Intention to Accept Vasectomy among Married Men in Kathmandu, Nepal

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1 Asia Journal of Public Health Journal homepage: Original Articles Intention to Accept Vasectomy among Married Men in Kathmandu, Nepal Kishori Mahat * Oranut Pacheun ** Pimsurang Taechaboonsermsak *** **Rural Health Training and Research Center, Faculty of Public Health, Mahidol University, Bangkok, Thailand *** Department of Family Health, Faculty of Public Health, Mahidol University, Bangkok, Thailand ARTICLE INFO Article history : Received 27 May 2010 Received in revised form 4 June 2010 Accepted 14 June 2010 Available online July 2010 Keywords: Intention Vasectomy Social support Belief about vasectomy Corresponding Author: Kishori Mahat, Lamtangin Marg, Baluwatar, Kathmandu, Nepal Asia J Public Health 2010;1(1):8 14 ABSTRACT Objective: This descriptive cross sectional study was undertaken to describe the factors affecting the intention to accept vasectomy among married men. Materials and Methods: Simple random sampling was employed to interview 200 married men aged years in Khadka Bhadrakali Village development committee (VDC), Kathmandu, during February Results: The mean age of the respondents was 35.7 years and mean duration of marriage 13.4 years % had an intention to accept vasectomy and were between years of age, married for less than ten years, had two living children. The average number of desired children of the respondents was The researchers selected factors that influence the intention to accept vasectomy by using backward logistic regression. The study found that the age of the respondent was associated with the intention to accept vasectomy (OR 6.77, 95% CI: ). Beliefs about vasectomy were also found associated with intention to accept vasectomy (OR 5.37, 95% CI: ). Emotional and material support from parents were associated with intention to accept vasectomy (OR 4.89, 95% CI: ) and (OR 15.46, 95% CI: ) respectively. Appraisal support from health personnel was also significantly associated with the intention to accept vasectomy (OR 9.34, 95% CI: ). Conclusion: The study suggests that focus should be on social support (emotional, material, appraisal and informational) and couple counseling for vasectomy to combat the misconceptions regarding the consequences of vasectomy, especially those regarding sexual problems. INTRODUCTION With the world population escalating, population growth which was once just a national concern has now come to have global ecological implications. The most significant burden is visible among the developing nations due to a combination of poverty and uncontrolled births. Taking a closer look at one of the least developed nations, Nepal s 10th population Census, conducted in June 2001, produced a population count of 23,214,681. That number marked an increase of 5 million since the previous census in 1991 and an average annual growth rate of 2.3 % 1. With a growth rate of 2.1% in 2005 and limited cultivable land, Nepal s economy will not be able to sustain the rising demand for food, shelter, education, health and other basic amenities; further increasing the poverty in the country. Thus, keeping in view the 38 percent of the population of Nepal who still live below the poverty line, and the highest MMR in Asia 1 of 538/100,000 live births, Nepal is in desperate need of good and sustainable family planning policies to control and protect itself from the detrimental effects of population growth. Already, family planning services have been deployed to provide a myriad of contraceptive methods/services that reduce fecundity, enhance maternal and neonatal health as well as child survival, and which will contribute to bringing about a balance in population growth and socio economic 8

2 development, causing less strain on Nepal s dwindling economy and its ability to recuperate and regenerate. The 10 th Five Year Plan in Nepal aims to reduce the fertility rate from 4.1 in 2001 to 3.05 by 2017, but the numbers of people who practice family planning methods are presently showing a decrease: from 2002 to 2004 there has been a decrease in the new acceptors of contraception. While injectable contraception is the most popular temporary method (53.8%), most prefer the permanent female sterilization method. The acceptance of female sterilization has increased by 7.0% from 2002 to 2004 as compared to male sterilization which has gone down by 4.0% during the same period. Moreover, this decrease is reportedly in the central development region of Nepal where major cities such as Kathmandu lie, and where vasectomy services are easily available and accessible. Also, there has been no substantial increase in the number of new acceptors of temporary methods since This discrepancy in the preferred family planning methods is a common phenomenon in a country like Nepal where gender inequity and women rights still remains a major issue. About 45 million couples worldwide rely on vasectomy for contraception, compared to 150 million who rely on female sterilization, in spite of the fact that male sterilization is safer and easier to perform 3. Information Education and Communication (IEC) campaigns have been used extensively for over a decade to promote vasectomy acceptance. Moreover, although hospitals, clinics, and vasectomy camps have been extensively providing vasectomy services for free, achieving vasectomy acceptance is still difficult. Education alone