The promotion of medical male circumcision (MMC) as a prophylaxis is not new. In 19th century medicine, male circumcision was believed to cure a wide range of ailments including alcoholism, masturbation, and orthopaedic problems among others. While many of these claims were subsequently dismissed, medical male circumcision remained a routine procedure in countries such as the United States of America, Britain, Canada and Australia. In recent years, medical male circumcision has been linked to diminished chances of getting urinary tract infection, sexually transmitted infections, and HIV. Studies carried out in South Africa, Uganda and Kenya show that medical male circumcision reduces the chance of getting infected by HIV for men (see Auvert et al, 2005; Gray et al, 2007; and Bailey et al, 2007). These findings were followed by studies which examined the acceptability of male circumcision for HIV prevention in communities that do not practice traditional male circumcision. Acceptability studies have been carried out in many African countries including Tanzania (see Wambura et al, 2011), South Africa (see Scott, Weiss and Viljoen, 2005), Kenya (see Herman-Roloff et al, 2011), and in Zimbabwe (see Halperin et al, 2005; Mavhu et al, 2011). These studies seem to suggest that acceptability of male circumcision is relatively good in areas that do not traditionally circumcise.
In 2009, Zimbabwe adopted medical male circumcision as an additional HIV prevention strategy following the findings of the RCTs in South Africa and Uganda and predictions by mathematical models which estimated that the country would avert 750 000 adult HIV infections between 2009 and 2025 if 1.1 million males are circumcised by 2012. It was also estimated that up-scaling male circumcision to about 80 percent of the male population would result in net savings of USD3.8 billion (USAID, 2009). However, less than 10 percent of the male population is currently circumcised and only 13 977 men had voluntary circumcision by the end of 2010. While mathematical models predicted a great impact of MC on HIV infection rates and acceptability studies showed strong support for the roll-out of MC, little is known about the meanings that people attach to circumcision and the implications of rolling out MC for HIV prevention. There is thus an urgent need to interrogate the socio-cultural dynamics underlying the adoption of male circumcision as an HIV prevention strategy and its subsequent uptake. In addition to establishing the acceptability of male circumcision for HIV prevention, the present study is also designed to investigate the conceptualisations of male circumcision and the feasibility of rolling out MC for HIV prevention.
Defining male circumcision
In a recent study by Hewett et al (2012) in Zambia and Swaziland, it was established that there is over-reporting of male circumcision as a result of varying understanding of the concept. The findings of this study are not surprising given the controversy surrounding the definition and classification of male circumcision. In defining male circumcision, the distinction between medical and traditional male circumcision must be made clear. A common characteristic of the two is that both involve the removal of all or part of the foreskin. However, in traditional male circumcision, not only are foreskins removed, but this is also accompanied by religious or customary rituals which vary from one culture to another. All circumcisions, be they neonatal, adolescent or adult, done in modern medical settings for non-therapeutic purposes are classified as medical. In the past, some medical circumcisions were done without anaesthesia but that has changed significantly with the changing perceptions of pain in medical circles. Medical male circumcision is practiced in many western countries at birth, particularly in the United States, Britain and Canada. Traditional circumcision on the other hand is done under varied but non-clinical settings depending on the socio-cultural and religious customs of the ethnic group performing the surgery. Most circumcisions in ‘traditional’ settings are done without anaesthesia. Another clear distinction between medical and traditional circumcision is that the latter is done as a rite of passage from childhood to adulthood. Traditional male circumcision is associated with many complications due to the non-hygienic settings under which the surgery is done (WHO and UNAIDS, 2007) and the inexperience of the service providers (Weiss et al, 2010). The major complications that have been associated with traditional male circumcision include severe haemorrhage, gangrene of the penis, penile amputations, torture and assault resulting in severe injuries, disabilities and even death (Peltzer, Nqeketo, Petros and Kanta, 2008). Some of these complications may lead to death or amputation of the penis depending on the degree of harm. There are several ethnic groups around the world that still practise traditional circumcisions as a rite of passage for example the Xhosa of South Africa, the Balante of Senegal and the Aborigines of Australia.
