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ORIGINAL ARTICLE
Year : 2019  |  Volume : 63  |  Issue : 1  |  Page : 10-14  

Barriers for low acceptance of no scalpel vasectomy among slum dwellers of Lucknow City


1 Junior Resident, Department of Community Medicine and Public Health, King George's Medical University, Lucknow, Uttar Pradesh, India
2 Professor and Head, Department of Community Medicine and Public Health, King George's Medical University, Lucknow, Uttar Pradesh, India
3 Professor, Department of Community Medicine and Public Health, King George's Medical University, Lucknow, Uttar Pradesh, India

Date of Web Publication12-Mar-2019

Correspondence Address:
Dr. Shazia Shafi
Department of Community Medicine and Public Health, King Georges' Medical University, Lucknow, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijph.IJPH_44_18

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   Abstract 


Background: Uttar Pradesh is the most populated state of the country having population of 199.581 million and total fertility rate of 3.3 (annual health survey [AHS] 2012–2013) with high fertile trajectory. Currently, female sterilization accounts for about 18.4% and male sterilization for 0.3% of all sterilizations in Uttar Pradesh (AHS 2012–2013). A strategy to promote men's involvement in effective birth control is needed to reduce the population growth. Since no scalpel vasectomy (NSV) is an easy method but still not being utilized; hence, the purpose of this research is to ascertain various factors of nonutilization of NSV. Objectives: The objective of the study is (i) to determine the barriers among married males for adopting NSV as a method of family planning, (ii) to determine the awareness about NSV, (iii) to suggest measures to increase uptake of NSV by the people. Methods: A cross-sectional study was carried out. A two-staged multistage random sampling technique was used. Lucknow is divided into eight Nagar Nigam zones. In the first stage, two urban slums from each geographical zone were selected randomly. In the second stage, from each selected slum a sample of 24 eligible households was selected at random to achieve the desired sample size. Results: It was observed that among the study participants maximum 89.2% perceived Sociocultural barriers, while 0.6% of the participants perceived service delivery barriers. However, 14% of the participants also perceived procedure-related barriers as the most important cause for not accepting NSV. Conclusion: Measures should be taken to remove these barriers, and increase uptake of NSV.

Keywords: Barriers, no scalpel vasectomy, urban slums


How to cite this article:
Shafi S, Mohan U, Singh SK. Barriers for low acceptance of no scalpel vasectomy among slum dwellers of Lucknow City. Indian J Public Health 2019;63:10-4

How to cite this URL:
Shafi S, Mohan U, Singh SK. Barriers for low acceptance of no scalpel vasectomy among slum dwellers of Lucknow City. Indian J Public Health [serial online] 2019 [cited 2019 May 23];63:10-4. Available from: http://www.ijph.in/text.asp?2019/63/1/10/253894




   Introduction Top


Uttar Pradesh is the most populated state of the country with a population of about 199.581 million.[1] Having a total fertility rate of 3.3 (annual health survey [AHS] 2012–2013),[2] the state continues to be on a very high fertile trajectory. Whatever family planning (FP) services are being in effect are utilized by women and very little by men. According to NFHS-4,[3] female sterilization is utilized by about 35.7% of women while male sterilization is utilized by only 0.3% of males. Currently, female sterilization accounts for about (18.4%) and male sterilization for (0.3%) of all sterilizations in Uttar Pradesh (AHS 2012–2013).[2]

No scalpel vasectomy (NSV) is a new sterilization technique that is safe, convenient, and acceptable to males. NSV is a simpler, faster, modified, and sophisticated technique that requires no incision but only a small puncture and no stitches. NSV is less expensive operation than tubectomy in terms of instruments, hospitalization, and doctor's training. Cost wise, the ratio is about 5 vasectomies to one tubal ligation.[4] NSV technique was introduced in India in 1992 to increase male participation in FP.[5] This is an easier and faster procedure and causes minimal damage to tissues. This is a safe and simple procedure that can be performed in low resource settings.[4] Despite being a simple and safe method, NSV seems to have failed to achieve its goal. Kaza et al.[6] in ther study. No scalpel vasectomy – An overview showed that in spite of the fact that vasectomy is safe and highly effective; only (0.1%) are utilizing it as a method of FP in Africa. According to HMIS Report MOHFW (2014–2015),[7] condom was the most preferred method, and sterilization was the least adopted method among the FP acceptors in India, comprising about just (14.0%). In 2014–2015, total 4,127,485 couples underwent sterilization, out of which (97.9%) were tubectomy and only (2.1%) were vasectomy.

