{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,12,12]],"date-time":"2025-12-12T19:24:15Z","timestamp":1765567455459,"version":"3.48.0"},"reference-count":43,"publisher":"Public Library of Science (PLoS)","issue":"12","license":[{"start":{"date-parts":[[2025,12,12]],"date-time":"2025-12-12T00:00:00Z","timestamp":1765497600000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["www.plosone.org"],"crossmark-restriction":false},"short-container-title":["PLoS One"],"abstract":"<jats:sec id=\"sec001\">\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>\n                      Voluntary medical male circumcision (VMMC) has been shown to reduce heterosexual human immune deficiency virus (HIV) transmission. In 2009, Botswana rolled out its VMMC program to expand existing HIV preventive strategies. However, in 2017, a study recorded an adverse event rate (AER) of 6.7% in Botswana. A quality improvement team was introduced to help reduce AER through standardized training and mentorship by ensuring that the World Health Organization VMMC and the Botswana safe male circumcision program standards are met. We hypothesized that\n                      <jats:bold>t<\/jats:bold>\n                      he introduction of the quality improvement team reduced the trend and magnitude of the moderate and severe AER for the day 7 routine follow-up visit.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec002\">\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>A quasi-experimental study was conducted using data from monthly district reporting tools. Interrupted time series analysis was used to compare the trend and magnitude of the moderate and severe AERs after circumcision for the day 7 routine follow-up visit in males aged 10 years and older. The comparison was done two years before (April 2015 to March 2017) and two years after (April 2017 to April 2019) the introduction of the quality improvement team. The most common adverse events (AEs) by age category, type, and severity between April 2015 and April 2019 were also reported. Frequencies and percentages were used to summarize the descriptive measures. Where indicated, all measures are reported with 95% confidence interval and statistical significance set at p\u2009\u2264\u20090.05.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec003\">\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>There was an overall downward trajectory of the day 7 moderate and severe AER throughout the study period. Nonetheless, prior to the intervention, the moderate and severe day 7 AER decreased significantly monthly by 0.1% (p\u2009=\u20090.046, 95% CI\u2009=\u2009\u22120.195, 0.002). However, after the intervention, the AER insignificantly increased by 0.08% (p\u2009=\u20090.107, 95% CI\u2009=\u2009\u22120.018, 0.181). Majority (68.5%) of the AEs occurred in the 10\u201314 years age category. Most of these AEs were mild (73.8%). Infections were the most common AE (45.1%).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec004\">\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>The effect of the quality improvement intervention on the rate of AEs was minimal. Regular audits and further research on why the quality improvement team was not able to significantly reduce the AER would be beneficial.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1371\/journal.pone.0335587","type":"journal-article","created":{"date-parts":[[2025,12,12]],"date-time":"2025-12-12T18:27:11Z","timestamp":1765564031000},"page":"e0335587","update-policy":"https:\/\/doi.org\/10.1371\/journal.pone.corrections_policy","source":"Crossref","is-referenced-by-count":0,"title":["An interrupted time series analysis of the effect of the quality improvement team on the rate of adverse events in the Botswana safe male circumcision program from 2015 to 2019"],"prefix":"10.1371","volume":"20","author":[{"ORCID":"https:\/\/orcid.org\/0009-0001-4283-4498","authenticated-orcid":true,"given":"Ludo S.","family":"Monene","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Billy M.","family":"Tsima","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Keikantse","family":"Matlhagela","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Mooketsi","family":"Molefi","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"340","published-online":{"date-parts":[[2025,12,12]]},"reference":[{"key":"pone.0335587.ref001","volume-title":"Policy brief: A framework for