Circumcision can be done for a range of religious, cultural, or medical reasons, and it’s often a mix of these things. Being circumcised is somewhat of a social norm, and the success of the VMMC programmes in areas where men typically aren’t circumcised relies on creating a demand among adult men to be circumcised – a shifting of a social norm.
In Zimbabwe, the rate of male circumcision prior to implementation of the VMMC programme was among the lowest in the Southern African region at 10% (1). Since the programme began in 2009, the numbers of new adult circumcisions has been lower than expected, with only 170,000 men circumcised against a five-year target of 1.9 million.
A new study published as part of the PLOS VMMC collection explored the barriers and motivators for circumcision among men in Zimbabwe, to understand why the circumcision rates are so low (2). The study authors conducted a nationally-representative survey in February 2013 of 2350 Zimbabwean men and women aged 15 to 49. Half of the survey respondents were women and half were men, which provided an interesting opportunity: the chance to learn about women’s perspectives towards circumcision, as they may influence their male sexual partners’ decisions to be circumcised.
A gap between knowledge about circumcision and actually having it done
In the survey, two-thirds of the Zimbabwean men (68%) and just over half of the women (54%) had heard about VMMC as a way to prevent HIV transmission. Most men (over 80%) knew that VMMC can protect against sexually transmitted infections, that it improves penile hygiene, and that VMMC is only partially protective against HIV transmission and circumcised men still need to used other HIV prevention methods (2). So, it seems like most people have correct knowledge about VMMC. However, only 11% of men were actually circumcised (the same as the nation-wide rate in Zimbabwe). The remaining men either said that they intended to get circumcised (49%) or that they were not interested in getting circumcised (40%). This gap between knowledge and behaviour brings about an important question: why do men who know about a simple medical procedure to help prevent HIV not want to get it done?
Why adult men do or don’t get circumcised
Among the men who said they were willing to be circumcised, over 90% said that they would do it to prevent HIV and other STIs (2). A second common reason among all men was to improve their hygiene. Interestingly, older men also said they would do it to improve their sexual performance and to set a good example for their community. When the men who did not want to be circumcised were asked why, the most important reason was fear of pain during the procedure. Other barriers to circumcision were that some men believed that they weren’t at risk for HIV and that they weren’t promiscuous. Misconceptions such as having the testes cut by mistake, and worry about having to take an HIV test before being circumcised were reported by some men as well.
The important influence of women
Importantly, social support was a major motivator for circumcision. Men who said that they had support from friends were three times more likely to have been circumcised than men who didn’t. Among older, married men, partner refusal was a major barrier to being circumcised. In the study, one man reported that his wife “confronted him and subsequently discouraged him from going for VMMC.
She [wife] asked ‘why do you want to go for circumcision when you are already married? They say it offers prevention from HIV; where do you think the HIV will come from?’” (2).
This issue of marital trust is a sticky issue, and may require careful communication to the public from VMMC programmes in order to increase support within committed couples. However, over 70% of women in the study who had heard of VMMC reported being supportive of their male partner being circumcised, which means that women may be an important source of influence in promoting circumcision as a social norm among men in Zimbabwe.
What does it all mean?
Clearly, lack of awareness or knowledge is not the major barrier to circumcision among adult men in Zimbabwe. Most men had heard about VMMC as a way to help prevent HIV, and had good knowledge about it. However, 40% of men still had no interest in being circumcised. The main barriers were fear of pain, misconceptions about circumcision, and lack of support from their partners. Importantly, only half of women had heard about VMMC to help prevent HIV, which means that women need to be better informed to help support their male partners. Given that the women who knew about VMMC were mostly positively towards having their partner circumcised, women probably represent an important influence upon the success of the VMMC programmes to reduce rates of HIV.
The Zimbabwe Ministry of Health and Child Care has used these and other research findings to inform a mass media campaign that frames VMMA as a lifestyle choice for the “’smart’ man, one who is clean and elegant” (2). Importantly, some of their messages have been tailored towards women to improve their knowledge by highlighting that VMMC improves a man’s hygiene and sexual appeal, while also protecting against cervical cancer.
Will the campaign work? It is a difficult thing to change health-related social norms at a population level, but we have seen it occur in Westernised countries with breast screening and mass immunisations.
The VMMC programmes and Zimbabwean health ministry are taking positive, evidence-based steps forward in promoting adult male circumcision. Hopefully time will tell us a major success story in the reduction of the HIV epidemic with these efforts.
1) Central Statistical Office (CSO) [Zimbabwe] and Macro International Inc. 2007. Zimbabwe Demographic and Health Survey (ZDHS) 2005-6. Calverton, Maryland: CSO and Macro International.
2) Hatzold K, Mavhu W, Jasi P, Chatora K, Cowan FM, Taruberekera N, et al. Barriers and motivators to voluntary medical male circumcision uptake among different age groups of men in Zimbabwe: results from a mixed methods study. PLOS One 2014; 9(5):e85051 doi: 10.1371/journal.pone.0085051
The Public Health Perspectives introductory post to this series, Part 1: How Male Circumcision Can Get Us Closer to an “AIDS-Free Generation”
Read all the papers in Voluntary Medical Male Circumcision (VMMC) for HIV Prevention: Improving Quality, Efficiency, Cost Effectiveness, and Demand for Services during an Accelerated Scale-up.