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Opinions and Perceptions Regarding Traditional Male Circumcision With Related Deaths and Complications

The notion of manhood values is highly treasured and respected by various cultural groups practicing traditional male circumcision (TMC) in South Africa. This study was conducted at Libode, Eastern Cape, South Africa. The goals of this study were to (a) explore opinions and perceptions related to TMC among boys from 12 to 18 years of age, and (b) determine the actions to be taken to prevent high mortality and morbidity rates related to TMC. A simple random sampling was used to select three focus group discussions with 36 circumcised boys, and purposive sampling was used to select 10 key informants. The overarching themes collated included the following: (a) accepted age for circumcision, (b) causes attributed to deaths and complications, (c) TMC is preferred to medical male circumcision, and (d) acceptable community actions to prevent the problem. The study concludes with discussion and recommendation of a comprehensive health promotion program that is considerate of community opinions and perceptions in the prevention of deaths and complications affecting the circumcision initiates and at the same time respecting the culture.

aspect, which has seen many initiation schools being set up outside the guidance of traditional leadership (Kepe, 2010;Douglas, 2013). According to Bottoman et al. (2009), in South Africa, TMC forms part of the belief system of various cultural groups. Among the AmaXhosa in the Eastern Cape Province is a tradition that remains widely practiced and is documented in reports from 1789 by Western sailors who survived from shipwrecks (Meel, 2005). The AmaXhosa people regard TMC as a rite of passage that prepares the initiate for manhood. The secret surgery involves traditional surgeons (iingcibi), traditional nurses (amakhankatha), parents, and initiates at male initiation schools. The initiate undergoes this rite of passage in three phases: separation (translocation), transition, and reintegration (Van Gennep, 1908). In the separation stage, the individual is symbolically separated from his current identity. The period between the shedding of the old and the assumption of the new identity is called the transition stage. The formal granting of the new identity occurs after the reintegration phase .
AmaXhosa initiates are translocated to an isolated temporary hut built of grass where the circumcision takes place in "male circumcision initiation schools." In the approximately 4 weeks the wound takes to heal, initiates are taught about traditional manhood values in this transition period. Then the initiate is welcomed back to the community as a real man and the ritual concludes with a celebration of the newly acquired manhood (reintegration; Bottoman et al., 2009). A traditional surgeon cuts off the foreskin with an assegai (umdlanga) and drops the foreskin onto the blanket in front on the initiate then moving to the next one. Immediately after being cut, the boy has to shout, "Hi ndiyindoda" ("I am a man"; Meel, 2005).
The initiates spend up to 4 weeks (or until properly healed) learning about manhood values from elders, and concurrently, the traditional nurses take care of the wound by wrapping it with traditional herbs World Health Organization, 2008). For the circumcision ritual to be considered a success, and the initiate to be declared a man, the endeavor must be completed according to tradition. This means that the initiate must heal properly without taboo violations that include coming into contact with females or the intervention of Westernized medicine (i.e., hospitalization). After the male initiation is over, the thatched initiation hut is burnt down and the newly circumcised men (amakrwala) are taken home by circumcised men singing songs of celebration. A huge traditional circumcision celebration (umgidi) is organized, with an abundance of meat from slaughtered animals and alcohol with the whole community united in celebration; men, women, and children. These traditional circumcision celebrations are highly treasured by the AmaXhosa people and passed on from one generation to another (Douglas, 2013). The belief is that an initiate who does not complete the initiation as per tradition is not considered to be a real man and will be treated with contempt and disrespect by fellow tribesmen. It is also believed that initiates' deaths and adverse complications occur due to failure to conduct the initiation per traditional prescripts ).

