Physicians’ knowledge, attitudes, and beliefs regarding practices of male and female surgical sterilization procedures in Lebanon

doi:10.21203/rs.3.rs-3236682/v1

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Physicians’ knowledge, attitudes, and beliefs regarding practices of male and female surgical sterilization procedures in Lebanon

https://doi.org/10.21203/rs.3.rs-3236682/v1

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Objective

Surgical sterilization, including vasectomy in males and tubal ligation in females, is a highly effective but underutilized contraception method. Adoption rates vary globally mostly due to misconceptions by both the general public and practicing physicians. Our survey aims to explore physicians' knowledge, attitudes and beliefs about surgical sterilization techniques.

Study Design

A web-based survey of four parts was sent to residents and attending physicians of different specialties in Lebanon between April 2022 and April 2023. 183 physicians responded to the survey. Data was analyzed using IBM SPSS Statistics. A descriptive analysis was performed using the chi-square test for categorical variables and ANOVA for continuous variables.

Results

Physicians specialized in Urology, OB/GYN, Family medicine and Internal medicine, filled the survey. The majority were resident physicians (79%), male (57%), single (72%) and did not receive training in family planning (73%). Knowledge assessment showed an average score of 5/7. After setting this as a passing score, 60.7% of participants passed the assessment with higher likelihood of passing among attending physicians (84.6%), OB/GYN physicians (94.4%), married participants (80.8%), and physicians who received training in family planning (91.8%). Recommendations varied among specialties, with urologists being more likely to recommend vasectomy depending on the clinical scenario (70–97%). Most physicians perceived the general public preferring tubal ligation as a sterilization method (98%).

Conclusion

Surgical sterilization is underutilized mostly due to lack of knowledge and cultural beliefs among practicing physicians in our region. Ongoing education is needed in medical training to promote family planning.

Surgical sterilization

Family planning

Vasectomy

Tubal ligation

Contraceptio

Surgical sterilization, which involves the surgical procedure of blocking or removing reproductive organs, is one of the most effective methods of contraception worldwide (1). There are two primary techniques for surgical sterilization: tubal ligation in females and vasectomy in males. Tubal ligation involves blocking or cutting the fallopian tubes, which prevents the eggs from reaching the uterus for fertilization (2). Vasectomy, a simple same-day office procedure, involves cutting or blocking the vas deferens, which prevents sperm from entering the semen that is ejaculated during sexual intercourse (1).

Sterilization is a popular choice of contraception for many couples due to its high effectiveness, long-term benefits, and low maintenance. However, the utilization of sterilization techniques varies depending on factors such as age, race/ethnicity, and level of education (3). In the United States, tubal ligation is performed more frequently than vasectomy, with approximately 600,000 tubal ligations and 200,000 vasectomies performed each year (4–6). However, the rates of these procedures in other parts of the world, particularly in Low- and middle-income countries (LMICs), are not well known.

In some countries, including Turkey, vasectomy is frowned upon by the general population due to misinformation and misconceptions surrounding the procedure. These misconceptions include beliefs that vasectomy is a sin, that it has a negative impact on men's health and strength, and that it affects sexual functioning. Additionally, cultural factors, such as the perception that contraception is a woman's responsibility, may also contribute to the underutilization of vasectomy as a method of contraception (7, 8).

Interestingly, misconceptions about sterilization techniques are not limited to the general population. Some physicians, including gynecologists, urologists, and primary care physicians, also share and disseminate misconceptions about sterilization techniques. For example, a survey of Nigerian gynecology residents showed that more than three-fifths of the residents believed that bilateral tubal ligation was the more appropriate sterilization procedure for couples seeking contraception (9). Similarly, a survey of family planning fellowship providers in the US found that only 57% recommended vasectomy over female sterilization (10).

Notably, family planning training in medical school and residency training curricula is often scarce. While didactic and clinical training in most contraception methods is common, there are still significant gaps, particularly when it comes to tubal ligation and vasectomy (11).

Given the effectiveness of sterilization as a method of contraception and the misconceptions surrounding these procedures, leading to highly divergent adoption in different cultures and societies, it is important to understand physicians' knowledge and beliefs about sterilization techniques. This survey aims to explore physicians' understanding and counseling practices regarding male and female sterilization procedures in Lebanon, with the ultimate goal of improving medical education programs and promoting family planning practices.

