Introduction
Botswana has been hard hit by HIV with an adult prevalence rate at around 19.03% (Statistics
Botswana, 2013a). Over the years many interventions have been put in place to curb the scourge
without any meaningful success. In response to three randomized controlled trials which found that
male circumcision reduced the risk of getting an HIV infection by up to 60%, in 2008 Botswana
introduced the Botswana National Safe Male Circumcision (BNSMC) Strategy to aggressively scale up
male circumcision in Botswana (Ministry of Health, 2008). However, when the strategy, was
evaluated, male circumcision had only increased by a mere 13.3% in four years, instead of the
anticipated 80% (Ministry of Health, 2008, Statistics Botswana, 2013a). The aim of this study
therefore was to explore adult male perceptions of the implementation of the BNSMC strategy in
Gaborone, Botswana, with an aim to inform future campaigns.
Methods
An exploratory qualitative cross-sectional study design was used and data were collected through Indepth
Interviews (IDIs) and Focus Group Discussions (FGDs). A total of 22 (circumcised and
uncircumcised) men between the ages of 18 to 49 residing in and around Gaborone, participated in
IDIs (10) or FGDs (2). Participants were recruited through purposive and snowball sampling. All
interviews were audio recorded and transcribed. A combination of deductive and inductive
thematic analysis of the transcripts was conducted.
Results
What emerged strongly is the role played by society, friends and relatives in influencing the
individual to circumcise, beyond formal campaign messages. In particular peer influence seemed to
have played a crucial role. The study has identified multiple types of fear as key barriers to SMC,
including fear of erectile dysfunction, fear of pain, fear of HIV testing and other fears related to
adverse effects such excessive bleeding and complications with the procedure. Participants also
expressed lack of trust in the health system which they attributed to incidents which occur at health
facilities.
Study participants did not think that the TV and radio broadcasters used for the campaign were
effective. Although most participants felt that edutainment was relatively effective because it
engaged people at an emotional level and is liked by the youth, nobody describe it as influencing
their own decision and some discredited using music because people do not listen to the embedded
iv
messages. On the other hand, the use of a musician celebrity to promote SMC reportedly influenced
some to circumcise.
Conclusions
Data from this study has shown that intended SMC key messages had limited reach and were
insufficient on their own to increase SMC. Building on the use of celebrities, more could be done in
the future to include other influential people, such as girlfriends and peers. Formative research is
indicated to identify more appropriate mass media broadcasters for intended audiences and to
explore additional channels. The content of messages must also be reviewed in light of what
audiences say influences their decisions. In particular, the fear of testing and lack of trust in the
health care services may have negatively affected the SMC up-take outcome more than
implementers think. Going forward, evidence based planning of future interventions could address
some of the identified gaps through the use of social and behavior change communication theories
as the basis for program design, implementation and evaluation.