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Su Y, Mukora R, Ndebele F, Pienaar J, Khumalo C, Xu X, Tweya H, Sardini M, Day S, Sherr K, Setswe G, Feldacker C. Cost savings in male circumcision post-operative care using two-way text-based follow-up in rural and urban South Africa. PLoS One 2023; 18:e0294449. [PMID: 37972009 PMCID: PMC10653449 DOI: 10.1371/journal.pone.0294449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 10/31/2023] [Indexed: 11/19/2023] Open
Abstract
INTRODUCTION Voluntary medical male circumcision (VMMC) clients are required to attend multiple post-operative follow-up visits in South Africa. However, with demonstrated VMMC safety, stretched clinic staff in SA may conduct more than 400,000 unnecessary reviews for males without complications, annually. Embedded into a randomized controlled trial (RCT) to test safety of two-way, text-based (2wT) follow-up as compared to routine in-person visits among adult clients, the objective of this study was to compare 2wT and routine post-VMMC care costs in rural and urban South African settings. METHODS Activity-based costing (ABC) estimated the costs of post-VMMC care, including counselling, follow-ups, and tracing in $US dollars. Transportation for VMMC and follow-up was provided for rural clients in outreach settings but not for urban clients in static sites. Data were collected from National Department of Health VMMC forms, RCT databases, and time-and-motion surveys. Sensitivity analysis presents different follow-up scenarios. We hypothesized that 2wT would save per-client costs overall, with higher savings in rural settings. RESULTS VMMC program costs were estimated from 1,084 RCT clients: 537 in routine care and 547 in 2wT. On average, 2wT saved $3.56 per client as compared to routine care. By location, 2wT saved $7.73 per rural client and increased urban costs by $0.59 per client. 2wT would save $2.16 and $7.02 in follow-up program costs if men attended one or two post-VMMC visits, respectively. CONCLUSION Quality 2wT follow-up care reduces overall post-VMMC care costs by supporting most men to heal at home while triaging clients with potential complications to timely, in-person care. 2wT saves more in rural areas where 2wT offsets transportation costs. Minimal additional 2wT costs in urban areas reflect high care quality and client engagement, a worthy investment for improved VMMC service delivery. 2wT scale-up in South Africa could significantly reduce overall VMMC costs while maintaining service quality.
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Affiliation(s)
- Yanfang Su
- Department of Global Health, University of Washington, Seattle, WA, United States of America
| | | | | | - Jacqueline Pienaar
- The Aurum Institute, Johannesburg, South Africa
- Centre for HIV-AIDS Prevention Studies (CHAPS), Johannesburg, South Africa
| | | | - Xinpeng Xu
- School of Public Health, Nanjing Medical University, Nanjing, China
| | - Hannock Tweya
- Department of Global Health, University of Washington, Seattle, WA, United States of America
- International Training and Education Center for Health (I-TECH), Seattle, WA, United States of America
| | - Maria Sardini
- Centre for HIV-AIDS Prevention Studies (CHAPS), Johannesburg, South Africa
| | - Sarah Day
- Centre for HIV-AIDS Prevention Studies (CHAPS), Johannesburg, South Africa
- School of Public Health, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Kenneth Sherr
- Department of Global Health, University of Washington, Seattle, WA, United States of America
| | - Geoffrey Setswe
- The Aurum Institute, Johannesburg, South Africa
- Department of Health Studies, University of South Africa (UNISA), Pretoria, South Africa
| | - Caryl Feldacker
- Department of Global Health, University of Washington, Seattle, WA, United States of America
- International Training and Education Center for Health (I-TECH), Seattle, WA, United States of America
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Feldacker C, Pienaar J, Wasunna B, Ndebele F, Khumalo C, Day S, Tweya H, Oni F, Sardini M, Adhikary B, Waweru E, Wafula MB, Dixon A, Jafa K, Su Y, Sherr K, Setswe G. Expanding the Evidence on the Safety and Efficiency of 2-Way Text Messaging-Based Telehealth for Voluntary Medical Male Circumcision Follow-up Compared With In-Person Reviews: Randomized Controlled Trial in Rural and Urban South Africa. J Med Internet Res 2023; 25:e42111. [PMID: 37159245 DOI: 10.2196/42111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 12/22/2022] [Accepted: 02/24/2023] [Indexed: 05/10/2023] Open
Abstract
BACKGROUND There is a dearth of high-quality evidence from digital health interventions in routine program settings in low- and middle-income countries. We previously conducted a randomized controlled trial (RCT) in Zimbabwe, demonstrating that 2-way texting (2wT) was safe and effective for follow-up after adult voluntary medical male circumcision (VMMC). OBJECTIVE To demonstrate the replicability of 2wT, we conducted a larger RCT in both urban and rural VMMC settings in South Africa to determine whether 2wT improves adverse event (AE) ascertainment and, therefore, the quality of follow-up after VMMC while reducing health care workers' workload. METHODS A prospective, unblinded, noninferiority RCT was conducted among adult participants who underwent VMMC with cell phones randomized in a 1:1 ratio between 2wT and control (routine care) in North West and Gauteng provinces. The 2wT participants responded to a daily SMS text message with in-person follow-up only if desired or an AE was suspected. The control group was requested to make in-person visits on postoperative days 2 and 7 as per national VMMC guidelines. All participants were asked to return on postoperative day 14 for study-specific review. Safety (cumulative AEs ≤day 14 visit) and workload (number of in-person follow-up visits) were compared. Differences in cumulative AEs were calculated between groups. Noninferiority was prespecified with a margin of -0.25%. The Manning score method was used to calculate 95% CIs. RESULTS The study was conducted between June 7, 2021, and February 21, 2022. In total, 1084 men were enrolled (2wT: n=547, 50.5%, control: n=537, 49.5%), with near-equal proportions of rural and urban participants. Cumulative AEs were identified in 2.3% (95% CI 1.3-4.1) of 2wT participants and 1.0% (95% CI 0.4-2.3) of control participants, demonstrating noninferiority (1-sided 95% CI -0.09 to ∞). Among the 2wT participants, 11 AEs (9 moderate and 2 severe) were identified, compared with 5 AEs (all moderate) among the control participants-a nonsignificant difference in AE rates (P=.13). The 2wT participants attended 0.22 visits, and the control participants attended 1.34 visits-a significant reduction in follow-up visit workload (P<.001). The 2wT approach reduced unnecessary postoperative visits by 84.8%. Daily response rates ranged from 86% on day 3 to 74% on day 13. Among the 2wT participants, 94% (514/547) responded to ≥1 daily SMS text messages over 13 days. CONCLUSIONS Across rural and urban contexts in South Africa, 2wT was noninferior to routine in-person visits for AE ascertainment, demonstrating 2wT safety. The 2wT approach also significantly reduced the follow-up visit workload, improving efficiency. These results strongly suggest that 2wT provides quality VMMC follow-up and should be adopted at scale. Adaptation of the 2wT telehealth approach to other acute follow-up care contexts could extend these gains beyond VMMC. TRIAL REGISTRATION ClinicalTrials.gov NCT04327271; https://www.clinicaltrials.gov/ct2/show/NCT04327271.
