Abstract
Recent trials demonstrate the effectiveness of male circumcision (MC) in reducing HIV acquisition in men. However, little is known about the prevalence and acceptability of the practice in northern Nigeria. A cross-sectional study design was employed to explore knowledge and attitudes to MC among university students in Kano, Nigeria (n = 375). Almost all respondents (98.1%) reported being circumcised (n = 368; 95% confidence interval = 96.2% to 99.2%). There was no variation in circumcision status by age, ethnicity, religion, or marital status. Majority of the respondents were circumcised by a health worker (51.2%). Most circumcisions were performed between the ages of 5 and 10 years (57.9%) and for religious reasons (79.2%). Only 38% of the respondents (n = 104) were aware of the role of MC in reducing HIV acquisition in heterosexual males. Three quarters of the respondents agreed that circumcised men still need to use condoms. The practice of MC is nearly universal in northern Nigeria, despite low awareness of its protective role in HIV transmission. Public health programs should seize the opportunity offered by high MC acceptance rates to integrate safe medical MC services into existing HIV/AIDS prevention initiatives.
Introduction
Male circumcision is one of the oldest and most common surgical procedures (Auvert et al., 2009; Williams & Kapila, 1993). The World Health Organization estimates that 30% of all males older than 15 years are circumcised globally (WHO, 2009), although country-specific estimates of prevalence vary (Crawford, 2002). The practice is most prevalent among Muslims and Jews, with near universal prevalence in the Middle East, parts of Africa, and central Asia (WHO, 2007). In Africa, the prevalence of male circumcision varies from <20% in Southern Africa to 98% in North and West Africa, including Nigeria (Drain, Halperin, Hughes, Klaussner, & Bailey, 2006). Recent studies demonstrating that circumcision of adult heterosexual African men reduces their risk of HIV acquisition by as much as 60% (Auvert et al., 2005; Bailey, Moses, & Parker, 2007; Gray, Kigozi, & Serwadda, 2007; Tobian, Gray, & Quinn, 2010) has fueled interest in the practice. Although the level of awareness of these protective effects has been reported to be low—even among medical practitioners—(Kretsinger, 2009), these findings could modulate the adoption and practice of male circumcision, especially in sub-Saharan Africa where the burden of the AIDS epidemic is most severe. This process has already started happening, for example, students at the University of Zambia are now offered free male circumcision services as part of a comprehensive HIV prevention package (Bowa & Lukobo, 2006).
Nigeria is Africa’s most populous country and has the third highest burden of HIV infections in the world (Joint United Nations Programme on HIV/AIDS, 2010). Nigerian youth, including university students, represent a HIV high-risk group because of the pervasiveness of unsafe practices, such as early sexual debut, multiple sexual partners, and low and inconsistent condom use (Sabitu, Iliyasu, & Baba, 2007). University students constitute an important cohort of future parents. Since a strong correlation exists between fathers’ circumcision status and that of sons (Brown & Brown, 1987); perceptions about male circumcision for HIV prevention among this cohort likely reflect future trends in the practice. In addition, it is important to assess contemporary perceptions about male circumcision, as they could have changed with new information and sociocultural changes. An understanding of factors that influence adoption of male circumcision in communities with traditionally high levels of the practice will be useful as methods of promoting male circumcision are developed as an important component of HIV prevention programs in all parts of the world, including areas with historically low male circumcision rates. Accordingly, the aim of this study was to assess the prevalence, knowledge, and attitudes of male circumcision among university students in Kano, Nigeria. The information presented could be used to develop programs to promote male circumcision as an important component of HIV prevention in young men.
Method
Setting
The study was conducted at the Bayero University campus. Established in 1975, Bayero University is located in Kano, the capital of Kano state in northern Nigeria. The university has two campuses spanning 3,400 hectares, a total of eight faculties and two schools, and an undergraduate student population of 28,548 (20,379 males and 8,169 females). Most of the students come from Kano, Jigawa, Katsina, Kaduna, Bauchi, and Zamfara states. In addition, there are students from other parts of Nigeria and from other parts of the world (Niger Republic, Sudan, India, Pakistan, and Bangladesh; http://www.buk.edu.ng/).
