Intrapersonal level (Individual characteristics that influence behaviour)
Individuals’ knowledge about male circumcision as a prevention of sexually transmitted infections
Both men and women stated that male circumcision is a procedure of removing or cutting the foreskin of the male sexual organ [penis]. Women in particular related this procedure with a kind of manipulation that exposes the hidden part of the penis:
"“Circumcision as circumcision is the act of removing the outer skin of the male sexual organ in order to expose the head of the penis” (Woman, 27 years, Christian)."
Other informants elaborated that such manipulation enhances hygiene of the private parts. They emphasised that cleanliness of the private parts can prevent sexually transmitted infections. They voiced additional views on how circumcision can contribute to the prevention of sexually transmitted infections from an infected woman to uninfected man. One informant stated:
"“A woman may be infected with syphilis, gonorrhoea; it is very easy to infect a man [uncircumcised] because the fluids [the infectious vaginal fluid] will be retained in the man’s foreskin…” (Man, 37 years, Christian)."
Most of the informants emphasised the importance of circumcision in preventing HIV transmission. They believed that uncircumcised men could easily get HIV from the infected women because of friction between the penis and vagina. They imagined that such friction could cause bruises that can facilitate HIV transmission from infected woman to uninfected man. Nevertheless, they cautioned about the effectiveness of circumcision in preventing HIV transmission. One informant said:
"“It doesn’t mean that HIV transmission cannot occur, it can, but not as quick as when one is uncircumcised; the chances of infection are low” (Man, 40 years, Christian)."
Despite the awareness that male circumcision can minimize chances of HIV transmission, some informants claimed that promotion of male circumcision might facilitate HIV transmission. They suspected that circumcised men might practice unprotected sexual intercourse believing that they are protected. One informant said:
"“If you tell those who are circumcised that they cannot get HIV infection, they will not use a condom. They will even stop all other prevention methods believing that they cannot acquire the HIV infection because they are circumcised. However, if you clarify that the chances of getting infection are low, they will understand” (Man, 35 years, Christian)."
Women emphasised that cleanliness and prevention of diseases are very important during sexual intercourse, and that women tend to disrespect uncircumcised men. One informant narrated:
"“When a woman notes that you [man] are not circumcised, she will disrespect you. This is because the retained powder [old dried seminal fluids] will get into her vagina during sex, and the woman does not know the diseases the powder carries” (Woman, 32 years, Christian)."
In addition, some of the informants stated that during sexual intercourse, an uncircumcised penis needs regular cleaning. Otherwise, the accumulated fluids would have an offensive smell. They added that the foreskin could interfere with penetrative sex. In comparison, they reported that a circumcised penis does not retain the fluids after sexual intercourse. Both men and women felt that a circumcised penis looks clean and good in shape.
Individuals’ beliefs towards male circumcision
The informants’ beliefs on circumcision were tied to religious rituals. They expressed their obligation to circumcising young boys to maintain these rituals. Christians referred to documentations regarding circumcision in the Holy Scriptures. They emphasised that after eight days Jesus was circumcised, and that it would be good to adhere to this ritual of circumcising boys while they are still young. Similarly, the Muslims emphasised that uncircumcised men cannot participate in mosque services or in burial ceremonies. They added that for the true Muslims, circumcision is compulsory.
Some of the informants stated that, traditionally, male circumcision is a period of transition for the boys from childhood to adulthood:
"“It is a transition… starting from ten years to fifteen years old. This is the period… For example in the village they prefer to take the boys to the initiation ceremonies [known as jando]” (Man, 37 years, Christian)."
Other informants reported that they circumcise their children based on both religious and traditional principles. One informant said:
"“My culture has influenced me to circumcise my child because I knew that a boy must undergo circumcision. Even in the Bible it is written that boys must be circumcised. Second, I knew if I do not circumcise him, he will feel bad when he becomes an adult” (Woman, 48 years, Christian)."
