Male circumcision will require high uptake among previously non-circumcising countries to realise the impact of circumcising in preventing HIV. Little is known about whether youths are knowledgeable about male circumcision and its relationship with HIV prevention and their perception of risk of HIV infection.
This article aimed to ascertain youth’s knowledge about male circumcision and perception of risk of HIV infection.
A quantitative study on 784 youth (men aged 15–35 years) was conducted in Harare, Zimbabwe, after obtaining their consent. Multivariate analysis examined the associations between background characteristics and knowledge about male circumcision and the perception of risk of HIV infection.
The results revealed that age was a significant predictor of knowledge about male circumcision among youth in Harare, as was educational attainment and ever having tested for HIV. In addition, youth who had heard of voluntary medical male circumcision were more likely to have high knowledge of male circumcision compared to those who had never heard of it. The results also showed that male circumcision status was associated with higher knowledge about male circumcision compared to those who were not circumcised. The study also found that educational attainment, belonging to the Shona ethnic group, never having tested for HIV and disapproval of voluntary counselling and testing prior to male circumcision were associated with the perception of risk of HIV infection.
The study provides two recommendations: the need to strengthen perceived susceptibility to HIV among the youth and the need for advocacy on the health benefits of male circumcision.
The aim of the study was to identify the sociodemographic factors associated with knowledge about male circumcision and the perception of risk of HIV infection among youth in Harare, Zimbabwe. Male circumcision as a subject is at the helm of HIV prevention. The eastern and southern Africa regions are most affected by HIV, with the number of people on treatment more than doubling since 2010, reaching nearly 10.3 million people, resulting in HIV- and AIDS-related deaths in the region decreasing by 36% since 2010.
Although strides have been made concerning improved sexual behaviour in most countries, some countries in sub-Saharan Africa have detected low condom use and an increase in the number of sexual partners in their surveys.
One of the potential challenges in adopting male circumcision in non-circumcising countries has been a lack of knowledge regarding the benefits in reducing HIV transmission.
Little is known about the impact of sociodemographic characteristics on knowledge about male circumcision and perception of risk of HIV infection among youth in Zimbabwe despite the fact that this is a key population in the fight against HIV. This study confines itself to youth aged 15–35 years, which is in line with the African Charter definition.
A cross-sectional study with a closed-ended questionnaire was conducted in Harare among male youth. The sample was calculated using Kish’s
Knowledge about male circumcision was measured by 10 items measured at the nominal level. The responses for each item were coded 0 and 1, with 0 indicating that an individual did not have knowledge about that particular question and 1 indicating that an individual did have knowledge about it. A knowledge score was obtained by summing up the individual knowledge questions. The score ranged from 0 to 10. The knowledge score was dichotomised. Previous studies have also dichotomised knowledge scores in a similar way.
Perception of risk of HIV infection was created from responses to a direct question: ‘Do you think you are at risk of HIV infection’? The responses were as follows: ‘Yes, at higher risk’ (assigned a value of 3); ‘Yes, at low risk’ (assigned 2); ‘No, not at risk at all’ (assigned 1).
The respondents were asked about their age in completed years, and these were categorised into 5-year age groups: 15–19, 20–24, 25–29 and 30–35 years. Education was categorised as primary, secondary and higher than secondary. Marital status was categorised as never married, married or living together, and never formerly married. Wealth status was measured using a household goods index, which was recoded into low, medium and high wealth status. The measure was derived from the presence of 10 household assets within the respondent’s household: generator, solar panel, radio, television, refrigerator, non-mobile telephone, computer, washing machine, car and electricity connected to the dwelling unit. Employment status was classified into unemployed or employed. Religion was categorised into mainline Christian, Pentecostal, apostolic sect, other Christian and no religion, while ethnicity was categorised into Shona or other. Respondents were also asked whether they had ever tested for HIV. The responses were ‘yes’ or ‘no’. Respondents were asked whether they approved of voluntary counselling and testing (VCT) prior to circumcision (yes or no). Lastly, respondents were asked whether they had ever heard of voluntary medical male circumcision (VMMC) (yes or no).
