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Citation: Surana R, Prasad R, Jain N, Prasad M,
Gangaramany A, Shashi Kumar A, et al. (2025)
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. PLoS One 20(4):
e0319472. https://doi.org/10.1371/journal.
pone.0319472
Editor: Hamufare Mugauri, University of
Zimbabwe Faculty of Medicine: University
of Zimbabwe College of Health Sciences,
ZIMBABWE
Received: January 17, 2024
Accepted: February 3, 2025
Published: April 29, 2025
Peer Review History: PLOS recognizes the
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available here: https://doi.org/10.1371/journal.
pone.0319472
RESEARCH 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 Surana1, Ram Prasad1, Namiya Jain1, Mothi Prasad1, Alok Gangaramany 1,
Aishwarya Shashi Kumar1, Tim Sweeney2, Jeff Mulhausen2, Steve Kretschmer3,
Alick Samona3, Alice Nanga3, Tina Chisenga4
1 Final Mile Consulting, New York, New York, United States of America, 2 Upstream Thinking, Austin,
Texas, United States of America, 3 DesireLine, Istanbul, Turkey, 4 Ministry of Health, Lusaka, Zambia
Abstract
Voluntary medical male circumcision (VMMC) to protect against sexual transmis-
sion 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 con-
text, 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 pos-
itive factors motivating decisions for VMMC. Demand generation should involve the
PLOS One | https://doi.org/10.1371/journal.pone.0319472 April 29, 2025 2 / 24
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.
Introduction
Since the efficacy of voluntary medical male circumcision (VMMC) in conferring
protection against sexual transmission of HIV from women to men was demon-
strated more than 15 years ago [1–3], VMMC has been a key part of HIV prevention
interventions in 15 priority countries in Southern and Eastern Africa as identified by
UNAIDS & WHO [4]. By 2020, an estimated 615,000 new HIV infections had already
been averted through the 29.5 million VMMCs performed [4].
In 2020, 79% of VMMCs conducted in 10 of the 15 high-priority countries were
among males aged 10–24 years, with a large proportion of them being adolescents
aged 15–19 [4]. VMMC is a one-time intervention, unlike Pre-exposure prophylaxis
(PrEP) or condoms, that significantly reduces the risk of HIV transmission and other
sexually transmitted infections (STIs) [1–3]. It is particularly relevant for adolescents
as the procedure offers the greatest protection if it is done before sexual debut, as it
reduces the lifetime risk of acquiring HIV. Therefore, targeting adolescent boys who
have not yet become sexually active maximizes the health benefits of VMMC. For
countries such as Zambia which are experiencing a youth bulge (in 2022, an esti-
mated 24% of the population was aged 10–19) [5], ensuring that VMMC programs
reach adolescent males is therefore critical to successful HIV prevention.
In 2020 the World Health Organization (WHO) revised the age criteria for VMMC
programs for adolescents (also referred to as Early Adolescent Male Circumcision)
to 15–19 years [6] because of concerns about 10–14 year old adolescents’ ability to
give informed assent to a medical procedure that is non-urgent and irreversible and
due to a higher rate of serious adverse events following Male Circumcision (MC)
among this age group. In line with this updated guideline, Zambia’s VMMC program
now focuses on reaching uncircumcised males aged 15 and above [7].
While EAMC is a collective decision involving the adolescent boy and his caregiv-
ers, most current interventions to drive demand for EAMC do not address key ques-
tions about the decision dynamics between adolescents, especially those under the
age of 18, and their caregivers. EAMC for boys under 18 requires both the adoles-
cent’s assent and the caregiver’s consent [8], as MC could the adolescent’s choice
acquiesced to by his caregiver, a collective decision by the caregiver and adoles-
cent, or a choice that caregivers make for the adolescent boy [9, 10]. Differences
in understandings, motivations, and beliefs about EAMC between the boy and his
caregiver, and varying individual maturity informing the adolescent’s ability to assent
to EAMC, all add an additional layer of complexity to the decision-making dynamic.
The present paper describes a methodology specially designed to address this
complexity underlying decision-making related to EAMC adolescents and their
caregivers in Zambia. By focusing on the joint decision-making dynamics within
families and identifying the drivers and barriers to circumcision for adolescents, our
Copyright: © 2025 Surana et al
.
This is an open
access article distributed under the terms of
the Creative Commons Attribution License,
which permits unrestricted use, distribution,
and reproduction in any medium, provided the
original author and source are credited.
Data availability statement: All relevant data
are within the manuscript and its Supporting
Information files.
Funding: Author: AG Funder: Bill & Melinda
Gates Foundation Investment ID INV-003302
https://www.gatesfoundation.org/ The funder
played no role in the study design, data
collection and analysis, or preparation of the
manuscript.
Competing interests: The authors have
declared that no competing interests exist.
PLOS One | https://doi.org/10.1371/journal.pone.0319472 April 29, 2025 3 / 24
methodology provided unique insights into how interventions could be more effectively tailored to increase EAMC uptake.
Our study included younger adolescents (10–14 years in addition to 15–19 years) as the study design and initial fieldwork
was completed prior to Zambia’s alignment with the revised WHO guidelines promoting VMMC for those aged 15 and
older [6]. This paper details the theoretical foundations and qualitative research methods we employed, highlighting how
these approaches successfully addressed limitations in traditional research methodologies. Ultimately we aim to provide
actionable insights and a behavioral decision-making framework for improving VMMC uptake (a more detailed account of
which will be published separately).
Background
Cultural context, social norms, and interpersonal dynamics between adolescents and their caregivers can create barri-
ers to decision-making for EAMC. Among non-circumcising tribes for instance, where ethnic identity is associated with a
negative perception of MC, the absence of circumcision traditions often leads caregivers to deny permission to their ado-
lescents, or to not consider the option of circumcision altogether [11–13]. In these provinces, scaled coverage of VMMC
is not possible unless positive messages about it are disseminated by traditional leaders. Caregivers and young people
report several barriers to open dialogue, including lack of knowledge and skills, as well as cultural norms and taboos
[14, 15]. There are also differences in caregiver engagement: while both female and male caregivers contribute to the
decision, they state that VMMC is primarily a matter for male heads of households to address [8, 9].
In addition to social and cultural challenges, EAMC uptake has some structural barriers as well, logistical challenges
such as distance to the medical facility, lost wages during the recuperation period (for those who work), and inconvenient
timing, as either because services are often unavailable outside school or work hours, or coincide with school exam peri-
ods or sports tournaments [16–20]. In addition, poor-quality services, an environment unwelcoming to adolescents, and
concerns about violations of privacy can serve as further deterrents to EAMC uptake [10].
Conversely, several factors have also been found to facilitate uptake of EAMC. Beliefs that MC reduces the risk of HIV
infection, improves hygiene, and enhances sexual desirability and satisfaction are prevalent [16–18]. Previous research
suggests that motivations for choosing EAMC vary among adolescents of different ages - for instance, in comparison with
adolescents aged 15–19 years, those aged 10–14 are less likely to seek EAMC for protection from HIV or other sexually
transmitted infections, or for hygiene reasons, instead, they are more motivated by advice from others [21]. Anticipation
of shame and stigma also changes with age, with younger adolescents less concerned than older ones about the poten-
tial stigma of being uncircumcised [22]. Despite these varying motivations, adolescents share some cognitive barriers to
EAMC including fear of pain, and the fear of stigma associated with potential HIV-positive results, as an HIV test is typi-
cally required prior to the procedure [18,21,22].
The capacity of adolescents to give informed assent is also crucial. Research shows that while a slightly higher propor-
tion of adolescents aged 13–17 than of adults passed a comprehension assessment of key concepts related to VMMC,
but adolescents scored significantly lower than adults on two questions related to the risks of surgery and whether all
circumcised men are HIV negative [8,11]. Age-related differences in risk tolerance and decision-making processes add
further complexity. Adolescents aged 14–17 have the same cognitive and reasoning capacity as 18–19-year-olds. How-
ever, the younger adolescents have a higher tolerance for risk, are easily influenced by peers/caregivers, and attend
primarily to short-term consequences of their actions [23]. The desire for caregiver involvement also differs: a larger pro-
portion of 15–19-year-olds than 10–14-year-olds report being a little or very uncomfortable with caregivers attending their
pre-procedure counseling session [8, 9]. A further concern is embarrassment about caregiver involvement in caring for the
wound after the procedure, since adolescents – particularly older ones – feel shame about exposing their genitals to their
caregivers (who are also embarrassed by this) [9].