The Oxford Dictionary (2009) defines circumcision as the cutting off of a boy or man’s foreskin. Other definitions of circumcision elaborate that this removal of the foreskin may be partial, for example, the American Heritage Medical Dictionary (2007) define male circumcision as the removal of all or part of the foreskin of the penis in males. The McGraw-Hill Concise Dictionary of Modern Medicine (2002) and the Mosby’s Medical Dictionary (2009) distinguish between circumcisions done by medical specialists and those performed as part of religious rites. A study by Niang and Boiro (2007) in West Africa noted that among most of the ethnic groups they studied, male circumcision means removal of the whole foreskin of the penis except among the Balante of Senegal who distinguishes between “small circumcision” and “large circumcision”. Small circumcision among the Balante refers to an incision made on the foreskin in preparation for the full circumcision.
The generally accepted definitions of male circumcision have been criticised for treating the understanding of male circumcision as universal. It has been argued, for example, that the length of the foreskin varies from one person to another and also that the determination of how much to remove rests entirely with the person performing the surgery as well as their experience. Given the above, it is difficult to use the same standard to define or classify male circumcision  .
Classification of male circumcision
Male circumcision has been classified according to several dimensions. It has been grouped depending on the age of those being circumcised, the setting under which the surgery is done, and recently there have attempts to classify it in terms of the amount of skin removed. The following types are most common:
1.3.1 Classification by age of circumcision
Neonatal circumcision- this is circumcision done at an early age. Among Jews, for example, circumcision is done on the eighth day after birth. Neonatal circumcision is most prevalent in Jewish communities and in the United States of America.
Adolescent/Adult circumcision- adolescent or adult male circumcision is done at adolescence or early adulthood. Socio-cultural and religious customs determine the age or age group within which circumcision can be done. Among the Xhosa, the Aborigines and many other ethnic groups, circumcision is done at puberty in preparation for adulthood.
1.3.2 Classification by indication/setting of surgery
Medical circumcision- all circumcisions, be they neonatal, adolescent or adult, done in modern medical settings are put in this category. In the past, some medical circumcisions were done without anaesthesia but that has changed significantly with the changing perceptions of pain in medical circles.
Traditional circumcision- traditional circumcision is done under varied but non-clinical settings depending on the socio-cultural and religious customs of the ethnic group performing the surgery. Most circumcisions done in ‘traditional’ settings are without anaesthesia. Another clear distinction between medical and traditional circumcision is that the latter is done as a rite of passage from childhood to adulthood. Traditional male circumcision is associated with many complications due to the non-hygienic settings under which the surgery is done (WHO and UNAIDS, 2007). Some of these complications may lead to death or amputation of the penis depending on the degree of harm.
1.3.3 Classification by type of surgery
This category is not really a separate grouping from those given above but rather represents attempts by scholars to separate male circumcision by the amount of skin removed or by the perceived severity of the surgery. One such attempt was made by Sami A. Aldeeb Abu-Sahlieh (2001) who identified four main types of male circumcision as follows:
Type 1- this type consists of cutting away a part or the whole of the foreskin of the penis.
Type 2- this type of circumcision is practiced mainly by Jews and it involves removal of the foreskin in two stages. Firstly, the outer membrane (skin) is cut exposing the inner membrane which is then removed by the sharpened fingernails of the person performing the procedure.
Type 3- this type involves completely peeling the skin of the penis and sometimes the skin of the scrotum and pubis. This is a rare type of circumcision and according to Abu-Sahlieh (ibid) it existed among some tribes of South Arabia and among the Namshi of Africa.
Type 4- in this type, the urinary tube is slit open from the scrotum to the glans, creating in this way an opening that looks like the female vagina. This form of circumcision is still performed by the Aborigines of Australia.
