Involving Men Through Specific Male Engagement Activities to Increase Uptake of Family Planning Services, Especially Non-Scalpel Vasectomy

Purpose: To provide guidance on devising male engagement strategies to increase the uptake of family planning (FP) methods in urban areas, especially non-scalpel vasectomy.

Audience:

  • Chief Medical and Health Officers (CMHO/CDMO/CMO)
  • Nodal Officer – Urban Health and FP
  • Chief Medical Superintendents (CMS)
  • District Program Managers (DPMs)/Urban Health Coordinators/Assistant Program Manager
  • District Community Process Managers (DCPMs)/City Community Process Manager
  • Facility-in-Charge of accredited private health facilities

Background: Improving male participation in family planning has always remained a challenge. For decades, the male method, non-scalpel vasectomy (NSV), has remained unpopular. The reason for this is the complete collapse of the entire ecosystem of ‘male participation’, as deep-rooted myths and misconceptions related to how NSV could negatively impact male virility abounded. Perceptions of weakness and lack of pleasure led most men to be disinterested in this method. This reduced the number of clients for NSV procedures, which indirectly affected the providers’ ability to perform the procedure due to limited cases and opportunities to practice this skill/procedure. This is reflected in the National Family Health Survey (NFHS-IV), which reveals that the modern contraceptive prevalence rate in India is 47.8%, of which male methods represent only 5.9%. Out of the 5.9%, 5.6% are condom users, while only 0.3% are NSV users. Thus, there is need to revive male methods – especially NSV – to contribute to family planning efforts and this requires a specific male engagement strategy.

Evidence of Effectiveness

In 2011, Urban Health Initiative (UHI) started interventions with a focus on demystifying deep-rooted myths related to male contraceptive methods among those groups where they were most prevalent. This included those who believe that NSV users cannot do work requiring heavy-lifting nor pull rickshaw. These specific groups were targeted through chauraha (cross roads) meetings, rickshaw puller intervention, etc. The result was:

  • In the first year, about 48% NSVs were done in the 11 UHI-supported cities.
  • By 2014, these 11 UHI-supported cities contributed to 77% NSV cases of UP in government facilities.

This was directly correlated to the male engagement strategy initiated by Department of Health with the support from UHI in the 11 cities.

Similar strategies were adopted and similar results were shown by PSI’s Expand Access and Quality to Broaden Method Choice (EAQ) project. The male engagement strategy created demand, which contributed to 31% of the total NSV in the state by accredited private sector. These results encouraged the government to scale up the model in a few more geographies within the state.

Learnings from UHI on Engaging Providers

  • Combine NSV surgeon training with NSV fixed day static services, which increases the number of trained and certified surgeons and improves service access and utilization for those in need of NSV services.
  • Draw upon skilled providers from all available resources such as the District Hospital, Police Hospital, Combined Hospital, or Medical colleges during NSV fixed day static services to address the shortfall of trained providers in some cities or facilities.
  • Leverage the strengths of NSV Master Trainer for training on NSV, which contributes to excellent results both in numbers reached and the quality of services.

Guidance on Facilitating the Male Engagement Strategy in Family Planning

The following steps can facilitate a successful male engagement strategy in a state.

Create a Pool of Trainers

Identify/create a pool of trained providers on NSV technique.

Organize Trainings

Organize trainings of providers on NSV method and match it with hands-on skills. Unless the doctor has observed five cases and has done five independent cases under supervision, the surgeon cannot be counted as a skilled surgeon to perform NSV (refer manual for male sterilization, October 2013, Annexure XI- guideline for training of medical officers on male sterilization, GOI).

Ensure Availability of NSV Kits

Ensure availability of NSV kits as per Government of India guidelines at the facility where the surgeon is going to be deployed.

Ensure Client Flow by Creating a Dedicated Male Engagement Team

For a consistent flow of clients, a team of both men or women, who are not hesitant to talk with men about male family planning methods and are very articulate and passionate about their work should be identified. Once identified, this team should do group sensitization or one-on-one sensitization with men at the places that they congregate and at times when they can actually pay attention to family planning discussions.

Impart Counselling Skills

Before deploying the team of mobilizers, an orientation/training of mobilizers on informed choice counselling techniques (group and one-on-one) and technical knowledge about NSV along with observation of a few clients undergoing NSV counselling should be organized.

Reach Out to Men

Create demand of male methods (NSV) through a number of interventions, such as:

Workplace Interventions: The mobilizers visit, identify and engage with men working in small and home-based industries in slums and clarify myths surrounding the male methods, like NSV, further helping them to understand the merits of NSV as a method of FP. Post-counselling, the mobilizers refer clients to nearby facilities. The mobilizers also advocate with the employer for two days of paid leave so that loss of wages due to NSV does not become an impediment for the worker to get NSV done.