Participants

This survey was conducted between April 2021 and April 2023. After IRB approval on 12 March 2021, an e-mail containing a link to access the survey anonymously was sent to residents and attending physicians specialized in Urology, Obstetrics & Gynecology, Family Medicine and other specialties who practice in Lebanon. E-mails reminding the target audience to fill the survey were sent every 3 months for 3 times over the duration of 1 year.

Questionnaire

A self-administered, electronic, web-based anonymous questionnaire was developed on Limesurvey and hosted on the American University of Beirut (AUB) servers. The questionnaire consisted of four parts. The first part (Background & Demographics) included questions on demographics, level of training, specialty and marital status. The second part (Knowledge) was a 7-item knowledge assessment. The third part (Attitudes) consisted of multiple scenarios where the physician provides a recommendation on the method of surgical sterilization. Finally, the fourth part (Beliefs) investigated the physicians’ perception of barriers to surgical sterilization procedures (Fig. 1). The questionnaire required an approximate time of 5–10 minutes to complete.

Data Management and Analysis

Collected data was stored on AUB servers and after data collection was completed, the entire dataset was imported from LimeSurvey into IBM SPSS Statistics, v.28 (IBM Corp., Armonk, N.Y., USA). Statistical significance was set at the alpha level of 0.05. A descriptive analysis was performed on all items of the questionnaire. Categorical and continuous variables were analyzed using the chi-square test and ANOVA (analysis of variance) respectively. The second part (Knowledge) was incorporated into the questionnaire to assess participants' understanding of surgical sterilization. We categorized the total scores, ranging from 0 to 7, based on the median into two groups (< 5 or ≥ 5) to examine variations based on participant’s demographics, education level, medical specialty, and whether the participant had received formal family planning training. Any participant receiving a score ≥ 5 was considered to have a passing grade.

Benefits & Risks

After successful completion of the questionnaire, each participant received a pop-up electronic brochure (Fig. 2) (12, 13) containing educational material on the topic and answering all the questions regarding knowledge of the two surgical sterilization procedures. The potential participation risk is minimal, and confidentiality measures were taken to protect any information obtained from the surveys. Physician identifiers were limited to minor essential identifiers that can in no way be used to trace back participants. There were no mandatory questions in the survey.

A total of 183 physicians filled the survey. Around 79% were resident physicians and 21% were attending physicians. There was an equal number of responses from the four targeted specialties (around 20% each), and around 16% were from other specialties. 57% of respondents identified as male physicians while 43% identified as females (male to female ratio 1:0.75), and only around 28% were married at the time they filled the survey. The majority of respondents (73%) did not receive any training in family planning during their medical school or residency training (Table 1).

Table 1

Baseline Characteristics and demographics of respondents to the survey
N = 183		N (%) or Mean ± SD
Age		31(9)
Level of Training	Junior Resident	75 (41)
	Senior Resident	69 (37.7)
	Attending	39 (21.3)
Specialty	Internal Medicine	40 (21.9)
	Family Medicine	40 (21.9)
	Ob/Gyn	36 (19.7)
	Urology	37 (20.2)
	Other	30 (16.4)
Gender	Male	104 (56.8)
Gender	Female	79 (43.2)
Marital status	Married	52 (28.4)
	Single	128 (69.9)
	Divorced/Widowed	3 (1.6)
Received Training in Family Planning	No	134 (73.2)
Received Training in Family Planning	Yes	49 (26.8)

The average score to the knowledge assessment (Part 2) among all participating physicians was 5. 74% correctly chose tubal ligation as the more invasive procedure, 80% correctly answered that tubal ligation is more complex to carry out and 64% correctly chose tubal ligation as the procedure requiring general anesthesia. 57% and 65% correctly identified that neither procedure affects hormonal secretion or affect sexual desire or potency, respectively. Almost two-thirds of respondents (65%) correctly identified that tubal ligation requires hospital admission, and 87% correctly chose that tubal ligation costs more (Table 2). After setting a passing score of 5/7, we found that 111 of the 183 participants have passed. The total test score was significantly different among different levels of training, specialties, marital status, and status of receiving a formal training in family planning (p < 0.001). 45.3% of Junior residents,63.8% of senior residents, and 84.6% of attendings have passed. Out of the physicians in each specialty, 72.5% specializing in internal medicine, 60% in family medicine, 94.4% in Ob/Gyn, 89.2% in Urology, and 30% in other specialties have passed. Moreover, 80.8% of married participants, 51.6% of single participants, and 100% of divorced or widowed participants had a score ≥ 5. 91.8% of physicians who received a formal family planning training have passed, while only 49.3% of physicians who did not receive a formal training did. When comparing both gender groups, there was not a significant difference between males and females, each having a passing rate close to 61%. (Table 3).

