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Print media reporting of male circumcision for preventing HIV infection in sub-Saharan Africa

Alberta L Wang ^a, William Duke ^b & George P Schmid ^b

a. The University of Texas Medical School at Houston, 6431 Fannin Street, Houston, Texas 77030, United States of America.
b. Department of HIV/AIDS, World Health Organization, Geneva, Switzerland.

Correspondence to Alberta L Wang (e-mail: alberta.l.wang@uth.tmc.edu).

(Submitted: 16 April 2009 – Revised version received: 15 June 2009 – Accepted: 16 June 2009.)

Bulletin of the World Health Organization 2009;87:595-603. doi: 10.2471/BLT.09.066704

Introduction

A consultation in Montreux, Switzerland, held on 28 March 2007 and sponsored by WHO and the Joint United Nations Programme on HIV/AIDS (UNAIDS) resulted in a recommendation that male circumcision be recognized as a strategy for the prevention of heterosexually-acquired HIV infection in men.¹ This was prompted by the results of three randomized controlled trials that showed a protective effect in men of about 60%.^2–4 The potential public health impact of male circumcision is most relevant in sub-Saharan Africa, where the practice is infrequent, HIV infection is hyperendemic and HIV transmission is primarily heterosexual.¹ In 2007, 67% of the 33 million people living with HIV resided in sub-Saharan Africa.⁵ People differ in their views about male circumcision as an acceptable means of preventing HIV infection, its cultural connotations, and how to best implement it as a public health policy.⁶ Nevertheless, in sub-Saharan African cultures where circumcision is not a common practice, 65% of uncircumcised men are willing to be circumcised.⁷

The mass media are the leading sources of information about health issues; it is from news reports that the majority of the public learns about HIV.^8,9 Both planned campaigns and unplanned mass media coverage can have consistent positive effects on health service utilization.¹⁰ For WHO and UNAIDS to effectively assist countries and for countries to effectively utilize the mass media, it is important to understand the national context in which male circumcision deliberations and efforts take place.

We examined the print media coverage of sub-Saharan Africa with four objectives: (i) to provide a structured overview of the types and accuracy of news reports on male circumcision for preventing HIV infection in sub-Saharan Africa, covering the period from 28 March 2007 to 30 June 2008, inclusive; (ii) to identify misconceptions and areas of missing information in the reports; (iii) to identify the environment and public perceptions surrounding male circumcision in sub-Saharan Africa; and (iv) to explore whether the media could be better used to maximize the impact of male circumcision for preventing HIV infection.

Methods

Sample selection

We queried LexisNexis^®, a global media archive with multilingual, same-day news coverage. The sample period began on 28 March 2007, the day the Montreux recommendations were released, and ended on 30 June 2008. A keyword search for “male circumcision” was completed in English, French and Portuguese to capture articles from English-, French- and Portuguese-speaking Africa (Fig. 1). This was followed by a secondary search using country filters to identify smaller publications from sub-Saharan Africa that may have been missed.

Fig. 1. Selection of English-, French- and Portuguese-language print media reports, from 28 March 2007 to 30 June 2008, on male circumcision for preventing HIV infection in men in sub-Saharan Africa

Over 2000 articles were identified. Each article was read and screened for the central theme of male circumcision for HIV prevention in men in sub-Saharan Africa. The criterion that “circumcision” must appear in the title of the article or at least four times in the body was applied to filter out articles that incidentally mentioned male circumcision for HIV prevention. The sample size was further reduced by screening for publication types targeting lay audiences – newspapers, magazines, newswires, or newsletters. Repeated articles (i.e. articles with the same title, content, and author but published in more than one news source) were archived and one was selected at random for further analysis as a unique article.