voluntary medical male circumcision: Effective HIV prevention and a gateway to improved adolescent boys\u2019 & men\u2019s health in Eastern and Southern Africa by 2021","author":"World Health Organisation WHO","year":"2016"},{"issue":"11","key":"pone.0335587.ref002","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pmed.0020298","article-title":"Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: the ANRS 1265 Trial","volume":"2","author":"B Auvert","year":"2005","journal-title":"PLoS Med"},{"issue":"9562","key":"pone.0335587.ref003","doi-asserted-by":"crossref","first-page":"643","DOI":"10.1016\/S0140-6736(07)60312-2","article-title":"Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomised controlled trial","volume":"369","author":"RC Bailey","year":"2007","journal-title":"The Lancet"},{"issue":"9562","key":"pone.0335587.ref004","doi-asserted-by":"crossref","first-page":"657","DOI":"10.1016\/S0140-6736(07)60313-4","article-title":"Male circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial","volume":"369","author":"RH Gray","year":"2007","journal-title":"Lancet"},{"key":"pone.0335587.ref005","unstructured":"Organization WH. New data on male circumcision and HIV prevention: policy and programme implications: WHO. 2007. https:\/\/iris.who.int\/bitstream\/handle\/10665\/43751\/9789241595988_eng.pdf?sequence=1"},{"key":"pone.0335587.ref006","unstructured":"Wellness MoHa. National Safe Male Circumcision Strategy 2017-20222017 19\/03\/2022."},{"key":"pone.0335587.ref007","volume-title":"Preventing HIV through safe voluntary medical male circumcision for adolescent boys and men in generalized HIV epidemics: enhancing uptake of VMMC among adolescent boys and men at higher risk for HIV: evidence and case studies: technical brief","author":"Organization WH","year":"2021"},{"issue":"1","key":"pone.0335587.ref008","doi-asserted-by":"crossref","first-page":"1042","DOI":"10.4102\/sajhivmed.v21i1.1042","article-title":"Sexual function after voluntary medical male circumcision for human immunodeficiency virus prevention: Results from a programmatic delivery setting in Botswana","volume":"21","author":"JC Pintye","year":"2020","journal-title":"South Afr J HIV Med"},{"key":"pone.0335587.ref009","volume-title":"Adverse Event Action Guide For Voluntary Medical Male Circumcision (VMMC) by Surgery or Device 2nd Edition","author":"Population Services International(PSI) CoSoE, Central and Southern Africa (COSECSA), Centre for Disease Control and Prevention (CDC)"},{"issue":"5","key":"pone.0335587.ref010","doi-asserted-by":"crossref","first-page":"559","DOI":"10.1097\/QAD.0b013e32834f3264","article-title":"Safety of task-shifting for male medical circumcision: a systematic review and meta-analysis","volume":"26","author":"N Ford","year":"2012","journal-title":"AIDS"},{"key":"pone.0335587.ref011","first-page":"88","article-title":"Mass safe male circumcision: early lessons from a Ugandan urban site - a case study","volume":"13","author":"M Galukande","year":"2012","journal-title":"Pan Afr Med J"},{"issue":"1","key":"pone.0335587.ref012","doi-asserted-by":"crossref","first-page":"93","DOI":"10.9745\/GHSP-D-13-00120","article-title":"Safety of adult medical male circumcision performed by non-physician clinicians in Kenya: a prospective cohort study","volume":"2","author":"V Frajzyngier","year":"2014","journal-title":"Glob Health Sci Pract"},{"issue":"1","key":"pone.0335587.ref013","article-title":"Implementation and Operational Research","volume":"69","author":"JB Reed","year":"2015","journal-title":"JAIDS Journal of Acquired Immune Deficiency Syndromes"},{"issue":"3","key":"pone.0335587.ref014","doi-asserted-by":"crossref","first-page":"403","DOI":"10.1016\/j.aogh.2016.04.130","article-title":"Application of medical student research objectives in an international medical elective: voluntary medical male circumcision in Swaziland","volume":"82","author":"A M. Bales","year":"2016","journal-title":"Annals of Global Health"},{"issue":"1","key":"pone.0335587.ref015","doi-asserted-by":"crossref","first-page":"21394","DOI":"10.7448\/IAS.20.1.21394","article-title":"Adverse event profile of a mature voluntary medical male circumcision programme performing PrePex and surgical procedures in Zimbabwe","volume":"19","author":"AF Bochner","year":"2017","journal-title":"J Int AIDS Soc"},{"issue":"11","key":"pone.0335587.ref016","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0185904","article-title":"A