The Perception of Ishaka – Bushenyi Municipality Residents on Male Circumcision Towards Reduction of Hiv/Aids

THE PERCEPTION OF ISHAKA – BUSHENYI MUNICIPALITY RESIDENTS ON MALE CIRCUMCISION TOWARDS REDUCTION OF HIV/AIDS.

PETER OLYAM

(BMS/0151/62/DF)

RESEARCH PROJECT PROPOSAL SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE AWARD OF THE DEGREE OF BACHELOR OF MEDICINE AND BACHELOR OF SURGERY AT KAMPALA INTERNATIONAL UNIVERSITY

JULY, 2013

KAMPALA INTERNATIONAL UNIVERSITY- WESTERN CAMPUS

FACULTY OF CLINICAL MEDICINE AND DENTISTRY

P.O BOX 71

BUSHENYI

UGANDA Table of Contents LIST OF TABLES ...... v TABLE OF FIGURES ...... vi DECLARATION ...... vii DEDICATION ...... viii ACKNOWLEDGEMENT ...... ix LIST OF ABREVIATIONS AND ACRONYMS ...... x ABSTRACT ...... xi CHAPTER ONE ...... 1 Introduction ...... 1 Background information ...... 1 Problem statement ...... 3 Research Question ...... 4 Objectives of the study ...... 4 General objective ...... 4 Specific objectives ...... 4 Significance of the study ...... 4 CHAPTER TWO-LITERATURE REVIEW ...... 7 Introduction ...... 7 History of male circumcision ...... 8 Cultures and Religions ...... 9 Prevalence of circumcision ...... 10 Sexual effects of circumcision ...... 11 Benefits from circumcision ...... 11 Complications of circumcision ...... 13 CHAPTER THREE ...... 14 Methodology ...... 14 Study design ...... 14 Setting of the study ...... 14 Study population ...... 14 Instruments of data collection ...... 14 Selection criteria ...... 14 ii | P a g e

Inclusion criteria ...... 14 Exclusion criteria ...... 15 Sampling ...... 15 Sample size estimation ...... 15 Method of data collection ...... 15 Data collection instruments ...... 15 Data analysis ...... 16 Ethical considerations ...... 16 Dissemination of findings ...... 16 Possible limitations ...... 17 CHAPTER FOUR ...... 18 INTRODUCTION ...... 18 AGE OF RESPONDENTS ...... 18 SEX OF RESPONDENTS ...... 19 MARRITAL STATUS OF RESPONDENTS ...... 19 RELIGION OF RESPONDENTS ...... 20 WHAT CIRCUMCISION IS ...... 21 KNOWLEDGE ON CIRCUMCISION...... 21 INDICATIONS FOR CIRCUMCISION ...... 23 IMPRESSION ABOUT CIRCUMCISED MEN ...... 24 PRACTICE OF CIRCUMCISION ...... 25 INFORMATION ON CIRCUMCISION ...... 29 COMPLICATIONS OF CIRCUMCISION ...... 31 ATTITUDE TOWARDS CIRCUMCISION ...... 31 CHAPTER FIVE ...... 34 DISCUSION ...... 34 DEMOGRAPHIC CHARACTERISTICS ...... 34 KNOWLEDGE ON CIRCUMCISION...... 34 PRACTICES WITH REGARD TO CIRCUMCISION ...... 35 ATTITUDE TOWARDS CIRCUMCISION ...... 36 CONCLUSION ...... 37 RECOMMENDATIONS ...... 38 iii | P a g e

WORK PLAN ...... 39 BUDGET ...... 40 REFERENCES ...... 41 APPENDICES ...... 43 APPENDIX A ...... 43 APPENDIX B ...... 48 APPENDIX C ...... 49

iv | P a g e

LIST OF TABLES Table 1: age of respondents ...... 18 Table 2: marital status of respondents ...... 20

v | P a g e

TABLE OF FIGURES Figure 1: sex of respondents ...... 19 Figure 2: religion of respondents...... 20 Figure 3: what circumcision is ...... 21 Figure 4: age of circumcision ...... 22 Figure 5: knowledge about anybody who has undergone circumcision ...... 22 Figure 6: indications for circumcision ...... 23 Figure 7: impression about circumcised men ...... 24 Figure 8: circumcision a health issue ...... 25 Figure 9: where circumcision should be conducted from ...... 26 Figure 10: how a circumcised person should be managed ...... 27 Figure 11: need for an attendant ...... 27 Figure 12: duration of medication after surgical circumcision ...... 28 Figure 13: importance of circumcision ...... 28 Figure 14: plans for the procedure ...... 29 Figure 15: information on circumcision ...... 30 Figure 16: source of information on circumcision ...... 30 Figure 17: knowledge on complications of circumcision ...... 31 Figure 18: traditional beliefs or taboos against circumcision ...... 32 Figure 19: attitude towards someone who is circumcised ...... 32 Figure 20: circumcision as a means to reduce spread of HIV/AIDS ...... 33

vi | P a g e

DECLARATION I PETER OLYAM declare that this research is my own work and it has never been presented for the award of a diploma, a degree or any other qualification whatsoever.

Where the work of other people has been included, acknowledgement to this has been made in accordance to the text and preferences.

This study has never been submitted before for either publication or award of any kind and also take note that this project is subject to changes and further researching with or without the consultation of the researcher.