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Affiliation(s)
- Caryl Feldacker
- Department of Global Health, University of Washington, Seattle, WA, United States
- International Training and Education Center for Health, Department of Global Health, University of Washington, Seattle, WA, United States
| | | | | | | | | | - Sarah Day
- Centre for HIV-AIDS Prevention Studies (CHAPS), Johannesburg, South Africa
- Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Hannock Tweya
- Department of Global Health, University of Washington, Seattle, WA, United States
| | | | | | | | | | | | | | | | - Yanfang Su
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Kenneth Sherr
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Geoffrey Setswe
- Aurum Institute, Johannesburg, South Africa
- Department of Health Studies, University of South Africa (UNISA), Pretoria, South Africa
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Transitioning a digital health innovation from research to routine practice: Two-way texting for male circumcision follow-up in Zimbabwe. PLOS DIGITAL HEALTH 2022; 1:e0000066. [PMID: 36812548 PMCID: PMC9931231 DOI: 10.1371/journal.pdig.0000066] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 05/16/2022] [Indexed: 11/19/2022]
Abstract
Adult medical male circumcision (MC) is safe: global notifiable adverse event (AE) rates average below 2.0%. With Zimbabwe's shortage of health care workers (HCWs) compounded by COVID-19 constraints, two-way text-based (2wT) MC follow-up may be advantageous over routinely scheduled in-person reviews. A 2019 randomized control trial (RCT) found 2wT to be safe and efficient for MC follow-up. As few digital health interventions successfully transition from RCT to scale, we detail the 2wT scale-up approach from RCT to routine MC practice comparing MC safety and efficiency outcomes. After the RCT, 2wT transitioned from a site-based (centralized) system to hub-and-spoke model for scale-up where one nurse triaged all 2wT patients, referring patients in need to their local clinic. No post-operative visits were required with 2wT. Routine patients were expected to attend at least one post-operative review. We compare 1) AEs and in-person visits between 2wT men from RCT and routine MC service delivery; and 2) 2wT-based and routine follow-up among adults during the 2wT scale-up period, January to October 2021. During scale-up period, 5084 of 17417 adult MC patients (29%) opted into 2wT. Of the 5084, 0.08% (95% CI: 0.03, 2.0) had an AE and 71.0% (95% CI: 69.7, 72.2) responded to ≥1 daily SMS, a significant decrease from the 1.9% AE rate (95% CI: 0.7, 3.6; p<0.001) and 92.5% response rate (95% CI: 89.0, 94.6; p<0.001) from 2wT RCT men. During scale-up, AE rates did not differ between routine (0.03%; 95% CI: 0.02, 0.08) and 2wT (p = 0.248) groups. Of 5084 2wT men, 630 (12.4%) received telehealth reassurance, wound care reminders, and hygiene advice via 2wT; 64 (19.7%) were referred for care of which 50% had visits. Similar to RCT outcomes, routine 2wT was safe and provided clear efficiency advantages over in-person follow-up. 2wT reduced unnecessary patient-provider contact for COVID-19 infection prevention. Rural network coverage, provider hesitancy, and the slow pace of MC guideline changes slowed 2wT expansion. However, immediate 2wT benefits for MC programs and potential benefits of 2wT-based telehealth for other health contexts outweigh limitations.
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Murenje V, Omollo V, Gonouya P, Hove J, Munyaradzi T, Marongwe P, Tshimanga M, Chitimbire V, Xaba S, Mandisarisa J, Balachandra S, Makunike-Chikwinya B, Holec M, Mangwiro T, Barnhart S, Feldacker C. Urethrocutaneous fistula following VMMC: a case series from March 2013 to October 2019 in ZAZIC's voluntary medical male circumcision program in Zimbabwe. BMC Urol 2022; 22:20. [PMID: 35172795 PMCID: PMC8849017 DOI: 10.1186/s12894-022-00973-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 02/02/2022] [Indexed: 11/30/2022] Open
Abstract
Background Urethrocutaneous fistula (subsequently, fistula) is a rare adverse event (AE) in voluntary medical male circumcision (VMMC) programs. Global fistula rates of 0.19 and 0.28 per 100,000 VMMCs were reported. Management of fistula can be complex and requires expert skills. We describe seven cases of fistula in our large-scale VMMC program in Zimbabwe. We present fistula rates; provide an overview of initial management, surgical interventions, and patient outcomes; discuss causes; and suggest future prevention efforts. Results Case details are presented on fistulas identified between March 2013 and October 2019. Among the seven fistula clients, ages ranged from 10 to 22 years; 6 cases were among boys under 15 years of age. All clients received surgical VMMC by trained providers in an outreach setting. Clients presented with fistulae 2–42 days after VMMC. Secondary infection was identified in 6 of 7 cases. Six cases were managed through surgical repair. The number of repair attempts ranged from 1 to 10. One case healed spontaneously with conservative management. Fistula rates are presented as cases/100,000 VMMCs. Conclusion Fistula is an uncommon but severe AE that requires clinical expertise for successful management and repair. High-quality AE surveillance should identify fistula promptly and include consultation with experienced urologists. Strengthening provider surgical skills and establishment of standard protocols for fistula management would aid future prevention efforts in VMMC programs.
