Located along Florida’s eastern coastline, Brevard County is a geographically and economically diverse community with a population of 500,000 citizens. An expanding workforce consisting of service industry and self-employment, has resulted in jobs that pay less and offer little to no health insurance coverage. The highest rates of uninsured in Brevard County are among the unemployed (38.2%) and for households with annual incomes less than $35,000. Over 36% of the employed population are actually earning less 100% of the Federal Poverty Level and are uninsured.
The health department has a long standing history of providing comprehensive family planning services to low-income individuals and families but unintended pregnancies still account for over 47% of the births in Florida. Permanent sterilization can be a viable solution for men and women but typically involves high costs, surgical risks, and long recovery periods. In an effort to increase accessibility and offer a full range of comprehensive family planning services, the Brevard County Health Department (BCHD) became the first health department in the United States to expand upon traditional family planning services by offering an in-house alternative, the No-Scalpel Vasectomy to its male clients.
This procedure is a low-cost, permanent, safe, and practical alternative to traditional vasectomy for men. Incorporated into an existing family planning program and utilizing the current staff, it represents an efficient use of funding and community collaboration while providing a safe and effective male sterilization procedure at very low or no cost to the client. The goal of this program was to ensure a more comprehensive family planning program by providing access to vasectomy as an alternative birth control method to all Brevard County men. Objectives included: (a) re-educate clients as to the risks and benefits of (no-scalpel) vasectomy; (b) provide safe and effective procedure, on premises, with quick recovery time; (c) provide low-cost alternative to birth control for men.
Unintended pregnancies still account for over 47% of the births in Florida. Unintended pregnancies are a socioeconomic burden on individuals, families, and communities and result in a myriad of complex issues, such as, chronic poverty, domestic violence, and child abuse/neglect, adverse health behaviors, and low infant birth weights. Although there are hormonal and barrier contraceptive options available, these are not always well tolerated and are not 100% effective. Surgical sterilization may be considered once an individual has decided to curtail reproduction. However, traditional vasectomy represents a financial burden to the low-income client, not only for the surgical procedure, but in terms associated surgical risk, outpatient costs, and recovery.
In contrast to traditional vasectomy, or female surgical sterilization, this procedure was found to be less invasive, posed minimal post-procedural risks, had few contraindications, and was a highly successful sterilization technique with very short recovery times. Thus, in an effort to increase accessibility and provide a full range of family planning services to low-income individuals, the BCHD became the first health department in the United States to offer No-Scalpel Vasectomy to men in 1994. The financial barriers experienced in the past were eliminated for the majority of male clients. This is a 1 to 2-hour in-house procedure that can be safely and routinely performed with a modest investment of time, space, and personnel, resulting in an efficient use of state and federal dollars. Vasectomy client numbers increased 10-fold compared to program numbers prior to implementation of this practice.
Agency Community RolesThis practice was developed, and has become sustainable, through partnerships between the health department, local physicians and hospitals, and the original publishers of the No-Scalpel Vasectomy procedure, the Association of Voluntary Surgical Contraception (AVSC). Initially, the health department and the AVSC collaborated to establish training, policies, and procedure protocols to establish the practice at the health department. Once proven to be a successful practice, BCHD sought to expand the practice by offering to serve as a model practice in Florida for other counties.
Again, BCHD and AVSC collaborated to develop curriculum, training modalities, and adopt trainer certification measures which allowed the practice to be replicated statewide. As an AVSC-certified trainer, Dr. Heshmati has trained over 50 physicians and continues to train those that wish to learn this procedure. Volunteer and retired physicians have been successfully trained and utilized to perform the procedure at the health department. One particular physician/instructor, trained by Dr. Heshmati, now teaches this innovative technique to medical residents at a Florida state university level resulting in widespread acceptance of this procedure. Local hospitals provide the health department with laboratory and histological services, as well as, a means for sterilizing instruments. Local physicians refer clients who desire a low-cost means of vasectomy to the health department.
ImplementationImplementation costs included minor facility modifications and equipment necessary to conduct an aseptic procedure, coordinating with a local hospital for sterilization of instruments, histology costs, the development of policies, procedures, and protocols, and staff training. Physicians completed didactic instruction and a minimum of six procedures under the direct supervision of a certified trainer.
Nurses, social workers, and other involved staff completed a minimum of four hours of training to include: counseling, role during procedure, data collection, and marketing. When incorporated into an existing family planning program, the routine costs consist of: physician time, nursing time (2 nurses during procedure and 1 nurse to perform pre- and post-counseling, and approximately 15-20 minutes to set up sterile field. Histology services and instrument handling may be donated or negotiated with local hospitals. Volunteer and retired physicians can be trained and utilized as providers. The most effective marketing strategy is to incorporate education, information, and materials into family planning visits with females who take the information home to male partners, friends, and associates.
The most effective marketing strategy is to provide information on No-Scalpel Vasectomy through family planning clinics to women and by providing them with educational material to take home. Once the client overcomes his fear through sensitive pre-counseling, and is reassured and validated by the procedure itself, word of mouth marketing is substantial. Identification of appropriate clientele and enthusiasm for this option among family planning nurses is also an important factor for marketing success.
Vasectomies are most often chosen as a method of contraception among men between the ages of 35 to 44, married, that have three or more children, are educated at the high school level or less, and have low to middle income. Recent studies suggest that although Hispanic rates of vasectomy are very low, professional bias related to cultural acceptance may be unfounded. Clear communication and education can overcome cultural barriers to vasectomy. The most common misconception among men and women of any race or ethnicity is that surgical sterilization for women is less invasive than for men. Limitations include physicians willing to be trained in the procedure and an existing family planning program. Volunteer and retired physicians have been successfully utilized as trained providers at BCHD.
The addition of an open-ended qualitative evaluation six months to a year post-procedure may reveal additional quality of life benefits, as well as, any unintended consequences, such as reduced use of condoms to prevent sexually transmitted disease.
Stakeholder commitment is insured through cooperation between the health department and the private providers to provide low-cost services to uninsured and underinsured by marketing through family planning processes, accepting private provider referrals, referring back to private providers those individuals that require traditional vasectomy, and by training interested private providers in the technique. The program is a practical and viable alternative to referring low-income clients for traditional vasectomy. It represents a fiscally responsible use of sterilization funding and can be easily sustained within an existing family planning program due to low cost of implementation, low on-going maintenance, and use of existing personnel and facilities.