Data coding

Data collected from the articles were classified into three categories: (i) article information, (ii) content review, and (iii) citations. The article information category included background data: title, date, source, publication type, country of origin, country of subject, word count, main theme, secondary theme(s) and overall perception of male circumcision as positive, negative or neutral. To categorize articles by content, we constructed a set of 21 themes by surveying the articles collected and using input from the WHO–UNAIDS Male Circumcision Working Group. The coding procedure enabled one entry for main theme and up to three entries for secondary theme(s) per article. We identified the major point(s) for each article and defined the main theme as that which represented the overall idea. Themes were coded for unique articles only. We then subjectively graded the tone of each article. Viewpoint, information and style were taken into account, and each article was coded as portraying male circumcision positively, negatively, or neutrally. The content review category recorded if each article mentioned accurately or inaccurately, or failed to mention, 15 key messages from the WHO–UNAIDS Montreux recommendations and a supplementary legal and ethical guidance document, which remained accurate throughout the time of our search (Box 1).^1,11 We checked the accuracy of the unique articles to identify misconceptions and areas of missing information. Demand for male circumcision, price per circumcision, and providers of circumcision services were also identified. The citations category identified the groups, organizations, and authorities involved in male circumcision in sub-Saharan Africa that were the most frequent sources of information for the press. Coding was completed for all unique articles.

The authors performed all coding. Trial runs were completed to resolve technical issues and check for intercoder reliability. Articles that were difficult to code were discussed to establish coding conventions and ensure coding consistency. Upon completion of coding, the authors together performed a final check to eliminate obvious errors and inconsistencies.

Results

Article information

Publication type

The search yielded a total of 412 articles, 219 of which were unique articles and 193 were repeats. Newsletters were the predominant medium; they comprised 70.1% (n = 289) of all articles and 48.9% (n = 107) of those that were unique (Fig. 2).

Fig. 2. Types of print media reports, from 28 March 2007 to 30 June 2008, on male circumcision for preventing HIV infection in men in sub-Saharan Africa

Articles per month

The number of articles per month varied over the 16-month sample period; there were more articles during the earlier half of the period than during the latter half (Fig. 3). The greatest number of articles per day (mean = 12) occurred in the last four days of March 2007. Peaks in publication frequency correlated with increases in press coverage after the release of scientific studies or conferences. Publication frequency fluctuated mainly due to changes in the number of repeat articles, whereas the number of unique articles per month was more stable.

Fig. 3. Number of monthly print media reports, from 28 March 2007 to 30 June 2008, on male circumcision for preventing HIV infection in men in sub-Saharan Africa

Country of origin

All articles originated from 24 countries (Fig. 4). Those published by multinational news agencies were classified by headquarters location. Countries with 10 or more publications in total were the United States of America (n = 274), Uganda (n = 28), South Africa (n = 26), Kenya (n = 14), Canada (n = 11) and the United Kingdom (n = 10). These six countries published 88.1% of the total number of articles. The majority (n = 185) of repeat articles originated from the United States. Of the total number of articles, 90 (21.8%) were published by countries in sub-Saharan Africa.

Fig. 4. Country of origin of all articles (n = 138),^a from 28 March 2007 to 30 June 2008, on male circumcision for preventing HIV infection in men in sub-Saharan Africa

Country of interest

Among all articles, 317 covered sub-Saharan Africa in general and 95 focused on an individual country. Among the unique articles, 130 covered sub-Saharan Africa in general and 89 covered individual countries. These 89 articles focused on 11 of the 48 countries in sub-Saharan Africa; 37 countries had no individual coverage (Fig. 5).

Fig. 5. Coverage of individual countries in sub-Saharan Africa print media reports on male circumcision for preventing HIV infection in men in sub-Saharan Africa

Word count

The word count of the 219 unique articles ranged from 71 to 3071 (mean, 611). Most (86.5%) articles were brief (fewer than 1000 words; mean, 473), and only a minority (13.5%) provided in-depth coverage (mean, 1483 words).

Main and secondary themes

The most frequent main theme (69.4% of articles) was male circumcision as a strategy for preventing HIV infection (n = 152), with a focus on its feasibility, adoption and implementation (Table 1). The second most frequent (5.0% of articles) was randomized controlled trials and scientific studies (n = 11), and the third (4.1% of articles) was a tie between sociocultural acceptability and impact on women (n = 9). Seven topics were never recorded as a main theme: impact on the HIV epidemic, benefits, sexually transmitted infections, neonatal circumcision, ethics, male circumcision methods and male circumcision instruments.