Table 2

Answers to the 7-item knowledge assessment of surgical sterilization procedures
		N (%)
More invasive	Both	35 (19.1)
	Neither	1 (0.5)
	Tubal Ligation	136 (74.3)
	Vasectomy	11 (6)
More Complex to Carry Out	Both	19 (10.4)
	Neither	2 (1.1)
	Tubal Ligation	146 (79.8)
	Vasectomy	16 (8.7)
Requires General Anesthesia	Both	49 (26.8)
	Neither	15 (8.2)
	Tubal Ligation	117 (63.9)
	Vasectomy	2 (1.1)
Affects Hormonal Secretion	Both	51 (27.9)
	Neither	105 (57.4)
	Tubal Ligation	13 (7.1)
	Vasectomy	14 (7.7)
Affects Sexual Desire/Sexual Potency	Both	37 (20.2)
	Neither	119 (65)
	Tubal Ligation	13 (7.1)
	Vasectomy	14 (7.7)
Requires Hospital Admission	Both	45 (24.6)
	Neither	15 (8.2)
	Tubal Ligation	119 (65)
	Vasectomy	4 (2.2)
Costs More	Both	8 (4.4)
	Neither	6 (3.3)
	Tubal Ligation	159 (86.9)
	Vasectomy	10 (5.5)

Table 3

Comparing scores of physicians to the 7-item knowledge assessment of surgical sterilization procedures according to baseline characteristics
Total Test Score		< 5	≥5	P-value
		N (%) or Mean ± SD	N (%) or Mean ± SD	P-value
Age		28 (6)	33 (9)	< 0.001
Level of training	Junior Resident	41 (54.7)	34 (45.3)	< 0.001
	Senior Resident	25 (36.2)	44 (63.8)
	Attending	6 (15.4)	33 (84.6)
Senior Resident (≥ PGY3)	No	47 (41.2)	67 (58.8)	0.53
Senior Resident (≥ PGY3)	Yes	25 (36.2)	44 (63.8)	0.53
Specialty	Internal Medicine	29 (72.5)	11 (72.5)	< 0.001
	Family Medicine	16 (40)	24 (60)
	Ob/Gyn	2 (5.6)	34 (94.4)
	Urology	4 (10.8)	33 (89.2)
	Other	21 (70)	9 (30)
Gender	Male	41 (39.4)	63 (60.6)	0.98
Gender	Female	31 (39.2)	48 (60.8)	0.98
Marital Status	Married	10 (19.2)	42 (80.8)	< 0.001
	Single	62 (48.4)	66 (51.6)
	Divorced/Widowed	0 (0)	3 (100)
Family Planning Training	No	68 (50.7)	66 (49.3)	< 0.001
Family Planning Training	Yes	4 (8.2)	45 (91.8)	< 0.001

Regarding recommendations, 61% and 59% of physicians would recommend both procedures for a healthy or educated couple, respectively. 59% and 77% would recommend vasectomy to a couple with limited financial resources or a couple where the wife has medical comorbidities, respectively. In addition, 51% would recommend tubal ligation to a couple where the husband has medical comorbidities (Table 4). Urologists were more likely to recommend vasectomy to all patients with percentages ranging from 70% if the husband has medical comorbidities to 97% if the wife has medical comorbidities. Family medicine and OB/GYN physicians were more likely to recommend both procedures to healthy or educated couples but would prefer vasectomy if the couple has limited financial resources or if the wife has medical comorbidities; and would recommend tubal ligation if the husband has medical comorbidities. Internal medicine had the highest rates of recommending neither surgeries, ranging from 20% in cases where the wife has comorbidities, to 37% in case of a healthy couple (Table 1S).

