There is compelling evidence that circumcision reduces men’s risk of becoming infected with HIV through heterosexual intercourse by at least one-half, and possibly as much as two-thirds. Three randomized clinical trials have shown that men who are circumcised were less than half as likely to become infected with HIV within the trial periods (Auvert et al. 2005, Bailey et al. 2007, Gray et al. 2007). This finding is supported by over 40 sociological and epidemiological studies which show a strong link between circumcision and reduced HIV prevalence (Nagerkerke NJD 2007, Siegfried et al. 2003, Weiss, Quigley, and Hayes 2000).

Based on the data from the clinical trials, models have estimated that routine circumcision across sub-Saharan Africa could prevent up to six million new HIV infections and three million deaths in the next two decades (Williams et al. 2006). Given this strong evidence, the World Health Organisation (WHO) andUnited Nations Programme on HIV/AIDS (UNAIDS) recommended that male circumcision should be considered as an important and additional intervention for HIV prevention (WHO 2007). As a result, different countries in the sub-Saharan Africa are at different stages of introducing and scaling-up circumcision services.

In 2007, Voluntary Medical Male circumcision (VMMC) program was launched in Southern and Eastern Africa as a recommended preventive strategy supported by WHO, UNAIDS, and others. VMMC emerged as an effective preventive measure to reduce the transmission of viral sexual infections such as the Human Immune Virus (HIV), (Keetile, 2018); herpes simplex type 2, and human papillomavirus (Bailey, 2018; Gray RH, et al (2018). Some studies have indicated that circumcised men were at low risk of acquiring chancroid and syphilis than uncircumcised men (World Health Organization 2019). Other evidence indicated that 48% of women with circumcised men had reduced vaginal infections, for example, trichomonas vaginalis, while in men it reduced genital ulcer diseases (Morris, et al 2019). Male circumcision is a surgical procedure that involves the removal of the foreskin of the penis by a health worker (UNAIDS, 2019). It is a common practice globally done for many reasons that are medical, cultural, religious, or social (Morris, et al, 2016). According to Klausner (2012), an uncircumcised man is likely to acquire HIV because the inner surface of the foreskin contains Langerhans cells where the Human immune Virus (HIV) receptors can attach hence a primary entry of the virus. WHO, (2018) asserts that by removing the foreskin, the glans become keratinized and creates a barrier to the virus to enter through the penis. Globally, 37-39% of men were circumcised, and half of the results for circumcision based on cultural and religious reasons and the last being medical reasons (Morris., et al, 2016).

In Africa, male circumcision is prevalent in North African countries with 93% compared to sub-Saharan African countries with 62%. The findings indicated that male circumcision was performed due to religious reasons more especially in north and western countries of Africa (UNAIDS 2016)

In Uganda, Mangula (2018) report indicated that the percentage of circumcised men rose in 2006 compared to 2016. In 2011, HIV prevalence stood at 4.5% among CM and 6.7% among uncircumcised men. Voluntary Medical Male circumcision was proven as a preventive intervention-reducing female to male transmission of HIV (WHO/Uganda Ministry of Health 2017).financial support and failure to reach the coverage areas were influencing accessibility of men for circumcision but the statistics of eligible men raised from 26.4% in 2011 to 40% in 2014 (Uganda AIDS Commission, 2016). In 2017, 847633 male circumcisions were performed, falling short of targeted annual coverage of 1 million (Uganda Ministry of Health, WHO, 2017).

According to Mpigi hospital records, there is a record that 152 surgical operations were done and only 16 bodaboda men participated despite the support from donors like the Rakai health science program (RHSP), WHO, and Centre for Disease Control (CDC) (HMIS report, 2018). Studies done in other regions about the prevalence and factors associated with low uptake of VMMC among men were; economic reasons, social reasons, culture, fear of pain, long healing, level of education and inadequate health workforce to carry out the services (Wambura et al, 2011). Therefore, the need to find out whether they are the same reasons affecting the uptake of VMMC among bodaboda men in Mpigi Town Council.

??/ The problem statement should appear after the background and not the purpaose. Please re-organise this section.

1.3 Purpose of the study

The purpose of this study is to identify the prevalence and factors influencing uptake of voluntary medical male circumcision among Bodaboda men in the Mpigi town council

1.4 Specific Objectives

To estimate the influence of Cultural factors on voluntary medical male circumcision uptake in the Mpigi town council.
To determine the facilitators and barriers associated with uptake of VMMC among bodaboda men in the Mpigi town council.
To establish the strategies that encourage bodaboda men to take-up the VMMC in the Mpigi town council.

