Married Men and Vasectomy: A Focused Group Study in an Urban Community in Ghana

Background

The world’s population has risen from 2.5 to 7.4 billion; this alarming rate has contributed in part to resource depletion, environmental degradation, and social issues (Onasoga, Edoni, & Ekanem, 2013; World Population Data Sheet, 2016). Of all the world continents, Africa’s population is expanding enormously and is said to contribute to almost half of this figure (United Nations Economic Commission for Africa, 2016). Overpopulation has been the trend in Africa and this is not expected to decline even in the next 30 years (World Population Review, 2018). Currently, the population growth rate exceeds by almost 3% per annum in most African countries including Ghana (Ghana National Population Council, 2017; United Nations Economic Commission for Africa, 2016; World Bank, 2018).

Family planning has been deliberated upon and accepted as a means of reducing rapid world population growth (State of the World Population, 2015). In addition, it plays a vital role in the reduction of infant, child, and maternal mortality and morbidity (Onasoga et al., 2013). The benefits of family planning go beyond improvement in maternal and child health as it extends to the individuals, families and country as a whole. These benefits include but are not limited to higher education for girls, better employment and empowerment for higher socioeconomic status, prevention of unwanted pregnancy and related health risks in women, prevention of the dreadful HIV/AIDS, reduction in the high incidence of adolescent pregnancies, and slowing of population growth (Jangu, 2013; Mutombo, Bakibinga, Mukiira, & Kamande, 2014; Suchithra & Sujina, 2016; World Health Organization [WHO], 2018).

There are a wide variety of family planning methods which include short-term, long-term, permanent, and emergency methods (Alireza, Shahriar, & Abdolah, 2017; Ghana Demographic and Health Survey, 2014; Kenya National Bureau of Statistics & ORC Macro, 2010; WHO, 2018) . Some short-term methods include condoms, spermicides, oral contraceptive pills, and natural approaches, while long-term methods include intrauterine device (IUD), implants, and progestin-only injectable. Voluntary surgical contraception, tubal ligation, and vasectomy are some of the permanent forms of family planning, while emergency contraceptives also include oral pill and IUD. These methods are more inclined toward women than men (Hardee, Croce-Galis, & Gay, 2017). The male condom and vasectomy are the only methods available for men who wish to practice family planning (Kols & Lande, 2008; Nordqvist, 2016; Shih, Turok, & Parker, 2014). As noted by the Ghana Demographic and Health Survey (2015), currently more than one fourth of married women (27%) are using some method of contraception. Twenty-two percent use a modern form of contraception with the remaining 5% using traditional methods of contraception. Furthermore, it was recorded that 45% of unmarried women are currently using some form of contraception (Ghana Demographic and Health Survey, 2015).

Literature Review

Vasectomy is a form of contraception that involves surgically cutting or blocking the tubes that transport sperm from the testis to the penis (Nordqvist, 2016). It is considered as safe and very effective in preventing pregnancy yet its patronage as a family planning method is not encouraging compared with the other methods (Shih, Turok, & Parker, 2014). Vasectomy is an important alternative to female sterilization for couples who want a permanent method of contraception; barriers to its wider use exist in many places (Brechin & Bigrigg, 2006). Among the barriers worth mentioning are limited information on vasectomy, lack of access as a principal constraint, negative attitudes, and misinformation (Bunce et al., 2007).

Vasectomy is an uncommon method in Ghana as in many developing countries such as Mexico, Botswana, Nepal, Nigeria, Pakistan, and Brazil among others (Asare, Otupiri, Apenkwa, & Odotei-Adjei, 2017; Ghana Statistical Service, 2008; Van Lith, Yahner, & Bakamjian, 2013). The prevalence of vasectomy is less than 0.1% and has been more difficult to obtain in Ghana than other family planning methods (Asare et al., 2017; Owusu-Asubonteng, Dassah, Odoi, Frimpong, & Ankobea, 2012). Meanwhile, vasectomy is unique among the array of modern methods of contraception as it enables the male partner to take primary responsibility for fertility control. Furthermore, vasectomy is highly effective in preventing pregnancy whether or not there is subsequent behavior modification by the vasectomized man (Asare et al., 2017).

Knowledge and attitudes of men toward vasectomy are known to have significant influence on its uptake (Ezegwui & Enwereji, 2009). Nishtar, Faruqi, Khowoja, and Ul-Hasnain (2012) highlighted the need to improve upon the knowledge and attitudes of men because there are widespread misconceptions that vasectomy could cause impotence and is exclusively meant for prisoners. Ignorance leading to widespread misconceptions among males has been reported to be a major reason for low acceptance of vasectomy (Ebeigbe, Igberase, & Eigbefoh, 2011). In addition, the belief systems of men have also been implicated as de-motivators to vasectomy. Findings show that majority of men believe that sterilization is the sole prerogative of women (Onasoga et al., 2013).

