Providers’ Perceptions and Training Needs for Counseling Adolescents Undergoing Voluntary Medical Male Circumcision
Providers' Perceptions and Training Needs for Counseling Adolescents Undergoing Voluntary Medical Male Circumcision
Aaron A. R. Tobian 1 3
Kim H. Dam 0
Lynn M. Van Lith 0
Karin Hatzold 7
Arik V. Marcell 1 6
Webster Mavhu 5
Catherine Kahabuka 4
Lusanda Mahlasela 9
Eshan U. Patel 3
Emmanuel Njeuhmeli 8
Kim Seifert Ahanda 8
Getrude Ncube 2
Gissenge Lija 10
Collen Bonnecwe 11
Michelle R. Kaufman 1
0 Johns Hopkins Center for Communication Programs , Baltimore, Maryland , USA
1 Johns Hopkins Bloomberg School of Public Health
2 Ministry of Health and Child Care , Harare , Zimbabwe
3 Department of Pathology, Johns Hopkins University School of Medicine
4 CSK Research Solutions, Ltd. , Dar es Salaam , Tanzania
5 Centre for Sexual Health & HIV/ AIDS Research , Harare , Zimbabwe
6 Department of Pediatrics, Johns Hopkins University School of Medicine , Baltimore, Maryland , USA
7 Population Services International , Harare , Zimbabwe
8 Office of HIV/AIDS, Global Health Bureau, United States Agency for International Development, Washington, District of Columbia , Washington D.C. , USA
9 Centre for Communication Impact , Pretoria , South Africa
10 Ministry of Health, Community Development , Gender, Elderly and Children, Dar es Salaam , Tanzania
11 National Department of Health , Pretoria , South Africa
Background. The majority of individuals who seek voluntary medical male circumcision (VMMC) services in sub-Saharan Africa are adolescents (ages 10-19 years). However, adolescents who obtain VMMC services report receiving little information on human immunodeficiency virus (HIV) prevention and care. In this study, we assessed the perceptions of VMMC facility managers and providers about current training content and their perspectives on age-appropriate adolescent counseling. Methods. Semistructured in-depth interviews were conducted with 33 VMMC providers in Tanzania (n = 12), South Africa (n = 9), and Zimbabwe (n = 12) and with 4 key informant facility managers in each country (total 12). Two coders independently coded the data thematically using a 2-step process and Atlas.ti qualitative coding software. Results. Providers and facility managers discussed limitations with current VMMC training, noting the need for adolescent-specific guidelines and counseling skills. Providers expressed hesitation in communicating complete sexual health information-including HIV testing, HIV prevention, proper condom usage, the importance of knowing a partner's HIV status, and abstinence from sex or masturbation during wound healing-with younger males (aged <15 years) and/or those assumed to be sexually inexperienced. Many providers revealed that they did not assess adolescent clients' sexual experience and deemed sexual topics to be irrelevant or inappropriate. Providers preferred counseling younger adolescents with their parents or guardians present, typically focusing primarily on wound care and procedural information. Conclusions. Lack of training for working with adolescents influences the type of information communicated. Preconceptions hinder counseling that supports comprehensive HIV preventive behaviors and complete wound care information, particularly for younger adolescents.
Voluntary medical male circumcision (VMMC) reduces the
risk of human immunodeficiency virus (HIV) and other
sexually transmitted infections (STIs) [
]. In 2011, the World
Health Organization (WHO) and UNAIDS launched the joint
strategic action framework for acceleration of the scale-up
of VMMC, aimed at reaching 80% of men aged 15–49 years
in sub-Saharan Africa to curb the HIV epidemic [
Younger adolescent clients (10–14 years) are also receiving
VMMC in the priority countries [
]. VMMC provides a
unique forum to educate young males not only about a range
of sexual and reproductive health issues, including HIV
preventive behaviors and gender issues, but also to link them into
care and treatment, if necessary [
]. The WHO
minimum package recommends providers, regardless of client age,
deliver HIV testing services, HIV risk reduction strategies,
information on VMMC risks and benefits, and instructions
on wound care [
Despite these recommendations, it is unclear if adolescents
(10–19 years), especially younger males (<15 years), are
receiving the same range of counseling regarding the procedure,
wound care, and/or other sexual and reproductive health
education as their adult counterparts [
]. In 3 priority countries,
HIV and sexual health counseling and in-service
communication were found to be largely absent during VMMC services
for adolescents, particularly those aged <15 years [
may be due to lack of specific guidance and providers’ belief
that sexual health information and risk reduction discussions
were unnecessary for younger clients who they assumed had
not reached sexual debut.
