Scoping review of barriers and facilitators to vasectomy uptake in Pakistan: a call for gender-equitable family planning.

Objectives: To systematically map and synthesise available evidence on the barriers and facilitators influencing vasectomy uptake in Pakistan and to identify evidence gaps relevant to gender-equitable family planning policy, practice and future research. Design: A scoping review guided by the Joanna Briggs Institute methodology and the Arksey and O'Malley framework and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). Data sources: PubMed, Scopus, CINAHL, Web of Science and PakMediNet were searched, along with grey literature sources including Google Scholar, government and non-governmental reports, policy documents, theses and dissertations. The initial search was conducted in Eligibility criteria: Eligible sources included peer-reviewed studies, reports, policy documents, theses, dissertations, opinion pieces and commentaries published in English that addressed vasectomy-related barriers, facilitators, attitudes, knowledge, beliefs, practices, services or programmatic factors in Pakistan or among Pakistani populations. Sources were excluded if they were not focused on vasectomy, did not include Pakistan-specific findings, or were not available in full text. Data extraction and synthesis: Data were charted using a standardised Microsoft Excel extraction tool. Extracted information included source details, study characteristics, population, setting, methods, key findings, barriers, facilitators and conclusions. Findings were synthesised descriptively and thematically using qualitative content analysis. The Socio-Ecological Model was used as a deductive framework to organise findings across intrapersonal, interpersonal, organisational/health system, and policy/programmatic levels. Results: Twenty-nine sources were included, comprising 21 studies and 8 grey literature sources. The evidence base was methodologically diverse but largely observational and descriptive, with no intervention-based studies evaluating vasectomy promotion strategies in Pakistan. Barriers operated across multiple levels. Individual-level barriers included limited awareness and misconceptions equating vasectomy with castration, impotence, sexual weakness and loss of masculinity. Interpersonal barriers included religious doubts, spousal or family disapproval, peer pressure, stigma and reliance on informal advice. Health system and policy barriers included limited routine service availability, a shortage of trained providers, provider bias, poor follow-up mechanisms and a predominantly female-focused family planning system. Facilitators included economic motivation, concern for women's health, completed family size, spousal communication, positive testimonials, community-based mobilisation and financial incentive schemes. Conclusions: The underuse of vasectomy in Pakistan reflects mutually reinforcing sociocultural, interpersonal, health system and policy barriers rather than individual preference alone. Increasing uptake will require culturally appropriate communication, male-friendly counselling and services, trained providers, community engagement and policy reforms that recognise men as legitimate family planning clients. Future research should prioritise locally adapted intervention and implementation studies.