'Get a Permanent Smile'- Increasing Awareness of, Access to, and Utilization of Vasectomy Services in Ghana

Published in December 2005, this 67-page report explores communication-centred strategies that have been used to increase vasectomy utilisation in Ghana. Provided by the collaborative ACQUIRE Project (Access, Quality and Use in Reproductive Health), the document describes a 2-year project initiated in 2003 by the Ghana Health Service, the ACQUIRE Project, and EngenderHealth (with financial support from the U.S. Agency for International Development, or USAID) to introduce and expand vasectomy services in a range of public- and private-sector health facilities in metropolitan Accra and Kumasi. This resource describes the results of the project and suggests that using a combination of site interventions focused on access and strategic interventions aimed at demand awareness can significantly impact attitudes and utilisation.

In developing the project, organisers were motivated by scientific evidence that vasectomy is "safer, simpler, and less expensive than female sterilization, and is just as effective a contraceptive method." However, "in many countries it remains one of the least-known and least-used methods. Worldwide, an estimated 42 million couples rely on vasectomy; by comparison, nearly 210 million women rely on female sterilization....Ghana is typical in this respect, with only about one couple in 1,000 relying on vasectomy." The authors suggest that vasectomy is underutilised not because men do not want to take responsibility for family planning but, rather, because men lack full access to both information and services and thus cannot make informed decisions or take an active part in family planning.

In this context, organisers began by training 7 providers at 7 sites in Ghana in no-scalpel vasectomy (NSV); members of this staff were also oriented with regard to provision of male-friendly services. This training process was designed to serve as a catalyst for men considering vasectomy, as well as to raise awareness of vasectomy as a contraception option and to dispel rumours. In addition, clinical and community health nurses organised community outreach events at each site. With technical assistance from Meridian Group International, Inc., a campaign was designed with the slogan "Vasectomy - Get a permanent smile" which featured satisfied vasectomy users; the campaign included two television advertisements, a television documentary, two radio advertisements, posters, brochures and flyers, and public relations efforts. A telephone hotline was also set up, with trained staff to answer calls during the project months.

As detailed here, initial results indicate that the project was a success: "NSV is a viable contraceptive choice for Ghanaian men when a targeted media campaign is coupled with interventions to provide quality client-centered vasectomy services. It further demonstrates that family planning services that traditionally serve women can provide quality care to vasectomy clients, and it verifies that men are interested in learning more about vasectomy." Specifically, after the programme was launched in early 2004:

• Access: 425 callers received information from the hotline counsellors. Other men and women sought (and continue to receive) information from the telephone's automated 24-hour pre-recorded information menu of answers to frequently asked questions about vasectomy.
• Knowledge: A panel study conducted in metropolitan Accra prior to and following the campaign among married men with 3 or more children showed that the number of men who were aware of vasectomy had nearly doubled. Fifty-six percent of the men who were interviewed recalled and were able to describe at least one element of the campaign, and more than half of the men who reported seeing the campaign television advertisements took action as a result (e.g., by visiting a doctor or health centre to discuss vasectomy). More than half of these men also were able to name a specific site where vasectomy services are offered.
• Attitudes: The panel study found that the men's "intention to consider vasectomy" also doubled, with the proportion willing to do so increasing from one in every 10 men at baseline to one in 5 at follow-up. Providers' attitudes were also shown to have been improved; doctors and nurses themselves now conduct outreach to potential clients.
• Practices: The number of vasectomies performed quadrupled over the volume provided in the prior year. A total of 81 men requested and received vasectomies at service sites in 2004, compared with an annual total of 18 in the preceding year. This service volume was 6.6 times higher than the average number of procedures provided in the 10 years prior to the project.

A number of lessons learned and project-specific recommendations are shared here; some of this discussion focuses specifically on the role of the communications campaign and is intended to be useful to other 'Permanent Smile' campaigns (the project is being replicated in Honduras) as well as related communication-centred NSV initiatives. Highlights include:

• Myths and rumours - e.g., that vasectomy causes impotence or is a risky procedure - must continue to be addressed.
• Many men perceive vasectomy's permanence to be a disadvantage (nearly half (47%) of the men in the panel study) - a finding that was surprising given the prominence of the concept of permanence in the campaign slogan. Future campaigns may want to explore this concept further through research.
• Television is an important medium for reaching men, especially those in urban areas.
• A telephone hotline is helpful as an additional, anonymous source of information about vasectomy where men can get further information and services.

Recommended next steps are also outlined for this or future Permanent Smile campaigns, and are organised into categories including "site-level support" and "demand and client communications".

In short, by using a variety of interpersonal approaches and mass media, this project "demonstrates that it is possible to change people's perceptions of vasectomy and increase the use of this method; we hope that the findings will inspire other countries and agencies to adopt similar approaches to increase the acceptance of underutilized family planning methods."