"On the cutting edge: Research to improve the informed consent process for adolescents in Zambia undergoing male circumcision for HIV prevention"
Katie Schenk, Barbara Friedland, Lou Apicella, Meredith Sheehy, Kelvin Munjile, and Paul Hewett
To assess the informed consent (IC) process for adolescents participating in the Zambian scale-up of male circumcision (MC) for HIV prevention, and offer practical suggestions for improvement.
The Male Circumcision Partnership is scaling up circumcision in Zambia as an HIV prevention intervention among adolescents and adults.
Between November 2009 and March 2010, we conducted semistructured interviews (SSIs) with MC clients (28 adolescents aged 13–17 years, 34 adults aged 18+) one week post-surgery, and 13 key informants (including community leaders, ethics experts, providers). We conducted six focus group discussions (FGDs) among 36 parents/guardians; half had chosen MC for their sons, half had declined. We also administered a test to assess comprehension of key MC concepts among clients (115 adolescents, 311 adults), between MC counseling and surgery at clinics in Lusaka. Clients achieving a score of 8 or more correct out of 10 true/false statements were said to have passed the comprehension test.
Mean ages of participants in the comprehension assessment were 15.4 and 25.7 years for adolescents and adults, respectively, and most were single (100% adolescents; 73% adults). Quantitative modeling explored client comprehension of key concepts associated with MC required to provide informed consent. Logistic regression indicated that age was not a factor associated with passing the comprehension test; however, adolescents scored significantly (p<0.05) lower than adult clients on two questions, reflecting difficulty understanding the risks associated with MC surgery and its relationship to prior HIV status. Adolescent clients were also significantly less likely than adult clients to report feeling comfortable with the decision to undergo MC (44% vs. 13%, p<0.05). Qualitative data from SSIs with clients and key informants and FGDs with parents/guardians indicated that IC procedures for minors are not universally understood and not consistently implemented. Not all clinic staff are aware of the age of consent for surgical procedures. A majority of adolescents interviewed reported that MC had been their own choice; most said that they had received parental approval. A few said that they had gone alone, without prior parental knowledge, and others reported having gone at the suggestion of a parent. Several adolescents indicated that circumcision had originally been a decision made by their parent/guardian to which they had eventually agreed; however one adolescent was upset and seemed to have been unduly pressured.
Based on study findings, we recommend that service providers improve aspects of the informed consent process for minors, including:
- Publicize consent requirements for minors during MC outreach activities so that clients arrive prepared;
- Conduct refresher training for clinic staff on age of consent (18 years) and IC procedures for minors;
- Even if formal written documentation is not legally required, train providers to actively seek assent from minors, including establishing a mechanism for ensuring that adolescents with trepidations receive appropriate counseling;
- Develop counseling protocols targeted to adolescents, including active probing to improve understanding of key concepts, rather than waiting for adolescents to ask questions.
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