PEPFAR

Systematic Monitoring of the Voluntary Medical Male Circumcision Scale-up in Eastern and Southern Africa:

Surgical Efficiencies and Provider Attitudes & Experiences

Webster Mavhu on behalf of the SYMMACS team

AIDS 2014 – Stepping Up The Pace

Background

• 14 African countries scaling up Voluntary Medical Male Circumcision (VMMC)

• The Systematic Monitoring of the VMMC Scale-up (SYMMACS) assessed scale-up in:– Kenya

– South Africa

– Tanzania

– Zimbabwe

Models for Optimizing the Volume and Efficiency of MC Services (2010)

Practitioners identified six elements of surgical efficiency that SYMMACS monitored:

1. “Task-shifting”

2. “Task-sharing”

3. Pre-bundling of surgical supplies with disposable

instruments (MC kits)

4. Rotation among multiple bays in operating theatre

5. Use of electrocautery/diathermy for hemostasis

6. Use of forceps-guided surgical method

SYMMACS Methodology • Process evaluation conducted in 4 countries– Kenya, South Africa, Tanzania & Zimbabwe

• 2 serial cross-sectional samples of VMMC sites– Data collected in 2011 and 2012 using same

instruments

• Included fixed, outreach and mobile sites– Kenya: only country that had mobile sites

RESULTS: Summary of Adoption of the 6 Efficiency Elements 2011-2012

Kenya South Africa Tanzania Zimbabwe

2011-2012 2011-2012 2011-2012 2011-2012

Multiple bays in operating theatre

X / X X / X X / X

Purchase of pre-bundled kits with disposable instruments

X / X X / X

Task-shifting X / X X / X

Task-sharing X / X X / X X / X X / X

Surgical method: forceps-guided X / X X / X X / X X / X

Electrocautery to stop bleeding X / X (x)* / X

RESULTS

• Task-sharing & electrocautery associated with:– Reduced provider time with a client

– Reduced operating time

• Quality of surgical technique not significantly related to time spent with client or operating time (except in S.Africa in 2012)

• Factors related to operating time varied by country and year, but task-sharing reduced operating time in S.Africa & Zimbabwe, and so did electrocautery

Regressions by Year & by Country, to Predict Primary Provider Time with Client (PPTC) in Seconds

  South Africa Tanzania Zimbabwe

  Coefficient CI Coefficient CI Coefficient CI

Data for sites in 2011

Type of hemostasis- Ligating sutures t -- t -- 178.40** (92.65, 264.15)

Task-sharing: who performed suturing

Primary & secondary -257.16**

(-362.19, -152.13) -347.84** (-466.23, -

227.44) (-235.53**) (-312.67, -158.43)

Data for sites in 2012

Type of hemostasis - Ligating sutures t -- t -- 166.59** (100.33, 232.85)

Task-sharing: who performed suturing

Primary & secondary t -- -264.02** (-468.15, -59.89) -184.51** (-249.43, -119.6)

Task-sharing: non-physician t -- -146.00** (-315.18, -23.18) t --

 Mean number of beds -48.60** (-61.67, -35.53) 65.42** (17.94,

112.90) -16.75 (-51.33, 17.82)

RESULTS:

• High concordance between each country’s policies and provider attitudes toward the efficiency elements

• However, providers expressed frustration over lack of provision for the conduct of certain practices (e.g., task-shifting in S.Africa & Zimbabwe)

RESULTS: Work Experience, Job Fulfillment & Burnout among VMMC Providers

– Perry et al. (2014)

• Providers in all countries reported high levels of personal job-fulfillment

• However, many providers reported work fatigue & burnout among themselves and their colleagues

• Burnout was highest in Kenya (country with longest running VMMC program)

Provider Burnout and Job Satisfaction

Kenya South Africa Tanzania Zimbabwe

% who agree or strongly agree that:

2011 n=85

2012n=82

2011 n=105

2012n=209

2011n=93

2012n=206

2011n= 74

2012n=94

Performing (or assisting in performing) VMMC is a personally fulfilling job

87.1 84.0 82.9 79.9 100 99.0 81.1 77.7

I personally have begun to experience work fatigue or burnout from performing (or assisting in performing) VMMC repeatedly

