Influences Impacting the Acceptance of Voluntary Medical Male Circumcision among Medical Students Pursuing Bachelor’s Degrees at Kampala International University Teaching Hospital
Musinzi Joel
Faculty of Clinical Medicine and Dentistry Kampala International University Western Campus Uganda
ABSTRACT
The primary objective of this investigation was to identify the determinants influencing the adoption of voluntary medical male circumcision services among bachelor’s male medical students at Kampala International University Teaching Hospital (KIU-TH). The study employed a cross-sectional descriptive design over a three-month period within Bushenyi District-Uganda, specifically at KIU-TH situated in Ishaka town. This hospital, a private institution, serves as a prominent teaching center for various medical programs. A sample of 372 bachelor’s male medical students participated in the study, responding to simple pretested semi-structured questionnaires. Analyzing the collected data via SPSS version 20 revealed a mean age of 28±5.504 years, ranging from 19 to 50 years. Predominantly, participants were in their 4th year of study (47.1%), unmarried (76.1%), identified as Christians (78.2%), and held Ugandan nationality (79.6%). Notably, 38.7% of students reported being circumcised, with 68.1% undergoing voluntary medical male circumcision (VMMC). However, among uncircumcised individuals, only 25.0% expressed willingness to undergo VMMC. All participants demonstrated awareness and comprehension of VMMC, with 96.5% acknowledging its role in HIV prevention and 77.2% recognizing potential complications associated with VMMC. Regarding attitudes, 68.5% held positive views on VMMC, highlighting that pain during the procedure is manageable (40.6%) and recovery is relatively swift (72.8%). Despite this, the uptake of Voluntary Medical Male Circumcision remained below national targets. While a majority exhibited favorable attitudes toward VMMC, a smaller fraction displayed willingness to engage in this procedure. The findings underscore the necessity for evidence-based health education initiatives and structured VMMC campaigns, specifically targeting medical students, to enhance the uptake of VMMC services.
Keywords: Male circumcision, Healthcare providers, Male medical students, HIV, Health education.
Circumcision is one of the oldest surgical procedures, dating from the Neolithic age. It is widely practiced throughout the world for religious reasons (e.g., Muslims and Jews), as part of traditional cultures among tribal groups in Africa (e.g., Kikuyu in Kenya and Bagishu in Uganda); and for medical reasons both preventive and therapeutic [1, 2]. The majority of procedures are performed in infancy or childhood, but in some cultures, circumcision is part of initiation rituals marking the transition from adolescence to adulthood (e.g., Xhosa of South Africa) [3]. About 665 million men (30% of all men) over 15 years of age worldwide are circumcised of whom approximately two-thirds (68%) are Muslim, 0.8% are Jewish, and 13% are men in the United States who are not Muslim or Jewish [4]. On one hand, there are communities that do not traditionally circumcise and those who see such campaigns to take up male circumcision (MC) as an affront to their culture [5]. Voluntary medical male circumcision (VMMC) is the surgical removal of the foreskin of the penis by trained healthcare providers after the client’s consent [6]. WHO and UNAIDS recommend MC as an emphasis for efficacious intervention for HIV prevention in countries and regions with heterosexual epidemics, high HIV, and low circumcision prevalence. This is further backed up by the evidence that the inner aspect of the foreskin is highly susceptible to only HIV infection but also other Sexually Transmitted Infections [7, 8]. Voluntary medical male circumcision has been shown to provide a 50% – 70% reduction in the risk of HIV infection without contributing to behavioral disinhibition of safer sexual practices [9]. VMMC is done among adult males of ages 18 years to 50 years who consent to the procedure. In Africa, it has been found that male circumcision (MC) can reduce the risk of HIV infection by 50% to 60% among heterosexual men [10]. Within Mazowe District, Zimbabwe, the prevalence of male circumcision was noted to be higher than the 10% that was reported by the WHO in 2009 [11]. In Kenya, the level of uptake of VMMC rates at 75% as per a study done in the Kibera division [12]. In Uganda, the male circumcision program was launched in September 2010, targeting 4,200,000 (80 percent) of uncircumcised men by 2015. By March 2012, however, only a total of 380,000 men (9.0 %) had actually been circumcised under the program [13]. Male Circumcision is more common in urban than rural. It is more common in Kampala than elsewhere in the country except for the eastern and western regions where MC is carried out as a rite of passage and maturity transition among the Bagisu, Sabiny, and Bakonzo, and 80% of men are reportedly circumcised [5].