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Affiliation(s)
- Vernon Murenje
- Zimbabwe Technical Assistance, Training and Education Center for Health (Zim-TTECH), Harare, Zimbabwe.
| | - Victor Omollo
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Paidemoyo Gonouya
- Zimbabwe Association of Church-Related Hospitals (ZACH), Harare, Zimbabwe
| | - Joseph Hove
- Zimbabwe Association of Church-Related Hospitals (ZACH), Harare, Zimbabwe
| | - Tinashe Munyaradzi
- Zimbabwe Community Health Intervention Project (ZiCHIRe), Harare, Zimbabwe
| | - Phiona Marongwe
- Zimbabwe Technical Assistance, Training and Education Center for Health (Zim-TTECH), Harare, Zimbabwe
| | - Mufuta Tshimanga
- Zimbabwe Community Health Intervention Project (ZiCHIRe), Harare, Zimbabwe
| | - Vuyelwa Chitimbire
- Zimbabwe Association of Church-Related Hospitals (ZACH), Harare, Zimbabwe
| | | | - John Mandisarisa
- The Centers for Disease Control and Prevention (CDC), Harare, Zimbabwe
| | | | | | - Marrianne Holec
- International Training and Education Center for Health (I-TECH), Seattle, WA, USA
| | - Tonderayi Mangwiro
- Department of Surgery, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | - Scott Barnhart
- Department of Global Health, University of Washington, Seattle, WA, USA.,International Training and Education Center for Health (I-TECH), Seattle, WA, USA.,Department of Medicine, University of Washington, Seattle, WA, USA
| | - Caryl Feldacker
- Department of Global Health, University of Washington, Seattle, WA, USA.,International Training and Education Center for Health (I-TECH), Seattle, WA, USA
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Tran V, Gwenzi F, Marongwe P, Rutsito O, Chatikobo P, Murenje V, Hove J, Munyaradzi T, Rogers Z, Tshimanga M, Sidile-Chitimbire V, Xaba S, Ncube G, Masimba L, Makunike-Chikwinya B, Holec M, Barnhart S, Weiner B, Feldacker C. REDCap mobile data collection: Using implementation science to explore the potential and pitfalls of a digital health tool in routine voluntary medical male circumcision outreach settings in Zimbabwe. Digit Health 2022; 8:20552076221112163. [PMID: 35847527 PMCID: PMC9280838 DOI: 10.1177/20552076221112163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 05/30/2022] [Accepted: 06/21/2022] [Indexed: 11/23/2022] Open
Abstract
Background Digital data collection tools improve data quality but are limited by connectivity. ZAZIC, a Zimbabwean consortium focused on scaling up male circumcision (MC) services, provides MC in outreach settings where both data quality and connectivity is poor. ZAZIC implemented REDCap Mobile app for data collection among roving ZAZIC MC nurses. To inform continued scale-up or discontinuation, this paper details if, how, and for whom REDCap improved data quality using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. Methods Data were collected for this retrospective, cross-sectional study for nine months, from July 2019 to March 2020, before COVID-19 paused MC services. Data completeness was compared between paper- and REDCap-based tools and between two ZAZIC partners using two sample, one-tailed t-tests. Results REDCap reached all roving nurses who reported 26,904 MCs from 1773 submissions. REDCap effectiveness, as measured by data completeness, decreased from 89.2% in paper to 76.6% in REDCap app for Partner 1 (p < 0.001, 95% CI: −0.24, −0.12) but increased modestly from 86.2% to 90.3% in REDCap for Partner 2 (p = 0.05, 95% CI: -.007, 0.12). Adoption of REDCap was 100%; paper-based reporting concluded in October 2019. Implementation varied by partner and user. Maintenance appeared high. Conclusion Although initial transition from paper to REDCap showed mixed effectiveness, post-hoc analysis from service resumption found increased REDCap data completeness across partners, suggesting locally-led momentum for REDCap-based data collection. Staff training, consistent mentoring, and continued technical support appear critical for continued use of digital health tools for quality data collection in rural Zimbabwe and similar low connectivity settings.