A similar strategy can used in the formal sector where discussion can be initiated first with the leadership/supervisor cadre of the industry/factory, and can be trickled down further in the same fashion as mentioned above.

Rickshaw Puller Intervention: This group was specifically targeted for counseling because they hold some of the strongest myths related to the impact of NSV on their ability to perform their job. The steps followed in approaching them included engagement with their associations and visiting parking points, where the mobilizers could counsel and connect them with the services.

Interventions at male congregation points like Chauraha (Cross Roads): Chauraha are places where most men gather at a fixed time daily for ‘finding odd jobs as laborers’. As men congregate, mobilizers can approach them and clarify myths about male methods. This activity is most critical since most of the myths associated with NSV are strongly perceived by this group who do physical labor.

The steps that are taken to conduct a Chauraha meeting include:

  • Install a canopy and do games with FP messaging and focus on NSV.
  • Provide motivational gifts to winners of these games.
  • Individually counsel those people who show interest and stay back to ask/inquire further and refer interested men to facilities for taking NSV services.

Evening community meetings in the slums: As men in the slums are mostly available in the evenings, this time is good for engaging men in one-on-one or group discussions on family planning methods.

Tips

• Association of auto rickshaw drivers, rickshaw pullers should be engaged with their leadership buy-in, all member drivers and rickshaw pullers should be reached out as mentioned above. • Referral and transportation from chaurahas and workplaces to service facilities on the same day ensure services access and use.

 

Give Handouts

Once sensitization is done, give brochures with key messages, frequently asked questions and information (such as the address) on the nearest trained providers to each participant (Refer to the handbill).

Refer to Providers

Refer the interested clients to the nearest government or accredited private provider trained in NSV.

Ensure In-Clinic Counselling

Ensure that once the client reaches the facility, they are counselled by a staff nurse/provider on all of their family planning options so that they can make an informed choice. If the client agrees to a method, then consent should be taken and documented.

Provider Refresher Training

Of all the trained providers (mentioned in Step 2: Organize Trainings), a mentor team of trainers should be identified. This team should be made responsible for providing on-site support to the other providers bi-annually. Such a visit will not only act as a supportive supervision visit but also provide an opportunity for the providers to seek solutions to the challenges that they face while performing male family planning procedures.

Roles and Responsibilities 

Role
Responsibility
CMHO/CMO/CDMO
  • Facilitate and guide the concerned officers (Additional CMO RCH/Nodal officer family planning) to create the pool of trained providers and master trainer of NSV in the district
  • Facilitate and guide the concerned officer (Additional CMO RCH/Nodal Officer family planning) to budget the cost of training of providers on NSV, hiring of male engagement team and their training in PIP
  • Facilitate training of male engagement team in counselling and other techniques of male engagement
  • Coordinate with State NHM/Directorate to ensure scheduled training in authorized training centers (i.e., Center of Excellence) with updated guidelines (refer manual for male sterilization, October 2013, Annexure XI- guideline for training of medical officers on male sterilization, GOI).
  • Send a directive to all rural and urban facility-in-charges and in-charge accredited private facilities to obtain FDS calendar for NSV by facility, and allocate and approve resources
  • Ensure that empaneled providers are available for conducting NSV in both public and accredited private facilities
  • Monitor quality and outputs by facility
Chief Medical Superintendent (CMS)/Facility-In-Charge (in case of private facilities)
  • Nominate ‘potential and interested providers’ for NSV training
  • Coordinate with CMO/CMHO/CDMO for ensuring the scheduling of induction or refresher training on NSV as per the requirement of the providers
  • Coordinate with CMO/CMHO/CDMO and identify NGO to conduct male engagement training for male engagement counsellors
  • Coordinate with CMO/CMHO/CDMO and nominate/bring-on-board male engagement counsellors
  • Develop the FDS calendar for NSV
  • Establish FDS teams for NSV service provision
  • Ensure the mandate of FDS is met as per government guidelines (refer to FDS tool, Standards & Quality Assurance in Sterilization Services (GOI, Nov. 2014)
Nodal Officer of Family Planning
  • Create the pool of trained providers and master trainer on NSV in the district with the support from CMO
  • Facilitate support to DPM and ensure to budget the cost of training of providers on NSV, hiring of male engagement team and their training in PIP
  • Ensure execution of scheduled training in authorized training centers (i.e. Center of Excellence) with updated guidelines (refer manual for male sterilization, October 2013, Annexure XI- guideline for training of medical officers on male sterilization, GOI)
  • Coordinate with CMO to issue directives to all public facilities and accredited private facilities for preparing FDS calendar for NSV services in the district
  • Ensure timely allocation of budgets related to training, FDS, wage loss compensation to clients are received by the public facilities on time
  • Ensure hiring, deploying and training of male engagement team for demand generation for NSV
  • Coordinate and oversee all quality parameters and work as an interface between district leadership and facilities
  • Monitor demand generation activities undertaken by male engagement team, and FDS for quality, and ensure data validity and reliability
  • Ensure client verification for accredited private facilities per government guidelines
Facility Counsellor
  • Develop the FDS calendar for NSV
  • Establish FDS teams for NSV service provision
  • Supervise facility readiness
  • Ensure informed choice and method specific counselling is done per guidelines
  • Ensure that clients are appropriately screened. If not eligible for NSV services, counsel the clients about other appropriate contraceptive methods
  • Ensure wage loss compensation for sterilization clients
  • Minimize client waiting time at the facility on the day of FDS
  • Ensure that all of the clients who accepts NSV services have signed the consent form, medical case record checklists, mandated ID cards, bank details (only in case of public facilities) and client follow-up cards for further use and action
  • Maintain the day-to-day client line listing database at the facility level
Male Engagement Team
  • Generate awareness and mobilize clients for family planning through Chauraha, rickshaw puller meeting, workplace intervention and evening meetings in the slums
  • Prepare potential client list before each FDS
  • Use IEC materials to provide information to men and community leaders about NSV
  • Use handbills to provide information on FDS schedules and availability
  • Accompany clients to facilities to help them access services
  • Provide feedback to facility-in-charge on services
  • Support post-procedure follow-up of NSV acceptors

