AN INTERVENTION STUDY TO DEVELOP A MALE CIRCUMCISION HEALTH PROMOTION PROGRAMME AT LIBODE RURAL COMMUNITIES IN THE EASTERN CAPE PROVINCE, SOUTH AFRICA by DOUGLAS MBUYISELO A thesis submitted in fulfilment of the requirements for the degree DOCTOR OF PHILOSOPHY IN HEALTH SCIENCES (DPHS) (Health Promotion) at WALTER SISULU UNIVERSITY SUPERVISOR: PROFESSOR TX MALULEKE CO-SUPERVISOR: Dr MJ NTSABA SEPTEMBER 2013 ABSTRACT The purpose of this study was to develop an intervention health promotion programme to prevent circumcision related health problem such as sepsis, botched circumcision, dehydration, penile amputation and reduce the number of deaths. The intervention programme was aimed at promoting a safe male circumcision practice affecting boys aged 12-18 years at Libode rural communities in Eastern Cape Province of South Africa. This was achieved through a mixed method design using both quantitative and qualitative approaches utilizing sequential transformative strategy to allow for the convergence of multiple perspectives of the traditional male circumcision in Libode. The study was conducted in 22 schools of the rural communities of Libode because most of the participants are still attending school. Frequencies and percentages were used to analyse the quantitative data, utilizing the Statistical Package for Social Sciences (SPSS). A total of 1036 participants, AmaXhosa circumcised young men (abafana) and uncircumcised boys (amakhwenkwe) participated in the cross-sectional survey, quantitative phase of the study. Qualitative phase of this study was composed of 7 focus group discussions with a total of 84 circumcised and uncircumcised male participants and 10 key informants’ interviews were conducted. In analysis qualitative data, the researcher found the most descriptive words for each topic and turned them into categories or sub-themes. Topics that related to each other were then grouped in order to reduce the number of categories and to create themes. The similar categories of data were grouped and analysed using Tesch’s method. Findings indicated that traditional circumcision is performed during winter and summer holidays in order to cater for the boys who are attending schools. The circumcision age at Libode ranges from 12 and 18 years of age which is against the Health Standards in Traditional Circumcision Act (Act No. 6 of 2001). Although the participants were aware of the complications of male circumcision in Libode, there was a high preference for traditional circumcision (92.3% of participants) to hospital circumcision. The participants were of the view that the benefits of traditional circumcision outweigh the complications or challenges related to traditional circumcision. They wanted to be socially accepted and wanted to learn about manhood values in the traditional circumcision which are values that cannot be achieved through the hospital based circumcision. As male circumcision initiation is seasonal and the intervention programme needed to be approved by different stakeholders, the testing of intervention programme could not happen before the programme was approved by all the stakeholders. ii DECLARATION I, Mbuyiselo Douglas, student number 209201061, solemnly declare that this thesis titled “An intervention study to develop a male circumcision health promotion programme at Libode rural communities in the Eastern Cape Province, South Africa” is my original work. All citations and sources used in the study have been indicated and acknowledged in the form of complete referencing. THESIS CANDIDATE: MBUYISELO DOUGLAS SIGNATURE: ................................................. DATE: .......................................................... SUPERVISOR: PROFESSOR TX MALULEKE SIGNATURE: ................................................ DATE: ......................................................... CO-SUPERVISOR: DOCTOR MJ NTSABA SIGNATURE: ............................................... DATE: ........................................................ iii PLAGIARISM DECLARATION a) I am aware that plagiarism is defined at Walter Sisulu University (WSU) as the inclusion of another’s or others’ ideas, writings, works, discoveries and inventions from any source in an assignment or research output without the due, correct and appropriate acknowledgement to the author(s) or source(s) in breach of the values, conventions, ethics and norms of the different professional, academic and research disciplines and includes unacknowledged copying from intra- and internet and peers/fellow students. b) I have duly and appropri ately acknowledged all references and conformed to avoid plagiarism as defined by WSU. c) I have made use of the citation and referencing style stipulated by my supervisor. d) This submitted work is my