MEASURES FOR ENSURING TRUSTWORTHINESS

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CHAPTER 3 DISCUSSION OF RESEARCH FINDINGS, WITH SPECIFIC LITERATURE CONTROL

INTRODUCTION

The preceding chapter presented the methodology applied in this study. The purpose of this chapter is to present the findings in the form of themes, categories and subcategories covering the perceptions of men regarding the use of male circumcision in the prevention of HIV infection in Kweneng East District, Botswana. The findings were achieved using Tesch’s (1990) analytical process, as cited in Creswell (2009:186). During the analysis process, the researcher coded the data manually to develop themes, categories, and subcategories. Where it was deemed necessary, the researcher sorted the data into some sort of order, by developing sub-codes from the main codes. The literature was reviewed deductively in the form of a literature control with regard to the themes that were identified from the data.
Therefore, the results of this study are discussed in form of direct quotes and edited format that reveal the perception of men regarding the use of male circumcision and applied within the assumptions of the Health Belief Model.

THE EXPERIENCE OF FIELDWORK BY THE RESEARCHER

The target population in this study was men of the Bakwena tribe of Kweneng East District, who, according to their culture, do not practise male circumcision. The district has Molepolole, Mogoditshane, Thamaga, and Gabane as the largest villages among other smaller villages. However, despite the population of the district being predominantly Bakwena, when he was in the field the researcher discovered that the district is also inhabited by other ethnic groups (although in the minority), such as the Bakgatla and Balete tribes. These tribes occupy the villages of Thamaga and Gabane, respectively, and practise male circumcision as part of their culture. In view of this fact, the researcher decided to concentrate on villages in Kweneng East that are predominantly inhabited by members of the Bakwena tribe, rather than all villages in Kweneng East, to avoid bias associated with the data gathered. For this reason, Molepolole and Lentsweletau villages were used to conduct the study. The researcher established rapport with the traditional leaders and participants and gained their support. Most of the men were very keen to participate in the interview, while others did not show interest in the interviews. Such subjects were not included among the participants of the study. Overall, the researcher enjoyed overwhelming support from all stakeholders for the entire five-month period of data gathering.

REALISATION OF DATA

The demographic description given below is of the characteristics of the sample participants used in the study. Six FGDs and five in-depth individual interviews were conducted. The total sample size consisted of 38 participants in age groups 18-29 years (n=20), 30-39 years (n=8), and 40-49 years (n=10). The age range of 18-49 years used in the study was in accordance with the findings of central statistics as outlined in Botswana HIV/AIDS Impact Survey III (2009:4), which states that HIV prevalence increases sharply with age, peaking between ages 30 and 45, and gradually declining with age. This is the age range with the highest rate of new HIV infections, with the 45-49-year age group having the highest incidence rate, at 7.3%, and the 15-19-year age group having the lowest incidence rate, with a rate of 0.7%.
Of the participants, the majority (n=22) had obtained secondary school education, while only a few participants (n=3) had no formal education. Establishing participants’ level of education enabled the researcher to gauge their level of understanding of the use of male circumcision in the prevention of HIV infection.
Regarding the marital status of the participants, only one participant (n=1) was married, while the rest (n=37) were single. Most of the participants, however, indicated that they had a sexual partner. This information was essential in order to understand the sexual patterns of the men in Kweneng East District, and the implications of these sexual patterns for the prevalence of infection with HIV and other sexually transmitted diseases. This is based on the understanding as stated by central statistics, in the Botswana HIV/AIDS Impact Survey III (2009:12), that males of all marital states except for “never married” have a higher prevalence rate than women have. Of the participants, all but one were single, but they had between one and three sexual partners each. With regard to the use of condoms, the majority of the participants (n=31) indicated that they always used condoms during sexual intercourse.
Of the participants, the majority (n=37) expressed awareness of the HIV prevention strategy of safe male circumcision (SMC), with radio (n=21) and television (n=8) cited as the main sources of information from which they had heard about the procedure. Despite their awareness of the strategy of male circumcision, only a few of the participants (n=12) were circumcised, with the majority (n=26) indicating that they were not circumcised. In this study it was essential to determine the effectiveness of the mode of dissemination of information commonly used to raise awareness about male circumcision and the response of the men in Kweneng East to the strategy. The tables below present the characteristics of the participants according to the age groups used to collect the data.