prospective cohort study of safety and patient satisfaction of voluntary medical male circumcision in Botswana","volume":"12","author":"KE Wirth","year":"2017","journal-title":"PLoS One"},{"key":"pone.0335587.ref017","unstructured":"Organization WH. Male circumcision for HIV prevention: manual for male circumcision under local anaesthesia and HIV prevention services for adolescent boys and men. 2018. https:\/\/iris.who.int\/bitstream\/handle\/10665\/272387\/9789241513593-eng.pdf?sequence=1"},{"issue":"5","key":"pone.0335587.ref018","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0079524","article-title":"Quality of voluntary medical male circumcision services during scale-up: a comparative process evaluation in Kenya, South Africa, Tanzania and Zimbabwe","volume":"9","author":"L Jennings","year":"2014","journal-title":"PLoS One"},{"issue":"5","key":"pone.0335587.ref019","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0080577","article-title":"Implications of the fast-evolving scale-up of adult voluntary medical male circumcision for quality of services in South Africa","volume":"9","author":"D Rech","year":"2014","journal-title":"PLoS One"},{"issue":"5","key":"pone.0335587.ref020","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pmed.1001641","article-title":"Achieving the HIV prevention impact of voluntary medical male circumcision: lessons and challenges for managing programs","volume":"11","author":"SK Sgaier","year":"2014","journal-title":"PLoS Med"},{"issue":"7","key":"pone.0335587.ref021","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0133369","article-title":"Improving the Quality of Voluntary Medical Male Circumcision through Use of the Continuous Quality Improvement Approach: A Pilot in 30 PEPFAR-Supported Sites in Uganda","volume":"10","author":"J Byabagambi","year":"2015","journal-title":"PLoS ONE"},{"issue":"8","key":"pone.0335587.ref022","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0254850","article-title":"Quality of service and continuous quality improvement in voluntary medical male circumcision programme across four provinces in South Africa: Longitudinal and cross-sectional programme data","volume":"16","author":"T Nyengerai","year":"2021","journal-title":"PLoS One"},{"key":"pone.0335587.ref023","doi-asserted-by":"crossref","first-page":"61","DOI":"10.1186\/s12913-016-1305-x","article-title":"Classification and rates of adverse events in a Malawi male circumcision program: impact of quality improvement training","volume":"16","author":"PK Kohler","year":"2016","journal-title":"BMC Health Serv Res"},{"issue":"2","key":"pone.0335587.ref024","doi-asserted-by":"crossref","first-page":"480","DOI":"10.1177\/1536867X1501500208","article-title":"Conducting Interrupted Time-series Analysis for Single- and Multiple-group Comparisons","volume":"15","author":"A Linden","year":"2015","journal-title":"The Stata Journal: Promoting communications on statistics and Stata"},{"key":"pone.0335587.ref025","unstructured":"Joachim J, Nyalali K, Mwakipesile P, Sewa P, Lweno Z, Fischer DF, et al. Robust Monitoring, Mentoring, and Training to Optimize the Quality of Voluntary Medical Male Circumcision Services. 2021. https:\/\/www.intrahealth.org\/sites\/default\/files\/attachment-files\/toharapluscqitechbriefweb.pdf"},{"issue":"8","key":"pone.0335587.ref026","doi-asserted-by":"crossref","DOI":"10.1136\/bmjopen-2018-021835","article-title":"Progress in voluntary medical male circumcision for HIV prevention supported by the US President\u2019s Emergency Plan for AIDS Relief through 2017: longitudinal and recent cross-sectional programme data","volume":"8","author":"SM Davis","year":"2018","journal-title":"BMJ Open"},{"issue":"1","key":"pone.0335587.ref027","doi-asserted-by":"crossref","first-page":"855","DOI":"10.1186\/s12913-019-4604-1","article-title":"Need for improved detection of voluntary medical male circumcision adverse events in Mozambique: a mixed-methods assessment","volume":"19","author":"A Brito","year":"2019","journal-title":"BMC Health Serv Res"},{"issue":"2","key":"pone.0335587.ref028","doi-asserted-by":"crossref","first-page":"173","DOI":"10.1097\/QAI.0000000000002751","article-title":"Adverse Event Trends Within a Large-Scale, Routine, Voluntary Medical Male Circumcision Program in Zimbabwe, 2014-2019","volume":"88","author":"O Victor","year":"2021","journal-title":"J Acquir Immune Defic