Table 4

Result of which surgical sterilization procedure physicians would recommend in 5 different scenarios
		N (%)
Healthy Couple	Both	111 (60.7)
	Neither	16 (8.7)
	Tubal ligation	10 (5.5)
	Vasectomy	46 (25.1)
Educated Couple	Both	108 (59)
	Neither	21 (11.5)
	Tubal ligation	10 (5.5)
	Vasectomy	44 (24)
Couple with Limited Financial Resources	Both	43 (23.5)
	Neither	23 (12.6)
	Tubal ligation	10 (5.5)
	Vasectomy	107 (58.5)
Couple where the wife has Medical Comorbidities	Both	23 (12.6)
	Neither	16 (8.7)
	Tubal ligation	4 (2.2)
	Vasectomy	140 (76.5)
Couple where the husband has Medical Comorbidities	Both	37 (20.2)
	Neither	16 (8.7)
	Tubal ligation	93 (50.8)
	Vasectomy	37 (20.2)

For perceptions, a striking 98% believe that the general public is more likely to choose tubal ligation as a method for surgical sterilization. 46% believe that the main barrier to tubal ligation is lack of knowledge or fear of the procedure, while 48% believe that both cultural/religious beliefs in addition to lack of knowledge and fear of the procedure are barriers to male sterilization (Table 5).

Table 5

Perception of physicians regarding the preference and barriers to surgical sterilization procedures among the general public
		N (%)
General Public More Likely to Choose as a Method for Family Planning/Sterilization	Vasectomy	4 (2.2)
	Tubal Ligation	179 (97.8)
Barriers to Female Sterilization	Religious/Cultural Beliefs	32 (17.5)
	Lack of Knowledge/fear of procedure	85 (46.4)
	Both	66 (33.1)
Barriers to Male Sterilization	Religious/Cultural Beliefs	89 (48.6)
	Lack of Knowledge/fear of procedure	7 (3.8)
	Both	87 (47.5)

Our study provides valuable insight on the knowledge, recommendations and perception of Lebanese physicians of different specialties on the topic of surgical sterilization, procedures that remain under-utilized in our region, but also globally (14). Our findings highlight that a higher level of training in any specialty, and that having received formal training in family planning, both confer a significantly higher score on the Knowledge section of the questionnaire (Table 3). In addition, the overall moderate level of knowledge observed among physicians in our study aligns with previous research.

Studies have shown that gaps in knowledge exist among healthcare professionals, particularly in areas such as the effectiveness, safety, and access to different methods of surgical sterilization (14, 15). For example, a study by Young et al. showed that only 17.5% of healthcare providers in Rhode Island, USA recommended vasectomy to more than 10% of their male patients. In that study, only 18% were aware of a state funded No Cost Vasectomy Program and only 7.5% reported referring patients to that program (14). In another cross-sectional study in Nigeria by Adeniran et al., a survey among healthcare workers showed that 76.5% supported the role of men in family planning while only 17% of men intended to undergo vasectomy on completion of their family size, the main reason being fear of sexual dysfunction (15).

Our data additionally reveals that urologists and OB/GYN physicians have a higher degree of knowledge of surgical sterilization procedures than physicians of other specialties, which is reasonable as these physicians are the ones who perform vasectomy and tubal ligation. The lower level of knowledge among primary care physicians including Family physicians, who are often the first to be consulted on fertility matters by patients, underscores the need for ongoing education and training to enhance providers' knowledge and ensure the delivery of accurate and up-to-date information to patients. The ministries of health and education can ideally take the lead on a national level, making family planning training a requirement within reproductive health courses across all medical schools in the country. Further advanced training can be implemented for primary healthcare providers (Family medicine and Internal medicine).

Also, other strategies to enrich the general population’s knowledge about surgical sterilization procedures, that do not depend directly on counseling by the physician, should be sought after (awareness programs, brochures, social media pages, etc.). As such, the patient has enough knowledge and exposure to initiate the discussion with the physician more comfortably, allowing for more extensive explanations on behalf of the healthcare provider.

Moreover, the only study investigating the topic of surgical sterilization procedures in Lebanon revealed a low level of knowledge on the subject and a lack of interest in surgical sterilization among Lebanese citizens (16); which further highlights the need for education and awareness on the topic, not only to physicians, but also to the general public through various media outlets.

