Caregiver acceptability, and uptake of voluntary medical circumcision among male children under 5 years in Gulu city, Northern Uganda

Abstract

Childhood male circumcision is a key intervention for reducing the transmission of HIV infection. Despite its proven efficacy, the uptake of childhood male circumcision across Uganda remains suboptimal. This study assessed the caregiver acceptability, and uptake of voluntary medical circumcision among male children under five years old in Gulu city, Uganda. A cross-sectional quantitative approach was employed, involving multistage sampling strategy to randomly select 16 parishes from Gulu City’s two divisions. Systematic household sampling, and random caregiver selection using even-numbered random assignments was conducted. Data was collected through structured surveys administered to 427 caregivers of male children under five years old, using a questionnaire informed by Sekhon’s theory of acceptability of medical interventions. Sekhon’s theory constructs (affective attitude, burden, perceived effectiveness, ethicality, intervention coherence, opportunity costs, self-efficacy), with Likert scale and categorical questions to quantitatively evaluate caregivers’ perceptions of childhood male circumcision acceptability. Data was analysed using STATA version 18 to determine uptake, acceptability, and associated factors. Pearson’s chi-square and modified Poisson regression was used to determine factors associated with caregiver acceptability of childhood male circumcision, while controlling for caregiver gender, marital status, education level, occupation, residence, attendance at information sessions, community information availability, and father’s circumcision status. P < 0.05 was considered statistically significant. The acceptability of childhood male circumcision was 40.1% (95% CI: 35.4–44.8). Uptake of childhood male circumcision among study respondents was at 37.0% (158/427). Among the 269 (63.0%) who had not circumcised their children, 105 (39.0%) were unsure of considering it for their children. Having a circumcised father (aPR 2.6; 95% CI: 1.59–4.17, p < 0.001), information availability concerning childhood circumcision in the community (aPR: 1.2, 95% CI: 1.01–1.46, p = 0.034), and attending information sessions or talks about childhood male circumcision (aPR: 3.2; 95% CI: 2.09–4.82, p < 0.001) were significantly associated with the uptake of childhood male circumcision among respondents. Concerning factors significantly associated with the acceptability of childhood male circumcision, secondary level of education (aPR 1.6; 95% CI: 1.08–2.41, p = 0.019) and tertiary level of education (aPR 1.5; 95% CI: 1.01–2.34, p = 0.043), having attended information sessions (aPR 2.8; 95% CI: 2.00–4.04, p < 0.001), being in informal employment (aPR 1.2; 95% CI:1.01–1.52, p = 0.041) and having a circumcised father (aPR 2.9; 95% CI: 1.83–4.67, p < 0.001) were independently associated with acceptability of childhood male circumcision. Much as the uptake of childhood circumcision is still low in Gulu City, the caregiver acceptability is moderate but suboptimal. Specific interventions geared towards increasing information sessions, will improve on its acceptability, hence significantly enhancing uptake for HIV prevention.

Introduction

Circumcision, the surgical removal of the foreskin (prepuce) in men, is one of the world’s most common and oldest medical procedures¹. It is generally performed electively, most often for preventive healthcare, religious obligations, or cultural practices². Additionally, circumcision is an option for treating phimosis, and chronic urinary tract infections (UTIs)^3,4. The procedure has been linked to lower rates of sexually transmitted infections and UTIs⁵. It also helps reduce the incidence of oncogenic human papillomavirus (HPV) and significantly lowers HIV transmission rates among heterosexual men^3,5. Nonetheless, its effectiveness in preventing HIV transmission in developed countries or among men who have sex with men is limited, due to the lower HIV incidence and higher coverage of alternatives like PrEP for those at high risk⁶ Additionally, neonatal circumcision has been shown to decrease the risk of penile cancer⁷.

Circumcision of male children offers lifelong partial protection against HIV infection. It is a highly cost-effective strategy for reducing HIV transmission and has been shown to reduce the risk of HIV acquisition among men by up to 60% ⁸. Many international organisations, such as the United Nations Children’s Fund (UNICEF), the United Nations Educational, Scientific and Cultural Organization (UNESCO), and PEPFAR, have incorporated childhood medical male circumcision as an important strategy for enhancing the sexual and reproductive health of males later in life⁹. However, for circumcision of male children to reach its full potential, acceptance by caretakers remains key.

Globally, about 665 million infants have been circumcised from 2007 to March 2025, contributing to about 15% of all males that are circumcised^10,11. In Africa, many countries have adopted circumcision of children under 5 years of age, however, its uptake has largely remained sub-optimal. In sub-Saharan African countries with a high prevalence of HIV infection, circumcision of male children remains a top public health priority⁹. In South Africa, the highest reported prevalence of childhood circumcision is 25%¹². In East Africa, Kenya and Tanzania have achieved high levels of childhood male circumcision ahead of Uganda¹³.

Parental attitudes towards circumcision of male children vary significantly across different regions, as evidenced by studies conducted in Canada, Hong Kong, and Kenya. In Canada, hygiene and infection prevention were primary reasons for supporting circumcision of male children, with paternal circumcision status playing a pivotal role in decision-making among 627 mothers and 493 fathers¹⁴. These studies collectively illustrate the complex interplay of cultural norms, medical beliefs, and healthcare access influencing parental decisions regarding circumcision of male children globally.

