Factors associated with acceptability of child circumcision in Botswana -- a cross sectional survey
Keetile and Bowelo BMC Public Health
Factors associated with acceptability of child circumcision in Botswana - a cross sectional survey
Mpho Keetile 0
Motsholathebe Bowelo 0
0 Department of Population Studies, University of Botswana , Private Bag UB 00705, Gaborone , Botswana
Background: Safe male child circumcision has been recently adopted as a potential strategy to prevent HIV/AIDS transmission in later life in Botswana. Methods: Data used was derived from a cross-sectional survey, the Botswana AIDS Impact Survey (BAIS) IV, conducted in 2013. A total sample of 7984 respondents in ages 15-64 years who had successfully completed the individual questionnaire during the survey were selected and included for analysis. Both descriptive and multivariable analyses were used to explore factors associated with acceptability of child circumcision. Data was analysed using SPSS version 22 program. Results: Results indicate that about 84 % of participants said they would circumcise their male children aged 18 years and below, while 93 % were aware of the safe male circumcision program. Bivariate analyses results show that acceptability of child circumcision was significantly associated with sex, age, education, religion, residence, HIV status of the parent, fathers circumcision status, father's intention to circumcise and parent's knowledge about the safe male circumcision program. Multivariable analyses results indicate positive association between respondent's HIV positive status (OR, 3.5), Men's circumcision status (OR, 3.7), men's intention to circumcise (OR, 9.3) and acceptability of child circumcision. Conclusion: Results of this study indicate some relatively high acceptability levels for child circumcision. Some individual behavioural factors influencing acceptability of child circumcision were also identified. This study provides a proper understanding of factors associated with acceptability of child circumcision which will ultimately enhance the successful roll-out of the school going children circumcision program in Botswana.
Acceptability; Child; Safe Male circumcision; Factors; Botswana
Male circumcision is one of the oldest surgical procedures,
traditionally accepted as a mark of cultural identity or
religious importance, or for perceived health benefits such as
improved penile hygiene or reduced risk of infection .
Traditionally, circumcising societies and religious sects
have used the procedure for cultural and religious
purposes . Recent epidemiological evidence has shown that
safe circumcision reduces the risk of acquiring HIV
infection in heterosexual males by 50–60 % . It is on the
basis of this evidence that several African countries with
high prevalence of HIV are now expanding access to safe
circumcision [3, 4]. Observational studies suggest that the
protective effect of male circumcision is similar if
circumcision occurs early in life . The immediate focus of
circumcision for HIV prevention has been on adolescents
and adult men, but a longer-term HIV prevention strategy
has to include the provision of child circumcision services.
Child circumcision is routinely practised in most
countries in the Middle East (in countries such as, Egypt,
the Islamic Republic of Iran, Jordan, Lebanon, the Syrian
Arab Republic, Turkey and Yemen), Israel [6–8], the USA
 and some West African countries, including Senegal,
Ghana and parts of Nigeria [10, 11]. This type of
circumcision is done mainly for religious and cultural purposes.
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Studies have provided that the best age to perform
circumcision is in childhood and it has been shown to have a
better protective effect than those performed at any other
age . It is also safer, easier and less costly but it is
not widespread in southern Africa countries including
Based on studies conducted in some parts of sub
Saharan Africa [SSA] in particular the randomized clinical
trials (RCTs) conducted in Uganda ; Kenya  and
South Africa , safe male circumcision has a protective
effect against HIV as well as reducing incidences of other
sexually transmitted infections (STIs) like genital ulcers,
human papilloma virus (HPV) and Chlamydia in female
partners. Meanwhile child circumcision is recognised as a
long term preventive strategy to reduce new infections
particularly in later life as recommended by UNICEF and
WHO . In 2009, the Ministry of Health (Botswana)
launched the safe male circumcision (SMC) policy as part
of the comprehensive strategy on HIV prevention.