Note: Your topic is on prevalence and factors influencing the uptake…..( I thought then, prevalence should be one of your specific objective and questions. If its not, then eliminate it from the tittle and just remain with factors……………..)

1.5 Research questions

What is the influence of Cultural factors on voluntary medical male circumcision uptake in the Mpigi town council?
What are the facilitators and barriers associated with uptake of VMMC among bodaboda men in the Mpigi town council?
What strategies could be taken to encourage bodaboda men to take-up the VMMC in Mpigi town?

1.2 Problem statement

Despite the government effort put in place to aid the prevention of HIV infection through voluntary medical male circumcision in the Mpigi Town Council, there is still a low uptake of VMMCs by the bodaboda men. Health workers try their best to see that they implement government-supported programs like VMMC but such activities are associated with an inadequate health workforce. Among studies that have investigated the reasons for poor uptake indicate that men’s fear of pain, the long period taken to heal, and economic issues could be the major reasons for not taking up the intervention (HMIS, 2018). Bodaboda men take up the significant percentage of men in the Mpigi town council and therefore, their low uptake of VMMCs could facilitate an increase in the spread of HIV/AIDS in this area. In Mpigi town council, no study of has been conducted yet there is need to implement the government initiatives of preventive programmes. Therefore the reason for taking up this project is to establish the factors influencing the uptake of Voluntary Medical Male Circumcision among Bodaboda men in the Mpigi Town Council.

Justification

Various studies carried out in Uganda indicated that Uganda aimed to circumcise 80% (4.2 million) of all uncircumcised men aged 15-49 years by the end of 2015. This was achieved by only 50% between 2008-2013 (WHO, 2015). Therefore, this study mayprovide insight into the prevalence and factors influencing uptake of VMMCs in Mpigi Town Council, so that what . So far, there is no study done on the same. The generated information could be of use to policymakers and interested Non-Government Organizations (NGOs) to design healthy strategies for the district.

Findings from this study may also act as a foundation for future researchers to find out more about voluntary medical male circumcision in different situations.

Significance of the study

Conceptual framework

Social-Economic factors

· Currently employed

· Unemployed

· Poverty

Male Circumcision uptake among bodaboda clients

Cultural factors

· Tribe

· Religion

Information factors

· Education

· Exposure to media

Fig 1. Showing the conceptual framework of independent and dependent variables.

Description of the Conceptual Framework

The conceptual framework highlights the relationship between the independent and dependent variables of the study. The dependent variable is the uptake of VMMC and the independent variables are the individual factors, social and economic factors affecting uptake of VMMC uptake among bodaboda men in the Mpigi town council. Some of the individual factors influencing uptake may include age, fear of surgery, fear of pain, fear of delayed wound healing while the social and economic factors may be religion, tribe, employment status, and education among others.

2.0 CHAPTER TWO

2.0 Introduction

This chapter presents the literature review from other scholars about factors affecting the acceptability of voluntary medical male circumcision by men in other areas. The literature will be presented according to the study objectives; a. The prevalence of VMMC in Mpigi town council.

Your missing literature on prevalence…..

2.1 Cultural factors influencing voluntary medical male circumcision uptake

Several strategies have been implemented in order to curb the spread of HIV including Voluntary Medical Male Circumcision (VMMC). VMMC is defined as the surgical removal of the foreskin by a trained health worker. It is a strategy to prevent the spread of HIV that was recommended by the World Health Organization (WHO) in 2007. It was specifically recommended in countries with high HIV prevalence and low prevalence of male circumcision such as Zimbabwe. This followed results of Randomized Control Trials (RCTs) done in South Africa, Uganda and Kenya which demonstrated that VMMC reduces HIV transmission by up to 60%. It has also been demonstrated that circumcising 80% of men could prevent 45% of new HIV infections between the years 2011 and 2015. However, it is worth noting that VMMC offers partial protection to HIV. This calls for use of other HIV prevention methods in conjunction with the strategy. Moreover, concerns have been raised about possibility of compensatory disinhibition after the procedure.

