Perceived Quality of In-Service Communication and Counseling Among Adolescents Undergoing Voluntary Medical Male Circumcision
Perceived Quality of Adolescent VMMC Counseling • CID
Perceived Quality of In-Service Communication and Counseling Among Adolescents Undergoing Voluntary Medical Male Circumcision
Lynn M. Van Lith 3
Elizabeth C. Mallalieu 3
Eshan U. Patel 1
Kim H. Dam 3
Michelle R. Kaufman 0
Karin Hatzold 7
Arik V. Marcell 6
Webster Mavhu 5
Catherine Kahabuka 4
Lusanda Mahlasela 9
Emmanuel Njeuhmeli 8
Kim Seifert Ahanda 8
Getrude Ncube 2
Gissenge Lija 10
Collen Bonnecwe 11
Aaron A. R. Tobian 1
0 Department of Health, Behavior and Society, Johns Hopkins University Bloomberg School of Public Health , Baltimore, Maryland , USA
1 Department of Pathology, Johns Hopkins University School of Medicine
2 Ministry of Health and Child Care , Harare , Zimbabwe
3 Johns Hopkins Center for Communication Programs
4 CSK Research Solutions , Dar es Salaam , Tanzania
5 Centre for Sexual Health and 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 , 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. Experience with providers shapes the quality of adolescent health services, including voluntary medical male circumcision (VMMC). This study examined the perceived quality of in-service communication and counseling during adolescent VMMC services. Methods. A postprocedure quantitative survey measuring overall satisfaction, comfort, perceived quality of in-service communication and counseling, and perceived quality of facility-level factors was administered across 14 VMMC sites in South Africa, Tanzania, and Zimbabwe. Participants were adolescent male clients aged 10-14 years (n = 836) and 15-19 years (n = 457) and completed the survey 7 to 10 days following VMMC. Adjusted prevalence ratios (aPRs) were estimated by multivariable modified Poisson regression with generalized estimating equations and robust variance estimation to account for site-level clustering. Results. Of 10- to 14-year-olds and 15- to 19-year-olds, 97.7% and 98.7%, respectively, reported they were either satisfied or very satisfied with their VMMC counseling experience. Most were also very likely or somewhat likely (93.6% of 10- to 14-year olds and 94.7% of 15- to 19-year olds) to recommend VMMC to their peers. On a 9-point scale, the median perceived quality of in-service (counselor) communication was 9 (interquartile range [IQR], 8-9) among 15- to 19-year-olds and 8 (IQR, 7-9) among 10- to 14-year-olds. The 10- to 14-year-olds were more likely than 15- to 19-year-olds to perceive a lower quality of in-service (counselor) communication (score <7; 21.5% vs. 8.2%; aPR, 1.61 [95% confidence interval, 1.33-1.95]). Most adolescents were more comfortable with a male rather than female counselor and provider. Adolescents of all ages wanted more discussion about pain, wound care, and healing time. Conclusions. Adolescents perceive the quality of in-service communication as high and recommend VMMC to their peers; however, many adolescents desire more discussion about key topics outlined in World Health Organization guidance.
Adolescents’ experiences with a healthcare provider can shape
the perceived quality of adolescent sexual and reproductive
health (ASRH) services. A systematic literature review focused
on ASRH services in sub-Saharan Africa highlights evidence of
a disregard for privacy, judgmental attitudes toward adolescents
seeking services, and a lack of respect, all of which negatively
affect adolescent–provider interaction [
]. Insufficient training
and inadequate guidelines outlining how best to address
adolescents’ sexual and reproductive health needs are barriers for
providers, with the result that the counseling needs of young
people remain largely ignored [
Global guidance on the standards for quality health services
for adolescents, as set forth by the World Health Organization
(WHO), advocates for competency-based trainings in
adolescent health, age-appropriate tools and materials, and ongoing
monitoring of the quality of health education and counseling
by providers [
]. This includes assessments of the
adolescents’ experience of care regarding confidentiality, privacy, and
friendly and nonjudgmental provider attitudes. The core
competencies in adolescent health for providers, also articulated by
WHO, highlight the need to approach every adolescent as an
individual with varying needs, levels of maturity, and degrees
of health literacy, while also understanding how the stages of
adolescent development (physical, cognitive, etc) influence an
adolescent’s behavior [
Adolescent experiences during voluntary medical male
circumcision (VMMC), which provides one of the few entry
points through which health services can reach male
adolescents, have the potential to influence future health-seeking
behavior. VMMC services constitute an important
opportunity to contribute to structural, policy, and healthcare setting
changes aimed at improving the health and well-being of
adolescent males [
]. Research shows that when boys feel they are
in a safe and confidential space, including with a healthcare
provider, they desire a genuine and caring relationship and
will talk honestly about their experiences [
regardless of country and socio-economic level, value
respectful patient-centered care, appropriate provision of information,
and high-quality communication, attributes which are already
endorsed by the WHO .
