The (Mis)Reporting of Male Circumcision Status among Men and Women in Zambia and Swaziland: A Randomized Evaluation of Interview Methods

BACKGROUND: To date, male circumcision prevalence has been estimated using surveys of men self-reporting their circumcision status. HIV prevention trials and observational studies involving female participants also collect data on partners' circumcision status as a risk factor for HIV/STIs. A number of studies indicate that reports of circumcision status may be inaccurate. This study assessed different methods for improving self- and partner reporting of circumcision status. METHODS/FINDINGS: The study was conducted in urban and rural Zambia and urban Swaziland. Men (N = 1264) aged 18-50 and their female partners (N = 1264), and boys (N = 840) aged 13-17 were enrolled. Participants were recruited from HIV counseling and testing sites, health centers, and surrounding communities. The study experimentally assessed methods for improving the reporting of circumcision status, including: a) a simple description of circumcision, b) a detailed description of circumcision, c) an illustration of a circumcised and uncircumcised penis, and d) computerized self-interviewing. Self-reports were compared to visual examination. For men, the error in reporting was largely unidirectional: uncircumcised men more often reported they were circumcised (2-7%), depending on setting. Fewer circumcised men misrepresented their status (0.05-5%). Misreporting by women was significantly higher (11-15%), with the error in both directions. A sizable number of women reported that they did not know their partner's circumcision status (3-8%). Computerized interviewing did not improve accuracy. Providing an illustration, particularly for illiterate participants, significantly improved reporting of circumcision status, decreasing misreporting among illiterate participants from 13% to 10%, although misreporting was not eliminated. CONCLUSIONS: Study results suggest that the prevalence of circumcision may be overestimated in Zambia and Swaziland; the error in reporting is higher among women than among men. Improved reporting when a description or illustration is provided suggests that the source of the error is a lack of understanding of male circumcision

Logistic regression on pooled data assessing illustration on misreporting of MC status.

†<p>p<.10,</p>*<p>p<.05,</p>**<p>p<.01;</p><p><b>OR:</b> odds ratio; <b>AOR:</b> adjusted odds ratio and significance tests. Tribal affiliation included in model, but results not shown. Standard errors adjusted for clustering within interview mode. Models do not include cases of partial circumcision.</p>±<p>Statistical computation based on approach by Norton et al. <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0036251#pone.0036251-Norton1" target="_blank">[24]</a>; includes full set of covariates shown above (results not shown). Odds of misreporting based on estimation approach suggested by Buis <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0036251#pone.0036251-Buis1" target="_blank">[25]</a>.</p

Direction of misreporting of MC status among those reporting.

<p>Direction of misreporting of MC status among those reporting.</p

Illustrations of circumcised and uncircumcised penis.

<p>Illustrations of circumcised and uncircumcised penis.</p

Visual examination refusal rates.

<p>Visual examination refusal rates.</p

Study design and experimental assignment by setting.

<p>Study design and experimental assignment by setting.</p

Logistic regression assessing experimental arms on misreporting of MC.

†<p>p<.10,</p>*<p>p<.05,</p>**<p>p<.01.</p><p><b>OR:</b> odds ratio; <b>AOR:</b> adjusted odds ratio: adjusted for all demographic and other variables in <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0036251#pone-0036251-t001" target="_blank">Table 1</a>; significant covariates discussed in text. Standard errors adjusted for clustering within interview method for. Samples sizes based only on those participating in the visual examination.</p><p><b>Ref:</b> reference or base category.</p>±<p>Dropped cases in which clinician indicated partial circumcision (n = 44) – see text.</p

Demographic characteristics of study participants (percentages unless otherwise indicated).

a<p>Adolescent sample was dropped in rural Zambia due to insufficient differences observed in urban Zambia and Swaziland.</p>b<p>Don't know and partially circumcised cases dropped from analysis of misreporting of MC status.</p>c<p>Defined as answering correctly that reducing partners, using condoms, and abstinence are HIV prevention methods; that a person cannot become infected by sharing food with someone who has AIDS; and that it is possible for a person who looks healthy to have AIDS <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0036251#pone.0036251-Central1" target="_blank">[16]</a>.</p

Replication Data for: Provider perspectives on PrEP for adolescent girls and young women in Tanzania: The role of provider biases and quality of care

Background Oral pre-exposure prophylaxis (PrEP) has the potential to reduce HIV acquisition among adolescent girls and young women (AGYW) in sub-Saharan Africa. However, health care providers’ (HCPs) perspectives and interactions with potential clients can substantially influence effective provision of quality health services. We examine if HCPs’ knowledge, attitude, and skills, as well as their perceptions of facility readiness to provide PrEP are associated with their willingness to provide PrEP to AGYW at high risk of HIV in Tanzania. Methods A self-administered questionnaire was given to 316 HCPs from 74 clinics in two districts and 24 HCPs participated in follow-up in-depth interviews (IDIs). We conducted bivariate and multivariable Poisson regression to assess factors associated with willingness to provide PrEP to AGYW. Thematic content analysis was used to analyze the IDIs, which expanded upon the quantitative results. Results Few HCPs (3.5%) had prior PrEP knowledge, but once informed, 61.1% were willing to prescribe PrEP to AGYW. Higher negative attitudes toward adolescent sexuality and greater concerns about behavioral disinhibition due to PrEP use were associated with lower willingness to prescribe PrEP. Qualitatively, HCPs acknowledged that biases, rooted in cultural norms, often result in stigmatizing and discriminatory care toward AGYW, a potential barrier for PrEP provision. However, better training to provide HIV services was associated with greater willingness to prescribe PrEP. Conversely, HCPs feared the potential negative impact of PrEP on the provision of existing HIV services (e.g., overburdened staff), and suggested the integration of PrEP into non-HIV services and the use of paramedical professionals to facilitate PrEP provision. Conclusions Preparing for PrEP introduction requires more than solely training HCPs on the clinical aspects of providing PrEP. It requires a two-pronged strategy: addressing HCPs’ biases regarding sexual health services to AGYW; and preparing the health system infrastructure for the introduction of PrEP.</p