Though being an ancient practise, WHO (2009) estimated that worldwide, only 30% of the males aged 15years and above are circumcised. Around 69% are Muslim, 0.8% are Jewish and 13% are non Muslim and Jewish men living in the United States of America (WHO, 2009). In the Jewish and Muslim religion, male circumcision is chiefly informed by religious beliefs and is mostly carried-out in the eighth and seventh day respectively (WHO, 2009). According to WHO (2009), Buddhism, Christianity and Hinduism have a neutral stance on male circumcision. Various ethnic groups practice MC in Sub-Saharan Africa and in Aboriginal Australasians (Dunsmuir & Gordon, 1999; Beidelman, 1987 as cited by WHO, 2009), the Aztecs and Mayans in the Americas (Tierney, 2003; Remondino, 1891; Schendel, Stellenbosch University http://scholar.sun.ac.za 6

The practise of male circumcision within countries varies. For instance, in Kenya 84% of the men are circumcised, yet, the percentage is much lower for the Luo and Turkana ethnic tribes with 17% and 40 % respectively (DHS, 2006 as cited by WHO, 2009). Similarly, in Uganda and South Sudan male circumcision is not practised among the Jopadhola, Acholi and other Luo-speaking River-Lake Nilotic who are the descendants of the Luo tribe (Bailey et al., 2002 as cited by WHO, 2009). In Tanzania, male circumcision is mainly conducted as a cultural and religious practice (Mujinja et al., 2009). Like in Kenya, the prevalence of the practise among other ethnic groups is low. The Demographic Health Survey data in Tanzania confirmed that 96.8% of Muslim, 60-70% Christians and 25% of men with indigenous beliefs were circumcised (Wambura et al., 2009). On the other hand, Mwanza Region comprise of the customarily non-circumcising population. Seventy-four percent of the Muslim Sukuma men were not circumcised signifying the influence of the non-circumcising tradition among Muslims in this locale (Nnko, Washija, Urassa, & Boerma, 2001).

According to Kripke et al, & Morris et al (2016), it is documented that voluntary medical male circumcision (VMMC) status and sexually transmitted infections (STI’s) risk are associated and VMMC is now part of the HIV prevention programs worldwide.

2.2 Facilitators and Barriers associated with the uptake of Voluntary Medical Male Circumcision (VMMC) referring.

The findings among the students at Midlands State University (MSU) by Mtemeri et al., (2013) revealed that a few were willing to go for circumcision because they were not aware of the importance of being circumcised and but had the opinion that some men do not opt for this method of prevention because the surgery is painful. ‘‘I was 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.” (FGD, respondent).

Mbabazi (2011) agree with the results of this study in that the major reason for men refusing to be circumcised is fear of pain, some men felt that they were too old for the surgery. This fear of pain and opinion about when to get circumcised indicates that information that gets to people about male circumcision is not fully addressing their concerns hence the inadequate knowledge and low turn up from communities.

In a study by Rapfute et al., (2014) about factors associated with uptake of VMMC, Mazowe district, Zimbabwe it was revealed that voluntary medical male circumcision was deterrent that most men wanted to keep it private and personal but the facility was exposed.

A research carried out in Machinga District Malawi (2017), showed that fear of complications associated with VMMC kept away some men from undergoing the procedure. They also stated that after operation they may fail to put on under wears and puts on women clothes and eventually you can die of severe bleeding. Fear of pain associated with undergoing the procedure, post-operative healing process and bleeding prevented them from accessing the VMMC services. (Albert et al., 2011)

A study done on male circumcision and penile sensitivity reported that circumcision after puberty reduces sexual pleasure and lower orgasm intensity due to much effort needed to achieve orgasm in clients. Some clients feared the complained issues stated by circumcised men like numbness, unusual sensations such as burning, prinking, itching or tingling. (Bronselar et al., 2013).

“I really tell you that I was told that men who are circumcised some time their sexual performance reduces even ending up not producing children.”

A study by Gasarira et al (2013), found out that old age was the main reason for the failure to attend voluntary medical Male Circumcision.

A study carried out by Plotkin et al (2013), showed that lack of special rooms to keep circumcised old men out of sight by their relatives and other villagers who visited hospital was perceived shameful. Such an environment compromises the status of adult men who enjoy a privilege place in society.

According to Kighoma (2011), when a follow up on the clients was made to ascertain the reasons for not turning up, the following were elicited; too busy to attend, refused by spouse, no longer interested, had health problems, refused by parents and was at school

A study carried out in Tanzania by Wambura et al., (2011), men and women said that cultural values did not support safe voluntary medical male circumcision after adolescence stage. Therefore, whoever above adolescent stage could not go for circumcision, which showed inadequate knowledge about the relationship.

