Introduction

The World Health Organization has advocated health universal access and coverage to all peoples. To do so, social, cultural, economic and geographical barriers need to be eliminated, in addition to institutional ones, and health systems need to be able to meet the needs required by individuals, collectivities and health professionals [1]. Regarding health needs, the Agenda of the United Nations (UN, 2016), from 2016 to 2030, established 17 interdependent sustainable development goals to be assumed by member countries, including Brazil. Among the 169 goals to be achieved is universal access to sexual and reproductive health services, including family planning, information and education, as well as the integration of reproductive health into national strategies and programs. In Brazil, family planning is part of public health policies and ensured by the Federal Constitution through Article 226 and Law no.9,263. According to that law, family planning is a “set of actions to regulate fertility that guarantees equal rights of constitution, limited or increased number of children by women, men or couples” [2]. The National Policy of Integral Attention to Men’s Health (PNAISH) emphasizes the discussion on the male sexual and reproductive health, including sexual and reproductive rights, as well as planned parenthood [3]. Oliveira et al. point out that the improved access to family planning requires expanding the supply of services and contraceptive methods to the male population, given the low participation of men in birth control [4].

Among the personal determinants, education levels, economic class and cultural factors stand out as influencing elements of male participation [5]. This demonstrates the relevance of developing studies capable of knowing this population in order to contribute to their real needs [6]. Costa (2016) states that, although timidly, male participation is increasing over time and the main reasons for this choice are: the desire to share the responsibility of contraception with their partners, the concern with the economic aspect due to the family increase and the knowledge of successful experiences with vasectomy [7].

In this sense, even with the difficult access, the change in male behavior is remarkable, seeking to participate more in family planning actions. Subramanian et al. recommend men’s insertion in sexual and reproductive education activities as a strategy to improve knowledge about the procedure, as well as the development of new contraceptive methods for men, which confer greater freedom and protection to sexual and reproductive health [8]. Considering the relevance of the theme and the intention to contribute to studies focused on the sexual and reproductive health of the male population, this research aimed to know the social representations of men participating in the family planning program.

Methods

This is an exploratory, descriptive and qualitative research, carried out during from November 2017 to May 2018, in Campo Grande, Mato Grosso do Sul, in the Municipal Specialized Center (CEM), which is the central reference place for family planning and care for candidates to vasectomy in the state. The participants were 54 men: 31 already submitted to vasectomy and 23 others preparing for the procedure. All those invited to participate in the study accepted the invitation, with no exclusion of participants. They were informed about the objectives of the research and requested to sign the Informed Consent Form (ICF).

Data collection was performed through a structured form with the following variables: age group, color, region of residence, religion, marital status, level of education, profession, family income and known contraceptive methods, performed through individual interviews to obtain their statements and social representations from the guiding question: “what is your opinion about family planning?”. The data were arranged in an Excel spreadsheet, using the double typing technique, which allows organizing the results and their subsequent illustration in tables. The interviews were recorded, transcribed and organized according to the collective subject’s discourse method and analyzed with the aid of the Theory of Social Representations [9]. According to the collective subject discourse is a technique to organize material resulting from fieldwork, usually derived from interviews, questionnaires, papers, graphic materials, etc. Social representations are considered as popular knowledge, myths, beliefs and customs, which converge in common sense and are socially shared [10,11]. The discussion was constructed after analyzing the findings according to the Theory of Social Representations based on official sources, such as the Ministry of Health and others resulting from studies published in indexed journals. The research was approved by the Human Research Ethics Committee at (information blinded for peer review purposes).

Results

The characterization showed that the mean age was 35.8 (± 7.16). It is interesting that young men are seeking a definitive contraceptive method, despite reversible. Especially when changing the opinion in relation to increasing the number of children, the success is not guaranteed in 100% of the reversals, in addition to their limited access by the Unified Health System. Regarding the level of education, 14.8% of the participants had college degree; only 5.5% did not complete primary education; 38.8% completed primary education and 40.7%, high school, as in (Table 1).

Concerning the participants’ marital status, most men are married or in a stable union, demonstrating that men who seek family planning have fixed partners. The average family composition regarding the number of children varied between one and five children with a significant concentration between two, three and four children. Another important variable refers to their family income, ranging from one to eight minimum wages, with an average of 2.8 wages among the participants, as revealed in (Table 2).

Most of them (79.5%) have religion, which denotes that there is no religious interference in the decision to limit the number of children for the study participants. The main reason that led them to seek the family planning service was vasectomy, chosen to preserve the partner’s health, legitimizing the relevance and existence of discussion between couples related to family planning. Thus, this conjuncture corroborates several studies that demonstrate the increased male participation with a leading role in the family composition, demystifying that the theme is only female. Another aspect mentioned was satisfaction with the number of children, a factor not associated with others such as financial, social and health. Regarding financial and social factors, 22.2% cited them as the main reason for seeking a definitive method to control the number of children. (Table 3) shows these findings.