High Mortality Rates
The high initiate mortality rates at the circumcision initiation school inflict a serious threat to the communities affected, to the traditional leaders who are regarded as custodians of the cultural activities, and to the entire South African government. The majority of deaths are reported in the Oliver Reginald Tambo (ORT) district, specifically in the Pondoland area of the Eastern Cape province (Eastern Cape Statistics, 2013). The ORT district had the highest number of illegal circumcision schools (224), hospital admissions (259), amputations of penises (24), and deaths (26) compared to other districts ( Table 1). The common causes of death are due to complications of TMC such as sepsis, pneumonia, dehydration, assault, thromboembolism, gangrene, and congestive heart failure (Meissner & Buso, 2007;Meel, 2010).
In 2001, a law was enacted, the Health Standards in Traditional Circumcision Act (South Africa, 2001), to regulate traditional practice and to reduce mortality. Also known as the Circumcision Act, it provides for the safe conduct of TMC by governing over its practices, processes, and the traditional practitioners. Provisions include that prospective initiates must be 18 years or older, have permission from parents or family guardians and undergo a mandatory pre-circumcision medical examination by a medical doctor. Traditional surgeons and nurses are required to obtain a written permission to perform circumcisions and care for the initiates. The legal traditional practitioners are those who are registered according to the Circumcision Act and also approved by the House of Traditional Leaders. The regulation requires that no person may perform any circumcision in the Eastern Cape Province without a written permission of the designated medical officer for the area in which the circumcision is to be performed.
The penalty of arrest for contravening traditional surgeons is seldom implemented. The legislation has encountered resistance because it is viewed as interfering with the local custom . The 2009 ORT District Circumcision Summit resolution noted that the success of the circumcision program depended on the participatory involvement of all the stakeholders in the district, and a revision of the Circumcision Act was suggested. The traditional leaders wanted the inclusion of a section that indicates that the House of Traditional Leaders is the custodian of the TMC custom and the Department of Health officials are medical advisers (Initiation Summit, 2009). Some authors have reported that the local context and meaning of circumcision is a crucial and overlooked aspect of the implementation of the medical male circumcision (MMC) intervention in sub-Saharan Africa. They explored how local communities filter information on MMC to its most locally salient parts and considered how these opinions and perceptions about circumcision could influence the uptake of MMC as a public health intervention (Khumalo-Sakutukwa et al., 2013). The aim of this study is to explore opinions and perceptions related to deaths and complications due to TMC and to determine the acceptable community actions to prevent related deaths and complications.

Study Design
The study utilized a Traditional Circumcision Forum (TCF) model adapted from Beattie Health Promotion theoretical model as explained in the Douglas study (2013). Data were collected during an intervention study to develop a male circumcision health promotion program at Libode rural communities in the Eastern Cape, South Africa, and full details are published elsewhere (Douglas, 2013;Douglas, Maluleke, Labadarios, Hongoro, & Nyembezi, 2016). The study population comprised circumcised males aged from 12 to 18 years attending school and living in the rural communities of Libode. The Libode District is in the Nyandeni municipality with a population of 290,390 people mainly of the AmaMpondo clan within the AmaXhosa tribe (Nyandeni Local Municipality Annual Report, 2012). A qualitative approach allowed the respondents to express themselves in their own language (Creswell, 2009). The same questions used for focus group discussions (FGDs) and key informant interviews (KIIs) included the following: What is the recommended age for boys to undergo male circumcision? What is the cause of death and complications among initiates? Which method of male circumcision is mainly preferred by Libode community members and why? What can be done to prevent deaths and complications related to male circumcision?

Study Sampling
The study used purposive sampling to select 10 KIIs, and simple random sampling was used to select 36 participants for FGDs.

Key Informant Interview
The key informants were from the 10 villages of Libode District, held responsible positions in the communities with knowledge related to TMC, and were willing to share information with the researcher. This group included three chiefs, a church pastor and a church elder, one of the king's liaison officers, three Life Orientation teachers, and one senior education specialist. Life Orientation is one of the subjects in the school curriculum, which has emphasis on the application of acquired knowledge. Four key informants were females and six were males. The KIIs were conducted using a semistructured interview guide, an audio recorder was used to record discussions, and the data were transcribed verbatim and translated from IsiXhosa into English.

