Pakistan Journal of Medical Sciences

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ISSN 1681-715X

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ORIGINAL ARTICLE

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Volume 22

July - September 2006

Number 3


 

Abstract
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Psychosocial Factors and Male Sterilization

Shaista Jabeen1, Shabana Afshan2, Muhammad Amjad Ramzan3, Haroon Rashid Chaudhry4

ABSTRACT

Objective: To study the demographic profile of vasectomy clients and the psychosocial factors motivating them to be sterilized.

Method and sample: One hundred fifty clients attending Reproductive Health Services Center (RHSC) Vasectomy Unit Sir Ganga Ram Hospital, Lahore were interviewed using a specifically constructed interview form. The form was developed on the basis of items generated through Focused Group Discussions (FGDs) with vasectomy clients. The investigators themselves conducted the interviews at Department of Psychiatry, Sir Ganga Ram Hospital, Lahore.

Results: Mean age of the sample was 36.13 years. Out of the total sample 62% were illiterate. Majority of clients were employed temporarily as laborers (i.e. 52.7%) and unskilled workers (i.e.15%). Eighty nine percent of the clients were earning less than Rs. 4000/- per month. Financial reasons were the main motivating factor to go for vasectomy.

About 63% of clients reported that they had never tried any other contraceptives. Twenty seven percent reported a history of extra marital or premarital sexual relationships. Sixty one clients were involved in drugs and out of them 57% had no specific hobby and would spend their leisure time at home.

Conclusion: The results indicate that majority of the sample belongs to low socio-economic class. They were mostly illiterate, employed as laborers or unskilled workers. Economical constraints came out as the basic motivating factor for decision of male sterilization.

KEY WORDS: Focused Group Discussion (FGD), Vasectomy, Psychosocial Factors, Male Sterilization, Birth Control, Contraception.

Pak J Med Sci July - September 2006 Vol. 22 No. 3 277-281


1. Shaista Jabeen M.Sc, ADCP
Senior Clinical Psychologist

2. Shabana Afshan M.Sc
Observer Psychologist

3. Dr. Muhammad Amjad Ramzan MBBS
Medical Officer,
Reproductive Health Services Center,
Vasectomy Unit, Sir Ganga Ram Hospital,
Lahore.

4. Prof. Haroon Rashid Chaudhry MRCPsych
Head of Department
1,2&4: Department of Psychiatry,
Sir Ganga Ram Hospital,
Lahore.

Correspondence:
Prof. Haroon Rasheed Chaudhry
E-Mail: pprc@wol.net.pk

* Received for Publication: July 11, 2005

* Revision Accepted: March 26, 2006


INTRODUCTION

Population in Pakistan has multiplied rapidly in last 50 years. In 1951, total population of the country was 33740 thousands which increased up to 132352 thousands in 1998 recording an increase of 57.08% during last 17 years i.e. (1981-1998). There is four times increase in population of the country over 47 years i.e. from 1951 to 1998.1 Population of Pakistan is 2% of world population and it has highest rate of population growth around 3% per annum which is quite higher than the overall average growth rate of other developing countries.2

Sterilization for contraception can be performed on man or woman. In the past emphasis was mostly on female contraceptives. As research findings indicate that almost 95% females had accepted contraception. The ratio of male to female sterilization acceptors has been strikingly unbalanced.3 With research and activities focusing male role in family planning men are becoming increasingly involved. Vasectomy or male sterilization is one of the available male contraceptives.4

Vasectomy is a permanent birth control measure for men. It is a surgical operation that causes sterility. It blocks the vas deferens and keeps sperms out of the seminal fluid. It is one of the safest and effective family planning methods.5

Vasectomy has been in practice for years to serve various purposes e.g. to prevent pregnancies, for rejuvenation, to improve virility, libido, general health and moods. Vasectomy was performed in some parts of the world to prevent children being born of criminals and mentally deranged persons, where laws existed to that effect.6

According to the world contraceptive use survey of United Nations Population Division 2001, 18% of men in the UK are reported to have undergone the procedure. This has made UK a joint world leader along with New Zealand where similar ratio of vasectomy has been reported.7 In a survey report of married women, vasectomy is widely used in South Korea, China, Nepal and India i.e. 12%, 10% 5% and 4% respectively.8 Prevalence of vasectomy has been reported as 16% in Canada, 13% in U.S and 11% in Netherlands. While in Bangladesh it is reported as 1.1% and in Sri Lanka as 4.9%.9