Syndr"},{"issue":"6","key":"pone.0335587.ref029","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0218137","article-title":"Trust but verify: Is there a role for active surveillance in monitoring adverse events in Zimbabwe\u2019s large-scale male circumcision program?","volume":"14","author":"P Marongwe","year":"2019","journal-title":"PLoS One"},{"issue":"9","key":"pone.0335587.ref030","article-title":"Timing of adverse events among voluntary medical male circumcision clients: Implications from routine service delivery in Zimbabwe","volume":"13","author":"C Feldacker","year":"2018","journal-title":"PLoS One"},{"issue":"10","key":"pone.0335587.ref031","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0258611","article-title":"Adverse event profile and associated factors following surgical voluntary medical male circumcision in two regions of Namibia, 2015\u20132018","volume":"16","author":"G O\u2019Bryan","year":"2021","journal-title":"PLoS ONE"},{"issue":"1","key":"pone.0335587.ref032","doi-asserted-by":"crossref","first-page":"16","DOI":"10.1097\/QAI.0000000000002198","article-title":"Reducing Provider Workload While Preserving Patient Safety: A Randomized Control Trial Using 2-Way Texting for Postoperative Follow-up in Zimbabwe\u2019s Voluntary Medical Male Circumcision Program","volume":"83","author":"C Feldacker","year":"2020","journal-title":"J Acquir Immune Defic Syndr"},{"issue":"5","key":"pone.0335587.ref033","doi-asserted-by":"crossref","first-page":"1383","DOI":"10.1007\/s10461-016-1515-6","article-title":"What Messages are Adolescent Voluntary Medical Male Circumcision (VMMC) Clients Getting and How? Findings From an Observational Study in Tanzania","volume":"21","author":"D Boyee","year":"2017","journal-title":"AIDS Behav"},{"key":"pone.0335587.ref034","doi-asserted-by":"crossref","DOI":"10.1093\/cid\/cix950","article-title":"Adolescent Male Circumcision for HIV Prevention in High Priority Countries: Opportunities for Improvement","volume":"66","author":"C Lane","year":"2018","journal-title":"Clin Infect Dis"},{"issue":"3","key":"pone.0335587.ref035","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0149892","article-title":"Adolescent Sexual and Reproductive Health Services and Implications for the Provision of Voluntary Medical Male Circumcision: Results of a Systematic Literature Review","volume":"11","author":"MR Kaufman","year":"2016","journal-title":"PLoS One"},{"issue":"1","key":"pone.0335587.ref036","doi-asserted-by":"crossref","first-page":"23","DOI":"10.1186\/s12894-021-00790-y","article-title":"Urethrocutaneous fistulas after voluntary medical male circumcision for HIV prevention-15 African Countries, 2015-2019","volume":"21","author":"T Lucas","year":"2021","journal-title":"BMC Urol"},{"issue":"1","key":"pone.0335587.ref037","doi-asserted-by":"crossref","first-page":"45","DOI":"10.1186\/s12894-020-00613-6","article-title":"Case series of glans injuries during voluntary medical male circumcision for HIV prevention - eastern and southern Africa, 2015-2018","volume":"20","author":"TJ Lucas","year":"2020","journal-title":"BMC Urol"},{"key":"pone.0335587.ref038","doi-asserted-by":"crossref","unstructured":"Lugada E, Seruwagi G, Nyanzi A, Lawoko S, Bwayo D, Kasujja V. Accelerated scale up of voluntary medical male circumcision within the military health services in Uganda: The race towards 2020 HIV epidemic control. 2021. https:\/\/www.researchgate.net\/publication\/350659768","DOI":"10.9734\/ISRR\/2021\/v10i230127"},{"issue":"10","key":"pone.0335587.ref039","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0240425","article-title":"Balancing competing priorities: Quantity versus quality within a routine, voluntary medical male circumcision program operating at scale in Zimbabwe","volume":"15","author":"C Feldacker","year":"2020","journal-title":"PLoS One"},{"issue":"1","key":"pone.0335587.ref040","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0086631","article-title":"Adverse events profile of PrePex a non-surgical device for adult male circumcision in a Ugandan urban setting","volume":"9","author":"M Galukande","year":"2014","journal-title":"PLoS One"},{"issue":"8","key":"pone.0335587.ref041","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0100008","article-title":"The safety and acceptance of the PrePex device for non-surgical adult male circumcision in Rakai, Uganda. 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