APPENDIX H
David Landry
The Alan Guttmacher Institute
Prepared for NICHD Workshop "Improving Data on Male Fertility and Family Formation" at the Urban Institute, Washington, D.C., January 16-17, 1997
Introduction
This report focuses on data sources that measure, or could potentially measure, items related to men's reproductive health, including sex education and particularly reproductive health services. Prominent data sources are reviewed and gaps in data collection are identified.
Much of the interest in increasing male involvement in reproductive health is driven by the premise that such involvement leads to healthier reproductive health outcomes for men and their partners. Indeed, sex education, counseling and health outreach services that have reached men have been shown to promote subsequent reproductive health by delaying the onset of sexual activity, and improving contraceptive efficacy (Kirby et al. 1994; Frost and Forrest, 1995; Danielson, 1990; Terefe and Larson, 1993).
There is a need for more detailed data about how men receive sexual health information and services. What type, when, from whom and why male involvement in reproductive health should be examined broadly to include the wide array of information sources and services that are related to their reproductive health. For example, sexual health information from peers, parents, the schools, the media and other informational sources should be included in measures of how men learn to maintain their reproductive health across the life course. A wide array of health services needs to be monitored as well, ranging from school athletic physicals and general physicals (where reproductive health is often a tertiary service at best, but not one that should remain uncounted), to more direct reproductive health visits made by men or visits where men accompany their partner to a family planning, abortion, prenatal, delivery, or post-natal care visit.
Sex Education/Information
There is a great deal of survey data that indirectly measures sex education via the respondent's knowledge of pregnancy and STD prevention. The Youth Risk Behavior Survey (YRBS), the National Surveys of Adolescent Men (NSAM), the National Survey of Men (NSM), and the National Health and Social Life Survey (NHSLS) are all prominent examples of this approach.
For instance, the NSM measures the respondents' knowledge of: the characteristics STDs (including HIV/AIDS), the period when a woman is most likely to become pregnant, and contraceptive methods by type. The NHSLS probes respondents about their knowledge on the level of effectiveness of various methods in the prevention of HIV transmission.
Another approach to collecting information about sex education/information is to identify the source of the respondent's information. In the NSAM respondents were asked if they ever talked with either parents about sexual health topics (such as the methods of birth control and AIDS). In addition, respondents were asked about the adequacy of the amount of information on sex that was given to the average young person. The NSAM 1994 follow-up (NSAM-3) probed respondents to ascertain if they had received information about AIDS, STDs, and contraception from a range of sources ranging from television to Health department brochures.
There is a paucity of survey data from teachers or administrators on the extent of teaching of sexual education in the schools, and the content, by grade level. The last large-scale survey of teachers on the topic of sex education was conducted in 1987 (Forrest and Silverman, 1989). Given the rise in awareness about HIV and the changes in the sex education curriculums during this period, another study is due.
Measurement of Reproductive Health Services
There are several problems related to collecting information about reproductive health services for men. First, despite the long existence of male reproductive health services, a consensus on what constitutes these services has only recently started to emerge (Green, Cohen and Belhadj-El Ghouayel. 1995). In the United States, Title X guidelines that detail reproductive health services for women have been in existence for some time, but only in the last year has work begun to develop such guidelines for men.
Second, the level of men's use of reproductive health services compared to women's is considerably lower. In some cases, when the traditional methods of asking female survey respondents about their use of reproductive health services in the last 12 months is applied to a survey of males, the results are likely to yield small proportions of men receiving services over this short time period.
Administrative Records
There is a limited amount of administrative data available about health behavior and men. Title X grantees are required by the Office of Population Affairs, to submit annual service data tabulating the number of family planning visits. Three tables stratified by sex are available for 1995 visits, these include: age by race, age by Hispanic/Latino origin and service delivered (STD tests excluding HIV and HIV tests). The data indicate that out of 4.5 million Title X visits in 1995, only 94 thousand or 2 percent are by men (Manzella and Frost, 1997). There are currently no plans to change the information collected about men.