Data management and statistical analyses were performed using SPSS version 22. The chi-square independence test was used to compare the various sociodemographic and dependent variables. A binary logistic regression model was used to identify predictors of knowledge about male circumcision. Multinomial logistic regression was used to predict the net effect of the predictor variables (background characteristics) on perception of risk to HIV infection. In the model, the reference category for the dependent variable was ‘No, not at risk at all’.
Ethical clearance was granted by the relevant ethics council (Ethics number: North-West University [NWU 00210-14-A9] and Medical Research Council of Zimbabwe [MRCZ/A/1848]). A written informed consent was obtained from all the study participants after describing the objectives of the study to them. In addition, the respondents were assured of confidentially and anonymity.
Background characteristics of the study respondents (
Variable | Frequency | Percentage |
---|---|---|
15–19 | 182 | 23.2 |
20–24 | 229 | 29.2 |
25–29 | 192 | 24.5 |
30–35 | 181 | 23.1 |
Married or living together | 263 | 33.5 |
Formerly married | 26 | 3.4 |
Never married | 495 | 63.1 |
Primary | 37 | 4.7 |
Secondary | 617 | 78.8 |
Higher | 129 | 16.5 |
Low | 276 | 35.2 |
Medium | 248 | 31.6 |
High | 260 | 33.2 |
Employed | 439 | 56.0 |
Unemployed | 345 | 44.0 |
Mainline | 265 | 33.8 |
Pentecostal | 193 | 24.6 |
Apostolic sect | 169 | 21.6 |
Other Christian | 83 | 10.6 |
No religion | 74 | 9.4 |
Shona | 710 | 90.6 |
Ndebele | 23 | 9.4 |
Yes | 512 | 65.3 |
No | 272 | 34.7 |
Yes | 171 | 21.8 |
No | 613 | 78.2 |
Yes | 759 | 96.8 |
No | 25 | 3.2 |
Yes | 118 | 15.1 |
No | 666 | 84.9 |
VCT, voluntary counselling and testing; MC, male circumcision; VMMC, voluntary medical male circumcision.
Proportion of respondents who answered correctly to the knowledge questions about circumcision (
Variable | Yes | Percentage |
---|---|---|
Is male circumcision a surgical removal of the end of the foreskin of the penis? | 521 | 66.5 |
Is circumcision as good as an ‘invisible condom’ in preventing HIV transmission? | 648 | 82.2 |
Does male circumcision reduce the chances of transmitting HIV? | 668 | 85.2 |
Does male circumcision reduce penile cancer? | 417 | 53.2 |
Are circumcised men still recommended to use condoms? | 738 | 94.1 |
Does male circumcision improve penile hygiene? | 727 | 7.4 |
Can male circumcision alone prevent HIV contraction? | 726 | 92.6 |
Can an HIV-negative woman contract HIV or STI after having unprotected sex with an HIV-positive circumcised man? | 638 | 81.4 |
Can an HIV-negative circumcised man contract HIV or STI after having unprotected sex with an HIV-positive woman? | 656 | 83.7 |
After being circumcised must a man abstain from sexual intercourse for six weeks? | 367 | 46.8 |
A little more than 8 in 10 (82.2%) of the respondents indicated that male circumcision was not as good as an invisible condom. On the other hand, 82.7% indicated that male circumcision reduces the chances of HIV transmission. With regards to male circumcision reducing penile cancer, 53.2% indicated that male circumcision reduces penile cancer. More than 9 in 10 (92.7%) indicated that male circumcision improves penile hygiene, and about the same proportion (92.6%) indicated that male circumcision alone can prevent HIV infection. Fewer than half (46.8%) of the respondents were aware that it was recommended that circumcised men abstain from sexual intercourse for a minimum period of 6 weeks following circumcision. More than two-thirds (66.5%) of the respondents were able to define male circumcision.
Background characteristics by knowledge about male circumcision.
