FACTORS INFLUENCING CIRCUMCISION OF YOUNG MALES IN HARARE, ZIMBABWE. CANDIDATE: KUDZAISHE MANGOMBE STUDENT NUMBER: 24903345 THESIS SUBMITTED IN FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY IN DEMOGRAPHY AND POPULATION STUDIES IN THE FACULTY OF HUMAN AND SOCIAL SCIENCES, NORTH-WEST UNIVERSITY (MAFIKENG CAMPUS), SOUTH AFRICA PROMOTER: PROFESSOR ISHMAEL KALULE-SABITI CO-PROMOTER: PROFESSOR ACHEAMPONG YAW AMOATENG DATE: APRIL 2017 DECLARATION I hereby declare that, except for references to other research works which have been duly acknowledged, this thesis is the results of my own research and it has not been submitted elsewhere either in part or wholly for another degree. Signature ………………………………………………. Kudzaishe Mangombe (Candidate) Date…………………………………………………….. i DEDICATION I dedicate this work to my family and friends ii ACKNOWLEDGEMENTS First, I thank the Almighty God for granting me abundant grace, wisdom and strength to withstand and overcome all challenges throughout this difficult journey. I would like to thank my principal Supervisor Professor Ishmael Kalule-Sabiti for his encouragement, wisdom, his moral support, and his constructive criticism from the smallest piece of my work. I am also indebted to my co-supervisor Acheampong Yaw Amoateng, whose passion for rigorous and meaningful research always encouraged me towards excellence. I am thankful for those who supported me for my fieldwork. I received financial support from North-West University -Mafikeng Campus, South Africa. I thank my research participants for sparing their precious time. Most importantly, I extend my sincere thanks to my research assistants, Tapiwa Chirenje, Washington Dune, Kudzai Ndemera, Josphat Jekera and Tapiwa Mangombe. I also extend my deep gratitude to my friend Kamil Fuseini, for his dedicated work, mentoring me through the quantitative part of this dissertation. He offered technical guidance, moral support, and encouraged me, when I felt I could not handle the pressure anymore. I would like to thank my friends Lutendo Malisha and Sithokozile Masuku for the financial support they gave me. I am forever grateful to Nyika Mangombe, my husband for his patience and belief in me. Not only did he spend almost three years in Zimbabwe taking care of our children during my studies but also without him, none of this could have been achieved. I could have not made it without the support from my lovely son, Tapiwa and, daughter Rumbidzai. You always gave me hope even in my darkest days. I would like to thank my mother, Shumirai Mativenga, for the encouragement and always checking on my welfare and progress. Additionally, I would like to thank my dearest twin brother, Kuzivakwashe Mativenga who constantly reminded me about my capability. I thank my sister in-law Dzidzai Mangombe, for your support. iii ABSTRACT This thesis is a study of the factors influencing young male circumcision in Harare, Zimbabwe utilising an explanatory sequential mixed method research approach to examine the factors. The study used cross-sectional data on 784 men, 26 in-depth interviews with the study population and 6 in-depth interviews with key informants (opinion leaders) collected in 2014. The quantitative data sought to examine factors influencing male circumcision and willingness to circumcise among men aged 15-35, utilising various data analysis techniques such as frequencies, binary logistic regression and multinomial logistic regression to achieve the objectives of the study. The qualitative data built on the quantitative results, which sought to provide a deeper understanding of the myths and perceptions surrounding male circumcision uptake and willingness to circumcise, using the thematic analysis approach. Respondents who had tested for HIV were less likely (OR=0.13, p<0.05) to be circumcised compared to those who never tested. There was a positive significant relationship between knowledge about male circumcision and male circumcision status. With respect to attitudes, men who indicated that they had favourable attitude towards male circumcision were more likely (OR, 2.79, p<0.05) to be circumcised. In addition, the study found that, there was a negative association between age and willingness to circumcise. Specifically, youth aged 25- 29 were less likely (OR, 0.91, p<.0.1) to be willing to circumcise compared to those aged 30- 35. Youth who reported to have attained primary education were less likely (OR=0.395, p<0.05) to be willing to circumcise compared to those aged 30-35. Additionally, youth who indicated that they had secondary education were (OR=0.581, p<0.05) less likely to be willing to circumcise. Respondents who belonged to the Apostolic sect were more likely (OR, 2.78, p<0.05) to be willing to circumcise than respondents who belonged to No religion. Furthermore, perception of risk to HIV infection was significantly related to willingness to circumcise. Respondents who perceived themselves to be at a higher risk to HIV infection were less likely (OR=0.573, p<0.1) to be willing to circumcise compared to those who perceived themselves to be at no risk. Moreover, the findings showed that young men who had favourable attitudes towards male circumcision were more likely (OR, 3.29, p<0.05) to report willingness to circumcise compared to those who had unfavourable attitude. Knowledge of male circumcision was not significantly related to willingness to circumcise. The qualitative results revealed that perceptions and myths surrounding male circumcision were widespread and they either inhibit or promote male circumcision uptake or willingness to circumcise. For instance, myths surrounding foreskin disposal, perceived fear of HIV testing, perceived adverse effects and perceived effect of circumcision on sexual pleasure impacted on uptake of male circumcision. There was also the recognition that respondents had incomplete knowledge about male circumcision and it partial prevention of HIV infection. The study’s findings highlight the need to promote HIV health education, which would emphasise the health benefits of male circumcision and deliver correct messages about the partial protective effects of male circumcision against HIV infection. In addition, there is the need to run programmes that would demystify perceptions and myths surrounding male circumcision in the communities. iv TABLE OF CONTENT Contents Page DECLARATION ..................................................................................................................................... i DEDICATION ........................................................................................................................................ ii ACKNOWLEDGEMENTS ................................................................................................................... iii ABSTRACT ........................................................................................................................................... iv TABLE OF CONTENT .......................................................................................................................... v LIST OF TABLES ................................................................................................................................. ix LIST OF FIGURES ................................................................................................................................ x CHAPTER 1: INTRODUCTION ......................................................................................................... 1 1.1 Introduction ................................................................................................................................... 1 1.2 Statement of the problem and rationale of the study .............................................................. 4 1.3 The main objective ................................................................................................................. 8 1.3.1 Specific objectives ......................................................................................................... 8 1.3.2 Research Questions ......................................................................................................... 9 1.4 Background of Zimbabwe ....................................................................................................... 9 1.4.1 Study area ............................................................................................................................. 12 1.5 Organisation of the study ..................................................................................................... 14 CHAPTER 2: LITERATURE REVIEW AND THEORETICAL FRAMEWORK ........................... 15 2.1 Introduction ........................................................................................................................... 15 2.2 Ritual circumcision to medical male circumcision .............................................................. 15 2.3 Male circumcision ................................................................................................................. 19 2.4 Male circumcision in sub- Saharan Africa ............................................................................ 19 2.5 Male circumcision in Zimbabwe ........................................................................................... 22 2.6 Knowledge about male circumcision .................................................................................... 23 2.7 Attitudes towards male circumcision ...................................................................................