Women's experience of male circumcision in Papua New Guinea: a grounded theory study

Background: Understanding how women experience and manage the myriad issues of male circumcision (MC) for themselves, their sexual partners and their sons is essential to understanding broader HIV and sexual health issues in Papua New Guinea (PNG). A great diversity of traditional and contemporary circumcision and foreskin cutting practices exist across the country. Medical MC is currently being investigated as a HIV prevention strategy. Studies have documented mixed responses by women to MC as a HIV prevention method in PNG. Methods: Between 2012 and 2014, a grounded theory study was conducted using a two-phase approach. Data from a large mixed methods multi-site MC study in 2010/2011 was analysed for themes to inform specific questions for women. Semi-structured interviews and focus group discussions, that incorporated visual methods such as storyboarding, were then conducted with 67 women at two of the initial study sites - a rural oil palm plantation and an urban university site. Data were inductively analysed to identify codes, categories and a grounded theory. Results: Women have extensive knowledge about MC and foreskin cutting practices, despite cultural norms that mean most women do not participate in decision-making about MC or other penile modifications. Women gain knowledge through personal (sometimes negative) experiences of their partners or children, through cultural traditions and/or through formal training or education. Women who have formal education or training, or who hold formal roles in their communities reported a greater power of choice about their own decision-making, including how MC affects them. Educated women reported more opportunities to influence their partner's decision about MC or other penile modifications, to choose a new partner or arrange MC for their male child/ren. Conclusions: Increased formal and informal education (such as HIV and sexual health training) results in increased status for women and access to a greater range of choices. The often culturally sanctioned low-status roles for women in PNG can be changed with training and/or formal education, which gives more power and thus more choices. If women have greater power of choice, they are less vulnerable to harmful, unintended consequences that may result from a policy of medical MC

Meeting in the Middle: Using Lingua Franca in Cross-Language Qualitative Health Research in Papua New Guinea

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Implications of male circumcision for women in Papua New Guinea: A transformational grounded theory study

BACKGROUND: Male circumcision reduces the risk of female-to-male transmission of human immunodeficiency virus (HIV) and is being explored for HIV prevention in Papua New Guinea (PNG). PNG has a concentrated HIV epidemic which is largely heterosexually transmitted. There are a diverse range of male circumcision and penile modification practices across PNG. Exploring the implications of male circumcision for women in PNG is important to inform evidence-based health policy that will result in positive, intended consequences. METHODS: The transformational grounded theory study incorporated participatory action research and decolonizing methodologies. In Phase One, an existing data set from a male circumcision study of 861 male and 519 female participants was theoretically sampled and analyzed for women's understanding and experience of male circumcision. In Phase Two of the study, primary data were co-generated with 64 women in seven interpretive focus group discussions and 11 semi-structured interviews to develop a theoretical model of the processes used by women to manage the outcomes of male circumcision. In Phase Three participants assisted to refine the developing transformational grounded theory and identify actions required to improve health. RESULTS: Many women know a lot about male circumcision and penile modification and the consequences for themselves, their families and communities. Their ability to act on this knowledge is determined by numerous social, cultural and economic factors. A transformational grounded theory was developed with connecting categories of: Women Know a Lot, Increasing Knowledge; Increasing Options; and Acting on Choices. Properties and dimensions of each category are represented in the model, along with the intervening condition of Safety. The condition of Safety contextualises the overarching lived realty for women in PNG, enables the inclusion of men in the transformational grounded theory model, and helps to explain relationships between men and women. The theory presents the core category as Power of Choice. CONCLUSIONS: This transformational grounded theory provides a means to explore how women experience male circumcision and penile modification in PNG, including for HIV prevention. Women who have had opportunities for education have a greater range of choices and an increased opportunity to act upon these choices. However, women can only exercise their power of choice in the context of safety. The concept of Peace drawn from the Social Determinants of Health is applied in order to extend the explanatory power of the transformational grounded theory. This study shows that women's ambivalence about male circumcision is often related to lack of safety, a consequence of gender inequality in PNG.Associated Grant:National Health and Medical Research Council of Australia;Associated Grant Code:GNT103820

"I was cut under the plantation palms": techniques and locations of penile cutting in Papua New guinea