Variable | Low knowledge (%) | High knowledge (%) | χ-value | Total | |
---|---|---|---|---|---|
15–19 | 28.6 | 71.4 | - | - | 182 |
20–24 | 20.1 | 79.9 | - | - | 229 |
25–29 | 19.8 | 80.2 | - | - | 192 |
30–35 | 11.6 | 88.4 | - | - | 181 |
Married or living together | 13.7 | 86.3 | - | - | 263 |
Formerly married | 19.2 | 80.8 | - | - | 26 |
Never married | 23.4 | 76.6 | - | - | 495 |
Primary | 29.7 | 70.3 | - | - | 37 |
Secondary | 22.3 | 77.7 | - | - | 618 |
Higher | 6.2 | 93.8 | - | - | 129 |
Low | 24.3 | 75.7 | - | - | 276 |
Medium | 19.4 | 80.6 | - | - | 248 |
High | 16.2 | 83.8 | - | - | 260 |
Employed | 16.4 | 83.6 | - | - | 439 |
Unemployed | 24.6 | 75.4 | - | - | 345 |
Mainline | 17.0 | 83.0 | - | - | 265 |
Apostolic sect | 21.9 | 78.1 | - | - | 169 |
Pentecostal | 18.7 | 81.3 | - | - | 193 |
Other religion | 25.3 | 74.7 | - | - | 83 |
No religion | 24.3 | 75.7 | - | - | 74 |
Shona | 23.0 | 77.0 | - | - | 710 |
Other | 19.7 | 80.3 | - | - | 74 |
Yes | 14.1 | 85.9 | - | - | 759 |
No | 31.3 | 68.7 | - | - | 25 |
Yes | 19.3 | 80.7 | - | - | 171 |
No | 20.2 | 79.8 | - | - | 613 |
Yes | 19.2 | 80.8 | - | - | 759 |
No | 44.0 | 56.0 | - | - | 25 |
157 | 627 | - | - | 784 | |
20.0 | 80.0 | - | - | 100 |
VCT, voluntary counselling and testing; MC, male circumcision; VMMC, voluntary medical male circumcision.
High knowledge about male circumcision was more common in respondents in the high wealth status group (83.8%) compared to those who belonged to medium and low wealth status (80.6% and 75.7%, respectively;
Eighty-six per cent of the respondents who had ever tested for HIV had high knowledge about male circumcision, compared to 68.8% of those who had never tested for HIV. Finally, 80.8% of the respondents who had heard of VMMC had high knowledge about male circumcision.
Predictors of knowledge about male circumcision.
Variable | B | SE | Exp(B) |
---|---|---|---|
30–35 (R) | - | - | - |
15–19 | −0.361 | 0.386 | 0.697 |
20–24 | −0.316 | 0.342 | 0.729 |
25–29 | −0.552 | 0.321 | 0.576 |
Never married (R) | |||
Married or living together | 0.379 | 0.289 | 1.461 |
Formerly married | 0.077 | 0.552 | 1.080 |
Higher (R) | - | - | - |
Primary | −1.503 | 0.559 | 0.223 |
Secondary | −1.231 | 0.402 | 0.292 |
High (R) | |||
Low | −0.209 | 0.249 | 0.811 |
Medium | −0.004 | 0.248 | 0.996 |
Unemployed (R) | - | - | - |
Employed | 0.201 | 0.231 | 1.223 |
No religion (R) | - | - | - |
Mainline | 0.426 | 0.342 | 1.531 |
Pentecostal | 0.321 | 0.359 | 1.378 |
Apostolic sect | 0.245 | 0.351 | 1.277 |
Other Christian | 0.024 | 0.399 | 1.024 |
Other (R) | - | - | - |
Shona | 0.175 | 0.316 | 1.191 |
No (R) | - | - | - |
Yes | 0.660 | 0.215 | 1.934 |
Disapprove (R) | - | - | - |
Approve | 0.187 | 0.233 | 1.205 |
No (R) | |||
Yes | 1.255 | 0.465 | 3.508 |
No, not at risk at all (R) | - | - | - |
Yes, at high risk | −0.085 | 0.322 | 0.919 |
Yes, at low risk | −0.041 | 0.215 | 0.960 |
Unfavourable attitude (R) | |||
Favourable attitude | 0.177 | 0.197 | 1.194 |
No (R) | - | - | - |
Yes | 0.577 | 0.333 | 1.782 |
Constant | 0.511 | 0.810 | 1.667 |
Observations | 784 | - | - |
Nagelkerke | 0.13.9 | - | - |
H-L G gof test | 0.993 | - | - |
VCT, voluntary counselling and testing; MC, male circumcision; VMMC, voluntary medical male circumcision; H-L G gof, Hosmer-Lemeshow Goodness of fit test; B, beta values; R, reference category.