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Affiliation(s)
- Vi Tran
- Department of Health Services, University of Washington, Seattle, WA, USA
| | - Farai Gwenzi
- Zimbabwe Technical Training and Education Center for Health (Zim-TTECH), Harare, Zimbabwe
| | - Phiona Marongwe
- International Training and Education Center for Health (I-TECH), Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Olbarn Rutsito
- Zimbabwe Association of Church-related Hospitals (ZACH), Harare, Zimbabwe
| | - Pesanai Chatikobo
- Zimbabwe Community Health Intervention Project (ZiCHIRe), Harare, Zimbabwe
| | - Vernon Murenje
- Zimbabwe Technical Training and Education Center for Health (Zim-TTECH), Harare, Zimbabwe
| | - Joseph Hove
- Zimbabwe Association of Church-related Hospitals (ZACH), Harare, Zimbabwe
| | - Tinashe Munyaradzi
- Zimbabwe Community Health Intervention Project (ZiCHIRe), Harare, Zimbabwe
| | - Zoe Rogers
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Mufuta Tshimanga
- Zimbabwe Community Health Intervention Project (ZiCHIRe), Harare, Zimbabwe
| | | | | | | | - Lewis Masimba
- Zimbabwe Technical Training and Education Center for Health (Zim-TTECH), Harare, Zimbabwe
| | | | - Marrianne Holec
- International Training and Education Center for Health (I-TECH), Department of Global Health, University of Washington, Seattle, WA, USA
| | - Scott Barnhart
- International Training and Education Center for Health (I-TECH), Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Bryan Weiner
- Department of Health Services, University of Washington, Seattle, WA, USA
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Caryl Feldacker
- International Training and Education Center for Health (I-TECH), Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Global Health, University of Washington, Seattle, WA, USA
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Lucas T, Cooney C, Prainito A, Godfrey C, Kiggundu V, Thomas AG, Ridzon R, Toledo C. Consolidated Overview of Notifiable Adverse Events in the U.S. President's Emergency Plan for AIDS Relief's Voluntary Medical Male Circumcision Program Through 2020. Curr HIV/AIDS Rep 2022; 19:508-515. [PMID: 36348185 PMCID: PMC9643893 DOI: 10.1007/s11904-022-00636-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/19/2022] [Indexed: 11/11/2022]
Abstract
PURPOSE OF REVIEW Through December 2020, the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) supported more than 25 million voluntary medical male circumcisions (VMMC) as part of the combined HIV prevention strategy in 15 African countries. PEPFAR monitors defined adverse events (AEs) occurring within 30 days of VMMC through its notifiable adverse event reporting system (NAERS). All NAERS reports through December 2020 were reviewed to quantify AE type, severity, and relation to the VMMC procedure. Interventions to improve client safety based on NAERS findings are described. RECENT FINDINGS Fourteen countries reported 446 clients with notifiable adverse events (NAEs); 394/446 (88%) were determined VMMC-related, representing approximately 18 NAE reports per million circumcisions. Fatalities comprised 56/446 (13%) with 24/56 (43%) of fatalities determined VMMC-related, representing 0.96 VMMC-related fatalities per million circumcisions. The remaining 390 NAEs were non-fatal with 370/390 (95%) VMMC-related. Multiple programmatic changes have been made based on NAERS data to improve client safety. Client safety is paramount in this surgical program designed for individual and population-level benefit. Surveillance of rare but severe complications following circumcision has identified pre-existing or new safety concerns and guided continuous programmatic improvement.
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Affiliation(s)
- Todd Lucas
- U.S. Centers for Disease Control and Prevention, Division of Global HIV and TB, HIV Prevention Branch, Atlanta, GA, USA.
| | - Caroline Cooney
- U.S. Department of State, Office of the U.S. Global AIDS Coordinator and Health Diplomacy, Washington, DC, USA
| | - Amber Prainito
- U.S. Department of State, Office of the U.S. Global AIDS Coordinator and Health Diplomacy, Washington, DC, USA
| | - Catherine Godfrey
- U.S. Department of State, Office of the U.S. Global AIDS Coordinator and Health Diplomacy, Washington, DC, USA
| | - Valerian Kiggundu
- U.S. Agency for International Development, Global Health, Office of HIV/AIDS, Washington, DC, USA
| | - Anne Goldzier Thomas
- U.S. Department of Defense HIV/AIDS Prevention Program, Defense Health Agency, San Diego, CA, USA
| | - Renee Ridzon
- U.S. Department of State, Office of the U.S. Global AIDS Coordinator and Health Diplomacy, Washington, DC, USA
| | - Carlos Toledo
- U.S. Centers for Disease Control and Prevention, Division of Global HIV and TB, HIV Prevention Branch, Atlanta, GA, USA
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O’Bryan G, Feldacker C, Ensminger A, Nghatanga M, Brandt L, Shepard M, Billah I, Aupokolo M, Mengistu AT, Forster N, Zemburuka B, Sithole E, Mutandi G, Barnhart S, O’Malley G. Adverse event profile and associated factors following surgical voluntary medical male circumcision in two regions of Namibia, 2015-2018. PLoS One 2021; 16:e0258611. [PMID: 34669709 PMCID: PMC8528325 DOI: 10.1371/journal.pone.0258611] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 09/30/2021] [Indexed: 12/12/2022] Open
Abstract
Introduction Monitoring clinical safety of voluntary medical male circumcision (VMMC) is critical to minimize risk as VMMC programs for HIV prevention are scaled. This cross-sectional analysis describes the adverse event (AE) profile of a large-scale, routine VMMC program and identifies factors associated with the development, severity, and timing of AEs to provide recommendations for program quality improvement. Materials and methods From 2015–2018 there were 28,990 circumcisions performed in International Training and Education Center for Health (I-TECH) supported regions of Namibia in collaboration with the Ministry of Health and Social Services. Two routine follow-up visits after VMMC were scheduled to identify clients with AEs. Summary statistics were used to describe characteristics of all VMMC clients and the subset who experienced an AE. We used chi-square tests to evaluate associations between AE timing, patient age, and other patient and AE characteristics. We used a logistic regression model to explore associations between patient characteristics and AE severity. Results Of the 498 clients with AEs (AE rate of 1.7%), 40 (8%) occurred ≤2 days, 262 (53%) occurred 3–7 days, 161 (32%) between day 8 and 14, and 35 (7%) were ≥15 days post-VMMC. Early AEs (on or before day 2) tended to be severe and categorized as bleeding, while infections were the most common AEs occurring later (p<0.001). Younger clients (aged 10–14 years) experienced more infections, whereas older clients experienced more bleeding (p<0.001). Conclusions Almost 40% of AEs occurred after the second follow-up visit, of which 179 (91%) were infections. Improvements in pre-surgical and post-surgical counselling and post-operative educational materials encouraging clients to seek care at any time, adoption of alternative follow-up methods, and the addition of a third follow-up visit may improve outcomes for patients. Enhancing post-surgical counselling and emphasizing wound care for younger VMMC clients and their caregivers could help mitigate elevated risk of infection.
