Involving Men in Reproductive Health - NCBI

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Geoffrey N. Do female primary care physicians practise preventive care ... McColvin Scott, MD, Lorraine Tiezzi, MS, and James F McCarthy, PhD. In recent years ...
Briefs 7. Social and Sexual Issues Committee. Committee opinion-sexual health counselling by physicians. J Soc Obstet Gynecol Canada. 1996;18:1160. 8. Canadian Task Force on the Periodic Health Examination. HIV antibody screening. Can MedAssoc J. 1992; 147:867-876. 9. Boekeloo BO, Marx ES, Kral AH, Coughlin SC, Bowman M, Rabin DL. Frequency and thoroughness of STD/HIV risk assessment by physicians in a high-risk metropolitan area. Am JPublic Health. 1991;81:1645-1648. 10. Maheux B, Haley N, Rivard M, GervaisA. STD risk assessment and risk-reduction counseling by recently trained family physicians. Acad Med. 1995;70:726-728. 11. Centers for Disease Control and Prevention. HIV prevention practices of primary-care physicians-United States 1992. MMWR Morb Mortal Wkly Rep. 1994;42:988-993.

12. Lewis C, Freeman HE. The sexual history-taking and counseling practices of California primary care physicians. West JMed. 1987;147:165-167. 13. Boekeloo BO, Rabin DL, Coughlin SS, Labbok MH, Johnson JC. Knowledge, attitudes, and practices of obstetricians-gynecologists regarding the prevention of human immunodeficiency virus infection. Obstet Gynecol. 1993;81:131-136. 14. Calabrese LH, Kelley DM, Cullen RJ, Locker G. Physicians' attitudes, beliefs, and practices regarding AIDS health care promotion. Arch Intern Med. 1991;151:1157-1160. 15. Wenrich MD, Curtis JR, Carline JD, Paauw DS, Ramsey PG. HIV risk screening in the primary care setting: assessment of physicians' skills. JGen Intern Med. 1997;12:107-113. 16. Gemson DH, Columbotos J, Elinson J, et al. Acquired immunodeficiency syndrome: prevention knowledge, attitudes, and practices of primary care physicians. Arch Intern Med. 1991; 15:1102-1108.

17. MacMillan HL, Fleming JE, Trocme N, et al. Prevalence ofchild physical and sexual abuse in the community. JAMA. 1997;278:131-135. 18. Green AH. Child sexual abuse: immediate and long-term effects and intervention. JAm Acad Child Adolesc Psychiatry. 1993;32:890-902. 19. Proceedings of the National STD Consensus Meeting and National Goalsfor the Prevention and Control ofSexually Transmitted Diseases in Canada. Ottawa: Health Canada; 1997. 20. Gully P. Chlamydial infection in Canada. Can MedAssoc J. 1992;147:893-896. 21. Woodward CA, Hutchison BG, Abelson J, Geoffrey N. Do female primary care physicians practise preventive care differently from their male colleagues? Can Fam Physician. 1996;42: 2370-2379. 22. Maheux B, Haley N, Rivard M, Gervais A. Do women physicians do more STD prevention han men? Quebec study of recently trained family physicians. Can Fam Physician. 1997; 43:1089-1095.

Involving Men in Reproductive Health: The Young Men's Clinic Bruce Armstrong, DSW, Alwyn T Cohall, MD, Roger D. Vaughan, DrPH, McColvin Scott, MD, Lorraine Tiezzi, MS, and James F McCarthy, PhD In recent years, efforts to target and address the reproductive health needs of young men have increased,3- although few of these service programs have been sustained.4 This is unfortunate, because adolescent and young adult males represent the other half of the equation for the reproductive health problems affecting millions of young people each year, and they may serve as vectors for possible solutions to many of these problems. There are many reasons for the lack of sustained development of affordable, developmentally and culturally appropriate reproductive health programs for men, as well as for men's reluctance to approach available services. Adolescent males typically see themselves as too old for the pediatrician but too young for the internist. Because they are young, many are uninformed about how to gain access to health care on their own or are reluctant to do so because of embarrassment or cultural proscriptions that equate seeking help with inappropriate masculine behavior. Moreover, unlike females who must visit a reproductive health care provider for most contraceptive methods, males may perceive fewer reasons to use reproductive health care. Even young men who are sufficiently motivated to gain access to repro-

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ductive health services face formidable structural barriers to receiving care, and health care staffs are often inadequately trained to address the needs of adolescent and adult young men.S As a result of both individual and environmental factors, young men often wait a long time before seeking needed reproductive health services. The consequences ofthis inattention and the magnitude of the reproductive health diseases experienced by US adolescents and young adults are enormous, and Bruce Armstrong, Roger D. Vaughan, Lorraine Tiezzi, and James F. McCarthy are with the Center for Population and Family Health, Joseph L. MailSchool of Public Health of Columbia University, New York, NY. Alwyn T. Cohall is with St. Luke's-Roosevelt Hospital, Joseph L. Mailman School of Public Health of Columbia University, and the Harlem Center for Health Promotion and Disease Prevention, New York, NY. At the time of the study, McColvin Scott was with St. Luke'sRoosevelt Hospital. Requests for reprints should be sent to Roger D. Vaughan, DrPH, Center for Population and Family Health, J. L. Mailman School of Public Health, Columbia University, 60 Haven Ave, Level B-2, New York, NY 10032. This paper was accepted January 27, 1999.