Following this decision, circumcision services are being extended
many public health facilities free of charge with the
intention to increase accessibility of the service to as many
males as possible. As a strategy to enhance uptake of
circumcision services, there has been some efforts to
reach out to school going children. The benefits of child
circumcision compared to adult circumcision have been
emphasized in several studies. For instance, in a qualitative
study conducted in Zimbabwe, it was observed that
circumcising children protected them against HIV
transmission in later life [4, 7, 14, 15].
Previous studies have shown high adult male
circumcision acceptability rate in Botswana and in the region
[14, 16, 17]. Kebaabetswe et al. , suggested that
circumcision for the children of Botswana would be highly
acceptable, and believed that parents in Botswana—as
in most developed countries worldwide be offered the
option of hospital based circumcision for their male
children to protect them from the acquisition of HIV.
Generally, male child circumcision is not yet performed
in most southern African countries and there are
questions regarding its acceptability, feasibility, safety and
optimal approaches to widespread implementation .
Although Botswana has adopted safe male
circumcision as a key strategy against HIV/AIDS transmission,
there is little information on factors influencing parental
acceptance of child circumcision. Botswana has been
running SMC program since 2009 and has not yet met
its target of circumcising 80 % of males by 2016 .
Recently (in 2015), the government introduced Early Infant
Safe Male Circumcision (EISMC) program as an add-on
to a series of response programs to reduce HIV
transmission in later life. The social and behavioural context of the
countries implementing male circumcision programs
might provide the reasons why set targets for SMC are
not being met. Very little research has been carried out to
explore factors (especially behavioural) influencing
willingness to accept child male circumcision in the general
population of Botswana. Plank et al.  conducted a
study in South Eastern part of Botswana among women to
assess whether they would accept their new-born male
children to be circumcised. Although their study provided
vital insights about acceptability of infant circumcision,
the main limitations of the study was that it did not
include men who are also role players in reproductive
decisions of their families and was limited in scope
This study uses nationally representative data and also
includes men who are vital in decision making of the
reproductive health of their families. The main aim of this
study was to assess factors associated with acceptability
of safe male child circumcision in Botswana. The study
of this nature is essential in the context of Botswana
where HIV prevalence rate continues to be high, and the
SMC program has failed to reach the expected target.
The study will serve to guide successful rollout of
different SMC programs in Botswana. Moreover, since child
circumcision has been found to decrease the risk of HIV
infection among men in later life, it is important to
determine its acceptability in the general population
as a potential HIV prevention strategy.
The study employed Theory of Reasoned Action, [TRA]
developed and several times modified by Ajzen and
Fishbein [19–21]. TRA proposes that behavioural
intentions are a combined function of the attitude toward
performing a particular behaviour in a given situation
and of the norms perceived to govern that behaviour
multiplied by the motivation to comply with those
norms . This theory assumes that human beings are
usually quite rational and make systematic use of the
information available to them. People consider the
implications of their actions before they decide to engage
or not engage in a given behaviour .
As child circumcision is recommended for medical
reasons [especially prevention of HIV acquisition in later
life], mothers and fathers who may choose circumcision
must also believe that circumcising their children may
reduce chances of HIV acquisition later in life. The study
attempted to determine factors influencing parent’s
decision to circumcise their children. We chose this model
mainly because, we believe that constructs of this model
are key in informing parental decision on accepting child
The assumption of TRA is that most behaviours of
social relevance are under volitional control and that a
person’s intention to perform or not perform behaviour
is the immediate determinant of that action . A person’s
intention regarding routine circumcision is determined by
personal and social influences. One personal factor is the
person’s evaluation of the outcome of circumcision, which
can be either positive or negative. Parents who believe
circumcision is necessary for reduction of HIV transmission
may choose the procedure. Meanwhile parents who believe
otherwise may have negative evaluation of circumcision
and may choose not to circumcise their children. Subjective
norm is the other determinant of a person’s intention which
is a person’s perception of the social pressures applied to
perform the behaviour . As illustrated in Fig. 1, an
individual’s intentions and behaviours are influenced by
certain background factors which include individual,
social and information factors.