doesn t seem to motivate married Nepali men to change their attitude. Vasectomy is a safe, cost effective and permanent method of contraception, but there are many factors that play a role in its relative lack of acceptance, such as sociodemographic factors, economic factors, low social support, and inaccurate knowledge and belief about vasectomy. Nepal is still a patriarchal society and men overlook all the family planning decisions. Family planning policies have been solely targeting women as primary clients due to their heavy burden of pregnancy. This is one major factor in the overall reduced acceptance of family planning methods by men. In 1994, the International Conference on Population and Development (ICPD) stressed the need for addition efforts to be made to sensitize men on their shared responsibility and promote their active participation in key areas of reproductive health including family planning 4. Men s fertility is life long as compared to that of women s fertility which lasts till menopause. Family planning and other reproductive health care programs and providers should therefore primarily target men for vasectomy in order to neutralize both gender inequity and also promote the advantages associated with it besides just being a permanent method of sterilization (e.g. studies show that vasectomy reduces the incidence of BPH (Benign Prostatic Hyperplasia) 5. Based on the previous studies conducted on acceptance of vasectomy, this study is aimed at describing the factors affecting the intention to accept vasectomy among married men in Nepal. MATERIALS AND METHODS The study was conducted in Khadka Bhadrakali Village Development Committee (VDC), a semi urban community located on the northern side of Kathmandu valley, with a total population of 12,000. This area was chosen for the study as it falls in the central development region where new acceptors of vasectomy have declined significantly over the past few years. Moreover, health care facilities varying from government to private nursing homes, with almost all of them providing vasectomy services are easily accessible from this VDC. The majority of the people living in this VDC were Hindus and a few were Buddhist, both do not have religious restrictions in terms of contraceptive acceptance. The study population comprised of married men from years of age, who had not undergone vasectomy and had at least two children. Those whose wives had undergone the permanent method or were in menopause were excluded from the study. Khadka Bhadrakali VDC has nine wards out of which two were chosen randomly. A sample size of 200 was taken from these two wards. The data was collected by using a pre tested structured interview form from 200 eligible married men which was calculated by applying the formula Z 2 α/2 p q/d 2 and 0.3 which is the acceptance of vasectomy among non adopter men based on research conducted by Amara Soonthorndhada 6. The structured interview was pretested among married men to evaluate the questions for clarity and to estimate Cronbach s alpha for reliability, which came out to be 0.80 for knowledge, and 0.81 for belief. The respondents were interviewed with regard to general characteristics of the respondents, social support, knowledge and belief concerning vasectomy during February In depth interviews were done among some of the respondents. Ethical approval This research was conducted in accordance with the principals of the Declaration of Helsinki 9

3 and approved by the Ethical Review Committee of Faculty of Public Health, Mahidol University, ref no. MUPH Data analysis Statistical analysis of the data was carried out after thorough scrutiny. Descriptive statistics, Chi square and logistic regression were applied to evaluate the association between independent and dependent variables. RESULTS The mean age of the sample was 35.74±6.83 years with the mean duration of marriage of 13.44±7.04 years. Majority of the respondents had completed high school, and were farmers and daily wage earners having the average monthly income of about Rs.6000 ($92). The majority had two children and also desired only two children(table 1). About 87.5% were using at least one contraceptive method where an injectable contraception was the most preferred one followed by condom, while 12.5% never used any contraception. The reasons for not using any contraception came out as a fear of side effects for the female temporary method, followed by the need of a son for one s cremation, in which it is believed that a son is necessary so that one can go to heaven. Some even said that it is a sinful act to practice contraception. It brings about bad luck and the existing children die. A majority of 71.5% said that both husband and wife participated in the decision making process regarding contraception while 14.0% said that it was their own decision. Regarding social support, four types of support namely emotional, information, material and appraisal support from wife, parent, friends and health personnel were included. No scoring system was applied, respondents answered as good, fair and poor support on each category and source of social support. Wife was the main source of appraisal support (70.5%), emotional support (56.5%), and material support (43.5%) concerning vasectomy, while health personnel was the main source of information support (75.5%). A majority (64.0%) had a low level of knowledge while 31.0% had a moderate level and only 5.0% had