Little is known about the type of training providers receive
and their approach to applying their training and knowledge.
The purpose of the current study was to explore provider
perceptions of past VMMC counselor training and reported
strategies for counseling adolescents as compared to adult clients, and
facility managers’ views of their support to providers working
with adolescents in 3 countries.
The Tanzania National Institute for Medical Research, the
Human Sciences Research Council in South Africa, the Medical
Research Council of Zimbabwe, and the Johns Hopkins
Bloomberg School of Public Health Institutional Review Board
approved the study prior to data collection.
Setting and Participants
In-depth, semistructured interviews, tailored for each group,
were conducted with providers (eg, VMMC counselors, nurses,
midwives) who deliver information to adolescent males
seeking VMMC services and with facility managers who oversee the
provision of VMMC services to adolescent males. Data were
collected in South Africa (February 2016–June 2016), Tanzania
(June 2015–September 2015), and Zimbabwe (August 2015–
December 2015). Research field supervisors visited facilities that
offer VMMC services to adolescents to inform VMMC facility
managers and staff about the research and to request
participation. Some sites were permanent health facilities, such as hospitals
and community clinics, while others were mobile clinics, such as
medical tents temporarily constructed in order to offer services in
a given community before moving on to other settings [
locations of the 12 service sites were rural (4), peri-urban (3), and
urban (5). The study recruited female and male VMMC
providers who primarily counseled adolescent males aged 10–19 years
and facility managers who oversaw VMMC service provision for
adolescent males at the selected facilities.
Individual informed consent was obtained before
interviewing eligible providers and facility managers. Local research
field workers conducted interviews in the countries’ local
languages (Sesotho, isiZulu, or isiSwati in South Africa; kiSwahili
in Tanzania; Shona or Ndebele in Zimbabwe) or in English if
the participant preferred. All interviews were audio recorded,
transcribed, and translated into English for coding and analysis.
Interviews with providers focused on the VMMC
counseling process, the providers’ knowledge and training specific
to VMMC, and strategies for counseling adolescent and adult
clients. Interviews with facility managers explored the
application of existing VMMC guidelines, as well as availability and
description of provider training, resources, and other structural
factors that may influence the quality of VMMC service
delivery for adolescents.
Two coders independently coded the data using a 2-step
process and Atlas.ti qualitative coding software (Berlin, Germany),
as previously described [
]. First, the 2 coders read through
all transcripts independently and identified organizational
categories. Discrepancies between their identification of
categories were discussed until a consensus was met. The coders then
applied the final list of categories to all transcripts and
identified themes under each category to help further organize the
data. The coders compared their interpretations and discussed
individual coded text for all manuscripts before reaching a
consensus. In the rare event that coders could not come to a
consensus, the Principal Investigator made the final decision.
We present the findings following the organizational categories
identified in the first step of the analysis and describe the
substantive themes within each category.
Demographic information for both providers and facility
managers is summarized in Table 1. A total of 33 (South Africa = 9,
Tanzania = 12, Zimbabwe = 12) interviews were conducted with
VMMC providers. The providers' mean age was 41.0 years, and
78.8% were female. Providers consisted of nurses/midwives
(60.6%), counselors (33.3%), and other healthcare workers
(6.1%). Overall, they had an average of 3.9 years of adolescent
VMMC service experience. In addition to counseling, providers
reported that it was their responsibility to deliver the following
services: HIV testing (84.8%); family planning, including
provision of condoms (48.5%); STI testing and treatment (42.4%);
and other general health services (45.5%).
Five of 12 facility managers were female. Facility managers
had a mean age of 42.4 years. A majority of facility managers
(83.3%) were head nurses or held director positions. Overall,
they had an average of 6.3 years of facility management
experience. Half of the facility managers also reported having direct
responsibilities related to VMMC counseling, conducting or
assisting with VMMC procedures, or HIV testing.
Counseling Approach for Adolescents
When asked how counseling was approached in daily practice
with adolescent clients compared to adult clients, providers
and facility managers in all 3 countries articulated that the
differentiation was not necessarily adolescent vs adult but rather
young nonsexually active adolescent compared to older
adolescent/adult (Table 2). Many providers felt it was important
to hold back some details perceived to be irrelevant (eg, sexual
health and HIV) for clients aged <15 years. These topics could
be broached with older adolescents if the provider deemed
Providers’ Training Needs for Adolescent VMMC Counseling • CID 2018:66 (Suppl 3) • S199
Abbreviations: HIV, human immunodeficiency virus; M, mean; SD, standard deviation; STI, sexually transmitted infection; VMMC, voluntary medical male circumcision.
aProviders could provide multiple responses regarding their responsibilities.
bIncluding the provision of condoms.
it appropriate. Facility managers in all 3 countries indicated
that their facilities generally conducted group counseling
sessions according to age and engagement in sexual activity, often
grouping younger adolescents (aged <15 years) separately from
those aged >15 years.