The above figure shows one way in which the
intentions and behaviour can be represented. There are
beliefs which are assumed to influence attitudes, subjective
norms, and perceived behavioural control which, in turn,
produce intentions and behaviour . Feng and Wu
, also state that, intention is the best predictor of
behaviour, and it is a function of the person’s attitude
towards performing the behaviour and general subjective
norms concerning the performance of that behaviour.
For example, if a father intends to circumcise his child
in future, he may eventually do so or he may also choose
not to circumcise his child given the prevailing
circumstances at the time. The Theory of Reasoned Action states
that beliefs determine attitudes and subjective norms
which then determine intention and the corresponding
behaviour . For instance, if the child’s father is
circumcised, the father may also believe circumcision to be
normal or necessary for their child. In addition, if most males
in the community or society have been circumcised, the
parents, in particular the father can subjectively intend to
circumcise their children or decide otherwise. Although
constructs of the TRA discussed above not been precisely
used in the paper, notions of the TRA have been used to
understand why would parents accept or reject child
This study used data derived from the 2013 Botswana
AIDS Impact Survey (BAIS-IV), which is the fourth and
latest of a series of nationally representative demographic
surveys aimed at providing up to date information on the
HIV /AIDS epidemic. The objectives of the BAIS IV
included providing latest information on the national HIV
prevalence and incidence estimates among the population
18 months and above; to provide indicative trends in
sexual and preventive behavior among the population aged
10–64 years; and provide a comparison between HIV rate,
behavior, knowledge, attitude, poverty and cultural factors
that are associated with the pandemic with estimates
derived from previous surveys.
All districts and major urban centres became their
own strata. Enumeration Areas [EAs] were grouped
according to ecological zones in rural districts and
according to income categories in cities/towns. Geographical
stratification along ecological zones and income categories
was undertaken to improve the accuracy of the survey
data because of the homogeneity of the variables within
BAIS-IV employed a national two stage sample survey
design. The first stage was the selection of EAs as
Primary Sampling Units [PSUs] selected with probability
proportional to measures of size (PPS), where measures
of size [MOS] were the number of households in the EA
as defined by the 2011 Population and Housing Census.
EAs were selected with probability proportional to size.
In the second stage of sampling, the households were
Fig. 1 Theory of reason action and planned behaviour. Adapted and modified from Brenda Wells Dyal, 2006
systematically selected from a fresh list of occupied
households prepared at the beginning of the survey's
fieldwork [i.e. listing of households for the selected EAs]
and households were drawn systematically. Estimates
for response rates showed that 83.9 % of persons aged
10–64 years answered individual questions.
Data collection for BAIS IV was done by trained
enumerators and was led by the National AIDS
Coordinating Agency. Data collection was done using smart phone
tablets instead of the conventional paper based method.
Twenty-nine teams comprising of 6enumerators, and 1
supervisor per team collected data as well as testing the
sampled population for HIV. Each team was expected to
cover between 10 and 11 enumeration areas during the
survey and there were 301 enumeration areas covered.
This study was commissioned by the government of
Botswana, and was implemented by National AIDS
Coordinating Agency under the Office of the President.
Ethical clearance was granted by the Ministry of Health’s
Health Research and Development Division and all
ethical issues were considered.
Sampled population for BAIS IV was 9807 and
responded population was 8231 [10–64 years], yielding a
response rate of 83.9 %1. Sample selection for this paper
was such that a total of 7984 individuals who had
successfully completed the individual questionnaire, and
were aged 15–64 years were considered for analysis. The
final selection of the sample yielded 3744 males and a
total of 4240 females [total sample = 7984], using SPSS
data selection command.
The dependent variable used in this study is acceptability
of child circumcision, measured by the following question;
“Suppose you had male children aged below 18 years
would you get them circumcised”. There were three
outcomes for this question, yes = 1, no = 2 and unsure = 3.
