Swazi Males’ Knowledge and Practices of Voluntary Medical Male Circumcision in one of the Communities in the Hhohho Region, Swaziland

Swazi Males’ Knowledge and Practices of Voluntary Medical Male Circumcision in one of the Communities in the Hhohho Region, Swaziland Vilane Zinto G3, Mathunjwa-Dlamini TR2,*, Mhlongo-Manana ZC3, Mkhonta NR3, Khumalo PP3, Nxumalo-Magagula N3 1Professional nurse at the University of Swaziland 2Associate Professor in Nursing Science at the University of Swaziland 3Lecturer at the University of Swaziland Research Open Access Journal of Women’s Health and Gynecology


Introduction
Male circumcision is the surgical removal of the foreskin, the tissue covering the glans of the penis which is usually done within the first or second day after birth [1]. In ancient times, male circumcision was practiced for religious purposes, even today some religions still practice male circumcision but it is mostly performed for medical reasons.

History of circumcision
The origins of circumcision are lost in antiquity. Male circumcision was portrayed among Egyptians 5000 years ago, even though others argue that male circumcision has origins before this prehistory up to 15000 years ago as a sacrificial rite [2]. Male circumcision was carried out as an initiation ordeal at about the time of puberty, but there was a tendency for the age at which it was performed to shift to earlier years, such that the Jewish ritual circumcision has been carried out on the eighth day of life since biblical times. Circumcision originates way back in Abraham's time in the bible where it was a minor ritual procedure and was called a "Milah" [2]. Routine infant circumcision was introduced around the 1800s based on the pretext that male circumcision offered health and hygiene benefits [2]. It was believed that male circumcision would stop the habit of masturbation, and proffered an endless list of presumed cures for a variety of ailments and diseases.
However, male circumcision changed from being a ritual procedure to a medical practice that started in the United States of America in New York around 1870 [3]. The main indications then were mainly cancerous lesions and phimosis. In addition, it was reported that male circumcision prevented masturbation, the retention of sebaceous secretion, and consequent balanitis [3]. Other benefits included were that male circumcision promoted continence by diminishing the prurience of the sexual appetite. In Africa, male circumcision is practiced by the Xhosa people for religious purposes. Male circumcision was performed between the ages of 18 to 20 years as a way of introducing boys to manhood. There is limited documentation on religious beliefs governing the practice among the Zulus and Swazis [4].

Knowledge of medical male circumcision
A study conducted in Rwanda by the Ministry of Health, to assess knowledge, attitudes and practices regarding male circumcision in the general population revealed that the prevalence of circumcision was 16.5% (95% CI, 14.3 -18.7) in the study population [5]. This proportion was the highest in the city of Kigali (52.5%) and in the Western Province (25.9%). The study demonstrated that male circumcision prevalence in Rwanda was low although it was known and an acceptable practice among the study participants. Major barriers to male circumcision acceptability could be removed by effective interventions like education and social mobilization [5]. The literature on the practices among Swazi males on medical circumcision is limited.
In a study conducted among university students in Zimbabwe to determine their attitude and knowledge about male circumcision and prevention of HIV infection, only 18.2% had read about male circumcision from posters and flyers [6]. Less than half of the respondents were aware of the importance of male circumcision. Only 33.8% reported that male circumcision reduced the risk of sexually transmitted infections (STIs) and HIV transmission, while 0.04% felt that it was just a religious practice or just to keep clean 0.08%. The majority of the respondents (49.4%) were sure that men were being circumcised, 36.7% were not sure. Although the majority of students were aware of the importance of being circumcised, only 0.05% were willing to go for the surgery, while the majority (50.6%) had reservations about undergoing the procedure. The study found out that knowledge deficit was cited as the major reason for not being circumcised by female students while a negative attitude was noted among male students. Both male and female students had the opinion that some men did not opt for this method of reducing the risk of contracting HIV because the surgery was painful.
In a study that was conducted in Swaziland about the beliefs among Swazi men on male circumcision and HIV mitigation, the findings showed that most participants had knowledge about the benefits of circumcision [7]. Seventy percent (70%) reported that medical male circumcision reduced the risk of penile cancer, 60% reported that the procedure reduced cervical cancer, and 90% of the participants reported that it reduced the risk of contracting STIs. Seventy-five percent (75%) of the participants who had primary and secondary education reported that they were not sure of the benefits of male circumcision, whilst 67% of those that had gone through high school and college were knowledgeable of the benefits of male circumcision [7]. These findings reveal that the level of education had a great influence on the knowledge of male circumcision.

