Perceived Risk and Severity of the Uptake of Safe Male Circumcision Services among Young Men Aged 15-24 Years in Rhino Camp Refugees Settlement, Arua District- Uganda


 Background

Safe male circumcision is a proven cost-effective intervention in reducing the risk of sexual transmission of Human Immunodeficiency Virus /Acquired Immune Deficiency Syndrome among heterosexual individuals by 60%. This study aimed at exploring the perceived risk and severity to the uptake of safe male circumcision among young men aged 15–24 years in Rhino Camp Refugees Settlement, Arua District, Uganda.
Methods

This was a cross-sectional study among 378 respondents, which utilized both quantitative and qualitative approaches with a semi-structured and three focus group discussions conducted among young men aged 15–24 years. Univariate analysis was used to determine the uptake of safe male circumcision. Chi-square test and binary regression model were used to determine the odds ratio at 95% confidence levels of safe male circumcision uptake and other exposure variables. Results from the focus group discussions were analysed thematically.
Results

The prevalence of safe male circumcision uptake was 42.1%. The major factor associated with increased likelihood of safe male circumcision uptake was the perceived benefit of cervical cancer prevention in my partner (AOR = 2.455, 95% CI = 1.278–3.627). Factors associated with reduced likelihood safe male circumcision uptake included: fear of perceived increased risk of meatitis (AOR = 0.726, 95% CI = 0.338- .959), fear that undergoing safe male circumcision is very painful and uncomfortable (AOR = 0.742, 95%, CI = 0.279–1.973). Also, the perception that safe make circumcision is not affordable at most private health facilities (AOR = 0.167, 95%, CI = 0.058–0.478).
Conclusions

Safe make circumcision uptake in Rhino Refugees Settlement is lower than Uganda’s national target of 80%. This is attributed to the perceived risks such as perceived risk of infection, pain, irritability, and costs involved. Awareness creation on myths and misconceptions is key to increasing up take of safe make circumcision.

Nations Programme on HIV/AIDS in 2007 (WHO/UNAIDS 2010). This followed research ndings of a study in Kenya, Uganda and South Africa in 2004 that indicated that circumcised heterosexual men were approximately 60% less likely to sexually acquire HIV compared to uncircumcised heterosexual men.
The uptake of SMC has been low over the decades due to perceived risks including adhesions, excessive skin removal, cysts, and penile amputation. Others perceive safe male circumcision to be associated with severe bleeding, infections, irritation of the glans and injury to the penis. These are myths and misconceptions that need to be addressed if the prevalence of HIV/AIDS is to be cabbed down.