The typology by Abu-Sahleih has been criticised by the Circumcision Information Australia  on the grounds that it captures some of the rarest forms of circumcision that may no longer be in existence (because they are no longer traditional rites but are now minor surgical operations done in hospitals by trained medical personnel) but overlooks other types of circumcision such as infibulation and piercing practiced in some parts of South East Asia. They have therefore proposed the following:
Type 1- a nick to or slitting of the foreskin; or premature or forcible separation of the prepuce from the glans, without amputation of tissue.
Type 2- amputation of the portion of the foreskin extending beyond the glans.
Type 3- amputation of the foreskin at a point partway along the glans; some foreskin and all of the frenulum left; some sliding functionality retained.
Type 4- amputation of the foreskin at or below the corona of the glans. This category has been subdivided into three other subtypes due to the absence of an agreed understanding of what constitutes circumcision- the quantity of tissue removed, the degree to which the foreskin is stretched during the operation, and the instruments used.
Type 4a- amputation of the foreskin at the corona of the glans, leaving glans fully exposed, but retaining frenulum; little or no sliding functionality; frenular nerves retained.
Type 4b- amputation of the foreskin at the corona of the glans, also excising frenulum; little or no sliding functionality; no frenular nerves left.
Type 4c- amputation of the foreskin beyond the corona of the glans, at any point along the penis shaft; all foreskin and variable quantities of shaft skin excised; all frenular nerves lost; zero sliding functionality; high risk of insufficient slack tissue for accommodating tumescence.
Type 5- includes other forms of penis mutilation, including meatotomy, subincision, infibulation, piercing and implants.
Prevalence of male circumcision
The actual prevalence of male circumcision is difficult to estimate owing to several factors. Firstly, the available data is several decades old and secondly, no studies to date have been carried out with the main objective of determining the prevalence rates of male circumcision (Williams et al, 2006). Williams et al further note that some of the studies that attempted to capture prevalence rates tended to rely on self-reported circumcision and this may overestimate the actual rates. Despite this gap, researchers have relied on Demographic and Health Surveys for data on the prevalence of male circumcision.
Globally, the World Health Organisation and UNAIDS (2007) estimate that 30 percent of all males aged 15 years and above are circumcised. More than 69 percent of these are Jews and Muslims  . They further note that neonatal circumcision is most common in the United States of America, Canada, Israel, West Africa and much of the Middle East while in East and Southern Africa most circumcisions take place in boyhood, adolescence or early adulthood. The WHO/UNAIDS report site several factors that influence the geographical and spatial distribution of male circumcision and these include religion, ethnicity and social factors such as the desire to conform, socio-economic status and the perceived health and sexual benefits of circumcision.
The prevalence of male circumcision in much of Africa is well above 80 percent, particularly in North and West Africa. Parts of Central and Southern Africa have a prevalence rate between 20 and 80 percent. Within Southern Africa, Namibia, Botswana, Zimbabwe, Zambia and Malawi have prevalence rates less than 20 percent. Williams et al (ibid) computed prevalence rates for several African countries based on different sources of data  . These estimates were taken by region and a regional average was computed. The male circumcision prevalence rates based on Williams et al’s study are shown in Figure 1.1.
Figure 1.1: Male circumcision prevalence rates in Africa by region
Source: Williams et al (2006) Table 1
In Zimbabwe, studies that attempted to estimate the prevalence of male circumcision are limited except the 2006 and the 2011 Demographic and Health Surveys which put the national prevalence rate at about 10 percent and 9.2 percent respectively. The distribution of prevalence rates by province is shown in Figure 2.4. A study by Mavhu et al (2011) in rural Zimbabwe found a prevalence rate of 20 percent. The latter estimate cannot be relied on because it was based on a small sample (n=203) compared to the DHS data. Based on the ZDHS results, it is difficult to get a clear pattern of the prevalence and hence it follows that it is too early to judge whether the up-scaling of medical male circumcision has had an effect so far on the prevalence. The observed variations are therefore likely to be a result of sampling than real change on the ground.
