Current scenario of Contraception and Indian Men

Dr. Sonia Puri, Associate Professor, Department of Community Medicine, Government Medical College Chandigarh, India. Dr. Dinesh Walia Associate Professor, Department of Community Medicine, Government Medical College Chandigarh, India. Dr. Chetna Mangat Resident, Department of Community Medicine, Government Medical College Chandigarh, India Dr. Meenu Kalia Demonstrator, Department of Community Medicine, Government Medical College Chandigarh, India. Dr. Alka Sehgal Associate Professor, Department of Obs & Gyn, Government Medical College Chandigarh, India Corresponding contributor: Dr. Chetna Mangat Resident, Department of Community Medicine, Government Medical College, Sector 32. Chandigarh - 160047, India. Email : chetna9709@yahoo.co.in

ABSTRACT Objectives: 1. To find the prevalence of various contraceptive methods in slum population. 2. To evaluate men's opinion on condom usage. Study Design: A cross-sectional study was done on slum inhabitants of Chandigarh, India. Methods: Two-stage random sampling technique was used. Sample population comprised 402 males whose wives were in the reproductive age group. Results: 265 (65.9%) respondents were using contraceptives. Condom was the most common contraceptive being used by 156 (58.9%) of the sample. Easy availability 124 (79.5%), no side effects 55 (35.3%) and unwillingness of spouse for other contraceptive method 51 (32.7%) were among the main reasons in favour of condom usage. More than one third of participants i.e. 141 (35.1%) felt that they should use the contraceptive methods and 74 (18.4%) felt that wives should opt for it. Condom users were more involved in pre-marital and extra-marital sex acts. High / middle socioeconomic status and involvement in pre-marital sexual activities were significant factors associated with condom usage. Conclusions: Men are showing an increased interest in family planning affairs and can play a vital role in deciding the size of the family. Hence their participation has to be encouraged. Key words: Condom, male preferences, reproductive age, family planning

INTRODUCTION

Encouragement of male participation is a promising strategy for addressing some of the world's most pressing reproductive health problems. [1] Men being the dominate decision makers regarding family affairs in developing countries can directly or indirectly affect women's reproductive health. They can promote safe motherhood by planning their families as well as accompanying their partners to meet health providers where they can learn about the available contraceptive methods. Further they can help their partners to use modern contraceptive methods correctly, can encourage them to seek help from health providers if side effects occur and also they themselves can opt for male contraceptive methods. Hence, men deserve more attention in the ongoing family planning and other reproductive health programmes for the betterment of their families and community. [2]

A lot of research programs in the developing as well as developed countries pertaining to the acceptance and promotion of family planning methods, are now focusing on men's involvement, which was encouraged even in 1994 during the Cairo International conference. [3] In India too, focus has been shifted to some extent from females to males in the promotion of contraceptive techniques. Condoms are being promoted widely via a condom promotion program, as this is the best method to thwart the continuing spread of HIV / AIDS and thus having a dual advantage. [4, 5] Along with this, vasectomy techniques have been made simpler, cheaper and safer, making male sterilization a more attractive option, both for providers and users.

In the past family planning programs were just focusing on women instead of men. So, there is dearth of data pertaining to male's participation in family planning. Hence, an effort was undertaken to seek men's perception towards various contraceptive methods with emphasis on condom usage in slums of Chandigarh, India.

METHODS

Study Settings: The study was conducted in UT Chandigarh, located in the northern part of India. According to the 2001 census, population of Chandigarh is 900,635. Out of the total population, urban population is 808,515, slum population comprises of 506,938 males and 393,697 females, with a sex ratio of 777 and population density of 7,900.

Study Design: A community based observational cross-sectional study.

Target Population: Males in slum setting whose wives were in the reproductive age group.

Sampling Design: Two-stage random sampling technique was used. In the first stage all the slums of UT Chandigarh were enlisted and randomly one slum was selected. Out of the total 26 slums, the slum randomly chosen was the largest slum of Chandigarh with a population of approximately 27,000 with 4,000 - 4,500 dwelling units. In the second stage, systematic random sampling technique was used. Every 7th house was visited and subjects who fulfilled the inclusion criteria were enrolled. The locked houses and people in those dwellings where subjects were not willing or were not fulfilling the inclusion criteria, were not taken into the study sample. Confidentiality was assured and informed consent was taken from the subjects after explaining the purpose of the study. In 592 households, 79 houses were locked.