Focus Group Discussion
The participants in focus groups were initiates who had undergone TMC in one of the initiation schools in Libode District and were able to describe the process. The FGDs were used to collect data and explore opinions of initiates (abafana) about deaths and complications while in the TMC initiation schools. One FGD was conducted in each school and three schools were selected using simple random selection from a total of 22 schools. The selected Accepted age of circumcision Recommended age is 18 years and above; less than 18 years of age brings problems; small boys of11 and 12 years cannot tolerate the pain, they cry in the bush hut; age of 21 years is the best Causes attributed to deaths and complications Illegal traditional attendants bring drugs and alcohol into the initiation schools; initiates who refuse to take drugs and alcohol are punished; drugs are referred to as painkillers; initiates are beaten and tortured; women and girls visiting initiates in the circumcision hut attract evil spirits responsible for witchcraft; some parents are not doing rituals such as washing initiates with herbal medicine and slaughtering of goats; initiates are assaulted deliberately to teach them to endure pain. Traditional male circumcision is preferred to medical male circumcision Social acceptance; traditional circumcision ceremony; new men are appreciated in the community and at school; social recognition as a real man; after initiation, one obtains a status of leadership and responsibility; initiates get instructions about their culture, manhood values, human dignity, and good behavior; transition between boyhood and manhood; manhood values are inculcated by elders; respect, love, building one's family; protecting women and children. Acceptable community actions to prevent the problem Traditional Circumcision Forum (TCF) model should be adopted; teaching very vigorously about manhood values; formal school sessions in the form of Life Orientation are requested; dagga should not be allowed in the initiation school; chiefs should go around checking and monitoring to avoid maltreatment, drugs, alcohol, and sicknesses in the initiation school; extension of circumcision holidays; this is our custom.
schools included Mt. Nicholus Junior Secondary School (JSS), Tutor Ndamase Senior Secondary School (SSS), and Victor Poto SSS. There were 12 participants per FGD who were also selected using simple random sampling from the three schools; a total of 36 circumcised boys participated in the three FGDs.

Ethics
Ethical approval was obtained from the Research Ethics Committee of Walter Sisulu University. No individual names of the participants were used in this study. All participants signed the consent forms and those less than 18 years of age had written consent to participate in the study from their parents or guardians. Permission to conduct the study was sought from the House of Traditional Leaders, Department of Education, community and youth leaders, and the school principals.

Data Analysis
Interviews were transcribed, translated into English, and entered into ATLAS.ti (version 7) for coding and analysis of the data. Thematic analysis method was used, which emphasizes on examining, pinpointing, and recording patterns within data (Miles, Huberman, & Saldana, 2013). As the interviews were conducted, responses were reviewed to identify additional questions that needed to be used or to offer descriptions of what was identified. For example, one question was; what is the reason behind the abuse of drugs and alcohol by initiates in the circumcision initiation schools? Another additional question was; why are the traditional nurses running away with sick initiates into the forest? A six-phase process enabled the organization of data into meaningful patterns, including (a) familiarization with the data, (b) generating initial codes, (c) searching for themes among codes, (d) reviewing the themes, (e) naming themes, and (f) producing the final report (Braun & Clarke, 2006). The themes emerged inductively and the coding was a cyclical rather than a linear process in which codes arose throughout the analysis process. For example, during the first phase, data were simplified by means of transcription and reduction to a more manageable feat to enable familiarization with the data.
Data reduction included a process of categorizing the data sets using interview transcripts ( Table 2). The cyclical process involved going back and forth between the six phases until we were satisfied with the final themes (Braun, & Clarke, 2006). In the second phase, the researchers generated initial list of items from the data set with a recurring pattern. The third phase involved searching for themes and the consideration of the relationships between codes and themes ( Table 2). The themes emerged from the data as follows: repeating ideas, indigenous terms, shifts in topic, and similarities and differences of participants' linguistic expression both from the FGDs and KIIs (Braun, & Clarke, 2006). In phase 5, the researchers defined and named the themes. The detailed analysis was conducted to identify the story of each theme. Data excerpts were used to qualify the themes. In the sixth phase, the researchers identified important aspects of the story considering excerpts from both the FGDs and KIIs.