Figure 1.2: Male Circumcision Prevalence by Province, Zimbabwe 2006 and 2011
Source: ZDHS Reports, 2007 and 2012
Background of the study
Zimbabwe has one of the highest HIV prevalence rates in the world. In the late 1990s, the HIV prevalence rate for adults 15-49 years was estimated at 33.5 percent, and recent estimates from the Ministry of Health and Child Welfare put the figure at about14.26 percent. The latter is a revision from the previously published estimate of 13.7 percent in 2009. However, the Zimbabwe Demographic and Health Survey of 2011 estimated the prevalence rate at 15 percent. The general trend over the past ten years has been one of plummeting HIV prevalence rates driven by high adult mortality and behaviour change (Gregson et al, 2010). Evidence from epidemiological studies indicate that as mortality increases surpassing the rate of new infections, the overall prevalence tend to plummet.
An analysis of HIV prevalence rates by province and gender show a consistently higher rate for females than males in all the provinces (Figure 1.2). This can be partly explained by arguments put forward by scholars such as Mate (2002) who suggested that females suffer the most from the HIV pandemic because of their compromised position in society. She argued that they cannot negotiate for safe sex and are sidelined on issues that affect their health.
Figure 1.3: HIV Prevalence by Province and Sex, Zimbabwe 2011
Source: ZDHS Report, 2012
Over the years, research findings to explain the factors behind the observed HIV prevalence rates have mounted. These studies can generally be grouped into those that focussed on individual behaviours and dispositions and those that focussed on structural causes of high HIV prevalence. Some of the structural causes cited in literature include colonialism and poverty. Ranger (2000) focused on the colonial administration systems that he blamed for social reengineering which transformed local institutions and ethos through the imposition of laws, practices and new value systems. One result of this social reengineering was the creation of a dual home syndrome which exposed the African population to an increased risk of HIV infection by separating families (Brycesson, 2005).
Poverty has also been cited as a major driver of HIV in many developing countries (UNDP, 2007). In May 2000, the then President of the Republic of South Africa, Thabo Mbeki, convened a meeting of experts to discuss the AIDS pandemic. At this conference, President Mbeki questioned the scientific paradigms on HIV/AIDS and rather argued that HIV/AIDS is a result of poverty. This argument attracted negative responses from experts and the media alike (Head, 2009).
In Zimbabwe, research studies established a link between culture and the spread of HIV. Mhloyi (2001) highlighted what she called a culture of silence on sexuality. Through this conspiracy of silence, sexual intercourse is neither discussed nor expressed in words. The result is that each individual is left to learn on their own through trial and error increasing their vulnerability to HIV infection. Mate (2002) focused on gender disparities and concluded that women are generally subjugated through patriarchy and rendered powerless to negotiate for safe sex. These gender disparities, according to Mate, explain the gender differentials in HIV infection rates in Zimbabwe. At an individual level, the spread of HIV has been linked to multiple and concurrent sexual partners.
While there are many channels through which HIV spreads, research concluded that 92 percent of all infections in Zimbabwe are through heterosexual contact followed by vertical transmission from mother-to-child (Macro International and CSO, 2007). Recognising the negative impacts of HIV/AIDS on national development, the government of Zimbabwe through the Ministry of Health and Child Welfare, the National AIDS Council and other implementing partners adopted a national behaviour change strategy. This strategy adopted a three-pronged approach based on the ABC model of behaviour change which integrates the following components:
faithfulness to one uninfected partner, and
consistent use of condoms
The ABC approach targeted increasing the age at sexual debut, increasing correct condom use, and reducing the average number of sexual partners. The approach also encouraged individuals and couples to get tested for HIV. In addition to targeting behaviour modification, the government also put in place strategies to cater for those already infected. Firstly, HIV screening was introduced for all pregnant women and those found HIV positive are encouraged to take a single dose of Nevirapine to prevent the transmission of HIV to the unborn child. This prevention of mother-to-child transmission programme (PMTCT) was launched simultaneously with the anti-retroviral therapy (ART) programme which sought to increase availability of ARVs for everyone despite socio-economic background. Several New Start Centres were opened to increase access to free HIV testing and counselling services.