The final outcomes for this paper are two, yes = 1
[acceptance] and no = 0 [refusal]. 69 respondents who reported
that they were unsure were filtered out.
This study investigates the effects of the following
variables on the respondent’s decision to accept child
i) Knowledge about safe male circumcision-This variable
was derived from the following survey question; “Have
you ever heard of Safe Male Circumcision or SMC
program? Possible responses were yes = 1 and no = 2.
ii) Religion of respondent2; This was derived from a
question asking respondents about their main
religious affiliations. The following religions were
listed; Christianity = 1, Islam = 2,Bahai = 3,
Hinduism = 4,Badimo = 5,No religion = 6 and
other religions (open responses). The final variable
codes were as follows; Christianity = 1, Islam,
Bahai, Hinduism, Badimo and other religions were
grouped together and coded as Other non-Christian
religions = 2 and no religion was coded 3.
iii) Men’s circumcision status-Men’s circumcision
status was derived from the survey question; “Are
you circumcised”? Yes = 1 & no = 2, don’t know
response was filtered out.
iv) Intention to be circumcised; This was derived from
a question asking uncircumcised men about their
intension to circumcise in the next 12 months:
“Do you intend to get circumcised in the next
12 months. Responses were yes = 1 & No = 2
v) HIV status of respondent: This was derived from
the question: “what was the result”? Positive = 1,
Negative =2, Don’t want to tell = 3 and Don’t
know = 4. This was a follow-up question to the
question asking respondents whether they were
told/given results for their last HIV test. The
don’t want to tell and don’t know responses were
treated as missing values and were filtered out
and not included in the analysis. Control variables
used are age, education, marital status, and place
Data analyses implored in this paper include both
bivariate and multivariable analyses. BAIS IV was a
national study and inference is made from the sample
to the entire population. Bivariate analysis results are
presented as percentages and are used to present the
association between acceptability of child circumcision,
behavioural and control variables. For multivariable
analyses logistic regression is used to identify key
factors associated with acceptability of child circumcision.
Logistic regression results are presented in the form of
unadjusted [Model I-gross effects] and adjusted odds
ratios [Model II-net effects], together with their 95 %
confidence intervals [C.I.]. Logistic regression results
explain the probability of accepting child circumcision
in a particular category of variable in comparison with
the reference category, while controlling other factors.
Data analysis was done using Statistical Package for
Social Sciences version 22 program [SPSS].
Logit Model I
Model I presents the probability of accepting child
circumcision based on socio-demographic factors [e.g.
sex, age, religion, education, marital status and place of
residence]. The regression equation for model I take
Where p is the probability that the respondent is likely
to accept their male child to be circumcised. 1-p is the
probability that the respondent will not accept their male
child to be circumcised. β0 and β1X are components of
the regression equation, the βs represent regression
coefficients and Xs represent a set of independent variables.
The key independent variables used are respondent’s age,
sex, residence, religion and education.
Logit Model II
Model II measures the probability of accepting child
circumcision based on a set of factors while controlling for
potential confounders. Model II introduces behavioural
factors [The following behavioural factors are included;
HIV status of the respondent, men’s circumcision status,
men’s intention to circumcise and knowledge about safe
male circumcision] which may influence the respondent’s
decision to circumcise their male children. The regression
equation fitted to data takes the form;
Where p is the probability that the respondent is likely
to accept their male child to be circumcised. 1-p is the
probability that the respondent will not accept their
male child to be circumcised. β0 and β1X are
components of the regression equation, the βs represent
regression coefficients and Xs represent a set of independent
variables and Xk is an array of behavioral independent
variables which may influence the respondent’s decision
to circumcise their male children. These are potential
confounders on the decision to circumcise a male child.
Ethics approval for Botswana AIDS Impact Survey IV
was granted by the Health Research and Development
Division in the Ministry of Health. During data
collection for BAIS IV written informed consent and assent
were sought from respondents who were informed about
the purpose and design of the study, and assured that
participation was voluntary and confidential.