Trustworthiness of Findings
The findings from the FGD and KII methods were analyzed separately to guarantee trustworthiness of the study (Babbie & Mouton, 2001).

Validity and Reliability
Data triangulation was used to generate meaningful data to ensure validity and reliability of the findings (Streubert & Carpenter, 2007). Data generated by each method were analyzed separately and then triangulated with the other methods. The collected data were also given to peers with clear written instructions to check the transcripts to ensure validity and reliability and to categorize and develop themes from the data. The categories and themes were compared with those identified by the researcher. There were similarities and differences in the categories and themes. Similar themes were adopted as themes for the analysis and the differences were reexamined, regrouped, and given new names (Table 2).

Credibility, Confirmability, and Dependability
Guba's model of trustworthiness was used to ensure appropriateness of inquiry through dependability, there was consistency across the process of study, time taken by the researchers, and the analysis techniques, all of which rest on credibility and confirmbility (Lincoln & Guba, 1985).

Results
In the thematic analyses for FGD and KII, opinions and perceptions of the participants related to TMC deaths and complications were filtered. The data analyses yielded four overarching themes as follows: (a) accepted age for circumcision, (b) causes attributed to deaths and complications, (c) beliefs about the purpose and benefits of TMC, and (d) acceptable community actions to prevent the problem.

Results From the FGDs
The FDG participants gave similar themes to those of the KII participants, with occasionally slightly differing opinions and perceptions in their clarifications.

Accepted Age for Circumcision
In FGDs, the participants referred to 18 years of age as the best age for TMC in Libode District, which is the same as the policy standards of the provincial government (South Africa, 2001).
The King of AmaMpondo publicly announced that boys should be circumcised at the age of 18 years and above; this is the best and acceptable age.

Causes Attributed to Deaths and Complications
The participants were of the opinion that the illegal traditional nurses introduce drugs and alcohol to the initiates. The initiates who refuse to take the illicit drugs are punished in the initiation school because of the perception that they violated the opinions of their custodians.
The illegal traditional nurses introduce smoking of dagga and drinking of alcohol to initiates, telling them that dagga is a good painkiller, those who refuse are emotionally abused and beaten up in the initiation school. The presence of females close to the initiates is believed to attract witchcraft into the initiation school. This is compounded if female nurses apply dressings to the circumcision wounds. Male caregivers (doctors and nurses) are preferred to dress the circumcision wounds.
In the hospital there are females who do not respect our custom, traditional male circumcision is conducted secretly and females are not allowed to mix with the initiates. Female nurses are even allowed to dress the circumcision wound, which is totally unacceptable. The presence of women carries along witchcraft in the initiation process. The participants believe that girls attract witchcraft after visiting initiates in the bush hut.
One boy died after the girls visited the initiation school, he was attacked by evil spirits (imimoya emdaka), he became confused, unable to sleep and he did not want to eat, the following day he died because he was bewitched (wathwetyulwa).
(Participant # 7, FGD, Mt Nicholus JSS) Different rituals are performed in various families before the initiation takes place. Some boys believed that others died due to not completing the preinitiation rituals. Some boys die in the bush because of witchcraft because they did not complete the ritual, for example, their fathers did not wash them with herbal medicine, slaughter goat and talk to the ancestors.

Traditional Male Circumcision is Preferred to Medical Male Circumcision
In the FGDs, initiates reported benefits of social acceptance when a young man has undergone TMC in their communities. They showed understanding of the benefits of MMC associated with prevention of HIV/AIDS and sexually transmitted diseases of male circumcision.
After attending the traditional circumcision initiation school, the family organizes circumcision celebration (umgidi) for the new man (ikrwala) and the whole community attends the ceremony with excitement and appreciation.
(Participant # 10, FGD, Tutor Ndamase SSS) So cleanliness is the main benefit for male circumcision and also medical male circumcision is said to prevent the spread of HIV/AIDS and other sexually transmitted diseases. But those who undergo medical male circumcision are rejected even by their friends at school and in the community, if one has undergone traditional male circumcision; one is regarded as a real man.

