1. Understanding community needs when providing VMMC services to adolescents: A case of a remote rural village in Zimbabwe.
Dr J Hove
ZACH

2. Background
Voluntary Medical Male Circumcision (VMMC) implementation started in 2009 in Zimbabwe
Rapid scale-up to rural areas began in 2013
ZAZIC supports VMMC in 21 rural districts
Integrated implementation model
Uptake has been mainly in adolescents
need parental/guardian assistance with wound care.
Clients reviews = Day 2, Day 7, Day 42
Most adverse events (AEs) identified during 1st week of MC

3. Background June 2014, a remote rural village, Zimbabwe
400 clients mobilized for clinic-based VMMC
Site VMMC team conducted 363 circumcisions in the week
far higher than their typical weekly performance. (30-40 MCs/week)
assisted by team from ZACH
18 adverse events (AEs) reported from the site a week after circumcisions
AE rate was 5.5%
all were adolescents (p=325)
all were wound infections
ZAZIC/CDC Quality Control Team constituted to investigate AE cluster

4. AEs significantly higher in June

5. Methods ZAZIC/CDC conducts Quality Assessment Observation
To determine the cause of AE cluster and institute a response
Observation
understanding the clinical operation of the facility
program systems contributing to the AE cluster
community factors contributing to AE cluster
Client chart review
management of the cases
Stakeholder Interviews
Site VMMC staff and outreach clinic staff
parents/guardians of admitted clients
community engagement regarding VMMC in the village.
councillors, headmen, teachers, villagers

6. Findings All MC procedures completed according to national guidelines
All procedures were done by VMMC trained staff
Complemented by extra staff from ZACH
VMMC commodities were in stock (no stock-outs)
Procedures done at a local clinic with limited space
Procedure rooms were clean and well ventilated
The clinic has a borehole in the premises
water for scrubbing was from a large urn with a tap
scrub soap and alcohol were available

7. Findings
3 clients had severe wound infection and 15 had moderate wound infection
All clients attended day 2 review, except 1 client (by site team)
The site VMMC team did not conduct some day 7 reviews due to transport challenges
Day 7 reviews done by a nurse not trained in the national program.
Some 2nd reviews done later than day 7
Clients with AEs came from 1 particular area (resettlement farms)
Located 20km from the nearest clinic
No proper roads.
Poor communication network

9. Findings The community uses ponds of stagnant water for domestic use
Do not boil their domestic water
ALL clients who developed AEs had no underwear
Knowledge of post-op wound care was lacking among most parents/guardians/community mobilisers/teachers.
Use of hypertonic saline was common
Traditional medicine was noticed on the wounds of 5 clients
All clients were admitted to hospital
For the 15 moderate AEs, admission was for logistical reasons
All clients were given oral antibiotics and healed well

10. No underwear, string used as support

11. Lessons Learnt
Target parents/guardians as well when mobilising, enrolling and counselling adolescents for MC
care givers/guardians are now involved in counselling sessions
preparation of salt solution during counseling is now demonstrated.
500ml plastic tumblers and plastic teaspoons now provided
Community structures with focal persons for post-op wound care, are needed
Parental/guardian involvement on wound care for young boys is now encouraged
community mobilisers also trained on salt use and wound care
teachers engaged to assist with inspection of wounds

12. Lessons Learnt
Commodities which promote hygiene should be dispensed at all VMMC sites
Provision of underwear, and soap tablets being done
Camping equipment is needed to enable trained teams to perform community-based post-op reviews
Has been procured and is now in use
Prophylactic antibiotics should be given to clients with obvious poor hygiene
ZACH team to support reviews in circumstances where many MCs are done in a short period of time

13. Recommendation
Community Engagement needs to be routinized before services are provided in our VMMC program so as to identify and understand community needs in order to minimise Adverse Events
Beliefs
Practices
Social/Economic
Challenges
Needs

14. Acknowledgements
Ministry of Health and Child Care (MOHCC), ATP
Zimbabwe Association of Church Related Hospitals (ZACH)
International Training and Education Center for Health (I-TECH)
Centers for Disease Control and Prevention (CDC)
Masase Mission Hospital, Mberengwa
This research has been supported by the President’s Emergency Plan for AIDS Relief (PEPFAR) through the U.S. Centers for Disease Control and Prevention (CDC) under the terms of grant #UWSC77303PO