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

Comprehension is fundamental for informed consent—an individual's right to choose a medical proce- dure, 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.