a high level of knowledge about vasectomy. A majority of the respondents (78.0%) knew that vasectomy is a permanent method of contraception while only 57.0% knew that vasectomy does not prevent one from getting HIV/STI s. Only 45.5% said that sexual function returns to normal following vasectomy. People had much less knowledge regarding precautions to be taken following vasectomy, since only 37.5% indicated the need for having protected sex for three months following vasectomy. Only 14.0% knew that hematoma is one of the commonest complications of vasectomy and only 12.5% agreed that vasectomy does not cause urinary tract infection. Table 1 General characteristics of 200 married men General characteristics Number Percent Age (years) Mean ± S.D 35.74±6.83 Min Max Duration of Marriage (years) < > Mean ± S.D 13.44±7.04 Min Max 3 35 Level of education No education Primary school Secondary school High school Bachelor degree and higher Occupation Employees(govt./private) Business Labor/farmer/daily wages Family Income (Rupees) < , > 10, Median 6000 Min Max ,000 Number of living children Mean± S.D 2.59± 0.99 Number of desired children Mean± S.D 2.42± 0.86 In regard to beliefs about vasectomy, if the total score was equal to or more than the mean score, it was classified as positive belief, and a score less than the mean score was negative. About 66.0% of the married men had a positive belief about vasectomy, while 34.0% have a negative belief about it (Table 2). A majority (83.0%) believed that vasectomy is a safe and effective family planning method which brings about economic stability in the family by limiting births. More than three fourths of the respondents 10

4 disagreed that contraception is only the wife s responsibility. More than half of the respondents believed that vasectomy has nothing to do with loss of self confidence and masculinity. About half of the respondents believed that vasectomy makes one weak and impotent. Only 38.0% believed that one can still have an orgasm after vasectomy. Table 2 Level of belief about vasectomy of 200 married men Level of belief about Number Percent vasectomy Negative Positive Mean± S.D 18.38± 2.67 Min Max In this study, a question regarding the intention to undergo vasectomy after having the desired number of children was asked. If the answer was yes, it meant the respondent had the intention. A major portion of the respondents (61.0%) did not have an intention to accept vasectomy while 39.0% had the intention to accept it (Table 3). Table 3 Intention to accept a vasectomy among 200 married men Intention for vasectomy Number Percent Yes No A majority (66.5%) of the married men said that their wives are the main person helping them make a decision about vasectomy, while 14.5% said that the decision to have a vasectomy or not is solely their own and 8.0% said that friends who have undergone vasectomy would be the key person in helping them make the decision to accept vasectomy or not. In order to find the factors that influence the intention to accept vasectomy, backward logistic regression was applied. The factors that were significant using Chi square were chosen for backward logistic regression. It was found that the age of the respondent was associated with the intention to accept vasectomy (OR 6.77, 95% CI: ). Beliefs about vasectomy were also found to be associated with intention to accept vasectomy (OR 5.37, 95% CI: ). Emotional and material support from parents were associated with intention to accept vasectomy (OR 4.89, 95% CI: ) and (OR 15.46, 95% CI: ) respectively. Appraisal support from health personnel was also significantly associated with the intention to accept vasectomy (OR 9.34, 95% CI: ) (Table 4). Table 4 Logistic regression prediction of factors influencing intention to accept vasectomy Predictor variables B S.E. p value OR 95%CI Lower Upper 1. Age (years) a 2. Belief about vasectomy Positive Negative a 3.Emotional support from parents Moderate Poor a 4. Appraisal support from health personnel Good < Moderate Poor a 5. Material support from parents Good Poor a a Reference group DISCUSSION In this study, the major portion of the respondents (61.0%) did not have the intention to accept vasectomy while only 39.0% had the intention to accept it. Among those who did not have the intention to accept vasectomy, more than half of the respondents gave their wife s disapproval as the major reason. As men are the main source of income in the Nepali society, if they undergo operation, they would have to rest for a few days, and longer if complications arise, during which period their family will be deprived of food. The wives wanted to do tubal ligation instead, as they could stay home and rest unlike their husbands who had to work and earn a living for the family. A study conducted in Nepal 7 had similar findings. Similarly, a study conducted in India also found out that 34.4% of the married men did not undergo sterilization as their wives opposed it, as they believed that the husband, being the main bread earner for the family, might become bedridden following sterilization 4. The success of the temporary method was indicated as a deciding factor by one fourth of those who did not intend to choose vasectomy. A study conducted by Indralal De Silva W 8 also found out that one of the main reasons for increased acceptance of sterilization among couples is the failure of temporary methods which means that if 11