The interviewees were also asked about their previous knowledge of the types of contraceptive methods. Most participants demonstrated knowing between two and four different contraceptive methods, with a predominance of 22% of three contraceptive methods. The participants mentioned 11 methods, with the male condom as the most cited, present in 88.8% of the answers, followed by oral contraceptives, with 83.3% of the answers. Main methods made available by the UHS.

Vasectomy was mentioned by 48.1% of the interviewees when asked about definitive contraceptive methods. (Table 4) shows the previous knowledge of contraceptive methods according to the variable known methods.

The interviews allowed organizing six central ideas, organized in positive social representations: satisfaction with vasectomy, controlling the number of children, satisfaction with the family composition and preservation of the partner’s health, and negative ones: fear related to the procedure and difficult access.

Satisfaction with Vasectomy

“I think the access [vasectomy] was easy...I found it fast through the system, very fast, because it took me less than 3 months and I was already undergoing it…the whole process was good, it does not hurt and the result corresponds to my expectations…I am satisfied because that is exactly what I wanted...I think the service is easy-access, good, helpful…For me it was great...I am enjoying it...I think the male method is better than the female one...in general, the time elapsed was good, I thought it would take longer...since the first day, the treatment has been great, the schedules were very flexible and I am already finishing everything, there was no barrier, so far it has been good ...I found it fast, easyaccess, I found it very good, very fast...it was good, fast, within the period since the first lecture...as a public agency, I comment with several people that the service is very fast, good, the staff is very attentive…we can reason and think more whether it is a good time...it was a good experience, everything has been fine, I am very happy...I think it is reasonable, I do not find it time consuming because when you start to participate, you see many people giving up,so, doing it too fast you may regret later, I think this was a good time”(p 2, p 5, p 6, p 7, p 8, p 9, p 10, p 16, p 17, p 23, p 24, p 26, p 27, p 28, p 29, p 30, p 32, p 33, p 34, p 36, p 37, p 39, p 30, p 41, p 42, p 43, p 44, p 46, p 49, p 50, p 51).

Controlling the Number of Children

“The decision was mine, currently having a child to suffer is not cool...I already have five children...for the educational issue, first of all, and for the issue of the cost of living, we are not so rich...I do not want any more children, that is why I am trying to undergo the vasectomy, I cannot provide for many children, so I prefer a definitive method...our financial condition is not that good, so we cannot have another child, I am seeking a method for me because she cannot do it, as she is only 24 years old...I want a family planning, I want vasectomy because I can only provide for three children, I do not want more children...for me four children are enough because I cannot spend more than I earn...we already have two children and raising a child nowadays is difficult...this decision has already been made by the number of children we have and due to our financial conditions...we are satisfied with all the strands, one of these strands was the financial issue...I already have two children, I am paying alimony for one of them, which is hard for me, as we do not earn that much in nursing, so things are sort of difficult...it is the financial issue, I think four are already enough...the situation is not so good for you to raise children, mainly considering the financial part” (p17, p 20,p 23,p 24, p 28, p 29,p 31,p 33, p 38,p 42,p 47,p 50,p 51).

Satisfaction with the Family Composition

“I am very satisfied because that is exactly what I wanted, I have four children from two marriages, two from the first and two from the second, I said now it is enough...I do not want any more because I already have four children. I decided to undergo vasectomy because I think it is the best for me, because despite preventing, we had a girl, so I decided to do not to occur again. I do not want any more kids; I already have a 25-year-old son. I already have children...there is no way we are having more children, we already have two children...my first two was not from stable relationships, we only had a few dates, she got pregnant twice, so I decided to do it. I was searching for a definitive method because I do not intend to have more children, already have enough” (p 7, p 10, p 22, p 37, p 44, p 48, p 49, p 52).