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Affiliation(s)
- Gillian O’Bryan
- Department of Global Health, International Training and Education Center for Health (I-TECH), University of Washington, Seattle, WA, United States of America
- Department of Global Health, University of Washington, Seattle, WA, United States of America
- * E-mail:
| | - Caryl Feldacker
- Department of Global Health, International Training and Education Center for Health (I-TECH), University of Washington, Seattle, WA, United States of America
- Department of Global Health, University of Washington, Seattle, WA, United States of America
| | - Alison Ensminger
- Department of Global Health, International Training and Education Center for Health (I-TECH), University of Washington, Seattle, WA, United States of America
- Department of Global Health, University of Washington, Seattle, WA, United States of America
| | - Magdaleena Nghatanga
- Department of Global Health, University of Washington, Seattle, WA, United States of America
- Department of Global Health, International Training and Education Center for Health (I-TECH), University of Washington, Windhoek, Namibia
| | - Laura Brandt
- Department of Global Health, University of Washington, Seattle, WA, United States of America
- Department of Global Health, International Training and Education Center for Health (I-TECH), University of Washington, Windhoek, Namibia
| | - Mark Shepard
- Department of Global Health, University of Washington, Seattle, WA, United States of America
- Department of Global Health, International Training and Education Center for Health (I-TECH), University of Washington, Windhoek, Namibia
| | - Idel Billah
- Department of Global Health, University of Washington, Seattle, WA, United States of America
- Department of Global Health, International Training and Education Center for Health (I-TECH), University of Washington, Windhoek, Namibia
| | - Mekondjo Aupokolo
- Directorate of Special Programs-Ministry of Health and Social Services, Windhoek, Namibia
| | | | - Norbert Forster
- Department of Global Health, University of Washington, Seattle, WA, United States of America
- Department of Global Health, International Training and Education Center for Health (I-TECH), University of Washington, Windhoek, Namibia
| | - Brigitte Zemburuka
- Centers for Disease Control and Prevention (CDC/DDPHSIS/CGH/DGHT), Windhoek, Namibia
| | - Edwin Sithole
- Centers for Disease Control and Prevention (CDC/DDPHSIS/CGH/DGHT), Windhoek, Namibia
| | - Gram Mutandi
- Centers for Disease Control and Prevention (CDC/DDPHSIS/CGH/DGHT), Windhoek, Namibia
| | - Scott Barnhart
- Department of Global Health, International Training and Education Center for Health (I-TECH), University of Washington, Seattle, WA, United States of America
- Department of Medicine, University of Washington, Seattle, WA, United States of America
| | - Gabrielle O’Malley
- Department of Global Health, International Training and Education Center for Health (I-TECH), University of Washington, Seattle, WA, United States of America
- Department of Global Health, University of Washington, Seattle, WA, United States of America
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Victor O, Phiona M, Vernon M, Thoko M, Paidamoyo G, Farai G, Joseph H, Munyaradzi T, Olban R, Pesanai C, Mufuta T, Vuyelwa SC, Sinokuthemba X, Batsirai MC, Marrianne H, Scott B, Feldacker C. Adverse Event Trends Within a Large-Scale, Routine, Voluntary Medical Male Circumcision Program in Zimbabwe, 2014-2019. J Acquir Immune Defic Syndr 2021; 88:173-180. [PMID: 34173789 PMCID: PMC8434989 DOI: 10.1097/qai.0000000000002751] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Accepted: 05/20/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Between 2008 and 2020, over 22.6 million male circumcisions (MCs) were performed among men ≥10 years in 15 priority countries of East and Southern Africa. Few studies from routine MC programs operating at scale describe trends of adverse events (AEs) or AE rates over time. SETTING Routine program data from a large MC program in Zimbabwe. METHODS χ2 compared characteristics of patients with AEs. Univariable and multivariable logistic models examined factors associated with AE severity. Cochran-Armitage trend tests compared AE rate trends by year (2014-2019), age, and MC method (2017-2019). RESULTS From 2014 to 2019, 469,000 men were circumcised; of the total men circumcised, 38%, 27%, and 35% were conducted among individuals aged 10-14; 15-19; and ≥20 years, respectively. Most MCs (95%) used surgical (dorsal slit or forceps-guided) methods; 5% were device based (PrePex). AEs were reported among 632 (0.13%) MCs; 0.05% were severe. From 2015 to 2019, overall AE rates declined from 34/10,000 to 5/10,000 (P-value <0.001). Severe AE rates also decreased over this period from 12/10,000 to 2/10,000 (P-value <0.001). AE rates among younger clients, aged 10-14 (18/10,000) were higher than among older age men (9/10,000) aged ≥20 years (P < 0.001); however, there was no significant association between age and AE severity. CONCLUSION AE rates each year and over time were lower than the World Health Organization acceptable maximum (2% AEs). ZAZIC quality assurance activities ensured guideline adherence, mentored clinicians to MC competency, promoted quality client education and counseling, and improved AE reporting over time. Decreases in AE rates are likely attributed to safety gains and increasing provider experience.