Individuals’ perceptions on male circumcision
The informants perceived that male circumcision could increase sexual pleasure and confidence during penetrative sexual intercourse among adults. Nevertheless, they felt that this kind of pleasure might exacerbate HIV transmission among uninfected men:
"“The chances of HIV transmission are high. During sexual intercourse, psychologically, a circumcised man experiences extra pleasure as compared to the uncircumcised one; and the more pleasure, the more intention to have sex with more women…” (Man, 35 years, Christian)."
Similarly, they added that some women experienced extra sexual pleasure with circumcised men than with uncircumcised ones. One informant stated:
"“Some (women) of us have been reporting that we feel very good when we have sex with a circumcised man…” (Woman, 27 years, Christian)."
Individuals’ attitudes towards male circumcision
The informants raised concerns about the age at circumcision. Most of them expressed negative attitude towards male circumcision after childhood. They stated that they would prefer circumcision at early childhood because young boys express less pain than adult men. They reasoned that men have matured vessels. In addition, unlike young boys, men experience sexual desires that lead to erection; the erection may impair the healing process of a circumcised penis:
"“It is difficult for an older man; remember the penis gets bigger and bigger [erection]. Then there is abundant blood supply in the matured vessels, eeh, So they [adults] experience severe pain. I have seen a man in his 40s being circumcised…you can imagine, but for a child it is different” (Woman, 32 years, Christian)."
Most informants supported that it is not desirable for a sexually active man to undergo circumcision. They expressed their worry that when a freshly circumcised man is in need of having penetrative sexual intercourse, the stitches might open up. They emphasised that erection of the penis may interrupt the healing process. For similar reasons, they viewed that uncircumcised men may hesitate to be circumcised. They related this worry to the perception that men establish sexual relationships and start practicing sexual intercourse early. Therefore, undergoing circumcision at older age may not be a desirable decision. However, they stated that if circumcision is compulsory, then their privacy is at stake. In line with keeping the procedure private, they expressed worries in case something went wrong at home or at workplace:
"“… it is shame to go back to the hospital; imagine people may be staring at you [circumcised man] that you were not circumcised at childhood… I mean it is shame for an adult man” (Man, 40 years, Christian)."
Other informants added that it is impossible for men working full-time to find time in their daily schedules to accommodate the circumcision procedure.
Interpersonal level (Interpersonal processes and personal groups: family, friends, and peers that provide social identity, support, and role definition)
The informants sensed that uncircumcised men might be neglected and disrespected in the community. Women elaborated that it is shameful, particularly for uncircumcised married men with children, to disclose their circumcision status. They considered that the surrounding community might know of the men’s circumcision status. One informant narrated:
"“Those who surround him will not understand him [uncircumcised man]. They will see him as an indigenous person. So he will keep it secret until when he experiences problems which require circumcision as a treatment” (Woman, 27 years, Christian)."
Another informant emphasised that there is uneasiness because everybody may know that a particular man has not been circumcised. Similarly, other informants stated that uncircumcised men might encounter shame when interacting with their peers. They voiced that, although seeking medical male circumcision might be for the best, the decision could be accompanied with negative consequences. One informant said:
"“They [uncircumcised] will feel guilty that, ‘I am now a grown up man. If I go to hospital, how are they going to perceive me?’ You see?… Perhaps, he may meet women who will laugh at him… (Man, 35 years, Christian)."
The informants reported that shame is obvious because instead of putting on a trouser, a freshly circumcised man wraps a cloth around his waist; sometimes he walks as if he has abscesses around the private parts. They thought that under such circumstances, one might skip going to work, and that colleagues could discover his circumcision status.
In addition, the informants stated that unlike circumcised men, uncircumcised men cannot date a woman or get married. Unlike the uncircumcised men, they felt that the circumcised men are more confident in initiating sexual relationships with women whom they love. One informant emphasised:
"“He [a circumcised man] has confidence… I mean if he wants to date a woman, he is always confident; not anxious like those who are uncircumcised. Uncircumcised men often suspect that if they date women, the women will see the penis, dislike it, disrespect them, and disclose their circumcision status to other women” (Man, 35 years, Christian)."
