Background

Papua New Guinea (PNG) has the highest Human Immunodeficiency Virus (HIV) prevalence in the Western Pacific with nearly 1% of the adult population infected [1]. Available data suggests that the epidemic is concentrated rather than generalized, reflecting higher prevalence in urban centres, highlands provinces and among high risk-groups including sex-workers [2–4]. However, national and international health experts warn that HIV is still a critical threat in the general PNG population [3, 5]. Innovative but context-specific approaches are urgently required to limit HIV spread in this setting.

HIV prevention in PNG has had impediments on many fronts. PNG has over 800 ethnic groups, some 850 indigenous languages, multiple religious denominations and rapidly changing socio-economic and political environments [6–8]. On top of that, 85% of the population lead tribal lives in isolated rural communities where essential services including basic health care and health promotion services are barely functional or non-existent. Where such services exist, their uptake and use is often hampered by low literacy levels and language barriers [6, 7, 9]. Furthermore, the negative impacts of rapid socioeconomic developments including destabilization of traditional social structures and value systems are contributing to high levels of gender inequity, domestic violence, poverty and corruption, all of which have interwoven effects on escalating HIV transmission in PNG [10–15].

Initiation ceremonies or transition rites have been important traditional activities that have contributed to community well-being in some parts of PNG (as elsewhere) for millennia [16–22]. These ceremonies were vital particularly in precolonial days to guide young adults through their turbulent adolescent stages and enabling them to discard carefree childhood behaviours and adopt adulthood responsibilities [19]. Adult responsibilities include active participation in gender specific roles, living independent lives and respecting established social structures and customary norms. However, these traditional behaviour-guiding practices have struggled to continue alongside modern interests in career-driven education, introduced Christianity and financial freedom [22–29]. Consequent discontinuation of initiation ceremonies meant that an important avenue for behavioural guidance was denied to adolescent boys and girls in this setting.

An undertaking to re-establish male initiation ceremonies (MICs) is underway in Yangoru-Saussia, a rural district in East Sepik Province, PNG [30]. Re-establishing MICs may be difficult considering that such a venture would require reviving previously abandoned practices, some of which are conflicting with Christianity–the dominant religion. In addition, local people, in their contemporary livelihood may not be willing to accommodate the requirements of another program in their daily routines, particularly if that program is deemed to be contradicting current efforts in pushing for modernization. Moreover, previously abandoned MICs in Yangoru-Saussia included high-risk penile-bleeding operations [18] which would need to be replaced with medical male circumcision (MMC), a safer modern alternative. However, these penile operations have significant cultural meaning including symbolising transition from childhood to adulthood [31–34]. Thus, there are significant questions that need to be answered before progress can be made towards establishing a MIC that could comprise substituting traditional penile-bleeding with modern MMC.

Replacing traditional penile-bleeding procedures with MMC could provide attractive health benefits to initiates. In the short term, substitution with MMC may prevent adverse events and reduce health risks to individual participants who would otherwise be subjected to the high-risk traditional penile-bleeding procedure. In the long term, the health benefits could include prevention of Human Immunodeficiency Virus (HIV)–as demonstrated by three randomized controlled trials [35–37]–and lowering disease risks (including of certain cancers) related to Human Papilloma Virus (HPV) [38–40]. Furthermore, if MMC at MICs could be complemented with HIV counselling and testing, a comprehensive approach to HIV prevention and a culturally relevant public health program could be realized in this contemporary setting.

Re-establishing MICs could provide attractive benefits to local communities and to health service providers. To local communities, re-establishing MICs means that adolescent boys in the communities may now have access to previously discontinued traditional process of behavioural mentoring. Local communities also stand to benefit through the revitalization of cultural practices (linked to MICs) including unique artwork and traditional dances [30]. To health service providers, re-established MICs may offer two main benefits; one: community ownership and enhanced participation (because of local relevance) could lead to better outcomes in preventing adverse events and controlling HIV [41–43]; two: cost to health program budget could be minimal given that custom requires initiates and their supporters to pay for their participation. In this part of the pre-colonial world and like initiating communities across Melanesia, participation at initiation ceremonies were associated with power and dominance–traits that cannot be gained without first sacrificing or depositing something of monetary value [44–46].