There is also evidence for the influence of peer dynamics on health behaviors such as circumcision uptake [24]. Peers
play an important role in decision-making for adolescents aged 10–17; for those who believe that their caregivers exert
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restrictive control over them, peers may become their primary source of guidance [25]. Younger adolescents also become
more concerned about peer acceptance and popularity and begin to turn to their friends more often as sources of advice
and comfort [26].
Despite these differences across ages, existing demand interventions also do not specifically address the needs of
older adolescents aged 18–19. They are only just maturing out of younger adolescence, and there are reasons to hypoth-
esize that there may not be a complete absence of caregiver involvement after the adolescent turns 18, especially since
in Zambia, 62% of 15–19-year-olds (male and female) live in a household with their parents or grandparents, and only 2%
of 15–19-year-old male adolescents are heads of their own households (see the analysis of data from the Zambia Demo-
graphic and Health Survey 2018 in S1 File).
Structural limitations of survey-based research
In order to study the aforementioned individual, social, and cultural barriers and enablers to VMMC, most research into
the factors hindering or enabling uptake of VMMC uses surveys, one-on-one interviews or focus group discussions.
These tools depend on the respondents’ ability to reflect and provide a considered and accurate response. However,
while people are often good at rationalizing their decisions in hindsight, in practice much of their decision-making process
is non-conscious. Decisions are driven by emotions, by mental shortcuts (heuristics) and other non-conscious drivers
[27]. These contribute to several potential weaknesses in responses given in surveys, interviews, and discussions. First,
the “say-do” gap highlights that in sensitive decision-making contexts, what people say and what they actually do can be
poles apart. For example, in a study in Zambia that interviewed 1,000 mothers of newborn boys across two public clinics,
97% of the sample said they probably or definitely would circumcise their newborn son, but only 11% of them brought their
son back to the clinic to be circumcised [28]. Second, social desirability bias can lead respondents to answer questions
in a manner they think will be viewed favorably by others [29, 30]. Surveys and interviews may create an environment
in which respondents feel fearful of being judged and respond accordingly, over-reporting “good/desirable” behavior or
under-reporting “bad/undesirable” behavior. For example, Malawian teenagers aged 16–18 were less likely to report ever
having had a girlfriend in audio computer-assisted self-interviews than in face-to-face interviews, but more likely to report
having had sex with a relative or teacher [31].
Third, respondent fatigue occurs when surveys are too long to maintain the respondent’s interest and motivation
[32, 33]. As they become tired of the task, their attention declines, and the quality of the data they provide deteriorates.
Finally, research methods like focus group discussions are conducted with a sample while they are out of their actual
decision-making context, which can affect their responses. A different manifestation of this problem occurs when the
context of the people recruited for research is not the same as the wider research context in terms of social norms, mental
models, and other contextual factors. For example, a study may recruit and survey university students to draw conclu-
sions about the attitudes and behaviors of people of that age, ignoring the fact that the respondents’ age peers outside of
university may have quite different social norms and mental models.
Understanding human decision-making
Individuals’ decisions that lead to “say-do” gap or social desirability bias can be deconstructed and better understood
through the application of theories from behavioral science. People do not make decisions rationally [34]. They must
search for options, evaluate them, and then select among them. This process is not efficient, since decisions are gener-
ally made with a non-exhaustive set of options and limited resources of time and mental capacity. This is referred to as
bounded rationality [34]. Appraisal theories offer a solution to this process by decoding decision-making and understand-
ing the underlying emotions, which are driven by stimuli (a trigger or a cue in the environment) and people’s percep-
tions of their context. The appraisal of the stimuli within the context generates emotions and leads to action tendencies.
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Modern appraisal theories provide a standard set of dimensions that underlie the appraisal process – the relevance,
implications, and normative significance of the stimulus, and the individual’s capacity to cope with the consequences of
the decision [35–37]. Additionally, people also appraise whether stimuli lead to an enhancement of their status
(status-seeking), the enabling assistance of their social group (reciprocity striving), and maintenance of strong social
bonds (group identity-seeking), as these enable survival [38].
Methodology
The research was conducted by a consortium supporting Zambia’s national VMMC program. There were three components
to this fieldwork: formative research, journey mapping, and Ethnolab. The formative research consisted of semi-structured
in-depth interviews with adolescent boys aged 10–17 (hereafter referred to as younger adolescents) that, along with previous
research undertaken by the consortium [39], informed the design of the journey mapping and Ethnolab. Sampling for these
phases was done primarily in 2 districts - the Western District of Sioma and Lusaka district, due to their rural, non-circumcising
tradition (Sioma) and urban and cosmopolitan cultural characteristics (Lusaka) respectively. Similarly, the selection of schools
and health centers was done based on their geographical location and characteristics, as has been outlined in Table 1 below.
Formative Research and journey mapping were not conducted with adolescents aged 18–19 (referred to hereafter as
older adolescents) because the insights gained from a previous study of adults aged 18 and over [39], together with the
formative research and journey mapping insights from younger adolescents, was judged to provide sufficient basis to
design the Ethnolab research tool for this group. Formative research was completed in June and July 2020 and fieldwork
for Ethnolab and journey mapping with younger adolescents was conducted in January and February 2021. Fieldwork
with older adolescents took place in December 2021 and consisted only of Ethnolab. Across the 3 phases of research,
data was collected from adolescents and caregivers (including parent and non-parent caregivers and single-parent house-
holds) to understand the joint-decision making dynamics at play for EAMC decisions.
Ethical approval was received from the ERES Converge review board (Approval number: 2020-Jan-019) in Zambia
before each stage of the research, and from Zambia’s National Health Research Authority, for both adolescents aged
10–17 and adolescents aged 18–19. Prior to their participation in any stage of the research, an informed consent script
was read to each participant in their preferred language. They were given the opportunity to ask questions about their
participation. Participants acknowledged their consent by initialing, signing, and writing the date on the consent form
(verbal consent was received for some interviews that took place over the phone because of restrictions imposed by the
Table 1. Characteristics of study sites.
Study Site Type Specifics Characteristics
Primary Public School New Kanyama Primary School Urban school based in Lusaka city with mainly cosmo-
politan mix of students from all tribes of Zambia.
Secondary Public School 1 (attend session) Chitimukulu Secondary School Rural school with primarily traditionally connected stu-
dents from non-circumcising tribe, Lozi.
Secondary Public School 2 (interview) St Monica’s Secondary School Urban school based in Lusaka city which mainly has
cosmopolitan mix of students from all tribes of Zambia
Primary Community School Chengelo Community Primary School Rural school with primarily traditionally connected stu-
dents from non-circumcising tribe, Lozi.
Public Health Care Facility 1 Kanyama First Level Hospital Urban, located in Lusaka district. Clients attending the
facility are mainly cosmopolitan in nature
Public Health Care Facility 2 Makeni Ecumenical Urban, located in Lusaka district. Clients attending the
facility are mainly cosmopolitan in nature
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COVID-19 pandemic). For illiterate respondents, an agreement to participate in the study illustrated with an inked thumb-
print was treated as written consent. An overview of these research phases is presented in Table 2 below.
Formative research
A sample of 16 adolescent boys aged 10–17 and 22 caregivers were recruited from Lusaka and Chongwe districts for
interviews. They were chosen based on the adolescent’s circumcision status, age, and school enrollment status (Table 3).
In studies utilizing qualitative methods, it is recommended that sample sizes be kept small to facilitate in-depth analysis of
participant responses [40]. The sample size for this phase therefore, whilst chosen to be large enough to collect extensive
and nuanced information on factors influencing EAMC, was limited to under 40 to allow detailed exploration. Additionally,
the concept of ‘informational redundancy’ or ‘data saturation’, in which ‘gathering fresh data no longer sparks new theoreti-
cal insights’ [41], proved instrumental in assessing the adequacy of sample size. It was important to sample both in-school
and out-of-school adolescents, because while EAMC outreach programs for this age group focus on schools, transition
rates from primary to secondary school are as low as 67.5% [42]. Purposive sampling for staff from schools and health
facilities was based on their role in promoting VMMC and interacting with adolescents undergoing VMMC.
