Since 2007, The WHO and UN AIDS have been recommending voluntary medical male circumcision (VMMC) as an important strategy for HIV prevention, particularly in settings with high HIV prevalence and low levels of male circumcision (1).
This is of course a lofty and ambitious goal. In order to obtain the 80% coverage they would need for this campaign to be successful, these public health professionals would have to perform 20.33 million circumcisions between 2011-2015, and a further 8.42 million from 2016-2025.
As you can imagine, this campaign requires an incredible amount of time and resources, and the impact this can have on practitioners is an important aspect of delivery. Not only must these people be trained medically to perform these procedures quickly and efficiently, they must also be taken care of to ensure that they can sustain delivery of the program and quit. This is a particular problem in the countries participating in the study, as they have critical shortages of healthcare professionals who are qualified to perform these procedures, with none having more than 1 physician per 1000 people. However, very little research has focused on these individuals and the consequence of being involved in these interventions.
How does the VMMC campaign impact practitioners?
To further our understanding of what happens to these healthcare providers, Perry and colleagues conducted a research study, recently published in the journal PLOS ONE (7) as part of the new VMMC collection. Practitioners in Kenya, South Africa, Tanzania and Zimbabwe were surveyed in 2011 (n=357) and 2012 (n=591). The study intended to describe the medical professionals associated with VMMC in these countries, differences between the countries, as well as then look at factors associated with job-related burnout.
Their findings were striking. In 2011, Tanzanian providers had very specific surgical roles, with some only performing the surgery (47%), and some exclusively assisting (12%). However, by 2012, this had shifted, with 99% both performing and assisting depending on need.
Filling the Training Gap
Very few providers had received formal training in VMMC in medical and nursing school, with the notable exception being Kenya, where 21% of providers received training. In the remaining countries, less than 5% of providers received this training in medical school. To counter this in the VMMC scale-up, almost all providers received additional VMMC specific training (above 97% in all countries but South Africa).
Program Duration and Burnout
In terms of duration of work, the median number of months each provider was performing VMMC ranged from a low of 10 months in South Africa, to a high of 31 months in Kenya. Research findings showed that providers had performed between 400 and 2400 procedures during their time in the VMMC program, with some as high as 4700.Burnout was incredibly common, with a shocking 89% of Kenyan providers reporting that they had witnessed feeling burnout frequently or occasionally, a number that was considerably higher than their South African (49%) and Zimbabwean (36%) peers.
So how do we prevent burnout?
Here’s where things get interesting. Once the researchers had all the information above, they could start looking at what predicts burnout, and thus provide guidelines on tangible issues that can be targeted for change. Factors such as age and number of months worked were significantly associated with burnout – the older you are, and the longer you work there, the more likely you were to burn out. Not all the findings were this predictable.
Conversely to what you might expect, according to the study, burnout was not due to number of surgeries performed. Those who performed a high volume of surgeries, i.e. 1000 or more, were less likely to report being burnt out than those who did a low number, i.e. less than 100.
In fact, those who performed a high number of surgeries were half as likely to burn out as those who did a low number. Speculatively, this may be due to a high dropout rate at the start of the process, or a “mental resiliency” that is built up from doing a high number of procedures. One of the most positive findings was that providers reported their work as being very fulfilling. However, this didn’t prevent burnout. Despite almost all Tanzanian providers reporting work fulfillment, burnout still persisted.
When asked about why they continued, many VMMC providers expressed pride in their work, and the reward that came from knowing they were helping their own community.
Tapping into this feeling of doing important and valuable work, as well as providing support for those who are new to the VMMC clinics, might help turn the tide on the spread of HIV.
1) World Health Organization. Voluntary medical male circumcision for HIV prevention. http://www.who.int/hiv/topics/malecircumcision/fact_sheet/en/ (accessed 22 April 2014).
2) Baily RC, Moses S, Parker CB, Agot K, Maclean I, Krieger JN, et al. Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomised controlled trial. Lancet 2007;369(9562):643-56.
3) Njeuhmeli E, Forsythe S, Reed J, Opuni M, Bollinger L, et al. Voluntary medical male circumcision: modelling the impact and cost of expanding male circumcision for HIV prevention in eastern and southern Africa. PLOS Med 2011;8:e1001132. doi:10.1371/journal.pmed.1001132
4) Hankins C, Forsythe S, Njeuhmeli E. (2011) Voluntary Medical Male Circumcision: An Introduction to the Cost, Impact, and Challenges of Accelerated Scaling Up. PLOS Med 2011;8(11):e1001127 doi:10.1371/journal.pmed.1001127
5) Centres for Disease Control and Prevention. Male Circumcision. http://www.cdc.gov/hiv/prevention/research/malecircumcision/ (accessed 22 April 2014).
6) Patterson BK, Landay A, Siegel JN, Flener Z, Pessis D, Chaviano A, et al. Susceptibility to human immunodeficiency virus-1 infection of human foreskin and cervical tissue grown in explant culture. Am J Pathol 2002;161(3):867-73.
7) Perry L, Rech D, Mavhu W, Frade S, Machaku M, Onyango M, Adudde DSO, Fimbo B, Cherutich P, Castor D, Njeuhmeli E, Betrand J. Work experience, job-fulfillment and burnout among VMMC providers in Kenya, South Africa, Tanzania and Zimbabwe.
Go here to find all the papers in Voluntary Medical Male Circumcision (VMMC) for HIV Prevention: Improving Quality, Efficiency, Cost Effectiveness, and Demand for Services during an Accelerated Scale-up.