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Healthcare providers’ perceptions and understanding of voluntary medical male circumcision in KwaZulu-Natal, South Africa: A qualitative study

Background There is compelling evidence that voluntary medical male circumcision (VMMC) reduces the chances of heterosexual transmission of HIV infection. Healthcare workers are among the key influencers in terms of the scale-up of VMMC as they are often involved in mobilisation for uptake. There is a paucity of qualitative research on healthcare workers’ experiences, understanding and perceptions of VMMC; particularly in the South African rural primary healthcare context. This study was conducted to examine healthcare workers perceptions and understanding of VMMC in KwaZulu-Natal, South Africa. Methods The study employed a qualitative approach using a phenomenographic design. A purposive sample of 15 doctors, nurses and clinical associates working in 6 different rural clinics in KwaZulu-Natal, South Africa, were interviewed in English in-depth using a semi-structured interview schedule. The interviews were audio-recorded, and transcribed. The results were analysed thematically using phenomenographic data analysis procedures. Results Categories of description in participants’ perceptions and understanding of VMMC emerged. The findings of this study revealed that healthcare workers perceptions and understanding of VMMC were predominantly influenced by the hegemonic religious and cultural norms associated with male circumcision in KwaZulu-Natal, South Africa. Conclusion The findings of this study suggest that tailored training to address healthcare workers misperceptions and poor understanding of VMMC is necessary to ensure that they become effective custodians for VMMC implementation.


Introduction
The results of three randomised controlled trials conducted in Kenya, Uganda and South Africa, have proven that voluntary medical male circumcision (VMMC) is an effective biological human immunodeficiency virus (HIV) prevention strategy. 1,2,3 Following these results, the World Health Organization (WHO) recommends that regions of high HIV prevalence adopt VMMC as an additional HIV prevention intervention. 4 In 2010, VMMC was introduced in KwaZulu-Natal (KZN), South Africa following recommendations made by the WHO. 5 https://www.safpj.co.za Open Access primary target group (15-49-year-old) for medical circumcision, including perceptual factors, the role of social influencers such as peers, key figures and role models, as well as the availability of healthcare services for men. 12, 13,14 The scale-up of VMMC, so that the stipulated age-specific targets are met, is also dependent upon health service providers' attitudes, perceptions and beliefs about the efficacy of VMMC.
While there has been extensive research on the uptake of VMMC in South Africa and the rest of southern and east Africa, where male hegemony is similarly part of the sociocultural value system, there is a paucity of contextual research on healthcare workers' perceptions and understanding of VMMC in southern Africa, particularly in KZN, South Africa. Aside from studies of healthcare workers' attitudes to and understanding of VMMC prior to the roll-out of VMMC in South Africa, 15 current research on healthcare workers' perceptions of VMMC in KZN, South Africa is limited to pharmacy and nursing students, and both of which are in urban settings. 16,17 The present study examines professional healthcare workers' perceptions and understanding of VMMC in KZN, South Africa. An awareness of healthcare workers' perceptions and understanding of VMMC has important policy implications in terms of the education and training of healthcare workers regarding VMMC.

Research design
A qualitative approach using a phenomenographic study design was used. This study was part of a larger study conducted to analyse primary healthcare stakeholders' experiences, understanding and conceptualisation of VMMC in KZN, South Africa, so as to propose a relevant intervention to support uptake.
Phenomenography is a qualitative research design that is interpretive in nature and seeks to clarify, discern and analyse the various ways in which individuals conceptualise, understand and experience a phenomenon in the world around them. 18 It does not consider the subject and aspect of the world as separate entities, but rather the individual's experience, conceptualisation or understanding is seen as setting up a relation between that person and a given phenomenon in the world. 19

Research setting
This study was conducted at six different rural clinics offering VMMC services in KZN, South Africa. The selected clinics serve an estimated population of 110 000-250 000 men in the age group of 15-49 years. Each clinic performs between 700 and 2800 VMMC's on boys and men annually, with the majority being young male children in the 10-14-year age group.