Preservation of the Partner’s Health

“She suffers too much in the procedure, her process is longer than mine...the recovery is much better for men, and as my wife already has two children from normal delivery, she is afraid of cesarean section...I have chosen vasectomy to protect my wife...I was at the birth, so the husband sees the reality, see it is not easy, if I had been to the first she would not have had the other children because she suffers too much, so I have decided to undergo vasectomy...we see that for men it is better and easier, the male procedure is simpler...I have chosen it because of my wife, she has a problem in the womb...and thinking with my wife, it was better for me then for her because the risks are much greater for her... my wife, in her current health condition, has many infections, if she is going to use the IUD, the situation will get worse, and the pill causes a lot of side effect...I have chosen it because my wife cannot take medicines because of her health problems, I ended up choosing this method because it is a way to protect her health...it was a way to protect my wife and the baby, a way to protect both...I have chosen it because my partner was feeling really bad about the injections she takes...my wife had two episodes of preeclampsia one in the second child and now in the third...the method is much less invasive than with the woman...I have chosen this method because my wife is already 42 years old, she has diabetes so she cannot take the medicine anymore...when we were about to have our daughter, she almost died, she almost did not return...my wife fails to take many drugs” (p2, p3, p4, p6, p9, p18, p21, p23, p26, p29, p32, p33, p34, p36, p38, p39, p40, p41, p43, p44).

Fear Related to the Procedure

“Surgery always gives me the creeps, afraid of something going wrong, fear of being impotent...I thought that the surgery would end [erection] I was afraid of becoming impotent” (p 46, p 52).

Difficult Access

“I was told it would be as fast as possible, but it has not been...I think for those who demonstrate indecision, the deadline is cool, but I think that those who are already sure, the meetings could be separately because it takes 60 days until the surgery, if it was faster it would be better because it hinders my life a little, besides my professional life...it has been about six months because the service stopped at the end of the year but as some tests delayed, it is taking longer...the only thing I found time consuming is that I do not know if it is different from unit to unit, I first went to family planning, I found the waiting time too long to participate in the lecture...in my opinion it is taking a while because it has already been about six months...I find it very complicated, I believe that they ask for too many information for something that is very simple, because I think that whoever is already coming here has already made his decision...my wife can no longer get pregnant, I think it is kind of complicated because during this period there is an impediment to having a relationship with the wife...where I live there is a waiting line for the procedure” (p4, p11, p18, p19, p21, p25, p45, p47).

Discussion

The data characterization outlined a profile among men who seek the family planning service and gaps in male participation, which are influenced by several factors such as education level, economic class, religious beliefs and the main motivations of those men when seeking the family planning service. In view of the mentioned results, the relationship that the portions with lower incomes, little schooling and living under the margins of development have little representativeness among the participants, even if the group is composed of a contingent of patients from the UHS. Knowing the profile and the opinion of family planning users is of paramount importance to understand the paths that led to building their history. Family planning is still a little explored theme in Brazil, especially when focusing on the man. The study participants were mostly between 30 and 40 years, being in line with the study by in which the largest proportion vasectomized men were older than 30 years, pointing out age as a decisionmaking factor among when talking about definitive methods of contraception [12].

According to the Brazilian legislation, vasectomy is legal in men with full civilian capacity aged over 25 years and with at least two children [2]. A minimum period of 60 days is also necessary between the manifestation of the will and the surgical procedure. Moreover, in the study by Bezerra and Rodrigues, there is equalization when observing the marital status of men: those married are higher in relation to those who declared a stable union and even greater in relation to those who declared themselves single, evidencing that the man who seeks family planning seems to show greater commitment in relation to his partner [12]. When verifying the participants ‘social issues, most of them are brown, with complete primary and secondary educations, income between two and three minimum wages and with at least three children. These characteristics are also present in the study by Marchi et al. evidencing that the man who seeks family planning in the public health service is still the one with a higher level of education, whose family income is not so low and who is not so unaware of social public policies [13]. Religious issues were not very influential in this case. Although Christian churches are against various contraceptive methods, as evidenced by the study by Gomes and Carvalho, the religious doctrine does not seem to interfere emphatically in the participants’ behavior [14]. Cultural issues associated with lack of information and low schooling are still the biggest obstacle to new methods, especially those that go against patriarchal society that subjugates man-centered medicine. A study by Marván, Ehrenzweig& Hernández-Aguilera [15], conducted in Mexico, shows the negative positions of the male population with lower levels of education. The discourses found corroborate Azevedo, Gonçalves and Rosa [16], which indicate an improved male participation in family planning, even if discreetly, with this improvement linked to several factors, evidenced in this research when most men indicated their satisfaction in participating in family planning.

This satisfaction of the male population when participating in family planning actions is also mentioned in international studies such as by Simbar [17], who report the satisfaction of the male participants in Iran. Several interviewees reported satisfaction in participating in family planning, mainly because they were motivated by the preservation of their partners’ health. That was the main concern reported.

Among the interviewees, there were several reasons for vasectomy, and the preservation of the partner’s health prevailed in the citations, with a wide advantage, representing 42.5%. This denotes that part of society has understood the harms that hormonal contraception can generate to women’s health and that men need to be co-responsible for their family future. It is noteworthy that the female definitive contraception methods are procedures of greater risk and surgical size, and this risk is a motivator for men to seek an alternative in preserving their partner’s health.