They reasoned that most women investigate the circumcision status of a man before they engage in a sexual relationship. Similarly, some men stated that most women prefer circumcised men.
Institutional factors (Rules, regulations, policies, and informal structures, which may constrain or promote recommended behaviours)
Informants described two types of male circumcision. These are medical male circumcision (MMC) and traditional male circumcision (TMC). They expressed confusion whether people should opt for MMC or TMC given the existing differences in terms of personnel and the cleanness of the procedure. They reported that a skilled person in the community (known as a Ngariba) performs TMC, while a trained health care provider in the hospital performs MMC. However, most informants expressed concerns about the cleanliness of the instruments in both types. They said that the ngariba performs the procedure by using shared unclean instruments and without painkillers. Although they realized that circumcision by the ngariba is cheaper, they noted that such an unclean environment could facilitate the transmission of infections. Nevertheless, they predicted that some people might choose the TMC and use their own cutting instruments to minimize the risks of infection. One informant stated:
"“Circumcision is performed at home by sharing knives and it is costless… people are now educated… those who prefer the traditional practice, they carry their own knives…” (Woman, 48 years, Christian)."
Although they said that some people might opt for a MMC because of hygiene, they expressed concern about the cleanliness of hospital instruments. Some of them suspected that people could acquire an infection from unsterilized and improper handling of the instruments. One informant cautioned:
"“Although you may be told the instruments were boiled [sterilized], you may find out that they are not clean. You do not know the truth! Perhaps, they [instruments] have been there for a long time and bacteria are there; then without knowing all that, a person is circumcised using those instruments” (Woman, 32 years, Christian)."
The informants encountered increased expenses in MMC as compared to TMC. They argued that the economically deprived parents might want to circumcise their children, but cannot afford the expense of the MMC. Based on experience, they predicted that many children are not undergoing MMC because their parents cannot afford the expenses of medicine, cotton wool, and gloves. Under such circumstances, they concluded that boys may get too old, and as they get older, the cost of circumcision increases. One informant reported:
"“To get circumcision service you need 15,000Tsh [US9$]… plus other costs; an older boy 20,000Tsh [US13$]; the oldest 30,000Tsh [US19$]. Don’t you see it is a budget for other things… school fees, house rent… The economic status may impose a barrier, and one can postpone the procedure, only to find out that the boy is getting older without being circumcised (Woman, 33 years, Muslim)."
Additionally, the majority of the informants were concerned about the cost involved in MMC. They stated that although the TMC is also costly, they found the cost to be negotiable. They also stated that the ceremonial expenses of TMC (jando) could be managed during the harvesting period.
Other informants reasoned that the issue of socio-economic status should not be a barrier to perform circumcision to the young boys. They proposed that the consequences of not circumcising might affect economic growth because men could get an HIV infection and die, leading to decreased manpower.
Commonly, informants embraced male circumcision as a cultural practice through which awareness of responsibilities among young boys is enhanced. They stated that during circumcision they can teach young boys about what the community expects from them, and this becomes part of the culture. According to one informant:
"“During ‘jando’, the boys are taught about moral issues such as how to live with their parents; how to live with different tribes according to their cultural preferences…” (Man 37 years, Christian)."
The informants added that uncircumcised men might be prone to ignorance about their roles and expectations in the society. Unlike the circumcised men who know their roles from “jando,” the uncircumcised men lack that education. Thus, the uncircumcised men may be considered useless in the community as exemplified in the following quote:
"“A man walking on the street may see a kanga [a piece of cloth Tanzanian women cover themselves with] spread on the road. Those who have passed jando know what it means. They will look around trying to find out if there is a woman who is alone, about to deliver, and in need of help… they know what to do…; they will assist the woman according to what they were taught …” (Man, 37 years, Christian)."
