To analyze the frequency of clinician counseling of male patients on circumcision for HIV prevention as well as interest in training, we used ordered logistic regression for ordinal response data.28,29 For the provision of male circumcision services or referrals, we used multinomial logistic regression for nominal response data.28,29 In these analyses, the reference group was those not providing any male circumcision services or referrals as compared with (1) those providing services and (2) those providing referrals. For all analyses, we present results from 2 final models: the first accounting for clinician, patient, and practice characteristics and the second assessing the contribution of clinician attitudes related to male circumcision and other HIV prevention practices. Gender was not included with clinician type in the multivariable analyses due to overlap of female and the nursing profession.
The analysis population for each outcome includes participants with data on that outcome variable. To address missing data in 15 independent variables, we utilized multiple imputation with 20 imputation cycles. Multiple imputation is a simulation-based statistical technique that involves 3 steps: (1) imputation of missing data for a specified number of imputation cycles, (2) completed data analysis for each imputation cycle, and (3) pooling of results from the completed data analyses.30 Use of multiple imputation requires less stringent assumptions about the random nature of missing data than are required for deletion of incomplete cases and averts the problem of biased estimates, which results from adding a “missing data” category for each variable included in the models.31 In our data, the rate of missing observations ranged from 1.0% to 5.4%. We used the data augmented by imputation for our final analyses and compared these results with those using the original data. For all 3 outcomes, the results obtained using the augmented data were largely consistent with those from the original data.
All multivariable analyses adjust for the facility-based sampling scheme through accounting for the clustered data collection. We also conducted analyses separately by country to check results. Data were analyzed using Stata/SE 11.1, and reported differences are significant at the P < 0.05 level.
Completed surveys were received from a total of 1444 respondents (830 in Zimbabwe and 614 in South Africa), yielding a clinician response rate of 73%. In Zimbabwe, physicians were more likely to respond than nurses (100% vs. 87%; P ≤ 0.05) and so were those in hospital settings as compared with those in clinics (92% vs. 81%; P ≤ 0.001). In South Africa, there was no difference between hospitals and clinics (61% vs. 60%; P = 0.63), although nurses were more likely to respond than physicians (66% vs. 39%; P ≤ 0.001).
Table 1 presents clinician, practice, and patient-related characteristics. The majority of respondents (72%) were advanced nurses with 3 or more years of nursing education and training. Eight percent (117) were physicians, reflecting the large share of health care provided by nurses. Most (80%) were trained in HIV/STI prevention. Just under one-half (45%) were practicing in urban locations, 37% in rural locations, and the remaining 19% in small town or periurban locations. Nearly all (99.5%) reported serving low-income populations. The majority (84%) reported provision of voluntary counseling and testing (VCT) services, which was slightly higher in Zimbabwe (88%) than South Africa (79%). Nearly all (>99%) reported serving HIV-positive patients, as well as those at risk of acquiring HIV/STIs. Provision of universal condom counseling was higher in South Africa than Zimbabwe (69% vs. 40%).
Table 2 presents male circumcision-related practices and attitudes. Provision of counseling was high given the recency of the evidence at the time of the survey. More than half of clinicians (57%) reported discussing male circumcision for HIV prevention with male patients, and for 18%, it was a routine practice (usually or always). A slightly lower proportion (46%) reported discussing male circumcision with female patients related to their male partners. One-half of respondents (49%) were offering male circumcision referrals, but only 17% were offering services. Desire for training was high, however, with 61% of clinicians indicating they would like training (See Fig. 1). Routine discussion (usually/always) about circumcision with male patients was nearly twice as high in South Africa (25%) as in Zimbabwe (13%). There were similar differences in service provision (22% in South Africa vs. 14% in Zimbabwe). In contrast, clinician desire for training was higher in Zimbabwe (66%) than in South Africa (55%).
There were large differences in provision of male circumcision by professional training, practice location, and setting. Although 56% of physicians reported providing services, only 14% of nurses did. Provision was twice as high in urban areas (23%) as in rural (11%) and was predominantly offered in hospitals (30%) as compared with clinics (2%). Nurses had greater interest in training than physicians (62% vs. 49%), while training interest in clinic settings (58%) and hospitals (63%) was similar, and interest in rural areas (59%) was almost as high as urban areas (63%).
