16th International Conference on AIDS
and Sexually Transmitted Infections in Africa (ICASA)
4–8 December 2011
"Improving the informed consent process for adolescents undergoing male circumcision in Zambia and Swaziland"
Barbara A. Friedland, Katie D. Schenk, Louis Apicella, Meredith Sheehy, Kelvin Munjile, Alfred Adams, and Paul C. Hewett
Promotion of male circumcision (MC) in Africa has focused on young men, including adolescents under 18 years old, who are considered children according to international human rights law. Although parents provide informed consent (IC) for their sons, UNAIDS has advocated for children to be involved in the decisionmaking process, to be given information about risks and benefits of the procedure, and to be asked for their assent. As MC services were being scaled up in Zambia and Swaziland (2009–2010), the Population Council evaluated the MC IC process to offer practical recommendations for improvement, with a specific emphasis on adolescents.
A 10-question true/false test was administered before the MC procedure to 228 clients in Zambia (159 adults, 18 years or older; 69 adolescents, 13–17 years old) and 953 MC clients in Swaziland (756 adults, 197 adolescents). Semi-structured interviews (SSIs) were conducted one week post-MC among 62 clients in Zambia (34 adults, 28 adolescents) and 30 clients in Swaziland (16 adults, 14 adolescents). T-tests were used to test the hypothesis that 90% of clients could pass the true/false test, scoring ≥80% (answering at least 8/10 questions correctly); chi-square tests compared the proportion of adults and adolescents passing the test; and logistic regression modeled factors associated with passing. SSIs were recorded, transcribed, translated into English, and analyzed thematically.
In both countries, most clients passed the true/false test; however, there were significant differences between adults and adolescents. In Swaziland, fewer adolescents than adults passed the test (85% vs. 96%; p < 0.001), and mean scores were lower among adolescents than adults (8.82 vs. 9.35; p< 0.001). In both countries, significantly fewer adolescents (p < 0.05) responded correctly to several questions indicating difficulty understanding "risk," both in relation to potential consequences of the surgery and reduced chances of getting HIV post-MC. Among clients who participated in the true/false test, adolescents were significantly less likely (p < 0.05) than adults to have been comfortable with the decision to undergo MC (13% vs. 44%, Zambia; 48% vs. 71%, Swaziland). In both countries, most adolescents who participated in SSIs said they had chosen MC for themselves. Some Zambian adolescents said it had been their parents' decision to which they had eventually been persuaded; however, one adolescent said he had been very upset, having felt unduly pressured by his father.
Conclusions and Recommendations
Adolescents may not be as comfortable choosing MC as adults, nor do they have sufficient understanding of some key MC IC concepts. Specific recommendations for improving IC for adolescents include introducing participatory counseling/education sessions that actively engage youth to ensure they understand the information being provided (vs relying on them to ask questions); developing alternative communication tools, like video, to help explain difficult concepts to adolescents who may have lower levels of education and are likely to have less sexual experience than adults; training providers to actively seek assent from minors, even if formal documentation is not legally required; and establishing a mechanism for ensuring adolescents with trepidations receive appropriate counseling.
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Contacts and Resources
The Population Council welcomes Landis MacKellar as co-editor of Population and Development Review.