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Journal of Community Health Nursing Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/hchn20
Community Health Nurses and Family Planning Services for Men Janice M. Swanson , Ingrid Swenson , Deborah Oakley & Shirley Marcy Published online: 07 Jun 2010.
To cite this article: Janice M. Swanson , Ingrid Swenson , Deborah Oakley & Shirley Marcy (1990) Community Health Nurses and Family Planning Services for Men, Journal of Community Health Nursing, 7:2, 87-96, DOI: 10.1207/s15327655jchn0702_5 To link to this article: http://dx.doi.org/10.1207/s15327655jchn0702_5
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditions
JOURNAL OF COMMUNITY HEALTH NURSING, 1990, 7(2), 87-96 Copyright O 1990, Lawrence Erlbaum Associates, Inc.
Community Health Nurses and Family Planning Services for Men Janice M. Swanson, RN, PhD Samuel Merritt College of Nursing
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Ingrid Swenson, RN, DrPh University of North Carolina at Chapel Hill
Deborah Oakley, MPH, PhD University of Michigan Shirley Marcy, RN, MN Portland, OR
Current concerns about sexually transmitted diseases (STDs) and acquired immunodeficiency syndrome (AIDS), as well as unintended pregnancy, have drawn increasing attention to reproductive health services for men. This report presents information about responses by 844 community health nurses (CHNs) to a self-administered mailed questionnaire that included questions about the extent of the nurses' involvement in delivering or administering family planning services to men, their knowledge and attitudes about men and family planning, and their preparation for working with men. Our sample included CHNs in practice in five states and a sample of CHNs belonging to a national organization of public health nursing, in order to gain information about CHNs in practice in the field and CHNs more likely to be in an educational or administrative position and thus able to influence or to set policy. Tho thirds of the nurses surveyed work with men in their reproductive years but only 17.8% delivered or administered family planning services to men (23% of the state sample and 12.5% of the organization sample). Deficits in knowledge about male birth control methods were identified; for example, only 32% knew the useeffectivenessrate of the condom. However, 90% of the CHNs knew the condom has to be put on before any genital contact is made. The CHNs' attitudes were positive; more than 90% said they felt men had equal responsibility with their partners in preventing unwanted pregnancies, using contraception, and contraceptive decision making. Yet, only 9.6% of the CHNs felt men have as much knowledge about contraception as women do. Seventy percent of the nurses felt that sex education in schools was directed more to female students than to male students. More than 90% said they believed that family planning providers have a responsibility to provide services to men; but two thirds felt that nurses are not as well prepared to work with male as with female clients. Increased educational preparation may improve CHNs' knowledge about men and Requests for reprints should be sent to Janice M. Swanson, RN,PhD, Samuel Merritt College, 370 Hawthorne, Oakland, CA 94609.
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family planning and enable them to feel professionally prepared to deliver and administer the services they feel are necessary for male as well as female clients. There are 101,430 CHNs in the United States, working in public health departments or other service agencies in almost every community across the country. These CHNs are a major resource for the family planning field.
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INTRODUCTION Although family planning and related services are widely available to women in the U.S. today, they are not serving men as they are women (Forrest, 1987). Title X legislation, first enacted in 1970, authorized federally funded family planning services for all low income persons; although some Title X funds have been used to serve men, the majority of these services are for women (Dryfoos, 1987; Public Law 91572). The Alan Guttmacher Institute reports that 20% of federally funded agencies offer family planning and reproductive health services to men (Torres & Forrest, 1985), yet only 1% of 3.6 million clients served by public funding for family planning in 1976 were men (U.S. House of Representatives, Select Committee on Population, 1978). The Title X administration, which oversees federally funded family planning clinics administered by the Office of Family Planning in the Department of Health and Human Services, no longer keeps records of services provided to men (Danielson, McNally, Swanson, Plunkett , & Klausmeier, 1988). Family planning services for men as well as women could provide convenient, cost-effective reproductive health care that could help reduce the incidence of unintended pregnancy and the transmission of AIDS and other STDs (Cates, 1984). Studies of both adolescent and adult men show that men want to share responsibility for family planning and are interested in using family planning services (Gallen, 1986). Many men are already using a male-oriented method of birth control. Forty-four percent of married women aged 18 to 44 exposed to the risk of unintended pregnancy report that their husbands use condoms or withdrawal, or have had a vasectomy (Forrest & Fordyce, 1988); and 65% of women 15 to 44 years of age who used a method of contraception before their first marriage reported use of condom or withdrawal at first intercourse (Mosher & Bachrach, 1987). Nurses are in positions in the community that could allow them to increase their involvement in delivering family planning services to men. Nurses have long been major providers of family planning services, and as agencies cut costs, they are increasingly likely to be direct careproviders (Silverman, Torres, & Forrest, 1987; Torres, 1984). The majority (57%) of family planning clinics in the U.S. are operated by public health departments (Forrest, 1988). Health departments or community agencies are the settings where nurses could most commonly be involved with family planning. CHNs in such settings traditionally give preventive care such as health teaching and referral to individuals, families, and groups of childbearing age. CHNs administer or provide direct services in public family planning, STD, prenatal, and well-baby clinics; in school health programs; and/or may carry a caseload of families to which home visits are made. CHNs are in a position to refer men to
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family planning and reproductive health services in these settings, for example, while working in STD clinics, or while giving preventive care on home visits to families of newborns, or as a part of sex education to adolescents in schools. Men are said to avoid family planning clinic services because they feel excluded by the focus on women (Scales, Etelis, & Levitz, 1977; Swanson, 1980, 1985, 1988). Ambivalent attitudes toward men and inadequate training of staff have also been found to exist. A lack of both resources for men (Swanson & Forrest, 1987), and specific services such as vasectomies (Orr, Forrest, Johnson, & Tolman, 1985) have also been noted. Due to these factors, we felt it was important to determine whether CHNs might be able to contribute to increasing male involvement in family planning. To explore CHNs' actual and potential contributions, we asked the following questions: How knowledgeable are CHNs about aspects of family planning for men? How accepting are their attitudes about the male role in family planning and service delivery for men? How involved are they in the delivery of family planning services to men? And, to what extent do they feel professionally prepared to work with men?