Though the ratio of females seeking sterilization at Sir Ganga Ram hospital is greater than males opting for vasectomy (i.e 3.02 to 2.6), local statistics shows that the number of cases of male sterilization in the province of Punjab in the last few years is also quite encouraging. The total number of vasectomies performed at various hospitals in Lahore as well as six other outreach centers located at Sheikhpura, Gujranwala, Okara, Gujrat, Mandi Bahauddin and Kasur in 2001 were 678 which increased to 1711 in the Year 2004. Local data regarding menís reproductive health is quite limited. Present study was undertaken to examine profile of vasectomy clients and compare it with other countries. The study was designed to examine:

* The demographic characteristics of vasectomy clients

* Reasons to chose vasectomy as a contraceptive

* Factors leading to decision of vasectomy

* The involvement of the clients in drugs

* The extra marital sexual relationships and

* Religious inclinations of the clients

The findings will help us make recommendations for agencies involved in the family planning reproductive health services and set future directions to improve, promote and extend the program do further research.

SUBJECTS AND METHOD

One hundred fifty male clients of Reproductive Health Services Center, Vasectomy Unit, Sir Ganga Ram Hospital Lahore were studied from June to August 2004. They were interviewed on the day of operation before surgery.

Setting: Clients were taken from RHSC Vasectomy Unit and they were individually interviewed in a peaceful room at Department of Psychiatry, Sir Ganga Ram Hospital, Lahore. Consent form was signed by all the clients. The form was read out for illiterate clients before taking their signatures or thumb impressions.

Assessment Measure: To exhaust the relevant items for construction of interview form to be used in the main study two sessions of Focused Group Discussions (FGDs) with vasectomy clients were conducted by the investigators. Each session comprised of 12 clients. Clients were encouraged to talk about their concerns and problems regarding reproductive health. The discussions were recorded by the investigators and later based upon the material of FGD, a questionnaire was made. The questionnaire enquires about demographic variables, factors which motivated and influenced the clients to chose vasectomy as a contraceptive, apprehensions about the procedure and after effects of having sterilization, sexual and drug history, religious inclination of the clients, use of their leisure time and their feelings about having vasectomy. Descriptive statistics through SPSS 10 was used to analyze the data.

RESULTS

One hundred and fifty men were studied. They belonged to various parts of Pakistan predominantly Lahore (33%). All were married. One forty six clients (97%) were Muslims. Age range was 20-55 years with mean of 36.13 SD 6.4. Most of the clients 84 (56%) falls between 25-35 years of age. Mean age of wives was 31 years SD 5.5. Average duration of marriage was 13.27 years. Average number of children was 3.91 SD 1.42. All men were father of at least one boy (mean No. of boys 2.3 and mean No. of girls 1.5). Ninety three clients (62%) were illiterate while only 6 (4%) has passed secondary school examination. Out of the total sample 106 (67%) clients were laborers and unskilled workers. Monthly income of 131 (89%) was < Rs. 4000/-. About one third of the sample (63%) opted vasectomy for financial reasons. Other reasons included limiting the family size and financial constraints 20%, wifeís health problems 5% and failure of other contraceptive measures 3%. One hundred and fourteen clients (76%) wanted to motivate others for vasectomy but 41% out of those respondents replied in negative when asked about sharing their experience of vasectomy with others. Majority of the sample 90 respondents (60%) wanted to work as "satisfied clients" and majority (80%) intended to do so for having a source of income.

Many of the clients i.e.57 (38%) had never used other contraceptives as a couple. Out of non users lack of knowledge and carelessness was reported in 40 (42%) and 39 (41%) clients respectively. Only 14% reported financial reasons for not using other contraceptives. Amongst contraceptive users 31 clients (53%) used condoms. No problem was reported by 31 (56%) clients while 24% reported pregnancy of the partner.

Sixty one clients (41%) had history of using illicit drugs of which 13 (21%) were using cannabis while 44% were using multiple drugs and remaining 41% were using various drugs or injections. Thirty nine clients (26%) didnít consult their wives for sterilization. On further analysis 36% reported pre/extra marital relationship. Overall 27% had history of extra/pre marital sexual relationships. Seventy nine percent clients were comfortable with their decision of vasectomy. One hundred and thirty (85%) of clients reported to practice religion casually or less than that.