Background
Safe Male Circumcision (SMC) is the surgical removal of the penile foreskin or tissue, which covers the head of the penis performed by a trained health professional such as a doctor or nurse under safe condition [1]. SMC was recommended as a Human Immunode ciency Virus (HIV)/Acquired Immune De ciency Syndrome (AIDS) prevention procedure by World Health Organisation (WHO) and The Joint United Nations Programme on HIV/AIDS in 2007 [2]. This followed research ndings of a study in Kenya, Uganda and South Africa in 2004 that indicated that circumcised heterosexual men were approximately 60% less likely to sexually acquire HIV compared to uncircumcised heterosexual men [3]. The second Random Controlled Trials (RCT) in Uganda's Rakai District studied four thousand nine hundred and ninety-six men aged between 15 and 49. Here, circumcision managed to reduce risk of infection by approximately 51 percent [4]. Reasons for low-risk infections is attributed to the fact that HIV target cells in the prepuce, which tremendously reduced as a result of circumcision. The prepuce may suffer mild trauma during intercourse prompting infection. At the same time, the prepuce harbors organisms that such as Escherichia coli, and Enterococcus avium and provides a conducive environment for prolonged viral survival [3].
Globally, Male Circumcision (MC) was historically associated with religious and cultural practices.
However, SMC has been increasingly adopted in many parts of the world. It is estimated that 38% of the world's males aged 15 years or older are circumcised of which about 62% are Muslims residing mainly in Asia, the Middle East and North Africa, 0.8% are Jewish and 13% are non-Muslim and non-Jewish men living in the USA [5].
In Africa, especially in Northern and Western regions, MC is almost universal. However, its' uptake in other parts varies considerably with low uptake reported in the African countries of Botswana, Namibia, Swaziland, Zambia and Zimbabwe [6]. According to WHO's report in 2018 [6], the prevalence of SMC is reported to be 21% in Malawi, 35% in South Africa, 48% in Lesotho, 20% in Mozambique and more than 80% in Angola and Madagascar. In East and Central Africa, the prevalence varies from almost 15% in Burundi and Rwanda to 70% in Tanzania and 93% in Ethiopia. In Uganda, SMC prevalence among men aged between 15 to 49 years was 27% in 2018, but with high levels of willingness to be circumcised among uncircumcised men. Those who expressed willingness at the time also seemed to be the ones with the largest need for protective measures [7].
A qualitative study in Iringa, Tanzania found that women had strong preferences for circumcised men because of the perception of low risk of infection of HIV from circumcised men, social norms favouring circumcised men, and perceived increased sexual desirability of circumcised men. The health bene ts of male circumcision were generally overstated. Several respondents falsely believed that women were directly protected against HIV infection and that the risk of all STIs was profoundly reduced or eliminated in circumcised men [8].
A population-based survey was conducted among purposively selected respondents aged 15-49 to explore barriers and motivating factors to SMC for HIV prevention, and to assess utilization of existing SMC communication channels in Zimbabwe. The survey reported that 68% and 53% of female and male respondents respectively had heard about SMC for HIV prevention. (Hatzold, et al., 2014). Public programs for SMC are available, but they are limited, which make the uptake sometimes little despite the level of awareness. Also, perceived severity such as bleeding and infection, irritation of the glans, injury to the penis and increased Meatitis made uptake of safe male circumcision services low [9].
Uganda's scenario of uptake of safe male circumcision is not far different from other countries in the region, up take is still low despite being free [10]. The country's target by 2015 was to circumcise 4.2 million adults, however, required an effective model to achieve [3]. A study done in Northern Uganda in 2018, indicated that, 42% of their study participants owned a misconception that Voluntary Male Medical Circumcision (VMMC) had an impact on their sexual performance. Similarly, 35% of the same study participants believed that VMMC. contributes to promiscuity [10].
Given the above-ground, the authors purposed to carry out a study on the perceived risk and severity of the uptake of safe male circumcision services among young men aged 15-24 years in Rhino Camp Refugees settlement, Arua district in Uganda. Rhino Camp Refugee Settlement is a Refugee Camp in Arua District in north-western Uganda and has seven zones, which includes Ofua, Omugo, Ocea, Odobu, Siripi, Tika and Eden. The settlement has about 56,865people of which 6,824 are young male aged 15-24 years [11]. The health services provided in Rhino Camp Refugee Settlement are VCT services, family planning, protection which encompasses prevention of sexual exploitation and abuse; maternal and child health services. The village health teams and home health promoters are the gateway to dissemination of key information on health services. Therefore, the study answered the following questions; what perceived risks are associated with the uptake of safe male circumcision among young refugee men aged 15-24 years in Rhino Camp Refugees' Settlement? And, how do these young men aged 15-24 years perceive the severity of uptake of SMC services? The study was carried out from January 2020 to November 2020. It intended to provide scienti c evidence that would aid in scaling up safe male circumcision campaign based through advocating for the involvement of community leaders during community sensitization meetings in the various communities on the health bene ts of safe male circumcision.

Study design and settings
The study adopted a cross sectional survey design employing both qualitative and quantitative data collection methods that helped determine perceived risk, and severity associated with the uptake of safe medical circumcision services among young men aged 15-24 year in Rhino Camp Refugee Settlement.
A total of 378 participants took part in the study. These were sampled using probability and nonprobability sampling procedures. Participants were assigned unique numbers used for sampling. First, a systematic random sampling was used to establish the sampling interval by dividing the required number of participants present by the number of participants to be interviewed. The sampling interval was determined by dividing the population (N) and sample size (n). Sample size (n) where; study population is the total number of young male refugees in Rhino camp refugees' settlement which was 6,824, and the sample size calculated was 378. Therefore, sampling interval was equal to 6824/378, which yielded 18.
A researcher-administered semi-structured questionnaire was the primary instrument used to collect quantitative data from the participants. Purposive sampling technique was used in selecting participants for the Focus Group Discussion (FGD). Three FDG sessions were conducted and were guide by openended questions designed in accordance with the speci c objectives of the study. Willingness to undergo SMC services was a dependant variable with a two-scale option; yes or no, coded as "1" or "0" whereas the perceived risks, and perceived severity, were independent variables, measured using a 4-point Likert scale of responses of "strongly agree", "agree", "and disagree" and "strongly disagree" respectively.
The data in Microsoft Excel was then exported into Statistical Package of Social Sciences (SPSS) version 21 for analysis. Descriptive statistics were used to summarize data on respondents' characteristics and presented as; graphs, charts, and frequency distribution tables are appropriately used.
Numerical data were summarized into descriptive statistics of mean, median, and standard deviation and categorical data into frequencies and percentages. At bivariate level, to determine whether there are differences in participant perceived risk, and severity, with SMC uptake, the Chi-squared Fishers exact test was used for categorical variables. At 0.05 level of statistical signi cance. At multivariate analysis, all statistically signi cant variables at bivariate level of analysis were subjected to binary logistic regression analysis and the results were reported as crude odds ratio with corresponding 95% con dence intervals and p-values. Second, a multi-nominal logistic regression analysis was considered for all variables at unadjusted analysis that are statistically signi cant, to establish those that were independently associated with the outcome. Analysis of qualitative data followed a framework approach (Ritchie and Spencer 2002), which provided a systematic structure, allowing for a priority and emergent codes. The transcripts were read and reread for the researcher to familiarize themselves with the data. Open coding was used to avoid biases in the development of codes based on the researchers' prior knowledge, beliefs and perceptions about SMC. Descriptive codes were also used to identify basic expressions found in FGD transcripts and categorized into sub-themes and themes.