Table 1 presents the sample population based on
sociodemographic characteristics and a set of behavioural
factors. Results indicate that there were slightly a high
proportion of females (53 %) than males (47 %) in the
sample. Respondents in ages 15–34 years accounted for
59 % of the sample, while those in ages 35–44 and 45–
64 years both accounted for 20 %. Respondents with
Suppose you had male children aged below 18 years would you get
secondary education (57 %) were the prominent education
group in the sample. Meanwhile respondents from rural
areas accounted for 64 %. The predominant religious
affiliation in the sample is Christianity (86 %) followed by no
religious affiliation (9 %).
When considering behavioural factors, 84 % of
respondents said that they would accept their male children
aged below 18 years to be circumcised. Meanwhile 19 %
Table 1 Sample characteristics
Place of residence
HIV status of respondent?
Men’s circumcision status?
Men’s intention to circumcise?
Knowledge about circumcision
of respondents in the sample reported that they were
HIV positive, while 25 % of men in the sample reported
that they were circumcised. Furthermore, results also
indicate that about 55 % of uncircumcised men in the
sample had the intention to circumcise in the next
12 months, whereas 93 % of study participants knew
about the safe male circumcision program.
Acceptability of child circumcision
Table 2 show acceptability of child circumcision among
respondents by sample characteristics. Results indicate
that a slightly high proportion of females (88 %) than
males (84 %) reported that they would get their male
children to be circumcised. When considering age of
participants, a relatively low proportion of respondents
in ages 25–34 years (84 %) than in other ages (over
85 %) said they would accept their male children to be
circumcised. Quite conversely, a significantly small
proportion of respondents with tertiary education (83 %)
than those with primary (92 %) and secondary education
(88 %) reported that they would get their male children
to be circumcised. Results also indicate that slightly more
respondents in urban areas (88 %) than rural areas (85 %)
reported that they would accept their male children to be
Furthermore, a significantly high proportion of Christian
(86 %) and participants of other non-Christian religions
(86 %) reported that they would circumcise their male
children compared to individuals who said they do not
affiliate to any religion (78 %). A higher proportion of
respondents who reported that they were HIV positive
(90 %) compared to those who reported that they were
negative (86 %) said they would accept circumcision of
their male children. A significant proportion of
circumcised men (94 %) than uncircumcised men (81 %) reported
that they would circumcise their children. On the other
hand, 92 % of men who intended to be circumcised in the
next 12 months, said they would accept circumcision of
children, compared to only 64 % of men who said they did
not intend to get circumcised themselves. Results also
show that about, 88 % of respondents who knew about the
safe male circumcision program, reported that they would
circumcise their male children compared to those who did
not know about the program (59 %).
Logistic regression results for the probability of accepting
child circumcision among respondents
Model I results
Table 3 shows the logistic regression results for the
probability of accepting child circumcision among
respondents. Results indicate that sex of the respondent is
a significant factor for the probability of accepting child
circumcision when considering demographic variables only.
For instance, women were more (OR 1.18, C.I. =1.02-1.38)
Table 2 Acceptability of child circumcision among respondents
by sample characteristics
P = 0.003
Place of residence
HIV status of respondent?
Men’s circumcision Status?
Men’s intention to circumcise?
Knowledge about safe male circumcision program
P = 0.000
P = 0.002
P = 0.000
P = 0.000
P = 0.000
P = 0.001
P = 0.000
P = 0.000
Place of residence
Table 3 Odds ratios (OR) and 95 % confidence Intervals for the probability of accepting child circumcision
Men’s circumcision status
Men’s Intention to circumcise?
Knowledge safe male circumcision program about circumcision
willing to accept their children to be circumcised compared
to men. Young adults in ages 15–24 years and 25–34 years
respectively, were less willing to accept their children to be
circumcised compared to adults in ages 55–64 years.