METHODOLOGY
To address these issues, a subset of questions regarding men and family planning was incorporated into a larger survey of CHNs' knowledge, attitudes, and involvement related to specific areas of reproductive health. A questionnaire was developed that was self-administered and covered a variety of topics: nurses' knowledge, attitudes, and involvement related to the provision of reproductive health services to women, men, adolescents, and clients seeking abortion; nurses' political involvement and advocacy in the community; and demographic characteristics. Many of the questions had been used previously in other large studies. We first pre-tested the questionnaire for clarity, appropriateness, and content validity, by administering it to 25 nurse practitioners who gave care to persons of child-bearing age from a Health Maintenance Organization (HMO) in a western state. Items were improved or adapted as necessary. We then conducted a pilot study also with nurses who gave care to persons of child-bearing age: 100 nurse practitioners who were members of a western state's Nurse Practitioner Association (minus those who had participated in the pre-pilot) and 100 nurses from the same HMO. Details of the questionnaire and its development are reported elsewhere (Oakley, Swenson, Swanson, & Marcy, in press). Questionnaires were mailed to 1,000 local CHNs in five states (Michigan, North Carolina, Oregon, Texas, and Washington), and to 900 CHNs from a national public health nursing organization. The total sample was drawn from both groups in order to gain information from local health department staff nurses (the five state sample), and from a sample which includes administrators and community health nursing educators in positions likely to influence or set policy (the organization sample). Permission to contact CHNs from the five states was obtained from a
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state-wide nursing group in each state, and permission to contact CHN members of the organization was obtained from the chairperson of the organization. The state sample was randomly drawn from lists supplied by local Directors of Nursing in four states, and from a computerized state listing of all CHNs in the fifth state. The organization sample was systematically sampled by selecting every third name from the total membership list. There was no duplication of names. Two follow-up efforts to reach non-respondents were made; a postcard was sent 4 weeks after the first questionnaire was mailed followed by a second questionnaire the 8th week to those who had not yet responded. A total of 906 returned the questionnaires, a 47.6% response rate. This rate is congruent with Kerlinger's (1975) report of researchers' experience that response rates to mailed questionnaires usually do not exceed 50%. Of the 844 usable quesionnaires available for analysis, 395 were from the state sample, and 449 were from the organization sample. Questionnaires were returned to the University of North Carolina at Chapel Hill, where data entry and analysis were carried out. Sample Characteristics
The background characteristics for the total sample and for the state and organization samples are shown in Table 1. As shown, respondents in the two groups differed in their demographic characteristics, except for religion and church attendance. There were no differences in demographic characteristics by state. Due to the statistically significant differences between the state and organization samples ( p < .01), we have reported them separately. Respondents in the state sample were younger and were more likely to be married, to live in an area with less than 50,000 population, to have had less education, to be an ethnic minority, to practice in a health department, and to provide or administer family planning services. As expected, the organization respondents were more likely to be administrators (27.8% vs. 12%) and educators (26.9% vs. 1.3%), and the state respondents were more likely to be providing direct care (69.6% vs. 19.3%). Only 1.3% of the respondents were men. Compared with the National Sample Survey of (Employed) Registered Nurses, 1984 (U.S. Department of Health and Human Services, 1986), our CHN sample included more minorities (16.3% vs. 10.5%), and tended to be younger (51% of the CHNs in this sample were 40 years of age or less; 57.2% of the national sample were 39 years of age or less). The CHNs were about as likely to be married as the national sample (68.5 % vs. 70.5 % respectively). Available data from a subsample of CHNs from the national sample of nurses shows our sample was similar in educational status; 37% of the CHNs in both our sample and the national sample held a baccalaureate degree as their highest educational preparation. Although only 8.4% of the national sample of CHNs held a master's degree as their highest nursing-related educational preparation, in our sample, 25.7% held a master's degree in nursing and 13.2% held a master's degree in another field. Our sample of
TABLE 1 Percentage Distribution of CHNs in State and Organization Groups, by Selected Background Characteristics Characteristic Age
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< 30 30-40 > 40
Ethnicity Black Hispanic White Asian Native American Other Marital status Single, never married Divorced, separated, widowed Married Residence City > 100,000 City 50,000-100,000 City/town < 50,000 Educational preparation Diploma Associate BS in Nursing Bacc. other MS in Nursing Master's other Doctorate Religious affiliation Protestant Catholic Jewish None Other Church attendance > Once per week Once per week 1-2 times per month < Once per month Never Primary work role Practice Administration Education Family planning Nurse practitioner Other nurse practitioner Other (consultant, inservice educator) Work setting Health department Private practice School, college Out-patient department Hospital in-patient School of Nursing Other
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CHNs was more likely to hold a doctoral degree than the national sample of nurses (7.6% vs. 0.3%) and most likely to be female (98.7% vs. 97%). FINDINGS
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Provision of Services to Men
The client population in the primary work setting of almost two thirds (66.4%) of the CHNs' included men in their reproductive years; there were no significant differences between the state sample (67.4%) and the organization sample (65.8%). Although 35% of the CHNs worked in settings where contraceptive programs were provided for men, CHNs in the state sample were more likely to work in settings where these programs existed than CHNs from the organizaion sample (42.6% vs. 29070, respectively). Fewer (17.8%) actually delivered or administered contraceptive programs for men; CHNs from the state sample were again more likely to be directly involved in these programs than CHNs from the organization sample (22.9% vs. 12.5%). Only 2.8% of the CHNs provided or administered vasectomy-related services (2.1% of the state sample vs. 3.6% of the organization sample). Knowledge Related to Male Methods of Contraception
