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Effect of Standardized Educational Materials on Parental Circumcision Decision-Making: A Prospective Intervention Study
Carlos Sebastian Justo-Jaume, B.A., Brayden Gaston, B.S., Dhruv Pillai, B.S., Lucie Lefbom, B.S. B.A., Nora Kern, M.D..
University of Virginia School of Medicine, Charlottesville, VA, USA.
BACKGROUND: Parental decisions regarding infant circumcision are often influenced by social norms, religion/culture, and myths that circumcision is more hygienic. At our East Coast hospital, circumcision rates greatly exceed the national average. We also found that a fair number of parents do not receive counseling on routine circumcision. We evaluated whether a standardized educational pamphlet could influence parental circumcision intent, hypothesizing that this information could alter decision-making and improve perceived understanding, particularly among parents who were initially undecided.
METHODS: We conducted a prospective pre-post intervention study of expectant parents of newborn boys at a single academic institution. Participants completed a baseline survey assessing circumcision intent, then reviewed a standardized educational pamphlet outlining procedural risks, benefits, and professional society guidance. A post-intervention survey evaluated changes in circumcision plan, perceived helpfulness of the pamphlet, and new information learned. Matched responses were analyzed; categorical comparisons used Fisher exact tests, and ordinal comparisons used Mann-Whitney U test.
RESULTS: One hundred and eight participants were enrolled, with 59 (55%) completing both surveys (Table). At baseline, 37 (63%) planned circumcision, 11 (19%) declined, and 11 (19%) were unsure. After reviewing the pamphlet, 9 participants (15%) changed their circumcision plan. Changes were concentrated almost entirely among initially unsure parents: 7 of 11 (64%) unsure parents changed their plan, compared with 2 of 48 (4%) who had already decided (p<0.001). For those initially unsure who changed their plan, decision-making was split between planning (n=3) and declining (n=4) circumcision. Parents who changed their decision reported lower baseline confidence in their understanding of the pros and cons (1.9 vs 3.1 on a 5-point scale; p=0.01). Most participants (85%) rated the pamphlet as helpful, including 37 (63%) rating it very helpful, and 46 (78%) reported learning new information.
CONCLUSIONS: A standardized educational pamphlet was associated with changes in circumcision intent almost entirely among parents who were undecided or less confident in their understanding at baseline. Rather than pushing parents toward or away from circumcision, the pamphlet appeared to help undecided parents reach a clear decision in both directions, reducing the proportion who remained unsure. The majority reported learning new information which satisfies our intent to increase evidence-based counseling for parents making decisions about circumcision.
Circumcision plans and pamphlet responses| Outcome Measure | n (%) |
| Circumcision Plan - Baseline | |
| Yes | 37 (63) |
| No | 11 (19) |
| Unsure | 11 (19) |
| Circumcision Plan - Post-Pamphlet | |
| Yes | 42 (71) |
| No | 13 (22) |
| Unsure | 4 (7) |
| Changed plan after pamphlet | 9 (15) |
| Among baseline unsure | 7/11 (64) |
| Among baseline decided | 2/48 (4) |
| Plan transitions | |
| Unsure → No | 4 |
| Unsure → Yes | 3 |
| No → Yes | 2 |
| Perceived Helpfulness of Pamphlet | |
| Very helpful | 37 (63) |
| Somewhat helpful | 13 (22) |
| Neutral | 4 (7) |
| Not very/not helpful at all | 5 (8) |
| New Information Learned | |
| Significant or very good amount | 27 (46) |
| Some or slight amount | 25 (42) |
| None | 7 (12) |
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