Introduction

Interventions by the Center for Disease Control and Prevention (CDC), the World Health Organization (WHO), and the Zambian government have been recommended to reduce HIV infection rates. One intervention widely implemented is voluntary medical male circumcision (VMMC), which reduces HIV acquisition risk by 50–70% [1]. Despite its effectiveness, VMMC initially faced low acceptance in Zambia due to varied concerns, e.g., pain and sexual abstinence [2]. The Spear and Shield (S&S) program, a VMMC promotion intervention, was highly successful in increasing VMMC in the Zambian context. Like VMMC, early infant male circumcision (EIMC) has faced challenges to uptake, despite faster healing time and long-term protection against HIV and certain STIs [3,4,5].

In 2017, the Zambian national level of EIMC uptake was 10%, which is low considering the procedure carries less risks than VMMC and benefits surpass the risks (200:1) [3, 6]. Acceptability of EIMC following discussion with mothers during perinatal care has been high, but actual uptake has remained low. The Zambian government has recommended demand generation strategies for EIMC to motivate parents to circumcise their male infants [7]. “Like Father, Like Son” (LFLS) is an intervention conducted in Zambia that combined demand generation strategies targeting both EIMC and VMMC.

Parents, family members, friends, and influential others may influence EIMC decision-making. Previously, components of parental EIMC decision-making pre- and post-partum were broadly examined among LFLS pilot study intervention participants [8]. The objective of the current study was to more specifically examine sociodemographic factors and the influence of extended family members and friends on parental EIMC decision-making. Given the high acceptability and low uptake of EIMC in Zambia, it was hoped this study would provide a more family-centric approach to enable insight into factors underlying the decision to circumcise male infants and serve as a foundation for future programs to stimulate EIMC uptake.

Methods

Ethical Considerations

Prior to study initiation, ethical approval was obtained from the University of Miami Institutional Review Board (ID: 0190354), the University of Zambia Research Ethics Committee (Ref No. 002-11-15), and the National Health Research Authority of Zambia (ID: MOD00003594). All procedures were followed in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) following the Helsinki Declaration of 1975, as revised in 2000. The parent study was registered with clinical trials.gov under trial number NCT04119414.

Written informed consent was obtained from participants before enrolling in the study. Study staff read and reviewed the informed consent document to each candidate in their preferred language in a private one-on-one session. Clarifications were made, if needed, by the study staff members. Once the staff member confirmed that the consent was understood, candidates were asked to sign or provide their mark on the consent form and the signature of a witness was obtained.

Setting and Recruitment

The study used a longitudinal design, and information on the intervention assessments and study design have been previously described [8]. In brief, eligible participants were recruited from expecting couples attending four urban antenatal clinics in community health centers (CHCs) in Lusaka District, Zambia. Couples were eligible if they were 18 years of age or older, expecting parents, and agreed to participate as a couple. Couple members were assessed individually.

Participants and Procedures

The sample consisted of N = 600 men and women (n = 300 couples). All women in the study were pregnant and participated with their partners. Recruited couple members provided individual written informed consent. Following consent, a baseline audio computer-assisted self-interview (ACASI) assessment was conducted in English, Nyanja, or Bemba (primary local languages) in private study offices. Participants were provided a tutorial of how to use the ACASI program by study staff. Study staff members were available to provide aid and respond to any questions as needed regarding the assessment in the participants’ preferred language.

Women and their partners were an average of 15.05 weeks pregnant and followed to 6 months postpartum. The two LFLS intervention sessions, detailed below, were deployed with couples at two months prior to delivery and immediately post-delivery. The EIMC decision-making questionnaire was deployed at 6 months postpartum.

Measures

Demographic Characteristics

Participants’ demographic characteristics collected included age, employment, religious affiliation, personal yearly income, education, marital status, pregnancy status, whether they had their own children or were raising others’ children, and both the mother and father’s HIV status.

LFLS Intervention

The LFLS intervention was developed by the US and Zambia teams [9]. LFLS sessions consisted of two 90-minute meetings; session one was pre-birth, and session two was postpartum. Both sessions explored factors that might influence parental decision-making regarding EIMC; the antenatal session focused on immediate benefits of EIMC such as easier recovery and healing and cost effectiveness, while the postpartum session focused on the influence of others on EIMC decision-making. Participants had the option to invite an influential other (family or friend of the parents) to be present during the second session.

EIMC Decision-Making Process

A survey at 6 months postpartum was used to assess the relationship between EIMC decision-making influencers, e.g., infants’ parents and extended family/friends, and EIMC uptake. The survey focused on their influence on decision-making, and assessed if the partner, partner’s mother, partner’s father, sister, uncle, grandmother, and friends were asked for an opinion on EIMC, and if they were asked, what that person recommended.

Statistical Analyses

Univariate statistics were conducted to describe demographic characteristics and the opinion/recommendation to undergo EIMC or not between the parents and their family/friends. A series of chi-squared test of independence was employed to evaluate the relationship between both demographic factors and the influence of parents’ family and friends on the uptake of EIMC. Statistical significance was designated as p < 0.05. Statistical Package for the Social Sciences (SPSS) version 26 was utilized for analyses.