The WHO/Joint United Nations Programme on HIV/AIDS
Framework for VMMC 2021 includes targets for reaching 90%
of males 10–29 years of age by 2021 with VMMC services that
include “age-appropriate, comprehensive sexuality and health
education” for 10- to 14-year-olds and “detailed sexual health
counseling” among other components for 15- to 19-year-olds
]. Given that, to date, the majority of individuals seeking
VMMC across most priority countries are adolescents. This
study sought to better understand male adolescents’ perceptions
of the quality of in-service communication and counseling they
experienced while receiving VMMC services.
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
all approved the study prior to data collection. Parent
permission was obtained for adolescent males <18 years of age, and
assent/consent was obtained for all adolescents.
Study Setting and Design
Participants were recruited from 14 facilities offering VMMC
services to adolescents in South Africa, Tanzania, and
]. Data were collected from June to September
2015 in Tanzania, August to December 2015 in Zimbabwe, and
February to June 2016 in South Africa. A preprocedure
quantitative survey was conducted with a convenience sample of
adolescent males aged 10–19 years seeking VMMC (n = 1526)
]. Participants completed a postprocedure quantitative
survey 7–10 days following VMMC (n = 1293). There was a 15.3%
loss-to-follow up rate; associations with loss to follow up have
been described elsewhere [
]. The present study was limited
S206 • CID 2018:66 (Suppl 3) • Van Lith et al
to 1293 participants who completed the postprocedure survey
(South Africa, n = 299; Tanzania, n = 498; Zimbabwe, n = 496).
Satisfaction With Voluntary Medical Male Circumcision Experience
Overall satisfaction with the VMMC experience and likelihood
of recommending VMMC to male peers were measured using
ordinal 4-point Likert response scales (very dissatisfied,
dissatisfied, satisfied, very satisfied; not at all likely, a little likely,
somewhat likely, very likely).
Comfort With Gender of Counselor/Providers
Adolescents’ gender preference for providers was measured
with a 3-point Likert response scale (less comfortable, did not
change comfort, more comfortable). Participants were asked
about their level of comfort with having a male or female
counselor during the individual and group preprocedure counseling
sessions. In addition, participants were asked about their level
of comfort with having a male or female provider perform the
VMMC or check the wound during follow-up.
Perceived Quality of In-Service (Counselor) Communication
A scale to measure the perceived quality of in-service
(counselor) communication, which taps into the quality of patient–
counselor interpersonal interactions, was developed using 9
items adapted from the WHO Quality Assessment Guidelines
] and the GATHER Tool [
]. Binary responses were coded
as 0 (“no/don’t remember”) or 1 (“yes”). Exploratory factor
analysis of all 9 items was conducted using a tetrachoric
correlation matrix (Supplementary Table 1). Principal
components analysis, scree plot visualization, and parallel analysis
(1000 repetitions) suggested extraction of a single factor
that explained 57.6% of the variance. Factor loadings (range,
0.55–0.84) confirmed the decision to retain all items in the
scale. The composite scale had good internal consistency
(KR-20 = 0.74) and had a theoretical range between 0 and
9, where a lower score indicated poorer perceived quality of
Perceived Quality of Facility-Level Factors in Service Delivery
Participants were asked 7 items related to facility-level factors
that could influence the perceived quality of their VMMC
experience (eg, “Were the working days and hours of the
facility convenient for you?”). Responses were coded as 0 (“no/don’t
remember”) or 1 (“yes”).
