**4. Thailand and NMC**

and risks of NMC as well as other supporting information such as availability and cost. The design of the education campaign should follow dedicated steps starting with a formative research targeting different audiences such as the general population and pregnant mothers. The formative research and subsequent baseline survey will define the content of the message and explore its suitability along with other relevant issues such as the dissemination channels. Clear and scientifically accurate information about NMC can prevent misconceptions and rumors about the procedure in the community. Perceived benefits of NMC at the societal level together with high level of satisfaction among early adopters will help increase the demand

NMC represents an added expenditure for the health care system even though the unit cost of NMC is lower than for circumcision at a later age. How the expenses are covered will depend on the nature of the program. However, the parents of the newborns should not have to pay for the total cost if NMC is promoted as a public health intervention. In developing countries, where resources are limited and a high number of recruitments are targeted in a short period of time, local governments usually do not have to pay, as the programs are supported by international agencies. In some other circumstances, the health insurance system may pay for

A baseline assessment of the readiness and capability of the health system should be conducted. For health facilities, the issues to be assessed should include the antenatal and child delivery service and availability of necessary medical equipment and supplies. Knowledge and attitudes toward NMC should be explored among health care personnel. The information gained from the surveys will help identify the basic elements needed for the service that are still lacking and the aspects that should be emphasized while training health care personnel. Safety is the first priority when implementing NMC as a public health measure. The surgery should be performed by trained health staff. The health staff who performs the surgery should be educated comprehensively on all aspects related to delivery of NMC, and not just the operation. A training package on NMC developed by the WHO and its partners is avail-

A system to routinely monitor the performance of the NMC program should be established. The indicators should cover both medical and public health aspects of the intervention. Newly trained staff should conduct first NMC cases under the supervision of more experienced persons. The results of the monitoring system will indicate whether the program is being implemented as intended and should be used to adjust the program to meet the goals in a timely manner. On an interval basis, the outcomes of the program should be comprehensively

the service. Partial payment by the parents is another possible option.

**3.7. Monitoring and evaluation (M&E) and quality assurance**

**3.6. Readiness of health system and staff training**

for the services.

178 Selected Topics in Neonatal Care

able online [66].

**3.5. Finance**

Soon after it was confirmed that MC was effective in reducing the heterosexual transmission of HIV among men, the author formed a research team at Chiang Mai University, in Northern Thailand, to investigate the possibility of adopting NMC as a public health intervention in Thailand. A critical review compiling related information and the author's thoughts was the first publication [7]. A series of surveys have been conducted to gain insight on related issues in the country including knowledge and opinions of health staff on the intervention [10], the experiences of health staff on the procedure and capability of the Thai health care system to implement NMC [8], and acceptability as well as concerns of NMC among postpartum mothers [9].

Following are the findings of the abovementioned studies. This case study can serve as an example for other countries that share a similar context to Thailand and are considering adopting NMC as a public health measure.

#### **4.1. Background on Thailand**

Thailand is an upper middle income country [67] and located in Southeast Asia. The country was categorized as a "high" human development country according to the most recent Human Development Index (HDI) report [68]. Thailand has a well-established health care system. The infant mortality rate is considered low at 11:1000 live births [69]. The coverage of antenatal care among pregnant women and rate of delivery at the health facilities are high. The country has three major health insurance systems that cover almost all of its citizens namely the Universal Health Coverage Scheme, the Civil Servant Medical Benefit Scheme, and Social Security Scheme. People who can afford or have private health insurance could go to private hospitals for convenience.

Thailand was one of the Asian countries hardest-hit by the HIV epidemic during the early 1990s. The AIDS Epidemic Model (AEM) estimates that more than 1 million Thais were infected by the HIV virus. High quality and good coverage of antiretroviral treatment has saved a lot of lives. It is estimated that there are currently more than 400,000 people living with HIV in the country [70]. Thailand's MC rate in general is quite low [13]. It is prevalent only in Muslim communities especially in the southern most provinces.

#### **4.2. Why should Thailand consider promoting NMC?**

Thailand is a good candidate country for promoting NMC as a public health measure for many reasons. Most HIV infections in Thailand occur through heterosexual transmission, of which the risk is substantially reduced by MC. Theoretically, the effect of MC on HIV risk reduction should be of significant magnitude in countries where the baseline MC rate is low and achievement of high coverage of MC is possible. Thailand has a relatively strong health care infrastructure as evidenced by the relatively low infant mortality rate [69]. An NMC program could possibly be built on this existing capability. The country has high coverage of maternal and child healthcare services including family planning, antenatal care, and deliveries that almost universally occur in the hospitals [71]. Thailand was the first developing country to eliminate mother-to-child HIV infection [72]. Health care personnel can educate pregnant mothers and their families about the benefits of having their children circumcised. Offering NMC could occur during the antenatal period if the fetus is identified as a boy intrapartum. Mothers can also be advised on how to care for their child after NMC and can be discharged from the hospital with the infant. Lastly, most Thais are Buddhists. Buddhism does not have any prohibition or negative beliefs toward circumcision. Further details on this issue were published in a critical review [7].