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Affiliation(s)
- Omollo Victor
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Marongwe Phiona
- Zimbabwe Technical Training and Education Center for Health (ZIMTTECH), Harare, Zimbabwe
| | - Murenje Vernon
- Zimbabwe Technical Training and Education Center for Health (ZIMTTECH), Harare, Zimbabwe
| | - Madoda Thoko
- Zimbabwe Community Health Intervention Project (ZiCHIRe), Harare, Zimbabwe
| | - Gonouya Paidamoyo
- Zimbabwe Technical Training and Education Center for Health (ZIMTTECH), Harare, Zimbabwe
| | - Gwenzi Farai
- Zimbabwe Technical Training and Education Center for Health (ZIMTTECH), Harare, Zimbabwe
| | - Hove Joseph
- Zimbabwe Association of Church-related Hospitals (ZACH), Harare, Zimbabwe
| | - Tinashe Munyaradzi
- Zimbabwe Community Health Intervention Project (ZiCHIRe), Harare, Zimbabwe
| | - Rutsito Olban
- Zimbabwe Association of Church-related Hospitals (ZACH), Harare, Zimbabwe
| | - Chatikobo Pesanai
- Zimbabwe Community Health Intervention Project (ZiCHIRe), Harare, Zimbabwe
| | - Tshimanga Mufuta
- Zimbabwe Community Health Intervention Project (ZiCHIRe), Harare, Zimbabwe
| | | | | | | | - Holec Marrianne
- International Training and Education Center for Health (I-TECH), Seattle, WA USA
| | - Barnhart Scott
- Department of Global Health, University of Washington, Seattle, WA, USA
- International Training and Education Center for Health (I-TECH), Seattle, WA USA
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Caryl Feldacker
- Department of Global Health, University of Washington, Seattle, WA, USA
- International Training and Education Center for Health (I-TECH), Seattle, WA USA
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Nyengerai T, Phohole M, Iqaba N, Kinge CW, Gori E, Moyo K, Chasela C. Quality of service and continuous quality improvement in voluntary medical male circumcision programme across four provinces in South Africa: Longitudinal and cross-sectional programme data. PLoS One 2021; 16:e0254850. [PMID: 34351933 PMCID: PMC8341521 DOI: 10.1371/journal.pone.0254850] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 07/03/2021] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Recent studies in the Sub-Saharan countries in Africa have indicated gaps and challenges for voluntary medical male circumcision (VMMC) quality of service. Less has focused on the changes in quality of service after implementation of continuous quality improvement (CQI) action plans. This study aimed to evaluate the impact of coaching, provision of standard operating procedures (SOPS) and guidelines, mentoring and on-site in-service training in improving quality of VMMC services across four Right to Care (RTC) supported provinces in South Africa. METHOD This was a pre- and post-interventional study on RTC supported VMMC sites from July 2018 to October 2019. All RTC-supported sites that were assessed at baseline and post-intervention were included in the study. Data for baseline CQI assessment and re-assessments was collected using a standardized National Department of Health (NDoH) CQI assessment tool for VMMC services from routine RTC facility level VMMC programme data. Quality improvement support was provided through a combination of coaching, provision of standard operating procedures and guidelines, mentoring and on-site in-service training on quality improvement planning and implementation. The main outcome measure was quality of service. A paired sample t-test was used to compare the difference in mean quality of service scores before and after CQI implementation by quality standard. RESULTS A total of 40 health facilities were assessed at both baseline and after CQI support visits. Results showed significant increases for the overall changes in quality of service after CQI support intervention of 12% for infection prevention (95%CI: 7-17; p<0.001) and 8% for male circumcision surgical procedure, (95%CI: 3-13; p<0.01). Similarly, individual counselling, and HIV testing increased by 14%, (95%CI: 7-20; p<0.001), group counselling, registration and communication by 8%, (95%CI: 3-14; p<0.001), and 35% for monitoring and evaluation, (95%CI: 28-42; p<0.001). In addition, there were significant increases for management systems of 29%, (95%CI: 22-35; p<0.001), leadership and planning 23%, (95%CI: 13-34; p<0.001%) and supplies, equipment, environment and emergency 5%, (95%CI: 1-9; p<0.01). The overall quality of service performance across provinces increased by 18% (95%CI: 14-21; p<0.001). CONCLUSION The overall quality of service performance across provinces was significantly improved after implementation of CQI support intervention program. Regular visits and intensive CQI support are required for sites that will be performing below quality standards.
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Affiliation(s)
- Tawanda Nyengerai
- Department of Epidemiology and Biostatistics, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Gauteng, South Africa
| | - Motshana Phohole
- Voluntary Medical Male Circumcision (VMMC) Programme, Right to Care, Johannesburg, Gauteng, South Africa
| | - Nelson Iqaba
- Voluntary Medical Male Circumcision (VMMC) Programme, Right to Care, Johannesburg, Gauteng, South Africa
| | - Constance Wose Kinge
- Department of Implementation Science, Right to Care, Johannesburg, Gauteng, South Africa
| | - Elizabeth Gori
- Department of Pre-Clinical Veterinary Science, University of Zimbabwe, Harare, Zimbabwe
| | - Khumbulani Moyo
- Voluntary Medical Male Circumcision (VMMC) Programme, Right to Care, Johannesburg, Gauteng, South Africa
| | - Charles Chasela
- Department of Epidemiology and Biostatistics, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Gauteng, South Africa
- Department of Implementation Science, Right to Care, Johannesburg, Gauteng, South Africa
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Lucas T, Hines JZ, Samuelson J, Hargreave T, Davis SM, Fellows I, Prainito A, Watts DH, Kiggundu V, Thomas AG, Ntsuape OC, Dare K, Odoyo-June E, Soo L, Toti-Mokoteli L, Manda R, Kapito M, Msungama W, Odek J, Come J, Canda M, Gaspar N, Mekondjo A, Zemburuka B, Bonnecwe C, Vranken P, Mmbando S, Simbeye D, Rwegerera F, Wamai N, Kyobutungi S, Zulu JE, Chituwo O, Xaba S, Mandisarisa J, Toledo C. Urethrocutaneous fistulas after voluntary medical male circumcision for HIV prevention-15 African Countries, 2015-2019. BMC Urol 2021; 21:23. [PMID: 33579261 PMCID: PMC7881669 DOI: 10.1186/s12894-021-00790-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 02/01/2021] [Indexed: 02/01/2023] Open
Abstract
Background Voluntary medical male circumcision (VMMC) is an HIV prevention strategy recommended to partially protect men from heterosexually acquired HIV. From 2015 to 2019, the President’s Emergency Plan for AIDS Relief (PEPFAR) has supported approximately 14.9 million VMMCs in 15 African countries. Urethrocutaneous fistulas, abnormal openings between the urethra and penile skin through which urine can escape, are rare, severe adverse events (AEs) that can occur with VMMC. This analysis describes fistula cases, identifies possible risks and mechanisms of injury, and offers mitigation actions. Methods Demographic and clinical program data were reviewed from all reported fistula cases during 2015 to 2019, descriptive analyses were performed, and an odds ratio was calculated by patient age group. Results In total, 41 fistula cases were reported. Median patient age for fistula cases was 11 years and 40/41 (98%) occurred in patients aged < 15 years. Fistulas were more often reported among patients < 15 compared to ≥ 15 years old (0.61 vs. 0.01 fistulas per 100,000 VMMCs, odds ratio 50.9 (95% confidence interval [CI] = 8.6–2060.0)). Median time from VMMC surgery to appearance of fistula was 20 days (interquartile range (IQR) 14–27). Conclusions Urethral fistulas were significantly more common in patients under age 15 years. Thinner tissue overlying the urethra in immature genitalia may predispose boys to injury. The delay between procedure and symptom onset of 2–3 weeks indicates partial thickness injury or suture violation of the urethral wall as more likely mechanisms of injury than intra-operative urethral transection. This analysis helped to inform PEPFAR’s recent decision to change VMMC eligibility policy in 2020, raising the minimum age to 15 years.