There are many barriers at the provider, facility and program levels for the adoption of NSV by people. A strategy to promote men's involvement in effective birth control is needed to reduce the population growth and to ameliorate the resultant health, social, and economic challenges. Men's participation in issues related to reproductive health especially FP is a promising strategy for addressing some of these reproductive health problems.[8] Furthermore, there is a dearth of information on the awareness and intention to adopt vasectomy. Since NSV is an easy method but still not being utilized, hence the first objective of this research is to determine the barriers among married males for adopting NSV as a method of FP. The second objective is to determine knowledge about NSV and to suggest measures for its uptake.


   Materials and Methods Top


Study design

A community-based cross-sectional study was conducted in the urban slums of Lucknow city. The period of study was 1 year from October 2016 to September 2017.

Study subjects

Married males living with their wife aged 15–45 years who had agreed for interview and had been living in the slums of Lucknow for at least 6 months. These married males were having at least two children with the younger child being greater than 1 year of age.

A study participants who were nonresponsive and those who were divorced/separated from their spouse were excluded from the study.

Sampling and data collection procedure

It is observed from the previous studies done that the proportion of people having knowledge about vasectomy is 50% and taking an absolute precision of 5%, the sample size was calculated to be 384 N = (Z1-α/2)2 * p * (1-P)/d 2.

  • n=sample size
  • Z=value of Z statistic at α level of significance
  • P=prevalence
  • d= precision of estimate.[9]


A two-staged multistage random sampling technique was used. Lucknow is divided into eight Nagar-Nigam zones containing around 700 slums. Out of each Nagar-Nigam zones in Lucknow, two urban slums were selected randomly from each zone in the first stage. In the second stage in each selected slum, all the households were visited until 24 married males were selected by simple random sampling based on inclusion and exclusion criteria. The married males were contacted by the investigator during the visits to the urban slums and an attempt was made to convince all the married males fulfilling inclusion criteria to participate in the study after informing them about the aims, objectives and likely benefits which would accrue from the study. Data were collected using a pre-designed and pre-tested interview schedule and a total of 384 cases fulfilling the inclusion and exclusion criteria were enrolled for the study. Information was collected regarding biosocial characteristics, knowledge of NSV, the barriers associated with low acceptance of NSV.

Statistical analysis

Data were analyzed using IBM SPSS Statistics for Windows Version 22.0. (Armonk, NY: IBM Corp). Chi-square test was used to show the relation between independent and dependent variables. The level of significance was set at <0.05. Multivariate logistic regression analysis was done for the dependent variable namely sociocultural Barriers and for the independent variables which were found significant in Chi-square analysis.

Ethical consideration

Owing to ethical considerations, permission was obtained from the Institutional Ethical Committee of the King George's Medical University U.P, Lucknow, before commencing the study. Written informed consent was taken from each selected participant to confirm willingness. Honest explanation of the survey purpose, description of the benefits and an offer to answer all enquires was made to the respondents and affirmation that they were free to withdraw consent and to discontinue participation at any point of time during the study. Privacy and confidentiality of collected information were ensured throughout the process. Data were collected in a way that makes it possible or at least very hard to identify the respondent.

Appropriate health education was given to the respondents. Importance of FP and small family size was emphasized. Advantages of NSV enumerated and an attempt was made to allay their apprehensions regarding use.


   Results Top


Majority (50.3%) of the married males were within the age group of 36–40 years. 83.1% were Hindus; majority (55.7%) belonged to OBC caste. Around majority (29.2%) of the study participants were educated up to high school, (23.7%) were educated up to primary school and (13.5%) were illiterate. Few (15.9%) were educated up to middle school, while (9.1%) were educated up to posthigh school. Majority (34.1%) of the participants were clerical/shop workers/farmers, followed by (28.6%) who were unskilled followed by (20.8%) who were skilled.

Around 62.5% of the study participants were of upper lower socioeconomic status followed by 35.4% of the study participants who were of lower middle socioeconomic group. About 1.8% of the participants were of upper middle group.