In Uganda, by 2019, the national average of circumcision among men aged 15 to 64; medical or non-medical, had risen to 42.2%¹⁶. Notably, circumcision services for HIV prevention have largely targeted adolescents and adults, with limited programmatic focus on young children. Nationally disaggregated data on circumcision among children aged 0–5 years are lacking, and where childhood circumcision has been implemented, it has occurred predominantly during early infancy rather than across the broader preschool age range. Nonetheless, a community study conducted in Wakiso district estimated a prevalence of 53.8%¹⁷. The decision to adopt childhood male circumcision is influenced by various factors, including health beliefs, social contexts, and perceptions of medical interventions^14,18,19.

Gulu City, a major urban hub in Northern Uganda with a population over 260,000, faces low male circumcision coverage (2–2.4%) due to cultural reluctance among non-circumcising ethnic groups. Its unique post-conflict and socio-cultural context limits its representativeness of Uganda’s diverse circumcision patterns. This study aimed to explore these factors using the Sekhon’s theoretical model²⁰ to provide a complete understanding for the factors that influence the caregiver acceptability and uptake of circumcision of male children under 5 years in Gulu City, Uganda. The Sekhon’s theoretical model provides a comprehensive, multi-faceted definition of acceptability for healthcare interventions, based on anticipated or experienced cognitive and emotional responses. By identifying the cultural, social, and health-related factors that influence caregiver decisions regarding childhood circumcision, this study will provide valuable insights to inform targeted interventions and strategies to enhance childhood circumcision uptake in this region and similar low resource settings globally.

Methods

Study design

This study employed a quantitative cross-sectional survey to gather information on the acceptability and uptake of circumcision among male children of caregivers.

Study setting

This study was conducted in Gulu city, Northern Uganda. Gulu city is the commercial centre of Gulu district. It is the largest and most populated city in northern Uganda, with an estimated 45,022 male children under the age of five²¹. Gulu city has 2 divisions; Bardege-Layibi and Laroo-Pece divisions, with 32 parishes and wards, and 128 villages. We randomly selected 8 parishes within each of the two divisions. Eight parishes per division were randomly selected from the 32 parishes in Gulu City to ensure a representative sample across urban, semi-urban, and rural areas, balancing statistical power with logistical feasibility in a resource-limited setting.

Study population

The study population consisted of caregivers of children under five years old residing in Gulu city, Uganda, who were the primary decision-makers regarding circumcision of their male children, and met the eligibility criteria. Potential respondents were considered eligible to participate if they were caregivers (parents or legal guardians) of male children under five who were eligible for circumcision based on national guidelines²², and were included in the study after obtaining informed consent. We obtained informed consent from all participants before their inclusion in the study. Caregivers who had resided in the study area for less than three months or those with children who had hypospadias, ambiguous genitalia, or other medical conditions contraindicating circumcision were excluded from the study.

Sample size determination

The sample size was estimated using Kish -Leslie formula for cross-sectional surveys.

. Since level of acceptability of childhood circumcision was unknown. We used a p of 50%, to provide a modest estimate of minimal sample size. With a Z-score of 1.96 at a 95% confidence interval, and 5% precision, a sample size of 384 was estimated. With a non-response rate of 10%, a final minimal sample size of 427 was estimated.

Sampling strategies

A multistage sampling strategy was employed to ensure a representative sample of caregivers in Gulu City. In the first stage, 8 parishes were randomly selected from each of the two divisions of Gulu City (Bardege-Layibi and Laroo-Pece), totaling 16 parishes out of the 32 parishes and wards. Random selection of parishes was achieved by assigning each parish a unique number and using a random number generator to select 8 parishes per division. In the second stage, households within each selected parish were identified through a household enumeration process conducted with the assistance of local community leaders and village health teams. Households with at least one male child under five years old and a caregiver (parent or legal guardian) meeting the eligibility criteria were listed. From this list, households were randomly selected using a systematic sampling approach, where every k-th household was chosen based on the estimated number of eligible households in the parish and the target sample size (427 caregivers). In the third stage, one eligible caregiver per selected household was randomly chosen to participate in the structured surveys. This was done by assigning eligible caregivers within the household (e.g., mother, father, or legal guardian) random numbers from 0 to 100 and selecting the individual with an even number. If multiple caregivers were eligible, only one was selected to avoid over-representation from a single household. If no eligible caregiver was available (e.g., due to refusal or absence), the next randomly selected household was approached. This multistage approach minimized selection bias and ensured generalizability to the broader caregiver population in Gulu City.

Data collection methods

Data was collected through structured surveys administered to eligible study participants using a structured questionnaire developed to assess awareness, uptake, and influencing factors of childhood male circumcision. The questionnaire included demographic questions, items related to knowledge, attitudes, and decision-making regarding childhood male circumcision, and constructs of Sekhon’s theory²⁰. It also incorporated Likert scale responses and categorical questions to quantitatively measure caregivers’ perceptions of childhood male circumcision acceptability. Trained interviewers, who are part of the research team, fluent in both English and Luo administered the surveys face-to-face, ensuring accuracy in data collection.