Perceptions and Preferences in Counseling Content
To explore participants’ perceptions of the content of
counseling, they were asked (1) “What do you wish had been
discussed (more) during counseling? and (2) “What do you wish
had not been discussed during counseling?” Participants
could provide multiple unprompted responses; interviewers
had a predetermined list of relevant categories but detailed
responses could also be documented. It should be noted that
due to the open-ended nature of this question, interviewers
did not consistently administer this question to all
adolescents. Furthermore, it was not clearly coded if the interviewer
skipped the question or the adolescent responded “nothing”
to each question. Thus, these findings should be cautiously
Differences in the distribution of ordinal Likert responses
between age-groups (10–14 vs 15–19 years) were assessed using
the nonparametric Somers D test with Fisher Z transformation;
the Somers D tests accounted for facility-level clustering using
the delta-jackknife method and adjusted for country by
Correlates of a perceived quality of counselor
communication score <7/9 (ie, the proportion of participants who
perceived the poorest quality of counselor-adolescent
communication) were examined. This threshold was selected based on
the distribution of scores among the entire sample population
(median, 8; interquartile range [IQR], 7–9). For this analysis,
modified Poisson regression models were used with
generalized estimating equations and robust variance estimation to
account for facility-level clustering. Factors shown to have
an association with the outcome after adjustment for
country were included in the final multivariable model (P < .15),
with the exception of age group and receipt of a postprocedure
counseling session, which were included regardless of
statistical significance. Only some participants experienced both a
preprocedure and postprocedure counseling session, and since
the outcome variable did not differentiate between the two, a
sensitivity analysis limited to participants who self-reported
only receiving preprocedure counseling was conducted. All
analyses were among complete cases only.
Analyses were performed using Stata SE software version
14.2 (StataCorp, College Station, Texas).
A total of 1293 adolescents completed the preprocedure
and postprocedure survey, including 836 (64.7%) 10- to
14-year-olds and 457 (35.3%) 15- to 19-year-olds across South
Africa, Tanzania, and Zimbabwe. Table 1 depicts the age
breakdown by country, indicating their VMMC facility setting as
urban (53.8%), periurban (14.8%), or rural (31.3%). Of the
participants who participated in the survey, 48.8% of 10- to
14-year-olds and 19.0% of 15- to 19-year-olds received both
individual and group counseling prior to receiving services. Of
remaining participants, 16.6% of 10- to 14-year-olds and 42.2%
of 15- to 19-year-olds received only individual counseling, and
33.7% and 38.3%, respectively, received only group counseling.
Although all respondents reported receiving either individual
or group preprocedure counseling, more than
three-quarters (78.5%) of the 10- to 14-year-olds did not receive a
postprocedure counseling session, nor did half (51.0%) of 15- to
19-year-olds. Just over half (56.1%) of parents attended
the preprocedure counseling session with 10- to 14-year-olds; 12.5%
attended for the older age group.
Satisfaction With Voluntary Medical Male Circumcision Experience
The majority of adolescent clients (97.7% of 10- to
14-yearolds and 98.7% of 15- to 19-year-olds) reported they were
either satisfied or very satisfied with their VMMC experience
(Figure 1). When asked how likely they were to recommend
VMMC to other males their age, 77.7% of 10- to
14-yearolds and 72.2% of 15- to 19-year-olds reported they were
very likely to do so, with most of those remaining (15.9% and
22.5%, respectively) reporting they were somewhat likely to
do so (Figure 1).
Perceived Quality of In-service (Counselor) Communication
The overall perceived quality of in-service communication was
high; the median perceived quality of in-service communication
in-service communication to be of lower quality despite
adjusting for country, facility setting, and receipt of postprocedure
counseling session (aPR, 1.61 [95% CI, 1.33–1.95]; Table 2).
Facility setting was independently associated with a lower
perceived quality of in-service communication (Table 2).
When comparing periurban and urban settings to rural
settings, those in periurban settings were significantly less
likely to perceive in-service communication as lower quality
(aPR, 0.50 [95% CI, .37–.68]; Table 2). No significant
difference was found between rural and urban facilities. The mode of
preprocedure counseling, preprocedure counselor gender,
parent/guardian’s attendance at the preprocedure counseling
session, and receipt of a postprocedure counseling session did not
appear to significantly affect the perceived quality of in-service
These findings were replicated in a sensitivity analysis limited
to participants who received only preprocedure counseling (ie,
excluding individuals who also received a postprocedure
counseling session) (Supplementary Table 2).
Influence of Counselor and Provider Gender
Adolescents in both age groups tended to feel more
comfortable having a male rather than female counselor
during both individual and group preprocedure counseling
PR (95% CI)a
score was 8 (IQR, 7–9) among 10- to 14-year-olds and 9
(IQR, 8–9) among 15- to 19-year-olds (Supplementary Table 1).