Voluntary medical male circumcision is a critical HIV prevention tool [14, 15]. After its launch in 2010 in Uganda, VMMC was intended to achieve 80% male circumcision by the year 2015 as part of a comprehensive HIV prevention strategy [16]. However, slower progress has been observed since then including a 9.0% reported uptake in two years after the launch [13]. Uganda is second (after South Africa) among the African countries that require a relatively high uptake of VMMC [17]. Despite being faithful to one sexual partner, using a condom for sexual intercourse with a person whom one is not sure of their safety and abstinence from sex [6] can help prevent STIs, Voluntary Medical Male Circumcision made part of HIV prevention programs in regions with a generalized HIV epidemic and a low level of male circumcision has shown commendable results regarding HIV prevention [12]. However, among medical students particularly at Kampala International University’s western campus, the level of uptake of VMMC is still incomprehensible. Thus, this study sought to determine the level of utilization of VMMC and the associated factors among bachelor’s medical students at KIU-WC.
METHODOLOGY
Study design
The study employed a cross-sectional descriptive study design to collect both quantitative and qualitative data.
Area of Study
The study was conducted at KIU-WC a private international university located in Ishaka Town about 3km from Bushenyi district headquarters. The university’s location lies approximately 360 kilometers (220 mi), by road, southwest of Kampala, the largest city in the country and its geographical coordinates are 0° 32′ 29.04″S, 30° 8′ 25.80″E (Latitude: 0.5414; Longitude: 30.1405). The university offers tertiary learning from certificate to PhD levels in various disciplines of higher learning including, health sciences, humanities, biomedical sciences, education, basic sciences, and computer sciences. It has up to about four thousand students with majority being the health science students. Among the health science students, a big proportion are males. It has a teaching hospital in its vicinity where medical students in their clinical years are taught practical skills.
Study population
Male bachelor’s medical students at Kampala International University Teaching Hospital.
Inclusion criteria
Male bachelor’s medical students at KIU-TH who were present at the time of data collection and consented to participate were included.
Exclusion criteria
Male bachelor’s medical students who declined consent and those who were mentally or physically ill were excluded.
Sample size determination
The sample size of respondents was determined using the Kish Leslie sample size formula (Kish Leslie, [18] as given below:
n=z2 p(1-p)/E2
Where;
n = sample size required.
p = 59%, Proportion of males who were circumcised in a study by Miiro et al. [19] in Entebbe, Uganda.
z = Standard normal deviation, i.e. 1.96, set at 95% confidence level
d = desired degree of accuracy i.e. 5%.
Therefore, n = 1.96 x 1.96 x 0.59 x (1- 0.59)/ 0.05 x 0.05
n = 3.8416 x 0.59 x 0.41 / 0.0025
n = 372 medical students were sampled.
Sampling techniques
Using simple random sampling male bachelor’s medical students were selected from three schools i.e. School of Clinical Medicine and Dentistry, the School of Allied Health Sciences, and the School of Nursing until the desired sample size was achieved.
Data collection methods and management
Data was collected using a pre-tested standardized self-administered semi-structured questionnaire in English developed to collect the data needed so as to fulfill the objectives. The questionnaire contained both closed and open-ended questions.
Data analysis
Using IBM Statistical Package for the Social Sciences (SPSS) version 20 data was analyzed and analyses were presented in the form of cross-tabulation, Bi-variate and multi-nominal logistic regression correlations, and also in graphs, frequencies, and percentages at a 95% confidence interval and 5% degree of precision.
Quality control
To ensure quality work, the inclusion and exclusion criteria were strictly adhered to and data forms were double-checked for completeness by the principal investigator. The reliability of the questionnaire was attained through pre-testing. Respondents who didn’t understand the question had the option of inquiring from the researcher. Collected data was checked for consistency and completeness and proper storage of the questionnaires was ensured.