The above initiatives seem to have enjoyed relative success if measured by the pattern of HIV prevalence and other indicators. According to the results of the Zimbabwe Demographic and Health Survey of 2011, knowledge of HIV is universal. The age at sexual debut remain fairly high, 20 years for males and 18 years for females. However, there appears to be gaps in some of the indicators, for example, the number of lifetime sexual partners remain high for males at 5.8 compared to 2.2 for females. While the number of people who have never been tested for HIV has declined significantly between 2006 and 2011, it remains very high at 61 percent for males and 58 percent for females.
The ABC approach has received considerable attention from scholars with some questioning its effectiveness on behaviour change (Mulwo, 2008). Mulwo also notes that many scholars agree that individual-centred approaches are effective in changing beliefs, attitudes and behaviour. The major criticism of the ABC model is that it assumes that individuals are autonomous and have power to change their behaviour. The ABC model, like the Health Belief Model and the other theories of behaviour modification from which it is derived, makes a linear assumption about human behaviour thus overlooking the power of structural forces such as culture that grip individual decision-making processes, particularly in Asia and Africa where societal norms override individual decisions and choices (Airhihenbuwa and Obregon, 2000).
Since the adoption of the ABC model, a number of developments have taken place in an attempt to curb the spread of HIV, for example, clinical trials for microbicides are currently under way. These are creams or gels that are put in the vagina or rectum and are believed to kill the AIDS virus on contact. In other related developments, recent ecological and clinical studies have linked male circumcision to HIV prevention. The earliest studies to link HIV infection and the prevalence of male circumcision were done in the 1990s. One of such pioneering studies attempted to establish a link between the geographic incidence of male circumcision and the sero-prevalence of HIV (Moses et al., 1990). In this study, the researchers took ethnographic data on circumcision practices of over 700 ethnic groups in Africa and used this to construct a map showing the geographic distribution of male circumcision. They also took data on sero-prevalence and juxtaposed it on the map of circumcision prevalence. They noticed that there were large differences in HIV sero-positive prevalence between population practising male circumcision and those who were not. The researchers attributed their findings to the observed differences in the prevalence of male circumcision. In subsequent studies, the link between male circumcision and HIV was further explored with the famous Randomised Controlled Trials in South Africa, Uganda and Kenya. It was found that male circumcision can reduce the risk of getting infection by between 51 and 64 percent. These findings had a profound impact on the drive to scale up male circumcision for HIV prevention, and the subsequent debates on safety, accessibility, the involved costs and acceptability of the procedure to non-circumcised communities.
Research problem and objectives
The present thesis is motivated by two broad objectives. Firstly, the present study intends to explore the conceptualisations of male circumcision and its acceptability as an HIV prevention strategy in Zimbabwe. While two earlier studies by Halperin et al (2005) and Mavhu et al (2011) concluded that there is a general acceptability of circumcision for HIV prevention, the number of those who have volunteered for the procedure imply otherwise. The emphasis on conceptualisations is expected to unlock a new dimension on the socio-cultural dynamics that influence acceptability of MC. This will be achieved using both qualitative and quantitative approaches to data analysis. The second broad objective of the thesis is to evaluate the feasibility of promoting medical male circumcision as an additional HIV prevention strategy in Zimbabwe.
Specific research objectives
The specific objectives of the study are:
To ascertain the acceptability of male circumcision among men and women
To investigate the factors influencing the uptake of male circumcision in Zimbabwe
To evaluate the possible implications of male circumcision on men’s sexual behaviour
To evaluate the role of women in the conceptualisation and uptake of male circumcision.