While restrictions related to the COVID-19 pandemic were in place, recruitment in Lusaka district was done by phone,
using a database of contacts available to the research partners. Phone recruitment proved challenging, and after restric-
tions on movement were relaxed, recruitment was conducted through door-to-door visits and snowballing. In Chongwe,
door-to-door recruitment was done in communities where one of the consortium partners had existing relationships. Par-
ticipants were offered an amount of 100 Kwacha (~$5.00 USD) per household, and 50 Kwacha (~$2.50 USD) for school
and facility staff, in lieu of any costs borne by them to participate in the study such as travel expenses, wage loss etc.
Table 2. Overview of research phases.
Research Phases Time orientation Sample Objectives
Formative
Research
June and July 2020 16 households - 16 ado-
lescents (10–17) and 22
caregivers;
7 health system
stakeholders
Exploring the socio-cultural context within which EAMC
decisions are jointly arrived at within the household
through in-depth interviews with the identified sample.
Journey Mapping January and February 2021 36 households - 36 ado-
lescents (10–17) and 72
caregivers
Based on learnings from the formative research, the
journey map leveraged participatory research methods to
understand the barriers and drivers that adolescents and
caregivers face in the EAMC journey.
Ethnolab January and February 2021
(10–17); December 2021 (18–19)
150 Adolescents (10–19)
and 180 caregivers
The Ethnolab built on the learnings of the first two phases
to identify actionable levers that help caregivers and ado-
lescents in overcoming barriers and move them forward
in their EAMC journey.
https://doi.org/10.1371/journal.pone.0319472.t002
Table 3. Selection of formative research interview participants.
Circumcision Status Circumcised Not circumcised TOTAL
School Enrolment Status In School Out of School In School Out of School
Age Group 10-13 14-17 10-13 14-17 10-13 14-17 10-13 14-17
Number of Adolescents 1 3 3 1 3 1 2 2 16
Number of Caregivers 1 3 5 1 5 1 3 3 22
2 school staff, 2 counselors, peer champions, VMMC coordination, Health Department health promotions officer
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Formative research interviews were in-depth interviews, lasting about one hour, conducted by a local field team trained
remotely by the consortium. Some interviews were conducted over the phone due to COVID-19 restrictions, with the
remainder conducted in person once restrictions were lifted. Interviews were audio recorded.
In the interviews, moderators explored the cultural and social context within which adolescents interact with the health-
care system, and more specifically, make decisions with respect to circumcision. Interviews with caregivers explored their
relationship with their adolescent boys generally and in the context of circumcision, their interactions with the health sys-
tem, and their beliefs and traditions. Interviews with school staff and facility providers explored their role, interactions with
adolescents and caregivers, and their perspective on the EAMC context.
The interview tool was a discussion guide created for each category of respondent, organized thematically, with the
objective and key questions of each theme defined, along with a detailed question bank. Some themes explored were,
for example, anticipated loss of wages (while going through the procedure, while caring for the teen), anticipated conflict
(when initiating conversation around EAMC). The themes used were identified from our previous research [39], which
were augmented, adapted and refined with findings from the formative research with adolescents and caregivers for the
EAMC context. The moderators explored the key questions in each theme using the question bank as needed, based on
how the conversation was progressing.
Transcripts of the interviews were analyzed using deductive analysis, drawing from Ellsworth & Scherer’s emotional
appraisal theory [43] and thematic learnings from our previous research [39]. The authors (Namiya Jain, Rasi Surana
and Alok Gangaramany) coded transcripts to systematically identify key themes and appraisal dimensions emerging from
the data. Data from each household were organized and analyzed together, allowing us to examine interviews across all
members of a single household in context of one another. This approach enabled more effective triangulation of insights.
After coding, the data were synthesized by respondent category and further grouped by age band to capture nuanced pat-
terns across different demographic groups. These learnings were leveraged to construct hypotheses around the barriers
faced and ways to overcome these. The formative research adapted hypotheses from the previous VMMC research for
the joint decision-making context of EAMC to arrive at the stages of a household’s journey to EAMC (Table 4). This was
used as a basis for further stages of research in the study.
Journey mapping
Journey mapping is a research methodology that analyzes the actual and/or ideal experience of people who have fully or
partially achieved a behavioral outcome [44]. It is participatory in nature. It is designed to counter the “say-do” gap through
the act of making: the respondent makes their own journey artifact over the course of a journey mapping interview [39].
Table 4. EAMC journey stages.
Stage Definition
Not Intending Caregivers and the adolescent are aware of EAMC but they do not perceive it to be relevant,
and/or anticipate barriers against it.
Actively Aligning The intending member may have barriers around EAMC to be overcome but seeks conversation
with the family. However, other member(s) do not perceive its relevance and/or anticipate barriers
and are inhibiting action. This stage comprises 2 family types, one where the adolescent is the
intending member (A + C-), and another where the caregiver is the intending member (A-C+).
Anticipating EAMC is relevant to both the key decision-maker and the adolescent (A + C+). However, there is
an intent-action gap due to perceived barriers by one or both of them.
Not Advocating The adolescent boy is circumcised. However, one or more family members do not encourage
others to go for the procedure.
Advocating The adolescent boy is circumcised, and one or more members of the family actively encourage
others to go for the procedure.
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Empowering people to make journey artifacts that represent their behavior not only creates a sense of ownership over
their story and the process, but also results in a more accurate articulation of behavior and the rationale driving it.
Journey mapping is particularly appropriate in the context of EAMC, since decisions about circumcision are complex
and take place over long periods through interactions among multiple people, which include second-guessing, the intro-
duction of new information, and social conflict or conflict avoidance. We therefore used the journey mapping methodology
to capture the historical journey of households (son, mother figure and father figure) on their way to EAMC and beyond, to
advocating for the procedure.
The journey structure aims to identify behavioral drivers that advance people toward the outcome, and barriers that
move people away from it. We used four key milestones as journey stage anchors for specific behavioral probes to under-
stand how they had advanced through prior stages, why they had not progressed through their current stage (if applica-
ble), and what it would take for them to do so:
1. Desire: During the Not Intending stage (see Table 3), how household members do or do not move from an awareness
about EAMC to at least one member desiring EAMC.
2. Intent: During the Actively Aligning stage, how households do or do not move from one member wanting EAMC to a
household commitment to get EAMC done.
3. EAMC: During the Anticipating stage, how households do or do not progress from a commitment to get EAMC done to
actually going through with the procedure.
4. Advocacy: Once the household is relieved that EAMC has been done, how household members do or do not evolve to
advocating for the procedure with other community members.
A sample of 36 households was recruited (12 each in Lusaka, Sioma, and Western districts), each consisting of 3
respondents: an adolescent male between the ages of 10 and 17, his father and his mother (or father figure and mother
figure), for a total of 36 households and 108 respondents (Table 5). This sample size was determined in accordance with
previous studies in healthcare research that made use of journey mapping, which have been found to have recruited
approximately 71–100 participants [45] as was done in the present study. The samples were evenly divided between 4
of the 5 journey stages (we did not recruit from the Not Intending stage). Since no household makes decisions in exactly
the same manner as others, we screened for a mix of caregiving styles identified in parenting literature (Table 6) [46, 47].
Table 5. Households sampled for journey mapping.
Actively Aligning Anticipating Not Advocating Advocating TOTAL
Authoritarian 3 households (HH) 3 HH 3 HH 3 HH 12 HH
Authoritative 3 HH 3 HH 3 HH 3 HH 12 HH
Permissive 3 HH 3 HH 3 HH 3 HH 12 HH
36 HH
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Table 6. Parenting styles sampled in journey mapping research.
Parenting Style Definition
Authoritarian Extremely strict: Parents expect their children to follow the rules, with no discussion or compromise.