Results

Demographic Characteristics

Demographic characteristics associated with the decision to undergo EIMC include marital status (X2 (1, N = 283) = 5.106, p = 0.024) and religious affiliation (X2 (3, N = 283) = 9.073, p = 0.028). The relationship between other demographic factors and the decision to undergo EIMC are shown in Table 1.

Table 1 Demographic characteristics by parents combined who circumcised Versus who did not (N = 283)
Full size table

Decision-Making Processes

Decision-making of both mothers and fathers are outlined in Table 2. Notably, partners’ suggestions were associated with the decision to undergo EIMC for both mothers (X2 (2, N = 125) = 17.760, p = < 0.001) and fathers (X2 (2, N = 125) = 22.297, p = < 0.001). Of infants who were circumcised, 90.0% of parents made that decision together, indicating collaborative decision-making among the sample. In terms of external influence, i.e. family and friends, while parents did tend to seek suggestion from family, there appeared to be no influence on the decision to circumcise the infant.

Table 2 Parental decision making who circumcised Versus who did not (N = 125)
Full size table

EIMC Rates

The rate of EIMC in previous research following an informational intervention directed only to mothers was 11% [6]. The LFLS intervention, addressing both parents, identified a rate of 35% for EIMC uptake among participating couples [8]. Out of 150 couples who met the criteria to participate, fifty-two had their newborn son circumcised [8].

Discussion

This study explored the influence of demographic and interpersonal factors on EIMC decisions. The results of this study offer insight into the decision-making process surrounding EIMC in Zambia, revealing its collaborative nature.

Demographic Characteristics and their Influence

Participants were predominantly young, employed, and identifying as Christian with modest income by Zambian standards, and reflected a broad cross-section of Zambian society. Notably, the decisions regarding EIMC were not influenced by other factors, e.g., age, employment status, income, or education. Previous research has found education, specifically no schooling, to be associated with a higher chance of EIMC [7]. The current study did not find this association, such that the decision to circumcise excluded this factor. In contrast, the influence of religious affiliation and marital status on the decision to circumcise indicated that cultural and religious values, as well as family structure, may play a role in the EIMC decision-making processes.

Decision-Making Dynamics among Parents

While the father is historically the primary decision maker in the family in Zambia, this study presents evidence that the mother has an influence. In fact, couples engaged in a predominantly collaborative decision-making process with a high level of agreement and a minimum of serious disagreements [10]. Both partners’ suggestions to circumcise their infant had an impact on the final decision to undergo EIMC. These results illustrate the role of mutual influence and spousal support in family health-related decisions. As such, the interdependent nature of partners’ opinions within mother and father dyads is an important foundation for implementation of future EIMC intervention strategies [11].

The Role of Extended Family and Social Networks

While mothers and fathers asked both extended and immediate family for their suggestions on EIMC, others’ suggestions to circumcise the infant did not appear to impact mothers’ and fathers’ final decision to undergo EIMC. Compared to the impact of partners’ suggestions to undergo EIMC, extended family and friends did not appear to have an impact on the decision to circumcise infants. As such, it appears that immediate family members had less influence over EIMC decisions compared to the parental unit.

Implications for Future Interventions

Study findings suggest strategies for future interventions aiming to increase EIMC rates, should address both parents, recognizing the collaborative nature of their decision-making process. Additionally, the influence of religious affiliation and marital status should be considered when implementing interventions. While the influence of extended family was not significant in this study, their role should not be discounted. Results may differ in other culture groups. As both mothers and fathers reach out to family members for health-related advice, broader familial engagement could support increased awareness and acceptance of EIMC.

Limitations and Future Research

The main limitation of this study is the location of the study, which was conducted in urban Lusaka, Zambia. Participants were predominantly from an urban region, and results should not be generalized to other communities and rural regions of Zambia or other sub-Saharan African countries. Future studies should be conducted across a larger geographic and cultural scale to understand if decision-making differs by region or culture. Another limitation includes barriers associated with the COVID-19 pandemic, which increased reluctance for parents to bring their infants to the clinic and may have reduced social contact. Finally, there was a cholera outbreak in the community, further increasing clinic limitations in participation. These barriers may have limited uptake of EIMC.

Conclusion

This study assessed the influence of family members and friends on parents’ EIMC decision-making. Results suggest that while demographic characteristics such as religion and marital status influenced the decision-making process, the strongest influence was the partners’ recommendation. The partner’s opinion is a key determinant in the decision to elect for an infant to undergo EIMC. Findings suggest that the influence of family members and friends are less pronounced than the collaborative decision-making of the parental unit.

Though there are challenges in promoting EIMC in Zambia, this study sheds light on the importance of engaging partners and understanding their influence on the decision-making process. Increasing awareness and education about EIMC, along with partner involvement, may contribute to the success of interventions in Zambia and ultimately reduce the prevalence of HIV and some STIs. However, future research and interventions should consider the cultural and regional variations within Zambia and the potential impact of external factors on healthcare decision-making.