 RESEARCHER

SIGNATURE------DATE------

APPROVAL

This is to certify that this research has been written under my supervision and is now ready for submission to the faculty of Clinical Medicine & Dentistry, Kampala International University with my approval.

Signed……………………………………...... Date……………………………………….

Supervisor:

vii | P a g e

DEDICATION I dedicate this research to my mother JOYCE OLYAM and my father JOHN OLYAM for their love and support and for ensuring that I am not alone in this entire venture of my life.

I furthermore express herewith my admiration for the artistry and skills the two of you have in bringing my sister, brother and I up into mature and disciplined beings. May you live longer to pass these skills to your grand children.

viii | P a g e

ACKNOWLEDGEMENT To God Almighty for His sufficient Grace and Blessings.

I wish to express my heartfelt appreciation to the Kampala International University Western Campus administration most especially faculty of Clinical Medicine and Dentistry and all the academic staff for their efforts to make our course a success during the time of our stay in the university.

To my brother, David Olyam, my sisters Anatalia Olyam and Janet Murugo for their strong support during this period of my education.

To my special friend Natalie Muhia, for your encouragement and assistance.

To my classmates and all the friends in Kampala International University, for the union we have shared together.

My gratitude goes to all respondents.

Lastly to my supervisor Mr. Ambrose Barasa, I owe my completion of this research to you.

ix | P a g e

LIST OF ABREVIATIONS AND ACRONYMS HC Health Centre

HH Household

KM Kilometre

LC Local Council

SQ Square

UNICEF United Nations Children’s Environmental Fund

WHO World Health Organization

HIV Human Immunodeficiency Virus

AIDS Acquired Immune Deficiency Syndrome

UNAIDS Joint United Nations Programme on HIV/AIDS

KIU-WC Kampala International University- Western Campus

AMA American Medical Association

CDC Centers for Disease Control

x | P a g e

ABSTRACT Circumcision is the surgical removal of the foreskin, the fold of skin that covers the head of the penis. The World Health Organization (WHO, 2007), the Joint United Nations Programme on HIV/AIDS (UNAIDS, 2007), and the Centres for Disease Control and Prevention (CDC, 2008) state that evidence indicates male circumcision significantly reduces the risk of HIV acquisition by men during penile- vaginal sex, but also state that circumcision only provides minimal protection and should not replace other interventions to prevent transmission of HIV.

A cross section and descriptive study was conducted in Ishaka – Bushenyi Municipality with an objective of community perception on Male circumcision as a means of reduction of HIV/AIDS.

xi | P a g e

CHAPTER ONE

Introduction The World Health Organization (WHO, 2007), the Joint United Nations Programme on HIV/AIDS (UNAIDS, 2007), and the Centres for Disease Control and Prevention (CDC, 2008) state that evidence indicates male circumcision significantly reduces the risk of HIV acquisition by men during penile-vaginal sex, but also state that circumcision only provides minimal protection and should not replace other interventions to prevent transmission of HIV. It is widely practiced for religious and traditional reasons, often within the first two weeks after birth, or at the beginning of adolescence as a rite of passage into adulthood. According to the World Health Organization (WHO, 2007), global estimates suggest that 30% of males are circumcised, of whom 68% are Muslim.

Background information A systematic review and meta-analysis of 28 published studies that uncircumcised men are 2-3 times more likely to be infected with HIV than uncircumcised men, with the difference being most pronounced in men with high exposure to HIV infection (AIDS, 2000). A sub-analysis of 10 African studies, involving men considered to be at high risk to being infected, found a 3.4 times higher incidence of HIV infection among those who had not been circumcised (AIDS, 2000).

Experimental evidence was needed to establish a causal relationship between lack of circumcision and HIV, so three randomized controlled trials were commissioned as a means to reduce the effect of any confounding factors. Trials took place in South Africa, Kenya and Uganda, between 2002 and 2004. All three trials were stopped early by their monitoring boards on ethical grounds, because those in the circumcised group had a lower rate of HIV contraction than the control group. In a prospective study in Uganda of HIV- negative men whose partners were HIV-positive, none of 50 circumcised men became infected within two years, compared with 40 of 137 uncircumcised men (AIDS, 2000).Inclusion of male circumcision into current HIV prevention measures guidelines is warranted, with further research required to assess the feasibility, desirability, and cost-effectiveness of implementing the procedure within local contexts.

Two further trials on male circumcision and HIV infection were stopped in December 2006 and published in early 2007. Both trials involved random of HIV-negative volunteers to either immediate circumcision, performed by trained medical professionals in a clinic setting (intervention group), or circumcision delayed for2 years (control group). The first trial in Kisumu, western Kenya, was conducted among men aged 18-24 years, and showed a 59% reduction in HIV incidence (Lancet, 2007). The second study was conducted in Rakai, Uganda, among men aged 15-49 years, and showed a 51% reduction in HIV incidence (Lancet 2007). As a result of these findings, the WHO and the Joint United Nations Programme on HIV/AIDS (UNAIDS) stated that male circumcision is an efficacious intervention for HIV prevention but should be carried out by well trained medical professionals and under conditions of informed consent. Some have challenged the validity of the African randomized controlled trials, prompting a number of researchers to

2 | P a g e

question the effectiveness of circumcision as an HIV prevention strategy. (UNAIDS, 2007).