Further, the odds of young men who reported ever having tested for HIV having high knowledge about male circumcision were 93% higher (OR = 1.93,
Perception of risk of HIV infection.
Perception of risk to HIV infection | Frequency | Percentage |
---|---|---|
No risk at all | 423 | 54.0 |
Low risk | 279 | 35.6 |
High risk | 82 | 10.4 |
Background characteristics by perception of risk to HIV infection.
Variable | No risk (%) | Low risk (%) | High risk (%) | χ-value | Total | |
---|---|---|---|---|---|---|
15–19 | 67.6 | 23.6 | 8.8 | - | - | 229 |
20–24 | 55.5 | 35.8 | 8.7 | - | - | 192 |
25–29 | 48.4 | 40.1 | 11.5 | - | - | 181 |
30–35 | 44.2 | 42.5 | 13.3 | - | - | - |
Never married | 58.4 | 31.9 | 9.7 | - | - | 263 |
Married or living together | 47.1 | 43.0 | 9.9 | - | - | 26 |
Formerly married | 23.4 | 45.8 | 30.8 | - | - | 495 |
Primary | 56.8 | 37.8 | 5.4 | - | - | 37 |
Secondary | 57.1 | 32.5 | 10.4 | - | - | 618 |
Higher | 38.0 | 49.6 | 12.4 | - | - | 129 |
Low | 55.1 | 34.8 | 10.1 | 276 | ||
Medium | 56.0 | 34.7 | 9.3 | - | - | 248 |
High | 50.8 | 36.8 | 12.4 | - | - | 260 |
Employed | 48.1 | 40.8 | 11.1 | - | - | 439 |
Unemployed | 61.4 | 29.0 | 9.6 | - | - | 345 |
Mainline | 53.2 | 37.0 | 9.8 | - | - | 265 |
Pentecostal | 55.4 | 37.9 | 6.7 | - | - | 169 |
Apostolic sect | 58.6 | 29.6 | 11.8 | - | - | 193 |
Other religion | 54.2 | 31.3 | 14.5 | - | - | 83 |
No religion | 41.9 | 43.2 | 14.9 | - | - | 74 |
Shona | 55.1 | 34.4 | 10.5 | - | - | 710 |
Other | 43.2 | 47.3 | 9.5 | - | - | 74 |
Yes | 47.3 | 42.1 | 10.6 | - | - | 759 |
No | 43.2 | 47.3 | 9.5 | - | - | 25 |
Yes | 57.9 | 31.6 | 10.5 | - | - | 171 |
No | 52.9 | 36.8 | 10.3 | - | - | 613 |
Yes | 53.4 | 36.1 | 10.5 | - | - | 759 |
No | 72.0 | 20.0 | 8.0 | - | - | 25 |
Number (Total) | 423 | 279 | 82 | - | - | 784 |
VCT, voluntary counselling and testing; MC, male circumcision; VMMC, voluntary medical male circumcision.
With respect to marital status, while about a third (30.8%) of formerly married men indicated that they were at high risk of HIV infection, only 10% of never-married men and the same proportion of men married or living together indicated that they were at high risk of HIV infection. Forty-three per cent of married men indicated that they were at a low risk of HIV infection, while 31.9% of never-married men indicated that they were at low risk of HIV infection.
There is a positive relationship between education and risk perception of HIV infection. Nearly half (49.6%) of the respondents with higher levels of education indicated that they were at low risk of HIV infection compared to about a third (32.5%) of respondents with secondary education and close to two-fifths (37.8%) of those with primary education.
There was a significant relationship between employment status and perception of risk of HIV infection (significant at
A similar proportion of respondents who had ever tested for HIV (10.6%) and those who had never tested (9.5%) indicated that they were at a high risk of HIV infection. Additionally, 42.1% of those who had ever tested for HIV reported that they were at a low risk. With those who had never tested for HIV, 47.3% and 9.5% indicated that they were at low risk and at high risk of HIV infection, respectively.
Predictors of perception of risk of HIV infection.