Responses to the male circumcision attitudinal variables reflect considerable uncertainty about whether patients would seek male circumcision services if they were to become available (Table 2). About one-third of respondents (31%) agreed with the statement that patients will be upset about male circumcision due to cultural beliefs, 44% agreed that patients will worry about what their partner thinks, and 35% agreed that patients won't want the surgical procedure. Furthermore, results suggest that clinicians have concerns about possible increased exposure to HIV/STIs as a result of the procedure. Forty-three percent agreed that circumcision patients will increase risky behaviors, and 27% agreed that patients won't abstain from sex during postoperation recovery. Clinicians in Zimbabwe expressed higher levels of concern about partners, the surgical procedure, and increase in risky behaviors.
Counseling on Male Circumcision With Male Patients
Table 3 presents results from ordered logistic regression analyses of factors associated with the frequency of male circumcision counseling with male patients. Interestingly, professional training and practice-related factors were not associated with variations in patient counseling, although clinician attitudes about their patients were. The model with clinician attitudes shows associations between less counseling and attitudes that patients will be upset about circumcision due to cultural beliefs (odds ratio [OR] = 0.53, 95% confidence interval [CI]: 0.41–0.67), patients won't want the procedure (OR = 0.53, 95% CI: 0.41–0.70), patients will increase risky behaviors (OR = 0.60, 95% CI: 0.46–0.78), and patients won't abstain from sex during postoperation recovery (OR = 0.73, 95% CI: 0.56–0.95). In addition, greater counseling was associated with other HIV prevention attitudes and practices: high perceived effectiveness of abstinence counseling with males (OR = 2.0, 95% CI: 1.40–2.87) and provision of condom counseling for most/all patients (OR = 1.4, 95% CI: 1.09–1.94).
Provision of Services
Table 4 presents results from multinomial logistic regression analyses of the factors associated with provision of male circumcision services or referrals. Results represent the relative probability of providing male circumcision services (or referrals) as compared with the reference category of no services or referrals. Clinician factors that were insignificant for provision of patient referrals were highly significant for provision of services. Service provision was higher among physicians as compared with mid-level nurses (relative risk ratios [RRRs] close to 4), among clinicians with a high proportion of patients at risk of HIV (RRRs, 2) and in South Africa as compared with Zimbabwe (RRR close to 7). Service provision was still far lower in clinics than in hospitals (RRR = 0.06). Clinician attitudes about male circumcision, however, were significant for both services and referrals. The perception that patients would be upset about circumcision due to cultural beliefs was associated with less service provision (RRR = 0.51), and so were beliefs that patients would increase risky behaviors as a result of the procedure (RRR = 0.49), and that condom counseling for males patients was highly effective (RRR = 0.69).
Similar to the results for provision of services, the relative probability of providing referrals was about 7 times as high in South Africa as in Zimbabwe. However, it was similar among physicians and nurses, about twice as high among those who worked in clinics as compared with hospitals and about 1.6 times as high among those providing voluntary counseling and testing services. The likelihood of providing referrals was lower among clinicians who thought that patients would be upset about male circumcision due to cultural beliefs (RRR = 0.67) and those who thought that patients wouldn't abstain from sex during postoperation recovery (RRR = 0.71).
Interest in Male Circumcision Training
Table 5 presents results from ordered logistic regression analyses of factors associated with the frequency of clinician communication with male patients about male circumcision for HIV prevention. The adjusted odds of training interest were higher in Zimbabwe, among mid-level nurses as compared with physicians, and for younger clinicians. Finally, the odds of desiring training were about 30% lower among clinicians who thought that patients would be upset about male circumcision due to cultural beliefs (Table 5).
For all 3 outcomes, we tested country-level interactions between training in HIV/STIs and provider types. The interactions were insignificant in all models with 2 exceptions, both of which were multinomial models comparing provision of services to no services/referrals. In the first, the relative probability of service provision was lower among clinicians trained in HIV/STIs from South Africa as compared with those from Zimbabwe; and in the second, it was lower among physicians from South Africa as compared with those from Zimbabwe.