Outcome measures

Acceptability of Childhood circumcision: This was measured through quantitative Likert scale responses informed by Sekhon’s theory of acceptability of medical interventions. The theory describes the multiple facets of acceptance using a single question per facet: Affective attitude, burden, perceived effectiveness, ethicality, intervention coherence, opportunity costs and self-efficacy scored individually on a scale of 1 to 5 where 1 is strongly positive and 5 is strongly negative and a composite score, derived by averaging these facet scores. A total average score greater or equal to 4 was categorized as ‘yes’ in acceptability and less than 4 was categorized as ‘no’²⁰.

Awareness and Knowledge: Quantitatively measured through structured questions on caregivers’ understanding of the benefits and risks of childhood male circumcision. Uptake of childhood male circumcision was quantitatively measured by the proportion of children who have undergone circumcision among the study population.

Data analysis

Data was analysed using Stata version 18 (April 25, 2023) to determine uptake, acceptability and associated factors. A value of p < 0.05 was considered statistically significant. Descriptive statistics were used to summarize demographic characteristics of caregivers, including age under 5, gender, education level, occupation, and geographic location (urban vs. peri-urban). Frequencies and percentages were used to describe awareness of childhood male circumcision, sources of information, and acceptability among caregivers. At bivariable analysis, associations between categorical variables (e.g., demographic characteristics and childhood male circumcision acceptability) were assessed using Chi-square tests when expected cell counts in 2 × 2 contingency tables were ≥ 5 for all cells. Fisher’s exact tests were applied when any expected cell count was < 5.

For continuous variables, such as knowledge scores about childhood male circumcision and perceived benefits (derived from Likert scale responses), normality was assessed using the Shapiro-Wilk test. T-tests were used to compare means between groups when data were normally distributed, and Mann-Whitney U tests were applied when data were non-normally distributed. Variables with a p-value < 0.2 in the bivariate were considered for inclusion in the multivariate analysis. At multivariate analysis level, modified Poisson regression model was employed to identify predictors associated with caregivers’ willingness to consider circumcision for their children utilizing the Akaike Information Criterion (AIC) for optimal stepwise selection. We chose the modified Poisson regression model because the prevalence of the outcome was not rare (> 10%), in which case a logistic regression would overestimate the relative risk. Adjusted prevalence ratios and corresponding 95% confidence intervals were reported.

Results

General characteristics of study participants

The study included 427 respondents who were majorly females (77.8%) with a median age of 30 years and an interquartile range of 25–36 years. A notable portion of respondents; 116 (27.2%), had no education, and 98 (23.0%) had only primary education. The majority of respondents; 303 (71.0%) had a monthly income above 100,000 Uganda shillings (about 26.9 USD). Regarding the circumcision status of the father, 240 (56.2%) reported that the father to the child was circumcised. Among circumcised fathers, 159 (66.3%) reported no change in sexual performance (Table 1).

Table 1.

General characteristics of respondents (N = 427).

Variable	Frequency (n = 427)	Percentage (%)
Age: (Median, IQR), Years	30	25–36
Age group
< 25	106	24.8
25–35	206	48.2
36–45	86	20.2
> 45	29	6.8
Gender
Female	332	77.8
Male	95	22.2
Marital Status
Separated/divorced	39	9.1
Widow/widower	23	5.4
Married	347	81.3
Unmarried	18	4.2
Relationship to the child
Father	79	18.5
Mother	321	75.2
Others	27	6.3
Occupation
Unemployed	150	35.1
Formal employment	77	18.0
Informal employment	200	46.9
Religion
Muslim	38	8.9
Pentecostal/Born Again	93	21.8
Anglican	83	19.4
Roman Catholic	202	47.3
Others	11	2.6
Level of Education
None	116	27.2
Primary	98	23.0
Secondary	114	26.7
Tertiary	99	23.2
Income (Ugx)
< 100,000	124	29.0
> 100,000	303	71.0
Place of Residence
Rural	105	24.6
Urban	162	37.9
Semi-urban	160	37.5
Is the child’s father circumcised?
No	187	43.8
Yes	240	56.2
For father, if circumcised, has circumcision affected your sexual performance
No, no change in sexual performance	159	66.3
Yes, enhanced my sexual performance	72	30.0
Yes, negatively affected my sexual performance	9	3.8

Awareness and knowledge

Most of the respondents 397 (93.0%), had ever heard about childhood male circumcision, with the primary sources being healthcare providers 166 (41.8%) and the media 92 (23.2%). Most respondents 309 (77.8%) were aware of the risks associated with childhood circumcision, with the most common risk cited being pain or discomfort 223 (72.2%) (Table 2).

Table 2.

Awareness and knowledge of childhood male circumcision among respondents.