A randomized controlled trial in Uganda found that male circumcision did not reduce male to female transmission of HIV. The authors could not rule out the possibility of higher risk of transmission from men who did not wait for the wound to fully heal before engaging in intercourse. (WHO, 2007).

Problem statement HIV/AIDS has been a global problem for almost three decades now, much has been done to stop the fast spreading pandemic, this include preventive and life prolonging strategies which has not yielded any good. WHO research has shown that circumcision can significantly reduce the fast spreading pandemic. There is need to assess peoples attitude and knowledge on the contribution of circumcision on reduction of HIV/AIDS transmission given that people have diverse cultural believes especially in Uganda in the Protection against HIV and AIDS.

3 | P a g e

Research Question

This study sought to investigate the perception of residents in Ishaka-Bushenyi Municipality regarding the relationship between circumcision and reduction of HIV incidence.

Objectives of the study

General objective To assess the perception of residents regarding male circumcision as a means of reducing incidence of HIV/AIDS in Ishaka –Bushenyi Municipality.

Specific objectives  To collect relevant socio- demographic variables among residents.

 To assess the knowledge of respondents on the importance of circumcision.

 To identify the cultural beliefs of residents on circumcision.

 To establish the knowledge of residents on the transmission of HIV/AIDS.

 To establish the knowledge on the relationship between circumcision and HIV/AIDS.

 To determine the level of practice of circumcision.

Significance of the study The assessment of perception of residents about circumcision in relation to HIV/AIDS incidence, will contribute a lot towards reducing the incidence of the disease. This is because the HIV prevalence rate in Uganda is still high, at over 6%. In assessing the perception, the probability of further reducing the

4 | P a g e

incidence by circumcision can be promoted through health education, proper practice of circumcision and other means. Furthermore, randomized controlled trials conducted in Rakai, Uganda, among men aged 15-49 years showed a 51% reduction in HIV incidence (AIDS, 2000).This shows that circumcision helps and should be promoted having assessed the people’s perception. The burden of HIV/AIDS is high on government resources as a lot of money is spent in provision of ante-retroviral for those infected. Moreover, many households are left without breadwinners leading to suffering in many families. The youth or the able bodied in society are also weakened by the scourge thereby causing decline in productivity, first at the family level and the nation as a whole. Therefore, resources can be saved or used for other projects and the nation’s productivity enhanced, with the reduction of the incidence and prevalence of HIV.

A study in Uganda observed lower rates of male-to-female transmission of HIV if the man was circumcised (AIDS, 2000).Among 47 couples in which the circumcised male partner was infected with HIV and whose viral load was below 50000 copies per ml, none of the female partners became infected in two years. By contrast, 26 of the 147women whose HIV-infected partners were not circumcised became infected. Thus, it is also important to include females in the study as it greatly influences the incidence. Though a direct benefit has not been shown, women should benefit if fewer men in the community are HIV-infected.

5 | P a g e

It will be important to find out from the community, and also emphasize to them that male circumcision is only partially protective, reducing the chances of HIV infection in men by about 60%. Therefore it must be promoted, not as stand-alone surgical procedure, but along with other proven methods of HIV prevention.

Apart from serving as a learning experience to the researcher, the community of Ishaka –Bushenyi Municipality will benefit from the information and also the students of KIU-WC will get information since the research book will be disseminated to the University Library, the findings will also be used to compile a report that will be submitted to Faculty of Clinical Medicine and Dentistry in partial fulfillment of the requirements for the award of the degree of Bachelor of Medicine and Bachelor of Surgery.

6 | P a g e

CHAPTER TWO-LITERATURE REVIEW

Introduction Male circumcision is the removal of some or entire foreskin (prepuce) from the penis. The word "circumcision" comes from Latincircum (meaning "around") and cædere (meaning "to cut"), (Wrana, 1939).

It has been variously proposed that circumcision began as a religious sacrifice, as a rite of passage marking a boy's entrance into adulthood, as a form of sympathetic magic to ensure virility, as a means of suppressing sexual pleasure or to increase a man's attractiveness to women, or as an aid to hygiene where regular bathing was impractical, among other possibilities. Immermanet al. suggest that circumcision causes lowered sexual arousal of pubescent males, and hypothesize that this was a competitive advantage to tribes practicing circumcision, leading to its spread regardless of whether the people understood this. It is possible that circumcision arose independently in different cultures for different reasons (Milos, 1992).

Early depictions of circumcision are found in cave drawings and Ancient Egyptiantombs; though some pictures are open to interpretation. Religious male circumcision is considered a commandment from God in Judaism. In Islam, though not discussed in the Qur'an, circumcision is widely practiced and most often considered being a Sunnah. It is also customary in some Christian churches in Africa, including some Oriental Orthodox Churches(Rizvi, 1999).

There is controversy regarding circumcision. Advocates of circumcision argue, for example, that it provides important health advantages which outweigh the

7 | P a g e

risks, has no substantial effects on sexual function, has a low complication rate when carried out by an experienced physician, and is best performed during the neonatal period.Opponents of circumcision argue, for example, that it interferes with normal sexual function, is performed due to excuses and myths believed or conjured by parents and health providers, is extremely painful, and when performed on infants and children violates the individual's human rights(Milos,1992).

The American Medical Association stated in 1999: "Virtually all current policy statements from specialty societies and medical organizations do not recommend routine neonatal circumcision, and support the provision of accurate and unbiased information to parents to inform their choice."(Gollaher, 2000).

