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Background: The influence of socio-economic determinants on choice of infant male circumcision provider is not known in areas with high population coverage such as rural Africa. The overall aim of this study was to determine the key socio-economic factors which influence the choice of infant male circumcision provider in rural Ghana. Methods: The study investigated the effect of family income, distance to health facility, and cost of the circumcision on choice of infant male circumcision provider in rural Ghana. Data from 2847 circumcised infant males aged under 12 weeks and their families were analysed in a population-based cross-sectional study conducted from May to December 2012 in rural Ghana. Multivariable logistic regression models were adjusted for income status, distance to health facility, cost of circumcision, religion, maternal education, and maternal age. Results: Infants from the lowest income households (325, 84.0%) were more likely to receive circumcision from an informal provider compared to infants from the highest income households (260, 42.4%) even after adjusting for religious affiliation (adjusted odds ratio [aOR] 4.42, 95% CI 3.12-6.27 p = <0.001). There appeared to be a dose response with increasing risk of receiving a circumcision from an informal provider as distance to a health facility increased (aOR 1.25, 95 CI 1.30-1.38 P = <0.001). Only 9.0% (34) of families in the lowest socio-economic quintile received free circumcision services compared to 27.9% (171) of the highest income families. Conclusions: The Government of Ghana and Non-Government Organisations should consider additional support to poor families so they can access high quality free infant male circumcision in rural Ghana.
This was a community level population-based cross-sectional study conducted in the Brong Ahafo Region of central Ghana from 21st May 2012 to 31st December 2012. Data were collected during a large neonatal vitamin A supplementation trial (Neovita) and full details are published elsewhere [15]. At the time of the circumcision study, 80% of the study population lived in rural settlements and almost 20% of mothers did not have primary school education. Four major district hospitals and 80 small health facilities provided health care services to the population. There were approximately 60 Wanzams and 100 formal circumcision providers (doctors, nurses, and medical assistants) at the time of the study. All births in the Neovita study area were reported to the trial team via a network of fieldworkers and key informants. Fieldworkers visited all families at home between two hours and two days after birth and interviewed the mother of the infant, or the primary care giver. Fieldworkers weighed the baby and asked the mother or the primary care giver about: date of birth, site of birth, current address, distance to health facilities, socio-demographic characteristics, and socio-economic information (using an asset index). The fieldworkers also collected data on the vital status of the baby (including if the baby was alive, dead, or hospitalised). Only male liveborn Neovita infants who were aged under 12 weeks were included to ensure the most accurate recall of circumcision related events. Infants were included in the Neovita trial if they were aged under three days, able to feed, were staying in the study area for at least six months after enrolment and their mother provided written informed consent. Follow-up visits were scheduled between eight to eleven weeks post birth and trained senior fieldworkers asked for consent to collect additional detailed data on: age at circumcision, site of circumcision, and type of circumcision provider. Infant male circumcision was supposed to be covered under the Ghana Health Insurance Scheme but it was well known that fees for circumcisions were charged by some formal and informal providers. So we also asked families if they had to pay any fees or “in-kind” contributions for the circumcision. Families were also asked if the study team could have access to the baby’s Neovita data including socio-economic, and socio-demographic data. Fieldworkers were trained for two weeks in all study procedures prior to the commencement of the study. Interrater reliability was checked between all fieldworkers. During the study fieldworkers received scheduled and unscheduled supervisory visits from the study coordinator to assess data quality and consistency. The fieldworkers used standardised paper based data collection tools (including a standardised list of closed ended questions) for all interviews. In our study a ‘formal circumcision provider’ was defined as a professionally trained, licensed, and regulated provider of circumcision services. This included: doctors, medical assistants, or nurses [2]. An ‘informal circumcision provider’ was an untrained, unlicensed, unregulated private provider of circumcision services including: Wanzams (village based traditional circumcision providers), drug sellers, and family members [2, 8, 16]. To assess ‘income status’ an asset index was constructed based on data collected on household assets (ownership of animals, television, motorcycle, etc) and housing material (walls, floor, windows, and roof). The index was analysed using principal component analysis (PCA) in Stata version 13 and categorised into five income quintiles [17]. ‘Distance to a health facility’ was measured in kilometres using Geographic Information System (GIS) software and the most commonly used roads from each village to the nearest health facility. It was categorised into four levels (<1 km (kilometre), 1–4.9 km, 5–9.9 km, 10 km or more). Many of the families in our study had limited recall about the exact cash amounts they paid for their circumcision but could categorise their responses. Thus information on the exact cash amounts for ‘cost of the circumcision’ was not collected and data were collected in the following categories: free, not free but less than 10 Ghana Cedis (Ghs), between 10 and 20 Ghs, 20 Ghs or more (at the time of conducting the study 1 Ghs = 0.6 United States dollars ($US)) [18]. ‘In kind contributions’ were defined as any non-cash payment to the formal or informal provider for the circumcision (e.g. bars of soap, chickens, kola nuts, and corn). Crude logistic regression models were used to examine the effect of income status on type of circumcision provider (informal vs formal). Odds ratios (ORs) and 95% confidence intervals (95% CI) were calculated. Multivariable logistic regression models were constructed apriori to adjust for the effect of important explanatory variables (income status, cost of circumcision, religion, maternal education, maternal age and distance to health facility). Model one assessed each of the infant and maternal characteristics as determinants of choice of informal provider, adjusting for income status, cost of circumcision, religion, maternal education and maternal age. Model two is the same as model one with an additional adjustment for distance to health facility. All analyses were conducted using STATA version 13. We calculated that the 2800 infants included in this study would provide 80% power to detect at least a 20% effect due to income status on choice of circumcision provider. We assumed a 5% significance level and a baseline 60% risk of receiving circumcision from an informal circumcision provider [6]. Ethical approvals were obtained from Ghana Health Service Ethical Review Committee, the Institutional Ethics Committee of Kintampo Health Research Centre (KHRC), the Research Ethics Committee of London School of Hygiene and Tropical Medicine, and the Human Research Ethics Committee of the University of Western Australia. Written informed consent was obtained from all the families of the circumcised male infants. The funders had no role in data gathering, data analysis, or writing of the report. The corresponding author had full access to all the data in the study, and for the decision to submit for publication.
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