The questionnaire included a knowledge test with four multiple-choice items related to men and family planning. There were no statistically significant differences between the state CHNs and the organization CHNs on any of the knowledge questions. Ninety percent chose the correct response related to condom use, "For best effectiveness, clients should be instructed to place the condom . . . before the penis comes into contact with any part of the vaginal area." Only 32% however, correctly identified the use-effectiveness rate of condoms, "Of typical users who start out the year using condoms as methods of birth control, the number pregnant by the end of the year will be . . . 10 percent"; 47% believed the failure rate was higher than 10%. Yet, 58.8% gave the correct response related to use of withdrawal, "The practice of coitus interruptus (withdrawal) involves . . . avoiding disposition of sperm in the vagina and on the external genitals." Only 32% were aware that there is no national survey data in the U.S. on adult men's knowledge and attitudes about contraception, "National surveys have not yet been conducted to determine the contraceptive knowledge, attitudes and practices of . . . adult men." There were no statistically significant differences between CHNs who provided or administered family planning services for men and those who did not, on any of the knowledge questions. Attitudes Toward the Male Role in Family Planning
As shown in Table 2, nurses in both samples expressed overwhelming support of the male role in family planning, including the ideas that male teenagers need to be encouraged to become more involved in using contraception, and that men have responsibility for preventing unwanted pregnancy, knowing if their partner is using
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TABLE 2 Percentage of CHNs in Agreement With Statements About Perceptions of Male Involvement in Family Planning and Abortion by Group Percent Agreeing Questionnaire Statements
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-
--
Totala
Stateb
Organizationc
98.7
98.8
98.4
95.2
97.2
93.5
95.1
97.2
93.2
97.4
98.2
97.0
91.6
88.8
94.2
69.7
68.4
70.0
75.7
74.3
76.9
-
Sexually active male teenagers need to be encouraged to become more involved in using contraception Men have as much responsibility as women for preventing unwanted pregnancies Men should take the responsibility for knowing whether or not their female sexual partners are using contraception Men should be encouraged to become more involved in contracepive decision making When a woman has an abortion, the father is also in need of counseling A woman having an abortion should be encouraged to inform the father before having the abortion Men would assume more contraceptive responsibility if they had services designed especially for them
contraception, and becoming involved in contraceptive decision making and abortion. Three out of four of the CHNs felt that men would take more responsibility for contraception if services were designed especially for them. There were no statistically significant differences between CHNs who provided or administered family planning services for men and those who did not, on any of the attitude toward male involvement questions. Attitudes Related to Provision of Family Planning Services to Men
In examining ways to increase men's involvement with family planning, we questioned CHNs about the men's own knowledge and the role of family planning providers. Only 9.6% of the CHNs felt that men have as much knowledge about contraception as women do. As shown in Table 3, the vast majority of the respondents felt that family planning providers have some responsibility to serve men. But TABLE 3 Percentage of CHNs in Agreement With Statements About Family Planning Providers by Group -
-
-
-
-
--
Percent Agreeing Questionnaire Statements Because more contraceptives are used by women, providers of family planning have little responsibility to give services to men Nurses who provide family planning services are prepared to work with male clients as well as they are prepared to work with female clients Nurses who provide family planning services are prepared to work with couples as well as they are to work with individual clients
Totala
Stateb
Organizationc
8.5
9.6
7.7
32.4
36.1
28.9
59.6
66.1
53.9
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two thirds felt that nurses who provide family planning services are not as well prepared to work with male clients as they are to work with female clients, and two out of five felt the same way about nurses' preparation to work with couples. Seventy percent felt that schools direct more of their education about sexuality at female students than at male students. There were no statistically significant differences between CHNs who provided or administered family planning services for men and those who did not, on any of the attitude toward family planning providers questions.
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DISCUSSION This study indicates that a majority of CHNs have access in the work setting to men in their reproductive years and hold very favorable attitudes toward contraceptive services for men-a considerable proportion providing or administering these services for men-yet most do not feel prepared to work with men. The finding that one third of the CHNs work in agencies that offer contraceptive services to men, and about 18% actually deliver these services or administer these programs, may be partially due to initiatives to promote family planning programs for men by administrators of the Title X program since 1984 (Danielson et al., 1988). The current epidemics of AIDS and other STDs have also increased interest in offering STD- and family planning information and services within the same setting (Upchurch, Farmer, Glasser, & Hook, 1987), which also may account for public health nurses' involvement in delivery of family planning services to men. Given the overwhelmingly positive attitudes toward men and family planning reported here, nursing staff in public health departments-traditionally a strong source of health educationmay be major resources supporting services for men. This study reveals public health nurses' perceptions that men have needs for contraceptive knowledge, sex education, and family planning services. It also suggests that knowledge deficits may prevent CHNs from giving men the information they need. Exaggerated failure rates for condoms are one example of biased information that needs to be corrected. This misconception is also held by family planning clinic staff who tend to give maximum or higher effectiveness rates for the contraceptive pill and actual or lower use effectiveness rates for diaghragm, foam, and condoms (Trussel, Faden, & Hatcher, 1976); this information is biased more by type of method than by sex of user. Family planning clinics, staffed predominantly by women, have traditionally been more interested in the woman's role than the man's role in family planning (Gallen, 1986). Public health nurses who provide or administer family planning education, counseling, and/or direct services to men or couples will need additional training and specialized supervision if they are to provide these services for men adequately. Education which will prepare CHNs to administer or deliver family planning services to men is needed at all levels. The finding that the CHNs from the organization did not differ in knowledge from the CHNs in the state sample suggests that education is needed by CHNs in education and in administration as well as by staff.