History of male circumcision The oldest documentary evidence for circumcision comes from ancient Egypt. Circumcision was common, although not universal, among ancient Semitic peoples. In the aftermath of the conquests of Alexander the Great, however, Greek dislike of circumcision (they regarded a man as truly "naked" only if his prepuce was retracted) led to a decline in its incidence among many people that had previously practiced it.

Circumcision has ancient roots among several ethnic groups in sub-equatorial Africa, and is still performed on adolescent boys to symbolize their transition to warrior status or adulthood (Wrana, 1989).

8 | P a g e

Cultures and Religions In some cultures, males must be circumcised shortly after birth, during childhood, or around puberty as part of a rite of passage. Circumcision is commonly practiced in the Jewish and Islamic faiths.

Jewish law states that circumcision is a ("positive commandment" to perform an act) and is obligatory for Jewish-born males and for non-circumcised Jewish male converts. It is only postponed or abrogated in the case of threat to the life or health of the child.

In Islam, circumcision is mentioned in some Hadith, but not in the Qur'an. Some Fiqh scholars state that circumcision is recommended, others that it is obligatory. Some have quoted the Hadith to argue that the requirement of circumcision is based on the covenant with Abraham. While endorsing circumcision for males, Islamic scholars note that it is not a requirement for converting to Islam (Rizvi, 1999).

The Catholic Church condemned the observance of circumcision as a mortal sin and ordered against its practice in the Ecumenical Council of Basel- Florence in 1442.Circumcision is customary among the Coptic, Ethiopian, and Eritrean Orthodox Churches, and also some other African churches. Some Christian churches in South Africa oppose circumcision, viewing it as a pagan ritual, while others, including the Nomiya church in Kenya, require circumcision for membership. Some Christian churches celebrate the Circumcision of Christ. The vast majority of Christians do not practice circumcision as a religious requirement (Wrana, 1989).

9 | P a g e

Among some West African groups, such as the Dogon and Dowayo, circumcision is taken to represent a removal of "feminine" aspects of the male, turning boys into fully masculine males. Among the Urhobo of southern Nigeria it is symbolic of a boy entering into manhood. The ritual expression, Omote Oshare ("the boy is now man"), constitutes a rite of passage from one age set to another. For Nilotic people, such as the Kalenjin and Maasai, circumcision is a rite of passage observed collectively by a number of boys every few years, and boys circumcised at the same time are taken to be members of a single age set(Wrana, 1939).

Prevalence of circumcision Estimates of the proportion of males that are circumcised worldwide vary from one-sixth to a third. The WHO has estimated that 664,500,000 males aged 15 and over are circumcised (30% global prevalence), with almost 70% of these being Muslim (WHO, 2007). Circumcision is relatively rare in Europe, Latin America, parts of Southern Africa, and most of Asia and Oceania. Prevalence is near-universal in the Middle East and Central Asia. The WHO states that "there is generally little non-religious circumcision in Asia, with the exceptions of the Republic of Korea and the Philippines". The WHO presents a map of estimated prevalence in which the level is generally low (< 20%) across Europe, and Klavs et al. report findings that ‘support the notion that the prevalence is low in Europe’, In Latin America, prevalence is universally low. (WHO, 2007).

10 | P a g e

The WHO estimates circumcision prevalence in the United States and Canada at 75% and 30%, respectively of the population. Prevalence in Africa varies from less than 20% in some southern African countries to near universal in North and West.

Sexual effects of circumcision The sexual effects of circumcision are the subject of much debate. The American Academy of Pediatrics (1999) stated "A survey of adult males using self-report suggests more varied sexual practice and less sexual dysfunction in circumcised adult men. There are anecdotal reports that penile sensation and sexual satisfaction are decreased for circumcised males." They continued, “it was noted that there is no difference in exteroceptive and light tactile discrimination on the ventral or dorsal surfaces of the glans penis between circumcised and uncircumcised men.” Conversely a 2002 review by (Boyle et al), stated that "the genitally intact male has thousands of fine touch receptors and other highly erogenous nerve endings many of which are lost to circumcision, with an inevitable reduction in sexual sensation experienced by circumcised males." They concluded, "Evidence has also started to accumulate that male circumcision may result in lifelong physical, sexual, and sometimes psychological harm as well.”(Rizvi, 1999).

Benefits from circumcision Cancer of the cervix in women is due to the Human Papilloma Virus. It thrives under and on the foreskin from where it can be transmitted during

11 | P a g e

intercourse. An article in the British Medical Journal in April 2002 suggested that at least 20% of cancer of the cervix would be avoided if all men were circumcised. Many older men, who have bladder or prostate gland problems, also develop difficulties with their foreskins due to their surgeon's handling, cleaning, and using instruments. Some of these patients will need circumcising (British Medical Journal 2002).

Some men develop cancer of the penis - about 1 in 1000 - fairly rare, but tragic, infant circumcision gives almost 100% protection, and young adult circumcision also gives a large degree of protection. It’s also suggested that circumcised men are 8 times less likely to contract the HIV virus. It is very important here to say that the risk is still far too high and that condoms and safe sex must be used - this applies also to preventing cancer of the cervix in women who have several partners .It has been found out that the infection thrives in the lining of the foreskin, making it much easier to pass on. As with HIV, some protection exists against other sexually transmitted infections. Accordingly, if a condom splits or comes off, there is some protection for the couple, (WHO, 2007).