To our knowledge, this is the first study to examine factors associated with the male circumcision practices and attitudes of clinicians in the Southern Africa region and to assess training interest among national samples of clinicians. It is encouraging that more than half (57%) of clinicians were counseling male patients on male circumcision, and half (49%) were providing referrals at the time of the survey because both countries were still planning for the rollout of services and national strategies and guidelines were not yet in place. Although this method of HIV/STI prevention is already beyond the stage of “early adopters,” service provision remains limited and concentrated in the highly specialized services delivered at hospitals and by physicians. These results show great potential for the diffusion of innovation to nurses and those in clinic settings, as well as outside of urban areas.
There was considerable training interest among nurses in both countries (57% of clinicians in South Africa and 66% in Zimbabwe), with no significant differences between the nurse types or by practice location or setting. Our results show that mid-level and advanced nurses are already playing an important role in counseling patients and offering referrals, and that both should be considered for future training in service provision. They could help ameliorate human resource constraints associated with the rollout of services in both countries. However, policy changes in both countries may be needed so that nurses can provide this simple surgical procedure. At present, they can only assist doctors in carrying out the surgery.32 Younger age was also associated with greater training interest. The inclusion of male circumcision training in nursing and medical school curricula would help reach younger trainees.
In general, our results suggest that training programs would be well-received. At the same time, this may not ensure clinicians would fully integrate training into clinical practice. The translation of scientific evidence into clinical practice often lags, though many factors can speed the process including a core group of clinicians willing to take the lead.25 In Zimbabwe and South Africa, core groups already exist, increasing the chances that training can be successfully implemented. However, the country crisis in Zimbabwe, including the collapse of the health system, presents myriad challenges.33
The country-level differences in male circumcision practices reflect the prevalence levels in each country. South Africa is starting from a higher baseline and greater acceptance of male circumcision in certain groups; furthermore recent initiatives have shown uptake in communities that traditionally do not have male circumcision, such as in Kwa-Zulu Natal, which accounted for 22,000 of the 49,803 male circumcision procedures nationally in the first part of 2010.34,35 A review of 13 acceptability studies of male circumcision in Sub-Saharan Africa showed that a significant proportion of men are willing to consider circumcision for HIV prevention, however, they strongly prefer services by trained health professionals.36
Despite the degree of training interest, the high level of provider concerns related to male circumcision in both countries, as reflected in responses to the attitudinal variables, raise questions about the extent to which clinicians would be willing to help increase access to services. Research has shown that access to services can be limited through provider attitudes.37 Efforts to address these concerns should therefore be part of male circumcision training programs. In particular, there is a need to educate providers about rising client demand for the procedure, even in communities that have not traditionally practiced male circumcision.
Although a strength of this study was its use of national probability surveys, there were several limitations. The response rate is relatively high for a national probability survey of clinicians,38,39 but South Africa had a lower response rate than Zimbabwe, and within the South African sample, physicians were less likely to respond than nurses. Therefore, provision of male circumcision in South Africa may be slightly underestimated as compared with Zimbabwe, where the physician response rate was high.
The sample focuses on primary care clinicians offering HIV/STI or family planning services in low-resource settings, rather than specialist surgeons who would be likely to have fewer hesitations about this relatively simple procedure. Country-level differences may partially reflect differences in mode of survey administration as well as cultural differences in reporting. Additionally, clinician responses are likely to carry social desirability bias, particularly when inquiring about the quality of care provided or HIV prevention practices such as condom counseling. The service provision measures may carry less bias because they relate to a clinical procedure, however, counseling and training interest may be overstated. Finally, the attitudinal measures did not require respondents to specify the proportion of patients they were referring to, thus preventing understanding of the extent to which each item may inhibit provision or uptake of services.
Many clinicians in South Africa and Zimbabwe were willing to integrate new HIV prevention evidence into practice: about one-half were offering male circumcision counseling and/or referrals and close to two-thirds indicated desire for training. Where maximizing involvement in training programs is the goal, both countries should consider involving nurses, including those in rural areas when scale-up in less densely populated areas is desired. Furthermore training programs should help clinicians to address cultural and other patient-related concerns.
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