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Constraints to expanding services for men have been identified by administrators as: (a) inadequate staff training and experience, (b) ambivalent or negative attitudes on the part of staff or administration, and (c) restricted resources such as a lack of pamphlets and films for men and materials for staff education (Swanson & Forrest, 1987). Priorities have been identified as the development and dissemination of educational materials for men, changing attitudes of clients, and increasing training for staff. Considering the positive attitudes of the CHNs in this study toward the male role in family planning and their lack of knowledge, it is recommended that educational initiatives through Title X programs be expanded to reach CHNs in more areas of the country. Although some training and materials for men's reproductive health services which include family planning as well as AIDS and other STDs are available, more are needed (Forrest, Swanson, & Beckstein, 1989). Services should now become a real priority. Experience in other countries suggests that local providers could significantly expand male involvement in family planning and in other aspects of preventive reproductive health by using community-based programs and social marketing (Gallen, 1986). To reach men cost-effectively, family planning programs may have to supplement direct services with public education that legitimizes male methods of birth control and supports male involvement in family planning. Because two thirds of the CHNs surveyed provide public health services of some kind to men in their reproductive years, there is potential for increasing family planning services to men in the U.S. However, the present heavy maternal-child focus of many health department programs, the weekday hours that CHNs work, and the lack of men in nursing may have constrained development of family planning services for men. In the future, as AIDS-related services make more demands on health departments, CHNs may be increasingly affected by needs for STD prevention in conjunction with family planning and other reproductive health-related services, and may therefore have to be more involved with marketing and delivering services to men. Men should be included as subjects in future studies of the use of contraception and in studies of service delivery. Studies which examine strategies for reaching men with low income and low educational attainment are needed, particularly as they are populations often served by CHNs. ACKNOWLEDGMENTS
This research was supported with funds from Sigma Theta Thu, Delta Alpha Chapter, and Sigma Theta Thu, International Honor Society of Nursing.
We are grateful to Katherine Forrest for her constructive advice and criticism. REFERENCES Cates, W., Jr. (1984). Sexually transmitted diseases and family planning: Strange or natural bedfellows? Journal of Reproductive Medicine, 29, 3 17-322.
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Danielson, R., NcNally, K., Swanson, J., Plunkett, A., & Klausmeier, W. (1988). Title X and family planning services for men. Family Planning Perspectives, 20, 234-237. Dryfoos, J. (1987). Whither family planning. American Journal of Public Health, 77, 1393-1 395. Forrest, J. (1987). Unintended pregnancy among American women. Family Planning Perspectives, 19, 76-80. Forrest, J. (1988). The delivery of family planning services in the United States. Family Planning Perspectives, 20, 88, 90-95, 98. Forrest, J., & Fordyce, R. (1 988). U.S. women's contraceptive attitudes and practice: How have they changed in the 1980s? Family Planning Perspectives, 20, 112-1 18. Forrest, K., Swanson, J., & Beckstein, D. (1989). Training and materials for men's reproductive health services. Family Planning Perspectives, 21, 120-1 22. Gallen, M. E. (1986). Men-New focus for family planning programs. Population Reports, 14, 5889J919. Kerlinger, R. (1975). Foundations of behavioral research (2nd ed.). New York: Holt, Rinehart. Mosher, W., & Bachrach, C. (1987). First premarital contraceptive use: U.S. 1960-82. Studies in Family Planning, 18, 83-95. Oakley, D., Swenson, I., Swanson, J., & Marcy, S. (in press). Public health nurses and family planning. Public Health Nursing. Orr, M. T., Forrest, J. D., Johnson, J.H., & Tolman, D. L. (1985). The provision of sterilization services by private physicians. Family Planning Perspectives, 17, 216-220. Public Law 91-572, Family Planning Services and Population Research Act of 1970. Scales, P., Etelis, R., & Levitz, N. (1977). Male involvement in contraceptive decision-making: The role of the birth control counselors. Journal of Community Health, 3, 54-60. Silverman, J., Torres, A., & Forrest, J. (1987). Barriers to contraceptive services. Family Planning Perspectives, 19, 94-98. Swanson, J. (1980). Knowledge, knowledge, who's got the knowledge? The male contraceptive career. Journal of Sex Education and Therapy, 6, 51-57. Swanson, J. (1985). Men and family planning. In S. Hanson & E Bozett (Eds.), Dimensions of fatherhood (pp. 21-48). Beverly Hills, CA: Sage. Swanson, J. (1988). The process of finding contraceptive options. Western Journal of Nursing Research, 10, 492-503. Swanson, J. M., & Forrest, K. (1987). Reproductive health services in family planning settings: A pilot study. American Journal of Public Health, 77, 1462- 1463. Torres, A. (1984). The effects of federal cuts on family planning services, 1980-1983. Family Planning Perspectives, 16, 134- 138. Torres, A., & Forrest, J. D. (1985). Family planning clinic services in the United States, 1983. Family Planning Rrspectives, 17, 30-35. Trussel, T. J., Faden, R., & Hatcher, R. A. (1976). Efficacy information in contraceptive counseling: Those little white lies. American Journal of Public Health, 66, 761-767. U.S. Department of Health and Human Services, Health Resources and Services Administration. Bureau of Health Professions, Division of Nursing. (1986, June). The registered nurse population. Findings from the national sample survey of registered nurses. November 1984. (Report available through NTIS, 5285 Port Royal Road, Springfield, VA 22161) U.S. House of Representatives, Select Committee on Population. (1978, December). FertiMy and contraception in the United States, final report. Washington, DC: U.S. Government Printing Office. Upchurch, D., Farmer, M., Glasser, D., & Hook, E. (1987). Contraceptive needs and practices among women attending an inner-city STD clinic. American Journal of Public Health, 77, 1427-1430.