Counseling Younger Adolescents (<15 Years Old)
Providers and facility managers largely believed that very young
boys (10–12 years) “don’t know much yet” and have fewer
sexual experiences, so the counseling does not have to address
sexual issues in detail or at all.
S200 • CID 2018:66 (Suppl 3) • Tobian et al
…the information that we talk about especially with
this younger group [10-year-olds] is not much about
people who have...these people they have not yet indulged [in
sex] so we will mainly be focusing on the wound care, on
hygiene, not much on like somebody who has...who has
indulged. [Facility Manager, Zimbabwe]
Often, providers talked about approaching young
adolescents by asking them what they already know about VMMC
and letting their current knowledge and misconceptions drive
the counseling process. While some providers did acknowledge
Counseling approach for
Counseling younger adolescents
(aged <15 years)
Counseling older adolescents
Lack of adolescent-specific training
Limited training capacity or
Recommendations for provider
training on counseling the
Abbreviation: HIV, human immunodeficiency virus.
that national guidelines, such as those in Tanzania, require
them to address all content related to wound care, HIV
prevention, and sexual health with all age groups, in practice
providers appear to make decisions on content based on the age and
assumed sexual experience of clients.
The young ones do not even know what condoms are;
although the guidelines tell us to discuss condoms even
with children, we do not discuss them with young
children. [Provider, Tanzania]
Both providers and facility managers viewed
post-procedure care information as being too advanced for younger boys,
preferring to share this information with parents or guardians
Counseling Older Adolescents
Providers and facility managers generally felt it was more
appropriate to address sexual topics with older adolescents
(>15 years) because they were more likely to have started
experimenting with their sexuality, although a few providers thought
sexual content was only appropriate for those aged ≥18 years.
We tell the older ones [18-19 years] to keep being
faithful and abstain from sex. If they fail to do this then they
should have one sex partner and always use condoms….I
tell those who are 10-15 years not to have sex. For those
who are 16 years or older, it is a bit tricky. At that age, many
of them are going through puberty, and they tend to try
out sex. Therefore, we tell them to do their best to abstain
from sex, but if they fail, then they should always use
condoms. [Provider, Tanzania]
Compared to counseling younger adolescents, providers felt
they were more equipped to discuss a broader range of sexual
• Assumed not sexually active
• Let adolescents drive information shared
• Post-procedure care information often too advanced
• Lack of consistency about what age to start sexual and reproductive health
education (eg, ages 16+ years or 18+ years )
• Older males had more questions in general about sex, so providers felt it more
appropriate to address sexual topics
• Training not consistently provided
• Trainings often too general and for all clients
• Limited training content
• Variation in scope of training receipt
• Lack of training within different age groups of adolescents
• Team meetings occasionally used to identify gaps in training
• Emphasized need for improvements in the area of counseling the younger male
• Addressed the need for adolescent-specific guidelines (on condom use, sexually
transmitted infection care and treatment, and HIV counseling in general and
specific to disclosing HIV-positive test results to younger clients)
topics with older boys, in part because older males had more
questions related to sex post-VMMC, while younger boys’
questions focused on pain and details of the procedure.
Providers and facility managers discussed the need for refresher
trainings to keep abreast of accurate and comprehensive
information regarding HIV and VMMC. They emphasized
incorporation of training on age-appropriate HIV health education and
counseling approaches, including communicating HIV-positive
test results to adolescents.