Education was not significantly associated with
accepting child circumcision. When considering place of
residence, respondents from rural areas were less willing
(OR 0.76, C.I. = 0.65-0.89) to accept their children to
be circumcised. Moreover, results indicate that the odds of
accepting child circumcision were significantly higher
among Christians (OR 1.55, C.I. = 1.22-1.97) and other
non-Christian religions (OR 1.63, C.I. = 1.05-2.54)
respondents than among individuals with no religion affiliation.
Model II results
Model II introduces behavioural factors. Results indicate
that when behavioural factors were introduced in the
model, sex was not a significant predictor of accepting
male child circumcision. The odds of willingness to accept
child circumcision was high among respondents in
ages 25–34 (OR 1.34, C.I. = 1.25-1.43), 35–44 (OR
1.41, C.I. = 1.31-1.50) and 45–54 years (OR 1.31, C.I. =
1.21-1.41). Respondents residing in rural areas were less
willing (OR 0.96, C.I 0.93-0.99) to accept their male
children to be circumcised compared to those in urban areas.
Christians (OR 2.36, C.I. = 2.27-2.45) and respondents of
other non-Christian religions (OR 3.10, C.I. = 2.91-3.31)
were more willing to accept child circumcision than
individuals with no religion.
Another observation is that individuals who reported
that they were HIV positive were more willing to accept
child circumcision than those who said they were HIV
negative. The odds of willingness to accepting male child
circumcision were significantly higher among men who
were circumcised (OR 3.69, C.I. = 3.58-3.81) than those
who were not circumcised. Men who had the intention
to be circumcised in the next 12 months after the survey
were nine times more willing (OR 9.32, C.I. = 9.02-9.64)
to accept circumcision of their male children compared
to those who did not have any intention to circumcise in
the next 12 months. Quite conversely, respondents who
said they knew about safe male circumcision program
were less willing to circumcise (OR 0.85, C.I. =
0.790.89) their children than those who did not know about
The government of Botswana has been running a series
of response programs aimed at reducing HIV
transmission. However, since the introduction of the SMC
program in 2009, it has not yet been able to meet its target
of circumcision of 80 % of males by 2016. Meanwhile,
the results of this study indicate a relatively high level of
acceptability (84 %) of child circumcision in the general
population of Botswana. Some previous studies in SSA
region focusing on the general male population have
also shown high levels of acceptability of circumcision
[13, 14, 16, 17]. In order to increase scope and coverage
of circumcision services, the government of Botswana
has adopted child circumcision in the HIV/AIDS
prevention package. This is done, in a context where little
is known about the acceptability of child circumcision
in the general population. These results provide
impetus for the successful roll out of child circumcision
services, especially among the school going children.
Acceptability of child circumcision in Botswana is
associated with gender of respondents, with women more
willing to accept their male children to be circumcised.
On the other hand, some studies in SSA have shown
that men have more decision-making power to decide
over child circumcision than do mothers [23–25]. These
studies have shown that when parents disagreed about
circumcising their male children, men’s decision not to
circumcise tended to predominate, regardless of whether
the mother favored circumcision. Even qualitative
studies have shown similar findings that men’s decision to
accept child circumcision is instrumental. For instance a
qualitative study in Zimbabwe has shown that both male
and female participants concurred that men have the
ultimate decision to circumcise their children . Child
circumcision programs should include education,
information and communication materials for men to enhance
When controlling for age, we found that men’s intention
to circumcise was also significantly associated with the
likelihood of accepting child circumcision. The theory of
reasoned action posits that intention is the best predictor
of behaviour, and it is the function of person’s attitude
towards performing behaviour or taking action towards
behaviour. For instance, a man who validates circumcision
may have the intention to be circumcised and that
intention may trickle down to the desire to have their male
child circumcised. This is so because a man who is willing
to be circumcised has the belief that circumcision is
acceptable, hence positive attitude and subjective norms
which then determine and reinforce the intension to
accept child circumcision.