Journal of Community Health Nursing Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/hchn20
Community Health Nurses and Family Planning Services for Men Janice M. Swanson , Ingrid Swenson , Deborah Oakley & Shirley Marcy Published online: 07 Jun 2010.
To cite this article: Janice M. Swanson , Ingrid Swenson , Deborah Oakley & Shirley Marcy (1990) Community Health Nurses and Family Planning Services for Men, Journal of Community Health Nursing, 7:2, 87-96, DOI: 10.1207/s15327655jchn0702_5 To link to this article: http://dx.doi.org/10.1207/s15327655jchn0702_5
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditions
JOURNAL OF COMMUNITY HEALTH NURSING, 1990, 7(2), 87-96 Copyright O 1990, Lawrence Erlbaum Associates, Inc.
Community Health Nurses and Family Planning Services for Men Janice M. Swanson, RN, PhD Samuel Merritt College of Nursing
Downloaded by [New York University] at 08:18 21 April 2015
Ingrid Swenson, RN, DrPh University of North Carolina at Chapel Hill
Deborah Oakley, MPH, PhD University of Michigan Shirley Marcy, RN, MN Portland, OR
Current concerns about sexually transmitted diseases (STDs) and acquired immunodeficiency syndrome (AIDS), as well as unintended pregnancy, have drawn increasing attention to reproductive health services for men. This report presents information about responses by 844 community health nurses (CHNs) to a self-administered mailed questionnaire that included questions about the extent of the nurses' involvement in delivering or administering family planning services to men, their knowledge and attitudes about men and family planning, and their preparation for working with men. Our sample included CHNs in practice in five states and a sample of CHNs belonging to a national organization of public health nursing, in order to gain information about CHNs in practice in the field and CHNs more likely to be in an educational or administrative position and thus able to influence or to set policy. Tho thirds of the nurses surveyed work with men in their reproductive years but only 17.8% delivered or administered family planning services to men (23% of the state sample and 12.5% of the organization sample). Deficits in knowledge about male birth control methods were identified; for example, only 32% knew the useeffectivenessrate of the condom. However, 90% of the CHNs knew the condom has to be put on before any genital contact is made. The CHNs' attitudes were positive; more than 90% said they felt men had equal responsibility with their partners in preventing unwanted pregnancies, using contraception, and contraceptive decision making. Yet, only 9.6% of the CHNs felt men have as much knowledge about contraception as women do. Seventy percent of the nurses felt that sex education in schools was directed more to female students than to male students. More than 90% said they believed that family planning providers have a responsibility to provide services to men; but two thirds felt that nurses are not as well prepared to work with male as with female clients. Increased educational preparation may improve CHNs' knowledge about men and Requests for reprints should be sent to Janice M. Swanson, RN,PhD, Samuel Merritt College, 370 Hawthorne, Oakland, CA 94609.
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family planning and enable them to feel professionally prepared to deliver and administer the services they feel are necessary for male as well as female clients. There are 101,430 CHNs in the United States, working in public health departments or other service agencies in almost every community across the country. These CHNs are a major resource for the family planning field.
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INTRODUCTION Although family planning and related services are widely available to women in the U.S. today, they are not serving men as they are women (Forrest, 1987). Title X legislation, first enacted in 1970, authorized federally funded family planning services for all low income persons; although some Title X funds have been used to serve men, the majority of these services are for women (Dryfoos, 1987; Public Law 91572). The Alan Guttmacher Institute reports that 20% of federally funded agencies offer family planning and reproductive health services to men (Torres & Forrest, 1985), yet only 1% of 3.6 million clients served by public funding for family planning in 1976 were men (U.S. House of Representatives, Select Committee on Population, 1978). The Title X administration, which oversees federally funded family planning clinics administered by the Office of Family Planning in the Department of Health and Human Services, no longer keeps records of services provided to men (Danielson, McNally, Swanson, Plunkett , & Klausmeier, 1988). Family planning services for men as well as women could provide convenient, cost-effective reproductive health care that could help reduce the incidence of unintended pregnancy and the transmission of AIDS and other STDs (Cates, 1984). Studies of both adolescent and adult men show that men want to share responsibility for family planning and are interested in using family planning services (Gallen, 1986). Many men are already using a male-oriented method of birth control. Forty-four percent of married women aged 18 to 44 exposed to the risk of unintended pregnancy report that their husbands use condoms or withdrawal, or have had a vasectomy (Forrest & Fordyce, 1988); and 65% of women 15 to 44 years of age who used a method of contraception before their first marriage reported use of condom or withdrawal at first intercourse (Mosher & Bachrach, 1987). Nurses are in positions in the community that could allow them to increase their involvement in delivering family planning services to men. Nurses have long been major providers of family planning services, and as agencies cut costs, they are increasingly likely to be direct careproviders (Silverman, Torres, & Forrest, 1987; Torres, 1984). The majority (57%) of family planning clinics in the U.S. are operated by public health departments (Forrest, 1988). Health departments or community agencies are the settings where nurses could most commonly be involved with family planning. CHNs in such settings traditionally give preventive care such as health teaching and referral to individuals, families, and groups of childbearing age. CHNs administer or provide direct services in public family planning, STD, prenatal, and well-baby clinics; in school health programs; and/or may carry a caseload of families to which home visits are made. CHNs are in a position to refer men to
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family planning and reproductive health services in these settings, for example, while working in STD clinics, or while giving preventive care on home visits to families of newborns, or as a part of sex education to adolescents in schools. Men are said to avoid family planning clinic services because they feel excluded by the focus on women (Scales, Etelis, & Levitz, 1977; Swanson, 1980, 1985, 1988). Ambivalent attitudes toward men and inadequate training of staff have also been found to exist. A lack of both resources for men (Swanson & Forrest, 1987), and specific services such as vasectomies (Orr, Forrest, Johnson, & Tolman, 1985) have also been noted. Due to these factors, we felt it was important to determine whether CHNs might be able to contribute to increasing male involvement in family planning. To explore CHNs' actual and potential contributions, we asked the following questions: How knowledgeable are CHNs about aspects of family planning for men? How accepting are their attitudes about the male role in family planning and service delivery for men? How involved are they in the delivery of family planning services to men? And, to what extent do they feel professionally prepared to work with men?