Informants insisted that in some tribes uncircumcised men are grouped with immature boys; in other tribes they are warned that they will never get married and they are restricted from participating in cultural ceremonies. For example, one informant stated:
"“They may participate in the dowry receiving ceremony, but they will not be allowed to hold the dowry; they may be there but not in the front line” (Woman, 48 years, Christian)."
Most informants discussed how the community perceives uncircumcised men. They predicted that uncircumcised men might get old and die without having a sexual relationship with any woman because most women prefer circumcised men.
In contrast, some informants recalled that men from tribes that do not place a priority on male circumcision could marry from within their tribes. Other informants insisted that men from the tribes that do not circumcise should be regarded as normal because circumcision is not their cultural norm. In addition, they emphasised that being uncircumcised is not a reason of not fathering a child. One informant emphasised:
"“I would accept them the way they are because they are human beings… being uncircumcised does not mean that one is missing lots of things. Let us say, for example, to father a child; no, they can. They are just like other men…” (Man, 43 years, Christian)."
They stated that the man’s value is always there given that his circumcision status is kept secret. One woman emphasised that when a woman goes [has sex] with a man who is uncircumcised, she will never disclose that she had been with an uncircumcised man because friends will stare at her. Others noted that uncircumcised men might feel inferior in front of their colleagues and might harbour a sense of incompleteness, not speaking up as men, and always lagging behind because of that sense of incompleteness.
The informants reported that problems could arise when uncircumcised men move to big cities where male circumcision is commonly practiced. They said that uncircumcised men might be prone to stigma and discrimination from their peers in the cities who are circumcised. One informant stated that he would convince those who are not circumcised to be circumcised because he knows the benefits of male circumcision. Similarly, after marriage, some women said they might convince their uncircumcised partners to be circumcised.
Public policy (policies and laws that regulate or support healthy actions and practices for disease prevention, early detection, control, and management)
Informants expressed eagerness to have health policies that promote male circumcision. However, they cautioned that policy implementers should assess people’s cultural preferences. Most informants voiced the need of promoting the advantages of MMC particularly in regions with low male circumcision prevalence. From their experiences, they stated that the majority of the uncircumcised men reside in the villages. They stated that the government should integrate free male circumcision services within the routine childhood vaccination programmes and waive the circumcision fee in the hospitals. The following quote elaborated the idea:
"“This procedure should be given free of charge… perhaps it should be integrated in the routine childhood vaccination; once the baby boy is born he gets the service… there should be a record of all boys born in a certain month. Immediately when they get the third vaccination, they should be circumcised… circumcision should be part of the vaccination programme” (Woman, 33 years, Muslim)."
In addition, they emphasised on the need of education to promote male circumcision right after birth of a baby boy in the hospital. They believed that if mothers of the boys were educated after delivery and before discharge home, they might easily understand the importance of circumcision for the well being of their boys.
Informants stated that educating the mothers right after delivery could be a crucial time to aid in the decision to circumcise their sons. They suspected that when boys become older it would be difficult to point out who has been circumcised and who has not. They believed that it is important to promote male circumcision through public education, particularly in regions where this practice is not a priority. They also highlighted the importance of educating all men and women about the benefits of male circumcision. They spoke about use of culturally appropriate approaches to reach more people as well. One informant shared a desirable approach:
"“The older and respected men who are influential in the community should be contacted first. It is commonly understood that if you want to succeed in any programme, those men should be involved… when they are educated and demonstrate understanding, the next generation will understand through them” (Woman, 27 years, Christian)."
Others believed in a sensitization approach that takes place in stages, as emphasized in the following quote:
"Educate pupils from class five; in turn, they should sensitize their parents… Parents should educate their girls so that they can convince their boyfriends during sports’ participation to undergo circumcision (Man, 25 years, Christian)."
Overall, the informants are proponents of public education that promotes male circumcision among the community members.