THEMES IDENTIFIED DURING DATA COLLECTION AND ANALYSIS

In this section the researcher presents the research findings in the form of themes, categories, and subcategories. Four themes were identified from the data. The discussion of research findings is authenticated by cases of verbatim quotes made by the participants and used as empirical data. A summary of the discussion of the themes, categories, and subcategories is presented in Table 3.1 below.

Theme 1: Perceived effects of participants’ value systems on the use of male circumcision among the Bakwena tribe in Kweneng East, Botswana

Individuals have different value systems that govern their existence and dictate how they operate. These systems act as basement membranes upon which behavioural traits of a particular individual, family or community are brewed. They are the conduits for nurturing individuals and basis for measurement of behavioural acts.
According to Gibson and Mitchell (1990:206-208) values provide an integral reference for what people consider to be important and desirable in life. Values generate behaviour and help solve common human problems for survival and they provide the answers as to why people do what they do and chose to do them. The understanding of the parameters within the value systems of a particularised individual, family or community pre-sets the entry points for knowledge derivation about what catalyses certain behaviours enveloped within a certain worldview. In this study the value systems have been categorised into those related to the need for consultations, culture and religion.

Category 1.1: Value systems associated with stakeholder consultation in the community

Consultation is a value that involves a two-way exchange of information. It is seen as an opportunity to add value to stakeholders’ decision-making processes. Consultation means to appropriately inform stakeholders, inviting and considering responses from them before a decision is made. The opinions of stakeholders should not be assumed. Sufficient action must be taken to secure stakeholders’ responses and to give their views proper attention (Comcare 2009:18). Consultation requires more than a mere exchange of information. Affected stakeholders must be able to contribute to the decision-making process, not only in appearance, but in fact. When done well, wide stakeholder consultation and participation in programme design and implementation leads to mutual benefits that encourage local ownership of development of activities (Griffiths, Maggs, & George 2007:10).
The theme of the value system of consultation is discussed according to the subcategories identified below.
Subcategory 1.1.1: Lack of consultation with men at the inception of male circumcision According to Engender Health (2005-2012:4), stakeholder engagement is the process of involving those who have a role in or are interested in and/or affected by the activities and goals of a programme. This engagement can span a continuum of activities, including dialogue and consultation, collaboration in identifying problems and solutions, partnering in implementation and evaluation, and capacity building and empowerment.
This is an inherent characteristic of the entire process that requires partnerships to implement the project or the programme. For this reason, it is important to identify stakeholders that can play the role of influencing in order to achieve the goals set. In addition to the need to identify major players in the implementation of any project is the need for engagement in the form of consultation with stakeholders, so as to promote a spirit of ownership and to identify value chains that are compatible with the prevailing value system framework. This is from the understanding that where there is a spirit of ownership, there is potential to influence (UNAIDS 2008:6-7).
In this study, most of the participants lamented the lack of consultation with men in Kweneng East from the inception of male circumcision programmes. The following are some of the views stated by the participants:
“Many people [men] have not done it [undergone circumcision], because from the initial stages we were not consulted about the programme and told about the advantages of it.”
“Many people [men] do not know the advantages of the programme because of lack of consultation […] consultation should have been done first.”
“Government authorities should have discussed the whole issue with the nation, so that people get to know the advantages of the programme.”
“Government did not do thorough consultation over this issue […] it only considered the dangers of the foreskin.”
According to the WHO (2007:6), in a document about the scaling up of male circumcision, it is cited that a wide range of sociocultural issues are to be considered in the context of introducing or expanding the availability of male circumcision services, which include broad community engagements in the form of consultations (WHO & UNAIDS 2007a:6).
Subcategory 1.1.2: Lack of involvement of the village elders during the service delivery process
The lack of involvement of the village elders, who could have an influence on men of reproductive age during service delivery, was identified as another obstacle. This was revealed by the participants, who, when asked what they thought the government authorities should have done, considering that men were not properly consulted before implementation commenced, responded as follows:
“They should have started at the top [with the village elders] in the community, until it reaches the family […] because if you deal with the elders of the villages, they further go to discuss with the people in the village […] the village elders later take the information to the kgotlas [wards] […] from there the message will be able to reach the families, and finally individuals.”
“Right now they are not even involving the elders of the village!”
“Even the health workers are not involving parents or even to reach them to give information so that they can support the young ones who intend to go for circumcision […] because if the health workers interact with the elders, then we shall be encouraged to do it.”
According to the literature, participation and consultation with stakeholders at all levels of the implementation process of a community health programme enhances the value of the programme and increases people’s ownership, reduces alienation, and mitigates the element of surprise among those involved. It helps to create an understanding of why something is happening and how the change might take place (WHO 2009:7). The WHO’s (2009:34) situation analysis toolkit for male circumcision indicates that conducting stakeholder meetings facilitates understanding, which, in turn, facilitates participation in efforts to increase the rate of male circumcision and increase ownership of the programme as a whole.
Subcategory 1.1.3: Involvement of women in male circumcision
When the participants were asked whether women are involved in and supportive of male circumcision among men, most of the men had this to say:
“Female partners should be consulted as well, as this will also benefit them […] because they play a role by encouraging us and giving moral support. But, in the final analysis, it is one’s choice either to do it or not.”
“But how can women support us if you do not involve elders of the villages in order for the women to understand and support us?”
“The good thing is that we do not think there are some female partners who discourage their men […] if there are some, then they are very few […] the government authorities did not just consult and involve people!”
“The right thing to do is to discuss with the female partners and arrive at an agreement. They may also end up encouraging us to go for circumcision when they understand.”
As regards the scaling up of male circumcision programmes, the World Health Organization in an information package on male circumcision, asserts that all communication strategies and outreach efforts need to engage a range of stakeholders, including women, in the development of key messages to address male circumcision (UNAIDS [Sa]:3).
Under this theme, the findings point to the importance of the aspect of engagement in the form of consultation at all levels within a continuum of service delivery. This is also essential for successful implementation of safe male circumcision. The identification of stakeholders at every level of activity and their involvement sets the ground for support to the providers of the service and the consumers. The views presented above validate the importance of engagement with individuals that are directly or indirectly affected by male circumcision. The implication is that the Bakwena men of Kweneng East feel no compulsion to utilise male circumcision due to lack of consultation and engagement with government authorities and service providers, right from the inception of the programme. This argument is based on the need for service providers to understand the value systems that govern their consumers.

