Enhancers and barriers to uptake of male circumcision services in Northern Uganda: a qualitative study.

Uganda adopted voluntary medical male circumcision (VMMC) in 2010, but uptake remains disproportionately low in the Northern region despite implementing several demand creation strategies. This study explored the socio-cultural and structural enhancers and barriers to uptake of VMMC services in Gulu, a district in Northern Uganda where uptake is lowest. In September 2016, we conducted 19 focus group discussions, 9 in-depth interviews, and 11 key informant interviews with 149 total participants. Data were collected and analyzed thematically using both inductive and deductive approaches, then framed in four levels of the social ecological model. Enhancers included adequate knowledge about VMMC services, being young and single, partner involvement, peer influence, perceived increased libido after circumcision, and availability of free and high-quality VMMC services. Barriers included sexual abstinence during wound healing, penile appearance after circumcision, religion, culture, and misconceptions. Optimizing enhancers and addressing barriers could increase VMMC service uptake in northern Uganda.

VMMC clients' perception of increased risk of HIV infection, circumcision preferred choice of method, providers' socio-demographics and mode of service delivery.

INTRODUCTION: Voluntary medical male circumcision (VMMC) is a scientifically proven HIV prevention intervention. Uganda, like many countries has been implementing VMMC for over 10 years but uptake is still low especially in northern Uganda. To attain 80% needed for public health impact, scale-up was recommended with many innovations implemented with sub-optimal results. This study therefore wanted to find out some of the correlates of VMMC uptake in Gulu district, northern Uganda. METHODS: Two studies were conducted separately but data was analyzed for this study. For the quantitative study, proportions and frequencies were used to measure perception of increased risk of HIV infection using age, gender, occupation, marital and circumcision status. Qualitative study provided data from FGDs, IDIs and KIIs were first transcribed in Acholi and then translated in English. Transcripts were uploaded in MAXDQA software for data management. A code book for emerging themes was developed. RESULTS: A total of 548 respondents were interviewed for the quantitative study, where two thirds (66%) of the participants perceived themselves to be at increased risk of HIV infection. For the qualitative study, 149 participants from 19 FGDs, 11 KIIs and 9 IDIs were interviewed. Data were analyzed thematically using both inductive and deductive approaches. Devices were preferred to conventional surgery while mobile services were preferred to static services. However, there were divergent views regarding circumcision service providers' socio-demographics and these were influenced mainly by age, level of education and location. CONCLUSION: People in Northern Uganda perceived themselves to be at an increased risk of HIV infection. They preferred devices to conventional surgery, mobile services to static services but had varying views about the socio-demographics of the service providers.