Male circumcision is one of the oldest surgical procedures, traditionally accepted as a mark of cultural identity or religious importance, or for perceived health benefits such as improved penile hygiene or reduced risk of infection [1]. Traditionally, circumcising societies and religious sects have used the procedure for cultural and religious purposes [2]. Recent epidemiological evidence has shown that safe circumcision reduces the risk of acquiring HIV infection in heterosexual males by 50–60 % [2]. It is on the basis of this evidence that several African countries with high prevalence of HIV are now expanding access to safe circumcision [3, 4]. Observational studies suggest that the protective effect of male circumcision is similar if circumcision occurs early in life [5]. The immediate focus of circumcision for HIV prevention has been on adolescents and adult men, but a longer-term HIV prevention strategy has to include the provision of child circumcision services.
Child circumcision is routinely practised in most countries in the Middle East (in countries such as, Egypt, the Islamic Republic of Iran, Jordan, Lebanon, the Syrian Arab Republic, Turkey and Yemen), Israel [6–8], the USA [9] and some West African countries, including Senegal, Ghana and parts of Nigeria [10, 11]. This type of circumcision is done mainly for religious and cultural purposes. Studies have provided that the best age to perform circumcision is in childhood and it has been shown to have a better protective effect than those performed at any other age [12]. It is also safer, easier and less costly but it is not widespread in southern Africa countries including Botswana [13].
Based on studies conducted in some parts of sub Saharan Africa [SSA] in particular the randomized clinical trials (RCTs) conducted in Uganda [2]; Kenya [3] and South Africa [4], safe male circumcision has a protective effect against HIV as well as reducing incidences of other sexually transmitted infections (STIs) like genital ulcers, human papilloma virus (HPV) and Chlamydia in female partners. Meanwhile child circumcision is recognised as a long term preventive strategy to reduce new infections particularly in later life as recommended by UNICEF and WHO [1]. In 2009, the Ministry of Health (Botswana) launched the safe male circumcision (SMC) policy as part of the comprehensive strategy on HIV prevention. Following this decision, circumcision services are being extended many public health facilities free of charge with the intention to increase accessibility of the service to as many males as possible. As a strategy to enhance uptake of circumcision services, there has been some efforts to reach out to school going children. The benefits of child circumcision compared to adult circumcision have been emphasized in several studies. For instance, in a qualitative study conducted in Zimbabwe, it was observed that circumcising children protected them against HIV transmission in later life [4, 7, 14, 15].
Previous studies have shown high adult male circumcision acceptability rate in Botswana and in the region [14, 16, 17]. Kebaabetswe et al. [18], suggested that circumcision for the children of Botswana would be highly acceptable, and believed that parents in Botswana—as in most developed countries worldwide be offered the option of hospital based circumcision for their male children to protect them from the acquisition of HIV. Generally, male child circumcision is not yet performed in most southern African countries and there are questions regarding its acceptability, feasibility, safety and optimal approaches to widespread implementation [13].
Although Botswana has adopted safe male circumcision as a key strategy against HIV/AIDS transmission, there is little information on factors influencing parental acceptance of child circumcision. Botswana has been running SMC program since 2009 and has not yet met its target of circumcising 80 % of males by 2016 [13]. Recently (in 2015), the government introduced Early Infant Safe Male Circumcision (EISMC) program as an add-on to a series of response programs to reduce HIV transmission in later life. The social and behavioural context of the countries implementing male circumcision programs might provide the reasons why set targets for SMC are not being met. Very little research has been carried out to explore factors (especially behavioural) influencing willingness to accept child male circumcision in the general population of Botswana. Plank et al. [13] conducted a study in South Eastern part of Botswana among women to assess whether they would accept their new-born male children to be circumcised. Although their study provided vital insights about acceptability of infant circumcision, the main limitations of the study was that it did not include men who are also role players in reproductive decisions of their families and was limited in scope and coverage.
This study uses nationally representative data and also includes men who are vital in decision making of the reproductive health of their families. The main aim of this study was to assess factors associated with acceptability of safe male child circumcision in Botswana. The study of this nature is essential in the context of Botswana where HIV prevalence rate continues to be high, and the SMC program has failed to reach the expected target. The study will serve to guide successful rollout of different SMC programs in Botswana. Moreover, since child circumcision has been found to decrease the risk of HIV infection among men in later life, it is important to determine its acceptability in the general population as a potential HIV prevention strategy.
Theoretical framework
The study employed Theory of Reasoned Action, [TRA] developed and several times modified by Ajzen and Fishbein [19–21]. TRA proposes that behavioural intentions are a combined function of the attitude toward performing a particular behaviour in a given situation and of the norms perceived to govern that behaviour multiplied by the motivation to comply with those norms [19]. This theory assumes that human beings are usually quite rational and make systematic use of the information available to them. People consider the implications of their actions before they decide to engage or not engage in a given behaviour [21].
As child circumcision is recommended for medical reasons [especially prevention of HIV acquisition in later life], mothers and fathers who may choose circumcision must also believe that circumcising their children may reduce chances of HIV acquisition later in life. The study attempted to determine factors influencing parent’s decision to circumcise their children. We chose this model mainly because, we believe that constructs of this model are key in informing parental decision on accepting child circumcision.
The assumption of TRA is that most behaviours of social relevance are under volitional control and that a person’s intention to perform or not perform behaviour is the immediate determinant of that action [21]. A person’s intention regarding routine circumcision is determined by personal and social influences. One personal factor is the person’s evaluation of the outcome of circumcision, which can be either positive or negative. Parents who believe circumcision is necessary for reduction of HIV transmission may choose the procedure. Meanwhile parents who believe otherwise may have negative evaluation of circumcision and may choose not to circumcise their children. Subjective norm is the other determinant of a person’s intention which is a person’s perception of the social pressures applied to perform the behaviour [21]. As illustrated in Fig. 1, an individual’s intentions and behaviours are influenced by certain background factors which include individual, social and information factors.
The above figure shows one way in which the intentions and behaviour can be represented. There are beliefs which are assumed to influence attitudes, subjective norms, and perceived behavioural control which, in turn, produce intentions and behaviour [21]. Feng and Wu [22], also state that, intention is the best predictor of behaviour, and it is a function of the person’s attitude towards performing the behaviour and general subjective norms concerning the performance of that behaviour. For example, if a father intends to circumcise his child in future, he may eventually do so or he may also choose not to circumcise his child given the prevailing circumstances at the time. The Theory of Reasoned Action states that beliefs determine attitudes and subjective norms which then determine intention and the corresponding behaviour [20]. For instance, if the child’s father is circumcised, the father may also believe circumcision to be normal or necessary for their child. In addition, if most males in the community or society have been circumcised, the parents, in particular the father can subjectively intend to circumcise their children or decide otherwise. Although constructs of the TRA discussed above not been precisely used in the paper, notions of the TRA have been used to understand why would parents accept or reject child circumcision.