own. e) I did not and will not allow anyone to copy my work and present it as his/her own. f) I am committed to uphold academic and professional integrity in the academic/research activity. g) I am aware of the consequences of engaging in plagiarism. ________________________ _____________________ Signature Date iv ACKNOWLEDGEMENTS I give all the praise and gratitude to Almighty God for allowing me an opportunity to conduct and complete this study. I thank the Lord for the knowledge and blessings He has granted me. I would also like to thank the following people and the organisations for the role they have played in this study: My supervisor, Professor Thelmah Xavela Maluleke, for her guidance, motivation, shared experience and tireless academic support; My co-supervisor, Dr Mohlomi Jafta Ntsaba, for his continuous motivation and unwavering support; My family for their understanding and patience when I could not be with them because of this study; Nyandeni Great Place for entrusting me to work with UBUNTU BETHU Circumcision Project and the Council of King Ndamase, Ndlovuyezwe; The Department of Health Promotion staff members, Faculty of Health Science Senior Management, Walter Sisulu University for their continued support; The Department of Education at Libode district for allowing me to do data collection at various schools at Libode rural communities; Professor Bernal, Mr Isaac Malema and Prof Longo Mbenza for helping with the data analysis of this study, and Ms Xolisa Madolo for translation; The Research Development Directorate, Walter Sisulu University for partly funding my study; DST/NRF, Risk and Vulnerability Assessment Centre (RAVAC) for backing up funding in times of financial difficulties at Walter Sisulu University; The participants in this study for their co-operation and willingness to participate in this project. To those whose names I might have omitted, I extend my sincere gratitude for your contribution to my study. May God richly bless you. v DEDICATION I would like to dedicate this research to my late mother, Notayiti Tokazi Douglas, who deeply inculcated inspiration inside of me to pursue knowledge and understanding of education. She taught me how to overcome barriers and face challenges ahead. I would also like to dedicate this study to my late grandmother, NoAmen Nomsebenzi Ngqubekile who devoted her life praying for me and for the whole family. Lastly, I would like also to dedicate this study to my dear wife, Nozuko Bukelwa Douglas who is always next to me, supporting me at all times whilst pursuing my academic endeavors. To my children Joshua, Linamandla, Siyanda, Nandipha, Xolisa, Lihle and Wanda for their understanding and comforting support whilst I was studying over the years. vi ACRONYMS AAP – American Academy of Paediatrics AFSA – AIDS Foundation South Africa AIDS – Acquired Immunodeficiency Syndrome DMO – Designated Medical Officer FGD – Focus Group Discussion HIV – Human Immune Deficiency Virus HPV – Human Papilloma Virus ID – Identity Document JSS – Junior Secondary Schools KSD – King Sabata Dalindyebo Municipality MEC – Member of Executive Council OR – Oliver Reginald Tambo District SPSS – Statistical Package for Social Sciences SSS – Senior Secondary Schools STI – Sexually Transmitted Infection TCF – Traditional Circumcision Forum USA – United States of America WHO – World Health Organization vii TABLE OF CONTENTS PAGE Abstract..…………………………………………………………………………………………… ii Declaration………………………………………………………………………………………… iii Plagiarism Declaration………………………………………………………………………… iv Acknowledgement……………………………………………………………………………… v Dedication………………………………………………………………………………………… vi Acronyns…………………………………………………………………………………………… vi LIST OF TABLES………………………………………………………………………………… xv LIST OF FIGURES……………………………………………………………………………… xvi LIST OF APPENDIXES………………………………………………………………………… xix CHAPTER 1 OVERVIEW OF THE STUDY 1.1 Introduction…………………………………………………………………………… 1 1.2 Background of the study…………………………………………………………… 3 1.3 Statement of the problem…………………………………………………………10 1.4 The purpose of the study ………………………………………………………… 13 1.5 Objectives of the study……………………………..……………………………… 13 1.6 Research Questions………………………………………………………………… 13 1.7 Significance of the study…………………………………………………………… 14 1.8 Concept Clarification………………………………………………………………… 15 1.8.1 Health promotion……………..……………………………………………………… 15 1.8.2 Intervention study…………………………………………………………………… 16 1.8.3 Male circumcision……………..……………………………………………………… 17 1.8.4 Rural communities…………………………………………………………………… 18 1.9 Conceptual or theoretical model………………………………………………… 19 1.9.1 Health Persuasion…………………………………………………………………… 20 1.9.2 Legislative Action………………………………………………………………………20 1.9.3 Personal Counselling………………………………………………………………… 21 1.9.4 Community Development……….…………………………………………………