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Affiliation(s)
- Todd Lucas
- Division of Global HIV and Tuberculosis, Centers for Disease Control and Prevention, Atlanta, GA, USA.
| | - Jonas Z Hines
- Division of Global HIV and Tuberculosis, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Julia Samuelson
- Global HIV, Hepatitis, and STIs Programmes, World Health Organization, Geneva, Switzerland
| | | | - Stephanie M Davis
- Division of Global HIV and Tuberculosis, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Ian Fellows
- Fellows Statistics, Contractor, Centers for Disease Control and Prevention, San Diego, CA, USA
| | - Amber Prainito
- U.S. Office of the Global HIV/AIDS Coordinator, Washington, DC, USA
| | - D Heather Watts
- U.S. Office of the Global HIV/AIDS Coordinator, Washington, DC, USA
| | - Valerian Kiggundu
- Office of HIV/AIDS, U.S. Agency for International Development, Washington, DC, USA
| | - Anne G Thomas
- Department of Defense, Defense Health Agency, San Diego, CA, USA
| | | | - Kunle Dare
- Division of Global HIV and Tuberculosis, Centers for Disease Control and Prevention, Gaborone, Botswana
| | - Elijah Odoyo-June
- Division of Global HIV and Tuberculosis, Centers for Disease Control and Prevention, Nairobi, Kenya
| | - Leonard Soo
- U.S. Agency for International Development, Nairobi, Kenya
| | | | - Robert Manda
- U.S. Agency for International Development, Maseru, Lesotho
| | | | - Wezi Msungama
- Division of Global HIV and Tuberculosis, Centers for Disease Control and Prevention, Lilongwe, Malawi
| | - James Odek
- U.S. Agency for International Development, Lilongwe, Malawi
| | | | - Marcos Canda
- Division of Global HIV and Tuberculosis, Centers for Disease Control and Prevention, Maputo, Mozambique
| | - Nuno Gaspar
- U.S. Agency for International Development, Maputo, Mozambique
| | | | - Brigitte Zemburuka
- Division of Global HIV and Tuberculosis, Centers for Disease Control and Prevention, Windhoek, Namibia
| | | | - Peter Vranken
- Division of Global HIV and Tuberculosis, Centers for Disease Control and Prevention, Pretoria, South Africa
| | | | - Daimon Simbeye
- Division of Global HIV and Tuberculosis, Centers for Disease Control and Prevention, Dar es Salaam, Tanzania
| | | | - Nafuna Wamai
- Division of Global HIV and Tuberculosis, Centers for Disease Control and Prevention, Kampala, Uganda
| | | | | | - Omega Chituwo
- Division of Global HIV and Tuberculosis, Centers for Disease Control and Prevention, Lusaka, Zambia
| | | | - John Mandisarisa
- Division of Global HIV and Tuberculosis, Centers for Disease Control and Prevention, Harare, Zimbabwe
| | - Carlos Toledo
- Division of Global HIV and Tuberculosis, Centers for Disease Control and Prevention, Atlanta, GA, USA
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Feldacker C, Murenje V, Makunike-Chikwinya B, Hove J, Munyaradzi T, Marongwe P, Balachandra S, Mandisarisa J, Holec M, Xaba S, Sidile-Chitimbire V, Tshimanga M, Barnhart S. Balancing competing priorities: Quantity versus quality within a routine, voluntary medical male circumcision program operating at scale in Zimbabwe. PLoS One 2020; 15:e0240425. [PMID: 33048977 PMCID: PMC7553309 DOI: 10.1371/journal.pone.0240425] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 09/26/2020] [Indexed: 12/11/2022] Open
Abstract
Background Since 2013, the ZAZIC consortium supported the Zimbabwe Ministry of Health and Child Care (MOHCC) to implement a high quality, integrated voluntary medical male circumcision (VMMC) program in 13 districts. With the aim of significantly lowering global HIV rates, prevention programs like VMMC make every effort to achieve ambitious targets at an increasingly reduced cost. This has the potential to threaten VMMC program quality. Two measures of program quality are follow-up and adverse event (AE) rates. To inform further VMMC program improvement, ZAZIC conducted a quality assurance (QA) activity to assess if pressure to do more with less influenced program quality. Methods Key informant interviews (KIIs) were conducted at 9 sites with 7 site-based VMMC program officers and 9 ZAZIC roving team members. Confidentiality was ensured to encourage candid conversation on adherence to VMMC standards, methods to increase productivity, challenges to target achievement, and suggestions for program modification. Interviews were recorded, transcribed and analyzed using Atlas.ti 6. Results VMMC teams work long hours in diverse community settings to reach ambitious targets. Rotating, large teams of trained VMMC providers ensures meeting demand. Service providers prioritize VMMC safety procedures and implement additional QA measures to prevent AEs among all clients, especially minors. However, KIs noted three areas where pressure for increased numbers of clients diminished adherence to VMMC safety standards. For pre- and post-operative counselling, MC teams may combine individual and group sessions to reach more people, potentially reducing client understanding of critical wound care instructions. Second, key infection control practices may be compromised (handwashing, scrubbing techniques, and preoperative client preparation) to speed MC procedures. Lastly, pressure for client numbers may reduce prioritization of patient follow-up, while client-perceived stigma may reduce care-seeking. Although AEs appear well managed, delays in AE identification and lack of consistent AE reporting compromise program quality. Conclusion In pursuit of ambitious targets, healthcare workers may compromise quality of MC services. Although risk to patients may appear minimal, careful consideration of the realities and risks of ambitious target setting by donors, ministries, and implementing partners could help to ensure that client safety and program quality is consistently prioritized over productivity.