Lack of Adolescent-Specific Training
Providers and facility managers reported that training on
adolescent VMMC counseling and adolescent sexual and
reproductive health was not consistently provided. In lieu of
such training, providers said that they drew from past
experiences and other trainings when providing adolescent VMMC
I was trained in VCT [HIV voluntary counseling and
testing] before the PITC [provider-initiative testing and
counseling] training. There are some techniques that I got
from the VCT training, some things that are not even in
the VMMC guidelines, but I do them anyways because the
situation requires me to. We are allowed to add a few other
things as long as we do not leave any gaps in the VMMC
guidelines that we are supposed to follow; the major aim is to
serve the client in the best way we can. [Provider, Tanzania]
In South Africa and Tanzania, providers stated that the
trainings were too general for all clients. They were not instructed on
how to counsel adolescents any differently from adult clients,
other than to focus on building rapport with adolescents to gain
Providers’ Training Needs for Adolescent VMMC Counseling • CID 2018:66 (Suppl 3) • S201
their trust; to speak in a way easily understood by younger clients;
and to make sure adolescents were accompanied by parents.
but it will be so brief that you don’t know how really to do
it. [Provider, Zimbabwe]
For the young ones we were trained on how to approach
them at the very beginning [of the VMMC process]. They
taught us to improve the way we counsel and deliver the
message so that young males understand well. [Provider,
Similarly, facility managers in all 3 countries reported that
the VMMC training curriculum for providers was generalized
and not age specific and had limited focus on adolescents.
No, no we are not trained [on how to talk about sexual
reproductive health issues, like sexual debut, STIs, condom
use, sexual violence] those are the things that I can say maybe
from the training that we had from tertiary education, yes
we have that knowledge but in terms of specific training that
is put in place to say go and do this training for adolescents
there is nothing or refresher course or anything, no. [Facility
manager, South Africa].
Facility managers noted that the training content pertaining
to adolescents was limited mostly to VMMC age requirements,
the consenting protocol, and the proper VMMC procedure for
adolescents. However, compared to accounts from providers in
other countries, providers and facility managers in South Africa
did mention that the training included specific HIV counseling
for adolescents. However, those who had received past training
that included adolescent-specific approaches judged it
insufficient in scope.
Limited Training or Refresher Courses
Facility managers in all 3 countries indicated that providers
receive training on the full VMMC service package from a
variety of sources, both governmental (department or Ministry of
Health) and nongovernmental. However, providers generally
reported being trained just once on VMMC counseling
(sometimes 4 to 6 years ago). A small number of providers said they had
occasionally received an update in training to then share with
colleagues. In Zimbabwe, some providers said they were trained
only once before offering VMMC services. The counseling
content addressed how to counsel adolescents regarding VMMC
and HIV; however, several respondents reported that they would
feel more confident and comfortable when working with
adolescents if they had more thorough and in-depth training.
Mainly the trainings we were doing were around adults.
For the adolescents… really, we weren’t doing much. But
the one [training] I got for the adolescent sexual and
reproductive health…Yes, they will be giving us information,
S202 • CID 2018:66 (Suppl 3) • Tobian et al
Facility managers discussed this deficit of in-depth provider
training and how adolescent training content has not been
available to all staff.
There is a certain training which was conducted by the
Ministry of Health about how to communicate with
adolescents. I do not remember well, there were some people
here who attended, it could be better if they could bring
that training to us all. [Facility Manager, Tanzania]
In South Africa and Tanzania, facility managers mentioned
working together with their staff to identify gaps in their
training and using staff meetings or facility-based trainings as
Recommendations for Provider Training on Counseling the Younger Male
Providers and certain facility managers emphasized the need for
improvements in the counseling of younger males and provided
examples on how to do so. For example, providers discussed
needing adolescent-focused guidance in their VMMC training on
specific content related to condom use, STI care and treatment, and
HIV counseling, in general, and specific to disclosing HIV-positive
test results to younger clients. They felt this would make them more
comfortable speaking with and counseling younger clients.
We teach the children about HIV, but I think this is a bit
higher than them…there must be a language that we can
use with children and a language which we can use with
adults. The language used in the guidelines is sufficient for
adults, but I stammer when I talk to children. [Provider,
I think to train the service providers on child counseling
would really help. Just getting the skills on how to deal with
these adolescents and also on HIV issues, because the other
reasons why we are not disclosing [their HIV status] maybe
could be because we are not trained. When they come with
their guardians, we sometimes refer them to family support
because we feel they are better trained in child counseling.
The need for adolescent-specific training was reinforced by
People [providers] also need to be trained in adolescent
sexual and reproductive health so that people
[providers] are well-versed with things that affect young people.
[Facility Manager, Zimbabwe]
Facility managers and providers agreed that VMMC training
needs to incorporate thorough adolescent-specific
recommendations to be effective.
Overall, VMMC providers and facility managers interviewed in
3 countries reported having received little, if any, training on
how to work with adolescent clients, especially younger clients.