Specific research questions
The present study will be guided by the following questions:
What is the prevalence of both traditional and medical male circumcision?
What is the place of MMC in the spectrum of existing HIV prevention methods?
What factors influence the uptake of male circumcision?
What are the implications of MC on men’s sexual behaviour?
What is the perceived impact of MC on men and women’s sexual pleasure and satisfaction?
A theoretical framework guides the way a research is conducted and how the results are interpreted. The present study proposes to use the Theory of Social Representations, the Health Belief Model and the Social Behaviour Model of Health Services Utilisation. These models attempt to explain health related decisions. Whereas the Theory of Social Representations emphasises the role of context and social interpretations and meanings and how they influence individual decision-making processes, the Health Belief Model focuses on the role of personal beliefs and cognitive processes. On the other hand, the adoption of the Social Behaviour Model of Health Services Utilisation for this study is premised on the understanding that it is not enough to recognise cognitive and social factors that may influence men to get circumcised or women to encourage their sons and partners to get circumcised without a clear comprehension of other factors that may lead to the actual utilisation of health care services. While the primary focus of these models appear different, they all recognise the role of information in the shaping of beliefs and the ultimate decision to seek medical assistance. Thus, the use of these theories in this study is an acknowledgement that health-related decisions are influenced by factors that are both internal and external to the individual.
1.7.1 The Theory of Social Representations
The theory of social representations is a revision of Durkheim’s concept of collective representations, which in Moscovici’s view, were inadequate to capture the plurality of representations (Moscovici, 1988). Moscovici defined social representations as “cognitive systems with a logic and language of their own and a pattern of implications, relevant to both values and concepts, and with a characteristic kind of discourse. They do not represent simply ‘opinions about’, ‘images of’ or ‘attitudes toward’ but ‘theories’ or ‘branches of knowledge’ in their own right, for the discovery of society” (in Herzlich, 1973). Winskell et al (2011) defined social representations as culturally shared mental phenomena that communicate norms and values in symbolic form. They further elaborate that social representations are often pre-conscious and therefore less subject to informant bias than conscious evaluative judgements like attitudes. Maurya (2009) defined social representations simply as commonsense theories generated by people to understand everyday reality. According to Moscovici, social representations have two main functions. Firstly, they enable individuals to have a good understanding of themselves and their surrounding world, and secondly, social representations facilitate the communication process by establishing a common way of identification and classifying among community members.
The main assumptions of the theory of social representations are that:
The social construction of societal life is shaped by an exchange and interaction process among individual society members.
There is plurality and diversity of representations within the same society.
Social representations are dynamic and constantly changing over time and space. The evolution of social representations is influenced by the complexity and speed of communication as well as the available communication media.
In elaborating the formation of social representations, Moscovici (1988) assumed that there exist a reified universe in which scientific or expert thinking is generated and discussed. The discourses in the reified universe are then transferred to the consensual universe in which the lay men interact. For example, the discourse of the potential of male circumcision is first discussed in the reified universe of ‘experts’ on epidemiology and HIV/AIDS, then these discussions are ‘repackaged’ for the consumption of the consensual world. However, the theory does not assume that the reified universe is the only source of knowledge. The eventual formation of social representations involves three major processes; transformation, anchoring and objectification (Joffe, 1998). Transformation involves the transmission of expert ideas from the reified universe, via communication, into lay thinking. During this process, the media plays an important role in the dissemination of information, a process that involves the reinterpretation of scientific knowledge into common language for easy of comprehension in the consensual universe. According to Joffe (1998), the mass media simplify and sensationalise expert issues. However, she immediately points out that the process of transmission is not one in which the lay persons in the consensual universe are passive recipients of expert knowledge. Lay people give their own meaning to the information that they receive, and this may even involve the challenging of the expert notions. The process of anchoring involves the ascribing of meaning to new phenomenon by means of integrating the object being represented into existing worldviews (Moscovici, 1976). In this way, the process of anchoring is similar to the concept of cognitive schemas. The latter involves the storage of mental schemas of past events which are then used as referral points to derive meaning to new and unfamiliar circumstances. Similarly, anchoring involves the bringing forward of past ideas and imposing them on the new event which needs to be understood. In Zimbabwe, for example, the early conception of HIV was likened to the traditional notions of runyoka  . It was initially believed that the ‘new sickness’ (HIV/AIDS) was one of the more serious forms of runyoka. Consequently, some traditional healers claimed that they could cure the new ailment. The process of objectification involves the transformation of an abstract concept into something concrete through the use of familiar images which become associated with the new phenomenon, for example, images of coffins and tombstones became associated with the fear that accompanied early messages of HIV/AIDS in Britain and South Africa (Joffe, op cit). According to Moscovici, this produces a domestication of the unfamiliar through saturation of unfamiliarity with everyday experiences. The processes of anchoring and objectification take place simultaneously.