Variable	Frequency (n = 427)	Percentage (%)
Have you heard about childhood male circumcision?
No	30	7.0
Yes	397	93.0
Where did you first learn about childhood male circumcision? (n = 397)
Friends or family	41	10.3
Healthcare provider	166	41.8
Others	16	4.0
School	23	5.8
Community meeting	25	6.3
Media (radio, TV, newspapers)	92	23.2
Religious institutions	34	8.6
Are you aware of any risks associated with childhood male circumcision?
No	88	22.2
Yes	309	77.8
If yes, what risks have you heard about? (n = 309)
Infection	25	8.1
Bleeding	33	10.7
Other complications	28	9.1
Pain or discomfort	223	72.2
Have you attended any information sessions or talks about childhood male circumcision?
No	238	55.7
Yes	189	44.3
Who organised sessions about male childhood circumcision (n = 189)
Healthcare providers	151	79.9
Community leaders	64	33.9
NGOs	16	8.5
Religious institutions	50	26.5
Others	5	2.6
Do you think there is enough information available in your community about childhood male circumcision?
No	297	69.6
Yes	130	30.4
If no, what information is lacking in your community about childhood male circumcision
Detailed benefits and risks	280	94.9
Availability of services	142	48.1
Cost of procedure	146	49.5
Personal testimonies	139	47.1
Others	16	5.4

Acceptability of childhood male circumcision among respondents

Our study found that, the acceptability of childhood male circumcision among participants was 40.1% (95% CI: 35.4–44.8) [n = 171/427]. Attitudes towards childhood male circumcision were generally positive, with 135 (31.6%) feeling strongly positive and 140 (32.8%) feeling positive, resulting in 64.4% positivity in total. More than half; 233 (54.6%) of respondents found it easy, and very easy to take their child for circumcision, 275 (64.4%) agreed, and strongly agreed that it is ethically appropriate to circumcise children. Understanding of the purpose and process of childhood circumcision varied, with 103 (24.1%) completely understanding and 110 (25.8%) not understanding. Majority of the respondents; 269 (63.0%) believed circumcision is effective and very effective. Confidence in accessing circumcision services was relatively high, including 108 (25.3%) being very 211 confident and 143 (33.5%) confident (Table 3).

Table 3.

Acceptability of childhood male circumcision among respondents.

Affective Attitude: How do you feel about the idea of childhood male circumcision?
Strongly positive	135	31.6
Positive	140	32.8
Neutral	89	20.8
Negative	56	13.1
Strongly negative	7	1.6
Burden: How easy do you think it would be to take your child for male circumcision?
Very Easy	102	23.9
Easy	131	30.7
Neutral	93	21.8
Difficult	78	18.3
Very difficult	23	5.4
Ethicality: Do you believe it is ethically appropriate to circumcise children?
Strongly agree	118	27.6
Agree	157	36.8
Neutral	93	21.8
Disagree	50	11.7
Strongly disagree	9	2.1
Intervention Coherence: Do you understand the purpose and process of childhood male circumcision?
Completely Understand	103	24.1
Mostly Understand	87	20.4
Slightly Understand	114	26.7
Somewhat Understand	13	3.0

Uptake of childhood male circumcision among the children of respondents

We found that, of all respondents, 37.0% (n = 158/427) had at least one child under 5 who was circumcised. Among these, 142 (89.9%) reported health benefits as the primary reason, 29 (18.4%) cited cultural reasons, 76 (48.1%) followed the advice of healthcare providers, and 41 (25.9%) were influenced by family. On the other hand, among the 269 (63.0%) respondents whose children were not circumcised; 160 (59.5%) expressed fear of risks, 21 (7.8%) attributed it to cultural beliefs, 62 (23%) to lack of information, and 55 (20.4%) mentioned accessibility issues. Moreover, 105 (39.0%) were unsure about considering it for their children (Table 4).

Table 4.

Caregivers’ Perspectives on Childhood Male Circumcision (N=427)

Category	Frequency(n=427)	Percentage (%)
Have any of your children undergone male circumcision?
No	269	63.0
Yes	158	37.0
If no, are you considering male circumcision for your children?
Not Sure	105	39.0
Yes	90	33.5
No	74	27.5
Why your child is not circumcised (n = 269)
Fear of risks	160	59.5
Cultural beliefs	21	7.8
Lack of information	62	23
Accessibility issues	55	20.4
Other	133	49.4
If yes, why has your child undergone male circumcision? (n = 158)
Health benefits	142	89.9
Cultural reasons	29	18.4
Advice from healthcare providers	76	48.1
Family influence	41	25.9
What factors influenced your decision to circumcise or not circumcise your children?
Health benefits	316	74
Cultural or religious beliefs	65	15.2
Advice from healthcare providers	124	29
Family influence	126	29.5
Fear of risks or complications	115	27
Accessibility of services	64	15
Cost of the procedure	48	11.2
Social norms	29	6.8
Other	29	6.8

Factors associated with acceptability of childhood male circumcision among respondents

At the bivariate analysis level, acceptability of childhood male circumcision was significantly higher among caregivers with secondary education (cPR = 2.1, 95% CI: 1.34–3.37) and tertiary education (cPR = 2.4, 95% CI: 1.52–3.78), those engaged in informal employment (cPR = 2.3, 95% CI: 1.38–3.69), those who had attended information sessions (cPR = 5.7, 95% CI: 4.05–7.98), those reporting adequate community information (cPR = 1.5, 95% CI: 1.20–1.89), and those whose child’s father was circumcised (cPR = 5.9, 95% CI: 3.84–9.01).