hospitals. HIV aside, 96% recognized the benefits of MC on hygiene, 74% knew about the effect of MC on cancer prevention, and 65% recognized that NMC could prevent STIs. Major concerns about NMC raised were safety and child rights. Physicians and nurses who had previous experience in performing circumcision on patients of all ages were more reluctant to

Update on Neonatal Male Circumcision: A Public Health Perspective

http://dx.doi.org/10.5772/intechopen.71948

181

In 2011–2012, a survey was conducted among 593 postpartum Thai mothers to determine their perceptions, concerns, and acceptability of NMC [9]. The study found that 70% of postpartum mothers knew or had heard of MC. Their biggest concerns were safety and pain of the procedure. After receiving information about the benefits and risks of NMC, one-third of the participants would choose to have their infants circumcised, one-third would not allow their sons to undergo NMC, and the last third were undecided. Mothers were the most influential person in deciding about NMC followed by fathers. Having a higher level of formal education, a circumcised husband, and knowing of at least one circumcised child were independent

The study showed that NMC was rarely performed in government hospitals where the intervention meant to take place. The health care staffs were unaware of the health benefits of NMC. Most health staffs were concerned about the difficulty and safety of the procedure. However, the fact that a large proportion of health staff agreed that NMC should be offered in their health facility after being educated about the benefits of NMC revealed an opportunity for the program to be adopted by the health staff. The majority of postpartum mothers did not know about the benefits of NMC and were concerned about safety issues. The results suggest that NMC may be culturally neutral with evidence that even modest educational efforts can

An education campaign on NMC for health professionals and general public is needed before NMC is promoted as a public health practice in Thailand. An economic study demonstrating the cost-effectiveness of NMC in Thailand is also needed in order to effectively advocate for

Though Thailand might gain considerable benefits from the implementation of NMC as a public health measure, its actual occurrence seems to be impassable according to our research findings. Knowledge and technologies on HIV prevention have evolved rapidly and there are a lot of other options to choose from. For Thailand, other interventions are regarded as more attractive strategies, e.g., routine HIV testing among key populations at higher risk of HIV infection, treatment as prevention, and pre-exposure prophylaxis. Another reason why NMC is overshadowed by other interventions is the lack of proof of an HIV prevention effect on MSM who are the current target population. Unless all necessary things have been done, NMC will not be administered as a public health intervention in Thailand and will only be

policies to introduce NMC as an established, offered in health facilities.

have NMC performed in their hospitals.

**4.5. NMC in Thailand, the way forward**

impact mothers' decisions in favor of NMC.

performed by request and on a case-by-case basis.

**4.4. Thai postpartum mothers' acceptability of NMC**

predictors of acceptability of NMC among postpartum mothers.

#### **4.3. Readiness of the Thai health care system to implement NMC**

A nation-wide survey was conducted in 2011 to gather baseline information on the capability of hospitals in Thailand to provide NMC [8]. Two questionnaires were sent to all hospitals in Thailand providing obstetric services and considered potentially able to perform NMC. The first questionnaire requested information about the facility's characteristics and its provision of NMC in 2010. The second questionnaire, directed to doctors or nurses who are familiar with delivery and postpartum care, contained opinion questions about NMC, and whether the procedure should be offered in the respondents' hospital. Of the hospitals that had deliveries in 2010, only 8.2% provided at least one NMC. Thirty-eight percent of private hospitals and 2.3% of government hospitals provided the service during 2010. The primary reason for performing NMC was parental request. Only a minority of the respondents thought that NMC was easy to perform (31.3%), was safe (39.1%), and should be offered in their health care facilities (29%). Ninety-two percent stated that physicians should perform the procedure instead of nurses. When asked about who should decide whether or not to conduct NMC, 55% indicated the choice should be left to parents. Forty-three percent believed that the service should be free of charge, while the same proportion felt that the parents should pay for some or all of the cost.

In another study conducted during 2011–2012, Thai health care providers' knowledge and attitudes toward NMC were assessed using face-to-face interviews [10]. The participants were physician administrators, practicing physicians, and nurses whose jobs involved NMC clinical procedures or oversight. The subjects were drawn to represent various hospital sizes and regions of the country using a multi-stage sampling technique. The participants were initially asked whether they agreed that MC had an effect on HIV prevention. Subsequently, printed educational materials on the benefits of NMC were presented to the participants for review. The participants were then asked whether NMC should be implemented at their facilities. Of the 133 health staffs who participated in the study, only 38% initially agreed that NMC reduced the risk of sexual HIV transmission. After reviewing the written information about the benefits of NMC, 59% of the participants thought that NMC should be offered in their hospitals. HIV aside, 96% recognized the benefits of MC on hygiene, 74% knew about the effect of MC on cancer prevention, and 65% recognized that NMC could prevent STIs. Major concerns about NMC raised were safety and child rights. Physicians and nurses who had previous experience in performing circumcision on patients of all ages were more reluctant to have NMC performed in their hospitals.

