Peer-reviewed article
Exploring joint decision-making and family dynamics to identify barriers and enablers for early adolescent medical circumcision (EAMC) uptake in Zambia for HIV prevention: An innovative methodology.
Rasi Surana, Ram Prasad, Namiya Jain, Mothi Prasad, Alok Gangaramany et al. ·
Summary
Written by AI, not yet AICS's view · claude-haiku-4-5-20251001This study explores how adolescent boys aged 10-19 and their caregivers in Zambia make decisions about early adolescent medical circumcision (EAMC) for HIV prevention. Researchers used interviews, journey mapping, and a decision-making game to understand family dynamics and what encourages or prevents boys from choosing circumcision. Key barriers included fear of pain, safety concerns, and uncertainty about family agreement, while enablers included social acceptance and hygiene benefits. The findings suggest that HIV prevention programs should involve whole families and address how decision-making changes as adolescents grow older.
Key points
- Barriers to EAMC uptake include anticipated surgical pain, mistrust about safety, boys' uncertainty about caregiver consent, and caregiver concerns about adolescent maturity
- Enablers for EAMC include in-group seeking behavior, belief that circumcision is valued by women, and perceived hygiene improvements
- Decision-making about EAMC involves complex joint dynamics between caregivers and adolescents that change with the boy's age through adolescence
- The study used behavioral science methods including interviews, journey mapping, and an Ethnolab decision-making game to overcome limitations of survey-based research
- Demand generation strategies should involve whole family units and encourage household-level discussion and trust
Limitations
This is a qualitative methodology paper that explores decision-making factors rather than testing the effectiveness of an intervention to improve EAMC uptake. The document does not provide data on whether implementing these recommendations actually increases circumcision rates or improves health outcomes.
Abstract
Voluntary medical male circumcision (VMMC) to protect against sexual transmission of HIV is a key part of HIV prevention interventions in 15 priority countries in Southern and Eastern Africa. Ensuring that VMMC programs reach adolescent males is important in countries with large young populations. We designed a methodology to explore the joint decision-making dynamics among caregivers and adolescents aged 10-19, and the drivers and barriers for circumcision, in order to identify levers which can drive uptake of VMMC. Our approach was grounded in behavioral science to address some of the limitations of survey-based research (e.g., the "say-do gap," social desirability bias, respondent fatigue). Our methods included 1) interviews with adolescent boys and their caregivers to understand how adolescents interact with their families, other key stakeholders, and the healthcare system; 2) journey mapping to understand how boys and caregivers move through the stages of progress toward the decision for VMMC, and the influence of context, family, and community members; and 3) Ethnolab, a decision-making game that tests behavioral hypotheses in hypothetical situations mimicking the real-life context of decision-making about VMMC, enabling an understanding of boys' and caregiver's motivators, barriers, and mental models via observation as well as questioning. Factors influencing the decision for VMMC included anticipated pain of the surgical procedure, mistrust about safety, the boy's uncertainty about his caregiver's consent, and caregiver's uncertainty about the adolescent's assent, and caregiver's concern about their adolescent boy's maturity level and ability to deal with VMMC, among others. Conversely, in-group seeking, the belief that being circumcised is appreciated by women, and improved hygiene were among the positive factors motivating decisions for VMMC. Demand generation should involve the whole family unit, encouraging discussion and trust within and among households, and recognizing and addressing the ways decision dynamics change as the boy ages through adolescence.