Practices on male circumcision
In 2014, A third of males aged 15 years and over were circumcised globally, with 70% of them being Muslims [4]. The overall prevalence of circumcision was reported to be 6.9% in Colombia, and 7.4% in Brazil, with most of those being circumcised due to medical issues later in life. The prevalence of circumcision in Mexico was estimated to be from 10% to 31%. According to the World Health Organization, fewer than 20% of males were circumcised in New Zealand [4]. In New Zealand routine circumcision for which there was no medical indication was uncommon and no longer publicly funded within the public hospital system.

In Germany, the German Health Interview and Examination
Survey for Children and Adolescents found that 10.9% of boys aged 0-17 years were circumcised [4]. In France, according to a telephone survey, 14% of men were circumcised. The overall prevalence of circumcision in Spain was reported to be 1.8%.
The prevalence of circumcision in Australia was roughly 58%.
Circumcision status was more common with males over 30 years than males under 30 years and more common with males who were born in Australia. About 66% of males born in Australia were circumcised and less than a third of males below 30 years were circumcised. There has been a decline in the rate of infant circumcision in Australia [4].
The World Health Organization further reported that about 62% of African males were circumcised [4]. However, the rate About 48.2% of black Africans were circumcised, with 32.1% of those traditionally circumcised and 13.4% circumcised for medical reasons [4]. While the prevalence of male circumcision in Swaziland remains low, it has doubled in the past five (5) years from 8% to 16% [4]. In accordance with the World Health Organization, circumcised men in Swaziland did not report riskier sexual behavior and were more likely to have been tested for HIV, compared to uncircumcised men [4]. HIV prevalence was significantly lower in circumcised men, reinforcing the evidence for a protective effect of male circumcision provided as a population-level intervention [4]. Circumcised men seem to be concerned about their sexual and reproductive health.
Swaziland is one of the countries with the highest prevalence of adults infected with HIV among developing countries, about 26% of the population is infected [8]. HIV infection has contributed to a delay in the economic, social and political progress of the country [4]. When a male is uncircumcised, moisture can get trapped between his penis and his foreskin creating an ideal environment for micro-organism to incubate [9]. If the uncir-cumcised individual engages in unprotected sexual activity, the moisture increases the risk of contracting sexually transmitted infections (STIs) including HIV [1]. STIs may impel the individual away from work due to clinical visits; reducing the country's economy. The individual's salary may decrease hence family income is reduced interfering with the provision of basic needs.
The lack of basic needs may result in the health of the individuals being compromised hence more money will be redirected to obtaining health services to treat health disorders. This may reduce the chance of children in obtaining education thus increasing the level of poverty in the country. The study assessed Swazi males' knowledge and practices regarding medical male circumcision. In addition, the association between knowledge and practices on medical male circumcision was examined.

Methodology
The research used a quantitative descriptive-correlational design. The study was conducted in a natural setting in one of the semi-urban communities in the Hhohho region, the Mangwaneni community. Potential participants were called in a meeting where the purpose of the study was explained. The simple random sampling method was used to obtain the sample where the names of all potential participants were written and put in a container. Thereafter, the names were picked randomly until the sample size was reached. Included in the study were males: aged 18 years and above; who spoke either siSwati or English; and who consented to participate in the study. The sample size of 45 participants was calculated based on parameters given by Lipsey, Hofer, Dong, Farran, and Bilbrey, method of sample size estimation [10]. A power size of 80%, significance level (alpha) of 5% and an effect size of 0.6 were used.
A questionnaire adapted from Ngodji was used to solicit information from the participants [11]. (n=5) reported that they were Muslims. The sample socio-demographic data are summarized in Table 1. 42.2% (n = 19) reported to prefer that male circumcision be done during the infant stage (less than a year old), 11.1% (n = 5) reported that they preferred to be performed male circumcision during childhood stage (1-13 years) and 2.2% (n = 1) reported that the preferred ideal age was between 14 and 19 years (during adolescence).

Who is the ideal person and place for performing male circumcision?
The majority (98.8%; n = 44) of the participants reported that they preferred that male circumcision be done by medical doctors in a health facility and 2.2% (n = 1) reported that they preferred that male circumcision be done by traditional circumcisers at home.