Authoritative Combines warmth, sensitivity, and the setting of limits. Parents use positive reinforcement and reasoning to guide
their children. They avoid resorting to threats or punishments.
Permissive Parents view their child as their equal. Gift-giving and bribery are their primary parenting tools, rather than setting
boundaries and expectations. They place few demands on the children and have a difficult time saying “no,” as they
avoid asserting authority and confrontation. They also always avoid punishment.
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We hypothesized that household decision-making dynamics would vary based on the dominant caregiving style within
the household. As decision-making around adolescent health combines factors like interactions between caregivers and
adolescents, family values/rules, and roles, the prior science around caregiving styles was a useful lens to understand the
existing context of the household as a unit [47].
Local moderators from each community were trained to conduct journey mapping interviews in local dialect over the
course of 2 weeks. Training included the methodology principles, use of discussion guides and the journey mapping tool-
kit, respondent interaction, and behavioral probing specific to each journey milestone.
Paired with the discussion guide, the journey mapping tool kit consisted of a paper “journey canvas” (see S2 File) to
record the perspective of household participants and capture insights at the transition from one journey stage to the next.
Moderators conducted mock journey-mapping interviews with each other and then finally on a small sample of actual
households to hone their approach before scaling up to field a full sample.
A screening questionnaire (see S3 File) was used by trained interviewers to identify the caregiving style of each house-
hold to ensure that the requisite number of each style was selected for journey-mapping interviews. Questions were
derived from “Development and Validation of a Short Form of the Alabama Parenting Questionnaire” [48], contextualized
to the Zambian community context. We took three steps in adapting the parenting style survey to the Zambian context: 1.
We highlighted phrases we judged as unique in the American (school) context and developed alternative phrasing more
suitable for the African/Zambian context. 2. Our local research lead in Zambia re-articulated and translated questions into
local context and language. 3. Questions were stress tested in a limited sample pilot study. The questionnaire was trans-
lated into local languages, and respondents were recruited door-to-door. The journey mapping took place at participants’
homes, but separately from each other to avoid social sensitivity, influence, and bias dynamics.
Each household member was provided with a journey canvas and set of tools to complete their journey with the aid of
the moderator. Journey mapping interviews lasted approximately 90 minutes and were audio recorded. Moderators com-
pleted a reporting template that captured all key insights gathered in the journey mapping interview. Reports not already in
English were translated.
The data was organized into household groups (son, mother figure, father figure) and then divided by stage and ana-
lyzed to identify key patterns of behavior, including goals, interactions that seek or avoid journey milestones, perceived
implications of interactions, and personal and social influences among all three household members. Analysis data was
then codified into normalized behavioral drivers and barriers within each stage of the journey. Tim Sweeney and Jeff
Mulhausen (authors) were primary coders for the data. Each has been deploying the underlying methodology for over 10
years. Initially, notes and transcripts were organized and translated by local moderators to interpret and preserve context.
The coders then took a thematic analysis approach to analyze the data. Each coder independently coded interviews. After
the initial coding round, coders collectively reviewed preliminary codes to refine the framework, address discrepancies
and capture key themes. Once the set of codes were finalized, the coders re-coded the interviews to ensure reliability and
consistency (For the analysis worksheet, see S4 File.)
Differences in the journeys between authoritarian and permissive caregiving styles were evident, but there were fewer
distinctions between either of these and the journey in households with an authoritative caregiving style. We therefore
developed two journey pattern indexes describing the key patterns and differences between the authoritarian and per-
missive households, including the perspectives of all 3 household members (see S5 File). Future interventions could be
designed to account for these differences.
Ethnolab
For the Ethnolab, 150 adolescent males aged 10–19 and 180 caregivers of adolescents were recruited through door-to-
door recruitment in Lusaka district (Lusaka province) and Sioma district (Western province), which have high population
density and high prevalence of HIV. This sample size was found to consistent with existing literature which have used
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mixed-methods [49] and gamification [50] to study HIV prevention, thereby enhancing the credibility of the findings and
allowing for a balance between quantitative rigor and qualitative depth. Selection criteria were the age group of the ado-
lescents (10–14 and 15–17, 18–19), and caregivers of adolescents in these age groups, and their alignment to 4 of the 5
journey stages, with the “actively aligning” stage subdivided into a) adolescent not actively aligning but caregiver actively
aligning (A- C+), and b) adolescent actively aligning but caregiver not actively aligning (A + C-) (Table 7). This alignment
was determined through a screening tool. An amount of 100 Kwacha (~$5.00 USD) was paid to each participant to com-
pensate them for their time or lost wages, if any.
Ethnolab was used as a research instrument to identify the levers which would enable adolescents and caregiv-
ers to overcome barriers faced individually and as a triad. Ethnolab is a proprietary behavioral research methodology
grounded in behavioral science that seeks a balance between the purity of ethnographic research and the controlled,
experimental nature of a laboratory. It counters the “say-do gap” by simulating the context in which respondents make
decisions, so that researchers can then observe them making choices and taking decisions. This helps researchers
understand respondents’ motivators, barriers, and mental models via observation as well as questioning. To avoid
social desirability bias, Ethnolab gamifies the context to help overcome judgments of right and wrong, encouraging
respondents to give honest responses. Gamification also makes it easier to build rapport and engagement, while reduc-
ing respondent fatigue.
Ethnolab addresses the out-of-context problem by countering the “hot-cold” empathy gap [51]. When we are in the “hot”
or emotional state, we do not understand how much it is affecting our behavior, but in the “cold” or rational state, we do
not realize how much our decisions would change were we in the hot state. Out-of-context surveys tend to take place in
the cold state, but the empathy gap leads respondents to incorrectly predict or account for their hot-state behaviors. The
realistic context and game-like context of Ethnolab move respondents into a hot state of decision-making. This makes it
possible to observe them taking the decision and immediately thereafter to have a conversation about it, while respon-
dents are still engaged with their emotions and other non-conscious drivers of decision-making. Hot-state discussions
thus provide insights which are closer to the respondent’s real-world decision-making.
Finally, Ethnolab provides a platform to test interventions or levers to overcome barriers by enabling decision-making in
this hot state. Thus, it can be used as a predictive research tool to identify levers for preference reversal.
In the Ethnolab, respondents with similar profiles (age, circumcision status, journey stage) are put in a simulated
decision-making context and presented with narrated and illustrated scenarios containing hypothetical situations that
Table 7. Sample of adolescents and caregivers for Ethnolab.
ADOLESCENTS PER PROVINCE
Not intending Actively aligning
(A- C+)
Actively aligning
(A + C-)
Anticipating Not advocating Total
10-14 years 5 5 5 5 5 25
15-17 years 5 5 5 5 5 25
18-19 years 5 5 5 5 5 25
TOTAL ADOLESCENTS in two provinces = 75 x 2 = 150
CAREGIVER PER PROVINCE
Not intending Actively aligning
(A- C+)
Actively aligning
(A + C-)
Anticipating Not advocating Total
10-14 years 3 M, 3F 3 M, 3F 3 M, 3F 3 M, 3F 3 M, 3F 30
15-17 years 3 M, 3F 3 M, 3F 3 M, 3F 3 M, 3F 3 M, 3F 30
18-19 years 3 M, 3F 3 M, 3F 3 M, 3F 3 M, 3F 3 M, 3F 30
TOTAL CAREGIVERS in two provinces = 90 x 2 = 180
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mimic the real-life context in which the behavior of interest takes place. The scenarios are aligned with the journey stage
of the participants. Each scenario is designed to test an underlying behavioral principle(s) and ends in a decision conun-
drum with multiple possible outcomes.
For each scenario, participants are asked to guess what other participants are likely to do in this scenario, rather than
stating what they themselves are likely to do. This helps reduce social-desirability bias. The scenarios are presented in the
context of a board game with seven or eight rounds. In each round, if a participant’s choice of decision outcomes matches
the choice of the majority of the participants, they win the chance to roll a die and move their game piece a corresponding
number of places toward the center of the board. After the game, the scenarios are discussed while the participants are in
the hot state. The data generated from the responses, along with the ensuing discussion, helps elicit behavioral insights,
identifying drivers of decisions and preference reversal.