This study sought to provide data on the utilization of vasectomy by men in the Greater Accra Region of Ghana. Previously, Ghanaian studies done have been quantitative in nature and have largely focused on women (Asare et al., 2017; Owusu-Asubonteng et al., 2012). Thus, this article contributes to empirical evidence on the acceptance of vasectomy as a measure of family planning in Ghana.

Methodology

A qualitative research design was employed with focused group discussion (FGD) as an approach to solicit information from participants. Participants were gathered for discussion to obtain their perceptions on the defined area of interest. A nonthreatening permissive environment was created to allow freedom of expression among the group members. The study was conducted in the central business district of the Greater Accra Region in Ghana. The Tema station is the largest and busiest transport terminal located in the heart of the district. It is the hub of all commercial transportation in the capital. The accessible population were all the drivers who worked on the day of the study.

The study population included all male drivers who have ever been married and were between the ages of 45 and 65 years. Male passengers and bus conductors who did not meet the inclusion criteria were excluded from the study. Purposive sampling was utilized to recruit married men in their sexual reproductive age groups from 45 years and above. These men might have already attained a desirable family size thus were likely to contribute meaningfully to the study. The purpose of the study was fully explained to the participants and they willingly participated without being compensated. Informed consent was obtained and confidentiality was assured before commencement of the study. To maintain confidentiality, participants were assigned alphabets (V) and digits in place of their names. At any point during the study, there was an opportunity for participants to opt out. The study was ethically cleared by the Research and Innovation Center of the Valley View University, Ghana, under exempted review.

With the use of FGDs, the number to be involved in the group was determined by the researchers; therefore, two FGDs were predetermined and constituted with 12 men. Focus Group 1 was made up of five men above 60 years, whereas Focus Group 2 comprised seven men between ages of 45 and 60 years. FGD guide developed by the researchers based on available literature was used as a tool to collect data. The focus group guide was developed based on the themes that emerged from literature reviewed. Subsequently, it was given to field experts for validation. This helped to contextualize the use of vasectomy as a fertility control method. The input from the validation helped to fine-tune the FGD guide. Questions were asked in a clear and nondirective manner in order not to predetermine or lead the answers. The FGD guide had main question areas in line with the objectives of the study. See Appendix A for the FGD guide.

Interviews were conducted by all authors on weekdays in March 2017. They typically lasted 2 hours and were held at the convenience of the drivers in the office of the station master. This was made possible because the public transport system in Ghana is such that drivers queue awaiting turns for passengers to board their vehicles. Thus, interviews did not affect their productive work time. In addition, during the afternoons, there are fewer passengers as this is not a peak period or rush hour. In all, there were five sessions. Interviews were conducted in three Ghanaian languages specifically Ga, Twi, and Ewe. The researchers were Ghanaians and could fluently speak these languages; therefore, translators were not required. During the interview session, when a question was asked, participants were allowed time to provide responses and follow-up questions were asked to clarify statements made. According to Lincoln and Guba’s (1985) recommendations on trustworthiness, the researchers held regular debriefing sessions, kept extensive field notes, and maintained a reflexive journal.

Data analysis was concurrent with data collection. Tape-recorded information was transcribed verbatim, and content analysis was done. Transcripts were read, reread, and line-by-line coding was done. During this process, words and phrases that captured the participants understanding of the issues were noted. Codes that had similar meanings were identified and put together to constitute refined themes. NVivo (version: 10.0.641.0) was used to manage the data and three themes were generated. Findings have been presented with verbatim quotes from participants.

Results

Discussion

The study revealed that some participants were aware of vasectomy but were not able to give detailed information about vasectomy which have been consistently reported in previous studies by Pile (2008), Onasoga et al. (2013), Babalola and John (2012) in which majority of the participants had limited knowledge. Participants had misconceptions and lacked correct information on vasectomy as this was clear in their responses. The low patronage of vasectomy is not completely due to the resistance from men to the method, but also the inability of health workers to make information available, attractive, and accessible to the public (Ebeigbe et al., 2011). If health worker attitudes remain unchanged, vasectomy will be totally relegated to the background despite its high graded effectiveness.

It is indeed true that knowledge played an important role in the uptake of vasectomy, but the study has revealed that the actual decision for acceptance of vasectomy was the sole responsibility of the man and not by the couple. This is largely attributable to cultural influences and also stems from the fact that in most African societies the man is regarded as the head of the family and usually dominates in decision-making (Onasoga et al., 2013). There is the need to change this mindset and to involve women in the final decision on vasectomy as a choice of family planning.

The study also revealed that participants had inadequate knowledge not only on vasectomy but also on other modern family planning methods. This was similar to the findings of studies conducted by Jangu (2013) on the attitude and willingness of men toward the use of modern family planning method and another by Akpamu, Nwoke, Osifo, Igbinovia, and Adisa (2010) on knowledge and acceptance on vasectomy as a method of contraception among literate men in Ekpoma, Nigeria.