METHODOLOGY
To address these issues, a subset of questions regarding men and family planning was incorporated into a larger survey of CHNs' knowledge, attitudes, and involvement related to specific areas of reproductive health. A questionnaire was developed that was self-administered and covered a variety of topics: nurses' knowledge, attitudes, and involvement related to the provision of reproductive health services to women, men, adolescents, and clients seeking abortion; nurses' political involvement and advocacy in the community; and demographic characteristics. Many of the questions had been used previously in other large studies. We first pre-tested the questionnaire for clarity, appropriateness, and content validity, by administering it to 25 nurse practitioners who gave care to persons of child-bearing age from a Health Maintenance Organization (HMO) in a western state. Items were improved or adapted as necessary. We then conducted a pilot study also with nurses who gave care to persons of child-bearing age: 100 nurse practitioners who were members of a western state's Nurse Practitioner Association (minus those who had participated in the pre-pilot) and 100 nurses from the same HMO. Details of the questionnaire and its development are reported elsewhere (Oakley, Swenson, Swanson, & Marcy, in press). Questionnaires were mailed to 1,000 local CHNs in five states (Michigan, North Carolina, Oregon, Texas, and Washington), and to 900 CHNs from a national public health nursing organization. The total sample was drawn from both groups in order to gain information from local health department staff nurses (the five state sample), and from a sample which includes administrators and community health nursing educators in positions likely to influence or set policy (the organization sample). Permission to contact CHNs from the five states was obtained from a
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state-wide nursing group in each state, and permission to contact CHN members of the organization was obtained from the chairperson of the organization. The state sample was randomly drawn from lists supplied by local Directors of Nursing in four states, and from a computerized state listing of all CHNs in the fifth state. The organization sample was systematically sampled by selecting every third name from the total membership list. There was no duplication of names. Two follow-up efforts to reach non-respondents were made; a postcard was sent 4 weeks after the first questionnaire was mailed followed by a second questionnaire the 8th week to those who had not yet responded. A total of 906 returned the questionnaires, a 47.6% response rate. This rate is congruent with Kerlinger's (1975) report of researchers' experience that response rates to mailed questionnaires usually do not exceed 50%. Of the 844 usable quesionnaires available for analysis, 395 were from the state sample, and 449 were from the organization sample. Questionnaires were returned to the University of North Carolina at Chapel Hill, where data entry and analysis were carried out. Sample Characteristics
The background characteristics for the total sample and for the state and organization samples are shown in Table 1. As shown, respondents in the two groups differed in their demographic characteristics, except for religion and church attendance. There were no differences in demographic characteristics by state. Due to the statistically significant differences between the state and organization samples ( p < .01), we have reported them separately. Respondents in the state sample were younger and were more likely to be married, to live in an area with less than 50,000 population, to have had less education, to be an ethnic minority, to practice in a health department, and to provide or administer family planning services. As expected, the organization respondents were more likely to be administrators (27.8% vs. 12%) and educators (26.9% vs. 1.3%), and the state respondents were more likely to be providing direct care (69.6% vs. 19.3%). Only 1.3% of the respondents were men. Compared with the National Sample Survey of (Employed) Registered Nurses, 1984 (U.S. Department of Health and Human Services, 1986), our CHN sample included more minorities (16.3% vs. 10.5%), and tended to be younger (51% of the CHNs in this sample were 40 years of age or less; 57.2% of the national sample were 39 years of age or less). The CHNs were about as likely to be married as the national sample (68.5 % vs. 70.5 % respectively). Available data from a subsample of CHNs from the national sample of nurses shows our sample was similar in educational status; 37% of the CHNs in both our sample and the national sample held a baccalaureate degree as their highest educational preparation. Although only 8.4% of the national sample of CHNs held a master's degree as their highest nursing-related educational preparation, in our sample, 25.7% held a master's degree in nursing and 13.2% held a master's degree in another field. Our sample of
TABLE 1 Percentage Distribution of CHNs in State and Organization Groups, by Selected Background Characteristics Characteristic Age
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< 30 30-40 > 40
Ethnicity Black Hispanic White Asian Native American Other Marital status Single, never married Divorced, separated, widowed Married Residence City > 100,000 City 50,000-100,000 City/town < 50,000 Educational preparation Diploma Associate BS in Nursing Bacc. other MS in Nursing Master's other Doctorate Religious affiliation Protestant Catholic Jewish None Other Church attendance > Once per week Once per week 1-2 times per month < Once per month Never Primary work role Practice Administration Education Family planning Nurse practitioner Other nurse practitioner Other (consultant, inservice educator) Work setting Health department Private practice School, college Out-patient department Hospital in-patient School of Nursing Other
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CHNs was more likely to hold a doctoral degree than the national sample of nurses (7.6% vs. 0.3%) and most likely to be female (98.7% vs. 97%). FINDINGS
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Provision of Services to Men
The client population in the primary work setting of almost two thirds (66.4%) of the CHNs' included men in their reproductive years; there were no significant differences between the state sample (67.4%) and the organization sample (65.8%). Although 35% of the CHNs worked in settings where contraceptive programs were provided for men, CHNs in the state sample were more likely to work in settings where these programs existed than CHNs from the organizaion sample (42.6% vs. 29070, respectively). Fewer (17.8%) actually delivered or administered contraceptive programs for men; CHNs from the state sample were again more likely to be directly involved in these programs than CHNs from the organization sample (22.9% vs. 12.5%). Only 2.8% of the CHNs provided or administered vasectomy-related services (2.1% of the state sample vs. 3.6% of the organization sample). Knowledge Related to Male Methods of Contraception
