by D. Lawrence Kincaid, Alice Payne Merritt, Liza Nickerson, Sandra de Castro Buffington, Marcos Paulo P. de Castro and Bernadet

Population Communication Services, Johns Hopkins Bloomberg School of Public Health Center for Communication Programs and Promoção da Paternidade Responsável (PRO-PATER)

1996

This paper is an impact evaluation of a mass media vasectomy promotion campaign in three major Brazilian cities: São Paulo, Fortaleza, and Salvador. The data is most comprehensive for São Paulo however, and it is that city’s clinic that receives an in-depth analysis in the article after an introduction and summary of data from all three. The campaign consisted of a combination of prime-time television and radio spots, magazine ads, flyer distribution and an electronic billboard along with other public relations activities. The impact data is derived from the numbers of telephone inquires and visits to the clinics, and the number of vasectomies performed. The result was a sharp increase in demand during and immediately after the campaign, followed by a relatively rapid return to normal levels.



Background

The authors note the growing importance of vasectomies as a global tool for family planning. By 1991 approximately 41.5 million couples had chosen vasectomies as a method for family planning, with three-fourths of those users concentrated in China and India. In Brazil, however, which had a modern contraceptive prevalence rate of 55% in 1986, the pill and female sterilisation accounted for nearly 95% of all methods chosen. Male methods were relatively low, and in São Paulo only 2.4% of total contraception usage was attributable to vasectomy, with a further 3.1% being composed of condom usage (1986). The authors suggest that these rates, higher than anywhere else in the country were in part due to the opening of the country’s first male-oriented health and sexuality clinic, Promoção da Paternidade Responsável (PRO-PATER) in 1981. PRO-PATER initially relied primarily on word-of mouth communication. In 1983, a 3-minute advert about vasectomy and the clinic was broadcast on national television, reaching as estimated 40 million people. The result was a doubling of clinic attendance in the following month. In 1985, after a 10-week print campaign developed in cooperation with The Population Council, the mean daily number of new clients increased by 60%, and the mean daily number of vasectomies increased by 54%.

In 1989, PRO-PATER and Johns Hopkins University's Population Communication Services collaborated to develop a mass media communications project to promote vasectomy in three Brazilian cities. It is this campaign that the article is evaluating. Several clinics were involved in the project, including the PRO-PATER clinic in Sao Paulo, the CEPARH clinic in Salvador, and the PRO-VAS clinic in Fortaleza.

The goal of the 1989-1990 project was to standardise the information provided to potential vasectomy clients and to respond to public myths about how the procedure was performed, its impact on sexual performance, and long-term health. The specific communication objectives were to increase knowledge and awareness of vasectomies, and increase the numbers performed within the target group of lower-middle class males aged 25-49. The data for this study is a quantitative analysis of this second, behavioural objective, and does not attempt to evaluate changes in knowledge and attitudes.

The campaign was conducted in four distinct phases: pre-campaign PR, television spot broadcasting (May-June 1989), rebroadcast (Sept. 1989), and a follow-up mini-campaign (early 1990). The 30-second television spot (broadcast 2-5 times daily from 8pm to midnight) featured a pair of "dancing hearts" and used the slogan, "Vasectomy is an act of love". This message was supported by a companion radio spot that used the same slogan and tag line, and all the pamphlets and magazine ads used the same image of two hearts. In addition, the campaign and the surrounding events generated approximately 70 news stories on television, radio, and daily newspapers. In the total 15-month campaign period, it is estimated that 4 million people were reached through the combined activities and press coverage.



Methodology

The authors evaluated the campaign by examining the clinic records and sources of referral (a standard intake question at all clinics, not requiring separate surveys). The authors compare monthly mean data from the six-month pre-campaign period, during the six-week campaign period, and the five and one-half months after the campaign. The in-depth analysis of the PRO-PATER clinic uses daily averages rather than monthly means, and examines the impact of the mini-campaign and post mini-campaign periods. This analysis also assesses the distribution of referrals that led clients to the clinic. In order to evaluate vasectomy rates over time and assess the potential long-term impact of media campaigns, the authors perform an 11-year longitudinal regressions analysis. A cost-effectiveness assessment is also performed. The evaluation results are organised by type, including the data from the overall assessment of the three clinics, the in-depth results from the PRO-PATER clinic, and the cost and longitudinal analyses.

Results

Overall - Monthly Averages

Across the three clinics, calls, visits, and actual vasectomies increased markedly during the campaign, though post-campaign performance varied substantially between them:

• PRO-VAS (Fortaleza): The mean number of calls and visits per month increased by 133% (from 15 to 35) during the campaign, while in the 6-months afterwards the monthly mean dropped to 12; less than before the campaign. The monthly mean number of vasectomies increased by 108% from 12 at pre-campaign, to 25 during the campaign, and then down to 7 for a total decline of 42%.
  
  
  • (Note: the PRO-VAS clinic was disrupted by a labour dispute during the post-campaign period, which partially skewed the findings.)

• CEPARH (Salvador): The mean number of calls and visits per month increased by 169% (from 39 to 105), while in the 6-months afterwards the monthly mean fell to 85, for a total gain from pre-campaign of 118%. The monthly mean number of vasectomies increased by 59% from 32 at pre-campaign to 51 during the campaign, and then increased further during the post-campaign period to 59, for a total gain of 84%.
• PRO-PATER (São Paulo): The mean number of calls and visits per month increased by 261% (from 529 to 1,911 during the campaign), while in the 6-months afterwards the monthly mean fell back to 679, for a total gain from pre-campaign of 28%. The monthly mean number of vasectomies increased by 82%, (from 303 at pre-campaign to 550 during the campaign. The mean then dropped off slightly, to 542 for an overall increase of 79% during the post-campaign period.

