title: Systematic monitoring of male circumcision scale-up in Nyanza, Kenya: exploratory factor analysis of service quality instrument and performance ranking.
abstract: BACKGROUND
  Considerable conceptual and operational complexities related to service quality measurements and variability in delivery contexts of scaled-up medical male circumcision, pose real challenges to monitoring implementation of quality and safety. Clarifying latent factors of the quality instruments can enhance contextual applicability and the likelihood that observed service outcomes are appropriately assessed.
  
  
  OBJECTIVE
  To explore factors underlying SYMMACS service quality assessment tool (adopted from the WHO VMMC quality toolkit) and; determine service quality performance using composite quality index derived from the latent factors.
  
  
  METHODS
  Using a comparative process evaluation of Voluntary Medical Male Circumcision Scale-Up in Kenya site level data was collected among health facilities providing VMMC over two years. Systematic Monitoring of the Medical Male Circumcision Scale-Up quality instrument was used to assess availability of guidelines, supplies and equipment, infection control, and continuity of care services. Exploratory factor analysis was performed to clarify quality structure.
  
  
  RESULTS
  Fifty four items and 246 responses were analyzed. Based on Eigenvalue >1.00 cut-off, factors 1, 2 & 3 were retained each respectively having eigenvalues of 5.78; 4.29; 2.99. These cumulatively accounted for 29.1% of the total variance (12.9%; 9.5%; 6.7%) with final communality estimates being 13.06. Using a cut-off factor loading value of ≥0.4, fifteen items loading on factor 1, five on factor 2 and one on factor 3 were retained. Factor 1 closely relates to preparedness to deliver safe male circumcisions while factor two depicts skilled task performance and compliance with protocols. Of the 28 facilities, 32% attained between 90th and 95th percentile (excellent); 45% between 50th and 75th percentiles (average) and 14.3% below 25th percentile (poor).
  
  
  CONCLUSIONS
  the service quality assessment instrument may be simplified to have nearly 20 items that relate more closely to service outcomes. Ranking of facilities and circumcision procedure using a composite index based on these items indicates that majority performed above average.
authors.affiliation: School of Public Health and Community Development, Maseno University, Maseno, Kenya.
authors.forename: Dickens S
authors.initials: DS
authors.lastname: Omondi Aduda
authors.affiliation: Department of Biomedical Sciences and Technology, School of Public Health and Community Development, Maseno University, Maseno, Kenya.
authors.forename: Collins
authors.initials: C
authors.lastname: Ouma
authors.affiliation: Department of Public Health, School of Public Health and Community Development, Maseno University, Maseno, Kenya.
authors.forename: Rosebella
authors.initials: R
authors.lastname: Onyango
authors.affiliation: FHI360, Kisumu Office, Kisumu, Kenya.
authors.forename: Mathews
authors.initials: M
authors.lastname: Onyango
authors.affiliation: Department of Global Health Systems and Development, Tulane University. New Orleans, Louisiana, United States of America.
authors.forename: Jane
authors.initials: J
authors.lastname: Bertrand
mesh_terms: D002944:Circumcision, Male / Q000592:standards*; D005163:Factor Analysis, Statistical; D006268:Health Facilities / Q000592:standards*; D006801:Humans; D007630:Kenya; D008297:Male; D011786:Quality Control; D012449:Safety