The questionnaire included a knowledge test with four multiple-choice items related to men and family planning. There were no statistically significant differences between the state CHNs and the organization CHNs on any of the knowledge questions. Ninety percent chose the correct response related to condom use, "For best effectiveness, clients should be instructed to place the condom . . . before the penis comes into contact with any part of the vaginal area." Only 32% however, correctly identified the use-effectiveness rate of condoms, "Of typical users who start out the year using condoms as methods of birth control, the number pregnant by the end of the year will be . . . 10 percent"; 47% believed the failure rate was higher than 10%. Yet, 58.8% gave the correct response related to use of withdrawal, "The practice of coitus interruptus (withdrawal) involves . . . avoiding disposition of sperm in the vagina and on the external genitals." Only 32% were aware that there is no national survey data in the U.S. on adult men's knowledge and attitudes about contraception, "National surveys have not yet been conducted to determine the contraceptive knowledge, attitudes and practices of . . . adult men." There were no statistically significant differences between CHNs who provided or administered family planning services for men and those who did not, on any of the knowledge questions. Attitudes Toward the Male Role in Family Planning
As shown in Table 2, nurses in both samples expressed overwhelming support of the male role in family planning, including the ideas that male teenagers need to be encouraged to become more involved in using contraception, and that men have responsibility for preventing unwanted pregnancy, knowing if their partner is using
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TABLE 2 Percentage of CHNs in Agreement With Statements About Perceptions of Male Involvement in Family Planning and Abortion by Group Percent Agreeing Questionnaire Statements
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-
--
Totala
Stateb
Organizationc
98.7
98.8
98.4
95.2
97.2
93.5
95.1
97.2
93.2
97.4
98.2
97.0
91.6
88.8
94.2
69.7
68.4
70.0
75.7
74.3
76.9
-
Sexually active male teenagers need to be encouraged to become more involved in using contraception Men have as much responsibility as women for preventing unwanted pregnancies Men should take the responsibility for knowing whether or not their female sexual partners are using contraception Men should be encouraged to become more involved in contracepive decision making When a woman has an abortion, the father is also in need of counseling A woman having an abortion should be encouraged to inform the father before having the abortion Men would assume more contraceptive responsibility if they had services designed especially for them
contraception, and becoming involved in contraceptive decision making and abortion. Three out of four of the CHNs felt that men would take more responsibility for contraception if services were designed especially for them. There were no statistically significant differences between CHNs who provided or administered family planning services for men and those who did not, on any of the attitude toward male involvement questions. Attitudes Related to Provision of Family Planning Services to Men
In examining ways to increase men's involvement with family planning, we questioned CHNs about the men's own knowledge and the role of family planning providers. Only 9.6% of the CHNs felt that men have as much knowledge about contraception as women do. As shown in Table 3, the vast majority of the respondents felt that family planning providers have some responsibility to serve men. But TABLE 3 Percentage of CHNs in Agreement With Statements About Family Planning Providers by Group -
-
-
-
-
--
Percent Agreeing Questionnaire Statements Because more contraceptives are used by women, providers of family planning have little responsibility to give services to men Nurses who provide family planning services are prepared to work with male clients as well as they are prepared to work with female clients Nurses who provide family planning services are prepared to work with couples as well as they are to work with individual clients
Totala
Stateb
Organizationc
8.5
9.6
7.7
32.4
36.1
28.9
59.6
66.1
53.9
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two thirds felt that nurses who provide family planning services are not as well prepared to work with male clients as they are to work with female clients, and two out of five felt the same way about nurses' preparation to work with couples. Seventy percent felt that schools direct more of their education about sexuality at female students than at male students. There were no statistically significant differences between CHNs who provided or administered family planning services for men and those who did not, on any of the attitude toward family planning providers questions.
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DISCUSSION This study indicates that a majority of CHNs have access in the work setting to men in their reproductive years and hold very favorable attitudes toward contraceptive services for men-a considerable proportion providing or administering these services for men-yet most do not feel prepared to work with men. The finding that one third of the CHNs work in agencies that offer contraceptive services to men, and about 18% actually deliver these services or administer these programs, may be partially due to initiatives to promote family planning programs for men by administrators of the Title X program since 1984 (Danielson et al., 1988). The current epidemics of AIDS and other STDs have also increased interest in offering STD- and family planning information and services within the same setting (Upchurch, Farmer, Glasser, & Hook, 1987), which also may account for public health nurses' involvement in delivery of family planning services to men. Given the overwhelmingly positive attitudes toward men and family planning reported here, nursing staff in public health departments-traditionally a strong source of health educationmay be major resources supporting services for men. This study reveals public health nurses' perceptions that men have needs for contraceptive knowledge, sex education, and family planning services. It also suggests that knowledge deficits may prevent CHNs from giving men the information they need. Exaggerated failure rates for condoms are one example of biased information that needs to be corrected. This misconception is also held by family planning clinic staff who tend to give maximum or higher effectiveness rates for the contraceptive pill and actual or lower use effectiveness rates for diaghragm, foam, and condoms (Trussel, Faden, & Hatcher, 1976); this information is biased more by type of method than by sex of user. Family planning clinics, staffed predominantly by women, have traditionally been more interested in the woman's role than the man's role in family planning (Gallen, 1986). Public health nurses who provide or administer family planning education, counseling, and/or direct services to men or couples will need additional training and specialized supervision if they are to provide these services for men adequately. Education which will prepare CHNs to administer or deliver family planning services to men is needed at all levels. The finding that the CHNs from the organization did not differ in knowledge from the CHNs in the state sample suggests that education is needed by CHNs in education and in administration as well as by staff.