Monitoring and Reviewing Outcomes

A male engagement strategy can be monitored by including NSV as a regular agenda item for discussion in the District Quality Assurance Committee (DQAC) and District Health Society (DHS) meetings and monthly meeting of Medical Officers-In-Charges’ convened by CMO. On these forums, data generated from HMIS and private sector data on NSV from Hausala Sajheedari web portal can be reviewed on the following indicators:

  • Number of facilities providing NSV
  • Number of providers trained on NSV
  • Number of Chauraha meetings planned compared to the number of Chauraha meeting held
  • Number of Rickshaw Puller meeting planned compared to the number of Rickshaw Puller meeting held
  • Number of workplace intervention meetings planned compared to the number of workplace intervention meeting held
  • Number of evening meetings in the slums planned compared to number of evening meetings held
  • Number of NSV acceptors over a period of time
  • Number of facilities providing NSV FDS

Further, spot checks by the CMO and the Facility-in-Charge of private sector should be undertaken to ensure attention to quality parameters and resolution of bottlenecks.

Monitoring the reasons for which men are screened out/postponed for service provision can provide important information on quality of care and provider barriers to services. This information can be obtained by noting the reasons for screening out/postponement in the client register.

Data Quality Assurance: Although there is a tendency to collect and report service provision from FDS together with information from routine service days, separate record keeping for a period of time is recommended for monitoring.

Cost Elements

The following cost elements are required for increasing male engagement and NSV services, which may exist in the Program Implementation Plan (PIP) of the current year but if not, they can be requested in the next year’s PIP:

Cost Elements FMR Code
Male sterilization fixed day services 1.1.3.1.2
Compensation for Male Sterilization 1.2.2.1.B
Family Planning indemnity scheme 1.2.2.3
Mission Parivar Vikas: Demand generation activities 3.2.1
Procurement of NSV kits 6.1.1.3.A
 ToT on NSV 9.5.3.9
Refresher training on NSV 9.5.3.10
Training of family planning counsellor 9.5.3.20
Quality Assurance Training 9.5.25
Media mix of mid media/mass media 11.6.1
IPC for family planning 11.6.2
IEC and promotional activities for world population day celebration 11.6.3
IEC and promotional activities for Vasectomy fortnight celebration 11.6.4
IEC activities under Mission Parivar Campaign 11.6.5
Dissemination of family planning manuals and guidelines 12.3.1
Printing for Mission Parivar Campaign 12.3.2
Processing accreditation/ empanelment for private facilities/providers to provide sterilization services 15.1.1
Family planning QAC meetings 16.2.3

Source: NHM PIP Guideline, 2018-19 This table illustrates the manner in which cost elements are provisioned in a government PIP, thus providing guidance on where to look for elements related to a strategy such as ‘male engagement’.

Sustainability

Institutionalizing the role of male engagement mobilizers to create continuous demand for male family planning methods, and ensuring trained providers to provide these methods would sustain the male engagement strategy. Also, champions can be identified among male engagement mobilizers who can be recognized in ASHA sammelans; and also acceptors can be recognized in this forum, where they can share their experience to motivate others. In addition, the most important thing to make anything sustain is ‘review’ of these activities on a monthly/quarterly/annual basis by DHS and similar authorities.

Disclaimer: This document is based on the learnings collated from Urban Health Initiative (supported by BMGF), Health of the Urban Poor (supported by USAID) and Expanded Access and Quality (EAQ) to broaden method choice in Uttar Pradesh (supported by BMGF). This document is not prescriptive in nature but provides overall guidance of how this particular aspect was dealt with in these projects for possible adoption and adaptation.