This data is corroborated by the research by Minister, Silva and Melo, who reported that most men demonstrated preferring vasectomy as a method of preserving their partners’ health. Another important point was the awareness that the number of children is already sufficient, presenting itself in second place as motivation for seeking family planning [18]. Another reason highlighted was family income, which has always been in the balance when the subject focuses on family composition. Over time, Brazilian development, the rise of knowledge and the understanding of expenses by the population have generated even more concern about the act of planning and taking care of the number of children. Hamm et al. also note that, although male participation in family planning is still timid, the financial aspect is among the main reasons found among low-income American men living in Pittsburgh, Pennsylvania, and the authors recommend tying the financial aspect to the family planning guidelines for men [19].

Unfortunately, this is not a reality that reaches all social spheres. Chang et al. indicated the correlation of the highest number of vasectomies among men who had higher education level and better economic condition [20].

Despite the remarkable participants’ satisfaction, several discourses reported difficult access, mostly related to the delay in performing the procedure. The inadequacy of schedules, difficult access, either due to the low offer or the difficulty to complete the process, distances them from effective participation when talking about reproductive health. Shattuck et al. state that disorganization of services, low offer and low quality are factors that distance men from family planning [21]. The existing access barriers is explained in Zordo’s (2012) research, which reports men’s difficult access to family planning due to the inefficiency and precariousness of service, making the service itself one of the barriers of access to family planning [22].

In a study conducted with members of the network of family planning physicians in the United States (scholarship, graduates and professors), few family planning physicians do the vasectomy procedure. Even though vasectomy is more effective, safer and less costly than female sterilization, it is still less common in the scenario of this research [23]. The study verified the low number 

of providers of vasectomy as a barrier to access it. Even in developed countries, male contraception is left in the background. According to White et al. respondents living in Texas, in the United States, report that low funding creates a barrier in the offer of vasectomy. The authors also comment on the low interest of the population especially among Latinos, pointing out the presence of access barriers, as well as perceived in other Brazilian and international studies.

A study by Adelekan, Omoregie and Edoni conducted in Nigeria, reveals that most family planning services are understood as not being welcoming to men, with poor health infrastructure for men, including health policies, services and service hours [24]. These reasons, among others, often lead men to give up participating in family planning actions, leading to the non-choice for vasectomy due to access difficulties. Corroborating a review study by Hardeee, Croce-Galis and Gay most programs act in the expectation that women are contraceptive users and that men should support their partners, with insufficient attention to men as users of family planning in their own right [25]. This same review highlights that men show a desire for information and services.

Health education stands out, with the involvement of community members and education workers includes a greater relationship between users and professionals, being all protagonists of health actions. The importance of universities and training centers as responsible for preparing professionals committed to social needs, with educational projects focused on reality and with the strengthening of the UHS, stands out. Even within a group of men postulating vasectomy, 48.1% answered that they had no prior knowledge of this method, which points out the need for disseminating and guiding the population regarding this method of contraception. An American study conducted in seven southern states showed that men without the knowledge about vasectomy showed negative opinions about the procedure, while vasectomized men pointed out and reported perceived benefits. This demonstrate the importance of health education in the field of sexual health in order to disseminate the method and further insert the male population into family planning programs [26]. Health managers and professionals must sensitize the population, especially men, that this procedure does not affect men’s sexual performance or desire [27]. Knowing those who seek health care with an emphasis on family planning is one of the ways of proposing new ways of acting, managing and implementing policies so that planning increasingly changes from a sphere of women’s health to family health. Thus, it is evident the need to improve family planning services in order to meet this population effectively, who has been taking over and understanding, increasingly, their responsibilities, rights and duties regarding their sexual and reproductive health [28].

Conclusion

The discourses found allow understanding men’s thought about family planning and point out some reasons why little male participation persists. The main motivations demonstrate a change in attitude of the male population, now concerned with the health status of their partner, which is the main motivator, in addition to the financial, social and family implications. To conduct a study such as this is to evidence two important points of Brazilian health: man’s distance from the center of family planning policies and the exclusion of some population groups from health programs, due to lack of information or access. Thus, immediate public policies need to be put on the agenda to modify this scenario, as recommended by the Ministry of Health and the United Nations [29]. This goal requires improvements in the work process focused on planning regarding investments, in order to attract a larger population, as well as in the investment in health education, attracting professionals and popularization of contraception in order to reach all populations, generating universality and equity within a system that needs this experience [30]. Promoting the guarantee of existing methods and stimulating the development of new methods are fundamental actions for this change, so that men’s right to sexual and reproductive health is integrally guaranteed.

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