Variable | Yes, at higher risk 95% CI |
Yes, at low risk 95% CI |
||||
---|---|---|---|---|---|---|
Exp(B) | LB | UB | Exp(B) | LB | UB | |
30–35 (R) | - | - | - | - | - | - |
15–19 | 0.588 | 0.223 | 1.551 | 0.733 | 0.379 | 1.419 |
20–24 | 0.561 | 0.254 | 1.241 | 0.886 | 0.526 | 1.491 |
25–29 | 0.813 | 0.400 | 1.651 | 0.888 | 0.553 | 1.426 |
Never married (R) | - | - | - | - | - | - |
Married or living together | 0.727 | 0.364 | 1.452 | 1.090 | 0.693 | 1.714 |
Formerly married | 3.135 |
1.054 | 9.324 | 1.252 | 0.455 | 3.443 |
Higher (R) | - | - | - | - | - | - |
Primary | 0.282 | 0.054 | 1.467 | 0.530 |
0.223 | 1.258 |
Secondary | 0.535 |
0.264 | 1.085 | 0.487 | 0.306 | 0.776 |
High (R) | - | - | - | - | - | - |
Low | 0.905 | 0.481 | 1.701 | 1.123 | 0.738 | 1.707 |
Medium | 0.777 | 0.419 | 1.441 | 1.016 | 0.679 | 1.522 |
Unemployed (R) | - | - | - | - | - | - |
Employed | 1.330 | 0.719 | 2.461 | 1.317 | 0.884 | 1.963 |
No religion (R) | - | - | - | - | - | - |
Mainline | 0.532 | 0.225 | 1.259 | 0.664 | 0.366 | 1.203 |
Pentecostal | 0.343 |
0.132 | 0.891 | 0.657 | 0.353 | 1.222 |
Apostolic sect | 0.598 | 0.248 | 1.446 | 0.518 |
0.277 | 0.970 |
Other religion | 0.719 | 0.267 | 1.939 | 0.582 | 0.281 | 1.208 |
Other (R) | - | - | - | - | - | - |
Shona | 0.994 | 0.406 | 2.435 | 0.554 |
0.324 | 0.945 |
No (R) | - | - | - | - | - | - |
Yes | 1.197 | 0.678 | 2.113 | 2.016 |
1.377 | 2.953 |
Disapprove (R) | - | - | - | - | - | - |
Approve | 0.486 |
0.238 | 0.994 | 1.000 | 0.683 | 1.464 |
No (R) | - | - | - | - | - | - |
Yes | 1.402 | 0.298 | 6.590 | 2.415 | 0.847 | 6.890 |
Low knowledge (R) | - | - | - | - | - | - |
High knowledge | 1.121 | 0.601 | 2.090 | 1.058 | 0.696 | 1.607 |
Unfavourable attitudes (R) | - | - | - | - | - | - |
Favourable attitudes | 0.651 | 0.391 | 1.085 | 0.879 | 0.634 | 1.218 |
No (R) | - | - | - | - | - | - |
Yes | 0.796 | 0.399 | 1.150 | 0.862 | 0.343 | 1.430 |
Observations | 784 | - | - | - | - | - |
Pearson | 0.112 | - | - | - | - | - |
Deviance | 0.833 | - | - | - | - | - |
VCT, voluntary counselling and testing; MC, male circumcision; VMMC, voluntary medical male circumcision; B, beta values; R, reference category; LB, lower bound; UB, upper bound; CI, confidence interval.
With regard to religion, the odds of a Pentecostal Christian perceiving himself to be at higher risk were 66% (
This study sought to examine youths’ knowledge about male circumcision and perception of risk of HIV infection on the one hand, and selected background characteristics, on the other. In the Zimbabwean context, little is known about the impact of background characteristics on social variables related to knowledge of male circumcision and perception of risk of HIV infection among urban men aged 15–35 years, despite the fact that this is a key subpopulation in the fight against HIV. While some studies have looked at these social variables related to male circumcision,
Knowledge about male circumcision appeared to increase with age. Youth aged 15–19, 20–24 and 25–29 years all were less likely to have high knowledge about male circumcision. However, only youth aged 25–29 years compared to those aged 30–35 years were less likely to have high knowledge about male circumcision. Studies elsewhere show contrary findings. For example, one study in particular
Furthermore, the findings showed that youth with primary and secondary education were less likely to have knowledge about male circumcision compared to those with a higher level of education. One study observed similar relationships in Zimbabwe among soccer players, with those with higher education levels having more knowledge about male circumcision compared to those with lower levels of education.