• Table 1. Main and secondary themes surrounding male circumcision in sub-Saharan Africa rendered in the English-, French- and Portuguese-language print media from 28 March 2007 to 30 June 2008 [pdf]
  html, 8kb

The most frequent secondary theme (14.7% of articles) was randomized controlled trials and scientific studies (n = 74). This was followed by impact on the epidemic of HIV infection (12.7%), benefits (12.3%), HIV infection (10.5%), supply and availability (6.0%) and changes in sexual behaviour (6.0%). The least frequent secondary themes were neonatal circumcision (1.0%), ethics (0.8%) and male circumcision methods (0.4%).

Overall portrayal

Among the total of 412 articles, 56.0% were positive, 14.6% were negative, and 29.4% were neutral in their portrayal of male circumcision as a method for preventing HIV infection. Among the 219 unique articles, 58.4% were positive, 8.2% were negative, and 33.3% were neutral. Within the 193 repeat articles, 53.4% were positive, 21.8% were negative, and 24.9% were neutral. Articles with a negative viewpoint had a ratio of repeat articles to unique articles 2.9 times higher than positive articles.

Content review

Misconceptions

There are three common misconceptions regarding the protective effect of male circumcision for preventing HIV infection: (i) that male circumcision is 100% protective; (ii) that risk compensation (i.e. an increase in risky sexual behaviour) will follow male circumcision; (iii) that discussion about male circumcision and about female genital mutilation will be conflated.

Information on male circumcision for preventing HIV infection was accurately reported overall (Table 2). Two of the 15 key messages however, were conveyed inaccurately more often than accurately. They were message 14, that no association has been found between male circumcision and risk compensation, and message 13, that male circumcision and female genital mutilation are very different. Risk compensation did not occur in any of the three randomized controlled trials.^2–4 The topic was mentioned in 24 articles and was portrayed inaccurately in 58.3% of them. Female genital mutilation was rarely mentioned (n = 3), but two articles discussed it in the context of male circumcision without distinguishing between the two. This could lead to public misconception. However, the lack of mention of female genital mutilation in articles about male circumcision may indicate that the press perceives the two as different enough to not warrant being mentioned together.

• Table 2. Coverage and accuracy of key messages on male circumcision for preventing HIV infection in men in sub-Saharan Africa, as found in unique print media articles (n = 219) from 28 March 2007 to 30 June 2008 [pdf]
  html, 10kb

Missing information

While 13 key messages were infrequently mentioned, two key messages were conveyed quite frequently. They were message 4, that male circumcision provides only partial protection against HIV (84.9% of articles), and message 5, that male circumcision is additional to, and not a substitute for, other proven methods for preventing HIV infection (54.3% of articles).

Another important point that lacked press coverage was the technical definition of male circumcision. Traditional male circumcision varies in the amount of foreskin removed, and it is common for men to confuse its ritual practice with medical circumcision. In one study, 45% of men who stated they were circumcised were not upon medical examination.¹² The press reported the concern that “40% to 50% of circumcisions in Southern Africa were only ‘ritual’ or ‘partial’ circumcisions”, in which “as little as 1–2 cm is removed compared with the 4 cm removed during most medical circumcisions”.^13,14

Demand for male circumcision

Six articles from three countries discussed the demand for male circumcision, and all of them focused on its increased demand.^15–20 Only Swaziland was reported as having plans for a targeted number of circumcisions as part of a campaign for the prevention of HIV infection.¹⁶

Price of male circumcision

The price per circumcision was reported by 26 articles. It ranged from 5.25–199 United States dollars (US$) (mean: US$ 60.34). (Prices quoted in local currency were converted to US$ using the Yahoo finance currency converter (http://finance.yahoo.com/currency?u) at the time of coding between 17 July and 4 August 2008.) The mean price reasonably reflects the price of male circumcision in public health programmes, which ranges from US$ 30–60.²¹

Providers of services

Twenty articles reported the provider of male circumcision services according to private, public or traditional sectors, and 6 articles reported more than one sector as a provider of services. The private sector was mentioned 6 times (22.2% of the articles), the public sector 18 times (66.7%), and the traditional sector three times (11.1%).