“Tell you what most of my friends are not circumcised and even in our family so I do not see the reason why I go for male circumcision (FGD, respondent)

A research carried out by Adams (2012) on the low utilization of male circumcision services in Kwaluseni, Swaziland showed that loss of income as they miss to go work during healing period prohibited them from getting circumcised.

3.3 Strategies to encourage bodaboda men to uptake VMMC in Mpigi town council

There have been many reasons given by bodaboda men hindering them from attaining the VMMC services and these included; Individual, Social and Economic factors. There are a number of strategies done in different areas according to the literature

A study done in Tanzania by Wambura et al (2017) highlighted that there was need to improve the communication skills in order to empower the men with knowledge about the benefits of VMMC and train their partners.

According to Kennedy et al (2020) a systematic review and a meta-analysis to increase the uptake of VMMC for HIV prevention in the sub Saharan African countries done and it stated that when the clients were supported economically with transport and food vouchers selected carefully, it improved the uptake of VMMC by the potential clients.Wambura et al (2017) pointed out that proper timing for the athletes, anglers and school going children as well as telling the clients the benefits of VMMC increased the uptake of by men in that area. circumcision leads to a decrease in STIs and a possible reduction in micro tears and trauma to the foreskin during sex (Rasool, Sameer &Saddiqi, 2011). Based on the epidemiological and experimental substantiation, MC could have a considerable impact on the HIV epidemic especially among the most highly affected countries (Westercamp and Bailey, 2007). In fact, models have estimated that routine MC in Sub-Saharan Africa could highly avert about 6 million new infections and 3 million deaths in the next two decades (Williams et al., 2006 as cited by Wambura et al., 2009).

CHAPTER THREE

METHODOLOGY

3.0 Introduction.

This chapter presents the research methodology, including the study setting, study design, study variables, sample size and sampling procedure. It also describes quality control, how data was processed and presented, tools and methods of data collection, ethical consideration of study results.

3.2 Study Design

The study will be descriptive cross sectional design using quantitative method of data collection. This descriptive and cross sectional design will provide information on which further studies will be carried out on factors affecting acceptability of VMMC.. The choice of this technique is also guided by the fact that the study aims at generating findings, which would facilitate a general

3.4 Study Population

The study population will involve bodaboda members operating in Mpigi Town Council. This isbecause they are the ones with low turn up for VMMC in the town council; this population was targeted for the study aimed at finding out factors affecting the acceptability of VMMC in Mpigi Town Council.

3.4.1 Sample Size Determination

3.4.1 Sampling Procedure

Simple random sampling employed. First the different bodaboda stages were randomly selected then the respondents also selected by simple random sampling method, whereby those at stage were considered. The names then coded. The codes of all the boda men were placed on pieces of paper of the same size, color or texture (one code per paper). These then were placed in a box. The box was shaken, and the research assistant asked to pick one piece of paper. Then shaken again, and another piece of paper picked. This procedure continued until 50 pieces of paper are picked, corresponding to the number of bodaboda men needed. The boda men of the codes on the picked papers were selected to participate in the study.

I then the men selected were briefed about the purpose of the study, and then requested them to offer the information needed for the study. In case the man declined to participate in the study, another was selected to replace him in the manner described above.

3.4.3 Inclusion Criteria.

All bodaboda cyclists who were willingly consented and operated in Mpigi Town Council were considered for the study.

3.4.4 Exclusion criteria

The study will not include people who are not boda riders and also it will be strictly for men above 18 years. The reason for choosing only Boda Boda riders is because this is the study topic.

3.5 .

The low turn up for VMMC by bodaboda men in Mpigi Town Council Mpigi district.

3.6 Research instruments

3.6.1 Questionnaire Method

3.7 Data Collection Procedure

The researcher will seekst for an introduction letter from the Agakhan university to help introduce me to Mpingi health centre IV will grant e permissions and in turn introduced me to the respondents. The researcher will then seek an informed consent of the respondents and administer the questionnaires to the Boda Boda riders around Mpigi Health centre IV and give them time to fill in the information and after three days collecte the completed questionnaires.

3.7.1 Data Management

3.10 Dissemination of the Study Results

Completed copies of the research report were distributed to the following offices;

Uganda Nurses and Midwives Examination Board (UNMEB)

Aga Khan University

Research supervisor

REFERENCES

Bailey RC, et al. (2018). Male circumcision for HIV prevention in young men in Kisumu, Kenya.

Chiringa, J.O., Ramathuba, D.U., Mashau, N.S., 2016. Factors contributing to the low uptake of medical male circumcision in Mutare Rural District, Zimbabwe. Afr J Prm Health Care Fam Med 8, a966.