Ethical considerations
Approval was sought from the Research Ethics Committee of Kampala International University, Western Campus, and ethical concerns were addressed. Restricted access to the data collection forms by persons other than the principal researcher was ensured. No names or any identifying information were used in the study. The respondents were properly informed upon this subject and neither were they forced or influenced to answer any question as per the researcher’s interest. Verbal consent was obtained from the respondents who were first informed about the importance of the study.
RESULTS
Uptake of Voluntary Medical Male Circumcision among bachelor’s medical students
Out of the 372 sampled bachelor’s medical students, 144 (38.7%) were circumcised while 228 (61.3%) were not. Of those who were circumcised, 98 (68.1%) were circumcised via VMMC, while 46 (31.9%) were not circumcised through VMMC and among those who were not circumcised, the majority (75.0%) were not willing to circumcise via VMMC with only 57 (25.0%) who were willing to circumcise through VMMC as illustrated in table 1 below.
Table 1; showing uptake and acceptance of VMMC among bachelor’s medical students
| Variable | Frequency, N/372 | Percentage |
| Are you circumcised | ||
| Yes | 144 | 38.7 |
| No | 228 | 61.3 |
| If yes, where you circumcised via VMMC? | ||
| Yes | 98 | 68.1 |
| No | 46 | 31.9 |
| N/A (228) | – | – |
| If no, would you wish to circumcise via VMMC? | ||
| Yes | 57 | 25.0 |
| No | 172 | 75.0 |
| N/A (144) | – | – |
Students socio-demographic characteristics
From Table 2 below, the minimum age was 19 years and the maximum was 50 years. The mean age was 28±5.504 and the median age was 26 years.
Table 2; shows age of the bachelor’s medical students
| VARIABLE | Median | Mean | Std. Deviation | Variance | Minimum | Maximum |
| Age | 26 | 28.35 | 5.504 | 30.293 | 19 | 50 |
Source: Field Data
Regarding their socio-demographic characteristics, the majority (47.1%) of the students were in their 4th year of study followed by those in the 3rd year (24.2%), those in 5th year (18.5%), and then those in the 2nd year (10.2%). Regarding their marital status, the majority were single (283), followed by those who were married (79) and those who were divorced/separated (10). Many of the students were Christians (78.2%) while Muslims were only 20.7% and those of other religious afflictions were 1.1%. The biggest of the students were Ugandans (79.6%) and only 20.4% were foreigners as shown in table 3 below.
Table 3; showing students’ socio-demographic features
| VARIABLE | FREQUENCY, n/372 | PERCENTAGE |
| Year of Study | ||
| Second year | 38 | 10.2 |
| Third year | 90 | 24.2 |
| Fourth year | 175 | 47.1 |
| Fifth year | 69 | 18.5 |
| Marital Status | ||
| Single | 283 | 76.1 |
| Married | 79 | 21.2 |
| Divorced/Separated | 10 | 2.7 |
| Religious Affiliation | ||
| Christian | 291 | 78.2 |
| Muslim | 77 | 20.7 |
| Others | 4 | 1.1 |
| Nationality | ||
| Ugandan | 296 | 79.6 |
| Non-Ugandan | 76 | 20.4 |
Source: Field Data
Students knowledge regarding Voluntary Medical Male Circumcision
From Table 4 below, all students had ever heard about VMMC and could explain what it means and the majority had heard about it through media (52.2%), followed by those through peers (22.3%), from school (12.9%), from other sources (8.6%) and then from the community. 96.5% of the students knew that male circumcision can help prevent HIV while only 1.6% and 1.9% didn’t know and were not sure respectively. Regarding their opinion about why VMMC is carried out, the majority (90.6%) mentioned that it is done to prevent HIV and other STIs followed by those who mentioned it due to hygiene purposes (8.3%) and then those with other reasons (1.1%). The biggest proportion (77.2%) knew that VMMC can result in complications while 20.7% said and 2.2% were not sure.