Lots of men, and their partners, prefer the appearance of their penis after circumcision, it is odour-free, it feels cleaner, and they enjoy better sex. Awareness of a good body image is a very important factor in building self confidence. Balanitis is an unpleasant, often recurring, inflammation of the glans. It is quite common and can be prevented by circumcision. Urinary tract infections sometimes occur in babies and can be quite serious, paraphimosis and phimosis are uncommon. Circumcision in infancy and old children makes it 10 times less likely, (WHO, 2007).

12 | P a g e

Complications of circumcision Complication rates ranging from 0.06% to 55% have been cited. Through a 1993 survey of circumcision complications by Williams and Kapilla, put the rate at 2-10%.According to the American Medical Association (AMA), blood loss and infection are the most common complications, but most bleeding is minor and can be stopped by applying pressure.

A survey of circumcision complications by Kaplan in 1983 revealed that the rate of bleeding complications was between 0.1% and 35%. A 1999 study of 48 boys who had complications from traditional male circumcision in Nigeria found that haemorrhage occurred in 52% of the boys, infection in 21% and one child had his penis amputated (Schmid, 2008).

13 | P a g e

CHAPTER THREE

Methodology

Study design This research design was a quantitative and descriptive cross sectional study on the perception of the community to male circumcision as a means of controlling HIV/AIDS in Ishaka- Bushenyi Municipality.

Setting of the study This study was carried out in Ishaka - Bushenyi municipality Bushenyi district, Western Uganda. Bushenyi district is bordered by Mbarara district in the East, Ntungamo district in the South West, Kasese and Kamwenge districts in the North.

Study population The study targeted residents of Ishaka-Bushenyi Municipality

Instruments of data collection In a bid to ensure quality, the researcher conducted one day pilot tour of the municipality. This was done to check on the effectiveness of the study instruments and identify possible source of errors that may be encountered during data collection by the data collection tool (questionnaire).

Selection criteria

Inclusion criteria  Must be 18 years and above.  Must be a resident of Ishaka-Bushenyi municipality.  Those who consent.

14 | P a g e

Exclusion criteria  People with mental disabilities.  Those who are terminally ill.  Non residents.

Sampling A simple random sampling technique was employed during this study where respondents were assessed based on their contact with the researcher. This was done until the required sample size of 100 was reached.

Sample size estimation The sample size determination was based on the pre-determined graph figures by R.V Krejeie and D.W Morgan (1970) which depends on the population size of the study area. In this research study, the sample size is 100.

Method of data collection A self administered questionnaire was used to collect data from study participants. This questionnaire contained all the necessary information concerning the objective of the study.

Data collection instruments This included the questionnaire, clip board and a pen. Questionnaire was used because it covers a wide number of participants and saves time; the

15 | P a g e

questionnaire contained the demographic data and other information concerning the study respondents.

Data analysis The data collected from the study area was analyzed using Microsoft Excel to obtain descriptive statistical correlation and the results presented in form of tables and figures. The calculations were done using a scientific calculator.

Ethical considerations The study was carried out after the approval of the proposal by the supervisor.

A letter of introduction from the Dean Faculty of Clinical Medicine and Dentistry was obtained before the study; this letter was used to introduce the researcher in the field.

An informed consent was obtained from all subjects who were involved in the study.

Dissemination of findings A copy will be submitted to the Faculty of Clinical Medicine and Dentistry in partial fulfillment of the requirements for the award of Bachelor of Medicine and Bachelor of Surgery. Another copy will be left in the library of Kampala International University western campus.

16 | P a g e

Possible limitations There was poor compliance by some respondents.

Financial constrain as the university does not sponsor the research.

17 | P a g e

CHAPTER FOUR

INTRODUCTION

This section involves the analyzing of data which was collected during data collection exercise. In this chapter the use of diagrams like pie charts, bar graphs, tables and other figures will be used. The data was analyzed by use of the calculator.

AGE OF RESPONDENTS

Out of the 100 respondents who were interviewed, 82(82%) of them were between the age of 18 and 25years, 14(14%) of them were between 26 and 35 years, 2(2%) of the respondents were of the age between 36 and 47 years, 0(0%) of them was of the age between 47 and 49 years, and 2(2%) of them were above 50 years.

AGE(years) NUMBER PERCENTAGE 18-25 82 82 26-35 14 14 36-47 2 2 47-49 0 0 >50 2 2 Total 100 100 Table 1: age of respondents

18 | P a g e

SEX OF RESPONDENTS

Most of the respondents who were interviewed were male 88 who represented (88%), while the female represented 12(12%) of the population.

Sex of respondents

12%

Male Female

88%

Figure 1: sex of respondents

MARITAL STATUS OF RESPONDENTS

Among the people who were interviewed, 84(84%) of them were single, 12(12%) of them were married, 0(0%) of them were separated, 4(4%) of them were either widow or widower, and 0 (0%) of them were divorced.

