The implications of male circumcision practices for women in Papua New Guinea, including for HIV prevention

Redman-MacLaren, Michelle (2015) The implications of male circumcision practices for women in Papua New Guinea, including for HIV prevention. PhD thesis, James Cook University.

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Men in Papua New Guinea (PNG) practice a variety of male circumcision and penile modifications for a wide range of social, cultural, spiritual and personal reasons. Most of the procedures occur outside of formal health services. Three large randomised controlled trials in Africa have shown that male circumcision is effective in reducing human immunodeficiency virus (HIV) acquisition for heterosexual men. The HIV epidemic in PNG affects men, women and children in PNG and health researchers and policymakers are exploring male circumcision as a possible HIV prevention measure. It is therefore essential that women's perceptions and experiences of male circumcision be more fully understood to avert negative, unintended consequences for women. This study goes some way to filling this current gap.

PNG is a middle-income Pacific island country of about seven million people that has an underperforming health care system and infrastructure challenges. Challenges of inadequate health care facilities, irregular access to medications and transport difficulties are compounded by human resource constraints. PNG has a largely rural population (85 per cent of the population) and rapidly expanding urban centres. The country faces enormous challenges in addressing the health needs of its population. Women generally have low status in PNG and experience very high rates of sexual and domestic violence. Only half the number of girls to boys complete secondary or higher education. Possible HIV prevention measures, such as increasing male circumcision services, need to be positive for women to ensure it is not a measure that further contributes to the many challenges women in PNG face.

This transformational grounded theory study builds upon a broader male circumcision research agenda. Consistent with the Pacific context in which the research is being conducted, an expanded grounded theory methodology was employed that included critical research approaches of participatory action research and decolonising methodologies. An existing dataset of questionnaires completed by 861 men and 519 women, focus group transcripts (M=36; F=10) and rich semi-structured interviews (M=40; F=24) were theoretically sampled and analysed using grounded theory methods of initial, intermediate and advanced coding. Preliminary categories were developed from the existing data, with portions or ‘chunks’ of data that exemplified the developing categories selected. These data ‘chunks’ were then taken to seven interpretive focus groups in PNG, where 64 women discussed the existing data in story circles. In addition, women generated additional primary data using storyboarding technique. Individual interviews (n=11) were also facilitated with 10 women and one man. Transcriptions of audio files and the storyboard pictures were analysed. The secondary and primary data were combined and analysed to inform a developing transformational grounded theory. This grounded theory was then taken back to women and men in PNG who had participated in the study. Discussions about the transformational grounded theory and recommended action for PNG were held.

The core category of the transformational grounded theory is Power of Choice. Women have a lot of knowledge about male circumcision and penile modifications (including injections and inserts into the penis), but most do not have the opportunity or authority to influence decisions based on this knowledge. Those women who have formal education or informal training have increased status in their community and an increased number of options available to them. These options include influencing discussions with male partners and decisions about male circumcision for their male children. As with most aspects of women’s lives in PNG, women need to feel safe (socially, culturally, spiritually and personally) before they can act upon their choice to influence decisions based on this knowledge.

The significant original contribution to knowledge reported in these research findings reflect broader understandings of social determinants of health. As a theoretical code, social determinants of health expand the explanatory power of this transformational theory and urge us onto action for positive change. Women in this study reported formal education and informal training increased the status of women and their options for health. As a recommendation for action, women requested increased opportunities for education and training about sexual and reproductive health for themselves as well as for men. This action has begun. Following recommendations from this study, sexual and reproductive health training has been provided with over 300 health staff and company employees at one of the study sites. More action is needed. There is an immediate need for local-level responses to increase formal education and training for women. Physical, social and cultural conditions need to change so that women can safely make decisions and act in their interests and those of their families. The findings from this research have also been presented to national and international HIV policymakers through formal presentations, published material and informal conversations.

This thesis is enriched by the inclusion of poetry written during the candidature, which reflects continuous and critical reflexivity. The development of the researcher-self, challenges of working as an Australian in PNG and the complexity of HIV as a public health issue have been explored through memos and poetry included throughout.