70.6 69.5 36.2 32.5 53.8 14.6 27.0 17.0

Recommendations

• No amount of surgical efficiency can compensate for weak demand for VMMC services (Rech et al. 2014a)

• Countries should consider how best to support & motivate its providers to maintain job-fulfillment and reduce burnout (Perry et al. 2014)

• Countries should consult providers & ensure greater understanding of policies to ensure compliance with efficiency elements (Mavhu et al. 2014)

Acknowledgment to Country Teams

Kenya South Africa Tanzania Zimbabwe

Implementing Agency FHI360/Kenya CHAPS MCHIP Jhpiego/Tanzania PSI/Zimbabwe, with ZAPP-

UZ as subcontractor

Co-investigatorDr. Nicholas Muraguri, Dr. Peter Cherutich, Dr. Kawango Agot, Dr. Walter Obiero, Dr. Jackson Kioko

Dr. Dirk Taljaard,

Dr. James McIntyreDr. Bennet Fimbo, Dr. Eleuter Samky

Dr. Karin Hatzold,  Christopher Samkange

Country Coordinator

Dr. Mores Loolpapit, Mathews Onyango Sasha Frade Michael D. Machaku Webster Mavhu

Clinician (data collection)

Omondi Dickens,

Nicolas Pule

Mulashi Biola, Daniel Shabangu, Sindiswe Zwane, Sindiswe Maseko

Dr. Sifuni Koshuma, Milton Kabiligi

Dr. Tendai MutwirahDr. Eric NyazikaDr. Kelvin Nemayire

Social Scientist for data collection

Rosemary Owigar, Dr. Violet Naanyu n/a n/a n/a

Data Manager Omondi Dickens Alexandra Spyrelis Flora Hezwa, Dr. Obadia Venance Nyongole Dudzai Mureyi

USAID Mission Anne Murphy Wendy Benzerga, Rebecca Fertziger

Duncan Onditi, Seth Greenberg, Eric Mlanga William Jansen

Technical assistance and/or sampling

Dr. Kate McIntyre, Zebedee Mwandi

Carlos Toledo, Lisa Mulwenga Koku Kasaura n/a

Manuscript review n/a n/a Hally Mahler Dr Karin Hatzold

Acknowledgement - Other CollaboratorsPrincipal investigators Jane T. Bertrand (PI), Dino Rech (co-PI)

Co-investigators Emmanuel Njeuhmeli, Delivette Castor, Jason Reed

Technical Advisory Group to the R2P Project for VMMC (convened in 2010)

Bertran Auvert, Stella Babalola, Robert Bailey, Kelly Curran, Kim Eva Dickson, Timothy Farley, Ron Gray, Jason Reed, Caroline Ryan; also present from USAID: Benny Kottiri, David Stanton, Alison Cheng, Timothy Mah, Emmanuel Njeuhmeli.

USAID/Washington:  Emmanuel Njeuhmeli, Delivette Castor, Alison Cheng, Benny Kottiri, Sarah Sandison, Timothy Mah

PEPFAR/CDC/Atlanta:  Jason Reed (at the time of initiation of the study)

Center for Communication Programs (CCP), Johns Hopkins Bloomberg School of Public Health: 

Susan Krenn, William Glass, and Mark Beisser; and from R2P staff (CCP): Deanna Kerrigan, Caitlin Kennedy, Brandon Howard, Emily Hurley, Heena Brahmbhatt, Andrea Vazzano,  ‘Kuor Kumoji, Erica Layer, Jessica Spielman and Margie Wild

Technical and administrative support / Tulane SPTHM

Alan Czaplicki, Bobbie Garner-Coffie, Frances Mather, Christopher Swalm. 

Research support / Tulane SPTHM

Linnea Perry, Margaret Farrell, Nicholas Thomas

The USAID | Project SEARCH, Task Order No.2,  is  funded by the U.S. Agency for International Development under Contract No. GHH-I-00-07-00032-00, beginning September 30, 2008, and supported by the President’s Emergency Plan for AIDS Relief.  The  Research  to  Prevention  (R2P)  Project  is  led by  the  Johns  Hopkins Center for Global Health and managed by the Johns Hopkins Bloomberg School of Public Health Center for Communication Programs (JHUCCP).