DISCUSSION

Demographic profile of respondents:
Mean age of the sample 36.13 years is quite similar to the findings of other studies done outside Pakistan but in contrast to local findings in which mean age of the sample was 42 years.
8-10 This shows that people now turning to vasectomy at a younger age as compared to past. Mean number of children was found to be 3.91(approximately 4), while 9% clients had no girl and there was none who was without a boy. So the possibility of increasing the family in the hope of having a son in some cases can not be ruled out. There is a diversity in findings of various studies regarding number of children of vasectomy clients. In Bangladesh, Mexico and USA average number of children has been reported as three while in Kenya and Rwanda the number is six.9 Although our findings show a decrease of 1.83 in mean No. of children as compared to previous study10 of vasectomy clients the target of a small family (consisted of maximum 3 children) of Family Planning Association Pakistan is still to be achieved.

Nearly two third of our sample was illiterate while on the other hand more than twenty years back illiteracy rate of Lahore based vasectomised sample was found as 14%.10 In spite of literacy rate going up from 35.05 in 1981 to 54.81 in 1998 for male population of Pakistan majority of our sample was illiterate.1,11 Contrary to the findings of Landry and Ward9 education level of wives was found higher at all levels with exception for middle (8th grade) in the present study. Consistent with our findings of illiterate and less educated people we found that more than two third (67%) clients were working as labourers or unskilled workers. Majority of clients were earning less than or up to rupees four thousand per month. This means taking care of a family of about 6 members including husband wife and about four children.

Psychosocial factors: More than half of the sample opted vasectomy because of financial reasons and only 11% did so for limiting the family. So possibility of having a larger family if clients were financially strong can not be ruled out. Our data confirms findings of economic reasons leading to decision of vasectomy from previous studies done in Sri Lanka and Bangladesh.9 This reveals that the need to create an awareness about the value of sterilization to have a tension free healthy sexual relationship for a happy married life is still there. Nearly two third of our sample wanted to work as satisfied clients. Out of them a fairly high majority (79%) intended to do it for supplementing their income highlights the importance of monetary reasons as a key factor to motivate men for vasectomy.

Though the Government of Pakistan like many other countries has asked their clients to recommend the procedure to their relatives and friends, figures strongly indicate that economic reasons for vasectomy acceptance can not be ignored. Economic factors and monetary incentives being the strongest motivating force for vasectomy raise another concern. These people may not have given a serious thought to other options of contraception and consequences of vasectomy before going for sterilization. This may result in disappointment after the surgery.

Two third of the sample had never used any other contraceptives as a couple, which is quite alarming and needs serious attention of the concerned departments. Many of non users 42% didnít use because of carelessness. Contrary to this previous data regarding Pakistan shows increasingly higher figures for knowledge of contraceptives among men and women. There were 61% and 85% men in 1980 and 1996 respectively who reported to have such knowledge. A survey findings of Department of Economic and Social Information and Policy Analysis Population Division of United Nations indicate that 78% Pakistani married women had knowledge about contraceptives in 1991.10-12 This points to the indifference of the clients who are most likely not serious about birth control and came for sterilization when approached. This also corresponds to the finding that majority of the sample was having vasectomy for monetary reasons and intended to work later as satisfied clients. Among users contraceptive condoms were the most commonly used mehthod i.e. 53%. More frequent use of condoms was reported by people with history of sexual relationship outside marriage which is more than quarter of the total sample. This is in keeping with earlier reports of condom use in various countries by 15% to 30% of men who were not married.12

More than half (57%) of the sample had some acquaintance or relationship with vasectomized person. This strengthens the idea of personal contact to make up of mind for vasectomy. This might be the case for other contraceptives as well. A large number of clients motivated through vasectomy campaign (i.e. 41%) and friends (i.e. 38%) further confirms the key role of personal contact of motivators in promoting vasectomy. This is also the case in other countries like Tanzania, Kenya where ratio of clients of vasectomy increased after they were provided with adequate information by related personnel.8,13 The role of media has however proved to be quite limited in present study and needs a serious consideration. A substantial increase in the requests for information for vasectomy was noticed after a media campaign aired on television in Tanzania, Kenya in 1994. The number of vasectomies in six months after a media campaign increased by 125% in Nairobi.14,15

A striking finding of this study is that many (40%) of our clients have been involved in drugs. This might be due to the focus of vasectomy campaign on a particular section of people. Besides this, potential vasectomy clients who are drug users might be influenced more easily by their fellow drug users who have had their vasectomy done, thus multiplying the number of drug user clients. Interestingly more than half of those who were involved in drugs were found without any hobby or use of leisure time. This confirms the interrelationship of drug and lack of any hobby. This could be an important issue of interest of social scientists for further investigation.