The intention of the respondents to adopt NSV in future was observed. Majority (89.3%) of the respondents were not ready to adopt NSV in future while only (9.1%) were actually ready to adopt. Thus, of 384 participants, 343 (89.3%) participants were not ready to adopt NSV in future.

Regarding distribution of barriers, it was observed that among the 343 study participants maximum (89.2%), that is, 306, mentioned the sociocultural barriers as the most important cause for low acceptance for NSV, while minimum (0.6%) of the participants perceived service delivery barriers as the most important cause for low acceptance of NSV.

Majority of the study participants perceived sociocultural barriers as one of the most important causes for low acceptance of NSV. Within the sociocultural barriers majority (35.9%) perceived that NSV diminishes the ability to perform manual work, while 35% also personally believed that due to the availability of other FP methods NSV is less needed. Among the study participants, who perceived procedure-related barriers, 12.5% stated the risk of surgery as a cause related to low acceptance of NSV [Table 1].
Table 1: Barriers for low adoption of no scalpel vasectomy n=343

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Majority (83.6%) of the study participants knew that NSV is a permanent method. Only 32% of the study participants had correct knowledge regarding the outpatient department (OPD) visits required for NSV. About 45.1% believed that NSV requires prolonged bed rest while about 42.2% believed that NSV causes adverse effects to health. Only 54.2% had the knowledge that NSV is charged free [Figure 1].
Figure 1: Knowledge about no scalpel vasectomy.

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Among the biosocial characteristics educational status (study participants), having male children and age at marriage were found to be associated with sociocultural barriers and this association was found to be statistically significant [Table 2].
Table 2: Relation of sociocultural barriers with biosocial characteristics of subjects

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The relation of procedure and service delivery barriers with knowledge of NSV was also accessed. It was observed that among the total study participants who perceived procedure and service delivery barriers majority (76.5%) knew the term “Nasbandi” and this association was found to be statistically significant while among the total participants who had correct knowledge regarding one OPD visit only (24.5%) of the study participants perceived procedure and service delivery barrier and this association was found to be statistically significant.

Multivariate regression analysis was done, and it was observed that educational status, knowing the term “Nasbandi,” and having correct knowledge of OPD visits were found to be predictors for sociocultural barriers, and they were significant in univariate analysis. However, on multivariate analysis, only educational status was found to be a significant predictor for perceiving sociocultural barriers. Thus, in comparison to illiterates, those who were educated up to middle school and primary schools were having less chances of perceiving sociocultural barriers [Table 3].
Table 3: Predictors for sociocultural barriers

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   Discussion Top


In the present study, only 1.6% of the total study participants had actually undergone NSV. Almost all the respondents were aware of NSV as an FP method. It is further important to highlight the fact that only 9.1% of the male respondents approved NSV as a possible option of FP for them. This highlights the fact that there is large gap in their knowledge about the advantages of vasectomy which contribute to their reluctance to undergo vasectomy. Similar findings were observed in the study by Bunce et al.,[10] which showed that male sterilization was done by about 1.0% of respondents. Afari et al., (2015),[11] in their study showed that the number of respondents who were actually practicing NSV was around 1% only. Thus, this is concluded that vasectomy including NSV is the least adopted FP method.

Majority (89.3%) of the study participants perceived sociocultural barriers as the most important cause for low acceptance of NSV. Among the sociocultural barriers, 35.9% of the study participants believed that NSV diminishes the ability to perform manual work, while 35% had their personal beliefs that due to the availability of other methods of FP, the uptake of NSV is less. Similar findings were observed in a study done by Dasgupta et al., (2015),[9] which showed that 22% participants believed on “personal beliefs” of the individual as an important factor for low utilization of NSV. The fear of surgical procedure was cited as the most frequent cause (12.5% among procedure-related barriers) for unwillingness to accept NSV. Many advantages of NSV including no incision, no stitches, and minimal pain were known to only 20.6% of the study participants. The requirement of prolonged bed rest after vasectomy was another important reason cited by the respondents for their reluctance to adopt NSV. This is highlighted by the fact that about 54.9% respondents were lacking the clear concept that NSV does not require prolonged bed rest. This aspect is likely to be important for the people who work on the basis of daily wages. Majority of the study participants were having unsatisfactory knowledge regarding NSV. Similar findings were observed in a study done in Uttar Pradesh by “State Innovation in Family Planning Services Project Agency” (2014),[12] which showed that about 14% of the study participants believed that NSV leads to decrease in physical strength and causes weakness. It was observed in the present study that the majority of the study participants were having unsatisfactory knowledge regarding NSV. Educational status of the respondent was found to be the most important predictor for perceiving sociocultural barriers.

