Evaluation of a project to reduce the risk factors associated with high complications and mortality from traditional male circumcision in the Umlamli community, Eastern Cape : outcome mapping
Thesis (MFamMed)--Stellenbosch University, 2011.
ENGLISH ABSTRACT: Background. Traditional circumcision is one of the oldest and most common operations performed worldwide, and are practiced as a religious fulfillment, or as a rite of passage from boyhood to manhood, in cultural settings such as my community at Umlamli in the Eastern Cape (South Africa) – where this study was carried out. The aim and objective of this research project was to design, implement and evaluate a project to improve the safety of traditional male circumcision practices in the Umlamli community, with the ultimate goal of reducing the high number of complications and mortalities. Methods An outcome mapping study design was used as this is empowering and participatory. Outcome mapping has also been successfully applied in other studies ( Eaerl et al., 2001) carried out within complex social systems, where a development project has attempted to accurately describe a contribution to a desired impact, without having to prove a direct cause-and-effect link between the local interventions and the ultimate impact. The goal is to effect changes by remodeling behaviours of the boundary partners (in this study eight boundary partners were identified). The study design involved three main steps: intentional design, outcome and performance monitoring and evaluation. The first four months of the study (February–May) involved initial mapping and systematic planning of the project design as well as associated monitoring and evaluation by a team of 15 members, known as the ‘safe circumcision group’, formed from the community, with the principal investigator as the head. The team implemented, monitored and evaluated all activities of the project during and after the June 2010 circumcision ritual. A total of 92 initiates were enrolled in the June 2010 circumcision ritual. All were physically examined at the local district hospital (Umlamli) prior to the ritual. Results The Umlamli District Hospital had two admissions due to haemorrhage and mild penile sepsis, but no deaths. These results were compared with past statistics from the community. Resulting from this study, the greatest changes emerged amongst the traditional surgeons and attendants, parents, initiates, community leaders and the police. The project was less successful in achieving changes in the Department of Health and least successful amongst the emergency medical services. Overall, the project was considered a success. The key aspects of this project that were considered to be responsible for its success were the following: • The use of outcome mapping as an explicit approach to project design and monitoring • The participatory nature of the process, which involved community leaders, traditional surgeons and health workers • Eliciting community support for a lower age limit of initiates and closure of illegal circumcision schools • The establishment of only two large, approved and accredited circumcision schools to allow for easier assessment and monitoring of the events at the schools • Organisation of training workshops on the correct surgical procedure and infection control practices, which led to an improvement in surgical skills and prompt recognition of complications • Designation of an isolated treatment room for initiates with complications, which had a positive effect on the acceptance of treatment at the district hospital • Assistance with materials vital for circumcision, like surgical blades, gloves, bandages and other materials used for circumcision, from the district hospital • Application of the safe Circumcision Act of 2001, which requires the pre-circumcision examination of initiates and the issue of certificates of fitness to qualify candidates for the ritual, in order to reduce complications, as exposure to a harsh environment is part of the mental toughness the initiates face during the ritual. Conclusions Despite the increase in the number of hospital admissions and deaths from circumcision, the demand for it appears to be ongoing, and even increasing. In future, in order to decrease complications and eventually totally eradicate mortality associated with traditional male circumcision it is important that there is a strong collaboration between the Department of Health and the communities involved.
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