The purpose of this study therefore, was to assess the acceptability of re-establishing MICs, including replacing traditional penile bleeding procedures with MMC for HIV prevention in Yangoru-Saussia, PNG. In this paper, we present the results of this acceptability assessment and discuss the implications in relation to a comprehensive approach to HIV prevention in this setting in PNG.

Method

Results

Most cultural leaders interviewed in phase one of this study expressed a desire to have a socio-cultural approach to HIV prevention that reflected local history and culture in Yangoru-Saussia. Initiation ceremonies (including female ceremonies) were depicted as mediums for education (pre-colonial schools) that had an emphasis on character building. Leaders stated that there was a general deficiency in moral standards in contemporary communities. Initiation ceremonies were seen to be able to instil positive values to initiates to improve their lives, their health and thereby protect them and their families from HIV. Not only this, but those traditions were an excellent way to preserve local cultural practices and male initiation ceremonies (MICs) were therefore further investigated in this study.

Most survey participants supported revival of male initiation ceremonies and inclusion of medical male circumcision (from phases two and three)

One of the key questions in the phase-two cross-sectional survey was “would you support revival of male initiation ceremonies?” This survey had 200 participants– 101 (50.5%) male and 99 (49.5%) female. Median age was 36 (inter-quartile range 25–47.75). Overall, 81.5% (n = 163) supported the proposition to revive MICs. Frequency of responses by demographic characteristics shown in Table 1.

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Table 1. Reponses by demographic characteristics (phase two cross-sectional survey).

https://doi.org/10.1371/journal.pone.0187577.t001

One of the key questions in the phase-three cross-sectional survey was “would you support including medical male circumcision at male initiation ceremonies?” This survey had 64 participants– 36 (56.3%) male and 28 (43.7%) female. Median age was 40.5 (inter-quartile range 30.25–49.74). Overall, 92.2% (n = 59) supported the proposition to include MMC at revived MICs. Frequency of responses by demographic characteristics shown in Table 2.

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Table 2. Responses by demographic characteristics (Phase three cross-sectional survey).

https://doi.org/10.1371/journal.pone.0187577.t002

Discussion

Re-establishing previously ceased traditional practices and adapting them with modern alternatives to address contemporary health and sociocultural needs is a relatively new area of investigation. Information presented can be of significant benefit to policy makers across many disciplines. This study to assess the acceptability of reviving and modifying male initiation ceremonies (MICs) for a comprehensive approach to HIV prevention is the first such study in Papua New Guinea (PNG). Results demonstrate a positive attitude towards establishing a safer version of the pre-colonial MICs in Yangoru-Saussia. Results also expand evidence for local, national and international policy makers to support locally appropriate HIV prevention strategies in PNG and other culturally, linguistically and geographically diverse nations [9, 14, 31, 33, 34, 41, 42, 53–57].

Overall, participants favoured the establishment of a modified version (that includes medical male circumcision) of the previously ceased MICs. Most participants (81.5%) supported the proposition to re-establish MICs and 92.2% approved inclusion of medical male circumcision (MMC). Participants consistently expressed an appreciation of traditional practices and the value of these practices for contemporary living. Although initiation ceremonies have now ceased, almost half of the survey participants were initiated, demonstrating existence of considerable experience and knowledge of past practices in the district. Cultural leaders depicted MICs as pre-colonial schools with an emphasis on character building. MICs were therefore seen to address a perceived deficiency in moral standards in contemporary communities and be a base for preventing HIV and other social challenges.

Support for the revival of MICs was consistently high across different sectors and characteristics of study participants. The only statistically significant difference was in gender with fewer females supporting the revival of MICs than men (72.7% vs 90.1% p = 0.002). However, the majority of women still supported the idea. Survey participants interviewed by researchers (because of low-literacy) were more likely to support the revival of MICs compared to those who self-administered the survey (85.1% vs 74.2% p = 0.064). However, both groups overwhelmingly supported the notion to revive MICs. Although not statistically significant, fewer young people, singles, Seventh Day Adventist (SDA) church affiliates and participants of Sausse local level government areas (LLG) supported revival of MICs. Lower support from young people may reflect less life experience and consequent limited understanding of MICs and the objective of reviving MICs. Conversely, lower support could portray an inclination towards modern lifestyles given the younger generations’ greater exposure (compared to older generation) to modern schools and modern influences. Younger generations’ lower support could also reflect their indifference towards a practice that may place them at risk of physical and emotional trauma inflicted by older men. Lower support from SDA affiliated participants may reflect the church’s introduced conservative Christian religious beliefs and general reticence to support local cultural traditions [58]. Cultural practices of some villages on the plains in Sausse LLG are closer to Sepik River practices than to the rest of Yangoru-Saussia and may explain lower support (70.0%) compared to other LLGs (82.0%, 84.3%, 89.8%). In addition, some villages used sharp objects like cassowary bones to split the glans penis as outlined by our study participants while other villages used barbed bush vines to bleed the penis in a ‘bottle-brushing’ fashion as described by Tuzin (1980)[22]. Future research could include mapping the type of penile bleeding practices in Yangoru-Saussia and their influence on an undertaking to revive MICs.