Category 1.2: Value systems associated with cultural beliefs

The concepts of self and world view that an individual employs in mental processing are embedded in beliefs and values; and the results are measured basing on how they influence people’s capabilities to exercise control over events that affect their lives (Byrne 1995:156-157). These cultural belief systems develop from shared experiences of a group in society and are expressed symbolically (Andrews & Boyle 2003:74). The category of cultural influence on the perception of male circumcision was discussed within the sub-categories stated below.
Subcategory 1.2.1: Lack of openness between parents and children on sexual matters
In the interviews with the Bakwena men, a salient issue that emerged was the lack of openness related to the use of male circumcision for the prevention of HIV infection. For example, when the men were asked how often discussions take place between parents and children (young people of reproductive age) on this subject, the following are some of the views that were articulated:
“It is a taboo for parents to discuss sexual issues with us young people […] they don’t interact with us regarding sexual issues. That is how it is.”
“But because of the taboos on sexual discussions we cannot share or be open with our parents.”
“It is a cultural norm for our parents not to discuss certain issues with us […] and it is not a sign of respect to ask elderly people about these issues.”
These views correspond to the findings in a study on male circumcision conducted in Botswana by Kebaabetswe, Lockman, Mogwe, Mandevu, Thior, Exxex and Shapiro (2003:14), where a significant number of respondents cited cultural reasons as the reason for not circumcising their male child. Therefore, this predisposition by the parents or guardians, as well as the taboo in the Bakwena culture to openly discuss sexual matters makes it difficult for young people to voluntarily engage in male circumcision.
Subcategory 1.2.2: Lack of traditional leadership support
The participants also communicated that they experienced difficulties related to traditional leadership support. When asked about how much support they receive from the traditional leadership in the utilisation of male circumcision, these were the responses of some of the participants:
“It is difficult to support us […] like we said earlier that it is a taboo […] so they cannot say much …] even if they talk about it, they just tend to limit the extent of discussion. They can’t get deeper […] maybe for only a short period of time, and quickly change the subject.”
“Within the context of our culture here in Kweneng, it is very hard for people [men] just to go back to male circumcision […] it needs people to sit down […] they told us to stop it initially, but now they say it should come back. It is contradictory.”
“There are conflicts in our culture […] we tend to copy what Westerners are doing, without a good understanding […] we seem not to be independent.”
The factors embedded in the cultural value system of the Bakwena, as expressed above, clearly show how difficult it is for Bakwena men of reproductive age to take decisions on male circumcision. This conflict has impacted on the openness and support needed to motivate the governed (young men) and the self-governed (the elders) in decisions regarding the use of male circumcision.

