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

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Abstract

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.

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Acknowledgments

We gratefully acknowledge the Zambian MOH, the University of Zambia Research Ethics Committee, and the Scientific and Ethics Committee of Swaziland for their review and approval of the study. The research team would like to acknowledge the collaborating institutions and their staff for their active involvement and support of this study; in particular, Steve Gesuale, Hayden Hawry, and Jessica Greene (Population Services International—Society for Family Health, Zambia); Marie Stopes International (MSI Zambia and MSI Swaziland); Family Life Association (FLAS) of Swaziland, and Jhpiego (Baltimore, MD). We are also grateful for the contributions of the study coordinators in Zambia (Kelvin Munjile) and Swaziland (Alfred Adams) and the data collection teams. We are especially grateful to the MC clients and to the parents and guardians of adolescent clients who generously gave their time to participate in the study. Significant support was provided by Population Council staff including Sharon Abbott, Maria Alevrontas, Nicole Haberland, Sherry Hutchinson, Virginia Kallianes, Barbara Mensch, Barbara Miller, and Naomi Rutenberg. This study was conducted under a subgrant from Population Services International (PSI) through the MC Partnership, which is sponsored by PSI with support from the Bill & Melinda Gates Foundation.

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Correspondence to Barbara A. Friedland.

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Friedland, B.A., Apicella, L., Schenk, K.D. et al. How Informed are Clients Who Consent? A Mixed-Method Evaluation of Comprehension Among Clients of Male Circumcision Services in Zambia and Swaziland. AIDS Behav 17, 2269–2282 (2013). https://doi.org/10.1007/s10461-013-0424-1

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