The authors note that this pattern of initial increase in demand, followed by a drop to a plateau that remains higher than the initial point is common in mass media campaigns. In contrast, the pattern of an increase followed by a post-campaign drop below original levels, suggests a "bunching-up" during the campaign period and will likely result in no net increase over the long-term.

The PRO-PATER Clinic

This clinic had been in existence for much longer than the other clinics and was more closely involved in the evaluation. As a result, the authors provide an in-depth analysis of the impact of the campaign in São Paulo. This includes a more detailed time-series (daily averages rather than monthly averages) and source-of referral data.

• Telephone Calls - Mean calls increased 276% during the campaign period (from 25 to 95), before falling back to an average of 33 calls per day in the post-campaign period, and then down to 29 during the mini-campaign and 22 per days thereafter.
• Clinic Visits - Mean daily visits to the clinic increased by 138% during the campaign period (from 21 to 51), and in the post-campaign period declined to 30 per day, and then down to 24 during the final period, representing an overall gain of 13% from the baseline.
• Vasectomies - The mean daily number of vasectomies increased by 81% from 15 to 28 per day, then declined to 24 during the post-campaign period, and subsequently down to 19. The final average was thus approximately 24% higher than at baseline.

Referrals

The source of referrals for the clinic shifted over the course of the campaign:

• Pre-Campaign: Friends/relatives = 55%, Other = 25.2%, Magazines/newspapers = 15.3%.
• Campaign: Television = 57.9%, Friends/relatives = 20.2%, Magazines/newspapers = 10%, Radio = 5%
• Post-Campaign: Friends/relatives = 43.3%, Television = 33.8%, Other = 25.2%, Magazines/newspapers = 6.2%.
• Mini-Campaign: Friends/relatives = 52.7%, Magazines/newspapers = 17.1%, Other = 16.2%, Television = 12.2%.
• The electronic billboard in downtown Sao Paulo was a very minor referral source (<1%).
• The proportion of referrals from the television spot ultimately returned to very low levels after the campaign, and referrals from friends/relatives returned as the dominant source.

Cost-Analysis

The authors also included a cost effectiveness analysis in the article. Data from all costs associated with the campaign, broken down by city and medium, are presented. Their calculations determine that the total cost of the campaign equalled $53 (USD) per visit, and $93 (USD) per vasectomy.



Longitudinal

The longitudinal analysis revealed the impact of the campaign over time. There is a clear and immediate increase in the number of vasectomies performed at the PRO-PATER clinic after the start of the mass media campaign. The number of vasectomies peaked in the first month after the campaign, and the difference was found to be statistically significant at p <.01. All three variables - time, campaign, and time-campaign interaction were also found to be statistically significant. What the authors note however is that the downward slope of vasectomy performance became substantially more negative after the communication campaign ended, with the end result a lower level of vasectomies than before. In order to assess this finding the authors expanded their longitudinal analysis to examine vasectomy trends going back to January 1981. Vasectomies had increased steadily between that period up until December 1983 when there was a sharp jump in demand caused by a three-minute television news report on the subject. This was followed by a mild decline, until another sharp jump in demand in late 1985, corresponding with an earlier more limited vasectomy campaign. Again, this was followed by another gradual decline until the commencement of the campaign referred to in this article (1989), which saw a major jump in vasectomies performed followed by a much steeper decline than that which had existed prior.

Thus, the authors note that it appears that the 1989 campaign only temporarily reversed a long-term downward trend in the number of vasectomies performed by the clinic.

Conclusions

In their final comments the authors discuss several possible hypothesis for this long-term decline. The first is financial, in that there was a corresponding decline in external funding during this period (partly tied to the Brazilian financial crisis and currency devaluation) that forced the PRO-PATER clinic to charge more for vasectomies. An alternative hypothesis is increased competition from other service providers, including the 44 local private physicians that PRO-PATER had trained in the procedure over the years.



Regardless of this overall trend, and despite the inability to determine true causality using this method, the authors believe that the combination of a substantial increase in demand and increased citation of television spots as the referral source does suggest that there is a link between the campaign and increased vasectomy demand. The longitudinal analysis of the PRO-PATER clinic revealed that all three media events had a significant impact on the number of procedures, even during periods of relative decline and in the face of rising procedure costs. This same long-term analysis does however suggest the need for some kind of ongoing promotion to maintain a given activity level. Without periodic reinforcement, they believe that clinic performance will eventually decline.



While the authors admit that this does at first not appear to be a particularly cost-effective method of contraceptive promotion, they note that the stigma associated with vasectomies in Latin cultures in general is bound to make promotion of this method more difficult, and that when the costs are interpreted in terms of couple-years of protection against pregnancy (a standardised measure for all contraceptive measures), it is relatively efficient.



Finally, the authors make some observations about the relative strength of each of the communication media employed in the campaign. Television was clearly the driving component of the campaign and the most effective, whereas radio - which in many settings is a primary medium - was largely ineffective. The print media generated more referrals than did the radio spots. The electronic billboard was also ineffective. As well, the authors believe that the evidence clearly reinforces the importance of interpersonal communication (friend/relative referrals) in encouraging contraceptive behaviours such as vasectomy. The authors suggest that large-scale adoption of the practice in Brazil will ultimately require the development of a critical mass of satisfied users who will encourage others to accept the procedure and multiply the effects of mass media campaigns.

D. Lawrence Kincaid; Alice Payne Merritt; Liza Nickerson; Sandra de Castro Buffington; Marcos Paulo P. de Castro; Bernadete Martin de Castro, "Impact of a Mass media Vasectomy Promotion Campaign in Brazil," International Family Planning Perspectives, Vol. 22, No. 4. (Dec., 1996), pp. 169-175.
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