At the multivariable level, independently significant factors influencing the acceptability of childhood male circumcision included level of education, participation in information sessions, and the circumcision status of the father. Specifically, respondents with secondary education (aPR 1.6, 95% CI 1.08–2.41, P = 0.019) and tertiary education (aPR 1.5, 95% CI 1.01–2.34, P = 0.043) had an almost 2 fold likelihood of acceptability compared to those with no formal education. With regard to occupation, respondents engaged in informal employment were significantly associated with the acceptability of childhood male circumcision (aPR 1.2, 95% CI: 1.01–1.52, p = 0.041). Attending information sessions remained a significant factor (aPR 2.8, 95% CI 2.00–4.04, P < 0.001). Additionally, the circumcision status of the father played an important role (aPR 2.9, 95% CI 1.83–4.67, P < 0.001) (Table 5.).

Table 5.

Factors associated with childhood circumcision acceptability among respondents

Variable	All Freq (%)	Acceptability		Crude PR (95% CI)	P-value	Adjusted PR (95% CI)	P-value
		No Freq (%)	Yes Freq (%)
Gender
Female	332 (77.8)	198 (77.3)	134 (78.4)	1.0 (0.78 – 1.38)	0.806	N/A
Male	95 (22.2)	58 (22.7)	37 (21.6)	1
Marital status
Separated/divorced	39 (9.1)	27 (10.6)	12 (7.0)	1.2 (0.67 - 2.12)	0.547	N/A
Widow/widower	23 (5.4)	15 (5.9)	8 (4.7)	0.9 (0.43 - 1.84)	0.743
Married	347 (81.3)	203 (79.3)	144 (84.2)	1.1 (0.50 - 2.50)	0.786
Unmarried	18 (4.2)	11 (4.3)	7 (4.1)	1
Occupation
Unemployed	150 (35.1)	104 (40.6)	46 (26.9)	1.0 (0.73 - 1.32)	0.882	0.8 (0.62 - 1.08)	0.155
Formal employment	77 (18.0)	39 (15.2)	38 (22.2)	1
Informal employment	200 (46.9)	113 (44.1)	87 (50.9)	2.3 (1.38 - 3.69)	<0.001	1.2 (1.01 - 1.52)	0.041
Level of education
None	166 (27.2)	57 (22.3)	59 (34.5)	2.6 (1.69 - 4.08)	<0.001	1.5 (0.99 - 2.14)	0.057
Primary	98 (23.0)	79 (30.9)	19 (11.1)	1
Secondary	114 (26.7)	67 (26.2)	47 (27.5)	2.1 (1.34 - 3.37)	0.001	1.6 (1.08 - 2.41)	0.019
Tertiary	99 (23.2)	53 (20.7)	46 (26.9)	2.4 (1.52 - 3.78)	<0.001	1.5 (1.01 - 2.34)	0.043
Nature of residence
Rural	105 (24.6)	57 (22.3)	48 (28.1)	0.9 (0.72 - 1.22)	0.631	0.9 (0.75 - 1.15)	0.497
Urban	162 (37.9)	117 (45.7)	45 (26.3)	1
Semi-urban	160 (37.5)	82 (32.0)	78 (45.6)	0.6 (0.43 - 0.77)	<0.001	1.1 (0.86 - 1.35)	0.503
Risks associated with childhood male circumcision
Infection	25 (8.1)	15 (10.0)	10 (6.3)	1.3 (1.01 - 1.69)	0.041	1.1 (0.89 - 1.28)	0.472
Bleeding	33 (10.7)	10 (6.7)	23 (14.5)	0.7 (0.46 - 1.23)	0.255	0.9 (0.59 - 1.48)	0.783
Other complications	28 (9.1)	21 (14.0)	7 (4.4)	0.5 (0.24 - 0.90)	0.023	0.7 (0.36 - 1.20)	0.174
Pain or discomfort	223 (72.2)	104 (69.3)	119 (74.8)	1
Have you attended any information sessions or talks about childhood male circumcision?
No	238 (55.7)	207 (80.9)	31 (18.1)	1
Yes	189 (44.3)	49 (19.1)	140 (81.9)	5.7 (4.05 - 7.98)	<0.001	2.8 (2.00 - 4.04)	<0.001
Do you think there is enough information available in your community about childhood male circumcision?
No	297 (69.6)	194 (75.8)	103 (60.2)	1
Yes	130 (30.4)	62 (24.2)	68 (39.8)	1.5 (1.20 - 1.89)	<0.001	1.0 (0.89 - 1.23)	0.571
Is the child’s father circumcised?
No	187 (43.8)	167 (65.2)	20 (11.7)	1
Yes	240 (56.2)	89 (34.8)	151 (88.3)	5.9 (3.84 - 9.01)	<0.001	2.9 (1.83 - 4.67)	<0.001

Factors associated with uptake of childhood male circumcision among respondents

At bivariate analysis, uptake of childhood male circumcision was significantly associated with having no formal education (cPR = 1.5, 95% CI: 1.11–2.03), attendance at information sessions (cPR = 5.0, 95% CI: 3.53–6.95), perceived availability of community information (cPR = 1.8, 95% CI: 1.43–2.30), and having a circumcised father (cPR = 4.1, 95% CI: 2.82–6.08).

