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 - 2013
1
PRESENTATION OUTLINE
Introduction/ Background.
Research Questions.
Methods.
Findings and Discussion.
Conclusions and Recommendations.
2
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.
3
Kisumu MC Trial Clinic
Orange Farm MC Center
Rakai Research Center
4
MALE CIRCUMCISION DURING MOBILE
VMMC
5
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.
6
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.
7
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?
8
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 semistructured 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.
9
FINDINGS
Returned For Review
Total (N=277)
Yes
No
P Value
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%)
No formal educ.
32(11.5%)
16(50%)
16(50%)
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%)
Demographic characteristics and
variables
Age in Years
Education Level
0.07
10
FINDINGS
Employment
Status
Child Status
Permanent
Resident of Yala
Health Facility
Permanent
42(15.1%)
24 (57%)
18 (43%)
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%)
Has children
153(55.2%)
82(54%)
71(46%)
No children
124(44.8%)
55(44%)
69(56%)
Yes
151(54.5%)
90(60%)
61(40%)
No
126(45.5%)
47(37%)
79(63%)
Malanga(OPD)
24(8.7%)
14(58%)
10(42%)
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%)
0.5
0.15
<0.0001
0.017
11
FINDINGS
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.
Satisfaction level with VMMC services offered
60
49
Proportion (%)
50
40
34
31
30
34
30
23
25
20
29
28
6
0
0
1
1
Very dissatisfied
5
Counseling Services
Theatre Services
Discharge Process
17
10
0
37 38
Outcome of Surgery
9
4
Somewhat
dissatisfied
Satisfied
Somewhat satisfied
Very satisfied
12
FINDINGS
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.
Efficiency in running VMMC services
60%
50%
40%
30%
20%
10%
0%
Strongly disagree
Disagree
Neutral
Agree
Strongly agree
13
FINDINGS
Follow Up Care
9.5% 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
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)
14
FINDINGS
Reason for Coming for
review
Free and efficient services
Education/instruction
during counseling
Fear of ill health
Medication/Bandage
removal
Emergency
reviews/Adverse events
Total
Frequency
Percent (%)
17
12.4
43
17
31.4
12.4
27
19.7
33
137
24.1
100.0
“Male circumcision is provided free of charge, at no cost and the
surgical procedure is very fast and efficient”.
15
FINDINGS
Reasons for Non-return for
review
Occupational
engagements/Presumption of
healing
Lack of free transport/Financial
Problems/Poor Weather
Lack of Post-Op care information
and fear of pain
Inconsistency of teams/Nature of
service providers
Frequency
Proportion (%)
76
54.3
28
20.0
21
15.0
6
4.3
Private consultations
5
3.6
Distorted body image
2
1.4
Non-Response
2
1.4
140
100.0
Total
“I came back after one week as instructed but did not find the Doctor”.
16
FINDINGS
Strongest points in service
delivery
Non-response
Free, available and efficient
services
Staff competency
Educative and Informative
counseling
Intense Mobilization
24 hours emergency
response
All gender team
representations
Total
Frequency
28
Proportion (%)
10
76
80
27
29
46
27
17
10
9
3
11
277
4
100
17
FINDINGS
Weakest points in service
delivery
Frequency
Proportion (%)
Non-response
32
12
Mandatory HIV testing
Inconsistency of teams and
transport
23
8
58
21
Lack of compensation
26
9
Long waiting time
All gender teams
representations
49
18
30
11
Ineffective pain management
Lack of Operations during
week-ends and in all facilities
28
10
28
10
Inadequate refreshment
3
1
277
100
Total
18
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
19
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.
20
“
21