Sampling and recruitment
Purposive sampling was used to select the clinics and the participants for data collection. Participants who were directly involved in rendering VMMC services were purposively selected from a study population of nurses, doctors and clinical associates working at the selected clinics.

Data collection
Individual in-depth interviews were conducted using a semistructured interview guide that contained a demographic section and guiding questions to elicit respondent perceptions and understanding of VMMC in KZN, South Africa. The interview schedule was written in English and translated into Isizulu. However, all interviews for this study were conducted in English as participants were comfortable with English as the language of communication. An audiotape was used to record all interviews. Each interview was conducted in a private consulting room within each of the clinics and lasted between 20 min and 35 min. Data collection ceased once data saturation was reached.

Data analysis
Following data collection, the audio recorded data were transcribed verbatim and then analysed following phenomenographic data analysis procedures. The data analysis was an iterative process which followed a step-by-step approach as recommended by Sjöström and Dahlgren. 20 Firstly, the interview transcripts were read several times while listening to the audiotapes to ensure that data were accurately transcribed, and to gain an overall understanding of the data. The second step entailed a more focused reading so as to extract similarities and differences from the data. Thirdly, significant aspects of the transcript were extracted. The fourth step involved a preliminary grouping of similar responses leading to the creation of an initial list of descriptive categories that were later refined through constant comparison with the transcript. The final set of categories were named and the outcome space was formulated, based on the internal relations between the categories of description.

Trustworthiness
Data was analysed in collaboration with an expert in qualitative research methods to ensure credibility and confirmability. To ensure richness of the data, a qualitative approach using in-depth interviews was employed and initial data analysis was conducted concurrently with data collection which ceased once data was saturated. To ensure credibility and dependability, voice recordings were reviewed many times and compared with the transcribed data. A detailed methodology of the study is provided to ensure transferability.

Ethical considerations
This study was part of a larger study conducted to analyse the qualitative differences in primary healthcare stakeholders' experiences, understanding and conceptualisation of VMMC in KwaZulu-Natal, South Africa. Ethical approval to conduct this study was obtained from the Biomedical Research Ethics Committee of the University of KwaZulu-Natal (BE 627/18). Informed consent was obtained verbally and in writing from the participants prior to data collection. A written information sheet was provided to the participants clarifying the nature of the study, and written consent was sought from the participants after verbal approval was obtained.

Results
Fifteen healthcare providers took part in the study. The participants included registered nurses (n = 5), enrolled nurses (n = 3), nursing assistants (n = 2) clinical associates (n = 3) and medical doctors (n = 2). The demographic details of the participants are shown in Table 1.

Perceptions of voluntary medical male circumcision in KwaZulu-Natal, South Africa
Three main categories of participants' perceptions emerged from the data analysis. These categories are described below, and relevant supporting statements from the participants are provided.

Foreskin removal
Healthcare workers perceived VMMC to be the removal of the foreskin of the penis but the extent of foreskin removal was not explicitly mentioned. This removal was seen to be medically beneficial. The following statements serve to justify this perception: 'In short I would say it is removal of the foreskin covering the glans. It's so that the glans is exposed.' (Participant 2, male, 34 years, registered nurse)

A procedure for young boys
Although the healthcare workers in this study appeared to be aware that medical circumcision is for men of all ages, they thought the procedure should mainly be performed on males at a young age. This was stated in their descriptions of the best time to perform medical circumcision. The excerpts below serve to support this category: 'For convenience, I think it is better circumcising boys starting from eight years and above ... Here we do them when they are that age because they are able to tolerate anaesthesia.' (Participant 4, male, 34 years, registered nurse) 'The older generation of boys and men are a problem because they often have adhesions that are a challenge when doing circumcision. In boys of a very small age, there are also challenges so I think 12 years is okay.' (Participant 1, male, 27 years, registered nurse) 'It is better to do the procedure on boys from 12 years old because they understand and know everything better. When you explain things to them, they do not have a problem only when you inject them there is some bit of challenge but after that they are fine and you carry on.' (Participant 5, female, 38 years, registered nurse)

