Vasectomy in Kenya: The First Steps
Pamela Lynam, Joseph Dwyer, David Wilkinson, and Evelyn Landry
Vasectomy is a simple, effective, safe, and cost-effective method of family planning. However, in Sub-Saharan Africa, for various reasons, vasectomy is almost unknown. This paper describes the strategies AVSC International has taken to assess the potential niche for vasectomy in Kenya--conducting research into knowledge of and attitudes toward vasectomy among men in both urban and rural settings; examining the characteristics of Kenyan men who have had vasectomy; laying the groundwork for quality services, including training of surgeons; organizing a workshop to bring all these initiatives together; and carrying out a pilot study using the mass media to explore interest in vasectomy. The results of these efforts suggest that vasectomy does indeed have a role to play in Kenya and potentially elsewhere in Africa.
Contraceptive prevalence in Africa, although generally low, is rapidly increasing for many reasons, the most compelling being economic necessity. This is especially true in Kenya, a society that increasingly values education, which parents must pay for, at least in part. Although Kenya has had one of the highest population growth rates in the world, the Demographic and Health Survey (DHS) of 1989 showed a lowering growth rate, a good knowledge of family planning methods among both men and women, and a relatively high rate of use of modern family planning methods compared to other countries in the region (National Council for Population and Development et al., 1989). Notable increases in the use of family planning have occurred in Kenya: in 1984, 9% of married women of reproductive age were using a modern method; by 1989, this rate had increased to 18% (Kenya, 1984; National Council for Population and Development et al., 1989). Increases in female sterilization have been especially notable, despite earlier predictions that this method would never gain acceptance in Africa (Caldwell and Caldwell, 1987). In 1984, only 2% of women had undergone sterilization, while in 1989, the figure was 5%. Female sterilization is now the second most popular modern method after oral contraceptives. Sites supported by AVSC International have provided tubal occlusions to more than 66,000 women in Kenya since 1985 (AVSC, 1992).
Vasectomy, on the other hand, is not widely known or used in Kenya or any other Sub-Saharan African country. In the 1989 Kenya DHS, only 35% of the men surveyed and 20% of women had heard of vasectomy, while awareness of female sterilization was higher: 83% and 73%, men and women, respectively (National Council for Population and Development et al., 1989). Moreover, vasectomy has been a somewhat politically sensitive issue, and the Ministry of Health banned advertising for it.
As a contraceptive method, vasectomy has several advantages, especially for people who may not have much disposable income--it is a once-only procedure; it is cost-effective for both clients and providers; and it is simple, safe, and effective. Despite the merits of vasectomy, few providers have offered vasectomy services in Sub-Saharan Africa until very recently. A record review to determine characteristics of Kenyan men who had a vasectomy between January 1976 and September 1988 found 185 reported procedures (Parkar, 1990). Service statistics for vasectomy at AVSC-supported sites in Kenya show a total of 246 procedures performed between 1987 and 1991 (AVSC, 1992).
Why is interest in vasectomy as a method of family planning apparently so low in Sub-Saharan Africa? Are African men uninterested in family planning? Or are they resistant to male methods? Is it the vasectomy operation itself that is a barrier? Would interest in vasectomy be greater if men knew more about it and good services were available? A 1988 focus group study in four areas of Kenya revealed resistance to the idea of vasectomy, even among participants who were supportive of tubal occlusion (Bertrand et al., 1989). Does this finding suggest that vasectomy is unacceptable in Kenya? Or is acceptability problematic only in the early stage of introduction, when the method is new to those interviewed?
To answer some of these questions, in 1988 AVSC developed a systematic strategy to explore the potential niche for vasectomy in Kenya. We know there are negative attitudes and cultural barriers to vasectomy, and we understand that vasectomy may never be as popular in Kenya as in other countries. Nevertheless, we believed that interest was sufficient to warrant some attitude studies and initiation of services in a few sites. The activities included the following: supporting research into attitudes and knowledge about vasectomy; training surgeons in vasectomy techniques; supporting services in a number of sites; bringing together service providers and policymakers for a national meeting on male involvement in family planning and vasectomy; and pilot-testing the effectiveness of using mass media to assess interest in vasectomy.
AVSC has supported studies to explore the attitudes of urban and rural men toward vasectomy and a record review study to examine the characteristics of Kenyan vasectomy acceptors.
