APHA 139th Annual Meeting and Exposition
29 October–2 November 2011
"A cut above? Evidence-based lessons for improving the informed consent process for male circumcision in Swaziland and Zambia"
Katie D. Schenk, Barbara Friedland, Lou Apicella, Meredith Sheehy, Kelvin Munjile and Paul C. Hewett
Male circumcision (MC) is being scaled up in Zambia and Swaziland to reduce HIV infection. International guidance stresses sound informed consent (IC) procedures, using a human rights-based approach.
We evaluated the MC IC process at clinics in Zambia and Swaziland during 2009–2010. We administered a quantitative clients assessment (Zambia: n=115 adolescents aged 13–17, 311 adults aged 18+; Swaziland n=197 adolescents, 756 adults) between MC counseling and procedure. We conducted semistructured interviews with clients one week postprocedure (Zambia: n=62; Swaziland n=30); and, in Zambia, focus group discussions with parents/guardians (n=36) who accepted and declined MC.
Quantitative data showed that most participants (e.g., Zambia: 84%/98% adolescents/adults) were comfortable with their decision to undergo MC, with adults significantly more likely than adolescents to report decision comfort (p<0.001). Most clients (e.g., Swaziland 93%/76%) decided on MC before clinic arrival, influenced by friends and family. Almost all said they chose MC voluntarily; however, many were confused about the IC form's significance: some misperceived it as a release from clinic liability while others could not remember signing. Consent procedures for minors were poorly understood and inconsistently implemented.
Recommendations have already been incorporated into provider training, including:
- Expand outreach messaging recognizing that the IC process begins during community sensitization;
- Reinforce the IC process step at which proceeding with surgery is authorized;
- Conduct refresher training for providers on consent for minors, and publicize requirements widely during outreach;
- Standardize mechanisms for adolescents to actively assert assent and receive additional counseling if trepidations remain.
- Administer health education strategies, interventions, and programs
- Conduct evaluation related to programs, research, and other areas of practice
- Ethics, professional and legal requirements
- Implementation of health education strategies, interventions, and programs
- Protection of the public in relation to communicable diseases, including prevention or control
- Provision of health care to the public
- Identify concrete steps for improving the client informed consent process implemented at clinics in high-HIV-prevalence areas conducting a high volume of male circumcision procedures for HIV prevention.
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