The call for government support by some cultural leaders may actually reflect perceived barriers in structuring and financing cultural programs including MICs. In terms of finance, there could be expectations of free or government sponsored MICs and it is paramount that any finance-related communication between program planners and cultural leaders (and members of their communities) be based on replicating the ‘user-pay’ arrangements of the precolonial MICs. It must be emphasized that custom requires participants to contribute to staging MICs. Custom also obligates participants to give back something of monetary value to those who facilitate the initiation process. Thus, without a ‘user-pay’ arrangement, re-established MICs could lose their customary worth and significance. Regarding program structure, it is important to note that the only time available for in-school boys to participate at MICs are the official school holidays, the sum in one academic year of which is just under three months [59]. This essentially means that the initiation process that previously took 3–12 months should be accelerated. Otherwise, program planners could consider omitting ceremonial activities that appear redundant or are conflicting with modern world views. Similarly, there is need for local authorities to articulate–perhaps in a clear policy direction–a conceptual and implementation framework for cultural activities including the potential re-establishment of MICs in the district.

Sorcery and Sanguma (malicious witchcraft) were of major concern to participants and were named as aspects of the old MICs that needed to be excluded. Sorcery and Sanguma herein referred to as ‘black magic’[60] are activities that participants said did not reflect contemporary values and therefore could not be included in revived MICs. In Yangoru-Saussia, most deaths and ailments are perceived to be related–even in current times–to black magic [61, 62]. Given this prevalent perception on the connection between black magic and adversities, some participants spoke against the revival of MICs because of their belief that black magic practices were to be included in the new program. Consequently, if the new program is perceived as a potential place for black magic to be strengthened, it was clear that most people would stop their young men from participating. Furthermore, most local people affiliate with Christian church denominations and oppose activities that support black magic or that challenge Christian principles. Any undertaking to revive MICs would have greater acceptance if it is communicated that black magic would not be included.

Local people in Yangoru-Saussia are custodians of their own traditional practices and as such, their views and opinions matter to future cultural programs. In addition, incorporating local views and suggestions into future MICs is vital because it is the local people who will design, adopt and implement any modifications to their contemporary society. Furthermore, including local people in this process reinforces respect and underpins their leadership, support and participation at future programs [41, 63, 64]. Similarly, it is essential that culturally sensitive modifications be carefully considered within revived MICs. Without this, the venture risks being meaningless to the very people it was intended to benefit. Therefore, a culturally sensitive inclusion of MMC at revived MICs, to replace foreskin cutting and penile bleeding procedures at traditional MICs, would require surgical procedures that usually occur in health facilities to happen at the ceremonial grounds. Further, health workers would need to be from the local area and they should partake in the ritual restrictions as required by custom [65]. This culturally sensitive alignment of MMC with a local cultural program is an excellent example of providing culturally specific male circumcision for HIV prevention as recommended by World Health Organization (WHO) and United Nations Program for HIV/AIDS (UNAIDS) [66]. Likewise, establishing a contemporary version of MICs will be in-line with a joint United Nations Educational, Scientific and Cultural Organization (UNESCO) and UNAIDS recommendation for HIV/AIDS education to include the teaching of life-skills and balanced gender roles [67]. Moreover, aligning MMC with a local cultural program would fulfil a PNG health priority for MMC to be made accessible for men who undergo high-risk foreskin cutting at non-clinical settings in PNG [68–70].