#### **4.4. Thai postpartum mothers' acceptability of NMC**

reduction should be of significant magnitude in countries where the baseline MC rate is low and achievement of high coverage of MC is possible. Thailand has a relatively strong health care infrastructure as evidenced by the relatively low infant mortality rate [69]. An NMC program could possibly be built on this existing capability. The country has high coverage of maternal and child healthcare services including family planning, antenatal care, and deliveries that almost universally occur in the hospitals [71]. Thailand was the first developing country to eliminate mother-to-child HIV infection [72]. Health care personnel can educate pregnant mothers and their families about the benefits of having their children circumcised. Offering NMC could occur during the antenatal period if the fetus is identified as a boy intrapartum. Mothers can also be advised on how to care for their child after NMC and can be discharged from the hospital with the infant. Lastly, most Thais are Buddhists. Buddhism does not have any prohibition or negative beliefs toward circumcision. Further details on this

A nation-wide survey was conducted in 2011 to gather baseline information on the capability of hospitals in Thailand to provide NMC [8]. Two questionnaires were sent to all hospitals in Thailand providing obstetric services and considered potentially able to perform NMC. The first questionnaire requested information about the facility's characteristics and its provision of NMC in 2010. The second questionnaire, directed to doctors or nurses who are familiar with delivery and postpartum care, contained opinion questions about NMC, and whether the procedure should be offered in the respondents' hospital. Of the hospitals that had deliveries in 2010, only 8.2% provided at least one NMC. Thirty-eight percent of private hospitals and 2.3% of government hospitals provided the service during 2010. The primary reason for performing NMC was parental request. Only a minority of the respondents thought that NMC was easy to perform (31.3%), was safe (39.1%), and should be offered in their health care facilities (29%). Ninety-two percent stated that physicians should perform the procedure instead of nurses. When asked about who should decide whether or not to conduct NMC, 55% indicated the choice should be left to parents. Forty-three percent believed that the service should be free of charge, while the same proportion felt that the parents should pay for

In another study conducted during 2011–2012, Thai health care providers' knowledge and attitudes toward NMC were assessed using face-to-face interviews [10]. The participants were physician administrators, practicing physicians, and nurses whose jobs involved NMC clinical procedures or oversight. The subjects were drawn to represent various hospital sizes and regions of the country using a multi-stage sampling technique. The participants were initially asked whether they agreed that MC had an effect on HIV prevention. Subsequently, printed educational materials on the benefits of NMC were presented to the participants for review. The participants were then asked whether NMC should be implemented at their facilities. Of the 133 health staffs who participated in the study, only 38% initially agreed that NMC reduced the risk of sexual HIV transmission. After reviewing the written information about the benefits of NMC, 59% of the participants thought that NMC should be offered in their

issue were published in a critical review [7].

180 Selected Topics in Neonatal Care

some or all of the cost.

**4.3. Readiness of the Thai health care system to implement NMC**

In 2011–2012, a survey was conducted among 593 postpartum Thai mothers to determine their perceptions, concerns, and acceptability of NMC [9]. The study found that 70% of postpartum mothers knew or had heard of MC. Their biggest concerns were safety and pain of the procedure. After receiving information about the benefits and risks of NMC, one-third of the participants would choose to have their infants circumcised, one-third would not allow their sons to undergo NMC, and the last third were undecided. Mothers were the most influential person in deciding about NMC followed by fathers. Having a higher level of formal education, a circumcised husband, and knowing of at least one circumcised child were independent predictors of acceptability of NMC among postpartum mothers.

#### **4.5. NMC in Thailand, the way forward**

The study showed that NMC was rarely performed in government hospitals where the intervention meant to take place. The health care staffs were unaware of the health benefits of NMC. Most health staffs were concerned about the difficulty and safety of the procedure. However, the fact that a large proportion of health staff agreed that NMC should be offered in their health facility after being educated about the benefits of NMC revealed an opportunity for the program to be adopted by the health staff. The majority of postpartum mothers did not know about the benefits of NMC and were concerned about safety issues. The results suggest that NMC may be culturally neutral with evidence that even modest educational efforts can impact mothers' decisions in favor of NMC.

An education campaign on NMC for health professionals and general public is needed before NMC is promoted as a public health practice in Thailand. An economic study demonstrating the cost-effectiveness of NMC in Thailand is also needed in order to effectively advocate for policies to introduce NMC as an established, offered in health facilities.

Though Thailand might gain considerable benefits from the implementation of NMC as a public health measure, its actual occurrence seems to be impassable according to our research findings. Knowledge and technologies on HIV prevention have evolved rapidly and there are a lot of other options to choose from. For Thailand, other interventions are regarded as more attractive strategies, e.g., routine HIV testing among key populations at higher risk of HIV infection, treatment as prevention, and pre-exposure prophylaxis. Another reason why NMC is overshadowed by other interventions is the lack of proof of an HIV prevention effect on MSM who are the current target population. Unless all necessary things have been done, NMC will not be administered as a public health intervention in Thailand and will only be performed by request and on a case-by-case basis.