Each scenario is composed of a narrative and question which describes a specific barrier to be overcome by the
adolescent or caregiver or both; and a set of options outlining ways in which the barrier may be overcome, based on
behavioral principles. Learnings from the formative research stage, together with prior work in VMMC conducted by the
consortium, informed the development of the scenarios. An example of a scenario and corresponding options have been
presented in Figs 1 and 2 respectively.
For a table of all the Ethnolab scenarios, options, and responses given, see S6 File.
For the discussion, the adolescents were divided into 2 groups, those in school and those out of school, and caregivers
were divided into female and male caregivers. Participants aged 18–19 were divided among those living with their care-
givers, and those living independently. The scenario was narrated again, followed by a discussion exploring participants’
experiences of facing the barrier and past experiences (their own or others’) which prompted them to choose a particular
option (lever) during the game. Since circumcision is a one-time decision and the participants had not yet overcome the
barriers represented by the scenarios (i.e., they/the adolescents had not yet been circumcised), they were encouraged to
share experiences of how others had used the chosen lever to overcome the barrier, or how they themselves had used
the lever in a different context.
Moderators for the Ethnolab were local people fluent in local languages (Nyanja and Lozi) who were trained remotely
by the consortium research team. Participants gave consent, and the sessions were audio-recorded and transcribed. The
transcripts were analyzed using deductive analysis, drawing from Ellsworth & Scherer’s emotional appraisal theory [43]
Fig 1. Sample Ethnolab scenario.
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and theme matching and pattern identification from our previous research [39]. The authors (Namiya Jain, Rasi Surana
and Alok Gangaramany) completed an initial coding of transcripts to systematically identify key themes and dimensions
emerging from the data. The dimensions mapped were barrier themes, context, and emotional appraisal elements. The
codes from each stage were further analyzed as separate groups.
Game data was analyzed to find similarities and differences between the responses given by caregivers and adoles-
cents, and between different age groups. The game data was further triangulated with data from the discussions. We
Fig 2. Sample Ethnolab options.
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focused on how the barriers were experienced, how they were overcome, how households progressed through the jour-
ney, and the interactions between the members of the household. The analyzed data was then synthesized into narratives
along the following dimensions: a) learnings by journey stage; b) barriers, and c) ways to overcome the barriers.
Finally, the learnings from the journey mapping and the Ethnolab were synthesized through a process of discussion
over multiple working sessions, to align on the journey and the barriers faced in each stage and map them onto a solution-
ing framework (to be published) to allow organizations to easily comprehend household decision dynamics, and optimize
existing interventions and/or design new interventions.
The COVID-19 pandemic impacted the initial research plans, and the methodology was adapted to the constraints
posed by remote research. Although all travel by the research team was suspended due to travel restrictions and the
uncertainty of the pandemic, the team was able to conduct the research, thanks to strong partnerships with in-country
teams. As noted, formative research recruitment initially had to be conducted by phone, but reverted to being done face-
to-face once lockdown rules were eased. For Ethnolab, the game design and interaction protocols were constructed to
ensure the safety of participants and moderators, including social distancing, wearing masks, providing handwashing
facilities, frequent sanitizing of the venue and materials, and giving participants sanitizer and masks to take home.
Results
An overview of the methodological challenges that qualitative research may face and our proposed solutions have been
highlighted in Table 8.
Based on the integrated methodology (journey mapping + Ethnolab) that we undertook, we were able to identify
nuanced barriers and drivers for VMMC among adolescents, along with actionable levers for change as recognized
through an extension of the research process.
The integrated findings of the three phases of research led to the development of a behavioral decision framework.
This framework explains the complexity of decisions made at the intersection of caregivers’ and adolescents’ own goals,
Table 8. Methodological challenges and proposed solutions.
Challenges How these were addressed
Understanding the decision-making dynamic when
multiple decision-making agents are involved [9]
Formative research: Through this phase, learnings from our previous VMMC research were
adapted for EAMC with the aim of understanding the joint decision-making context and socio-
cultural influences on the EAMC decisions. Furthermore, data was organized by households to
identify hypotheses through triangulation of data points across members of a single household.
Journey mapping: We organized data based on households so we could jointly understand and
analyze the barriers and drivers to decision-making faced by the household unit, i.e., adolescents
and caregivers.
Say-do gap [52]Journey mapping: Participants were required to fill out their journey canvas highlighting their
goals, social influences and journey milestones which moved them forward or held them back in
the EAMC journeys.
Ethnolab: By simulating the decision-making context, the Ethnolab allows researchers to
observe the decisions and choices made by respondents.
Social desirability bias [29]Ethnolab: In the FGD setting, participants are given a limited time frame to anonymously
respond to decision-simulations by guessing what other participants would do, rather than stating
what they themselves are likely to do. This takes away the spotlight from the respondent, thereby
encouraging more honest responses.
Respondent fatigue [32]Ethnolab: The Ethnolab leverages gamified tools to build rapport and engagement with the
participants, while reducing respondent fatigue.
Hot-cold empathy gap [51]Ethnolab: The decision-simulations are based on relatable, real-life contexts that are constructed
based on learnings from prior phases of primary research. These simulations aim to move people
closer to a hot state of decision making.
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beliefs, and emotions associated with EAMC. By doing this, we aim to create more actionable and effective strategies for
the household as a unit that targets the nuanced, complex decision of EAMC uptake. We present a brief description of
the framework, including barriers, drivers, and levers as evidence of the richness of emotionally charged discussions that
our methodology enabled. With each phase of our research, we identified key learnings and refined and built on learnings
from the previous phase of research. A more detailed account of the study results and the behavioral decision framework
will be published separately.
Stages
Our research and analysis identified 4 distinct stages (Fig 3) anchored to a household’s experience of EAMC
decision-making, along with certain barrier themes that prevent households from advancing through their decision-making
journey.
Stage 1: Relate. In this stage, one member of the household unit—either the caregiver or adolescent—has learned
of EAMC and has formed an intention to undergo the procedure. We refer to this member as the “initiator,” i.e., the
household member who initiates the intention for the procedure within the household. To arrive at this intention, the
initiator first learns of the procedure (i.e., gains awareness) and then aligns their beliefs with EAMC to avoid any
dissonance that might arise from fears, concerns, or mental models that could act as a barrier to intention-building.
According to Festinger’s cognitive dissonance theory [53], people experience psychological discomfort when holding
conflicting thoughts or beliefs and are therefore motivated to modify one of the conflicting beliefs to resolve this
[54; see citation for an overview of cognitive dissonance theory]. We found that this alignment process is typically
facilitated through information-seeking behaviors and interactions with trusted others, which expand the agent’s
understanding of EAMC, its benefits, drawbacks, and long-term consequences. Thus, at this stage, the initiator must
internalize the value of medical circumcision to develop a strong intention to undergo the procedure.
Stage 2: Actively align. Here, the initiator must actively communicate their intention to undergo EAMC with other
decision-makers in the household. Conversations about sexual and reproductive health are often uncomfortable, if not
taboo, to discuss with family members in African cultures [55], including in Zambia [56]. Given the nature of the topic
and the prevalence of patriarchal norms in the culture [57] adolescents and caregivers alike may face challenges when
initiating this conversation within the household. Adolescents as initiators must demonstrate agency in introducing and
persuading their caregivers, while caregivers as initiators need to assess the adolescent’s maturity and contend with
potential backlash from close relatives. This is a key stage in joint decision-making, as the journey progresses from a
single initiator to a commitment by the household unit to proceed with the adolescent’s circumcision.
Stage 3: Anticipate. Since the long-term benefits of EAMC have already been internalized by this point, household
members no longer question the procedure’s benefits. However, the adolescent and caregivers may still grapple with
challenges the procedure poses to their near-term goals, such as pain, wound management, and potential loss of wages.
Interestingly, while these short-term concerns may have emerged at earlier stages, we found that they often need not
Fig 3. Four stages through EAMC decision making at the household level.
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be resolved for households to commit to the procedure, as they become more salient closer to actual behavior uptake.
Consequently, households may delay the adolescent’s circumcision even after committing to it. Intent-to-action gaps
are well-studied and documented in public health demand generation literature [see 52 for review]. Addressing these
individual, short-term concerns is essential for bridging this intent-action gap and completing the circumcision procedure.
