Results of using a systemic model to introduce vasectomy services in Guatemala

1

• Results of using a systemic model to introduce
  vasectomy services in Guatemala
• Ricardo Vernon
• Frontiers in Reproductive Health Program,
  Population Council
• rvernon_at_popcouncil.org.mx
•  
• Guatemala
• 34.4 of MWFA use a modern method (DHS, 2002)
• Slightly more than one half of these use female
  sterilization.
• Even though vasectomy is just as effective, is
  less expensive and presents fewer risks
• for the user, less than one percent of the
  couples use this method.
• Between 2001 and 2003, the MOH performed only
  43 vasectomies, even though four
• surgeons were trained in 2001. Why is this?
• Traditional model for introducing vasectomy
  services
• Physician is sent to a health unit where a high
  number of vasectomies is performed.
• Trainee performs 5-10 supervised vasectomies.

2

• Systemic model for introducing vasectomy
•  
• In this project we tested a systemic model for
  introducing vasectomy in MOH hospitals and
• maternities. The model had four basic components
  
•  
• Self-selection of health units according to the
  response to an invitation to participate in the
  project
• The development of a counseling and information
  model for potential clients
• Training and sensitizing of health teams
• On-site training of surgeons
•  
• Self-selection of health units according to the
  response to an invitation to
• participate in the project
•  
• We invited 15 hospitals and maternities to
  participate in the project.
• To start training activities, we required that
  they identify at least one man interested in

3

• Development of a counseling and information model
  for potential clients
•  
• We developed three printed materials a poster,
  a leaflet and a brochure.
• We requested vasectomy acceptors to identify and
  inform friends and relatives about
• the method.
• We requested that clients attending health
  facilities are informed about vasectomy
• We asked providers to always offer vasectomy as
  an alternative for all women
• interested in a permanent method.
• We asked providers to always mention vasectomy
  in family planning talks to women
• who just had a birth and in family planning
  counseling sessions.
• Training and sensitizing of health teams
• We conducted one-half day sessions with all the
  staff in the six hospitals /maternities that
• identified at least one vasectomy candidate
• We also conducted these sessions in two or
  three health centers near the hospital, so
• that they functioned as referral centers.
• In the sessions, we explained what a vasectomy
  was and trained them to implement the

4

• On-site training of surgeons
•  
• Surgeon training was carried out in two stages
•  
• One-half day theoretical training
• Supervised practice sessions in their own
  health units with the vasectomy candidates
• identified by their health teams.
• Once the hospital team identified at least
  three candidates for vasectomy, a vasectomy
• trainer visited the hospital and trained the
  surgeon in the service.
• The trainer repeated visits until he reported
  the trainee could provide services without
• supervision and until the trainee reported
  feeling confident to do the vasectomies without
• supervision.

5
Table 1. Average of no-scalpel vasectomies by
place and number of sessions
6
Table 2. Number of no-scalpel vasectomies per
hospital, surgeon, certification time and
sessions before and after certification
7

• Effectiveness of Promotion Strategies
• 68 consulted their wives and 41 said they had
  been the most influential person in
• making the decision
• Health providers were the source of information
  for 31 and the most influential
• source for 9.
• Friends and relatives were a source of
  information for 21 of men and the most
• influential source for 6.
• However, 81 said they knew a vasectomized man.
• 46 said they had made the decision on their own
  without any influence.
• 53 were exposed to the projects brochure and
  poster
• 29 received information from their wives,

8

• Effectiveness of Promotion Strategies (continues)
•  
• The maternity in Zone 19 of Guatemala was the
  most successful unit in generating
• patients.
• Maternity director and nurse auxiliary
  attributed their success to daily family planning
  talks
• for women who had just delivered a baby.
• Health providers highlighted the importance of
  operating on Friday after 1100 a.m.,
• (easier for men to rest/ only one-half day
  off work)

9
Characteristics of the 158 clients that had a
vasectomy during the project
10

• Decision-Making Process
•  
• We asked how long it took them from first
  hearing about vasectomy until they decided to
• get an operation 56 said they less than
  two months, 13 said two months 14 3-6
• months
•  
• 92 discussed with partner whether vasectomy or
  female sterilization was a more
• convenient method.
•  
• 65 chose vasectomy to protect their partners
  health or because a doctor recommended
• it. Significant proportions mentioned
  advantages of vasectomy over female sterilization
• (greater safety, greater effectiveness, quick
  recovery, refusal of wife to have an operation.
•   
•  

11

• Cost Analysis
•  
• The total cost per trained surgeon was 4,335
  dollars or 274 per surgery performed.
•  
• If we do not include the costs of the time of
  the personnel trained (but including the
• time of coordinators, instructors and
  supervisors), the cost per trained surgeon would
• be 2,930 and 185 per vasectomy performed.
•  
• If we take into account the MOHs salary
  structure and the per-diem and travel
• expense scale, the total cost of the project
  would be 29,204 and 17,571 without
• taking into account the time of personnel
  still being trained.
• The projects most expensive component was the
  training of health teams in 30 health
• units (nearly US 20,000). If only the teams
  from the six vasectomy service delivery
• units were trained, these costs would be
  reduced by 80. This component should be
• eliminated.
•  
• The theoretical and practical training of
  surgeons was relatively inexpensive

12

•  Cost Analysis (continues)
•  
• Promotion and information costs were about
  400 per participant center, including time
• used by nurses, as well as IEC materials.
•  
• If the MOH were to replicate the introduction
  strategy, the costs would be lower given
• that the MOHs salary structure and
  per-diem.
•  
• We believe the MOH could replicate training at
  an approximate cost of US 900 per
• surgeon, including post-certification
  follow-up costs and promotion costs, but
  decreasing
• costs related to training health teams in
  nearby health centers.
•  
• These costs would decrease as the number of
  trained surgeons increases and the
• methods popularity rises.