Sample Size: A total of 402 respondents were interviewed by a trained team of social workers and interns. 111 were not willing to participate in the study, (46 had no time, 46 showed no interest and 19 felt uncomfortable over the subject). Study Instrument: A questionnaire for the study was especially designed to compile information relating to aims of study. Open ended and close ended simple questions were used to elicit information on the background characteristics of subjects like age group, education, occupation, marital status and socio-economic status, family size preferences etc. Along with this their preferred method of contraceptive was asked Condom users were asked in detail about the place of procurement, problems with condom usage, satisfaction level etc. Appropriate statistical methods were used to analyse data using epi info and SPSS version 12.

RESULTS

Socio-demographic characteristics of respondents are shown in Table 1. These were 402 respondents, with the maximum 178 (44.3%) belonging to the 31-40 years age group followed by 157 (39.1%) in the age group 21-30 years. A very low proportion19 (4.7%) were educated above secondary level and 158 (39.3%) were either illiterate or just literate. Labourers represented the maximum 271(67.4%) respondents and there were a minimum 16 (4.0%) unemployed respondents. More than three-quarters of respondents were married and between 18-24 years of age. The majority of respondents 371 (92.3%) were of low socioeconomic category.

Table 1: Distribution of Respondents by Socio-Demographic Characteristics

Table 2 presents attitude and practices regarding contraception. More than 1/3rd of subjects 141(35.1%) felt that husbands should use any method of contraception and 74 (18.4%) of them felt that their wives should use contraceptive methods. About 105 (26%) respondents were of the opinion that neither wife nor husband should use any methods of contraception. Awareness regarding contraception was found among 286 (71.1%) respondents, mostly through mass media. Only 97 (33.9%) had awareness regarding contraception from health workers. Other sources of awareness contributed a very small proportion. Condom 145 (36.1%) followed by OCP 91 (22.6%) came out to be most common choices. Permanent methods somehow were found to be preferred methods of contraception only in 23 (5.7%) respondents. Contraceptive prevalence rate came out to be 265 (65.9%) and condom was the most common method of contraception currently. There were 112 (44.3%) users who were not satisfied with the use of current contraceptive method, whereas degree of satisfaction from condom among contraceptive users, was quite high.

Table 2: Attitudes and Practices Towards Contraception

Contraceptive prevalence rates by socio-demographic characteristics and methods of contraception are shown in Table 3. On the basis of bivariate analysis all the factors except age, like educational status (P=0.003), occupation (P=0.01), and SES (P=0.03) were significant correlates of contraceptive use. Condom use rate was found to be maximum in the 21-30 years age group where 68 (43.3%) respondents reported condom use. Other contraceptive methods were reportedly more popular among respondents aged 31-40 years. Overall increasing trends of both types of contraceptives were observed with educational status. Contraceptive prevalence rate (CPR) was least, 91 (57.6%) among illiterate / just literate respondents CPR and condom usage was found to be maximum 41 (82%) and 23 (46%) respectively within the service class. CPR was found to be maximum 21 (91.3%) within middle SES.

Table 3: Use of Contraceptives by Socio-Demographic Characteristics

Out of the total subjects, 156 (38.8%) were using condoms. There were six respondents using more than one method of contraception. Among all respondents, 178 (44.3%) were aware of condoms and the majority 156 (87.6 %) of them were using condoms as shown in Table 4. Chemist shop came out to be the commonest source of procurement of condom as reported by 98 (62.8%) of respondents followed by Health Centre by 74 (47.5%) respondents. Easy availability was the most common perceived reason in favour of condom usage in 124 (79.5%) respondents, other reasons being no side effects in 55(35.5%) and unwillingness of spouse for other method in 51 (32.7%) respondents. More than three quarters were satisfied 121 (77.6%) with its usage. Reasons reported for dissatisfaction by the rest of respondents were interference with sex sensation in 14 (48.3%) and risk of rupture of condom in 12 (41.3%).

* multiple responses

Table 4: Knowledge, Attitude, and Practice Of Male Contraception

Table 6: Logistic Regression Analysis of Factors Affecting Contraception

Only 97 (62.2%) condom users were regular users making its use non-effective. Only 48 (30.8%) users were aware of its correct method of usage. According to 116 (74.4%) users, their wives were also satisfied by condom usage as a contraceptive choice. Prevention of HIV/AIDS by condom was known to 124 (79.5%) users while 28 (17.9%) were not aware of any disease preventable by using condom. High risk behaviour in terms of premarital sex and extra-marital sex was found to be among 39 (9.7%) and 22 (5.5%) of all respondents respectively. There practices were found to be most prevalent among respondents of aged 21-30 years (11.5% & 10.2%) less educated (15.2% & 8.3%).

Respondents of business class were reportedly more involved 8 (12.3%) in pre-marital sex act whereas extra-marital sex activity was reportedly highest among unemployed respondents 2 (12.5%). Both of there practices were more common among respondents of middle Socioeconomic status (SES) category. Condom users were found to be more involved in such type of behaviour / activities.