The findings of this study also show that circumcised
men were more willing to accept their male children to
be circumcised. Another study in Zambia also found
that father’s circumcision status was one of the reasons
for their positive decision to accept circumcision of their
children . Furthermore, in Nyanza province, Kenya
parents also identified father’s circumcision status as
being one of the strongly associated factors with decision
favouring child circumcision . A father’s intention
regarding accepting child circumcision is determined by
personal and social influences. A circumcised man
perceives circumcision as a socially acceptable practice hence
they would easily accept it. A personal evaluation of the
outcome of the procedure will have a direct influence on
their decision to circumcise their male children.
Meanwhile respondents who reported that they were
HIV positive were more willing to accept child
circumcision than those who said they were HIV negative. This is
the expected norm, that HIV positive parents would be
eager to circumcise their male children. This finding is in
conformity with what was found in Kampala, Uganda
where HIV positive parents showed high propensity and
willingness to circumcise their children than HIV negative
parents . There is need to understand the
complications underlying the attitude of HIV negative parents to
refuse circumcision of their male children.
Religion was found to be one of the factors influencing
acceptability of child circumcision. Christians and other
non-Christian religions such as Muslim, Hindu were
more willing to accept their male children to be
circumcised than those who reported to be non-religious. These
findings are consistent with results from other studies
such as in Malawi , where aacceptability was higher in
central and southern districts where MC is practiced by a
minority Muslim group (Yao) while in Kenya church
membership is associated with being circumcised . In
Zambia, there is prevalent perception that circumcision is
linked with Islam while Christians believe that they should
practice circumcision since Jesus was circumcised and the
Bible teaches the practice .
Strengths of our study included a relatively large sample
size and a diverse population of respondents. However,
the use of secondary data limited the scope of this study
to variables within the dataset. Like most demographic
surveys, the absence of qualitative data denies this
analysis an in-depth understanding and explanation of
patterns observed in the quantitative analysis. For instance,
results indicate that HIV negative respondents were less
likely to accept their male children to be circumcised
and only qualitative results would explain this observed
pattern. Despite these limitations, the data provides
important insights into the potential of child safe male
circumcision in Botswana as a strategy to mitigate HIV
infection in later life.
This study identified some individual behavioural factors
influencing decisions of people to accept or reject child
circumcision. For instance, willingness to circumcise
male child was observed to be positively associated with
men’s circumcision status, men’s intention to circumcise,
and respondent’s HIV status. The findings of the study
provide evidence base for the successful implementation
and rolling-out of the broad safe male circumcision
program targeting school going children and the recently
introduced EISMC program. There is need to improve
demand creation strategies for the EISMC program in
order to achieve far-reaching acceptance levels.
1Refer to BAIS IV report online for further
2Religion has been identified as one of the key
determinants of circumcision
BAIS: Botswana AIDS Impact Survey; EISMC: Early infant safe male circumcision;
HIV: Human immune virus; RCTs: Randomised clinical trials; SMC: Safe male
circumcision; TRA: Theory of Reason Action
Availability of data and materials
Data used for this study was derived from the Botswana AIDS Impact Survey
through the permission of the National AIDS Coordinating Agency. Any
enquiries about the dataset can be directed to NACA.
MK conceived and wrote the paper; MB reviewed the literature; MK performed
data analysis. MK & MB reviewed the final draft of the paper. Both authors read
and approved the final manuscript.
MK is a lecturer in Populations Studies and Demography in Department of
Population Studies at University of Botswana. He is currently a PhD Candidate
in Population Studies. MB is a former director in the Sexual and Reproductive
Health Department in the Ministry of Health. He is also a Lecturer in Population
Studies and Demography in Department of Population Studies at University of
The authors declare that they have no competing interests.
Consent for publication
Ethics approval and consent to participate
All the respondents who participated in the Botswana AIDS Impact Survey IV
signed the informed consent form and consented to participate in the study.
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