Results
Socio-demographic characteristics. Uptake of safe male circumcision Perceived risks and uptake of safe male circumcision services Three in every ten (30.4%) of the participants disagreed that there is possibility that they may develop adhesions when circumcised and 117/378 (31.0%) agreed that they worried a lot about developing cysts after safe male circumcision. This is indicated in Table 2. Perceived severity and uptake of safe male circumcision services  Table 4. .106 Increased fear of Meatitis (Crude OR = 0.503, 95% CI .281-.898) was signi cantly associated with uptake of safe male circumcision at bivariate analysis as indicated in Table 5. to be signi cantly associated with uptake of SMC services at multivariate analysis (Refer to Table 6).

Presentation of the qualitative data from the FGDs
Facilitating factors for SMC uptake Participants in all FGDs cited increased protection from HIV and other STIs as an advantage of SMC. Similarly, it was consistently reported that circumcised men are cleaner and more hygienic than those who are uncircumcised. The concept of cleanliness manifests itself in the FGDs in two disparate ways SMC improves general hygiene of the penis, including the reduction of foul odors. FDG 1 SMC reduces the transmission of STIs via improved cleanliness due to the removal of the foreskin. Most men can spend the entire day without showering. Such a man harbors a lot of dirt under the prepuce, unlike a circumcised man. Therefore, that is the source of syphilis, HIV and other STIs. .. it is easy to contract them, especially if the woman is not ready for sex. FDG 2 In FGDs, circumcision was described as protective against HIV acquisition because it reduced "bruising." However, there were inconsistencies with the description of how bruising affected HIV transmission.
When bruising was mentioned in the FGDs, participants reported that circumcision reduced bruising of the penis and subsequently, risk of HIV transmission.
"A circumcised person cannot easily get HIV. He penetrates into the vagina smoothly, but a person who is not circumcised can easily get infected. Since the foreskin keeps on moving up and down, he gets bruises and the blood mixes up, thus being infected with HIV if the woman is infected". A participant in FDG 3.
However, when discussed in the FGDs, SMC was described as protective against HIV transmission through reduced bruising of the vagina: The foreskin keeps a lot of dirt. After removing the foreskin, the woman does not get bruises so much. The bruises are caused by the small size of the woman's entry point because the skin rubs so much on it if one is not circumcised. FDG 1 In several of the FGDs, participants connected SMC with cancer prevention. The mechanisms through which circumcision reduces the risk of cancer were described in varying manners.
A male participant explained the relationship between circumcision, pregnancy, and cancer: "We were taught that the foreskin keeps germs, so if you have sex with a pregnant woman before circumcision, it may cause cancer. One is clean after circumcision to the partner, which helps her deliver with no problem". Participant in FDG 2 The perceived advantages and disadvantages of Safe Male Circumcision General fear of pain regarding circumcision was the concern mentioned most often. Young men expressed concern over pain speci cally during the SMC procedure but they also feared pain during recovery due to potentially poor suturing or a surgical mishap resulting in a deformity. A few teenagers thought that pain could result from a lack of follow-up wound assessment by SMC health providers. Concern over pain during morning erections was another common concern. Some men and women feared that pain during recovery would cause a man to miss work and lose income.
"We are afraid because those who had gone for the circumcision were saying that it was very painful when the foreskin is cut, during suturing, and then after that you were unable to perform your normal duties as usual. Being a person with dependents, it was not appealing to me." Said one of the male respondents. FDG 1 However, concern about pain was not universal; those who were not circumcised at the time of their interviews said that they were not concerned about pain.
"No, no, right now I am 23, and there is no pain I will feel when I become circumcised because I have endured painful things so there is none I will feel when I become circumcised". A participant in FDG 3 Circumcised participants were asked about pain during the post-circumcision recovery period. All of the circumcised men reported that they managed their pain well during recovery by following the postcircumcision instructions given to them by their SMC providers primarily, taking prescribed painkillers and urinating when waking with a morning erection. They said their circumcision experiences were not as painful as they feared prior to the procedure.
"The provider who performed the circumcision gave me some pain killers, and I used them as prescribed to me. The drugs really helped me such that the pain was bearable…I did not have too much pain." One of the respondents in FDG 1 aged 18 years.