At the multivariable level, having a circumcised father (aPR 2.6, 95% CI: 1.59–4.17, p < 0.001), information availability concerning childhood circumcision in the community (aPR: 1.2, 95% CI: 1.01–1.46, p = 0.034); and attending information sessions or talks about childhood male circumcision (aPR: 3.2, 95% CI: 2.09–4.82, p < 0.001) were significantly associated with the uptake of childhood male circumcision among respondents (Table 6).

Table 6.

Factors associated with uptake of childhood male circumcision among respondents.

Variable	All Freq (%)	Acceptability		Crude PR (95% CI)	P-value	Adjusted PR (95% CI)	P-value
		No Freq (%)	Yes Freq (%)
Gender
Female	332 (77.8)	198 (77.3)	134 (78.4)	1.0 (0.78–1.38)	0.806	N/A
Male	95 (22.2)	58 (22.7)	37 (21.6)	1
Marital status
Separated/divorced	39 (9.1)	27 (10.6)	12 (7.0)	1.2 (0.67–2.12)	0.547	N/A
Widow/widower	23 (5.4)	15 (5.9)	8 (4.7)	0.9 (0.43–1.84)	0.743
Married	347 (81.3)	203 (79.3)	144 (84.2)	1.1 (0.50–2.50)	0.786
Unmarried	18 (4.2)	11 (4.3)	7 (4.1)	1
Occupation
Unemployed	150 (35.1)	104 (40.6)	46 (26.9)	1.0 (0.73–1.32)	0.882	0.8 (0.62–1.08)	0.155
Formal employment	77 (18.0)	39 (15.2)	38 (22.2)	1
Informal employment	200 (46.9)	113 (44.1)	87 (50.9)	2.3 (1.38–3.69)	< 0.001	1.2 (1.01–1.52)	0.041
Level of education
None	166 (27.2)	57 (22.3)	59 (34.5)	2.6 (1.69–4.08)	< 0.001	1.5 (0.99–2.14)	0.057
Primary	98 (23.0)	79 (30.9)	19 (11.1)	1
Secondary	114 (26.7)	67 (26.2)	47 (27.5)	2.1 (1.34–3.37)	0.001	1.6 (1.08–2.41)	0.019
Tertiary	99 (23.2)	53 (20.7)	46 (26.9)	2.4 (1.52–3.78)	< 0.001	1.5 (1.01–2.34)	0.043
Nature of residence
Rural	105 (24.6)	57 (22.3)	48 (28.1)	0.9 (0.72–1.22)	0.631	0.9 (0.75–1.15)	0.497
Urban	162 (37.9)	117 (45.7)	45 (26.3)	1
Semi-urban	160 (37.5)	82 (32.0)	78 (45.6)	0.6 (0.43–0.77)	< 0.001	1.1 (0.86–1.35)	0.503
Risks associated with childhood male circumcision
Infection	25 (8.1)	15 (10.0)	10 (6.3)	1.3 (1.01–1.69)	0.041	1.1 (0.89–1.28)	0.472
Bleeding	33 (10.7)	10 (6.7)	23 (14.5)	0.7 (0.46–1.23)	0.255	0.9 (0.59–1.48)	0.783
Other complications	28 (9.1)	21 (14.0)	7 (4.4)	0.5 (0.24–0.90)	0.023	0.7 (0.36–1.20)	0.174
Pain or discomfort	223 (72.2)	104 (69.3)	119 (74.8)	1
Have you attended any information sessions or talks about childhood male circumcision?
No	238 (55.7)	207 (80.9)	31 (18.1)	1
Yes	189 (44.3)	49 (19.1)	140 (81.9)	5.7 (4.05–7.98)	< 0.001	2.8 (2.00–4.04)	< 0.001
Do you think there is enough information available in your community about childhood male circumcision?
No	297 (69.6)	194 (75.8)	103 (60.2)	1
Yes	130 (30.4)	62 (24.2)	68 (39.8)	1.5 (1.20–1.89)	< 0.001	1.0 (0.89–1.23)	0.571
Is the child’s father circumcised?
No	187 (43.8)	167 (65.2)	20 (11.7)	1
Yes	240 (56.2)	89 (34.8)	151 (88.3)	5.9 (3.84–9.01)	< 0.001	2.9 (1.83–4.67)	< 0.001