The findings from this study also showed that previously testing for HIV was associated with knowledge about male circumcision. Respondents who had ever tested for HIV were more likely to be knowledgeable about male circumcision. This could be attributed to counselling sessions that happen before and after testing. In Zimbabwe, VCT centres disseminate information about male circumcision. Male circumcision services have also been an integral part of male sexual and reproductive health programmes.
In addition, ever having heard of VMMC was found to be statistically significantly associated with knowledge about male circumcision. Youth who had ever heard of VMMC were more likely to have high knowledge of male circumcision compared to those had never heard of it. This could be a result of availability of different mass media advertisement about VMMC. According to a study in Zimbabwe among respondents aged 15–49 years in rural and urban areas, a higher proportion of the respondents had heard of VMMC.
As expected, youth who were circumcised were knowledgeable about male circumcision in comparison to those who were uncircumcised. The present findings are consistent with other research, which found that males who were circumcised were more likely to have high levels of knowledge about male circumcision.
The findings suggest marital status had a significant influence on perception of risk of HIV infection. For example, formerly married youths were more likely to perceive themselves to be at higher risk of HIV infection compared to those who had never married. However, previous findings have found that, in general, people tend to underestimate their risk of HIV.
In addition, the present study found that education influences perception of risk of HIV infection. For instance, youth with secondary education were less likely to perceive themselves to be at a higher risk of HIV infection compared to respondents with higher education. However, youth with primary education were less likely to perceive themselves to be at low risk of HIV infection compared to those with both secondary and higher education. As education increases, the young men are more likely to perceive themselves to be at high risk of HIV infection, most likely because they understand the dynamics of HIV infection. However, these results are inconsistent with previous studies; for instance, a study among military personnel in Nigeria found an inverse relationship between educational attainment and HIV risk perception.
Furthermore, the results showed religious variations in perception of risk of HIV infection. Youth who belonged to Pentecostal churches and apostolic sects were less likely to perceive themselves to be at a higher risk of HIV infection compared to respondents with no religion. However, the findings of the current study do not support previous research, which found that these men perceived themselves to be at no risk for HIV infection.
With regard to Pentecostal Christians, the findings of the current study are consistent with those of a previous study,
Youth belonging to the Shona ethnic group were less likely to perceive themselves to be at low risk of HIV infection compared to other ethnic groups, which perceived itself to be at no risk of HIV infection. Perhaps the Shona perception of risk of HIV infection is not surprising considering the fact that in Zimbabwe and other sub-Saharan Africa communities they have cultural practices conducive to the spread of HIV such as wife inheritance, which involves relatives of the deceased husband marrying the widow.
In addition, those who had ever tested for HIV were more likely to perceive themselves to be at low risk of HIV infection compared to those who had never tested. This relationship could be explained by the fact that HIV is highly stigmatised. Hence, ever taking the test and obtaining negative HIV results makes men aged 15–35 years feel they are not at risk of HIV infection. With respect to approval of VCT prior to male circumcision, respondents who approved of VCT prior to circumcision were less likely to perceive themselves to be at risk of HIV infection compared to those who did not approve of it. Perhaps those who approve of VCT prior to circumcision are youth who regularly check their status and for that reason perceive themselves to be at low risk of HIV infection.
The findings identified a knowledge deficit about male circumcision among youth with primary and secondary education, indicating the probability of low uptake of male circumcision as an HIV intervention measure in Harare. Furthermore, as education increases, youth are more likely to perceive themselves to be at high risk of HIV infection. The study recommends the need to strengthen perceived susceptibility to HIV across all educational levels, and advocacy is needed on health benefits of male circumcision.
The authors would like to thank the following research assistants: Tapiwa Chirenje, Washington Dune, Kudzai Ndemera, Josphat Jekera and Tapiwa Mangombe.
The authors declare that they have no financial or personal relationship(s) that may have inappropriately influenced them in writing this article.
K.M. made conceptual contributions, data analysis and led the writing process. I.K.-S. contributed substantially to the writing and reviewing of the article.