Service to be rendered by males
Healthcare providers views are influenced by their participation in and knowledge of a socio-cultural value system where circumcision is associated with traditional gender specific rites of passage. The following statements support this category: 'In my opinion, I can say that sometimes you do not become comfortable to be assisted by a female.' (Participant 7, male, 33 years, enrolled nurse) 'In the rendering services, I think it best for a man to be performing the circumcision seeing that the procedure is very much influenced [by] traditional beliefs especially here in the Zulu culture. Even more this is something private, for a woman

Understanding of voluntary medical male circumcision in KwaZulu-Natal, South Africa
Three main categories of participants' understanding regarding VMMC emerged from the data analysis. The categories of description and relevant support statements from the participants are described below.

Prevention of human immuno-deficiency virus and other sexually transmitted infections
Participants seemed to understand that VMMC reduces the chances of HIV infection. They were also aware that medical circumcision only partially reduced the chances of infection. However, some participants did not fully understand the concept of partial HIV protection provided by VMMC.

Traditional verses voluntary medical circumcision
Participants seemed to consider traditional circumcision in terms of the complications associated with the procedure because of the manner and context in which it is carried out. Participants in this instance seemed to understand that medical circumcision is a safer option compared with the traditional method. The understanding of healthcare workers regarding medical and traditional approaches to circumcision seems to be largely influenced by their clinical orientation to healthcare, including medical circumcision.

Healing time versus medical circumcision time
In terms of healing time, participants agreed that it takes 6 weeks for a male to be fully healed after VMMC; healing time was well understood by participants in this regard. However, in terms of best age to circumcise, participants appeared to have a limited understanding of when VMMC can be safely and effectively performed. This was supported by the following statements: 'It takes 6 weeks; we tell them that. We also teach them that after two weeks, maybe they will think that the wound is healing. But that does not necessarily mean that it is completely healed to engage in sexual intercourse … they need to wait for 6 weeks.' (Participant 1, male, 27 years, registered nurse) 'There is no specific time, but for convenience, it's better to do them when born. But because of the anaesthesia challenges it's better to do them when they are 8 and above because they are better able to tolerate the procedure…' (Participant 4, male, 42 years, registered nurse) 'For us, we start at 12 because most of the time, the younger ones less than 10 cry a lot. You cannot work properly. You cannot do the procedure properly because they will give you a little trouble. They cry and cannot keep their hands away from the procedure area. It takes even longer to finish doing them.' (Participant 3, male, 31 years, registered nurse)