19 | P a g e

MARRITAL STATUS NUMBER PERCENTAGE Single 84 84 Married 12 12 Separated 0 0 Widow/widower 4 4 Divorced 0 0 Table 2: marital status of respondents

RELIGION OF RESPONDENTS Majority of the respondents were Christians 84(84%), followed by the Muslims who were 16(16%) in number.

religion of respondents

16%

christians muslims

84%

Figure 2: religion of respondents

20 | P a g e

WHAT CIRCUMCISION IS:

Most the respondents 90 (90%) understood circumcision as an act of the removal of the fore skin of the male genital organ. 5(5%) of the respondents understand circumcision as cleanliness or as way to prove manhood while another 5(5%) were not sure what it was.

what circumcision is

5% 5%

cutting of fore skin cleanliness/prove manhood not sure 90%

Figure 3: what circumcision is

KNOWLEDGE ON CIRCUMCISION

29% of the interviewed respondents agreed that people should circumcise only infants, 18% of the respondents agreed that people should circumcise while they are adolescents, 6% said that only adults should undergo circumcision. 43% of the respondents were of the opinion that a male at any age could undergo

21 | P a g e circumcision while 4% were not sure of the age. 98% of the respondents knew someone who was circumcised while 2% did not know anybody.

age of circumcision

4% 29% infants 43% adolescents adults 18% male at any age 6% not sure

Figure 4: age of circumcision

knowledge about anybody who has undergone circumcision

yes no

98%

Figure 5: knowledge about anybody who has undergone circumcision

22 | P a g e

INDICATIONS FOR CIRCUMCISION

21% believed that the decision to circumcision should be based on someone’s religion, 20% of the respondents believed that some culture demand one to circumcise, 15% of them think it is due to some illnesses. 38% of them thought the decision to circumcision is based on personal hygiene. 6% had other reasons for circumcision which included self satisfaction, peer influence, religion and to reduce sexual pleasure.

Indications for circumcision 40% 38%

35%

30%

25% 21% 20% 20% Indications for circumcision 15% 15%

10% 6% 5%

0% Illness Religion Culture Hygiene Other

Figure 6: indications for circumcision

23 | P a g e

IMPRESSION ABOUT CIRCUMCISED MEN

67% of the respondents viewed a circumcised man better while 33% did not find a circumcised man different. 61% found circumcision a health issue in their area, while 37% it was not a health issue and 2% did not know.

impression about circumcised men 80%

70% 67%

60%

50%

40% impression about circumcised 33% men 30%

20%

10%

0% Better Not different

Figure 7: impression about circumcised men

24 | P a g e

circumcision as a health issue

37% Yes No Don't know 61%

Figure 8: circumcision as a health issue

PRACTICE OF CIRCUMCISION

92% of the respondents thought circumcision should be conducted from a hospital, 6% at a village health facility and 2% thought that it should be conducted from home.

About how a circumcised man should be managed: 47% thought drugs could be administered at home, 8% thought that the person should be managed in isolation at home, 43% thought management should take place from hospital and 2% did not know how he should be managed.

78% thought a circumcised person needs an attendant at home while 22% did not think so.

25 | P a g e

Of those interviewed, 6% thought that a person should be on medication for one month after surgical circumcision. 49% thought medication should be continued until full recovery, 25% for one week, 14% for two weeks while 6% did not know for how long medication should be continued.

90% of the respondents considered circumcision important. Out of these: 10% had plans for the procedure, 10% had no plans for the procedure, 68% were already circumcised and to 12% the question was not applicable. However, 10% did not consider circumcision important.

100% 92% 90%

80%

70%

60%

50% where circumcision should be 40% conducted from

30%

20%

10% 6% 2% 0% Hospital Village health Home facility

Figure 9: where circumcision should be conducted from

26 | P a g e

how a circumcised person should be managed

47% 43% Administer drugs at home Isolation at home Managed from hospital

8% Don't know

Figure 10: how a circumcised person should be managed

need for an attendant

22%

Yes No

78%

Figure 11: need for an attendant

27 | P a g e

Duration of medication after surgical circumcision

6% 6%

14% One month Until full recovery one week two weeks 25% 49% Don't know

Figure 12: duration of medication after surgical circumcision

Importance of circumcision

10%

Yes No

90%

Figure 13: importance of circumcision

28 | P a g e

Plans for the procedure

12% 10% 10%

Yes No Already circumcised

68% Not applicable

Figure 14: plans for the procedure

INFORMATION ON CIRCUMCISION

90% of the respondents had received information on circumcision while 10% had never received such information. Among those who had received such information: 28% had got it from health workers, 28% from friends, 25% from mass media, 16% from medical journals and 3% from other sources such Holy scripture.

29 | P a g e

Information on circumcision 100% 90% 90% 80% 70% 60% 50% Information on circucision 40% 30% 20% 10% 10% 0% Yes No

Figure 15: information on circumcision

Source of information on circumcision

3% 16% 28%

Health workers Friends 25% Mass media Medical journals 28% Other

Figure 16: source of information on circumcision

30 | P a g e

COMPLICATIONS OF CIRCUMCISION

69% of the respondents knew some of the complications of circumcision while 31% did not.

Knowledge on complications of circumcision

31%

Yes No

61%

Figure 17: knowledge on complications of circumcision

ATTITUDE TOWARDS CIRCUMCISION

On traditional beliefs or taboos against circumcision, 14% of the respondents said that they did have them, 84% did not have any and 2% did not know. Some of the traditional beliefs given were; that circumcision reduces fertility, reduces excitement during sex, form of proving manhood and for personal hygiene.

Regarding how people view someone who is circumcised in the community, respondents gave the following responses; 29% civilized, 18% cultured, 25% religious, 28% other (normal, healthy, clean, mature).

