actual acceptance when EIMC is eventually rolled-out
In conclusion, this study found that EIMC is a potentially acceptable HIV prevention intervention in Zimbabwe and provided a framework for addressing likely barriers to uptake. Specifically, awareness campaigns that increase knowledge will be crucial to translating hypothetical acceptability into actual uptake. These data suggest that barriers are not insurmountable - which bodes well for achieving high EIMC targets in sub-Saharan Africa, in general and Zimbabwe, specifically.
We thank study participants, without whom this study would not have been possible. We would also like to thank Sibusisiwe Sibanda, Nqabutho Nyathi and Sekai Mukaro for assisting with data collection.