Acceptable Community Actions to Prevent the Problem
The FGD participants noted that they would like to have formal sessions at schools to share information on TMC. These kinds of information-sharing sessions would be linked with HIV/AIDS prevention program to empower the boys.
We are from different communities, we do not talk about circumcision program in a formal way at school, it would be better if we can have circumcision talks together with HIV/ AIDS sessions here at school in the Life Orientation classes.
(Participant # 5, Mt. Nicholus SSS) The participants demanded health personnel to train traditional practitioners about infection control. The health personnel should respect the culture, and the participants explained their perceived need of why they do not want to be circumcised by the medical practitioners.
Health staff like doctors and nurses must only show traditional surgeons of how to prevent infection, but some of them do not understand our culture and others undermine our culture. We do not want to be circumcised by medical doctors but we want to be circumcised by our skilled traditional surgeons (iingcibi) who will preserve our culture; this is our custom (lisiko lethu).

Results From KIIs
The KII analysis gave background information about the four reoccurring themes to validate the information from the FGDs with minor variations.

Accepted Age for Circumcision
The key informants differed in their opinions with regard to the acceptable age for circumcision. At least 18 years of age is the best age for male circumcision of the boys to get circumcised, even myself I was circumcised at that age.
(Participant # 1, KII) Another key informant suggested that 21 years is the best age for circumcision because at this age initiates can make their own decisions and think reflectively.
In my own view, 21 years is the best age, because boys at that stage are capable of using their own thinking and decision well, the 18 years issue is from the Western culture whereby the age of 18 years is universally regarded as the age of discretion.

Traditional Male Circumcision is Preferred to Medical Male Circumcision
The key informants confirmed that the teaching the initiates receive during the initiation period inspires them to become "real men." Initiates are prepared to take leadership positions in their families and in the community at large, and as such, this is a respected custom. It is believed that without TMC, there will be no "real men" who would assume leadership roles in the community.
After traditional initiation school we believe that the young man is ready to be a leader at home and in the society. He is filled with energy and vigor inspired secretly in the bush to become a real man. There is hope that problems will be solved because there is a man that is inspired and filled with energy. (Participant # 4,KII) At initiation schools, initiates are taught about culture, acceptable behavior, and manhood values.
In a traditional way initiates get instructions about their culture. They are taught about developing themselves, human dignity and good behavior. An initiate is taught that circumcision is a transitional stage between boyhood and manhood. (Participant # 5,KII) The values are taught to initiates by respectable elderly men from the community.
In the initiation school there were manhood teachings, the values of manhood were inculcated by elderly men in the initiates, these included respecting people, young and old, loving, building ones family and protecting women and children.

Causes Attributed to Deaths and Complications
The key informants described different scenarios of abuse the initiates suffer in the circumcision initiation schools.
One key informant was shown scars on the back of a survivor of circumcision initiation school torture. The purpose of the unacceptable assault and torture is interpreted to be a way of training the initiates to graduate as real men by tests of pain.
Another young man showed his back which was scarred, he narrated that they were whipped at the back chased up the mountain by inexperienced, young illegal traditional nurses; the reason behind this cruelty, they claim that they are training them to become real men, so they must endure the pain.
(Participant # 9, KII) The key informants explained that some of the deaths and amputations are due to delays in accessing urgent medical care by the initiates who fear the loss of cultural status in the community. The situation becomes complex when health officials forcefully remove the initiates and destroy the circumcision initiation school in an effort to rescue their lives without proper consultation of the legal traditional custodians and the parents of the initiates. It becomes worse when there are sick and dying initiates in the initiation school; the traditional nurses hide and run away into the forest with the initiates especially when they see the oncoming vehicles from the department of health. The health officers take the initiates to the hospital forcefully, close and burn the initiation schools.
(Participant # 10, KII) One key informant gave a differing opinion of not supporting TMC for not achieving its purposes. This is an absolute truth, nowadays things have changed, is just like your child should better not go for traditional male circumcision." (Participant # 2, KII)

