Implementation and Operational Research

Mavhu, Webster; Larke, Natasha; Hatzold, Karin; Ncube, Getrude; Weiss, Helen A.; Mangenah, Collin; Mugurungi, Owen; Mufuka, Juliet; Samkange, Christopher; Sherman, Judith; Gwinji, Gerald; Cowan, Frances M; Ticklay, Ismail

doi:10.1097/qai.0000000000000694

Cited by 13 publications

(34 citation statements)

References 31 publications

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“…The follow-up study (conducted in 2013) explored actual acceptability of EIMC among parents who had either opted or declined to have their newborn son circumcised. The second study was nested within a trial that assessed the feasibility, safety, acceptability and cost of rolling out EIMC using devices in Zimbabwe, described in detail elsewhere [9, 16, 22]. In both studies, researchers explored among other issues, decision-making around EIMC.…”

Section: Methodsmentioning

confidence: 99%

“…The program aims to reach 1.3 million 15-29 year-olds by 2017/18. Zimbabwe also intends to offer EIMC alongside VMMC [15, 16, 22]. Since large-scale EIMC for HIV prevention, or indeed for other reasons, has never been practiced in Zimbabwe or more widely in Southern Africa, there is a dearth of literature on EIMC decision-making within this context.…”

Section: Introductionmentioning

confidence: 99%

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Unpacking early infant male circumcision decision-making using qualitative findings from Zimbabwe

Mavhu

Hatzold²,

Ncube

et al. 2017

BMC Int Health Hum Rights

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BackgroundEarly infant male circumcision (EIMC) has been identified as a key HIV prevention intervention. Exploring the decision-making process for adoption of EIMC for HIV prevention among parents and other key stakeholders is critical for designing effective demand creation interventions to maximize uptake, roll out and impact in preventing HIV. This paper describes key players, decisions and actions involved in the EIMC decision-making process.MethodsTwo complementary qualitative studies explored hypothetical and actual acceptability of EIMC in Zimbabwe. The first study (conducted 2010) explored hypothetical acceptability of EIMC among parents and wider family through focus group discussions (FGDs, n = 24). The follow-up study (conducted 2013) explored actual acceptability of EIMC among parents through twelve in-depth interviews (IDIs), four FGDs and short telephone interviews with additional parents (n = 95). Short statements from the telephone interviews were handwritten. FGDs and IDIs were audio-recorded, transcribed and translated into English. All data were thematically coded.ResultsStudy findings suggested that EIMC decision-making involved a discussion between the infant’s parents. Male and female participants of all age groups acknowledged that the father had the final say. However, discussions around EIMC uptake suggested that the infant’s mother could sometimes covertly influence the father's decision in the direction she favoured. Discussions also suggested that fathers who had undergone voluntary medical male circumcision were more likely to adopt EIMC for their sons, compared to their uncircumcised counterparts. Mothers-in-law/grandparents were reported to have considerable influence. Based on study findings, we describe key EIMC decision makers and attempt to illustrate alternative outcomes of their key actions and decisions around EIMC within the Zimbabwean context.ConclusionsThese complementary studies identified critical players, decisions and actions involved in the EIMC decision-making process. Findings on who influences decisions regarding EIMC in the Zimbabwean context highlighted the need for EIMC demand generation interventions to target fathers, mothers, grandmothers, other family members and the wider community.

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Section: Methodsmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Unpacking early infant male circumcision decision-making using qualitative findings from Zimbabwe

Mavhu

Hatzold²,

Ncube

et al. 2017

BMC Int Health Hum Rights

Self Cite

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“…Other circumcision sequelae of sufficient severity to require emergency room evaluation or hospital admission and contribute toward allostasis include infection, urinary retention, inflammatory redness and swelling ascribed to healing (86, 87), and amputation/necrosis of the glans (88). Behavioral abnormalities, such as eating disturbance and disturbed sleep, are also the consequence of pain exposure (89).…”

Section: Introductionmentioning

confidence: 99%

“…Postoperative circumcision pain of ample severity to require analgesia is expected for about 10 days for healing with incomplete wound healing past day 14 seen in up to 6% of infants depends on the device used to amputate the foreskin (88), which is also associated with various adverse events (56, 90). The overall complication rate for circumcision ranges from 0.2 to 10% with many USA physicians performing the procedure without formal training, being unaware of contraindications, and incapable of handling post-op complications (56, 91, 92).…”

Section: Introductionmentioning

confidence: 99%

A “Wear and Tear” Hypothesis to Explain Sudden Infant Death Syndrome

Elhaik

2016

Front. Neurol.