Category 1.3: Value systems associated with religious beliefs

Obstacles related to religious beliefs were also cited in the interviews conducted. The responses reflected the impact that religious beliefs have on the use of male circumcision among men in Kweneng East District. In this study, the views of some of the participants show that the religious values of men of reproductive age have had a negative effect on the way they perceive the use of male circumcision in the prevention of HIV infection. Below are some of the sentiments expressed:
“Our culture here in Kweneng is that we are religious, and another thing is the impact of [our] religion [Christianity], as it is against circumcision.”
“There is conflict between culture and religion […] religion may be a problem, since we go to different churches.”
“When it comes to the Bible, circumcision is an old practice in the Old Testament. As such, going back to it will be like going back to the old practice.”
“The Bible teaches us not to please the flesh. Therefore, we should live as per God’s expectation and stay away from earthly activities […] there is no way I can advise people to do male circumcision while I know that it is ungodly.”
According to reports in the literature, religion has been found to influence how people regard male circumcision. For example, in a study conducted among a non-circumcising society in rural western Kenya, the participants expressed that many people look up to their religious leaders for direction, and most people trust the religious leaders (Francisco 2011:7). Andrews and Boyle (2003:433) state that religious beliefs could influence a client’s explanation of a disease or a condition and the causes thereof, perceptions of the severity of the disease, and the choices made. The views on religious beliefs were looked at from two different perspectives.
Subcategory 1.3.1: Those in opposition to the position adopted by government authorities to implement male circumcision
When asked whether they believe in what the government is doing regarding male circumcision, these were the responses of some of the participants:
“That now suggests that the government is contradicting itself. Why preach circumcision and use of condoms at the same time? We should be faithful and stay away from fleshly activities […] Again it will not make sense to circumcise after marriage, as one has to remain faithful to his wife […] instead the government should finance pastors to preach the Word of God and do away with circumcision.”
“It is not proper to do it, as this is an earthly practice. It is against spiritual life. Jesus Christ came for these things, and all problems were solved […] That is why at the end he said ‘It is finished’.”
“Whether people are dying or not it is difficult to preach circumcision in church.”
When the informants were asked “Don’t you think the government is just reacting to the situation of HIV prevalence in the country, especially that people are dying, including those in churches?” different views were expressed. The following is one of the views that was articulated:
“The government is committing a sin by encouraging people to use condoms and circumcision.”
The above sentiments correspond to the findings of a study conducted by Rain-Taljaard (2003:3) in a town in South Africa with a high HIV infection rate and the potential for an intervention based on male circumcision. The participants communicated that they regarded male circumcision as a pagan practice, with many Christian churches opposing the practice and seeing it as a pagan tradition.
Subcategory 1.3.2: Those in support of the position adopted by government authorities to implement male circumcision
However, other participants had a different view regarding this issue, as they expressed appreciation at what the government is doing. These are some of the responses that were articulated:
“Whether you are a believer or not, let us do what the government has asked us to do, otherwise we will perish, because the government is fighting a good cause. Some of us are alive because of ARVs [an intervention implemented by the government]. So let the government continue with this programme […] it is either believers take it or not. The government is doing things right. Take it or leave it.”
“The government has taken a right step […] my children and nephews have done it, and my partner also encourages me to do it.”
“It is upon an individual to choose between good and evil […] God gave us that choice.”
The views expressed by the participants pertaining to religious beliefs and the use of male circumcision clearly indicate that the values embodied in religion do dictate people’s perceptions. The wide spectrum of views expressed suggests that there is much diversity among the religious groups. It also indicates that the religious values that the various religious groups impart on their members have a direct effect on how men view the use of male circumcision as a strategy in the prevention of HIV infection. For this reason, religion can either promote or hinder the use of male circumcision among men. From the above it would be appropriate to conclude that the religious beliefs of men have contributed to the low utilisation of male circumcision in Kweneng District.
Under the theme of value systems, it can be said that culture and religion have had an effect on how men perceive the use of male circumcision in Kweneng East District of Botswana. The lack of openness among parents and children regarding sexual matters and the lack of traditional leadership support in the form of motivation were some of the obstacles identified. Furthermore, the religious beliefs of the people also do not support the use of male circumcision, as it is regarded as an inappropriate practice for Christians to engage in.