Study Design and Participants
A cross-sectional descriptive study design was used for the survey. All registered undergraduate males regardless of age were eligible for inclusion in the study. Postgraduate students were excluded. A sample size of 400 students was obtained using the hypothesis testing method (Lwanga & Lemeshow, 1991) and based on the following assumptions: 95% confidence level, a 5% margin of error, and prevalence of circumcision obtained from a previous study (Weiss et al., 2008). The sample size was increased by 10% to account for anticipated subject nonresponse. A multistage sampling technique was used. In the first stage, four faculties were selected by a one-time ballot as follows; each of the eight faculties of the university was assigned a unique serial number. These numbers were written on equal sized pieces of paper, folded, and placed in a box. The box was shaken vigorously, and four pieces of paper were picked from the box, one at a time without replacement. The faculties whose serial numbers correspond with the numbers picked from the box were studied. In the second stage, one department was selected from each of the four selected faculties using simple random sampling. In the third stage, 20 male students each were systematically selected from each level of study (first to fifth year) in the sampled departments. Anonymous self-completed questionnaires were administered to those who consented. Respondents were instructed not to write their names on the questionnaire to ensure anonymity and confidentiality. Ethical clearance was obtained from the Bayero University Institutional Review board.
Study Instrument
A structured interview questionnaire with mostly close-ended questions was adapted from an earlier survey questionnaire used in the 2008 Nigeria Demographic and Health Survey (NDHS; National Population Commission & ICF Macro, 2009). The questionnaire was pretested among students of a department that was not selected for the study, and necessary changes were then implemented. The questionnaire collected information on sociodemographic characteristics of respondents, circumcision status, and attitudes toward male circumcision, including knowledge and HIV risk behavior.
Data Analysis
Data were analyzed using SPSS version 16 (SPSS Inc, Chicago, IL). Quantitative variables were summarized using appropriate measures of location and variability. Categorical variables were presented as frequencies and percentages. Bivariate analysis involved the use of the chi-square test for assessing the significance of associations between categorical variables. The level of significance was set at P < .05.
Results
Sociodemographic Characteristics
A total of 375 questionnaires out of 400 were completed and returned, yielding a response rate of 93.8%. Respondents’ age ranged from 16 to 42 years (mean ± SD = 23.2 ± 3.54 years). Similar numbers of respondents were received from the faculties of science (n = 96, 96.0%), social and management sciences (n = 95, 95.0%), law (n = 93, 93.0%), and medicine (n = 91, 91.0%). The majority of the respondents were of Hausa-Fulani ethnicity (n = 303, 80.8%), Muslim (n = 336, 89.6%), single (n = 361, 96.3%), and residents of Kano state (n = 180, 48.0%; Table 1).
Sociodemographic Characteristics of Respondents, Kano, Nigeria, 2011
Ever married includes respondents who were married (n = 11), divorced (n = 2), and widower (n = 1).
Sexual Behavior
Of the 375 respondents, 19.7% were sexually experienced. Eighty-five percent (n = 301) of the remaining uninitiated students indicated planning to defer sexual debut till they get married. Of the sexually experienced respondents, 35.1% (n = 26) reported using a condom at sexual debut whereas 48.6% (n = 36) reported subsequent consistent condom use (Table 2). Up to 44.6% (n = 33) of sexually experienced respondents had multiple sexual partners (range = 2-10). Approximately 12% of the respondents (n = 9) reported having had sexual intercourse under the influence of alcohol and illicit drugs, including intravenous drugs. A quarter (n = 94) of the respondents admitted to having had voluntary counseling and testing for HIV done previously.
Sexual Behavior Among Male Students at Bayero University, Kano, Nigeria, 2011
NA indicates not applicable, already sexually experienced.
Prevalence of Male Circumcision
In all, 368 of the 375 respondents (98.1%; 95% CI = 96.2% to 99.2%) reported being circumcised (Table 3). There was little variation in male circumcision by sociodemographic characteristics. All respondents aged 40 years and older were circumcised. Similarly, all students of Igbo descent and those who had ever been married were all circumcised. The differences by age, ethnicity, religion, and marital status were not statistically significant (P > .05). The majority of the respondents were circumcised between the age of 5 and 10 years (n = 217, 57.9%) and at a health facility (n = 192, 51.2%; Table 4). Approximately 17% of the respondents (n = 64) reported being circumcised in groups with their peers. An overwhelming majority of the respondents (n = 288, 76.8%) reported no complications following the procedure. A total of 47 (12.5%) respond ents could not recall having complications or not. Complications reported by respondents include excessive bleeding (n = 22, 66.7%), infection (n = 4, 12.1%), difficulty with urination (n = 4, 12.1%), and residual disfigurement of the penis (n = 3, 9.1%).
Prevalence of Male Circumcision by Sociodemographic Characteristics, 2011
Fisher exact after converting to 2 × 2 tables. Age-groups were recategorized into <30 and ≥30 years while Hausa and Fulani were merged. Other Nigerian tribes were also placed in one category.