Citations

Eight groups, organizations and authorities involved in male circumcision in sub-Saharan Africa were cited in 10.0% of the articles or more (number of citations ≥ 22), with WHO (n = 134) and UNAIDS (n = 107) cited first and second most frequently (Fig. 6).

Fig. 6. Groups, organizations and authorities cited at least 22 times (10% of unique articles) in print media reports, from 28 March 2007 to 30 June 2008, on male circumcision for preventing HIV infection in men in sub-Saharan Africa

Article perception

In March 2007, print articles on male circumcision for preventing HIV infection were strongly positive. They portrayed male circumcision as “a significant step forward in HIV prevention” and pointed out its potential to prevent “5.7 million new HIV infections and 3 million deaths over 20 years” in sub-Saharan Africa.^22,23 They also stated it could offer an opportunity “to engage men in discussions about safer sex” and to integrate “gender-transformative approaches to HIV prevention”.¹⁵ In September 2007, the print media shifted its coverage from male circumcision as a strategy for preventing HIV infection to the implementation of mass male circumcision programmes.^16,24,25 Reports on the benefits of male circumcision broadened from the prevention of HIV infection to a reduction in genital herpes and genitourinary infections in men.^26,27 Reports on male circumcision’s indirect positive effect on women also began to appear.^15,28

In articles that expressed a negative viewpoint, risk compensation was the most prominent negative theme.²⁵ Several articles questioned men’s motives in seeking circumcision. Their statements included that “avoiding the sexual dissatisfactions of condom use and the desire to have more partners are likely to be significant motivations” and that HIV+ men would seek “circumcision because it leaves a physical mark that would remove the stigma of being infected”.^29,26 In September 2007, “physician shortages, lack of medical regulations and low education levels” were reported as barriers to the early implementation of mass male circumcision programmes.³⁰ For example, Namibia’s health infrastructure was reported as “not yet equipped to handle providing the procedure on a large scale,” and Uganda’s Ministry of Health was portrayed as needing “to develop a policy, plan and cost resources without hurting the existing health programs”.^24,31

From a cultural and ethnic standpoint, traditional leaders criticized male circumcision as a “western attempt to force foreign values and solutions on Africans”.¹⁷ Kenya’s Luo Council of Elders, speaking for a tribe that does not traditionally circumcise, voiced concerns about male circumcision and “the erosion of their culture on the basis of controversial studies”.³² However, the Elders indicated that men who chose to become circumcised would not be disowned by the Luo community.³² Other anti-circumcision advocates argued that the circumcision trials had a faulty design because early termination “has the effect of overestimating any benefits,” and they questioned “if these results justify the use of limited health care funds”.³³

Civil society

Civil society’s diversity of opinions on male circumcision reflected its diverse composition of actors. With few exceptions, donors, academia, professional medical associations and HIV advocacy groups supported male circumcision for the prevention of HIV infection. Major donors like the Bill and Melinda Gates Foundation and the United States President’s Emergency Plan for AIDS Relief were willing to fund male circumcision programmes,¹⁷ and non-profit entities wanted male circumcision to receive the same kind of attention as antiretroviral therapy.³⁴ The Southern African HIV Clinicians Society in Namibia defended male circumcision as “not new to Africa or to Namibian society [nor] an attempt at neo-colonialism”,³⁵ and the Treatment Action Campaign, an HIV advocacy group in South Africa, “called for free circumcision for men” and added that “the state has a responsibility to ensure that circumcisions [are] performed safely and in accordance with the relevant national and provincial laws”.³⁶

A positive view also prevailed among faith-based organizations. Both Jews and Muslims practice circumcision for religious reasons, and their organizations have assisted in meeting the increasing demand for it.³⁷ Social advocates in Kenya urged parents to have their sons circumcised in medical rather than traditional settings, and in response, Christian hospital missions began “to offer safe, medical circumcisions in their communities”.³⁰