Table 4; shows students’ knowledge regarding VMMC
| Variable | Frequency, N/372 | Percentage |
| Have you ever heard about VMMC? | ||
| Yes | 372 | 100.0 |
| No | 00 | 0.0 |
| Where did you hear it from? | ||
| From school | 48 | 12.9 |
| Through media | 194 | 52.2 |
| From community | 15 | 4.0 |
| From peers | 83 | 22.3 |
| Other sources | 32 | 8.6 |
| Can explain what VMMC means? | ||
| Yes | 372 | 100.0 |
| No | 00 | 0.0 |
| Male circumcision helps prevent HIV | ||
| Yes | 359 | 96.5 |
| No | 6 | 1.6 |
| Not sure | 7 | 1.9 |
| Why do you think VMMC is carried out? | ||
| HIV and other STI prevention | 337 | 90.6 |
| Hygiene reasons | 31 | 8.3 |
| Other reasons | 4 | 1.1 |
| VMMC can result in complications | ||
| Yes | 287 | 77.2 |
| No | 77 | 20.7 |
| Not sure | 8 | 2.2 |
Source: Field Data
Student’s attitude and perception towards Voluntary Medical Male Circumcision
Out of the 372 sample medical students, 255 (68.5%) had a positive attitude towards VMMC while 115 (31.5%) had a negative attitude. 30.4% agreed with the statement that pain during VMMC is unbearable, 40.6% disagreed and 29.0% were not sure. While 72.8% disagreed that it takes long to heal after VMMC, 21.8% agreed however 5.4% were not sure. More than (57.0%) agreed that male circumcision reduces sexual pleasure in men, with 29.0% and 14.0% disagreeing or being not sure respectively. Over ninety percent of the students disagreed with the statement that VMMC is against my religion as illustrated in Table 5 below.
Table 5; shows students’ attitude and perceptions toward VMMC
| VARIABLE | FREQUENCY, n/372 | PERCENTAGE |
| How do general feel about VMMC? | ||
| Good practice | 255 | 68.5 |
| Bad practice | 115 | 31.5 |
| Pain during VMMC is unbearable | ||
| Yes | 113 | 30.4 |
| No | 151 | 40.6 |
| Not sure | 108 | 29.0 |
| It takes long to heal after VMMC | ||
| I agree | 81 | 21.8 |
| I disagree | 271 | 72.8 |
| Not sure | 20 | 5.4 |
| Male Circumcision reduces sexual pleasure in men | ||
| I agree | 212 | 57.0 |
| I disagree | 108 | 29.0 |
| Not sure | 52 | 14.0 |
| VMMC is against my religious practice | ||
| Yes | 34 | 9.1 |
| No | 338 | 90.9 |
Source: Field Data
Uptake of VMMC
This current study has discovered that 38.7% of the students were circumcised of which 68.1% were circumcised via VMMC. However, among those who were not circumcised only 25.0% were willing to circumcise via VMMC. These findings were slightly lower as compared to discoveries in Kenya, where the level of uptake of VMMC was high at 75% as per a study done among adult men in the Kibera division [12]. However, slightly higher as compared to results in Entebbe Uganda where the prevalence of VMMC among adolescent boys was 59% [19] and another by Mukama and colleagues where about half (50.6%) of the respondents had undergone VMMC at the health care facility [20]. This improvement may be attributed to the fact that these are medical students who are believed to have awareness and easy accessibility to the services. However, with such assumed awareness and accessibility, the level of uptake is still below target. Considering willingness to uptake VMMC, this current rate (25.0%) is slightly lower as related to an earlier study carried out in Rakia District Central Uganda which showed that 27% of the studied population was willing to undergo circumcision. This low rate may be attributed to the existence of misconceptions towards VMMC even among medical professionals which is a big hindrance to the overall level of uptake across all social and economic sects.