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adolescents of color are disproportionately afflicted by these diseases.4' Nevertheless, both national and international data provide numerous indications that many men are motivated to participate in reproductive health care behaviors and services, despite the formidable obstacles they face.'2 We believe, however, along with others,2 that men will continue to be reluctant participants in reproductive health care until they receive clear messages that their needs are important and that they themselves are vital in efforts to promote the reproductive health of both genders. One model for delivering reproductive health services to men that conveys this message is the Young Men's Clinic in New York City. This report describes the patient population of young men who use the clinic, presents a profile oftheir reproductive behaviors, and introduces our model of service delivery, including a brief description of the development and staffimg of the clinic and the services that are currently provided. A more thorough description of programs that create the context for operating the Young Men's Clinic can be found elsewhere.'3-18

Methods Description of Community and Clinic The Young Men's Clinic operates in the northern Manhattan community ofWashington Heights. This area has a growth rate 3 times that of New York City as a whole. It has the largest number of people on public assistance among all community districts in New York City, with over one quarter of its residents receiving some form of public assistance; nearly two fiftfhs are eligible for Medicaid.19 The community is currently more than two thirds Hispanic, primarily of Dominican descent. Forty percent of immigrants to New York City are from the Dominican Republic20; Dominicans are the fastest-growing segment of the population in New York City, where, in the 1990s, overall immigration increased 52% over the 1980s rate.20 In 1986, a pilot Young Men's Clinic program was initiated that has continued to expand in size and in services provided; it now operates 1 evening and 1 afternoon a week. At each session, 25 to 40 young men are typically served; individual visits usually consist of 80% medical counseling and 20% mental health counseling. Approximately 1200 visits are made to the clinic each year by men aged 14 to 34 years. The services provided by the Young Men's Clinic are comprehensive and include physical examinations, treatment for acute illness, and the management of chronic illness, as well as dealing June

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with issues related to reproductive health and psychosocial problems. The Young Men's Clinic is usually staffed by 2 physicians (1 attending and 1 resident), 1 nurse-practitioner or physician's assistant, 1 master's-level social worker, 1 health educator, 1 laboratory technician, 1 receptionist, and a rotating pool of first-year medical students who participate as part of a clinical elective. In addition, graduate students from the Joseph L. Mailman School of Public Health provide group health education services in the waiting room of the clinic. While general primary health care services are available, the clinic's focus is on the reproductive health behaviors of young men. Medical providers introduce the idea of being screened for sexually transmitted diseases (STDs) regardless of the presenting complaint. Public health students design health education group activities to provide basic reproductive health information (e.g., how to do testicular self-examinations), as well as to encourage men to disclose and critically examine the behavioral and normative beliefs underlying their sexual and reproductive behaviors. Groups also create opportunities for practicing skills such as proper use of condoms, initiating conversations about contraception with sexual partners, and expressing support for a partner's use of contraception. Medical students take thorough biopsychosocial histories by using the "BiHEADS" approach21-24 (an acronym incorporating Body image; Home situation; Education and employment; daily Activities; history of Depression, suicidal feelings, and substance use; and Sleeping and eating habits). The main emphasis of these interviews is completing detailed sexual histories, helping young men to examine reproductive health beliefs, and providing education and roleplaying opportunities regarding condom use. Psychosocial problems in need of further attention (e.g., depression, difficulty finding work or reconnecting to school) are referred to the clinic's social worker.

Data Collection A clinic visit form is completed by a medical student, social worker, or medical provider for each new patient and for any patient who has not used the Young Men's Clinic for at least 6 months. The form contains items regarding patient demographics, type of visit, employment and school status, reason for visit, sexual and reproductive information, psychosocial assessment items, medical diagnoses, and services rendered. Patients are identified and forms are linked across visits by medical record numbers issued by the hospital. The data presented here represent

visits in 1995 from all new patients and from patients whose follow-up visit occurred more than 6 months after the initial visit (n= 529). Means and proportions of patient characteristics and clinical services were calculated, and simple %2 tests for significance ofthe equality of proportions were computed.

Results As shown in Table 1, the vast majority of Young Men's Clinic patients were of Dominican descent and close to half listed Spanish as their primary language. Approximately one quarter were covered by Medicaid, and over one third indicated that they had no source of health care in the past year. Seven percent of patients listed a hospital emergency room as their primary source of health care. Of particular interest is that while most young men presented for physical examinations, nearly one quarter also presented because of a suspected STD. Over one quarter (26%) of the young men who presented for a routine physical examination were also treated for an STD (data not shown). Reproductive characteristics of sexually active patients are presented in Table 2. Nearly 70% of the Young Men's Clinic patients who presented in 1995 were sexually experienced. Although three quarters ofthose who were sexually active reported ever using birth control, consistent birth control use and consistent condom use were somewhat lower (61% and 54%, respectively). Over one third of men indicated being responsible for a pregnancy and close to one fifth reported ever having had an STD. A major goal of the Young Men's Clinic is to provide reproductive health services to a medically underserved segment of the population. Although the goal of the current study was not meant to provide formal evaluation of the impact of the clinic, we did note that among the subset of males (n = 247) who in calendar year 1995 made both an initial and follow-up visit, the proportion who reported condom use at last sexual encounter increased from 32.0% to 47.4% (X2=12.2, P