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Sudden infant death syndrome (SIDS) is the leading cause of death among USA infants under 1 year of age accounting for ~2,700 deaths per year. Although formally SIDS dates back at least 2,000 years and was even mentioned in the Hebrew Bible (Kings 3:19), its etiology remains unexplained prompting the CDC to initiate a sudden unexpected infant death case registry in 2010. Due to their total dependence, the ability of the infant to allostatically regulate stressors and stress responses shaped by genetic and environmental factors is severely constrained. We propose that SIDS is the result of cumulative painful, stressful, or traumatic exposures that begin in utero and tax neonatal regulatory systems incompatible with allostasis. We also identify several putative biochemical mechanisms involved in SIDS. We argue that the important characteristics of SIDS, namely male predominance (60:40), the significantly different SIDS rate among USA Hispanics (80% lower) compared to whites, 50% of cases occurring between 7.6 and 17.6 weeks after birth with only 10% after 24.7 weeks, and seasonal variation with most cases occurring during winter, are all associated with common environmental stressors, such as neonatal circumcision and seasonal illnesses. We predict that neonatal circumcision is associated with hypersensitivity to pain and decreased heart rate variability, which increase the risk for SIDS. We also predict that neonatal male circumcision will account for the SIDS gender bias and that groups that practice high male circumcision rates, such as USA whites, will have higher SIDS rates compared to groups with lower circumcision rates. SIDS rates will also be higher in USA states where Medicaid covers circumcision and lower among people that do not practice neonatal circumcision and/or cannot afford to pay for circumcision. We last predict that winter-born premature infants who are circumcised will be at higher risk of SIDS compared to infants who experienced fewer nociceptive exposures. All these predictions are testable experimentally using animal models or cohort studies in humans. Our hypothesis provides new insights into novel risk factors for SIDS that can reduce its risk by modifying current infant care practices to reduce nociceptive exposures.

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“…Studies conducted within the region have shown poor concordance between hypothetical and actual EIMC acceptability. In Zambia and Zimbabwe, actual uptake was lower than previously suggested by hypothetical acceptability studies (11% vs. 97% and 12% vs. 60%, respectively) [15–16, 19, 38–39]. Given the low levels of knowledge or experience of EIMC found in the FGDs and KIIs, it is unclear whether or not the high hypothetical acceptability will translate into actual uptake once EIMC is introduced.…”

Section: Discussionmentioning

confidence: 83%

Acceptability and feasibility of early infant male circumcision for HIV prevention in Malawi

et al. 2017

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BackgroundVoluntary medical male circumcision (VMMC) has been successfully implemented in 14 countries as an additional HIV prevention intervention. As VMMC programs mature in most countries, the focus is now on how to sustain the HIV prevention gains realised from VMMC. As part of preparations for the sustainability phase, countries are either piloting or preparing to pilot early infant male circumcision (EIMC). This qualitative study explored the acceptability and feasibility of EIMC in Malawi in order to inform pilot implementation.MethodsIn 2016, 23 focus group discussions were held across Malawi with participants from several ethnicities and religions/faiths. Additionally, 21 key informant interviews were held with traditional and religious leaders, traditional circumcisers (ngalibas), policy-makers, programme managers and health-care workers. Audio recordings were transcribed, translated into English (where necessary), and thematically coded using NVivo 10.ResultsDiscussions highlighted the socio-cultural significance of MC in Malawi. Knowledge or experience of EIMC was poor although acceptability was high among most ethnic/religious groups and key informants. Participants identified EIMC's comparative HIV benefits although a few health-care workers expressed scepticism. All participants said EIMC should be offered within a clinical setting. In addition to fathers, maternal uncles and traditional leaders were deemed key decision-makers. Potential barriers to EIMC included concerns about procedure safety as well as cultural considerations. Key informants felt it was feasible to offer EIMC in Malawi. Participants' recommendations, including phased implementation, engagement of traditional leaders, use of external mobilisers and initially reaching out to influential parents, will be taken into account when designing a pilot EIMC program.ConclusionsEIMC is potentially an acceptable and feasible HIV prevention intervention for most ethnic/religious groups in Malawi if wide-ranging, culturally appropriate demand-creation activities are developed, piloted, evaluated and appropriately implemented.

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Implementation and Operational Research

Cited by 13 publications

References 31 publications

Unpacking early infant male circumcision decision-making using qualitative findings from Zimbabwe

Unpacking early infant male circumcision decision-making using qualitative findings from Zimbabwe

A “Wear and Tear” Hypothesis to Explain Sudden Infant Death Syndrome

Acceptability and feasibility of early infant male circumcision for HIV prevention in Malawi

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