When asked about circumcision as a means of reducing transmission of HIV/AIDS, the following was their response; 72% said yes, 12% said no while 16% were not sure.

31 | P a g e

Traditional beliefs or taboos against circumcision

14%

Yes No Don't know

84%

Figure 18: traditional beliefs or taboos against circumcision

Attitude towards someone who is circumcised

28% 29%

Civilised Cultured Religious 18% 25% Other

Figure 19: attitude towards someone who is circumcised

32 | P a g e

Circumcision as a means to reduce spread of HIV/AIDS

16%

12% Yes No 72% Not sure

Figure 20: circumcision as a means to reduce spread of HIV/AIDS

33 | P a g e

CHAPTER FIVE

DISCUSSION DEMOGRAPHIC CHARACTERISTICS Out of the 100 respondents who were interviewed, 82(82%) of them were between the age of 18 and 25years, 14(14%) of them were between 26 and 35 years, 2(2%) of the respondents were of the age between 36 and 47 years, 0(0%) of them was of the age between 47 and 49 years, and 2(2%) of them were above 50 years.

Most of the respondents who were interviewed were male 88 who represented (88%), while the female represented 12(12%) of the population.

Majority of the respondents were Christians 84(84%), followed by the Muslims who were 16(16%) in number

KNOWLEDGE ON CIRCUMCISION Most the respondents 90 (90%) understood circumcision as an act of the removal of the fore skin of the male genital organ. 5(5%) of the respondents understand circumcision as cleanliness or as way to prove manhood while another 5(5%) were not sure what it was.

92% of the respondents thought circumcision should be conducted from a hospital, 6% at a village health facility and 2% thought that it should be conducted from home.

29% of the interviewed respondents agreed that people should circumcise only infants, 18% of the respondents agreed that people should circumcise while they

34 | P a g e are adolescents, 6% said that only adults should undergo circumcision. 43% of the respondents were of the opinion that a male at any age could undergo circumcision while 4% were not sure of the age.

69% of the respondents knew some of the complications of circumcision while 31% did not.

PRACTICES WITH REGARD TO CIRCUMCISION About how a circumcised man should be managed: 47% thought drugs could be administered at home, 8% thought that the person should be managed in isolation at home, 43% thought management should take place from hospital and 2% did not know how he should be managed.

78% thought a circumcised person needs an attendant at home while 22% did not think so.

Of those interviewed, 6% thought that a person should be on medication for one month after surgical circumcision. 49% thought medication should be continued

35 | P a g e until full recovery, 25% for one week, 14% for two weeks while 6% did not know for how long medication should be continued.

90% of the respondents considered circumcision important. Out of these: 10% had plans for the procedure, 10% had no plans for the procedure, 68% were already circumcised and 12% did not apply to them since they were female. However, 10% did not consider circumcision important.

98% of the respondents knew someone who was circumcised while 2% did not know anybody.

ATTITUDE TOWARDS CIRCUMCISION Regarding traditional beliefs or taboos against circumcision, 14% of the respondents said that they did have them, 84% did not have any and 2% did not know. Some of the traditional beliefs given were; that circumcision reduces fertility, reduces excitement during sex, form of proving manhood and for personal hygiene.

When asked about circumcision as a means of reducing transmission of HIV/AIDS, the following was their response; 72% said yes, 12% said no while 16% were not sure.

67% of the respondents viewed a circumcised man better while 33% did not find a circumcised man different. 61% found circumcision a health issue in there area, while 37% it was not a health issue and 2% did not know.

36 | P a g e

CONCLUSION According to this study the following was revealed:

 Most of the respondents (82%) were between the ages of 18-25 years.  Most of those interviewed were male (88%). Marital status of those interviewed was single (84%)  Most of the respondents were Christians (84%).  90% understood circumcision as an act of the removal of the fore skin of the male genital organ and the same percentage had received information about circumcision. Furthermore, 90% considered circumcision important and almost all (98%) knew of somebody in the community who had undergone the procedure.  68% of the males interviewed had already been circumcised.  72% of the respondents thought that circumcision can reduce the spread of HIV/AIDS.

37 | P a g e

RECOMMENDATIONS  The ministry of health through health service providers should health educate the community on the importance of circumcision through outreaches and health talks in the health service facilities.  The government of Uganda should join hands with non-governmental organizations to provide sufficient information to people on the importance of circumcision towards reduction of HIV/AIDS.  The attitude of people should be changed and to be let them be aware and know that it is every ones responsibility to fight against HIV/AIDS.  Personal hygiene educational programs should be arranged in various institutions like in schools, churches, hospitals, political meetings to discourage poor personal hygiene which to some extent contribute to diseases of the genitals.

38 | P a g e

WORK PLAN OBJECTIVES ACTIVITIES MAY JUNE JULY INDICATORS

Administrative Choosing & Supervisor and Requirements Presentation of the Researcher research topic for approval

Proposal Writing Writing a proposal and Supervisor and preparing research tools Researcher

Typing and binding the proposal

Handing the proposal to the supervisor

Gathering Data Distribution of research Researcher tools and collection

Data Analysis Making sense of the Researcher collected information

Compiling the analyzed information

Discussing, finalizing, the findings.