5 available temporary methods work well, couples usually do not opt for permanent methods. In Hinduism, a son should perform the religious rituals at death and death anniversaries of parents. Thus, the need to have at least one son was indicated by 7.4% of the respondents who did not have intention for vasectomy 10. The uncertainty of the lives of their children was indicated by some. Dibaba A 11 in his study in Ethiopia found that one of the reasons for opposing vasectomy was because of the possible loss of children due to death. Schuler SR et al, 12 in his study also had a similar finding. Infant mortality in Nepal is still high, 64.4 per 1000 live births (2005), so fear of losing their children does play a role in not choosing a permanent method like vasectomy. Cultural and religious beliefs have deep roots in the Nepali society. In Hinduism, the castrated goat Khasi (in Nepali) cannot be sacrificed to God during Puja (religious rituals). Some of the respondents said I will be like a castrated goat if I undergo vasectomy, my religious rituals and offerings will not work as I will not be whole 9. This was a very interesting finding of this study. Although Hinduism does not prohibit the practice of contraception, some animistic beliefs still seem to have an effect on practicing contraception. Some other reasons like I want to die as a goat, not a castrated goat, it s a shame also came up. The study conducted in Ghana also showed that 39.0% of the people related vasectomy with castration and considered it to be a shameful procedure 12. Some 5.7% in Nepal said that vasectomy decreases the force of ejaculation and causes impotency. Sturley A 9, and the AQUIRE project 13, have also indicated similar findings. Health problems like increase in backache and decreases in eyesight following vasectomy also came up. The study conducted in rural Nepal by Sturley A 9, supports these findings. Both these findings seemed to be related to one misconception where they said that They cut a nasa (nerve in Nepali) in vasectomy and this nasa also goes to back and eyes, so one will get backache and have decrease in eyesight slowly. There is no specific word for vas deferens in Nepali. It is called as sukrakit jane nali meaning a way for spermatozoa or nasa. Very few referred to vas deferens the former way and most of them called it nasa. It was found that they referred to a tube like structure as nasa,.i.e.. both nerve and vas deferens were called nasa. Thus, this seemed to have created the misconception of a nerve being cut during vasectomy and the occurrences of backache and impaired vision being the result of it. Stopping child birth brings about bad luck was indicated as a reason by some respondents, as a result of which existing children die. One of them said My uncle under went vasectomy and few days after that his son died, since then we don t even utter that word in the family. Thus people tend to correlate such co incidences of life with vasectomy which makes it difficult for people to choose to accept it. Medical diseases like high blood pressure and diabetes including parents fear of surgery were indicated by some as reasons for non acceptance or rejection of the procedure. Some respondents said that friends who have undergone vasectomy would be the key persons in helping them make the decision as they would share their first hand experience about the vasectomy, which would strongly influence the other person about whether to accept vasectomy or not. Lynam P et al 14 in her study in Nairobi also found that 38.0% of the people said that they learnt about vasectomy from their friends who had undergone vasectomy. Very few indicated medical personnel, parents, vasectomy counselors and friends as key persons in helping them to make a decision about vasectomy. Some of the respondents said that most of the counselors were women and they found it awkward to ask questions regarding sexuality and sexual problems that might arise after vasectomy. They said It s no use going and listening only, I should feel free to ask questions which is very difficult with a women counselor. I would rather talk to my friend who has undergone vasectomy as he will give me the first hand information and share his experience. She would just be transferring her bookish knowledge which I can get from books too. This study also found a significant association between age of respondents and intention to accept vasectomy, with the younger respondents being more likely to undergo vasectomy. With an increase in age, the intention to accept vasectomy tends to decrease. A study conducted by Banerjee B 15 in an urban community in West Bengal also revealed that acceptance tends to decrease with age; peak age of acceptance was years. The young men who live in the study site have easy access to information. They tend to be more highly educated than those who are old, and to have steady jobs and a stable family life. Emotional and material support from parents were associated with the intention to accept vasectomy. Tekhre Y L 16 in his study also indicated that the wife was the source of information about vasectomy among one fourth of the respondents. Similarly appraisal support from health personnel was also associated with the intention to accept vasectomy. Since the majority of the respondents were the main source of income in the family, they relied on emotional and material aid from their parents in times of need. In the Nepali context, parents show their greed to be grandparents as early 12