Discussion
The purpose of this study was to examine healthcare workers' perceptions and understanding of VMMC in KZN, South Africa. The results of this study revealed that while healthcare workers were aware of the medical rationale for VMMC, it appears that their perceptions and understanding of VMMC were primarily influenced by the cultural and religious norms that influence circumcision in the KZN context.
It was found that participants' perceptions of VMMC in this study were centred on the nature of the procedure as a surgical intervention, one involving removal of the prepucea layer of skin covering the glans penis. Participants seemed to perceive this procedure to have medical benefits. This finding confirms the impact of the clinical training that health workers received regarding VMMC. Moreover, it agrees with the available evidence which suggests that medical circumcision has significant health benefits such as a reduction in HIV transmission in female-to-male sexual encounters, a reduced risk of contracting sexually transmitted infections (STIs) such as herpes, chancroid and syphilis, a reduced risk of urinary tract infections (UTIs), and a lower risk of penile cancers and carcinomas. 21,22,23 Participants in this study revealed their perceptions of VMMC in terms of the delivery of the health service and in relation to who they thought were the ideal recipients of this service. In this regard, participants' perceptions were influenced by their participation in and knowledge of a socio-cultural value system where circumcision is associated with traditional gender specific rites of passage. Culture and tradition are often used interchangeably in literature to depict a sense of shared values that influence human behaviour and, as a result, their response to health and ill-health. 24,25,26 Research on the socio-cultural barriers affecting uptake VMMC among men has revealed that culture and religion can act as both barriers and drivers to the acceptability of medical circumcision by men. 12,27 Alluding to the cultural barriers affecting VMMC among men, Nxumalo and Mchunu 28 found that cultural and religious norms were a major influences for uptake of VMMC among Zulu men in KZN, South Africa. The present study's finding that healthcare workers' perceptions of VMMC are influenced by cultural dynamics is significant as it highlights the deeprooted influence of the socio-cultural context on healthcare and health service delivery. It is therefore important that health programmes such as VMMC engage with indigenous practices and beliefs to reap the maximum benefit from such programmes. 29 Furthermore, engagement with such practices should be directed not only to services users but also to the healthcare providers as some beliefs are held by healthcare workers and may influence how they advocate for such health programmes.
Participants' understanding of VMMC was related to knowledge of the partial nature of protection afforded by VMMC against HIV infection and certain STIs. These findings agree with the results of previous studies that explored women's understanding of the partial protection offered by VMMC against HIV infection. 30,31 Healthcare workers' demonstration of their accurate understanding of the concept of partial protection is encouraging as it shows that they will be able to relay such information to patients when mobilising for uptake to prevent men's risky sexual health behaviour following VMMC. The provision of information to prevent risk compensation following VMMC is important for the promotion of overall positive sexual and reproductive health as post-VMMC behaviour change interventions have been shown to promote medical circumcision's positive outcomes. 32 The participants were aware of the nature of VMMC; most were unsure of how traditional male circumcision was performed. However, most perceived medical circumcision to be safer than traditional circumcision. Similar findings were in Malawi among circumcising and non-circumcising communities. 33 These findings are also significant as healthcare providers are advocates for health programme implementation. In order for healthcare providers to effectively advocate, they must be aware of the details of alternative approaches. Therefore, the gap in knowledge regarding traditional approaches to male circumcision should be addressed to deepen healthcare providers understanding of the issues involving their patients.
Participants seemed to understand the VMMC healing process and the 6-week sexual abstinence period. However, in terms of VMMC performance, most participants seemed to think that younger boys would benefit more from VMMC because of the perception that younger boys are less likely to experience postoperative complications. This demonstrates a misunderstanding of VMMC on the part of healthcare workers. These findings support the belief that intensifying neonatal circumcision is preferable because it is associated with fewer medical risks. 34 These findings represent one of the many perceptual barriers that hinder the uptake of VMMC by older males. Furthermore, the results of the current study suggest that this barrier may be perpetuated by an inherent misperception among healthcare workers. Other studies have also found that healthcare workers lack knowledge about VMMC and the need for HIV testing. 35 Training interventions aimed at healthcare workers thus remain instrumental to facilitating the successful uptake of VMMC since demand generation activities rely on the messaging provided by healthcare workers.

Limitations
The study was limited as a result of the small sample size and the research design used, which did not allow for generalisation of the findings. The choice of individual indepth interviews as the sole method of data collection may have compromised the depth of findings. Nevertheless, the study findings provide an awareness of healthcare workers' perceptions and understanding of VMMC which may help to inform training interventions that may be required by healthcare workers. This may in turn ensure that healthcare workers are better equipped for demand generation activities such as providing tailored patient messaging about VMMC.

Conclusion
Participants' understanding of the procedure was influenced by their culture and tradition together with general misinformation about the procedure and the biology of the penis and foreskin. The perceptions of healthcare workers also seemed to be influenced mainly by stereotypical norms of culture, tradition and the prevailing hegemonic masculinity.
The study findings provide important information on some of the impediments to the successful scale-up of VMMC. They also highlight the need for training interventions to be directed towards healthcare workers in order to address misinformation about VMMC; such interventions should consider the traditional and religious issues related to medical circumcision.
direction. Both authors approved the manuscript for submission.

Funding information
The

Data availability
Data will be made available upon request from the corresponding author.

Disclaimer
The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position affiliated agency of the authors.