Timing, Place, and Perception of Male Circumcision Among University Students, Kano, Nigeria, 2011
Multiple responses allowed.
Perceived Reasons and Benefits of Male Circumcision
Of the 375 respondents, 79.2% attributed the practice of male circumcision to fulfilling religious obligations. Approximately 55% (n = 206) and 36% (n = 135) of the respondents were of the opinion that male circumcision had health and sexual benefits, respectively. Respondents indicated that it was easier for circumcised men to maintain hygiene and believed that circumcision facilitates sexual satisfaction.
Attitudes Toward Male Circumcision
Overall, 353 (96%) of the 368 circumcised students were pleased with their circumcision status (Table 5). Ninety-six percent (n = 353) would recommend circumcision to friends and family, whereas 96.5% (n = 355) would ensure that their sons are circumcised. Majority of the respondents (n = 360, 97.8%) favor continuation of the practice. Only 38% (n = 144) of the respondents were aware that male circumcision could reduce HIV transmission. Of this number, 13.9% (n = 20) respondents considered male circumcision to be 100% protective. Approximately 73% (n = 274) of the respondents agreed that circumcised men still need to employ condoms during sex for protection against sexually transmitted infections (STIs), including HIV. A total of 83 (22.1%) respondents pointed out the problems associated with the availability and the standardization of circumcision services at health facilities, and that explained the patronage of traditional circumcisers.
Attitude Toward Male Circumcision Among University Students, Kano, Nigeria, 2011
Discussion
The near universal (98.1%) prevalence of male circumcision among our respondents is similar to the national (97.9%) and local figures for the northwest zone (98.2%) reported by the 2008 NDHS (National Population Commission & ICF Macro, 2009). However, our prevalence rate is slightly lower than that of southwest Nigeria (98.5%). The modest variation in prevalence of male circumcision by sociodemographic characteristics also concurs with observations from the 2008 NDHS. This finding could be because of the near universal adoption of male circumcision by major tribes and cultures across the country.
The variation in timing of circumcision observed among our respondents is in agreement with findings from southwest Nigeria (Okeke, Asinobi, & Ikuerowo, 2006). Timing of circumcision has been reported to be related to the reason for circumcision. For instance, Pacific islanders prefer their children to be circumcised between the ages of 6 and 10 years (Afsari, Beaseley, Maoate, & Heckert, 2002), whereas among the Xhosa tribe in eastern cape, South Africa, circumcision is performed during adolescence as an initiation rite to manhood (Mogotlane, Ntangulela, & Ogunbanjo, 2004). Similarly, the practice of group circumcision—which poses risk of blood-borne infections (such as hepatitis B, hepatitis C, and HIV)—has been reported elsewhere (Schmitz, 2001).
The complication rate reported by our respondents (8.8%) is high compared with other studies (Ahmed, 1999; Muula, Prozesky, Mataya, & Ikechebulu, 2007), although the types of complications were essentially similar (Ahmed, 1999; Auvert et al., 2005). Studies in sub-Saharan Africa reported complication rates for male circumcision in the range of 0% to 50% (Muula et al., 2007), most of which were minor. A much higher complication rate (20.2%) was documented by investigators in Ibadan, Nigeria (Okeke et al., 2006). Complications rate for male circumcision are much lower in North America (0.2% to 0.5%) and in Israel (0.34%; Ben Chaim et al., 2005; Muula et al., 2007). These differences could be because of variation in skills of persons performing the procedure (traditional surgeons versus trained health workers), in addition to relative deficiencies in aseptic practices in developing countries. Reports from Kenya (Kim & Goldstein, 2009) and Turkey (Atikeler, Gecit, Yuzgec, & Yalcin, 2005) indicate that the incidence of complications is higher in groups circumcised by traditional surgeons compared with health workers, although a systematic review from sub-Saharan Africa failed to confirm these findings (Muula et al., 2007).
The perception of religious, cultural, and hygiene factors as reasons for circumcision concurs with reports from other parts of Nigeria (Okeke et al., 2006). In addition to religion and ethnicity, male circumcision is often performed for its social desirability. The desire to conform is an important motivation for circumcision in places where the majority of boys are circumcised (Brown & Brown, 1987). Certain ethnic groups, including the Dogon and Dowayo of West Africa and the Xhosa of South Africa, view the foreskin as the feminine element of the penis, the removal of which contributes to making a man out of the child (Crowley & Kesner 1990; Silverman, 2004). As in this study, respondents in reports from southern Nigeria identified the need to conform with cultural practices and the sexual benefits associated with the practice as important motivators for male circumcision (Myers, Omorodion, Isenalumhe, & Akenzua, 1985).