Penile bleeding is a culturally significant ritual at MICs in Yangoru-Saussia and emerged as a contentious and contested issue in this study. Some participants were happy that old penile bleeding procedures be replaced by MMC, while others were not. The loss of blood through the penile bleeding process is symbolic of initiates severing maternal ties (and therefore their childhood) and transitioning into adulthood. It is therefore important to understand both natures of blood loss: the procedural and symbolic. That is, while MMC may provide a ‘bio-medically safer’ option than using a cassowary bone during MICs, it may not satisfy the symbolic significance of disconnecting with childhood where pain (both physical and emotional) and blood loss is expected. In acknowledging the latter, some cultural leaders indicated that penile bleeding at future MICs could continue even if MMC were to be included. This fact points to the challenge of including modern alternatives without compromising the cultural meaning and significance of MICs in this setting. If this is the case and penile bleeding, even in its mild contemporary form (with use of razor blades) takes place at future MICs, the objective of minimizing health risks including HIV prevention could be undermined. Hence, the possibility of initiates undergoing razor-blade-induced penile bleeding must be considered and accommodated in risk-reduction plans (including for HIV prevention) for future programs.

There are limitations to this study that should be noted. Firstly, the findings and implications presented are specific to Yangoru-Saussia district and cannot be extrapolated to other settings in PNG. Yet, the rural contemporary setting in Yangoru-Saussia and the issues discussed are quite similar to other initiating indigenous communities striving to counter the side-effects of rapid modernization on local cultural practices and values. Secondly, it is acknowledged that local researchers including CM belong to the district and culture under study and raises the possibility of participant and researcher bias. Conversely, researchers’ indigenous, education and health professional backgrounds may have fostered trust between participants and research team, resulting in open and honest responses [71]. Thirdly, the application of convenience sampling means that views captured in this study may not be representative of all people in Yangoru-Saussia. However, a reasonable representation of local peoples’ views may have been captured given that people in Yangoru-Saussia belong to a society that prioritises collective pursuits over individual pursuits and regularly congregate at popular meeting venues such as markets, health centres, schools and conference chambers.

Future studies should further investigate results presented in this paper. Differences in support for revived MICs by men and women should be explored. Many cultural leaders expect government support for the revival and maintenance of their native cultural practices. Subsequent enquiry should investigate cultural leader expectations and provide an assessment on the practicality or otherwise of reviving MMC-integrated MICs with or without government support. In addition, the health benefits of penile blood-letting claimed by some participants of this study could be an interesting area for further studies. For instance, the health benefits claimed could be related to therapeutic phlebotomy, although the point of blood-letting is different. Therapeutic phlebotomy refers to deliberate release of blood (usually from external veins) to treat certain medical conditions. This therapeutic option is being investigated for its potential in reducing blood viscosity and enhancing oxygen circulation and tissue perfusion [72–74]. It is also important to note that the local native language has become second-place to introduced languages, local culture experts are too few and government support is lacking. Moreover, program planners should note that older men in this setting could use MICs to place adolescent boys under duress and every effort must be made to ensure that future MICs are free of coercion, violence and abuse. These multiple and interlinked issues all need to be carefully considered in the undertaking to re-establish safer MICs in Yangoru-Saussia, PNG. Insights to these issues will emerge through ongoing research by CM and his team of local and international researchers over the coming years.

Conclusions

This study broadens evidence supporting locally appropriate HIV interventions in PNG and other diverse cultural, linguistic and geographical settings. Most people in this study in Yangoru-Saussia accept safer MMC-integrated MICs as a viable option for their contemporary society given the focus on character building and cultural preservation. However, implementation of modified MICs will require considerable effort, especially when modern education, introduced religion, contemporary economic pursuits and abuse prevention must be incorporated. Similarly, penile bleeding is a culturally significant ritual and emerged as a contentious and contested issue in this study. Allowing blood loss at initiation is thought by some to help a boy transition into a man and needs to be carefully considered in future programs. A culturally sensitive alignment of MMC with a proposed local cultural program is an example of providing culturally-specific male circumcision for HIV prevention as recommended by WHO/UNAIDS. It also responds to a national health priority to avail safe-circumcision to men risking foreskin cutting at non-clinical settings in PNG.

Supporting information

Acknowledgments

We convey our sincere gratitude to study participants and research assistants who made this research possible. We also acknowledge and appreciate the invaluable support and guidance from research support officers at PNG National AIDS Council, East Sepik Provincial AIDS Committee, Divine Word University, PNG Medical Research Advisory Committee, Australia Awards PNG and James Cook University.