Background: Papua New Guinea is a diverse country with a population of 6.8 million people speaking more than 800 languages. PNG has more than 90% of all reported cases of HIV in Oceania. There are a plethora of penile cutting styles, penile cutting techniques and penile cutting locations in Papua New Guinea. \ud \ud Methods: Structured questionnaires, interviews and focus group discussions were utilised to enquire about locations and techniques of male circumcision, penile cutting and/or penile modification. This occurred across four locations where people from across the country gather to study and/or work (two university campuses in large urban centres, a remote mountain gold mine and coastal oil palm plantation). The questionnaire included specific questions for men about where penile cutting occurred and what techniques were used to cut the foreskin. \ud \ud Results: 57% of the 864 male study participants reported having some form of penile cut. The majority have some form of longitudinal cut of the foreskin performed outside the medical system. Many men describe having their foreskin cut in or near a village by a male relative, friend or village expert and often linked to initiation ceremonies. Men who had attended boarding school or university reported having their foreskin cut while at school or university. Tools used include bamboo, razor blades, scalpel blades and large craft needles with strips of rubber tyre or fishing line. Many young men sourced scalpel blades, pain relief and antibiotic medication from medical clinics (either directly or via friends or relatives) and presented these to foreskin cutters. \ud \ud Conclusion: Any potential male circumcision for HIV Prevention programs in Papua New Guinea need to take into account the range of traditional and contemporary penile cutting practices

Meeting in the middle: Using lingua franca in cross-language qualitative health research in Papua New Guinea

With words as data, qualitative researchers rely upon language to understand the meaning participants make of the phenomena under study. Cross-language research requires communication about and between linguistic systems, with language a site of power. This article describes the use of the lingua franca of Tok Pisin in a study conducted to explore the implications of male circumcision for human immunodeficiency virus (HIV) prevention for women in Papua New Guinea. Utilizing a transformational grounded theory methodology, researchers conducted an analysis of data from an HIV prevention study. Researchers then facilitated individual interviews and interpretive focus groups to explore preliminary categories identified during the analysis. Most focus groups and interviews were conducted in the local lingua franca Tok Pisin, which is neither the researchers’ nor most participants’ first language. Audio recordings were transcribed and analyzed. Researchers returned to research participants to discuss research findings and recommendations. Following critical reflection by the authors and further discussions with participants, it was evident that using Tok Pisin enriched the research process and findings. Using the lingua franca of Tok Pisin enabled interaction in a language closer to the lived experience of participants, devolved the power of the researcher, and was consistent with decolonizing methodologies. Participants reported the use of Tok Pisin, em i tasim (pilim) bun bilong mipela, “it touches our bones,” and enabled a flow of conversation with the researchers that engendered trust. It is critical researchers address hierarchies of language in order to enable cogeneration of quality research findings. © The Author(s) 2019

Women and HIV in a moderate prevalence setting: An integrative review

Background: Almost 32,000 people are living with human immunodeficiency virus (HIV) in Papua New Guinea (PNG). The primary route of transmission in this moderate prevalence setting is through heterosexual sex. Thus a gendered understanding of HIV is required to inform HIV prevention, treatment and care options. The aim of this review is to investigate understandings specifically about women and HIV in PNG and to identify gaps in the literature to inform future HIV research. Methods. An integrative review of literature about women, HIV and PNG was conducted using a systematic search of online databases, including book chapters and grey literature. Prior to inclusion, literature was assessed using inclusion and exclusion criteria, and the Critical Appraisal Skills Programme (CASP) appraisal tool. Selected articles, book chapters and reports were coded and a constant comparative method of analysis used to construct a series of themes. Results: The 26 articles, book chapters and reports included in the review were predominantly descriptive, original research (23/26 pieces of literature). Six themes were identified in the literature: economic, social and cultural factors (including mobility); gender issues (including violence against women); knowledge about HIV (including perception of risk of HIV); religious beliefs about HIV; women perceived as responsible for HIV transmission; and prevention of HIV. Literature about women and HIV in PNG is predominantly focussed upon women who sell sex, women as mothers or young women. Women are usually represented as either victims of HIV or responsible for transmitting HIV. Anthropological and social research has described the economic, social and cultural context along with the lived experience of HIV in PNG, but there is limited operations research or implementation research available. Conclusions: The literature reviewed has highlighted the importance of a gendered analysis of HIV prevention, care and treatment in PNG. There is an opportunity for operations, implementation and health systems research about HIV in PNG to shift research from description to action. © 2013 Redman-MacLaren et al.; licensee BioMed Central Ltd