Stage 4: Relieve. Descriptive norms—i.e., behaviors that are practiced because they are commonly observed in
the community—are important drivers of behavior as they signal what is considered socially acceptable, particularly in
contexts of uncertainty [58]. In this stage, while caregivers and adolescents may feel relieved to have completed the
procedure, there is often lingering reluctance to share their experience openly with peers. We believe that enabling
households to advocate for EAMC can create positive community narratives and perceptions, which is key to generating
sustained demand and uptake. Providing adolescents and caregivers with the right communication skills, tools, and
opportunities to engage in these conversations will extend the impact of each household’s decision to others in the
community.
Barriers
Several barriers can hinder progress along this journey, while certain drivers can help households move forward. Briefly
presented below, these factors represent trade-offs that households encounter at various stages of EAMC uptake. Most
barriers and drivers manifest in different ways throughout the EAMC journey, depending on what is relevant at each stage
of decision-making.
1. Anticipation of pain. Anticipated pain includes the pain of the procedure and pain during the healing process.
Adolescents’ understanding of VMMC and the associated pain is largely determined by the vivid narratives and lived
experiences shared by their peers and elder brothers who have undergone circumcision. Many adolescents have an
inherent dislike or fear of injections (which are needed for anesthetic), and they are scared by the idea of having their
penis cut with a knife or scissors. A representative quote from a boy was: “I always imagine how sharp the knife is even
when you accidently cut yourself; imagine cutting the foreskin on one’s manhood. It would really be painful.”
Upon arriving at the clinic, anticipation of pain may be driven by seeing the surgical equipment laid out, hearing other
boys crying during the procedure, and observing how they walk differently immediately afterward; this may cause adoles-
cents to run away from the clinic. “I saw friends who were crying and I got scared... People were being circumcised and
were crying so I thought it was painful and I decided to run away.” The anticipation of pain early in the journey toward cir-
cumcision may be overcome by clarifying what the procedure entails and assuring the adolescent that someone close to
them will support them as they go through the pain. Caregivers in favor of circumcision can help younger adolescents by
asking them what they are afraid of and discussing it to make them feel better. Adolescents require caregivers to commu-
nicate confidence that he can go through with the decision, and to provide support immediately after the procedure, such
as taking him home in a vehicle. “I told my son that when you go for circumcision, we will take good care of you. We will
be cleaning you and will give you the medication that you will be given at the hospital. At the hospital, they will give you an
injection before they start the procedure so that you don’t feel any pain. When you come back home, you will not be doing
anything until you recover.”
Adolescents can vividly anticipate the pain of healing, based on the experiences of others. These experiences include
boys crying in pain, walking with their legs apart, having to stay indoors and wear a chitenge (a loose fabric wrap around
the waist), and experiencing pain during activities such as bathing, cleaning the wound, urinating, sleeping, or getting
erections. They may feel that if their peers and older brothers could not cope with the pain, they will not be able to either.
This can cause them to delay going through with circumcision. Caregivers trying to persuade adolescents must overcome
these internalized narratives, for example by reassuring them that they will be given painkillers to cope with the pain. As
one father said of his adolescent son: “I had to sit him down and explain all the procedures to him step by step. I first told
him that he was going to be given an injection to make the area numb so that he won’t be able to feel the pain as they are
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carrying out the operation. I also told him that after the operation was done, he was going to be given painkillers to carry
with him home… I reminded him that he was going to be able to go back to his usual self within a short period of time.
That really motivated him a lot.”
A further element is the perception of how well the adolescent can tolerate pain at his specific age. Some female
caregivers decide to not circumcise their adolescent because they cannot bear to put them through the pain or see them
in pain. They lack clarity themselves on the extent of the pain adolescents experience and would benefit from an effective
heuristic to estimate this. For example, a pain-o-meter that could help mothers associate the severity of pain at different
stages of the procedure and recovery period with more commonly occurring pains that they can relate with such as head-
aches, thorn pricks or cuts.
2. Anticipated loss. In contexts of uncertainty, people are often willing to undertake risks (such as maintaining the
status quo) to avoid perceived losses [59]. This effect is more pronounced among individuals who believe they lack the
necessary economic or social resources to manage these losses [59]. The avoidance of anticipated losses is a major
barrier holding people back in their EAMC journeys, given the irreversibility of, and uncertainty associated with, the
procedure.
Families from traditionally non-circumcising tribes may consider circumcision as a loss of family identity. They may
feel they cannot deviate from the path shown to them by their ancestors and must raise their boys in the way they were
brought up: “It’s up to us parents to make sure we raise our children according to our origins and tradition.” Adolescents
seeking consent from caregivers anticipating this loss may struggle to convince them due to this barrier. Approaches to
addressing this concern could include making a clear distinction between medical circumcision and traditional circum-
cision, emphasizing that making an exception to traditional practice in this one case is not a wholesale rejection of the
family’s identity.
For younger boys, there may be anticipated loss in the form of the inability to play while they are healing. “I was scared
that maybe when we go to play soccer because we formed a team, I will not play for four weeks.” Older adolescents and
caregivers are concerned about the enforced break from school activities or household responsibilities during convales-
cence. “One has to have a good choice so that he knows that if I go on this day, I will be able to have enough time to heal,
because I will not be the one to herd the cattle.” Caregivers depending on an adolescent for household chores either may
not give consent, or may delay circumcision, if they anticipate that their adolescent boy will be unavailable to help while he
is healing. This can be overcome if caregivers are helped to plan the procedure for a time when the adolescent can more
easily take time off from household chores, or when someone else is available to manage these. “He chose the date/day
because he wanted to herd cattle the first two weeks before going for circumcision so that he could heal before his turn
for herding cattle comes.” Caregivers can also be motivated not to delay by highlighting their potential regret if their boy
should contract HIV as a result of being uncircumcised.
Older adolescents may also be concerned about lost time at school, or lost wages if they are working. They may also
anticipate that sex will be less pleasurable if they are circumcised, while those with a sexual partner may worry about hav-
ing to abstain from sex during the healing period. Addressing these barriers of anticipated loss would involve reassuring
the adolescents that the cessation of sexual activities is for a short time and that the benefits are long-lasting. The barrier
of loss of pleasure can be overcome by highlighting women’s preference for men who are circumcised, as they perceive
them to be desirable, caring, and responsible.
3. Uncertainty. Uncertainty refers to a conscious awareness of lacking sufficient information to predict outcomes
accurately [60]. Feelings of uncertainty have been shown to result in cognitive distortions [61], negative affect [62], and
avoidance behaviors [63]. In the context of EAMC, uncertainty manifests in various ways across the four stages, often
preventing adolescents and caregivers from progressing along this journey.
A barrier for some boys is uncertainty about whether their caregivers will give permission for them to be circumcised.
Younger boys may be scared of approaching caregivers. “My mother said, ‘I don’t know why your father is refusing [your
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request]; it might be too painful for you’ … so I just stopped [asking].” Older adolescents might address this by reminding
their caregivers of other ways in which they have demonstrated maturity and responsibility for significant decisions. Health
providers could also help address this barrier by communicating reasons for circumcision that are relevant and reassuring
to caregivers. “My friend just took himself to the hospital, but when he got there he was told to go back home and come
back with his parents. But the good part for him was, one of the nurses there knows my friend’s mother so they went
together and the nurse explained to the mother, and she agreed and took him to get circumcised.”
Conversely, sometimes caregivers who want the adolescent to be circumcised struggle to convince him, because the
benefits either seem too distant to him (e.g., future protection from disease) or insufficient to balance the trade-offs. Care-
givers often fail to identify and address the adolescent’s specific barriers. Presenting circumcision as a topic for discussion
and learning, rather than something they insist that the adolescent do, may help caregivers alleviate their adolescent’s
uncertainty. Involving health providers can help, since older adolescents tend to trust them more than their caregivers for
accurate information on health issues. “The [parents] said if you want to know more let me just take you to the clinic…
I am not forcing you to get circumcised but I just want you to hear more about circumcision. He accepted going to the
clinic, and they went together, and they took him to the counselors who counseled him very well, and that is how he got
circumcised.”