Forsythe, S. S., McGreevey, W., Whiteside, A., Shah, M., Cohen, J., Hecht, R. … & Kinghorn, A. (2019). Twenty years of antiretroviral therapy for people living with HIV: global costs, health achievements, economic benefits. Health Affairs, 38(7), 1163-1172.

Frisch, M., Lindholm, M., Grønbeck, M.M., 2011. Circumcision and sexual function in men and women: a survey-based-cross-sectional study in Denmark. Int J Epidemiol 40, 1367–81.

Gray RH, et al (2018). Male circumcision for HIV prevention in men in Rakai, Uganda

Hankins, C., Forsythe, S., Njeuhmeli, E., 2011b. Voluntary medical male circumcision: an introduction to the cost, impact, and challenges of accelerated scaling up. PLoS Med. 8.

Keetile (2018). Factors associated with uptake of voluntary medical male circumcision among University of Botswana undergraduate male students.

Kibira, S., Peter, 2017. Male circumcision, sexual risk behaviour, and HIV Infection in Uganda-a mixed methods study among men age 15-59 years (PhD Thesis). Bergensis Universities, Faculty of Psychology.

Klausner. J., Morris, (2012). Benefits of Male Circumcision. JAMA the Journal of American Medical Association.

Kripke, K., Opuni, M., Odoyo-June, E., Onyango, M., Young, P., Serrem, K., … & Njeuhmeli, E. (2018). Data triangulation to estimate age-specific coverage of voluntary medical male circumcision for HIV prevention in four Kenyan counties. PloS one, 13(12), e0209385.

Mangula. G (2018). Ugandan Men Embracing Circumcision-Survey.

Mao, L., Templeton, D., Crawford, J., 2008. Does circumcision make a difference to the sexual experience of gay men? Findings from the Health in Men (HIM) Cohort. J Sex Med 5, 2557–61.

Morris, B.J., Wamai, R.G., Henebeng, E.B., Tobian, A.A.R., Klausner, J.D., Banerjee, Hankins, C.A., 2016. Estimation of country-specific and global prevalence of male circumcision. Popul. Health Metr. 1–13. https://doi.org/10.1186/s12963-016-0073-5

Morris. B. J, et al. (2016). Estimation of Country Specific and Global Prevalence of Male Circumcision.

Mpigi hospital records (2018), voluntary medical male circumcision

Reed, J. B., Njeuhmeli, E., Thomas, A. G., Bacon, M. C., Bailey, R., Cherutich, P., … & Hatzold, K. (2012). Voluntary medical male circumcision: an HIV prevention priority for PEPFAR. Journal of acquired immune deficiency syndromes (1999), 60(0 3), S88.

UAC, 2014. Uganda AIDS Commission. The HIV and AIDS Uganda progress report 2014. Kampala, Uganda

Uganda AIDS Commission (2016). The Uganda HIV and AIDS Country Progress Report July 2015-June 2016.

Uganda MOH, WHO (2017). The Uganda Population-Based HIV Impact Assessment.

UNAIDS (2016). Prevention Gap Report.

UNAIDS (2019). Voluntary Medical Male Circumcision.

Wambura, M., M., Ahler, H., Grund, J. M., Larke, N., M Shana, G., Kuringe, E., … & Hayes, R. J. (2017). Increasing voluntary medical male circumcision uptake among adult men in Tanzania. AIDS (London, England), 31(7), 1025.

WHO (2018). Progress Brief: VMMC for HIV Prevention.

WHO (2018). Voluntary Medical Male Circumcision for HIV Prevention.

WHO (2019) sexually transmitted infections.

WHO/UNAIDS (2016). ‘A framework for voluntary medical male circumcision: effective HIV prevention and a gateway to improved adolescent boys’ & men’s health in Eastern and Southern Africa by 2021’, p.7 [pdf].

World Health Organization. (2015). Voluntary Medical Male Circumcision for HIV prevention in 14 priority countries in East and Southern Africa. Retrieved from http://apps.who

World Health Organization. (2017). Male circumcision for HIV prevention—implementing the 2017–2021 framework for voluntary medical male circumcision 27 February–1 March 2017: meeting report. UNAIDS (2019). Voluntary Medical Male Circumcision.

Appendices?

Where is the sample of the data collection tool, consent form, budget and timeline?

research proposal

LIST OF ACRONYMA AND ABBREVIATIONS.