Theme 2: Perceptions of the source and provision of information

Health communication is seen to have relevance for virtually every aspect of health and well-being, including disease prevention, health promotion, and quality of life. When conducting communication, it is important to think carefully about the channel through which the intervention message will be disseminated, who the message is being addressed to, how the target audience will respond, and the features of messages that have the greatest impact (Rimal & Lapinski 2009:2). The aim of information, education and communication (IEC) in health programmes is to increase awareness, change attitudes, and bring about a change in specific behaviours. The purpose is to assist people to live healthy lives by increasing people’s awareness, which will enable them to take appropriate action to improve their health and make healthy choices (Zimbabwe National Family Council 1998:4). To determine the extent to which information, education and communication (IEC) can be developed, knowledge of the value system for a particular ethnic group is critical. This sets the basis for analysis of every adopted channel of communication in terms of appropriateness.
Under this theme, categories pertaining to the perceptions regarding the conduits used for acquisition of information and their effects on male circumcision utilisation in the Kweneng East District of Botswana were identified.

TABLE OF CONTENTS
CHAPTER 1 OVERVIEW OF THE STUDY
1.1 INTRODUCTION
1.2 BACKGROUND TO THE PROBLEM
1.3 STATEMENT OF THE PROBLEM
1.4 RESEARCH QUESTIONS
1.5 AIM AND OBJECTIVES OF THE STUDY
1.6 PARADIGMATIC PERSPECTIVE OF THE RESEARCH
1.7 RESEARCH DESIGN
1.8 RESEARCH METHODS
1.9 MEASURES FOR ENSURING TRUSTWORTHINESS
1.10 ETHICAL CONSIDERATIONS
1.11 SCOPE OF THE STUDY
1.12 STRUCTURE OF THE THESIS
1.13 SUMMARY
CHAPTER 2 RESEARCH DESIGN AND METHODS
2.1 INTRODUCTION
2.2 PURPOSE OF THE STUDY
2.3 OBJECTIVES AND STEPS OF THEORY GENERATION
2.4 A THEORY-GENERATING RESEARCH DESIGN
2.5 RESEARCH METHODS
2.6 REASONING STRATEGIES
2.7 MEASURES FOR ENSURING TRUSTWORTHINESS
2.8 ETHICAL CONSIDERATIONS DURING DATA GATHERING
2.9 SUMMARY
CHAPTER 3 DISCUSSION OF RESEARCH FINDINGS, WITH SPECIFIC LITERATURE CONTROL
3.1 INTRODUCTION
3.2 THE EXPERIENCE OF FIELDWORK BY THE RESEARCHER
3.4 THEMES IDENTIFIED DURING DATA COLLECTION AND ANALYSIS
3.5 APPLICATION OF THE HEALTH BELIEF MODEL TO THE FINDINGS OF THIS STUDY
3.6 SUMMARY
CHAPTER 4 DEVELOPMENT OF A CULTURE-CONGRUENT MALE CIRCUMCISION MODEL FOR HIV PREVENTION
4.1 INTRODUCTION
4.2 CONCEPT IDENTIFICATION
4.3 CONCEPT ANALYSIS
4.4 A CULTURE-CONGRUENT MALE CIRCUMCISION DEVELOPMENT PROCESS
4.5 SUMMARY
CHAPTER 5 DESCRIPTION OF A CULTURE-CONGRUENT MALE CIRCUMCISION MODEL FOR HIV INFECTION PREVENTION
5.1 INTRODUCTION
5.2 AN OVERVIEW OF THE MODEL
5.3 PURPOSE
5.4 THE ASSUMPTIONS OF THE MODEL
5.5 THE CONTEXT OF THE MODEL
5.6 THE STRUCTURE OF THE MODEL
5.7 GUIDELINES FOR OPERATIONALISATION OF THE MODEL FOR PROVISION OF CULTURE-CONGRUENT MALE CIRCUMCISION SERVICES
5.8 EVALUATION OF THE MODEL, AND GUIDELINES FOR CULTURE-CONGRUENT MALE CIRCUMCISION
5.9 SUMMARY
CHAPTER 6 CONCLUSIONS, LIMITATIONS, AND RECOMMENDATIONS
6.1 INTRODUCTION
6.2 LIMITATIONS OF THE STUDY
6.4 CONCLUSION
LIST OF REFERENCES
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