Promotional activities for NSV should focus on bridging the prevailing knowledge gap regarding NSV among the potential clients. A client satisfied with NSV may prove instrumental in convincing other persons to opt for NSV. This has been very aptly narrated by Dr. R. C. M. Kaza, NSV Master Trainer to the Government of India as follows: “NSV is as much an IEC operation as a surgical operation.”[13] Propagating positive stories and examples of successful NSV cases through the influential media of television is likely to improve the acceptability of NSV among the masses. There is a need to design and develop a need-based IEC strategy to bridge the existing information gap among the eligible couples regarding NSV to improve its adoption. The involvement of community leaders and satisfied clients in the promotional activities and utilization of television and radio would enhance the effectiveness of such interventions.

Strengths of this study are that first, it is a community-based study. Second, the perception of married males regarding NSV has been explored, and an attempt has been made to discover the real challenges behind the acceptance of NSV. The privacy was maintained while interviewing the respondents.

Acknowledgment

We would like to thank State Innovation in Family Planning Services Project Agency for their guidance, and all the male participants who were interviewed for their patience and cooperation.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Government of India. Census 2011, Provisional Population Report. Office of the Registrar General and Census Commissioner India, Ministry of Home Affairs; 31 March, 2011; 2012.  Back to cited text no. 1
    
2.
Annual Health Survey: Family Planning [Fact sheet] (2012-2013).  Back to cited text no. 2
    
3.
National Family Health Survey-4: Family Planning [Fact Sheet] (2015-2016). National Family Health Survey; 2015-2016.  Back to cited text no. 3
    
4.
Park K. Park's Textbook of Preventive and Social Medicine. 22nd ed. India: M/s Banarsidas Bhanot; 2013. p. 470.  Back to cited text no. 4
    
5.
Kumar V, Kaza RM, Singh I, Singhal S, Kumaran V. An evaluation of the no-scalpel vasectomy technique. BJU Int 1999;83:283-4.  Back to cited text no. 5
    
6.
Kaza RC. No scalpel vasectomy – An overview. J Indian Med Assoc 2006;104:129-41.  Back to cited text no. 6
    
7.
Shattuck D, Wesson J, Nsengiyumva T, Kagabo L, Bristow H, Zan T, et al. Who chooses vasectomy in Rwanda? Survey data from couples who chose vasectomy, 2010-2012. Contraception 2014;89:564-71.  Back to cited text no. 7
    
8.
Ministry of Health and Family Welfare. Annual Report HMIS Report 2014-2015. Ministry of Health and Family Welfare; 2014-2015.  Back to cited text no. 8
    
9.
Dasgupta A, Das MK, Das S, Shahbabu B, Sarkar K, Sarkar I. Perception towards no scalpel vasectomy (NSV): A community based study among married males in a rural area of West Bengal. Int J Health Sci Res 2015;5:30-6.  Back to cited text no. 9
    
10.
Bunce A, Guest G, Searing H, Frajzyngier V, Riwa P, Kanama J, et al. Factors affecting vasectomy acceptability in Tanzania. Int Fam Plan Perspect 2007;33:13-21.  Back to cited text no. 10
    
11.
Afari EM. Community Perceptions of Male Sterilization as a Birth Control Method in the La Dadekotopon Municipality, Accra (Doctoral Dissertation, University of Ghana); 2015  Back to cited text no. 11
    
12.
State Innovation in Family Planning Services Project Agency”: NSV brochure 2014.  Back to cited text no. 12
    
13.
The ACQUIRE Project. Get a “permanent smile”-Increasing awareness of, access to, and utilization of vasectomy service in Ghana; 2006. Available from: http://www.acquireproject.org/archive/files/5.0com munityengagementmarketingandcommunications/5.2resources/ 5.2.1projectbriefsandworkingpapers/acquireknowledge Ghanafinal.pdf. [Last accessed on 2015 Feb 16].  Back to cited text no. 13
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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