It is important for VMMC staff to be trained on how to
properly assess the client’s sexual activity level, to frame counseling
around the individual client’s needs, and to ensure that
counseling is comprehensive for each adolescent client, regardless of
their age or sexual experience.
The study findings in all 3 countries, which revealed training
deficits on the needs of adolescents can have a potential
negative impact on care, is supported by previous studies. A small
qualitative study in South Africa suggested that clinics were
not prepared to handle youth HIV counseling and testing [
A systematic review of general HIV interventions found that
counseling for older adolescents may not be relevant or
effective for younger adolescents [
]. A recent systematic
review of best practices in adolescent VMMC found a general
absence of health services addressing the specific needs of male
]. The review suggested that barriers included
incomplete information provision to adolescents,
infrastructure limitations, stigmatization of sexuality, patient privacy
violations, and fear of pain associated with the procedure, all of
which can make the VMMC experience less than desirable for
adolescents. The same review showed that factors linked to an
effective experience for adolescents included engagement with
parents and the community, an adolescent-friendly service
environment, and use of age-appropriate VMMC materials that
can be easily understood by young males.
This study has some limitations. Qualitative data, by nature,
are not generalizable beyond the included participants. The
study did not account for cultural differences among
countries or between sites within countries but rather focused on
the training and the counseling prescribed by WHO or local
governments for adolescent VMMC clients. VMMC sites were
identified in conjunction with the Ministry of Health in each
country and the organizations conducting the procedures. The
counseling approaches used and the experiences of adolescents
might differ between sites, geographic locations, and the
organizations managing the sites and providers. In addition, VMMC
guidelines for counseling vary between countries.
For many young males, VMMC is their first contact with the
health delivery system. The current lack of adolescent-specific
guidelines and appropriate training curricula creates a
challenge to adequate counseling by VMMC providers and facility
managers for adolescents of varying ages about HIV
preventive behaviors and risk reduction strategies. This situation
leaves VMMC service providers to rely on their own best
judgment to determine what approach is deemed
appropriate. In the absence of clarity, each provider may be assessing
clients using a different set of criteria, leaving little to no
consistency within the VMMC counseling experience. VMMC
programs may also consider having certain providers who
are more comfortable communicating with younger
adolescents about their sexuality dedicated to working with this
clientele. Adolescent VMMC counseling is a neglected gateway
to engage young clients in ongoing sexual and reproductive
healthcare and falls short of delivering the WHO minimum
package of services. If VMMC services are to be responsive
to adolescent clients and prepare them for a lifetime of
HIVpreventive and health-seeking behaviors, additional training
related to both adolescent-specific messaging and age-specific
counseling skills is essential.
Acknowledgments. We are grateful to the adolescent participants in this
study for sharing their perspectives and experiences. The authors also thank
the VMMC facility managers, community mobilizers, and providers for their
support. Further, the authors acknowledge the contributions of the Technical
Advisory Group for the adolescent VMMC assessment and their guidance
throughout the study. We are privileged to work with this group of
dedicated professionals from the US President’s Emergency Plan for AIDS Relief
(PEPFAR), Centers for Disease Control and Prevention, US Department of
Defense, the World Health Organization, United Nations Children’s Fund,
and the Bill and Melinda Gates Foundation. Thank you to the Human Sciences
Research Council in South Africa, CSK Research Solutions in Tanzania, PSI/
Zimbabwe, and the Centre for Sexual Health & HIV/AIDS Research in
Zimbabwe for their assistance with data collection. The authors also
appreciate the assistance of Meaghen Murphy with copy editing and Maria Elena
Figueroa with project start-up.
Disclaimer. The findings and conclusions in this report are those
of the authors and do not necessarily represent the official position of
the United States government, United States Agency for International
Development (USAID), PEPFAR, or any other affiliate organizations or
Financial support. This work was supported by the United States
Agency for International Development with PEPFAR funding
(cooperative agreement AID-OAA-A-12-00058) to the Johns Hopkins Center
for Communication Programs and cofunded by the UK Department of
International Development through the Integrated Support Program in
Supplement sponsorship. This article appears as part of the supplement
“Adolescent Voluntary Medical Male Circumcision: Vital Intervention Yet
Improvements Needed,” sponsored by Johns Hopkins University.
Potential conflicts of interest. All authors: No reported conflicts of
interest. All authors have submitted the ICMJE Form for Disclosure of
Potential Conflicts of Interest. Conflicts that the editors consider relevant to
the content of the manuscript have been disclosed.
Providers’ Training Needs for Adolescent VMMC Counseling • CID 2018:66 (Suppl 3) • S203
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