Discussion
Perceived risks associated with the uptake of safe male circumcision services among young refugee men aged 15-24 years.
This study found out that SMC uptake in respondents who agreed that their health is at risk due to infection, pain and discomfort (p < 0.05). The possible explanation for this could be the low knowledge levels about the protective bene ts of SMC among respondents who disagreed. These results are similar to Bailey [12] who noted that having knowledge that SMC is a means of HIV prevention was linked with increased uptake of the service. It is further argued that based on the available information on epidemiology and clinical information, SMC will have a signi cant contribution to HIV/AIDS prevention and spread. [12]. On the other hand, in a study conducted in Botswana [13], ndings from the study indicate that being circumcised and the willingness and urge of people to be circumcised was linked to the likelihood of a person having more than two sexual partners. It is also argued that it was also linked to a person having sex with multiple sexual partners and whereas this was a case linked to Botswana, this is the same scenario that applies to Uganda. This therefore, answers the misconceptions regarding sexual drive or performance reducing as a result of SMC. The indications from the study conducted as well as the arguments presents it as an item that has no effect on the sexual drive or performance of a person.
Perceived severity associated with the uptake of safe male circumcision services among young refugee men aged 15-24 years.
In this study, respondents agreed that being circumcised reduces their chances of getting the HIV infection (p < 0.05). This result agrees with previous nding from earlier studies by Hatzold [9] who reported that a higher perception of HIV/STI risks among men aged 15-49 years was associated with uptake of SMC and this is probably because SMC has been found to reduce chances of contracting HIV infection by 60%. This means stakeholders should provide clear messaging on SMC and bring this service closer to young men aged 15-24 years in Refugees Settlements. The ndings suggest that when men perceive the risk of HIV and the protective effect SMC provides, they are more likely to take up circumcision.
Furthermore, this study found out no relationship between perceived fear of serious side effects upon undergoing SMC and its uptake. This is probably because of the few reported cases of adverse events that occur. This nding is inconsistent with a study by with Bailey [9] who noted that respondents expressed concern of over bleeding in medical, traditional or religious circumcisions. Another study by CDC [14] also identi ed the fear of negative outcomes (pain, death, damage to penis, wound not healing well) as a major SMC uptake barrier. However, this same study indicates that with SMC, the surgical risks associated are extremely low and the bene ts gained far exceed the risks. In addition to that, the researchers argue that SMC has been proven to have no long-term adverse effects especially to the infants on physiological or sexual outcomes. [14] This study found that uptake of SMC among the participants was affected by the perceived fear of receiving HIV test results as a requirement among those who had SMC. This is probably because many men would not wish to know their HIV status. This is in line with Govender [15] who identi ed barriers to SMC which included fear of HIV testing that precedes circumcision and Skolnik [16] who found that one of the key perceived barriers to SMC was compulsory HIV testing (fear of HIV testing and knowing one's sero status).

Limitations
There is currently insu cient evidence of individual or public health bene t to recommend male circumcision for HIV-positive men and since persons with severe immunode ciency may have increased complication rates following surgery, male circumcision in HIV-infected men should only be recommended when it medically indicated.

Conclusion
Safe Male Circumcision uptake in Rhino Refugees Settlement is lower than Uganda's national target of 80%. This is attributed to the perceived risks such as perceived risk of infection, pain, irritability, and costs involved. To enhance SMC uptake among young men aged 15-24 years in Refugees Settlement the current SMC programs should unpack the bene ts to this subpopulation and redesign speci c cues to action to increase uptake of SMC. Healthcare providers should portray simpler and positive messages to improve perceptions about the bene ts of SMC.