Evaluation of Satisfaction of Men Receiving Voluntary Medical Male Circumcision Services

in Yala Division, Siaya County, Kenya.

 Abunah Bonface1, Prof. Ombaka James2, Dr. Guyah Bernard2, Onkoba

Rueben2.

1. AMREF Kenya.

2. Maseno University.

©2012 - 20131

PRESENTATION OUTLINE

Introduction/ Background.

Research Questions.

Methods.

Findings and Discussion.

Conclusions and Recommendations.

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INTRO/BACKGROUND

Circumcision is one of the oldest and most common surgical procedures worldwide, undertaken for religious, cultural, social, and medical reasons.

Three RCTs were completed in Africa (Orange Farm, South Africa; Kisumu, Kenya; and Rakai, Uganda). All the three trials were stopped during an interim analysis due to the protective effect afforded by male circumcision against HIV acquisition, All the three RCTs reported remarkably consistent results of approximately 60% protective effect suggesting a similar efficacy in divergent populations (Auvert et al. 2005, Gray et al., 2007; Bailey et al., 2007).

Based on the RCTs evidence WHO and UNAIDS issued recommendations on MC in march 2007, Kenyan MOH also adopted a policy on MC in 2007 that led to the roll out in 2008.

Rolled out in former Nyanza province in 2008 (the province with the lowest MC and highest HIV prevalence) and targeted the sexually active males aged 15-49 years.

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4

Kisumu MC Trial Clinic

Orange Farm MC Center Rakai Research Center

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MALE CIRCUMCISION DURING MOBILE VMMC

INTRO/BACKGROUND CONT’

Circumcision for men is an important component of a comprehensive multi-faceted National HIV prevention policy aiming at increasing demand and capacity of the health systems.

Though VMMC services are free at all stages of client care, the set targets for some elements of its minimum package have never been met by the providers since the inception of the program 4 years ago.

Thus it called for an evaluation study to assess the client’s level of satisfaction with the services offered and identification of areas that could be improved.

Evaluation: A process of making a comparative assessment of the value of an intervention through systematic collection and analysis of data.

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INTRO/BACKGROUND CONT’

Satisfaction: The customer level of approval when comparing a product’s perceived performance with his or her expectations.

Patient satisfaction is a key criterion by which the quality of health care services is evaluated.

Patient satisfaction data are routinely collected and used for continuous quality improvement by health care institutions and hospitals.

This study measured the level of satisfaction among circumcised clients, established facilitatory and inhibitory factors behind the uptake of day 7 reviews and also sought opinions on how VMMC services could be improved.

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RESEARCH QUESTIONS

To what level are the clients satisfied with the received circumcision and counseling services?

What are the facilitatory and inhibitory factors behind the uptake of day 7 post MC reviews in Yala division?

How can VMMC service provision be improved in Yala division?

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METHODS

A cross-sectional survey was carried out on 277 men who received VMMC services at Yala SDH (56) and in Malanga, Marenyo, Nyawara and Ramula Health Centres (221).

Data was collected through phone interviews using semi-structured questionnaires with closed and open ended questions between 21st and 31st day following MC procedure.

Analysis was done using descriptive statistics and inferential statistics using SPSS for the quantitative questions. Qualitative data was grouped into themes then sieved out. The themes were coded, grouped and analyzed.

A chi-square tests were done to evaluate the statistical significance (p<0.05) of the respondent’s return to the health facility for review and other socio-demographic variables.

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FINDINGS

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      Returned For Review  

    Total (N=277) Yes No P ValueDemographic characteristics and variables        

 Age in Years 18-25 125(45.1%) 55(44%) 70(56%) 0.19

  26-35 95(34.3%) 47(49%) 48(51%)  

  36-45 25(9.1%) 13(52%) 12(48%)  

  46-55 22(7.9%) 16(73%) 6(27%)  

  56-65 8(2.9%) 5(63%) 3(37%)  

  Over 65 2(0.7%) 1(50%) 1(50%)  

 Education Level No formal educ. 32(11.5%) 16(50%) 16(50%) 0.07

  Primary 60(21.7%) 36(60%) 24(40%)  

  Secondary 110(39.7%) 44(40%) 66(60%)  

  college 51(18.4%) 30(59%) 21(41%)  

  University 24(8.7%) 11(46%) 13(54%)  

FINDINGS

 Employment Status Permanent 42(15.1%) 24 (57%) 18 (43%) 0.5

  Temporary 61(22.0%) 32 (52%) 29 (48%)  

  Self employed 70(25.3%) 35 (50%) 35 (50%)  

  Unemployed 104(37.6%) 46 (44%) 58 (56%)  

