Pre-post training intervention assessment of traditional male circumcision of initiates attending 17 initiation schools in two Local Service Areas (LSAs), Nyandeni and Qaukeni of the O.R.Tambo district, Eastern Cape province.
Sample and procedure
The sample included 160 Xhosa initiates, mean age 18.7 years (SD = 1.9), range16 to 26 years; 27 (16.9%) were below 18 years; the number of years of formal education completed was mean 8.1 years (SD = 2.6), range 2 to 14 years.
Initiates were first informed about the study when undergoing medical examination for circumcision. Two junior HSRC researchers contacted traditional surgeons who had previously been trained and had also formally consented to the study about their circumcision schedule. At the second day after circumcision the designated medical officer, the clinical research nurse and an HSRC researcher visited the initiation school to introduce the study and individual formal consent was taken from the initiates about physical examination and an interview by the research nurse and the HSRC researchers. The clinical research nurse physically examined all initiates in each initiation school at the 2nd, 4th, 7th and 14th day after circumcision. In addition, they were interviewed with a semi-structured questionnaire on the 7th day after circumcision by the HSRC researcher. Complications identified at examination were either treated by the clinical nurse or referred to a health facility. Permission had been obtained from traditional surgeons and nurses to conduct examinations and an interview with their initiates. The clinical male nurses had been trained in circumcision physical examination by XK. Recruitment began on June 2007, and follow-ups were completed by mid July, 2007; all initiates agreed to participate in the study. The research protocol was reviewed and approved by the Human Sciences Research Council (HSRC) research ethics committee protocol REC 1/17/05/06. The provincial health department of the Eastern Cape, the district health office and traditional authorities in the study areas approved the study.
The traditional surgeons and nurses from which the initiates were recruited had undergone a five day training by XK and GP including modules on: Introduction into initiation rites; Traditional Community Regulation as well as statutory regulation of Traditional Male Circumcision and Initiation into Manhood; Structure and function of the male sex organs; Procedure of safe circumcision, Infection control; STIs/STDs; HIV/AIDS; Infection control measures; Aftercare of the initiate including after care of the circumcision wound and initiate as a whole; Detection and early management of common complications of circumcision; Nutrition and fluid management; Code of conduct and ethics for traditional health practitioners; and Sexual health education . Traditional surgeons were also provided with a tool box including surgical (scalpel) blades, scalpel handles, latex hand gloves, sterilization instruments, and paper towel rolls, and traditional nurses received also the tool box including latex hand gloves, sterilization instruments, and paper towel rolls. Details on the training, the manual and its evaluation are reported elsewhere .
The assessment of initiates included a physical examination of the operation area following a standardized index of adverse reactions of male circumcision including pain, bleeding, haematoma, swelling, wound infection, delayed wound healing, excessive skin removed, insufficient skin removed, problems with urination and problems with appearance [12, 13].
The interview schedule for the initiates included socio-demographics, sexual and HIV risk behaviour and expectations about circumcision, based on a literature review [6, 14–16]. Response options included mostly "yes" and "no" responses.
In addition, four items of the Body Parts Satisfaction Scale by Berscheid, Walster, and Bohrnstedt  were used. Individual items indicated respondents' level of satisfaction with aspects of their body ranging from 1 = extremely dissatisfied to 6 = extremely satisfied.
The SPSS (version 14.0) statistical programme was used to analyze the data with descriptive statistics.