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Constraints to expanding services for men have been identified by administrators as: (a) inadequate staff training and experience, (b) ambivalent or negative attitudes on the part of staff or administration, and (c) restricted resources such as a lack of pamphlets and films for men and materials for staff education (Swanson & Forrest, 1987). Priorities have been identified as the development and dissemination of educational materials for men, changing attitudes of clients, and increasing training for staff. Considering the positive attitudes of the CHNs in this study toward the male role in family planning and their lack of knowledge, it is recommended that educational initiatives through Title X programs be expanded to reach CHNs in more areas of the country. Although some training and materials for men's reproductive health services which include family planning as well as AIDS and other STDs are available, more are needed (Forrest, Swanson, & Beckstein, 1989). Services should now become a real priority. Experience in other countries suggests that local providers could significantly expand male involvement in family planning and in other aspects of preventive reproductive health by using community-based programs and social marketing (Gallen, 1986). To reach men cost-effectively, family planning programs may have to supplement direct services with public education that legitimizes male methods of birth control and supports male involvement in family planning. Because two thirds of the CHNs surveyed provide public health services of some kind to men in their reproductive years, there is potential for increasing family planning services to men in the U.S. However, the present heavy maternal-child focus of many health department programs, the weekday hours that CHNs work, and the lack of men in nursing may have constrained development of family planning services for men. In the future, as AIDS-related services make more demands on health departments, CHNs may be increasingly affected by needs for STD prevention in conjunction with family planning and other reproductive health-related services, and may therefore have to be more involved with marketing and delivering services to men. Men should be included as subjects in future studies of the use of contraception and in studies of service delivery. Studies which examine strategies for reaching men with low income and low educational attainment are needed, particularly as they are populations often served by CHNs. ACKNOWLEDGMENTS
This research was supported with funds from Sigma Theta Thu, Delta Alpha Chapter, and Sigma Theta Thu, International Honor Society of Nursing.
We are grateful to Katherine Forrest for her constructive advice and criticism. REFERENCES Cates, W., Jr. (1984). Sexually transmitted diseases and family planning: Strange or natural bedfellows? Journal of Reproductive Medicine, 29, 3 17-322.
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Danielson, R., NcNally, K., Swanson, J., Plunkett, A., & Klausmeier, W. (1988). Title X and family planning services for men. Family Planning Perspectives, 20, 234-237. Dryfoos, J. (1987). Whither family planning. American Journal of Public Health, 77, 1393-1 395. Forrest, J. (1987). Unintended pregnancy among American women. Family Planning Perspectives, 19, 76-80. Forrest, J. (1988). The delivery of family planning services in the United States. Family Planning Perspectives, 20, 88, 90-95, 98. Forrest, J., & Fordyce, R. (1 988). U.S. women's contraceptive attitudes and practice: How have they changed in the 1980s? Family Planning Perspectives, 20, 112-1 18. Forrest, K., Swanson, J., & Beckstein, D. (1989). Training and materials for men's reproductive health services. Family Planning Perspectives, 21, 120-1 22. Gallen, M. E. (1986). Men-New focus for family planning programs. Population Reports, 14, 5889J919. Kerlinger, R. (1975). Foundations of behavioral research (2nd ed.). New York: Holt, Rinehart. Mosher, W., & Bachrach, C. (1987). First premarital contraceptive use: U.S. 1960-82. Studies in Family Planning, 18, 83-95. Oakley, D., Swenson, I., Swanson, J., & Marcy, S. (in press). Public health nurses and family planning. Public Health Nursing. Orr, M. T., Forrest, J. D., Johnson, J.H., & Tolman, D. L. (1985). The provision of sterilization services by private physicians. Family Planning Perspectives, 17, 216-220. Public Law 91-572, Family Planning Services and Population Research Act of 1970. Scales, P., Etelis, R., & Levitz, N. (1977). Male involvement in contraceptive decision-making: The role of the birth control counselors. Journal of Community Health, 3, 54-60. Silverman, J., Torres, A., & Forrest, J. (1987). Barriers to contraceptive services. Family Planning Perspectives, 19, 94-98. Swanson, J. (1980). Knowledge, knowledge, who's got the knowledge? The male contraceptive career. Journal of Sex Education and Therapy, 6, 51-57. Swanson, J. (1985). Men and family planning. In S. Hanson & E Bozett (Eds.), Dimensions of fatherhood (pp. 21-48). Beverly Hills, CA: Sage. Swanson, J. (1988). The process of finding contraceptive options. Western Journal of Nursing Research, 10, 492-503. Swanson, J. M., & Forrest, K. (1987). Reproductive health services in family planning settings: A pilot study. American Journal of Public Health, 77, 1462- 1463. Torres, A. (1984). The effects of federal cuts on family planning services, 1980-1983. Family Planning Perspectives, 16, 134- 138. Torres, A., & Forrest, J. D. (1985). Family planning clinic services in the United States, 1983. Family Planning Rrspectives, 17, 30-35. Trussel, T. J., Faden, R., & Hatcher, R. A. (1976). Efficacy information in contraceptive counseling: Those little white lies. American Journal of Public Health, 66, 761-767. U.S. Department of Health and Human Services, Health Resources and Services Administration. Bureau of Health Professions, Division of Nursing. (1986, June). The registered nurse population. Findings from the national sample survey of registered nurses. November 1984. (Report available through NTIS, 5285 Port Royal Road, Springfield, VA 22161) U.S. House of Representatives, Select Committee on Population. (1978, December). FertiMy and contraception in the United States, final report. Washington, DC: U.S. Government Printing Office. Upchurch, D., Farmer, M., Glasser, D., & Hook, E. (1987). Contraceptive needs and practices among women attending an inner-city STD clinic. American Journal of Public Health, 77, 1427-1430.
