title: Provider attitudes toward the voluntary medical male circumcision scale-up in Kenya, South Africa, Tanzania and Zimbabwe.
abstract: BACKGROUND
  Countries participating in voluntary medical male circumcision (VMMC) scale-up have adopted most of six elements of surgical efficiency, depending on national policy. However, effective implementation of these elements largely depends on providers' attitudes and subsequent compliance. We explored the concordance between recommended practices and providers' perceptions toward the VMMC efficiency elements, in part to inform review of national policies.
  
  
  RESULTS
  As part of Systematic Monitoring of the VMMC Scale-up (SYMMACS), we conducted a survey of VMMC providers in Kenya, South Africa, Tanzania, and Zimbabwe. SYMMACS assessed providers' attitudes and perceptions toward these elements in 2011 and 2012. A restricted analysis using 2012 data to calculate unadjusted odds ratios and 95% confidence intervals for the country effect on each attitudinal outcome was done using logistic regression. As only two countries allow more than one cadre to perform the surgical procedure, odds ratios looking at country effect were adjusted for cadre effect for these two countries. Qualitative data from open-ended responses were used to triangulate with quantitative analyses. This analysis showed concordance between each country's policies and provider attitudes toward the efficiency elements. One exception was task-shifting, which is not authorized in South Africa or Zimbabwe; providers across all countries approved this practice.
  
  
  CONCLUSIONS
  The decision to adopt efficiency elements is often based on national policies. The concordance between the policies of each country and provider attitudes bodes well for compliance and effective implementation. However, study findings suggest that there may be need to consult providers when developing national policies.
authors.affiliation: Zimbabwe AIDS Prevention Project-UZ, Department of Community Medicine UZ, Harare, Zimbabwe.
authors.forename: Webster
authors.initials: W
authors.lastname: Mavhu
authors.affiliation: Centre for HIV and AIDS Prevention Studies, Johannesburg, South Africa.
authors.forename: Sasha
authors.initials: S
authors.lastname: Frade
authors.affiliation: Tulane School of Public Health and Tropical Medicine, Department of Global Health Systems and Development, New Orleans, LA, USA.
authors.forename: Ann-Marie
authors.initials: AM
authors.lastname: Yongho
authors.affiliation: Tulane School of Public Health and Tropical Medicine, Department of Global Health Systems and Development, New Orleans, LA, USA.
authors.forename: Margaret
authors.initials: M
authors.lastname: Farrell
authors.affiliation: Population Services International, Harare, Zimbabwe.
authors.forename: Karin
authors.initials: K
authors.lastname: Hatzold
authors.affiliation: Jhpiego, Dar es Salaam, Republic of Tanzania.
authors.forename: Michael
authors.initials: M
authors.lastname: Machaku
authors.affiliation: FHI 360, Kisumu, Kenya.
authors.forename: Mathews
authors.initials: M
authors.lastname: Onyango
authors.affiliation: Ministry of Health and Child Welfare, Harare, Zimbabwe.
authors.forename: Owen
authors.initials: O
authors.lastname: Mugurungi
authors.affiliation: Ministry of Health and Social Welfare, Dar es Salaam, Republic of Tanzania.
authors.forename: Bennett
authors.initials: B
authors.lastname: Fimbo
authors.affiliation: National AIDS/STD Control Programme, Nairobi, Kenya.
authors.forename: Peter
authors.initials: P
authors.lastname: Cherutich
authors.affiliation: Centre for HIV and AIDS Prevention Studies, Johannesburg, South Africa.
authors.forename: Dino
authors.initials: D
authors.lastname: Rech
authors.affiliation: United States Agency for International Development, Washington, DC, USA.
authors.forename: Delivette
authors.initials: D
authors.lastname: Castor
authors.affiliation: United States Agency for International Development, Washington, DC, USA.
authors.forename: Emmanuel
authors.initials: E
authors.lastname: Njeuhmeli
authors.affiliation: Tulane School of Public Health and Tropical Medicine, Department of Global Health Systems and Development, New Orleans, LA, USA.
authors.forename: Jane T
authors.initials: JT
authors.lastname: Bertrand
mesh_terms: D000328:Adult; D001291:Attitude of Health Personnel; D002944:Circumcision, Male / Q000523:psychology*; D005260:Female; D006801:Humans; D007630:Kenya; D008297:Male; D008875:Middle Aged; D013019:South Africa; D013636:Tanzania; D015030:Zimbabwe