Attitudes among Urban Men
A 1989 survey of attitudes toward and knowledge of vasectomy among a sample of approximately 400 men (including a small subsample of health workers) in Nairobi revealed that 37% had heard of vasectomy (see Table 1); twice as many had heard of a permanent method of family planning for men, but were not able to name the operation. Some 35% reported they did not want more children, and approximately another one-third were unsure. In all, 7% expressed interest in vasectomy, and 46% of the men interviewed wanted more information on it. Those who wanted more information were younger men and were more likely than others to talk to their wives about contraception. The survey found a good deal of misunderstanding about the procedure: many men confuse it with castration. One notable point to emerge was that health workers in Nairobi were as ill-informed as the general public when it comes to accurate and complete facts about vasectomy (Wilkinson, 1990).
Attitudes among Rural Men
Between 1988 and 1990, AVSC conducted an operations research project in Chogoria, a rural area of Kenya, to assess the effectiveness of training health workers to provide more accurate information about vasectomy. This study used focus group discussions, and two community surveys, a baseline survey in 1988-1989 and a follow-up in 1990, to examine attitudes toward and knowledge of vasectomy among married men 30-50 years of age (see Table 1). Approximately 300 men participated in each survey. Awareness of vasectomy was 36% at the baseline survey and increased to 48% at the follow-up survey. About one-third of the men interviewed in each survey said they might consider vasectomy as an option once they had all the children they wanted. Most men (86% at baseline and 88% at follow-up) said they would like to have more information on vasectomy (Landry et al., 1990).
Both the urban and the rural surveys revealed far more interest in learning about vasectomy than we had expected, despite many misunderstandings about the procedure.
In addition to these studies, the 1989 Kenya DHS husbands' survey showed that 37% of the respondents had heard of vasectomy, and that interest in limiting family size was substantial. Forty-nine percent of all Kenyan men who are married to women of reproductive age want no more children (National Council for Population and Development et al., 1989).
Characteristics of Kenyan Vasectomy Acceptors
A 1989 record review sought to determine what kind of Kenyan men choose vasectomy (Parkar, 1990). To obtain demographic profile information, the investigator examined records for all clients throughout the country who had had a vasectomy between January 1976 and September 1988 and could be traced. A total of 185 vasectomy cases over this period were identified, and 163 records were available for analysis. The information from these records reveals the following information about Kenyan vasectomy acceptors:
In addition to reviewing the records, the researcher was able to contact 27 vasectomy acceptors to determine if they had experienced changes in their health or sexual relations following the procedure. Surprisingly, 19 of them said that their overall health had improved; the quality of sexual relations had remained the same for 15 and improved for 12. None reported a deterioration in health or in the quality of sexual relations.
Of course, we cannot generalize about all Kenyan men from these small numbers of acceptors. Indeed, as pioneers in the Kenyan context, they may be atypical of men in their society. However, the profile of the Kenyan vasectomy acceptor mirrors that of vasectomy acceptors derived from international data, with the exception that most Kenyan acceptors do not first discuss the procedure with another vasectomized man (Philliber and Philliber, 1985; Mumford, 1983). The paucity of men who have had the procedure makes it difficult to find one with whom to do so. Findings from focus group discussions and interviews show that before men will have a vasectomy, they would like to talk to a man who has undergone the operation.
In addition to the studies and surveys, AVSC has supported training for Kenyan doctors so that quality services will be in place if demand grows. Since the caseload in Kenya is too low for effective in-country training, these surgeons generally received training in Thailand and Brazil, in the no-scalpel technique.
As of 1992, eight Kenyan surgeons had been trained. These surgeons include key clinical personnel from the major governmental and nongovernmental umbrella family planning organizations--the Ministry of Health (MOH), the Family Planning Association of Kenya (FPAK), and the Christian Health Association of Kenya (CHAK)--and from the private sector (AVSC 1992). They form a cadre of skilled and enthusiastic professionals who will be able to cope with any likely increase in demand for their services until the number of clients is sufficient to allow for local training of their colleagues. Several of the trained surgeons have started their own local campaigns to let men know more about vasectomy. In some areas of the country that are resistant to the idea of family planning, such as Kisii and Mombasa, these surgeons have succeeded in doubling or tripling the number of acceptors.
AVSC has supported vasectomy services in several sites in Kenya. This support, after the training of surgeons in the no-scalpel technique, has taken several forms. AVSC-sponsored counseling workshops for service providers have addressed the special needs of vasectomy clients, potential clients, and spouses. We have reimbursed expendable supplies required for the procedure, so that a hospital or clinic that offers vasectomy services will not have to deplete its store of gauze, local anesthetic, lotions, and other supplies normally used for curative services. We have developed brochures for Kenyan men who are interested in learning more about the procedure and for those who have chosen the procedure. Both brochures carry the contact information for the nearest clinic that offers vasectomy. AVSC is currently investigating other information and education activities, to ascertain their impact and usefulness.