Factors responsible for condom use, and satisfaction from use of contraception were analyzed using logistic regression analysis, as shown in Table 6. Several potential factors were entered. However, for condom only SES and involvement in pre-marital sex activity came out to be significant factors in step-wise logistic regression analysis.

Premarital sex was the main factor associated with satisfaction from use of condom followed by middle or high socioeconomic status. Individuals belonging to high socioeconomic status other than low, and those who were involved with pre-marital sexual activity were found to be comparatively more satisfied with use of condoms.

For either of contraceptive use, the only significantly associated factor was age (below 30) of respondents. In all these three logistic regression models, all other variables not listed in the table had lost their significance.

The following three logistic regression models were fitted:-

DISCUSSION

Preference for usage of contraceptive to limit family size is more or less decided by the male partners especially in less developed countries like India. Our study showed that contraception use rate was more than 50%, and out of these almost half were condom users. Another study done in same population showed the condom usage to be 31% that increased to 70% after intervention in Chandigarh.[6] But the results were in contrast to the study done in Tanzania[7] and Yorubas[8] that showed that though the awareness about condoms was high, the usage was less.

More than one third of subjects affirmed the usage of OCP's and IUCD by their spouse for family planning, which was comparable to NFHS-3 data.[9] Females out-numbered males in sterilization. The study done in Orissa showed that almost half of the subjects were using some family planning methods and 1/3rd of them relied on traditional method of contraception (LAM Safe Period). [10] In the rest of respondents female sterilization predominated.

In spite of many Government initiatives taken for family planning, a sense of hesitancy was observed in subjects in procuring condoms.[11] The majority of them procured condoms from the chemist shop instead of getting them from a health centre. Only 1.3% were obtaining them from grocery shops. One major reason for a smaller percentage of people buying them from grocery shops can be ignorance, as most of people staying in slums have migrated from underserved states where reproductive and health facilities are not reaching the masses. Another interesting finding was that the wives were obtaining condoms during the days of under five clinic in our health center instead of husbands. Maharaj's qualitative work also revealed that profound embarrassment was found regarding condom procurement, [12] that's why subjects procured them either at night or away from their neighbourhood. This highlights the importance of government initiatives in installing the vending machines at different places for easy availability and privacy. In our study more than 1/3rd of husbands felt that contraceptive measures can be used by males also and this supports the fact that male interest in family planning affairs is increasing.[2] Preference for condom usage was found in 1/3rd of subjects. The main reasons for using condoms among condom users, were easy availability and no side effects. These results corroborate with that of the Mitra and Mitra study. [13] Varied responses were given for dissatisfaction with condom usage. Interference with sex sensation predominated among those, followed by danger of breakage; similar findings were evident in other studies. [14, 15]

Undoubtedly, Condom access and promotion should go hand in hand. They should be available not only in health centers but also at hotels, bars and grocery shops. In this sphere an initiative was taken by UT administration by opening of a condom bar to create a positive image of condom usage portraying them as fun, reliable and important. They can be made available at standardized prices at retail shops through social marketing.

It was found that 3 quarters of females were satisfied with condom usage as per the husband's opinion. This finding may be owing to the fact the females were not interviewed about the same during the survey. Another finding so evident in the study done in Bangladesh was that when males were decision makers they preferred the male method of contraception irrespective of spouse's approval.[16]

More than 3 quarters of the subjects were aware of the uses of condoms such as prevention of HIV/AIDS and around 30% were knowledgeable about prevention against STD's. The same findings were obtained from a study done by Meekers and Rahaim. [17] Similarly a study from India has shown that people have a fairly good knowledge because of increased exposure to various media.[10] The various steps of condom usage that includes correct method of usage and disposal were reported by almost 30% of subjects. This implies the importance of making them aware of the correct method. These results were similar to that of a study done by Bhatia et al. [6] Efforts to increase condom use are a good social, economic and health investment, but if only knowledge about it increases this won't lead us to achieve our target. Communication campaigns and community health programs can help to make a positive image of condom use. World wide condom usage ranks near the bottom among contraceptive methods used by married couples. This can be assessed from the fact that in Japan the number of married couples who are relying on vasectomy as mode of sterilization equals that of 1/5th of the number of married couples worldwide. [18] In India, condom use declined from about 5% in 1988 to about 2% in 1994 but most of the data is based on surveys done in women of reproductive age group only.

CONCLUSIONS

Authors concluded that men are showing keen interest in reproductive health matters and being the prominent decision-makers they should be the suitable targets for coordinated and strategic family planning programs. Everyone, government, international agencies, non-governmental organizations social marketing programs, individual health care providers, educators and communicators should contribute in promoting their participation.

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