Item ID: 42315
Item Type: Thesis (PhD)
Keywords: HIV, Papua New Guinea, male circumcision, transformational grounded theory, grounded theory, women, Pacific island countries, action research, participatory action research, decolonising, social determinants of health
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For this thesis, Michelle Redman-MacLaren received the Dean's Award for Excellence 2016.

This is a thesis by publication. Published articles included in appendices 10.9 and 10.10 have been redacted from the thesis due to copyright restrictions. The full thesis may either be requested via document delivery at your local library or viewed in the Eddie Koiki Mabo Library at JCU, Townsville.

Publications arising from this thesis are available from the Related URLs field. The publications are:

Chapter 3: Redman-MacLaren, Michelle L., Mills, Jane, Tommbe, Rachael, MacLaren, David J., Speare, Richard, and McBride, William J.H. (2013) Women and HIV in a moderate prevalence setting: an integrative review. BMC Public Health, 13 (1). pp. 1-13.

Chapter 4: Redman-MacLaren, Michelle, and Mills, Jane (2015) Transformational grounded theory: theory, voice, and action. International Journal of Qualitative Methods, 14 (3). pp. 1-12.

Chapter 5: Redman-MacLaren, Michelle, Mills, Jane, and Tommbe, Rachael (2014) Interpretive focus groups: a participatory method for interpreting and extending secondary analysis of qualitative data. Global Health Action, 7. pp. 1-6.

Chapter 8: Redman-MacLaren, Michelle (2015) Becoming a researcher: an auto-ethnographic account of a doctoral researcher re-presented in poetry. Journal of Poetry Therapy, 28 (3). pp. 207-214.

Appendices: Maclaren, David, Tommbe, Rachael, Mafile'o, Tracie, Manineng, Clement, Fregonese, Federica, Redman-MacLaren, Michelle, Wood, Michael, Browne, Kelwyn, Muller, Reinhold, Kaldor, John, and McBride, William John (2013) Foreskin cutting beliefs and practices and the acceptability of male circumcision for HIV prevention in Papua New Guinea. BMC Public Health, 13. pp. 1-17.

Appendices: Redman-MacLaren, Michelle, MacLaren, David J., Harrington, Humpress, Asugeni, Rowena, Timothy-Harrington, Relmah, Kekeubata, Esau, and Speare, Richard (2012) Mutual research capacity strengthening: a qualitative study of two-way partnerships in public health research. International Journal for Equity in Health, 11. pp. 1-12.

Appendices: Redman-MacLaren, Michelle, Api, Unia K., Darius, Matupit, Tommbe, Rachael, Mafile'o, Tracie A., and MacLaren, David J. (2014) Co-interviewing across gender and culture: expanding qualitative research methods in Melanesia. BMC Public Health, 14. pp. 1-7.

Appendices: Redman-MacLaren, M., Tommbe, R., Mills, J., MacLaren, D., and McBride, W.J. (2014) Women's experience of male circumcision in Papua New Guinea: a grounded theory study. In: Abstracts from the 20th International AIDS Conference. From: AIDS 2014: 20th International AIDS Conference, 20-25 July 2014, Melbourne, VIC, Australia.

Appendices: Manineng, Clement, MacLaren, David, Redman-MacLaren, Michelle, Tommbe, Rachael, and Mafile'o, Tracie (2014) A Papua New Guinea - Australia HIV research partnership: generating new knowledge, building capacity and forging new friendships. HIV Australia, 12 (2). pp. 72-74.

Appendices: MacLaren, David, Redman-MacLaren, Michelle, Timothy-Harrington, Relmah, Asugeni, Rowena, Muse, Elmah, Jimuru, Emmy, Moutoa, Kenny, and Speare, Rick (2015) Strengthening capacity for local evidence to inform local responses to HIV in a remote Solomon Islands health service. Western Pacific Surveillance and Response, 6 (2). pp. 1-8

Date Deposited: 21 Jan 2016 02:48
FoR Codes: 11 MEDICAL AND HEALTH SCIENCES > 1117 Public Health and Health Services > 111715 Pacific Peoples Health @ 100%
SEO Codes: 92 HEALTH > 9205 Specific Population Health (excl. Indigenous Health) > 920599 Specific Population Health (excl. Indigenous Health) not elsewhere classified @ 100%
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