Recent Experiences and Lessons Learned in Vasectomy Programming in Low-Resource Settings: A Document Review

"By maximizing the confluence of existing infrastructure and more positive attitudes toward FP [family planning] use, and by building upon the existing body of effective male involvement interventions, now is an opportune time to incorporate vasectomy into national FP strategies. Evidence related to vasectomy uptake and outcomes are essential to ensure that policymakers have what they need to make informed decisions on strengthening vasectomy in FP programming."

FHI 360 with support from the Evidence Project has reviewed the recent research literature on vasectomy acceptability, as well as programmatic reports from the leading international family planning (FP) programmes conducted over the last decade, to synthesise the existing evidence and programmatic experiences around common barriers and facilitators to vasectomy adoption and to make recommendations for future research, programmatic, and advocacy efforts. The review consolidates the evidence supporting the premise that vasectomy uptake is an important component to national FP programmes - particularly, in settings where government and family resources are limited - and that with proper planning, technical assistance, and political and financial support, an increase in vasectomy use can be a reality. Vasectomy is described here as an easy-to-provide, safe, and highly effective method for helping couples reach their desired family size, but is too often under-utilised.

The review summarises 75 studies published between April 2005 and April 2015 exploring the knowledge of, attitudes toward, and acceptability of vasectomy among individuals in many low-resource settings around the world. It also culls out the common characteristics and motivations for vasectomy among the early adopters in these societies - men who have set aside the cultural norms of their social environment and adopted vasectomy. Finally, the review describes the various ways in which vasectomy services have been promoted and provided over the last decade, including descriptions of programme implementation models, promotional and provider training costs, and lessons learned from recent programmes. The review further categorised the latter section (vasectomy service provision) following the Supply-Enabling Environment-Demand (SEED) Programming Model™: 1) creating, increasing, and sustaining demand for vasectomy services; 2) increasing supply of vasectomy services; and 3) creating an enabling environment for vasectomy programmes.

Based on previous work, the literature, and their experiences, the authors present ideas to promote and support vasectomy in the following areas:

Demand creation: In general, almost all of these articles found that men, women, and many health service providers had low awareness of and/or several misperceptions about vasectomy. Low knowledge or misperceptions about vasectomy lead to negative attitudes, which negatively influence acceptability of vasectomy. They found that formative research was often conducted early on to understand local knowledge and acceptability of potential clients and their partners. Targeted messaging and educational materials were then developed to directly address misconceptions and lack of knowledge about the vasectomy procedure and side effects. In many cases, multiple media were used to reach the intended audience, and satisfied users were encouraged to dispel rumours and misconceptions about the procedure in their communities at a grassroots level. Most salient for many men and women was the personal accounts/experiences of vasectomy clients. Testimonials dispelling myths were well received across settings and mentioned as key aspect of attitudinal change and helped to bridge the reproductive health (RH) gap for men. This is similar to activities from the voluntary medical male circumcision activities in East Africa, which used marketing campaigns that depicted satisfied users (men and their partners). In addition to mass media and interpersonal communication, many men in the review heard about vasectomy through health care workers, which highlights the importance of health care workers at all levels being trained to counsel men and women on vasectomy as a contraceptive method.

Despite the demand-creation achievements of all of the programmes included in this report, the authors feel that more needs to be done in many of these settings to increase the RH awareness of men and boys in general. Advocacy efforts should focus on reaching adolescents and men in their 20s to take a more active role in their own RH, rather than relying solely on women to bear the burden of a couple's reproductive potential. This includes encouraging young men to start thinking about getting a vasectomy once they have reached their desired family size. Emphasising the safety of the procedure, the money-saving potential of having fewer children and not having to spend money on contraception, and the health benefits to the woman (avoiding unintended pregnancies and side effects or complications related to contraception) could be salient messages. However, they stress that attempts to focus communication efforts on men should not ignore women as important agents in the decision-making process. Some documents highlight the concerns that women have that vasectomy may reduce their partner's desire for sex and that they, instead, offer to undergo sterilisation to avoid any change in his sexual behaviour.

Supply of services: A "whole-site" training approach has been documented to improve engagement of health care staff at all levels to promote vasectomy services. Stronger public-private partnerships are thought to enable sites to initiate capacity-building activities among their staff. Several tools are available to assist in quality assurance of training and service provision, much of which has been consolidated and made publically available through the K4Health Permanent Method Toolkit. A cascade approach to initiating and building capacity to scale up non-scalpel vasectomy (NSV) services has been demonstrated to be successful in a number of small pilot programmes across the various United States Agency for International Development (USAID) cooperative agreements identified in the review.

The authors note that it is critical that demand for and supply of vasectomy services be mutually reinforced. For example, if demand dwindles, providers will not have clients and then may lose desire to or confidence in their ability to perform vasectomies.

Enabling environment: "Local policymakers need to be convinced of the importance of a male RH agenda, most immediately the inclusion of vasectomy into a comprehensive method mix." Furthermore, the authors argue that addressing and changing current gender norms through social and behavioural change strategies is critical to facilitate couples' communication, shared decision-making, and use of more gender-equitable FP practices. Research has repeatedly found that both men and women perceive FP to be women's responsibility, despite men's control of most decisions within the household. These roles are reinforced in the standard practice at health facilities, according to the review. The literature reveals a number of potentially beneficial approaches to improving gender equitable norms, including targeted promotional campaigns that emphasise that male engagement in RH and use of available FP options is characteristic of responsible male behaviour, engaging couples in group FP informational sessions, and promoting FP and offering RH referrals to men at the workplace. In addition, examples from the review in Tanzania, Bangladesh, and Iran highlight the important impact that religious endorsement can have on vasectomy uptake. "At the policy level, an extension of the existing paradigm to include men as active members in the FP discourse is needed....Meanwhile, the international community must help to facilitate this paradigm expansion by developing new ways to monitor and evaluate the impact of male inclusion in FP/RH programming."

The following list outlines current gaps in the literature and practice of vasectomy in low-resource settings that the authors argue should be prioritised in the future:

• Further advance post-vasectomy outreach.
• Develop new metrics to comparatively measure effectiveness of novel male-centred contraceptive methods.
• Include more men and more RH questions tailored to men in national RH monitoring and surveys to better understand male perspectives.
• Better understand motivations for limiting births among various groups (e.g., men younger than 30 versus men 30 and older). This may facilitate better marketing of the use of permanent methods.
• Develop means of adding the use of permanent methods as a regular and logical part of the FP conversation. As stated here, permanent methods should be considered a logical "final step" to ensure an individual or couple achieves their desired family size.
• Elucidate the psychosocial effects of receiving a permanent method of contraception among men and women in order to better inform marketing and counselling messaging.
• Identify country-specific barriers and opportunities to access permanent method services (e.g., public awareness, misconceptions, gender norms, provider biases, or service barriers).
• Identify types of interpersonal or community-level interventions or strategies that address strong cultural tendencies that support large family size in order to create an environment in which choosing to limit family size is a viable option.
• Identify effective, evidence-based strategies to reform gender-related behaviours and social norms that hinder vasectomy uptake as well as, more generally, male engagement in FP.

The authors conclude that "[c]reating continual demand for services and access to and supply of well-trained health teams are mutually reinforcing components to a successful vasectomy program. At the same time there is an underlying need for an enabling policy, cultural, and gender environment that extends beyond vasectomy and addresses male health in general. The FP/RH paradigm should be expanded to include men not just as default partners of female FP clients and potential advocates or deterrents of RH promotion, but as equal beneficiaries of FP/RH programs in their own right."