The high level of satisfaction, positive attitudes toward male circumcision, and universal adoption of male circumcision in this part of the world offer a unique opportunity for public health program planners and HIV prevention practitioners. HIV programmers need to seize this opportunity to ensure that male circumcision is performed under hygienic conditions by trained health care providers in hospital settings. Group circumcisions should be discouraged to prevent the transmission of blood-borne infections. Male circumcision should be promoted along with other proven methods of HIV prevention, such as reduced number of sex partners and correct and consistent use of condoms (Wilkinson & Rutherford, 2001).
The low level of awareness of the role of male circumcision in reducing HIV transmission is similar to findings from Uganda, where only 35% of circumcised adults were aware that male circumcision protects against acquisition of HIV infection among heterosexual men (Wilcken, Miiro-Nakayima, Hizaamu, Keil, & Balaba-Byansi, 2010). This finding is of concern but not surprising, as awareness of this relationship is low; even among health care providers, this fact is not widely known (Kretsinger, 2009). Intensive information, education, and communication efforts are needed to strengthen support for adoption of medical circumcision as a component of HIV prevention. Tailored educational materials about the benefits and risks of male circumcision as an HIV prevention intervention should be made available to young men and to health care providers.
The proportion of sexually active students in our sample (19.7%) was lower than figures reported from Ibadan, Nigeria (Ogbuji, 2005), Enugu, Nigeria (Okafor & Obi, 2005), other parts of Africa (Agardh, Emmelin, Muriisa, & Ostergren, 2010; Othero, Aduma, & Opil, 2009), and the United States (Simon, Roach, & Dimitrievich, 2003). It is however higher than the figures from China (11%; Abdullahi, Fielding, & Hedley, 2003). These differences could be due to religious, cultural, and societal attitudes toward premarital sex. In the predominantly Muslim population of our catchment area, premarital sex is strongly discouraged. The low condom use among our respondents is similar to observations from Uganda (Agardh et al., 2010) and Kenya (Othero et al., 2009) and highlights the need for targeted sexual information, education, and communication activities. Sexually experienced individuals may be more likely to know about STIs, including HIV, and may be more curious about means of preventing STIs through condom use and emerging HIV prevention methods, such as male circumcision. Therefore, the low proportion of sexually experienced students in this study may partly explain the limited knowledge of the role of male circumcision in preventing heterosexual HIV transmission among our respondents.
This study had several limitations. First, our respondents are a select cohort of university students from a single institution in Nigeria, a very diverse country. They may differ from students in other universities in northern Nigeria both in ethnic composition and cultural traits. There is, therefore, a need to exercise caution in extrapolating our findings to all university students or to all young men in northern Nigeria. Second, this study was based on self-report, and respondents were not clinically examined to ascertain true circumcision status. Therefore, our findings could be prone to social desirability bias, particularly among noncircumcised students who could be embarrassed by their circumcision status. In addition, several respondents reported being circumcised in childhood and could not accurately recall the events surrounding their circumcision, thereby increasing the likelihood of recall bias. HIV status may influence sexual behavior and secondary prevention. Failure to ascertain respondent HIV status can be considered a limitation. Strengths of this study include a very high response rate (94%), use of a validated questionnaire, and a robust sampling method.
In conclusion, despite near-universal rates of male circumcision and wide support for the practice among a relatively well-educated cohort of young men from northern Nigeria, this study found major gaps in knowledge of the protective advantages conferred by male circumcision against acquisition of HIV/AIDS in men. In addition, high-risk sexual behavior (inconsistent condom use, multiple sex partners) was common among respondents. Our findings highlight the importance of concerted information, education, and communication efforts targeting young Nigerian men in institutions of higher learning. Finally, a substantial proportion of male circumcision services continue to be provided outside health facilities. Male medical circumcision services should be embedded within comprehensive HIV prevention programming, including informed consent and risk-reduction counseling. Future needs for male circumcision services should be matched by provision of adequate equipment and training of qualified personnel to conduct safe, voluntary, and affordable male circumcision. Peltzer, Nqeketo, Petros, and Kanta (2008) have already shown that safer circumcision training can be successfully given to traditional surgeons and nurses with improvements in HIV knowledge and in circumcision knowledge, attitudes, and practice. If correctly planned, provision of accessible, safe adult male circumcision services will increase opportunities to educate men about a variety of sexual and reproductive health topics, including personal hygiene, sexuality, and gender relations.
Footnotes
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.