1.7.2 The Health Belief Model
The Health Belief Model (HBM) is a cognitive model that focuses on individual beliefs to predict health behaviour. The model was developed in the 1950s by Hochbaum, Rosenstock and Kegels in an attempt to understand the failure of a free tuberculosis screening programme. The original model had four theoretical constructs but was revised by Becker and Rosenstock in 1988. The model has been used to understand health behaviour in the context of HIV and AIDS. The Health Belief Model is based on the premise that a person is a rational being and will take a health-related action if the following conditions are present:
the person must feel that a negative health condition can be avoided,
the person has to believe that a negative health condition can be avoided by taking a recommended action, and
the person must also believe that s/he is capable of taking the recommended action.
The Health Belief Model is premised on six main theoretical precepts. Firstly, an individual carries a self-assessment to review the possibility of getting a condition, say HIV (perceived susceptibility). Furthermore, a person also assesses the severity of the condition (perceived severity) and their perceived effectiveness of the recommended action to minimise risk or severity of consequences (perceived benefits). After those evaluations, the Health Belief Model also presupposes that a person also evaluates the tangible and psychological costs of the recommended action (perceived barriers). The model assumes that after the evaluations, there exist cues to action or factors that may trigger a person to start changing behaviour. The final theoretical precept put forward by the model is self-efficacy in which a person evaluates their ability to execute the recommended action.
1.7.3 The Social Behaviour Model of Health Services Utilisation
The Social behaviour model of health services utilisation was developed by Andersen and Newman in the 1960s and has been modified four times to accommodate emerging research findings on the factors that influence health services utilisation. The goal of the model is to provide measures of access to medical care. An individual’s access to and utilisation of health care services is determined by three dynamics: predisposing factors, enabling factors and need. Predisposing factors are socio-cultural characteristics of individuals that exist prior to the illness and these include demographic factors such as age and sex, health beliefs such as attitudes, values and knowledge that people have concerning the health care system, and social structure factors such education, ethnicity, culture, social networks and social interactions. Enabling factors are the logistical aspects of getting help including the means and know-how to access health services, travel, income, health insurance, availability of health personnel and facilities and waiting time. Finally, the model identifies need factors as the most immediate cause of health services utilisation. Andersen (1995) distinguished between perceived need and evaluated need. The former determines whether a person will seek medical help or not depending on their personal judgement of their health as well as their experience of symptoms of illness, pain and worries whereas the latter determines the quality of services a person will get after they present themselves to a health practitioner. While the model focuses on the individual as the unit of analysis, it culminates in health outcomes as the endpoint of interest.