Bringing It All Together: The Vasectomy Workshop
Armed with the knowledge about how men have begun to accept vasectomy in other parts of the world, and with the results of Kenyan studies showing much more interest in vasectomy than we had imagined, AVSC organized a national workshop on vasectomy and male involvement in November 1990. The workshop, which took place in Nairobi, brought together personnel involved in vasectomy and male involvement in family planning; representatives from the MOH, FPAK, CHAK, the National Council for Population and Development, and the University of Nairobi; service providers and vasectomy acceptors.
A major question participants addressed was "Should we work harder to involve more men in family planning?" The answer was simple: Men are involved in family planning, for better or worse. When men are well informed, they have a positive involvement. When they are left out and poorly informed, they often stand in the way of their partners' using family planning and are unlikely to use family planning themselves.
A large part of the workshop involved participants working in small groups, with the focus on four major themes: medical issues; organization of services; counseling; and information, education, communication, and the media.
Each group made recommendations, which the plenary group ratified and accepted as future standards. The major recommendations were similar to those that emerged from the 1982 Sri Lanka international vasectomy conference (Atkins and Jezowski, 1983). They were as follows:
The growing national program is now being implemented with these recommendations.
One of the major outcomes of the workshop was the lifting of a ban on advertising the availability of vasectomy services in Kenya. As a result of this, AVSC, in collaboration with Innovative Communication Services (ICS), a nongovernmental organization concerned about male involvement in family planning and vasectomy issues, implemented a pilot study using the newspapers to assess from another perspective the interest among Kenyan men in finding out more about vasectomy. In May 1991, small newspaper advertisements were run twice weekly for four weeks in an English-language newspaper with nationwide circulation and in a Kiswahili newspaper appealing to rural and lower socioeconomic groups. The advertisements were also placed in the May and June issues of a magazine with a target group of urban, middle class readers.
Those wishing to learn more about the procedure had to cut out a small coupon from the paper, fill it in, and mail it to ICS. As the purchase of an envelope and stamp is a significant expense, especially for a rural worker with limited disposable income, the very fact that men replied indicates the degree of interest the campaign generated. ICS mailed each inquirer an information leaflet about vasectomy, along with a list of centers where more information, or the procedure itself, was available.
These advertisements produced over 800 written inquiries within a few weeks--an unexpectedly large response. Many inquiries came from rural areas of Kenya and in response to the Kiswahili newspaper. In addition, 67 letters of comment on the advertisements were received, every one favorable to the campaign. Recent follow-up of the inquirers who had received the pamphlets showed that at least seven had accepted vasectomy soon thereafter (Wilkinson et al., 1992).
PLANS FOR VASECTOMY IN KENYA
On the basis of the above experiences, AVSC has planned, or is already carrying out, several additional activities:
The Kenya DHS and AVSC-supported studies and contraception introduction activities show that Kenyan men have interest in planning their families. Despite widespread misinformation about vasectomy, all these studies reveal considerable interest in learning more about it. When accurate and complete information, including information on how and where to get services, is available, the use of vasectomy will likely increase in Kenya.
Working Paper #4 Authors:
Pamela Lynam, M.D., is senior advisor for medical and client-centered quality of care and David Wilkinson is evaluation and research consultant for AVSC's Regional Office for East and Southern Africa based in Nairobi. Joseph Dwyer is director of the Regional Office in Nairobi. Evelyn Landry, director of evaluation and research for AVSC, is based in New York.
Barriers to Acceptance of Vasectomy in Kenya: Major Findings from Surveys and Focus Groups
Sources: Wilkinson, 1990; Landry et al., 1990.
The purpose of AVSC Working Papers is to capture on paper AVSC's experience and to disseminate the results of AVSC-supported research. We welcome your comments and suggestions.
The authors wish to acknowledge Terrence W. Jezowski for his helpful comments on the manuscript. Thanks also to Lynn Bakamjian, Cynthia Steele Verme, Pamela B. Harper, and Hugo Hoogenboom for reviewing the manuscript. Dore Hollander edited the manuscript. Renée Santhouse designed the publication.
This publication may be reproduced without permission, provided the material is distributed free of charge and the publisher and authors are acknowledged. This publication was made possible, in part, through support provided by the Office of Population, U.S. Agency for International Development (AID) under the terms of cooperative agreement HRN-A-00-98-00042-00. The opinions expressed herein are those of the authors and do not necessarily reflect the views of AID.
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