The change in attitude of males in sharing about their decision of vasectomy with their wives has been observed. In our study 76% consulted their wives as compared to 34% in a study done eighteen years ago by Mirza and Bloch.10 A positive role of women in decision of vasectomy has also been reported in other countries.9 Spousal communication across societies and its variation can be understood in terms of different structural and cultural factors in which the couples live. This is interesting to note that hundred percent of those clients who did not consult their wives for vasectomy reported history of pre/extra marital relationships. Over representation of our sample by clients practicing religion casually or rarely points to the need of addressing the issue by religious experts to clarify misunderstandings among people who seriously practice religion.

Although many similar and other psycho- social factors remain to be explored, present study provides us with findings about demographics and unexplored variables relevant to the issue of vasectomy in Pakistan. There is a need to do research on a larger group including clients from out reach centers and private clinics providing reproductive health services to generalize the results. There is also a need of follow-up and longitudinal studies to see the level of satisfaction among users of different contraceptives in the general population and comparing it with other countries.

Program managers and policy makers need to focus their attention to a variety of underrepresented sections of society to motivate men for vasectomy. Besides this other methods of birth control practiced by a limited number of clients because of ignorance and carelessness also need to be taken care of. Role of mass media should be highlighted in future endeavors to contraceptive promotion campaign of Family Planning Association of Pakistan.

ACKNOWLEDGEMENT

Authors wish to thank Ms. Nadia Arshad, Research Associate of Pakistan Medical Research Centre Lahore for her assistance and cooperation.

REFERENCES

1. Population Census Organization Statistics Division, Government of Pakistan. 1998. Census Report of Pakistan. Census publication No.160. Islamabad: Pakistan 2001.

2. Annudin AAR, Farooqui MNI. The state of population in Pakistan. Islamabad: National Institute of Pakistan Studies 1987.

3. Edward SR. The role of men in contraception and decision making: Current knowledge and future implication: Family Perspectives 1994; 26 (2):77-82.

4. Finger WR. Getting more men involved. [Abstract]. Retrieved May 9, 2004, from http//www.plannedparenthood.org/BIRTH-CONTROL/allaboutvas.htm 1992; 13(1):4-6.

5. Brechin S, Bigrigg A. A current obstetrics and gynaecology. [Abstract]. Retrieved March 15, 2004, from http:// www.infoforhealth.org/topics/ male-steril.shtml 2003; 1:38-44.

6. Jhaver PS. Vasectomy papers published by Dr. PS Jhaver. Retrieved January 30, 2004, from http//www. vasectomy-information.com (n.d).

7. Marie Stopes International. Views on vasectomy: The male perspective. Retrieved February 22, 2004, from http//:www.mariestopes .org.uk 2003; 1-6.

8. Drennan M, Robey B. Reproductive health: New perspective on menís participation population reports, series J. Family Population Programs 1998; (46):1-35.

9. Landry E, Ward V. Perspective from couples on vasectomy decision: A six country study. Retrieved Februray 17, 2004, from http//www.who.int//publication beyond acceptability-users-perspective-on-contraceptive/Landery.en.pdf 1992-1995; 58-67.

10. Mirza L, Riaz M, Baluch GN. (Eds) A study of male motivation for family planning. Lahore: Family Planning Association of Pakistan 1987; 78-81.

11. Bhatti MH, Hakim A. Malesí attitudes and motivation for family planning in Pakistan. National Institute of Population Studies, Islamabad 1996; 69-73.

12. Department of Economic and Social Information and Policy Analysis Population Division: Levels and trends of contraceptive use as assessed in 1994. United Nations Publications 1996; 76-80.

13. Munhondwa E, Rutenberg N. Effects of the vasectomy promotion on knowledge, attitudes and behavior among men in Dar- es- Salaam, Tanzania. Nairobi, Kenya Population Council, Africa Operation Research and Technical Assistance Project 1997; 6: 3-16.

14. John Hopkins Population Communication Services. Reaching men worldwide: Lessons learned from family planning and communication projects, 1986-1996. Baltimore, Johns Hopkins School of Public health, Centre for communication Program 1997; (Working paper Series No.31) p 50.

15. Kincaid DA, Merrit AP, Nickerson I, De Castro SB, De Castro MPP, De Castro BM. Impact of a mass media vasectomy campaign in Brazil. International Family Planning Perspectives 1996; 22 (4): 169-75.


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