1. Results of using a systemic model to introduce vasectomy services in Guatemala Ricardo Vernon Frontiers in Reproductive Health Program, Population Council rvernon@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.  Trainee returns to work site and is expected to provide the service  BUT: a large proportion do not do so due to limited demand for the method and a lack of confidence in their skills.

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: a)Self-selection of health units according to the response to an invitation to participate in the project b)The development of a counseling and information model for potential clients: c)Training and sensitizing of health teams: d)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 getting a vasectomy and communicating this to the project team. Out of the 15 hospitals invited, only six complied with this first step and began training.

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 counseling and information model.

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. Place No. of sessions No. of Vasectomies Average per session Surgeons CertifiedIn process Amatitlan12312.5822 Chimaltenango7172.4320 Zone 1812312.5830 Zone 1919713.7410 Cuilapa133.0001 Progreso- Guastatoya 351.6701 Total541582.9384 Table 1. Average of no-scalpel vasectomies by place and number of sessions

6. Hospital / Type of Physicial Weeks 1st. Practice to Cerfication # Sessions # Vasectomies until Certificaction Weeks certific to Sept. Sessions Certification to Sept. 30 Post- Certification Vasectomies Amatitlan 1 Surgeon9382444 2 Surgeon9592436 Chimaltenengo 3 Surgeon9272033 4 Ob/Gyn9343234 Zone 18 5 Ob/Gyn13362635 6 Ob/Gyn11441945 7 Ob/Gyn13361545 Zone 19 8 Ob/Gyn2472219442 TOTAL9730661792874 AVERAGE12.123.758.2522.373.59.25 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 project’s brochure and poster 29% received information from their wives, 38% from hospital staff members and 25% from other health centers, 18% friends or relatives, and slightly less than 10% from radio/ TV, health promoter, poster, leaflet or another vasectomized man. Therefore, the data indicate that the effectiveness of the intervention depended more on the multiplicity of channels and sources

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 11:00 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 VARIABLEPERCENTVARIABLEPERCENT AGECIVIL STATUS 20 to 24 years8.2Married81.0 25 to 29 years27.2Consensual Union19.0 30 to 39 years46.3NUMBER OF CHILDREN 40 to 44 years11.40-1 children1.3 45 and more years7.02 children32.2 EDUCATION3 children32.9 None1.94 children or more53.6 Primary28.5AGE OF YOUNGEST CHILD Secondary23.4Younger than 1 year56.3 Highschool32.91 to 5 years39.9 University14.4More than 5 years3.8 ETHNICITYEMPLOYMENT Ladino (Spanish speaking)70.3Employed96.8 Indigenous29.7Unemployed3.2 TOTAL100.0TOTAL100.0

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 partner’s 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 MOH’s 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 project’s 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 ($8,000, i.e., about 800 dollars per trained surgeon). With post-certification follow-up, the costs were almost twice as high. (1,600 dollars per trained surgeon; but these costs would be about $660 with MOH trainers, considering their salary levels)

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 MOH’s 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 method’s popularity rises.