Background: Greater than 10 million males have been circumcised through voluntary medical male circumcision (VMMC) programs in sub-Saharan African countries. Although adverse events (AE) have remained low, WHO has reported an increase in severe infection-related AEs and has emphasized the need to mitigate post-VMMC infection risk, including proper wound management by clients. This study explored reasons that hinder adolescents´ proper wound management in order to inform risk-reduction strategies.
Methods: Between August and September 2015, 20 in-depth interviews were conducted with VMMC adolescent clients (10-19 years) 6-8 weeks post-procedure. Eight focus group discussions (FGDs) were also held with male (n=4 FGDs) and female (n=4 FGDs) parents/caregivers. Discussions explored adolescents´ wound care practices and reasons for non-adherence to wound care instructions. Audio recordings were transcribed, translated into English, and thematically coded.
Results: Data suggested that although wound care instructions were adequately articulated and comprehended during counseling, younger adolescents (10-14) failed to recall these instructions. Parents/guardians described having to phone or visit VMMC sites to obtain proper instructions. Adolescents reported misrepresenting instructions to parents/guardians in a bid to avert possible pain from having to dip the wound in saline water for recommended periods. Parents/guardians (mostly female) were often deceived by their sons who pretended to have undertaken proper wound care and only found out when an infection had occurred. Some adolescents reported disregarding clinicians´ instructions and adopting their own/peer-recommended instructions such as using methylated spirit and other substances to "quicken" wound healing. Conversely, adolescents reported parents/guardians disregarding clinicians´ wound care instructions and recommending, for example, larger salt quantities based on their past experiences of caring for non-MC wounds. Both parents and adolescents reported unsafe practices such as boys displaying/touching their fresh surgical wounds with the intention to prove to others that they had been circumcised.
Conclusions: This study identified possible explanations for the rising numbers of infections in adolescents. Involving parents/guardians during some of the counseling for younger adolescents and creating age-appropriate materials on wound care will likely be important factors in curbing these infections. Minimizing VMMC-related AEs, including post-operative ones, is important to ensure the overall acceptability and sustainability of the intervention.

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