Age was independently associated with the perceived
quality of in-service communication (score <7). Adolescents aged
10–14 years were more likely than 15- to 19-year-olds to perceive
This analysis was conducted to identify correlates of was a low perceived quality of in-service (counselor) communication score (<7/9) since scores were generally high (median, 8
[interquartile range, 7–9]). Prevalence ratios for a score <7 were calculated by modified Poisson regression models with generalized estimating equations and robust variance estimators to
account for clustering of responses at the facility level. Factors shown to have an association with the outcome after adjustment for country were included in the final multivariable model
(P < .15), with the exception of age group and the receipt of secondary counseling after the procedure, which were included regardless of statistical significance; Effect sizes for country
are not shown. Estimates in bold have a P value < .05.
Abbreviations: aPR, adjusted prevalence ratio; CI, confidence interval; PR, prevalence ratio.
aUnadjusted prevalence ratios for each covariate shown.
bFinal multivariable model included adjustment for country, age, facility setting, and receipt of postprocedure counseling session.
S208 • CID 2018:66 (Suppl 3) • Van Lith et al
sessions, but this was only significant among 15- to
19-year-olds receiving group counseling after adjustment
for country. In comparison to reported comfort among
adolescents who had a female provider, both age groups
were significantly more comfortable with a male
provider performing the procedure and with a male provider
being the one checking their wound during the follow-up
appointment (Figure 2).
Facility-Level Contributions to an Adolescent-Friendly Environment
Overall, adolescents had positive perceptions of the
facilities where they received VMMC. The majority reported the
facilities to be welcoming, they were made to feel
comfortable by all staff, wait times were reasonable, and the hours of
the facility were convenient (Figure 3). A significant
difference was found between the 2 age groups when asked about
finding transportation to the clinic and feeling embarrassed
because others might overhear what was being said during
their counseling session. The 10- to 14-year-olds were less
likely to report issues with finding transportation than the
older age group (8.1% vs 10.7%, respectively; P = .005) and
were less likely to report feeling embarrassed because others
might overhear what was said (11.5% vs 15.3%, respectively;
P < .001). Although there were significant differences between
the 2 groups (independent of country), the majority had not
experienced transport issues or embarrassment during the
Adolescent Opinions on Counseling Topics
When asked what topics they wish had been discussed more
during the counseling sessions, both 10- to 14-year-olds and
15- to 19-year-olds reported they wish there had been more
discussion about pain (35.7% and 45.0%, respectively),
followed by wound care (29.6% and 30.0%, respectively) and
healing time (13.9% and 20.0%, respectively) (Table 3). Adolescent
respondents reported they would like more information about
partial human immunodeficiency virus (HIV) protection
(13.0% for 10–14 years of age and 12.5% for 15–19 years of
age), the VMMC procedure (11.7% for 15–19 years of age),
side effects (13.3% among 15- to 19-year-olds), and condom
use (12.2% among 10- to 14-year-olds). However, when asked
what they wish had not been discussed, the same 3 topics—
pain, wound care, and healing time—were most frequently
mentioned (7.8%, 10.8%, and 11.0%, respectively, for both age
groups combined) along with partial HIV protection and the
VMMC procedure among 15- to 19-year-olds (7.4% for both).
Figure 3. Adolescent perceptions of facility-level factors of service delivery.
Proportions reflect a response of “yes.” 95% confidence intervals were estimated
by Taylor series linearization. P values were calculated from modified Poisson
regression models with generalized estimating equations and robust variance
estimation; models were adjusted for country. P values >.05 are not shown.
Despite reporting high levels of satisfaction with their VMMC
service and overall high perceived quality of in-service
communication, younger adolescents were significantly more likely to
perceive the in-service communication as lower quality
compared to older adolescents. Overall, adolescents of all ages
found facilities welcoming and reported feeling more
comfortable with male counselors and providers compared with female
counselors and providers. However, adolescents across all ages
reported they would have liked to receive more information
about pain, sexual health, wound care, and healing time, and
the majority reported not receiving postoperative counseling
or a combination of individual and group counseling, as
recommended by WHO guidance.
The absence of a postprocedure counseling session is
concerning since WHO guidance [
], the US President’s
Emergency Plan for AIDS Relief (PEPFAR) external quality
assurance assessment tools [
], and country-specific
] require postoperative counseling to highlight the
6-week healing period and to include instructions on wound
care and other key messages, including how to avoid risk of
tetanus. The postprocedure counseling session aims to ensure client
understanding and confirm follow-up appointments. Given that
Abstain from sex for 6 weeks
Abstain from masturbation for 6 weeks
Partial HIV protection
HIV testing and counseling
HIV heterosexual transmission
HIV homosexual transmission
Varying risk by type of sex behavior
Non-HIV sex education
General sexual health
What Do You Wish Had Been Discussed (More)
What Do You Wish Had Not Been Discussed
(n = 115)
Data are presented as no. (%).