Variable	All Freq (%)	Childhood circumcision uptake		Crude PR (95% CI)	P-value	Adjusted PR (95% CI)	P-value
		No Freq (%)	Yes Freq (%)
Gender
Female	332 (77.8)	203 (61.1)	129 (38.9)	1.3 (0.91–1.77)	0.155	1.1 (0.79–1.42)	0.701
Male	95 (22.2)	66 (69.5)	29 (30.5)	1		1
Marital status
Separated/divorced	39 (9.1)	26 (66.7)	13 (33.3)	0.9 (0.51–1.70)	0.822	N/A
Widow/widower	23 (5.4)	11 (47.8)	12 (52.2)	0.9 (0.41–1.78)	0.679
Married	347 (81.3)	221 (63.7)	126 (36.3)	1
Unmarried	18 (4.2)	11 (61.1)	7 (38.9)	1.3 (0.67–2.70)	0.410
Occupation
Unemployed	150 (35.1)	97 (64.7)	53 (35.3)	1.2 (0.87–1.64)	0.282	N/A
Formal employment	77 (18.0)	44 (57.1)	33 (42.9)	1
Informal employment	200 (46.9)	128 (64.0)	72 (36.0)	1.0 (0.74–1.31)	0.898
Level of education
None	166 (27.2)	51 (44.0)	65 (56.0)	1.5 (1.11–2.03)	0.009	1.2 (0.93–1.58)	0.146
Primary	98 (23.0)	78 (79.6)	20 (20.4)	0.5 (0.34–0.87)	0.11	0.9 (0.60–1.40)	0.670
Secondary	114 (26.7)	78 (68.4)	36 (31.6)	0.8 (0.6–1.22)	0.375	1.0 (0.72–1.31)	0.852
Tertiary	99 (23.2)	62 (62.6)	37 (37.4)	1		1
Nature of residence
Rural	105 (24.6)	64 (61.0)	41 (39.0)	0.9 (0.69–1.26)	0.649	N/A
Urban	162 (37.9)	112 (69.1)	50 (30.9)	1
Semi-urban	160 (37.5)	93 (58.1)	67 (41.9)	0.7 (0.55–0.99)	0.042
Risks associated with childhood male circumcision
Infection	25 (8.1)	12 (36.4)	21 (63.6)	1.4 (1.00–1.81)	0.044	1.1 (0.90–1.41)	0.301
Bleeding	33 (10.7)	18 (72.0)	7 (28.0)	0.6 (0.31–1.13)	0.114	0.8 (0.45–1.47)	0.490
Other complications	28 (9.1)	19 (67.9)	9 (32.1)	0.7 (0.39–1.19)	0.179	1.1 (0.56–2.06)	0.835
Pain or discomfort	223 (72.2)	118 (52.9)	105 (47.1)	1		1
Have you attended any information sessions or talks about childhood male circumcision?
No	238 (55.7)	206 (86.6)	32 (13.4)	1		1
Yes	189 (44.3)	63 (33.3)	126 (66.7)	5.0 (3.53–6.95)	< 0.001	3.2 (2.09–4.82)	< 0.001
Do you think there is enough information available in your community about childhood male circumcision?
No	297 (69.6)	209 (70.4)	88 (29.6)	1		1
Yes	130 (30.4)	60 (46.2)	70 (53.8)	1.8 (1.43–2.30)	< 0.001	1.2 (1.01–1.46)	0.034
Is the child’s father circumcised?
No	187 (43.8)	162 (86.6)	25 (13.4)	1		1
Yes	240 (56.2)	107 (44.6)	133 (55.4)	4.1 (2.82–6.08)	< 0.001	2.6 (1.59–4.17)	< 0.001

Discussion

This study found that the acceptability of childhood circumcision among caretakers with male children under 5 years in Gulu City was moderate yet suboptimal. Other studies present higher acceptability of childhood circumcision among respondents. For example, a study conducted in south Africa reported 77% acceptability of childhood male circumcision²³.Much as this study presented higher statistics, it assessed acceptability of childhood circumcision in a traditionally circumcising community. In our study, several factors were seen to be significantly associated with the acceptability of childhood male circumcision. Notably, the level of education of caretakers was seen to play an important role in the acceptability of childhood male circumcision. Compared to those with no formal education, respondents with secondary education as the highest level attained were 1.6 times more likely to accept childhood male circumcision for their children and those with tertiary education were 1.5 times more likely to accept childhood male circumcision. This aligns with many studies that have demonstrated the positive impact of higher educational attainment on health behaviors²⁴ For example, research in South Africa identified social-demographic factors such as education level, which influences knowledge of HIV status, as important predictors of circumcision incidence¹².

Several theories such as the health belief model, theory of reasoned action and planned behavior, and social learning theory have supported the role of health education in influencing positive behavioural change towards adopting health practices²⁵. These theories collectively suggest that behaviour change is influenced by personal beliefs (e.g., susceptibility, benefits, control), social norms (e.g., peer influence), and the environment (e.g., modelling, reinforcement). Health education can utilize these frameworks to customize interventions and support individuals in adopting healthier behaviours. Similarly, some studies have emphasized the contribution of health information to improving health program uptake²⁶. Significantly, respondents who had ever attended health information sessions regarding childhood male circumcision were almost 3 times more likely to accept the practice, and were more than 3 times more likely to circumcise their male children. Additionally, information availability in the communities concerning childhood circumcision was seen to positively influence the uptake of childhood male circumcision. This emphasizes the importance of targeted health education programs in enhancing awareness and acceptance of various health programs, including childhood male circumcision.