Vasectomy seems to have gained acceptance and popularity in developed countries but certainly not in developing countries. This is because inadequate knowledge exists on vasectomy in Ghana. There is, therefore, the need to improve dissemination of accurate information on vasectomy to families and community members through the print and electronic media, churches, mosques, and other public meeting places, which can then serve as a leading source of information for vasectomy.

From our findings, it is evident that as reported elsewhere, men have inadequate knowledge, which subsequently leads to negative perceptions about vasectomy. Negatively, vasectomy was equated to castration with negative effects such as sexual weakness and impotence (Temach, Fekadu, & Achamyeleh, 2017). This term “castration” has many negative connotations in our Ghanaian community. Castration is a practice linked to the male animal; hence, a man who is vasectomized is likely to be seen as such. The findings described earlier were similar to the findings from Adongo et al. (2014) and the ACQUIRE Project (2008), which indicated that communities understood male sterilization to be castration of men. We discern that this false impression is a threat to the sustainability of vasectomy in Ghana. The participants also feared the future uncertainty of vasectomy. Some believed that vasectomy could have adverse effects on their health such as prostate cancer. Obviously, people will not embrace that which is synonymous with castration if they consider it a procedure that will put an end to their sexual life (Nishtar et al., 2012). Sexual prowess is highly valued in the Ghanaian community whereby men go to long lengths to purchase creams, powders, and concoctions that will make them perform better in bed (Danquah, Koffour, Anto, & Nimako, 2011). As such, many Ghanaian men might not even consider a procedure with ‘future consequences’. Recently, a Ghanaian study examining vasectomy from a female perspective unearthed that in a religiosociocultural society like Ghana, childbirth is a prestigious enterprise and for this reason and more, women disapprove of vasectomy especially when they perceive the masculinity of their partners to be challenged (Asare et al., 2017). This translates to a myriad of misbeliefs working in tandem. Vasectomy has been rendered unattractive because of some of these negative perceptions and these eventually have cluttered the minds of men and the public in general. It is not surprising, therefore, that the uptake of vasectomy in a low resource setting like Ghana is poor.

We also found out that men displayed a strong dislike toward vasectomy. They expressed their dislike by saying that they would not go for vasectomy and would advise other men not to do so and this has been previously documented (Akpamu et al., 2010). According to Adongo et al. (2014), some participants felt that once they had vasectomy done they would lose their power and control over their wives. Participants feared that of losing their manhood particularly with the mentality of castration meant that their wives may find lovers to satisfy their sexual demands and thus may no longer be respected in their homes. Upon further probing, the participants had no wish of undergoing vasectomy not even under the influence of a friend.

Interestingly enough, the findings of a study conducted by Dayanand et al. (2014) to assess the level of knowledge and attitude toward vasectomy in adult males from Pokhara, Western Nepal revealed that majority of the participants were in support and showed positive attitude toward vasectomy which was in absolute contrast to the findings of this study. Vasectomy, as mentioned earlier, seems to be very popular in developed nations but certainly not in Africa. It is evident that these men in developing countries have, over the years, showed negative attitude toward vasectomy because of the rather poor knowledge they have on vasectomy. Therefore, to improve on the uptake of vasectomy, the basic reason, which is inadequate knowledge, must be tackled and this will eventually reflect in its uptake.

From the study, it was appreciated that the participants had good knowledge on the short-term methods but knew only few long-term methods. The participants knew vasectomy as a reversible family planning method with adverse health effects such as prostate cancer and inability to ejaculate. The men in this study showed negative attitude and perceptions toward vasectomy.

Strengths and Limitations

The unique nature stems from the fact that it is the first of its kind examining vasectomy as a family planning option from a standpoint of married men in a developing country. The findings from this study will enable policy makers to have insight into factors that militate against vasectomy in order to design appropriate policies and strategies to reach out to men. In addition, the qualitative descriptive nature of the study allowed for in-depth exploration of information from participants. One limitation centers on the study findings which may not be applicable to all urban communities in Ghana. This is because there are varying characteristics of men in the urban communities. The researchers are cognizant of the cultural underpinnings of the Ghanaian society that might have inadvertently influenced participant responses. However, this limitation also illuminates the need for future studies examining the cultural influences on vasectomy.

Conclusion

Vasectomy is poorly patronized in Ghana. From the study findings, the researchers can conclude that this is in part due to several misbeliefs and negative attitudes concerning vasectomy. There is an urgent need for behavioral change strategies and programs to be implemented in order to change the mindset of men in Ghana toward vasectomy. Relevant information must be provided in order to remove the negative impression that has obscured the benefits of vasectomy.