Knowledge towards VMMC
Findings from this study have shown that all students have ever heard about VMMC and knew the meaning of VMMC. It has also revealed that 96.5% knew that male circumcision prevents HIV transmission and 77.2% knew that VMMC can result in complications. This was similar to a study among healthcare providers in Haiti where the majority (90%) of the participants said that MMC would reduce STIs [21] and in another study carried out in Uganda, most of the men who were health educated about VMMC were aware of the safety of VMMC during surgery [22]. On the contrary, however, these findings are contradictory as related to earlier discoveries including one in Botswana where the majority of the respondents were not aware that medical male circumcision reduces the risk of HIV infection [23], in Eastern Uganda, where some men never realized the value in medical male circumcision as far as HIV infection prevention is concerned when they are advised to continue using condoms after the procedure, in Namibia where the majority (84.6%) of the respondents did not out rightly know that circumcision reduces the risk of HIV infection [24] and in Rakai, Uganda where most males never had adequate knowledge about MMC and the few who had knowledge was not translated into actual utilization of MMC available in the area due to misconceptions that they had about the efficacy of the equipment used to perform the service [25]. This current level of knowledge regarding VMMC is comparable to findings by Hoffman et al. [26] in South Africa which revealed that majority (93.3%) of the respondents had heard about male circumcision, and many (64.4%) knew of VMMC from someone in the community who was circumcised, others from a family member (46.2%) while 28.8% heard from government campaigns and less than one fifth through formal contact with the health care system either directly or through the media [26].
Attitude and Perception towards VMMC
This study has shown that 68.5% of the students have a positive attitude towards VMMC and majorities reported that pain during VMMC is bearable (40.6%), that VMMC reduces sexual pleasure among men (57.0%) and that it does not take long to heal after VMMC (72.8%). Similar discoveries have been found in China where it was concluded that circumcision decreases sexual enjoyment due to loss of nerve endings [27], in South Korea where majority of the respondents believed that men were twice more likely to experience diminished sexuality rather than improved sexuality when they are circumcised [28]. Another study at Mutare Rural District Zimbabwe also revealed that majority 204 (87%) of the respondents believed that circumcision diminishes sexual pleasure which would eventually lead to loss of their partners [28]. On the contrary however other studies revealed that VMMC doesn’t adversely affect the sexual function among men [29] and another study in Nyanza Province Kenya, showed that most respondents thought that the removal of the fore skin of the penis enhances sexual pleasure which would help them to strengthen their marriages [30]. Similar beliefs were still obtained in Uganda where most of the respondents never believed that male circumcision diminishes sexual pleasure [5]. These current findings may be attributed to the fact that more than half of the respondent has a positive attitude and had circumcised via VMMC, an indication of acceptance and uptake. Thus responding to the questions was from personal experience and not from peer or other misconceptions.
Uptake of Voluntary Medical Male Circumcision is still below national target; and much as more than half of the students had a positive attitude towards voluntary medical male circumcision, a small proportion of them were willing to circumcise through voluntary medical male circumcision.
Recommendations
Basing on the study findings above, the following are recommended to help improve level of acceptance and uptake of voluntary medical male circumcision across all social groups:
- Evidence based health education should be offered even among the medical workers including health care students as a way to increase acceptance and eventual uptake of voluntary male medical circumcision.
- The hospital and campus management through it co-curricular activities should schedule yearly or quarterly campaigns for voluntary medical male circumcision involving even the students.
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- WHO (2010). WHO technical advisory group on innovations in male circumcision, meeting report, 30 September – 2 October 2014, Geneva, Switzerland.
- Alum, E. U., Ugwu, O. P. C., Obeagu, E. I., Aja, P. M., Okon, M. B., & Uti, D. E. (2023). Reducing HIV Infection Rate in Women: A Catalyst to reducing HIV Infection pervasiveness in Africa. International Journal of Innovative and Applied Research, 11(10):01-06. DOI: 58538/IJIAR/2048.
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CITE AS Musinzi Joel 2023 Influences Impacting the Acceptance of Voluntary Medical Male Circumcision among Medical Students Pursuing Bachelor’s Degrees at Kampala International University Teaching Hospital. INOSR Experimental Sciences 12(2):68-77. https://doi.org/10.59298/INOSRES/2023/2.5.1000