Abbreviations: HIV, human immunodeficiency virus; STI, sexually transmitted infection; VMMC, voluntary medical male circumcision.
S210 • CID 2018:66 (Suppl 3) • Van Lith et al
parents play an important role in supporting wound care and
healing of their adolescent sons [
], if no postprocedure
counseling session is performed, neither the adolescent client nor, by
extension, his parents are likely to receive adequate information.
Furthermore, most adolescent clients, regardless of age, did not
receive both group and individual
preprocedure counseling sessions, although both are clearly defined in the WHO guidelines
]. The group education session is used to provide basic
information about VMMC and should be followed by individual
counseling to address an adolescent’s individual issues in a private
and confidential setting. This information gap was demonstrated
by the adolescents in this study through their desire for
additional discussion on several topics related to VMMC, including
the associated pain, which multiple studies have also shown is a
primary concern for adolescent VMMC clients [
complete counseling, it is unlikely adolescents are receiving all of
the information they need, which in turn increases their risk of
postoperative complications and may influence their subsequent
uptake of other services and quality care.
Beyond worries regarding pain, a main topic also reported by
adolescents needing further discussion is sexual health. Younger
adolescents aged 10–14 years, reported they would also like more
information about condom use. As found in Kenya [
providers may be hesitant and uncomfortable counseling younger
adolescent clients on comprehensive sexuality education due to
personal, cultural, and religious beliefs or because they assume
that the adolescent is not yet sexually active or is too young to
understand such issues [
]. These barriers infringe on the rights
of adolescents to receive this much-needed information and
present a missed opportunity to disseminate HIV prevention
messages. It is essential to reach adolescents aged 10–14 years as
their in-depth knowledge of sex and ways to prevent HIV
acquisition, including the use of condoms, is often quite low; condom
use among sexually active males in this age group is typically
lower than that of older adolescents [
]. As outlined in other
findings from this study population , younger adolescents
aged 10–14 years received fewer elements of the minimum
package overall than did 15- to 19-year-olds, despite the fact that
adolescents stated they wish they had more of this information.
This study has limitations. Given the cross-sectional study
design, reported associations should be descriptively interpreted,
and the measures for perceived quality must be taken in context
of this particular study. The study population may contain
selection biases, as the study only captured adolescents who underwent
VMMC and completed the postprocedure survey. The responses
of this study sample may vary from adolescents who did not
complete the follow-up survey and adolescents who attended the
service provision site but did not ultimately undergo VMMC.
While adolescents across the 3 study countries reported high
perceived quality of in-service communication and would
generally recommend VMMC to their peers, they also reported
wanting additional discussion on topics including pain, wound
healing, sexual health, and the VMMC procedure itself. As
stated by the WHO, adolescents “are not simply older children or
younger adults,” but instead are individuals with particular needs
who require providers sufficiently competent to respond to those
needs and ensure adolescent-responsive care [
programs are therefore expected to ensure that all counseling (group,
individual, and a postprocedure session) is provided according
to global guidance and all topics are discussed to the satisfaction
of adolescent clients. When the specific needs of all adolescent
clients are addressed through comprehensive counseling that
considers the developmental competencies of individual clients
], encompassing both their desires and the global guidelines,
VMMC has the potential to have the greatest impact on both
immediate and long-term male health-seeking behavior.
Supplementary materials are available at Clinical Infectious Diseases online.
Consisting of data provided by the authors to benefit the reader, the posted
materials are not copyedited and are the sole responsibility of the authors,
so questions or comments should be addressed to the corresponding
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, and 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, World Health Organization, United Nations Children’s Fund,
and Bill & Melinda Gates Foundation. Thanks go to the Human Sciences
Research Council in South Africa, CSK Research Solutions in Tanzania,
PSI/Zimbabwe, and the Centre for Sexual Health and HIV/AIDS Research
in Zimbabwe for their assistance with data collection. The authors also
appreciate the assistance of Meaghen Murphy with copyediting and Maria
Elena Figueroa with project startup.
Disclaimer. The findings and conclusions in this report are those of the
authors and do not necessarily represent the official position of the US
government, US Agency for International Development (USAID), PEPFAR, or
any other affiliate organizations or institutions.
Financial support. This work was supported by USAID (cooperative
agreement number AID-OAA-A-12-00058) to the Johns Hopkins Center
for Communication Programs and co-funded 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.
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