Additionally, being in informal employment was significantly associated with the acceptability of childhood male circumcision among study respondents. However, no available study specifically examines the association between informal employment and the acceptability of childhood male circumcision. The significant association between informal employment and the acceptability of childhood circumcision therefore presents a novel contribution to existing literature.

The circumcision status of the child’s father also significantly influences the acceptability of childhood male circumcision among respondents. Among all caregivers, those whose child had a circumcised father were almost 3 times more likely to accept childhood circumcision for their children. Moreover, we also saw a close to 3 times fold of uptake of childhood circumcision among fathers who were circumcised. Our findings are not far from findings from other studies¹¹. For instance, a study conducted in Tanzania found that fathers held positive attitudes towards circumcision and awareness of the availability of services were significant factors influencing the uptake of infant medical male circumcision. This finding stresses the role of family health practices and traditions in shaping health-related decisions for children²⁷.

Although this study examined caregiver acceptability and uptake across the 0–5 year age range, it is important to recognize current programmatic realities in Uganda, where circumcision for HIV prevention is rarely delivered to large numbers of healthy children aged 1–5 years due to training, safety, and service delivery constraints. In this context, our findings are likely most applicable to early infant male circumcision, for which some providers are trained and equipped, and which is increasingly considered within prevention programming. Caregiver attitudes, informational needs, and decision-making processes identified in this study therefore provide relevant insights to inform the design, counseling strategies, and demand-creation efforts for infant circumcision services, while also highlighting considerations that would need to be addressed should circumcision services for older young children be contemplated in the future.

Implications of study findings

This study used a cross-sectional study design to determine the acceptability. The sampling method was random sampling which is based on probability to prevent potential selection bias in recruiting participants. The study suggests development of clear policies to promote childhood male circumcision as an important way to prevent HIV, and support community education efforts to increase acceptance of circumcision for children, in line with WHO guidelines.

While the biological efficacy of male circumcision for HIV prevention is well established and unlikely to differ by age at circumcision, important evidence gaps remain regarding the optimal delivery of circumcision services in early childhood. Future research should therefore prioritize programmatic and implementation-focused questions, including short- to medium-term safety outcomes, post-procedure follow-up for late complications, caregiver counseling needs, and health system readiness to deliver safe, age-appropriate circumcision services for young children in Uganda.

Strengths and limitations of the study

Limitations in this study include the cross-sectional design of this study for quantitative data, which may limit the ability to establish causal relationships between variables. Furthermore, potential biases in self-reported data on childhood male circumcision awareness and practices, which was minimized through rigorous survey design, including clear and standardized questions, and by employing trained interviewers to reduce response bias. These strategies aimed to enhance the reliability and validity of findings, despite inherent limitations, and contribute robust insights to inform effective interventions and policies promoting childhood male circumcision in Gulu city, Uganda. Furthermore, our findings may over-represent people in less populous parishes since the parishes were all selected with equal probability rather than with probability proportional to size (parish population). However, parish populations in Gulu city are relatively similar, which potentially mitigates this effect.

Conclusion and recommendations

Our study reveals a sub average rate of acceptability of childhood male circumcision among parents with male children under 5 years in Gulu city, northern Uganda. Acceptability was however influenced by a complex interplay of familial relationships, educational attainment, participation in information sessions, and fathers’ circumcision status. These findings suggest that enhancing formal education and promoting targeted health education programs, can significantly improve the acceptance of childhood male circumcision. Further research should explore the development and implementation of interventions that address these factors to support informed decision-making and improve health outcomes.

Abbreviations

aPR

Adjusted prevalence ratio

CI

Confidence interval

cPR

Crude prevalence ratio

GUREC

Gulu university research and ethics committee

HBM

Health belief model

HIV

Human immunodeficiency virus

SEM

Social ecological model

UNCST

Uganda national council for science and technology

VMMC

Voluntary medical male circumcision

WHO

World health organization

Author contributions

D.O and F.B conceptualized the study, methodology, investigation, formal analysis, interpretation of results, drafting and revising manuscript.M.O.O. Methodology, Investigation, Formal analysis, interpretation of results.D.S.E. Funding acquisition, investigation, interpretation of results, manuscript revision.J.O, J.A, J.N.O, R.O, H.A, P.A, J.B.B, P.F.P. Methodology, investigation, formal analysis, interpretation of results, manuscript revision.

Funding

There was no formal funding for this research study.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Declarations

Competing interests

The authors declare no competing interests.

Ethical considerations and informed consent

The study sought protocol approval from the Gulu University Research Ethics Committee (GUREC-2024-902). In addition to obtaining approval from the appropriate institutional ethics committee, we confirm that all methods were performed in accordance with relevant ethical guidelines and regulations. Administrative clearances were obtained from City Clerk and Chief Administrative Officer and the division mayor of the selected study sites. We also sought permission from Gulu City Health Officer. All procedures involving human participants in this study were conducted in accordance with the ethical principles outlined in the Belmont Report and the Declaration of Helsinki.