As with distrust, boys and their families are influenced by the experiences of people in their own community. Stories
they have heard or experiences they have observed may make them uncertain about whether the circumcision wound will
heal properly, or whether it will take longer to heal than it should, and this can deter them from circumcision. “Those who
have been circumcised already, they say, ‘Mine delayed to heal,’ the other, ‘Mine healed fast,’ so I would ask myself, what
if mine delays to heal?” For older adolescents, uncertainty about the healing process may become linked to fears of loss
of sexual functioning or of death. As with distrust, the experiences of people in their own community influence the con-
cerns of boys and their families. The uncertainty also leads to hesitation in advocating for circumcision. These concerns
can be addressed through expert communication about the length of the healing period, how to take care of the wound,
and how the adolescent should expect to feel each day during the process.
A final element of uncertainty can be the adolescent’s lack of self-efficacy about recommending circumcision to his
peers after undergoing the procedure himself: he may feel he lacks the knowledge and authority to talk about it, is uncer-
tain how to raise the topic, or that his peers will not be interested. Approaches to counter this include providing the adoles-
cent and his caregivers on their last visit to the clinic with tools and materials to help them recommend circumcision, along
with opportunities to “shadow” others who are already successful advocates. Families that do not wish to advocate directly
themselves can be encouraged to direct other individuals to learn more from the health system.
4. Distrust. Trust refers to the degree to which one feels they can rely on a person, process, or institution to act in a
predictable and dependable manner [64]. Trust plays a key role in bridging information gaps, particularly in contexts of
uncertainty and information asymmetry [65]. While trust in the EAMC procedure and the health system is essential for
helping household members overcome the uncertainty they face, existing trust barriers currently prevent progress along
the EAMC journey.
Some boys and their caregivers are distrustful of the safety of the circumcision procedure and have concerns about the
quality of the clinic and the professionals working there. They may worry that a mistake by an inexperienced provider will
lead to lasting negative consequences for the boy, such as penile deformity, or an inability to urinate or to father children;
the latter is a concern particularly among older adolescents. “Some boys were saying there are some health workers who
do not know how to cut, so if they cut you … your manhood can be destroyed.” These concerns can be allayed by verbal
communication from family members, peers, or a doctor that the procedure will be done by experts who have performed
many such procedures, that only the foreskin will be removed and that the boy will not be injured or die.
Although most adolescents and their caregivers understand that circumcision helps protect them from HIV, they
may be skeptical about this if they know people who were circumcised who went on to contract HIV, or if they are from
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non-circumcising traditions but know no one who has contracted the virus. Some adolescents feel that since wearing a
condom confers protection from HIV, circumcision is unnecessary. Potential approaches to address this skepticism include
acknowledging the importance of wearing a condom during sex even after circumcision, while pointing out that a man may
not always remember to do so, and that even condom use does not provide complete protection, which is why the 60%
reduction in HIV risk conferred by circumcision is valuable.
5. Anticipated shame. Shame is a social emotion that arises from a perceived failure to meet standards set by one’s
social group [66]. Since shame is associated with negative evaluations of one’s social standing, it can lead to negative
affect not only toward the situation or action, but also toward oneself as a whole [67]. We found that anticipated shame
acts as a deterrent to desired actions across various stages of the EAMC journey.
A significant concern for younger adolescents is the anticipated shame of having to discuss their genitals, or to be
naked in front of a female caregiver for wound care; adolescents of all ages feel they are too old to be undressed in
front of their caregivers. Caregivers (especially female caregivers) may be similarly embarrassed about tending to
their adolescent boys, since it is considered taboo for a female caregiver to see the male child’s genitals once he has
reached adolescence. Older adolescents find conversations with their female caregivers about sexual matters shame-
ful, though they may be more willing to discuss such topics with the male caregiver. This awkwardness can lead fam-
ilies to delay the decision for circumcision until such time as the adolescent boy can care for the wound himself. To
alleviate this concern, caregivers can reassure their male child that they will be taught how to care for the wound them-
selves, and if necessary, older male siblings or relatives can help wound care, to protect boys from embarrassment with
their caregivers. Families can be supported in identifying a helper who the adolescent is comfortable with. “When I told
him about circumcision he asked, how am I going to take care of myself, how will I be able to sit? So I told him that your
father will help you, before he goes for work he will clean you and after work. I also told him that if you will allow me, I
can also help to clean you.”
In an environment with both circumcised as well as uncircumcised people, circumcised families may anticipate being
shamed and mocked for being circumcised. This concern grows as the date for the procedure nears. Boys anticipate
being laughed at for having to wear the chitenge, which is seen as feminine, or for walking differently, during the healing
period. A potential way to address this is to reinforce that most of his peers will support him following the procedure and
will say that they are proud to see him wearing the chitenge as a sign that he has taken steps to protect himself and the
community from HIV. A further source of anticipated shame for older adolescents is the idea that they might be required to
undress in front of a female health care provider, or that the surgery would be performed by a woman. Assuring them that
they can choose a male health provider can alleviate this concern.
6. Concerns about lack of ability or responsibility. The sense of responsibility stems from feeling accountable
toward achieving specific intended outcomes through voluntary action [68]. Perceived responsibility serves an important
social function. It aids in judging whether a person can be held accountable for an action, with transgressions often
leading to punishment or risk of harm [69]. We found that the sense of adolescents’ responsibility for undergoing the
procedure and ensuring recovery was low among both, caregivers and adolescents themselves. This lack of responsibility
hinders households from progressing in their EAMC journeys across the four stages.
Caregivers may feel that their adolescent boys are not mature enough to understand circumcision and its effect on their
lives, and as a result they may ignore messaging about it, or avoid or block discussions with the adolescent. Conversely,
caregivers who feel their adolescent boy is mature enough to make the decision may avoid discussing it directly because
they do not want to impose their views, or because they anticipate feeling guilty if they appear to press him towards a
decision that he later regrets. Older adolescents aged 18–19 are legally able to consent to circumcision without their
caregiver’s agreement but may still look to them for support, especially if they lack the confidence to make a decision
that they perceive as carrying risks; however, caregivers may also regard their adolescent as too immature to make the
decision, especially if he is still living with them. Having community mobilizers remind caregivers of the adolescent’s ability
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to take responsibility in age-appropriate ways but also of the importance of continuing to support his health decisions, may
address these concerns.
Caregivers of younger adolescent boys may be concerned that their boy is not old enough to care for the wound
properly during the healing period. The boys are also concerned about their self-efficacy for wound care, especially if
they have heard stories of other boys who forgot to wash the wound or did so incorrectly. This leads them to believe that
there is a high chance they will do the same. “I saw my friends were failing to clean themselves, so their fathers and uncle
were the ones cleaning them, so I would ask myself, can I manage to clean my wound if my friends are failing to do it on
their own? So I developed that fear not to do it.” Caregivers may distrust their adolescent’s ability to refrain from playing
or other activities that are not allowed during the healing period. In the case of older adolescents, female caregivers are
unwilling to tend the wound because of taboos about seeing their adolescent boy naked, yet they worry that he will be
unable to manage the wound care adequately himself. Caregivers and their adolescent boys need reassurance that they
will be able to manage, and to be given instructions on wound care. Younger adolescents need reassurance that they will
not have to cope on their own, and older adolescents that they will be able to manage it themselves. “When [my son] was
refusing to go for circumcision, he was telling me that he will not be able to do wound care. So as a way of convincing him,
I told him that he won’t have to worry because I will help him with everything.” “My son refused [to be circumcised], saying
I cannot manage to handle this wound on my own… I told him that I will find a friend who has been circumcised so that he
can also tell you how they managed.”
7. Anticipated conflict. Studies have found that conflict avoidance or minimization is an important goal driving (or
inhibiting) action in collectivist cultures – such as those in Africa – compared to individualistic and honor-driven cultures
[68]. This becomes particularly relevant in the EAMC context in Zambia where there are power and status differentials
exist within households and communities [70].
Adolescent boys may avoid discussing EAMC with their caregivers if they anticipate that either or both will be upset.