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Affiliation(s)
- Caryl Feldacker
- International Training and Education Center for Health (I-TECH), Seattle, WA, United States of America
- Department of Global Health, University of Washington, Seattle, WA, United States of America
- * E-mail:
| | - Vernon Murenje
- International Training and Education Center for Health (I-TECH), Harare, Zimbabwe
| | | | - Joseph Hove
- Zimbabwe Association of Church-related Hospitals (ZACH), Harare, Zimbabwe
| | - Tinashe Munyaradzi
- Zimbabwe Community Health Intervention Project (ZICHIRE), Harare, Zimbabwe
| | - Phiona Marongwe
- International Training and Education Center for Health (I-TECH), Harare, Zimbabwe
| | - Shirish Balachandra
- United States Centers for Disease Control and Prevention, Division of Global HIV & TB, Harare, Zimbabwe
| | - John Mandisarisa
- United States Centers for Disease Control and Prevention, Division of Global HIV & TB, Harare, Zimbabwe
| | - Marrianne Holec
- International Training and Education Center for Health (I-TECH), Seattle, WA, United States of America
| | | | | | - Mufuta Tshimanga
- Zimbabwe Community Health Intervention Project (ZICHIRE), Harare, Zimbabwe
| | - Scott Barnhart
- International Training and Education Center for Health (I-TECH), Seattle, WA, United States of America
- Department of Global Health, University of Washington, Seattle, WA, United States of America
- Department of Medicine, University of Washington, Seattle, WA, United States of America
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12
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Reducing Provider Workload While Preserving Patient Safety: A Randomized Control Trial Using 2-Way Texting for Postoperative Follow-up in Zimbabwe's Voluntary Medical Male Circumcision Program. J Acquir Immune Defic Syndr 2020; 83:16-23. [PMID: 31809358 PMCID: PMC6903365 DOI: 10.1097/qai.0000000000002198] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Supplemental Digital Content is Available in the Text. Voluntary medical male circumcisions (MCs) are safe: the majority of men heal without complication. However, guidelines require multiple follow-up visits. In Zimbabwe, where there is high mobile phone ownership, severe health care worker shortages, and rapid MC scale up intersect, we tested a 2-way texting (2wT) intervention to reduce provider workload while safeguarding patient safety.
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13
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Feldacker C, Holeman I, Murenje V, Xaba S, Korir M, Wambua B, Makunike-Chikwinya B, Holec M, Barnhart S, Tshimanga M. Usability and acceptability of a two-way texting intervention for post-operative follow-up for voluntary medical male circumcision in Zimbabwe. PLoS One 2020; 15:e0233234. [PMID: 32544161 PMCID: PMC7297350 DOI: 10.1371/journal.pone.0233234] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 04/30/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Voluntary medical male circumcision (MC) is safe and effective. Nevertheless, MC programs require multiple post-operative visits. In Zimbabwe, a randomized control trial (RCT) found that post-operative two-way texting (2wT) between clients and MC providers instead of in-person reviews reduced provider workload and safeguarded patient safety. A critical component of the RCT assessed usability and acceptability of 2wT among providers and clients. These findings inform scale-up of the 2wT approach to post-operative follow-up. METHODS The RCT assigned 362 adult MC clients with cell phones into 2wT; these men responded to 13 automated daily texts supported by interactive texting or in-person follow-up, when needed. A subset of 100 texting clients filled a self-administered usability survey on day 14. 2wT acceptability was ascertained via 2wT response rates. Among 2wT providers, eight key informant interviews focused on 2wT acceptability and usability. Influences of wage and age on response rates and client-reported potential AEs were explored using linear and logistic regression models, respectively. RESULTS Clients felt confident, comfortable, satisfied, and well-supported with 2wT-based follow-up; few noted texting challenges or concerns about healing. Clients felt 2wT saved them time and money. Response rates (92%) suggested 2wT acceptability. Both clients and providers felt 2wT was highly usable. Providers noted 2wT saved them time, empowered clients to engage in their healing, and closed gaps in MC service quality. For scale, providers reinforced good post-operative counseling on AEs and texting instructions. Wage and age did not influence text response rates or potential AE texts. CONCLUSION Results strongly suggest that 2wT is highly usable and acceptable for providers and patients. Men with concerns solicited provider guidance and reassurance offered via text. Providers noted that men engaged proactively in their healing. 2wT between providers and patients should be expanded for MC and considered for other short-term care contexts. The trial is registered on ClinicalTrials.gov, trial NCT03119337, and was activated on April 18, 2017. https://clinicaltrials.gov/ct2/show/NCT03119337.
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Affiliation(s)
- Caryl Feldacker
- Department of Global Health, University of Washington, Seattle, WA, United States of America
- International Training and Education Center for Health (I-TECH), Seattle, WA, United States of America
| | - Isaac Holeman
- Department of Global Health, University of Washington, Seattle, WA, United States of America
- Medic Mobile, Nairobi, Kenya
| | - Vernon Murenje
- International Training and Education Center for Health (I-TECH), Harare, Zimbabwe
| | | | | | | | | | - Marrianne Holec
- International Training and Education Center for Health (I-TECH), Seattle, WA, United States of America
| | - Scott Barnhart
- Department of Global Health, University of Washington, Seattle, WA, United States of America
- International Training and Education Center for Health (I-TECH), Seattle, WA, United States of America
- Department of Medicine, University of Washington, Seattle, WA, United States of America
| | - Mufuta Tshimanga
- Zimbabwe Community Health Intervention Project (ZiCHIRE), Harare, Zimbabwe
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