6 as possible and insist on having a grandson and do not allow the couple to practice contraception until they get one 7. Thus parents, as social supports, act as great driving forces for accepting any behavior change Kelsey KS et al 17. Health personnel play an important role in provision of information that is useful for self evaluation, feedback and social comparison. A significant association was found between belief about vasectomy and intention to accept it. A majority of the respondents thought that vasectomy is a safe and effective method and that it brings economic stability in the family while half of the respondents believed that vasectomy causes impotency and weakness. One fourth thought that vasectomy will affect their masculinity. More than three fourths disagreed that contraception is the wife s responsibility. This is probably due to slowly changing opportunities for women through education, employment and political efforts, with positive repercussions for their reproductive health decision powers. Thus it can be seen that men s decisions on choosing vasectomy or not are strongly guided by their cultural beliefs and beliefs regarding the consequences that might arise after adopting it. Rashid GA 18 also found the negative belief about vasectomy acts as a barrier in accepting vasectomy as a method of contraception, such as impotency, religious objection and physical weakness. The current study should be interpreted in light of some limitations. This is basically because the study area is just one of the semi urban areas of Kathmandu valley and hence the results from this study cannot be generalized to the entire population. Despite the limitation, the result does shed light on the factors affecting intention to accept vasectomy among married men in Nepal and association between those factors. The intention to accept vasectomy among married men in Kathmandu is very low in spite of the government s effort to provide the service for free and the introduction of cash incentives. A wife s disapproval came out as the major factor influencing men s intention not to accept vasectomy. In addition, various cultural beliefs and misconceptions, which are still deeply rooted in the Nepali society, immensely affect the intention to accept vasectomy. Age of respondents, belief about vasectomy, emotional and material support from parents and appraisal support from health personnel were identified as the predictors of intention to accept vasectomy. To encourage the men in having an intention to accept vasectomy, an adopter s forum should be established for advocacy and removal of myths and misconceptions about vasectomy. A couple counseling system has to be introduced as wife s disapproval was found as the main reason for not adopting vasectomy. If wives know the simplicity of the vasectomy procedure, it will help them to motivate the husbands to get one. ACKNOWLEDGEMENTS The authors would like to express gratitude to all the respondents for sparing their precious time responding to the interview. REFERENCES 1. Sankhayan PL, Gurung N, Sitaula BK, Hofstad O. Bio economic modeling of land use and forest degradation at Watershed Level in Nepal. Agriculture, Ecosystem and Environment 2003; 94: Annual Report. His Majesty s Government of Nepal, Ministry of Health, Department of Health Services, William RF. Vasectomy Offers Many Advantages. Network, Dutta M, Kapilashrami MC, Tiwari VK. Knowledge, Awareness and extent of male participation in key areas of reproductive and child health in an urban slum of Delhi. Health and Population Perspectives and Issues 2004; 27: Nie Y, Guo XK, Gao WY, Zhang Y, Li WL, Cheng QX et al. A survey of the long term incidence rate of benign prostate hyperplasia after vasectomy. Zhonghua Yi Xue Za Zhi. China, Soonthorndhada A. The Effect of informal communication on vasectomy Practice in Rural Areas of Thailand. Institute for Population and Research, Mahidol University, 1987: Dahal GP. Contraceptive behavior among men in Nepal, Annual conference of BSPS Leicester, Indralal De Silva W. Do fertility intentions and behaviour influence sterilization in Sri Lanka? Asia Pacific Population Journal 1992; 7: Sturley A. Mapping the effects of vasectomy, PLA notes 37: Sexual and Reproductive Health, FPA Factsheet. Sexual Health Direct, Dibaba A. Rural men and their attitude towards vasectomy as means of contraception in Ethiopia. Tropical Doctor 2001; 2: Schuler SR. Family planning in Nepal from users and nonusers perspectives. Studies in Family Planning 1986; 26: The ACQUIRE Project. Get a permanent smile Increasing awareness of, access to, and utilization of vasectomy services in Ghana.New York; Engender Health / The Acquire Project, Lynam P, Dwyer J, Wilkinson D, Landry E. Vasectomy in Kenya : The First Steps. AVSC Working Paper,

7 15.Banerjee B. Socioeconomic and cultural determinants on acceptance of permanent methods of contraception. The Journal of Family Welfare 2004; 50: Tekhre YL. Assessment of contraceptive acceptance among males in district in Kullu, Himalchal Pradesh. Department of Social Sciences, Kelsey KS, Kirkley BG, De Vellis RF, Earp JA, Ammerman AS, Keyserling TC et al. Social support as a predictor for dietary change in low income population. Health Education Research 1996; 11: Rashid GA. Factors affecting acceptance of vasectomy among married men in new satellite town Sargodha, Pakistan. Master in Public Health, Mahidol University,