Original Paper

AIDS and Behavior

, Volume 17, Issue 6, pp 2269-2282

First online:

How Informed are Clients Who Consent? A Mixed-Method Evaluation of Comprehension Among Clients of Male Circumcision Services in Zambia and Swaziland

  • Barbara A. FriedlandAffiliated withPopulation Council Email author 
  • , Louis ApicellaAffiliated withPopulation Council
  • , Katie D. SchenkAffiliated withPopulation Council
  • , Meredith SheehyAffiliated withPopulation Council
  • , Paul C. HewettAffiliated withPopulation Council

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Comprehension is fundamental for informed consent—an individual’s right to choose a medical procedure, such as male circumcision (MC). Because optimal benefits depend on post-surgical behaviors, comprehension is particularly critical for MC programs. We evaluated clients’ comprehension of MC’s risks and benefits, wound care instructions, and risk reduction post-MC using a true/false test (n = 1181) and 92 semi-structured interviews (SSIs) in Zambia and Swaziland. Most participants (89 % Zambia, 93 % Swaziland) passed the true/false test, although adolescents scored lower (significantly so in Swaziland) than adults and one-third (including nearly half of adolescents in Zambia) said MC has no risks. SSIs indicated confusion between “risk” of adverse surgical outcomes and reduced “risk” of HIV; most respondents acknowledged the 6 week abstinence period post-MC, yet few said resuming sex early increases HIV risk. Providers should distinguish between surgical “risks” and reduced HIV “risk,” and emphasize that HIV risk increases with sex before complete healing.


Male circumcision Comprehension Informed consent Risks Risk behavior VMMC programs