Advocates of both gay rights and women’s health, however, cautioned against unthinkingly supporting male circumcision for the prevention of HIV infection. Homosexuality is little discussed in Africa and few articles mentioned it, although the lack of demonstrated protection for anal sex was one key message (message 12). Gay rights advocates in Senegal warned about the fact that the hidden nature of homosexuality places many people at risk.³⁸ Women’s groups were “wary of an initiative that could give men one more excuse not to use condoms” and hesitant to support “an intervention [that] in itself will do nothing to change the harmful behaviour patterns – unprotected sex, coercion and violence – that are putting people, especially women, at risk”.^15,39 Conversely, women were also presented as a gatekeeper population that can make sure men become circumcised by refusing to have sex with them until they do.¹⁵

Discussion

We performed a review of the types, content and accuracy of print media reports on male circumcision for the prevention of HIV infection among men in sub-Saharan Africa. We also identified misconceptions, areas of missing information, sources of information used by the media, and positive and negative themes. The majority (56.0%) of the articles examined were positive in their protrayal, an indication that the environment is receptive to male circumcision. Nevertheless, the fact that negative articles had an overall repeat rate 2.9 times higher than positive articles suggests an inclination to publish anti-circumcision articles or articles with a controversial viewpoint.

The mass media are in a powerful position not only to present prevailing opinion, but also to influence and lead it. The majority of the public derives its knowledge about HIV from the media, and by reporting current events, the press is able to generate and disseminate public opinion.^8,9 While the mass media generally fails to provide the public with complete and accurate information on new medical interventions, studies of HIV-specific communication have shown that in this area, they have accurately directed the public towards acquiring new medical knowledge, increased its knowledge of HIV transmission, and reduced high-risk sexual behaviour.^40–42 To help the media convey messages appropriately, public health authorities must assist them in understanding the issues that are important. When the press translates the language of research reports to everyday language, some information is predictably lost due to the absence of comparable lay terminology.⁴³ In the case of male circumcision, the relatively small proportion of inaccuracies may be evidence that the media, guided by the public health authorities, succeeded in portraying issues in easily understandable terms.

On the other hand, the frequent omission of important messages concerning male circumcision in the media may indicate that public health authorities must work harder to get such messages disseminated. Fluctuations in the amount of coverage given to male circumcision indicate the need for calculated timing and sequencing of messages to maintain adequate publicity of a male circumcision programme. While media articles can contain only a certain number of important points, a communication strategy to convey such points sequentially could both increase the frequency of media messages and the coverage of most messages over time. This has not occurred, perhaps because male circumcision scale-up programmes are not yet developed enough.

Lastly, media reports on male circumcision are few in the part of the world where its adoption could most markedly help curb a devastating epidemic. Although this should be of concern to public health authorities, the latter must be careful not to create demand that will go unmet until health care systems can deliver circumcision to the men who seek it.

When the mass media are scientifically aware, they can provide useful information to public health officials and even prod reluctant officials to make decisions of national importance. Whatever those decisions, aware and independent media report them in a more transparent and timely fashion.⁴⁴ Over the next 20 years, male circumcision could prevent 6 million new infections and 3 million deaths in sub-Saharan Africa.⁴⁵ The mass media, if appropriately informed, can greatly assist in the adoption and promotion of male circumcision programmes.

Limitations

Due to time limitations, the authors searched only one media archive, LexisNexis^®. Factiva, another media archive, was also available, but an initial search yielded fewer results than LexisNexis^®. The latter was intrinsically limited by having less coverage of smaller, local African news sources. It also had an English language bias and limited our search for articles in French and Portuguese. However, at the time of sample collection, LexisNexis^® offered broader global coverage than other media archives. The sample period ended in June 2008 to allow completion of data collection before the internship of the lead author ended. The results, however, are almost certainly applicable in June 2009, as there have been no major scientific announcements concerning male circumcision since then. ■

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Acknowledgements

The authors thank Gilbert Padey and Valeri Abramov for their help in identifying and gathering print media articles, Andy Seale for advice early in the study design, and the WHO–UNAIDS Male Circumcision Working Group (Bruce Dick, Kim Dickson, Isabelle DeZoysa, Tim Farley, Cate Hankins and Nic Lohse) for comments and review throughout this project.

Competing interests: None declared.

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