The finding that physicians in this study were more likely to recommend both tubal ligation and vasectomy for healthy or educated couples is consistent with previous studies, indicating that these procedures are generally regarded as safe and effective methods of permanent contraception. For example, in a study from Brazil by Bailey et al, physicians of different specialties were found to recommend both procedures equally often; however, physicians who perform one procedure or the other were more likely to recommend the procedure they perform (17). Another study from Egypt by Hassanin et al, revealed that 52% of physicians perceive vasectomy positively, but only round 25% would recommend it to a couple seeking surgical sterilization (18).

In our study, we found that one factor influencing the recommendation of one procedure over the other is the physician’s specialty. For instance, urologists, due to their expertise in male reproductive health, may be more inclined to recommend vasectomy. On the other hand, family medicine and OB/GYN physicians, who often may have a broader scope of reproductive healthcare, may consider multiple factors when making recommendations. Another important factor is the particulars of the society and the culture in the country where the physician is practicing. For instance, Egyptian physicians are less likely to recommend vasectomy due to religious factors related to male’s duty in reproducing (18). Moreover, in the United States, two papers by Shih et al. showed that vasectomy remains less widely performed than tubal ligation; particularly in relation to religious and cultural beliefs, especially among the Black and Latino communities (19, 20). Our data aligns with findings in the literature regarding barriers to male surgical sterilization. Males in our region are likely to reject vasectomy due to lack of knowledge of the procedure, misconceptions regarding reversibility and impact on sexual desire, but also due to religious beliefs that capitalize on the male’s need to conceive, often from multiple female partners (16). For example, in a study from Saudi Arabia by Sait et al., a survey was done on 243 men which showed that only 13% of respondents knew that vasectomy is a male contraception method, and 62% perceived this method as associated with complications (21). However, this study was limited to men only, compared to our sample which reflects attitudes and knowledge of all genders in society.

The identified barriers to surgical sterilization emphasize the need for targeted interventions to improve awareness, dispel misconceptions, and address cultural/religious considerations in order to promote informed decision-making and access to both tubal ligation and vasectomy as viable options of contraception.

Finally, our study represents the largest survey among physicians on surgical sterilization procedures done in Lebanon. Our target population was restricted to physicians involved in counseling about contraception, leading to a small sample size. Another limitation is potential response bias. Future research should aim to include a larger and more diverse sample to enhance generalizability.

Surgical sterilization remains under-utilized as a method of contraception. Moreover, lack of knowledge and religious or cultural beliefs create disparities in the use of one procedure over the other. This highlights the need of ongoing education and training to physicians on the matter and the implementation of Family planning as a requirement in medical school and residency training curricula.

Ethical approval- The study was approved by the American University of Board Institutional Review Board. All participants consented to participate prior to filling the web-based questionnaire. Responses were anonymously collected and stored electronically through the institution’s web database on LimeSurvey.

Competing interests- The authors certify that there is no conflict of interest (financial or personal) with any organization regarding the material discussed in the manuscript.

Authors’ contributions- J.N. contributed to design of the study, data collection, data analysis and interpretation and writing of the manuscript. A.A. contributed to design of the study, data collection and writing of the manuscript. E.A.C. contributed to data collection, data analysis and interpretation and writing of the manuscript. N.A.H contributed to design of the study, data collection and writing of the manuscript. M.Z. contributed to data collection and writing of the manuscript. A.F. contributed to data collection and data analysis and interpretation. J.N. contributed to data collection and writing of the manuscript. B.B. contributed to design of the study, data analysis and interpretation, writing of the manuscript, revising the final manuscript and coordinating between authors.

All authors approved the final manuscript draft before submission. All authors have contributed to the final draft and understand that they are held accountable for their contributions.

Funding –The authors report no involvement in the research by any sponsor that could have influenced the outcome of this work. This study was an unfunded work.

Availability of data and materials- The dataset imported from limesurvey is saved on the PI’s password-protected desktop and is available if requested for review.

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No competing interests reported.

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Physicians’ knowledge, attitudes, and beliefs regarding practices of male and female surgical sterilization procedures in Lebanon

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Abstract

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Introduction

Material and Methods

Participants

Questionnaire

Data Management and Analysis

Benefits & Risks

Results

Discussion

Conclusion

Declarations

References

Additional Declarations

Supplementary Files

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