The Behavioural Model by Andersen has generated a lot of research and has been used in several studies that attempted to validate its constructs. The model was used, for example, by Willis et al (2010) to understand informal support among Britain’s ethnic minorities, by Girma et al (2011) to investigate health service utilisation in south west ethiopia, and by luseno et al (2010) in South Africa. Willis et al (ibid) concluded that the behavioural Model is very flexible and useful for gerontological research. However, after an analysis of several studies that utilised the Behavioural Model, Babitsch et al (2012) concluded that while the model has been used extensively in studies investigating the use of health services, there is evidence of substantial differences in the variables used.
Relevance and limitations of the selected theoretical frameworks
The contribution of the Health Belief Model to the understanding of individual decision-making processes and behaviour change cannot be overemphasised. However, it has been received criticism on the grounds that many of its constructs have not been tested because studies based on the model have incorporated selected components of the model (Family Health International, 2002). Secondly, the relationship between the various components of the model has not been clearly spelt out. In addition, the model overlooks the role of social influence and cultural beliefs on behaviour (Munro et al, 2007). Other critics such as Joffe (1996) have argued that the role of individual volition in health behaviour is restricted by others who may subtly or coercively exercise their control, for example, women may find it difficult to request the use of a condom even if they want to (pg. 172). These assumptions on which the model is based have little relevance for communicating HIV/AIDS related messages in most of Africa, Asia, Latin America and the Caribbean where social norms take precedence and are more reliable predictors of behaviour (Airhihenbuwa and Obregon, 2000). This is particularly the case with male circumcision which is practised as a social norm to mark the transformation of boys into men in many African societies.
While the strength of the Health Belief Model lie in its ability to predict individual health seeking behaviour, the Theory of Social Representations focuses on factors external to the individual. Much of the criticism against the Theory of Social Representations has focussed on four main aspects: ambiguities in defining social representations, social determinism, cognitive reductionism, and lack of a critical agenda (Voelklein and Howarth, 2005). However, some of these criticisms stem from the misunderstandings that arise from “the complex and dynamic relationship between social structure and individual agency put forth in the theory” (ibid). According to Joffe (1998), the theory of Social Representations is superior to the current paradigms in HIV/AIDS research such as the Theory of Reasoned Action and the Health Belief Model.
In the final analysis, no theory or model is without deficits. In attempting to explain human behaviour, the Health Belief Model and the Theory of Social Representations overemphasised the role of one factor at the expense of the other attracting sharp criticism in the process. The former places emphasis on individual cognitive processes in decision making while the latter puts social factors at the fore. On the other hand, the Social Behaviour Model of health service utilisation attempts to predict factors that may lead to the consumption of health care services. This is important for the present study which is seeking to understand factors that may attract or impede men from getting medical circumcision fro HIV prevention. Thus, in selecting these models as theoretical frameworks for this study, it was felt that the weaknesses inherent with one model would be complemented by the strengths of the others.
Structure of the dissertation
The dissertation is organised into six chapters as follows:
Chapter One: Introduction- this chapter will bring out the purpose of the study, the background information on the importance of the study, justification of the study, and the pertinent questions and objectives that the study intends to fulfil. Also to be included in this chapter are the theoretical frameworks.
Chapter Two: Literature Review- this chapter will discuss the main scholarly debates on male circumcision, its origins, symbolic significance, prevalence, and its role in aetiology and as prophylaxis against HIV. The chapter will also discuss the emerging debates on male circumcision and HIV/AIDS particularly situating the present study in those debates.
Chapter Three: Methodology- the description of the research methods used for sampling, data collection and data analysis will be discussed in this chapter. The rationale behind the selection of each method will also be highlighted.
Chapter Four: Conceptualisations and Implications of MC- this chapter looks at how male circumcision is understood by the study participants and its implications on behaviour. The discussion on conceptualisations in this chapter will be based on qualitative data collected from secondary sources and focussed group discussions.
Chapter Five: Prevalence and Acceptability of MC- this chapter will present the study findings on prevalence and acceptability of male circumcision as prophylaxis against HIV. Multinomial logistic regression analysis will help isolate the factors that predict acceptability of MC for HIV prevention.