Acceptable Community Actions to Prevent the Problem
The key informants felt that community groups and committees should be established as TCFs. The common purpose of TCFs is to prevent deaths of the initiates and at the same time respect and preserve the culture while representing the Nyandeni Royal Place. Boys wanting to undergo TMC must be registered by the TCFs.
All communities and chiefs in Nyandeni should have TCFs. Parents should be empowered to register their children in the book which is kept by the TCFs; we need our culture to be respected. (Participant # 8,KII) The key informants confirmed that education must be given about manhood; parents and children must be taught; chiefs should lead the people in this teaching; and parents must look for trained traditional surgeons who are knowledgeable and skilled in the circumcision procedure.
Teaching very vigorously about what manhood is; manhood should mean a very important life stage that is full of responsibility. Chiefs and parents must look for skillful and trained traditional surgeons to circumcise the boys.

(Participant # 5, KII)
The key informants identified the duration of initiation school in the current era as a challenge where initiates are taken out of the initiation school very quickly to accommodate school holidays. Teachings about manhood values are compromised because the initiates are school pupils; they have to rush and go back to school.
We are blaming the fact that initiation period is too short, so the teachings are not done effectively. Also these young traditional nurses are unable to take care of the circumcision wound; we need to add more days to the circumcision holidays and reinstate the elderly men as traditional nurses into the circumcision initiation schools.