Surveys
There are few national surveys that provide estimates on the total number of men receiving reproductive health services by a large range of services categories. Among 21-26 year olds, the NSAM-3 measured if respondents had received the following services during the past 12 months: a physical exam, STD testing, counseling to prevent pregnancies and counseling to prevent STDs and AIDS. A separate item measured if respondents discussed contraception, pregnancy, STDs or AIDS in the past 12 months with a doctor or nurse. A drawback to the using only a 12 month recall period is that no information can be obtained on the number of respondents who ever received medical services related to reproductive health.
Most surveys that include men and measure reproductive health services focus on only a few categories of reproductive health services rather than the range of sexual health services. For instance, the NHSLS concentrates on sexual dysfunction and STD incidence and treatment; there are few questions about counseling and other services to prevent STDs and unintended pregnancy. The NHSLS sexual dysfunction section measures if respondents experienced 8 categories dysfunction in the past 12 months, and if they sought help by type of provider.
The NHSLS STD incidence and treatment measures are relatively detailed. For 11 types of STDs, the survey measures: ever been diagnosed in lifetime, frequency of diagnoses, diagnosis in last 12 months, place of treatment and partner that infected respondent. The survey also measures if the respondent: ever wondered if they were infected with an STD; ever visited an STD clinic (and the main reason for going to the clinic) and ever experienced STD related symptoms in the last 12 months. The utility of the detailed STD data, particularly when only males and STDs in the last 12 months are analyzed, is limited by the sample size of the NHSLS (3,432 men and women).
The National Survey of Men (NSM) provides data on: ever had an STD, how many times, the month and year, the length of episode, visits to a doctor or clinic for treatment, any return for treatment, and ways in which the respondent altered his sexual behavior after he contracted an STD.
The questionnaire from the National Survey of Family Growth Cycle V (NSFG), serves as a useful model for beginning to design survey questions to measure the range of male reproductive health services and the distribution of these services across the male reproductive life cycle. Of course, the NSFG questions would need to be modified to address services particular to males, such as testicular cancer and prostate screening and treatment. The dimensions of health services the NSFG measures are: 1) the type of service received (such as sterilizing operation, HIV test, testing and treatment for other STD, a method or prescription for method, a check-up or test related to birth control, counseling about birth control and sterilization, abortion); 2) the period when the service was obtained (in the last 12 months from interview and the first visit for respondents under 25); 3) the type of provider; 4) the type of facility; 5) the method of payment; 6) the century month of 1st clinic visit after first menstrual period.
Proxy reports by women about their partners are a common method of collecting information. The NSFG itself could be expanded to measure which of the respondent's partners ever accompanied her on a reproductive health visit (including prenatal, delivery and postnatal care visits).
References
Danielson, Ross et al. 1990. "Reproductive Health Counseling Services for Men: Is There a Need?" Family Planning Perspectives, 22:115-121.
Green, Cynthia, P., Sylvie J. Cohen and Hedia Belhadj-El Ghouayel. 1995. Male Involvement in Reproductive Health, Including Family Planning and Sexual Health, Technical Report 28, New York: United Nations Population Fund.
Forrest, Jacqueline Darroch, and Jane Silverman. 1989. "What Public School Teachers Teach About Preventing Pregnancy, AIDS and Sexually Transmitted Diseases," Family Planning Perspectives, 21](2):65-72.
Frost, JJ and Forest, J.D. 1995. Understanding the Impact of Effective Teenage Pregnancy Prevention Programs. Family Planning Perspectives, 27:188-195.
Kirby, Douglas et al. 1994. "School-Based Programs to Reduce Sexual Risk Behaviors: A Review of Effectiveness," Public Health Reports, 109:339-360.
Manzella, Kathleen and Jennifer Frost. 1996. "Family Planning Annual Report: 1995 Summary, Part 2, Detailed Tables and Data Forms," Report submitted to The Office of Population Affairs, U.S. Department of Health and Human Services, New York: The Alan Guttmacher Institute.
Terefe, Almaz and Charles P. Larson. 1993. "Modern Contraceptive Use in Ethiopia: Does Involving Husbands Make a Difference?" American Journal of Public Health, 83(11):1567-1576.