Situation analysis of male circumcision in Malawi April 2010 A report prepared by the College of Medicine Joseph Mfutso Bengo, PhD Kondwani Chalulu, MBBS, FCSECSA Jobiba Chinkhumba, MBBS, MSc Lawrence Kazembe, MSc, PhD Kenneth M Maleta, MBBS, PhD Francis Masiye, BA Don Mathanga, MBBS, MSc, PhD Situation analysis of Male Circumcision in Malawi Page 2 of 136 ACKNOWLEDGEMENTS .......................................................................................................... 5 ABBREVIATIONS AND ACRONYMS ..................................................................................... 6 GLOSSARY OF TERMS .............................................................................................................. 7 LIST OF TABLES ......................................................................................................................... 8 LIST OF FIGURES ..................................................................................................................... 10 EXECUTIVE SUMMARY .......................................................................................................... 11 ..................................................................................................................................................... 14 1. INTRODUCTION ............................................................................................................ 15 OBJECTIVES OF THE SITUATION ANALYSIS .................................................................... 19 2.1 MAIN OBJECTIVE ................................................................................................................ 19 2.2 SPECIFIC OBJECTIVES ........................................................................................................ 19 3.0 METHODOLOGY ............................................................................................................. 19 3.1 STUDY SITES AND SAMPLING CONSIDERATIONS .................................................... 19 3.2 DATA COLLECTION METHODS ...................................................................................... 21 Objective 1: ................................................................................................................................... 21 Objective 2: ................................................................................................................................... 22 Objective 3: ................................................................................................................................... 22 Objective 4: ................................................................................................................................... 23 Objective 5. ................................................................................................................................... 24 3.3 DATA HANDLING AND PROCESSING .......................................................................... 24 3.4 DATA MANAGEMENT AND ANALYSIS ....................................................................... 25 3.5 STUDY LIMITATIONS ........................................................................................................ 26 4. FINDINGS ......................................................................................................................... 27 4.1. CHARACTERISTICS OF PARTICIPANTS ........................................................................... 27 4.1.1 Demographic characteristics of KABP respondents ....................................................... 27 4.1.2 Socioeconomic status of KABP respondents ................................................................... 27 Situation analysis of Male Circumcision in Malawi Page 3 of 136 5. DISTRIBUTION AND DETERMINANTS OF MALE CIRCUMCSION IN MALAWI 32 5.1 PREVALENCE OF MALE CIRCUMCISION IN MALAWI ............................................. 32 5.2 AGE AT MALE CIRCUMCISION ....................................................................................... 37 5.2.1 Age at which male circumcision is conducted ................................................................ 37 5.2.2 Trends in male circumcision........................................................................................... 41 5.2.4 Estimated number of and timing male circumcisions in traditional settings. ................ 42 5.3 DETERMINANTS OF MALE CIRCUMCISION IN MALAWI ........................................ 43 5.3.1 Religion ........................................................................................................................... 43 5.3.2 Ethnicity ......................................................................................................................... 44 5.3.3 Social determinants ........................................................................................................ 47 Social desirability .................................................................................................................................. 47 Socioeconomic status ............................................................................................................................ 49 Perceived health and sexual benefits .................................................................................................. 50 5.3.4 Medical indications ......................................................................................................... 51 6 KNOWLEDGE, ATTITUDES AND PRACTICES SURROUNDING MALE CIRCUMCISION ....................................................................................................................... 53 6.1 KNOWLEGDE OF MALE CIRCUMCISION ................................................................ 54 6.2 ATTITUDES AND PERCEPTIONS ABOUT MALE CIRCUMCISION .......................... 56 6.2.1 Attitudes and perceptions of non-circumcised men towards male circumcision ............ 56 6.2.2 Perceptions of women towards male circumcision ......................................................... 57 6.2.3 Perceived benefits of circumcision .................................................................................. 59 6.2.4 Perceived consequences of circumcision ......................................................................... 59 6.3 ACCEPTANCE OF MALE CIRCUMCISION .................................................................... 63 6.3.1 Personal acceptance of circumcision among uncircumcised males. ................................ 63 6.3.2 Acceptance of circumcision for children of circumcised and uncircumcised men. ......... 66 6.3.3 Willingness to pay for male circumcision ....................................................................... 69 6.4 PREFERRED AGE OF CIRCUMCISION AND PROVIDERS .......................................... 70 6.5 DECISION-MAKING ABOUT WHETHER A MALE SHOULD BE CIRCUMCIZED OR NOT 71 7. SERVICE DESCRIPTION OF MALE CIRCUMCISION IN MALAWI. ................................................ 72 7.1 LOCATION AND TIMING: ................................................................................................. 73 7.2 TRAINING OF PERSONS PROVIDING MALE CIRCUMCISION: ................................ 74 7.3 COSTS ASSOCIATED WITH MALE CIRCUMCISION ................................................... 75 7.4 PROCEDURE OF MALE CIRCUMCISION: ...................................................................... 79 7.5 ADVERSE EVENTS ............................................................................................................... 80 7.6 PACKAGE AND SERVICE LINKAGES ............................................................................. 80 8 FACTORS AFFECTING RATES OF MALE CIRCUMCISION IN MALAWI ............. 81 81 FACTORS DECREASING RATES OF CIRCUMCISION ................................................. 81 8.2 FACTORS THAT NEED TO CHANGE IN ORDER TO INCREASE PROVISION OF HEALTH FACILITY-BASED MALE CIRCUMCISION ............................................................. 82 8.3 FACTORS THAT WOULD INCREASE DEMAND .......................................................... 83 9 SERVICE AVAILABILITY ASSESSMENT ..................................................................... 84 9.1 HEALTH FACILITY TYPES. ................................................................................................ 85 9.2 INFRASTRUCTURE, EQUIPMENT AND SERVICE AVAILABILITY. ......................... 85 9.3 SERVICE OUTPUTS .............................................................................................................. 86 9.4 MALE CIRCUMCISION SERVICE BENEFICIARIES ....................................................... 86 9.5 HEALTH WORKERS CAPACITIES ................................................................................... 87 9.6 HEALTH WORKERS TRAINING NEEDS ......................................................................... 87 9.7 MALE CIRCUMCISION COSTS ESTIMATES .................................................................. 88 9.8 MALE CIRCUMCISION SUPPY AND DEMAND ESTIMATIONS. .............................. 89 Situation analysis of Male Circumcision in Malawi Page 4 of 136 APPENDICES ............................................................................................................................. 91 APPENDIX 1 LIST OF ORGANISATIONS CONSULTED FOR DOCUMENTS ON MALE CIRCUMCISION. ............................................................................................................................ 91 APPENDIX 2. SUMMARY OF PUBLISHED AND UNPUBLISHED STUDIES ON MALE