Discussion
TMC as a bridge to manhood values is part of the treasured and inherited belief system of the AmaXhosa people. There is a strong belief that if the initiate fails to complete the ritual, he will not be considered to be a "real man" according to tradition and will be treated with contempt and disrespect by fellow tribesmen . The opinions and perceptions discussed with focus groups were validated by information from the key informants. The study confirms that the practice of TMC is influenced by changes in value systems, schooling, age of boys, poverty, unemployment, commercialization, illegal traditional practice, violence, assaults, drug, alcohol, and the emergence of new diseases (Nqeketo, 2008). In this study, there was a concern that the duration of initiation schools in the current era was compromised by initiates being removed early (2-4 weeks) from initiation school with the wound healing occurring outside initiation school and the wound dressing continuing at home. One suggested way of overcoming this problem is to increase the length of school holidays (Douglas, 2013). The concern was that the teachings about manhood values were compromised because initiates were rushed to go back to school. Some participants felt that the delay in wound healing was due to inadequate care because it was often handled by inexperienced and illegal traditional nurses. The suggested action was that there must be an emphasis on safe male circumcision to empower communities and parents to protect their children. The reinstatement of elderly men in the ritual was recommended to bring back the value and prestige of TMC.
Young and illegal traditional surgeons violate the Circumcision Act by circumcising boys at the ages of 11 or 12 years, provided money is paid for the procedure (Kepe, 2010), when the legal minimum age is 18 years. Circumcision schools and the traditional surgeons and nurses who operate them are required to be registered by provincial health authorities.
The use of illicit drugs was identified to be another serious problem in the circumcision initiation schools. The initiates understand that dagga is an illicit drug with harmful effects but its use is beyond their control as it is forced on them by traditional nurses in the circumcision initiation school. Some illegal traditional nurses are known to assault initiates who do not smoke dagga. Meel (2010) indicated that 12% of deaths in Mthatha General Hospital were caused by assaults in the initiation school. Initiates were abused and beaten up in the initiation schools to increase the degree of pain. The purpose of this cruel exercise is falsely believed to be a way of training the initiates to become "real men." The whole myth of this cruel exercise seems to be misconstrued that initiates must endure pain, pass through assaults and tests of torture. The lack of supervision of male circumcision by elderly people and violation of policies and regulations were to be blamed for these kinds of assaults (Kepe, 2010).
The participants stated that some families perform a ritual using herbal medicines for their boys before they undergo TMC, and this ritual is believed to strengthen and protect them from the evil spirits associated with witchcraft. This forms part of the ritual processes of the traditional circumcision initiation. In other families, the father of the boy takes the boy to the kraal to connect him with the ancestors and a goat is slaughtered as part of the ritual. The meaning of this ritual is for the father to request for the son's protection from the ancestors (World Health Organization, 2008).
Participants reported a particular instance where certain females visited a circumcision school. It was believed that one of the initiates was affected by witchcraft following this said visit and the same initiate became confused, had disturbed sleep, refused to eat, and was reported to have died the following day.
Initiate deaths and health complications occurred as a result of delays perpetuated by the illegal traditional nurses who ran and hid in the forest with the sick initiates to avoid hospitalization. The situation becomes complex when health officials forcefully remove the initiates from the initiation school to rescue them without the proper consultation with the legal traditional custodians and their parents. This study recommends a circumcision health promotion education program to manage the problem and misconceptions holistically. The study participants suggested that the Life Orientation syllabus offered at school should incorporate circumcision health sessions to empower the boys. This can serve as a convenient avenue where boys can be presented with other realistic options about attaining social respect than exposing themselves to health risks. For example, career opportunities in different academic fields can be linked to the attainment of social respect of individuals in the future.
At school the boys do not have an opportunity to talk about circumcision in the context of HIV/AIDS as there are no formal school sessions to empower boys on circumcision health. A health-promoting school program can be key to the empowerment of boys to make good choices rather than choosing uninformed risky health behaviors (Scriven, 2010). The circumcision health promotion program was developed by the initiatives of TCF, the King of Amampondo at Nyandeni and chiefs. This program is based on the Ottawa Charter principles and is available for implementation (Douglas, 2013). The study recommends that to prevent health-related problems, it is imperative for health promotion program designers to be sensitive to the cultural practices associated with TMC so that the full cooperation of the affected communities is achieved.
The recommended program can be ultimately adopted for the district and provincial implementation, utilizing piloted models such as the TCF model adopted in Libode rural communities (World Health Organization, 1986;. The TCF was adopted from Beattie's Health Promotion Model (Scriven, 2010). The model's effectiveness is attributed to the relationship of working together with trained circumcision practitioners under the mentorship of culturally orientated professional male health promotion practitioners and nurses. The health sector personnel (including medical doctors, professional nurses, and health promotion practitioners) play a meaningful role at a primary health-care level to facilitate health promotion programs in partnership with the traditional leaders. The main custodians of the culture are armed with evidence-based epidemiological findings.
Qualified health promotion practitioners are trained to facilitate programs and work with communities as catalysts at a primary level of prevention. They have in-depth specialized knowledge that health promotion is a combination of educational, organizational, economic, motivational, technological, legislative, and political actions designed with consumer participation. Health promotion is a process of enabling individuals, groups, and whole communities to increase control over their health and its determinants, and to improve their health through knowledge, attitudinal, behavioral, social, and environmental changes (Scriven, 2010;World Health Organization, 1986). Therefore, this study recommends the implementation of the developed health promotion program, which is available in the Douglas study (2013).
The first limitation of this study is that only circumcised boys are allowed to speak freely about TMC among AmaXhosa people. A second limitation is that the opinions and perceptions of AmaXhosa people may not necessarily be the same as those of other ethnic groups practicing TMC in South Africa and elsewhere.

Conclusion
The notion of cultural beliefs as reflected in this study is highly embedded in and respected by the various cultural groups practicing TMC in South Africa, such as the AmaXhosa people. For example, the belief system that dictates that TMC is a custom that makes one a real man is fixed. Despite the yearly reports of high mortality rates of initiates, the various cultural groups are in favor of maintaining TMC with minimum interference from the national health-care system. This study concludes that the ideal strategy is to strengthen the approach of health promotion and prevention of deaths and complications rather than expanding efforts in changing the culture. The key informants were of the opinion that the suggested community action of establishing TCFs would possible yield an acceptable solution in preventing deaths and complications of the initiates that are common in the region, while at the same time respecting the culture.

Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.