What is (are) the reason for not choosing male circumcision?
Amongst those who chose not to be circumcised, a majority (13.3%; n = 6) reported that it was due to the fear of complications and 4.4% (n = 2) reported that it was due to the fact that it was a painful procedure. The results also revealed a relationship between age and marital status (r = 0.699; p = 0.001) which means that participants that were older in age were more likely to be single.
Data revealed a relationship between age and employment status (r = 0.575; p = 0.001). The older participants were more likely to be employed. The data did not support any association between knowledge and practices on medical male circumcision. The associations between the variables are summarized in Table 2.

Discussion
Consistent with research, the current study revealed that participants were knowledgeable about circumcision as a way of reducing the risk of contracting HIV, STIs, prevention of penile cancer as well as a method to improve penile hygiene [12,13].
Knowledge is power [14,15], the assumption is that if people are knowledgeable regarding male circumcision, they are more likely to get circumcised and reduce the risk of contracting STIs including HIV. When more males are circumcised the incidence and prevalence of HIV in Swaziland is likely to reduce, increasing the country's economy.
Similarly to previous research [11], the current study revealed that most participants were eager to choose to be circumcised.
It has been over five (5) years that circumcision campaigns such as SokaUncobe (Circumcise and Conquer) which was initiated in 2008 [16], have been ongoing in Swaziland. It is possible that most males in the country have been exposed to education from the campaigns. Moreover, the participants resided in the peri-urban area where they are likely to have increased access to health care facilities which provide the services of male circumcision.
Having increased accessibility to health facilities make it easier for them to reach out to these facilities and utilize the services provided. Another contributing factor is that male circumcision is being offered free of charge to all males which make it affordable for everyone.
Having a higher proportion of males that would choose to be circumcised is encouraging because their risk of contracting HIV will be reduced once they are circumcised [17]. The future generation is therefore likely to be HIV-free [18,19]. Circumcision exposes the tender skin making it tougher over-time and less susceptible to be damaged during sexual intercourse. Intact skin reduces the transmission of HIV to both women and men who are HIV negative in case one of the partners is infected. Circumcision removes certain cells within the foreskin that act as an entry point for HIV [16]. Correspondingly to research [12], the results of the current study revealed that a majority of the participants preferred that the circumcision procedure be conducted by a medical doctor in a health facility. Having circumcision conducted by a professional in a health facility reduces the possible risks associated with the procedure. Sterility and surgical cleanliness are better observed in a health facility than in a home-based setting. Health facilities provide quality care in the sense that the procedure is performed by trained personnel hence there are minimal chances of sustaining complications. In the case where complications arise, the facility is able to detect them earlier during follow-up visits and early interventions are provided. During circumcision, there is a likelihood of developing hemorrhage especially in a child [21].
Hemorrhage is an emergency hence can be easily attended to if the person is in the health facility rather than when they are at home.
However, similarly to previous research, the findings in the current study showed that more than half of the participants were not circumcised [11]. Being not circumcised increases the risk of acquiring HIV as well as increasing the incidence and prevalence of herpes simplex virus 2 [22]. This might be an indication that intensive health education campaigns on male circumcision need to continue.

Conclusion
The participants revealed good knowledge on the benefits of male circumcision. They were aware of the effects of male circumcision on penile hygiene, STIs including HIV, and cancer.
Only a few participants indicated that they would not opt to be circumcised so as to prevent acquiring HIV infection. Overall, a majority of the participants were not circumcised and they cited various reasons which included fear of pain and other complications that could arise from the procedure.

Recommendations
• There is a need for the pre-service and in-service curriculum to be strengthened on voluntary medical male circumcision.
• .There need to also design programs or incorporate male circumcision under the existing wellness programs at the workplace that will provide specific services and information on male circumcision.
• There is a need to conduct campaigns to incorporate issues on pain related to voluntary medical male circumcision • There should be in-service training to foster effective pain management following voluntary medical male circumcision.
• There is a need to involve traditional and religious leaders to ensure the adoption of the procedure in both traditional and religious communities.
• More studies need to be conducted to establish evidence-base on the relationship between male circumcision and sexuality.
• The study could be replicated on a larger scale for inference to the Swazi populace.

Strengths of the study
The strength of the study lied in its rigor, sample size and statistical analysis performed. The sample was obtained using random probability sampling to ascertain the representativeness of the participants.

Study Limitations
Even though the study was successful, it had some limitations. Data were collected in only one community hence findings can be generalized to other communities with caution.