Dissemination Of Copies of the Researcher Findings dissertation presented to DEAN, KIUWC library and conferences

39 | P a g e

BUDGET

ACTIVITY QUANTITY AMOUNT PER TOTAL QUANTITY AMOUNT

Reams of plain papers 4 25000 100,000

Pens 4 500 2000

Research assistant 2 170,000 340,000

Collection of information 280,000 280,000

Typing and printing 6 110,000 660.000 sTransport 10 8000 80,000

Miscellaneous 200,000 200,000

Total 1,662,000Ugshs

40 | P a g e

REFERENCES

Wrana, P. (1939). "Historical review: Circumcision". Archives of Pediatrics56: 385–392.

Gollaher, David L. (February 2000). Circumcision: a history of the world’s most controversial surgery.

Rizvi, Naqvi, Hussain, Hasan (1999). "Religious circumcision: a Muslim view"

Schmid GP, Dick B. (2008). "Adolescent boys: who cares?"

Schoen, Edgar (01 Dec 2007). "Should newborns be circumcised? Yes".

Milos, Marilyn Fayre; Donna Macris (March–April 1992)."Circumcision: A medical or a human rights issue?"

New Data on Male Circumcision and HIV Prevention: Policy and Programme Implications.World Health Organization. March 28, 2007. http://www.who.int/hiv/mediacentre/MCrecommendations_en.pdf. Retrieved on 2007-08-13.

Male Circumcision and Risk for HIV Transmission and Other Health Conditions: Implications for the United States". Centers for Disease Control and Prevention. 2008. http://www.cdc.gov/hiv/resources/factsheets/circumcision.htm

41 | P a g e

Trends of circumcision among newborns.National Hospital Discharge Survey.National Center for Health Statistics. January 11, 2007. http://www.cdc.gov/nchs/products/pubs/pubd/hestats/circumcisions/circum cisions.htm. Retrieved on 2008-08-19.

Weis H, Quigley M, Hayes R. male circumcision and risk of HIV infection in sub- Saharan Africa: a systematic review and meta-analysis. AIDS 2000; 14: 2361- 2370.

Bailey RC, Moses S, Parker CB, Agot K, Maclean I, Kreiger JN et al. male circumcision for HIV prevention in young men in KIsumu, Kenya: a randomized controlled trial. Lancet 2007; 369:643-656.

Gray RH, Kigozi G, SerwaddaD,Makumbi F, Watya S, Nalugoda F et al. male circumcision for HIV prevention in men in Rakai, Uganda: a randomized trial.Lancet2007; 369: 657-666.

Gray RH, Kiwanuka N, Quinn TC et al. male circumcision and HIV acquisition and transmission: cohort studies in Rakai, Uganda. Rakai Project Team.AIDS2000; 14: 2371-2381.

42 | P a g e

APPENDICES

APPENDIX A

Questionnaire on the assessment of the attitude and knowledge on circumcision towards reduction of HIV/AIDS incidence among Ishaka- Bushenyi residents.

PART A: SOCIO DEMOGRAPHIC DATA

1. Age (years) of the respondents a) 18-25 b) 26-35 c) 36-47 d) 47-49 e) Above 50 2. Sex a) Male b) Female 3. Marital status a) Single b) Married c) Separated d) Widow/widower e) divorced 4. Religion a) Christians b) Muslims

43 | P a g e

PART B: KNOWLEDGE OF RESPONDENTS ON MALE CIRCUMCISION

1. What is circumcision in your own understanding ………………………. ……………………………………………………………………………………………………………

2. Where do you think circumcision should be conducted from? a) hospital b) at village health facility c) home 3. Who do you think in the community should undergo circumcision? a) infants b) Adolescents c) adults d) male e) Other {specify}……………………………………………………………

4. What reason do you know that leads to male circumcision? a) illness b) religion c) culture d) hygiene e) Other ………………………………………………………………………… 5. I) Have you ever received any information on circumcision? a) YES

b) NO

44 | P a g e

ii) If Yes, where

a) health workers b) Friends c) Mass media ( Radio, TV, Newspaper) d) Medical journals e) Other …………………………………………………………… 6. Mention the complications of circumcision a)……………………………………….

b)……………………………………….

c)………………………………………

PART C: PRACTICES

1. How do you think a circumcised person should be managed?

a) Administer drugs at home

b) Isolation at home

c) Managed from hospital

d) Don’t know

2. Do you think he needs any attendant at home?

a) YES

b) NO

45 | P a g e

3. For how long should a person be on medication after surgical circumcision?

a) one month b) until full recovery c) one week d) two weeks e) Others {specify} ……………………………………………………….. 3. Have you ever considered circumcision important? a. Yes b. No ii. If yes, do you have plans for the procedure? A) Yes B) No C) Already circumcised 4. Do you know of anybody who has undergone circumcision in your community? a. YES b. NO PART E: ATTITUDE

1. Do you have traditional beliefs or taboos against circumcision?

a) Yes

b) No

46 | P a g e

ii. If YES, what are they? ……………………………………………………………………………………………………………………………… ………………………………………………

2. How do people in your community regard someone who is circumcised? a) civilized b) cultured c) religious d) Other ……………………………………………… 3. Do you think circumcision can reduce the spread of HIV/AIDS?

………………………………………………………………………..

4. What is your impression on a person who is circumcised? a) Better b) Not different c) worse 5. Is circumcision a health issue in your area? a) YES b) NO

47 | P a g e

APPENDIX B MAP OF BUSHENYI SHOWING STUDY AREA

48 | P a g e

APPENDIX C MAP OF UGANDA

49 | P a g e