 Child Status Has children 153(55.2%) 82(54%) 71(46%) 0.15

  No children 124(44.8%) 55(44%) 69(56%)  

 Permanent Resident of Yala Yes 151(54.5%) 90(60%) 61(40%) <0.0001

  No 126(45.5%) 47(37%) 79(63%)  

 Health Facility Malanga(OPD) 24(8.7%) 14(58%) 10(42%)  0.017

  Marenyo(OPD) 87(31.4%) 41(47%) 46(53%)  

  Nyawara(OPD) 91(32.8%) 46(51%) 45(49%)  

  Ramula(OPD) 19(6.9%) 3(16%) 16(84%)

  Yala SDH(IPD) 56(20.2) 33(59%) 23(41%)  11

FINDINGS

12Very dissatisfied Somewhat dissatisfied Satisfied Somewhat satisfied Very satisfied0

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20

30

40

50

60

0

6

3134

29

0

5

23

3734

1

9

25

38

28

14

17

30

49

Satisfaction level with VMMC services offered

Counseling Services Theatre ServicesDischarge ProcessOutcome of Surgery

Pro

port

ion (

%)

Level of satisfaction with the VMMC services offered were measured under 4 major categories of: counseling services, theatre services, discharge process, and outcome of the surgery.

FINDINGS

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Strongly disagree Disagree Neutral Agree Strongly agree0%

10%

20%

30%

40%

50%

60%

Efficiency in running VMMC services

23.8% strongly agreed, 53.4% agreed, 18.4% were neutral, 4.0% disagreed and 0.4% strongly disagreed. This shows that most of the beneficiaries believe that the services are well run by the service providers.

FINDINGS

Statistical significant difference at alpha level of 0.05 No statistical significant difference at alpha level of 0.05

Health facility attended (p=0.0173) Age group (p=0.191)

Residence of Yala (p<0.001) Education attained (p=0.0731)

Satisfaction with discharge process (p=0.0150) Employment status (p=0.5023)

Marital status (p=0.2633)

Religion (p=0.1285)

Satisfaction with counseling services (p=0.2154)

Satisfaction with theatre services (p=0.1546)

Satisfaction with surgical outcome (p=0.2732)

Efficiency in running of services (p=0.0986)

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Follow Up Care9.5% were followed up (Overall).Sub group A (IPD) 58.9% while Sub group B (OPD) 47.1%.35.7% consulted privately of which 63.6% paid for the services.

Determinants of follow up care

FINDINGS

Reason for Coming for review Frequency Percent (%)

Free and efficient services 17 12.4Education/instruction during counseling 43 31.4Fear of ill health 17 12.4Medication/Bandage removal 27 19.7Emergency reviews/Adverse events 33 24.1Total 137 100.0

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“Male circumcision is provided free of charge, at no cost and the surgical procedure is very fast and efficient”.

FINDINGS

Reasons for Non-return for review Frequency Proportion (%)Occupational engagements/Presumption of healing 76 54.3Lack of free transport/Financial Problems/Poor Weather 28 20.0Lack of Post-Op care information and fear of pain 21 15.0Inconsistency of teams/Nature of service providers 6 4.3

Private consultations 5 3.6

Distorted body image 2 1.4

Non-Response 2 1.4

Total 140 100.0

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“I came back after one week as instructed but did not find the Doctor”.

FINDINGS

Strongest points in service delivery Frequency Proportion (%)

Non-response 28 10Free, available and efficient services 76 27

Staff competency 80 29Educative and Informative counseling 46 17

Intense Mobilization 27 1024 hours emergency response 9 3All gender team representations 11 4

Total 277 100

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FINDINGS

Weakest points in service delivery Frequency Proportion (%)

Non-response 32 12

Mandatory HIV testing 23 8Inconsistency of teams and transport 58 21

Lack of compensation 26 9

Long waiting time 49 18All gender teams representations 30 11

Ineffective pain management 28 10Lack of Operations during week-ends and in all facilities 28 10

Inadequate refreshment 3 1

Total 277 10018

FINDINGS

Opinions on service delivery and its improvement

MOH staff empowerment.

Nationwide roll out of VMMC/Moonlight/Home based service provision.

Client compensation.

Intense mobilization.

Effective pain management

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CONCLUSIONS AND RECOMMENDATIONS

Findings showed that men are generally satisfied with VMMC services offered and

the beneficiaries agree that the services are well run, however, there are elements

that need to be improved in order for more people to be reached and for the services

to be friendly and customer oriented.

There is need to improve service delivery and review of the policy, strategies and

operations to meet the efficiency and effectiveness threshold in a bid to combat new

HIV infections.

Further studies should be considered on the effects of HIV testing on acceptability of VMMC.

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THANK YOU

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