Reassurance from peers and help finding the best opportunity to initiate a discussion can alleviate this barrier. Some older
adolescents anticipate conflict if they get circumcised without first consulting their caregivers, especially if there were to
be medical complications. A potential approach to addressing this would include building their capacity to address their
caregiver’s fears (e.g., anticipated loss of family identity, uncertainty around wound care responsibility, child’s maturity in
handling the procedure) to help them discuss the issue with parents beforehand. It is also important to build older adoles-
cents’ confidence that their caregivers will trust their decision if he shows that he understands what he is consenting to.
Once an adolescent is circumcised, there may also be an expectation of conflict if they recommend circumcision to
another person who goes on to have an adverse experience. This can deter a circumcised adolescent – or his family –
from advocating for circumcision among his peers or in the general community. As a parent described it, “The problem
with persuading other people to get circumcised [is that] if anything goes wrong, one can be blamed for having been the
one to have persuaded them against their wishes. That’s why I just kept my secret with my son after getting him circum-
cised.” Ensuring that caregivers and the adolescent do not bear all the responsibility of advocating for circumcision, but
that it is shared with trained mobilizers and healthcare professionals, could help ensure that blame for any adverse experi-
ence is not directed at the families.
Enablers for circumcision
We noted several enabling factors for circumcision. In-group seeking, i.e., the desire to be similar and part of a group
of friends, motivates the adolescent to seek circumcision. “I am no longer afraid of getting circumcised … It is because
all my friends in our group are circumcised except for me.” Caregivers are also motivated towards circumcision when
there are many circumcising families in their community. Some older adolescents are motivated to choose circum-
cision precisely because they are teased by their age peers for not being circumcised. For older adolescents, key
motivators include being appreciated by women for having taken responsibility for one’s sexual health, as well as the
PLOS One | https://doi.org/10.1371/journal.pone.0319472 April 29, 2025 20 / 24
perception of improved sexual attractiveness and better sexual performance after circumcision. For some caregivers,
better hygiene is a reason for having their adolescent boys circumcised. Caregivers of younger adolescents tend to
believe that the healing process is faster at a younger age, since younger adolescents have fewer responsibilities
requiring physical activity, and it is easier to control the adolescent boy during the healing period. Related to this is
a concern about the cost of inaction if the adolescent were to contract HIV or another sexually transmitted infection
as a result of not being circumcised. This is particularly the case for caregivers of older adolescents who are (or may
shortly become) sexually active. This fear can create a sense of urgency that overcomes any tendency to procras-
tinate on the decision. Finally, the desire of families to be liked and appreciated by their community can motivate
them to seek circumcision for their adolescent, if this is something that is valued and supported by the community.
Institutions such as the church – an arbiter of respect and esteem in the community – can reinforce this motivation by
explicitly supporting circumcision.
Discussion
While EAMC is not a new strategy, programs have historically focused on persuading the individual to undergo cir-
cumcision. For boys who have not reached legal adulthood (18 years in most countries), given the need for caregiver
consent as well as the adolescent’s assent, this simplistic approach does not take full account of the boy’s context
and relationships. It is reaching the limits of its effectiveness, and new strategies are required to reach targets for
EAMC.
Our work builds an understanding of EAMC as a group decision dynamic made among the triad of adolescent, mother
figure and father figure. It takes account of the differing barriers faced by the adolescent boy and by his caregiver, and
how the concerns of each can be effectively addressed. In families of younger adolescents, EAMC is not treated like other
decisions, and caregivers seek the agreement of the adolescent, since his cooperation is necessary for a successful
outcome. It is an active negotiation between the younger adolescent and his caregiver. Among 18–19-year-olds, a range
of caregiver involvement is seen: some adolescents feel they cannot make the decision on their own, some feel they
must involve their caregiver even if they make the decision for themselves, while others make the decision independently.
Often, their living situation influences their VMMC decision-making. In families where older adolescents continue to live
with their caregivers, they tend to have lower decision-making power, find it challenging to seek alignment with their care-
giver, and the caregivers have better opportunities to influence the adolescent boy’s decisions. By contrast, caregivers of
older adolescents who are living independently feel a reduced sense of control, as they cannot easily know or predict their
adolescent’s thoughts and actions.
From a programmatic standpoint, there are three main conclusions. First, the demand generation strategy for EAMC
needs to be rethought at the level of a family unit by bringing caregivers into the conversation, in addition to engaging with
adolescents. Programs need to progress from targeting adolescents – for example through school-based initiatives where
caregivers are excluded from the intention-building and decision-making processes – to more community-driven programs
that encourage conversation within (and among) households. Second, power structures, decision-making dynamics and
barriers faced by the household continue to evolve as adolescents move across the 10–19 age band. It becomes imper-
ative to approach EAMC demand generation based on nuanced barriers and needs of the household at different points
in the adolescent’s and caregivers’ journey. This could entail differentiated outreach to households depending on whether
younger or older adolescents are being targeted, and aiding community outreach workers in identifying the relevant bar-
riers to be addressed. Third, we find that the initiator of positive EAMC attitudes into households differs from household
to household – in some cases it may be the caregivers who build intention around EAMC first, whereas in other cases
it could be the adolescent himself. Strategies need to be devised to build trust and engagement between members of
the household to enable conversation for more holistically informed judgements on the risks and benefits of undergoing
EAMC. This is especially important in instances where adolescents or caregivers who feel like they are not in control of
PLOS One | https://doi.org/10.1371/journal.pone.0319472 April 29, 2025 21 / 24
the EAMC decision must convince other household members to overcome their fears associated with the procedure and
post-procedure care.
Conclusion
The family as a whole perceives EAMC to be a risky decision with uncertain consequences. Our study was able to draw
out nuanced barriers and levers for different actors involved in this decision at different stages of the proposed EAMC
journey. An integrated approach to data collection, analysis and synthesis was important. The methodologies leveraged
played dual roles in contributing to understanding adolescents’ EAMC journey: 1) Journey mapping was integral to the
development of the proposed journey and associated barrier identification, and 2) Ethnolab further shaped the barri-
ers and identified strong levers to help guide future attempts to change household behaviors. The integration of these
approaches allowed a nuanced understanding of the various actors and factors that come into play during the EAMC
decision-making process and enabled a credible perspective on how these could be tackled to guide adolescents and
households forward in their EAMC journey.
Supporting information
S1 File. Zambia adolescent stats.
(PPTX)
S2 File. Journey canvas.
(PDF)
S3 File. Journey screener.
(DOCX)
S4 File. Journey analysis worksheet.
(XLSX)
S5 File. Journey pattern indexes.
(XLSX)
S6 File. Ethnolab scenarios and responses.
(XLSX)
Acknowledgments
James Baer assisted with the editing and proofreading of the manuscript.
Author contributions
Conceptualization: Rasi Surana, Ram Prasad, Namiya Jain, Alok Gangaramany, Tim Sweeney, Jeff Mulhausen, Steve
Kretschmer, Tina Chisenga.
Formal analysis: Rasi Surana, Alok Gangaramany, Tim Sweeney, Jeff Mulhausen.
Funding acquisition: Alok Gangaramany.
Investigation: Rasi Surana, Namiya Jain, Jeff Mulhausen, Alice Nanga.
Methodology: Rasi Surana, Namiya Jain, Alok Gangaramany, Tim Sweeney, Jeff Mulhausen.
Project administration: Rasi Surana, Mothi Prasad, Tim Sweeney, Jeff Mulhausen, Alice Nanga.
PLOS One | https://doi.org/10.1371/journal.pone.0319472 April 29, 2025 22 / 24
Resources: Jeff Mulhausen.
Supervision: Rasi Surana, Ram Prasad, Namiya Jain, Mothi Prasad, Alok Gangaramany, Tim Sweeney, Jeff Mulhausen,
Tina Chisenga.
Visualization: Tim Sweeney, Jeff Mulhausen.
Writing – original draft: Rasi Surana, Namiya Jain, Jeff Mulhausen.
Writing – review & editing: Rasi Surana, Namiya Jain, Alok Gangaramany, Aishwarya Shashi Kumar, Tim Sweeney, Jeff
Mulhausen, Steve Kretschmer, Alick Samona, Tina Chisenga.
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