Page 1SYMMACS | Final report ACKNOWLEDGEMENTS

the development and implementation of the SYMMACS project. Drs. Emmanuel Njeuhmeli, Delivett

Systematic Monitoring of Voluntary Medical Male Circumcision Scale-up: adoption of efficiency elements in Kenya, South Africa, Tanzania, and Zimbabwe.

SYMMACS, the Systematic Monitoring of the Voluntary Medical Male Circumcision Scale-up, tracked the implementation and adoption of six elements of surgical efficiency-use of multiple surgical beds, pre-bundled kits, task shifting, task sharing, forceps-guided surgical method, and electrocautery--as standards of surgical efficiency in Kenya, South Africa, Tanzania, and Zimbabwe.This multi-country study used two-staged sampling. The first stage sampled VMMC sites: 73 in 2011, 122 in 2012. The second stage involved sampling providers (358 in 2011, 591 in 2012) and VMMC procedures for observation (594 in 2011, 1034 in 2012). The number of VMMC sites increased significantly between 2011 and 2012; marked seasonal variation occurred in peak periods for VMMC. Countries adopted between three and five of the six elements; forceps-guided surgery was the only element adopted by all countries. Kenya and Tanzania routinely practiced task-shifting. South Africa and Zimbabwe used pre-bundled kits with disposable instruments and electrocautery. South Africa, Tanzania, and Zimbabwe routinely employed multiple surgical bays.SYMMACS is the first study to provide data on the implementation of VMMC programs and adoption of elements of surgical efficiency. Findings have contributed to policy change on task-shifting in Zimbabwe, a review of the monitoring system for adverse events in South Africa, an increased use of commercially bundled VMMC kits in Tanzania, and policy dialogue on improving VMMC service delivery in Kenya. This article serves as an overview for five other articles following this supplement

Multivariate logistic regression: work fatigue/burnout in Kenya in 2011 and 2012.

<p>Multivariate logistic regression: work fatigue/burnout in Kenya in 2011 and 2012.</p

Association of VMMC provider job-fulfillment and work fatigue/burnout<b>.</b>

*<p>P<.05, **p<.01, ***p<.001, using the Pearson’s chi-square test statistic.</p

Proportion of VMMC sites by month and by country using forceps-guided method, January 2010 –mid-2012.

<p>The number of sites on which these data are based varies markedly by month over the observation period, as shown in <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0082518#pone-0082518-g001" target="_blank">Figure 1</a>.</p

Proportion of sites adopting each efficiency element by year and by country.

<p>Proportion of sites adopting each efficiency element by year and by country.</p

Job-fulfillment and work fatigue/burnout among VMMC providers by country.

<p>Job-fulfillment and work fatigue/burnout among VMMC providers by country.</p

Bivariate analysis of correlates of work fatigue/burnout in Kenya in 2011 and 2012.

*<p>p <0.05, ** p <0.01, ***p <0.001, using Pearson’s chi square, except in cases of small cell frequencies (< 5 cases per cell) which use the Fisher Exact.</p

VMMC provider profile in the four SYMMACS countries.

<p>[A] Primary providers perform VMMC (removes foreskin).</p><p>[B] Secondary providers assist the primary surgical provider.</p><p>[C] full time defined as dedicated ≥90% of working hours to VMMC.</p

Proportion of VMMC sites using pre-packaged kits with consumables and disposable instruments, January 2010 – mid-2012.

<p>The number of sites on which these data are based varies markedly by month over the observation period, as shown in <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0082518#pone-0082518-g001" target="_blank">Figure 1</a>.</p