Stronger or tougher: reasons for penile cutting in Papua New Guinea

Background: Papua New Guinea is a diverse country with a population of 6.8 million people speaking more than 800 languages. PNG has more than 90% of all reported cases of HIV in Oceania. Following trials that showed male circumcision reduces the risk of heterosexual men acquiring HIV, MC is now recommended in comprehensive HIV prevention packages for populations with a heterosexual, generalised epidemic and where most men are not circumcised. The 'Acceptability and Feasibility of Male Circumcision for HIV Prevention in PNG' study documented reasons for penile cutting in four locations across PNG.\ud \ud Methods: Both men and women completed structured questionnaires about penile cutting. Sites were two university campuses in large urban centres, a remote mountain gold mine and coastal oil palm plantation. These are locations where people from across the country gather for work or study. The questionnaire included specific questions on the reasons for penile cutting.\ud \ud Results: 864 males and 560 females completed questionnaires. 57% of males reported some form of penile cutting. Reasons reported by men were both historical and contemporary: being a part of custom/tradition; cleanliness; peer influence; to increase the size of the penis; avoid STI; increase sexual pleasure; prolong sexual intercourse; perceived increase in female sexual pleasure.\ud \ud Conclusion: There was a diverse range of reasons for penile cutting reported in this study population. Any potential male circumcision for HIV prevention programs in Papua New Guinea need to take into account the wide range of traditional and contemporary penile cutting practices, and the reasons these cuts are being done

Co-interviewing across gender and culture: Expanding qualitative research methods in Melanesia

Background: The social and cultural positions of both researchers and research participants influence qualitative methods and study findings. In Papua New Guinea (PNG), as in other contexts, gender is a key organising characteristic and needs to be central to the design and conduct of research. The colonial history between researcher and participant is also critical to understanding potential power differences. This is particularly relevant to public health research, much of which has emerged from a positivist paradigm. This paper describes our critical reflection of flexible researcher responses enacted during qualitative research in PNG. Methods: Led by a senior male HIV researcher from PNG, a male from a PNG university and a female from an Australian university conducted qualitative interviews about faith-based responses to HIV in PNG. The two researchers planned to conduct one-on-one interviews matching gender of participants and interviewer. However, while conducting the study, four participants explicitly requested to be interviewed by both researchers. This experience led us to critically consider socially and culturally situated ways of understanding semi-structured interviewing for public health research in Melanesia. Results: New understandings about public health research include: (i) a challenge to the convention that the researcher holds more power than the research participant, (ii) the importance of audience in Melanesia, (iii) cultural safety can be provided when two people co-interview and (iv) the effect an esteemed leader heading the research may have on people's willingness to participate. Researchers who occupy insider-outsider roles in PNG may provide participants new possibilities to communicate key ideas. Conclusions: Our recent experience has taught us public health research methods that are gender sensitive and culturally situated are pivotal to successful research in Melanesia. Qualitative research requires adaptability and reflexivity. Public health research methods must continue to expand to reflect the diverse worldviews of research participants. Researchers need to remain open to new possibilities for learning. © 2014 Redman-MacLaren et al

Implications of male circumcision for women in Papua New Guinea: A transformational grounded theory study

BACKGROUND: Male circumcision reduces the risk of female-to-male transmission of human immunodeficiency virus (HIV) and is being explored for HIV prevention in Papua New Guinea (PNG). PNG has a concentrated HIV epidemic which is largely heterosexually transmitted. There are a diverse range of male circumcision and penile modification practices across PNG. Exploring the implications of male circumcision for women in PNG is important to inform evidence-based health policy that will result in positive, intended consequences. METHODS: The transformational grounded theory study incorporated participatory action research and decolonizing methodologies. In Phase One, an existing data set from a male circumcision study of 861 male and 519 female participants was theoretically sampled and analyzed for women's understanding and experience of male circumcision. In Phase Two of the study, primary data were co-generated with 64 women in seven interpretive focus group discussions and 11 semi-structured interviews to develop a theoretical model of the processes used by women to manage the outcomes of male circumcision. In Phase Three participants assisted to refine the developing transformational grounded theory and identify actions required to improve health. RESULTS: Many women know a lot about male circumcision and penile modification and the consequences for themselves, their families and communities. Their ability to act on this knowledge is determined by numerous social, cultural and economic factors. A transformational grounded theory was developed with connecting categories of: Women Know a Lot, Increasing Knowledge; Increasing Options; and Acting on Choices. Properties and dimensions of each category are represented in the model, along with the intervening condition of Safety. The condition of Safety contextualises the overarching lived realty for women in PNG, enables the inclusion of men in the transformational grounded theory model, and helps to explain relationships between men and women. The theory presents the core category as Power of Choice. CONCLUSIONS: This transformational grounded theory provides a means to explore how women experience male circumcision and penile modification in PNG, including for HIV prevention. Women who have had opportunities for education have a greater range of choices and an increased opportunity to act upon these choices. However, women can only exercise their power of choice in the context of safety. The concept of Peace drawn from the Social Determinants of Health is applied in order to extend the explanatory power of the transformational grounded theory. This study shows that women's ambivalence about male circumcision is often related to lack of safety, a consequence of gender inequality in PNG