Potential impact of hormonal male contraception: cross-cultural implications for development of novel preparations

C.W. Martin1, R.A. Anderson2,6, L. Cheng3, P.C. Ho4, Z. van derSpuy5, K.B. Smith1, A.F. Glasier1, D. Everington1 and D.T. Baird1

1 Contraceptive Development Network at Department of Obstetrics and Gynaecology, University of Edinburgh, 2 MRC Reproductive Biology Unit, Centre for Reproductive Biology, Edinburgh, UK, 3 Institute of Family Planning and Technical Instruction, 145 Guangyuan Road, Shanghai, People's Republic of China, 4 Department of Obstetrics and Gynaecology, University of Hong Kong, Queen Mary Hospital, Pokfulam Road, Hong Kong and 5 Department of Obstetrics and Gynaecology, University of Cape Town, Anzio Road, Cape Town, South Africa


    Abstract
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 References
 
The prospect of a hormonal male contraceptive is no longer distant. Data on the potential impact of this improvement in contraceptive provision, however, is limited, particularly between different cultures. We have therefore carried out a multi-centre study to assess men's attitudes to proposed novel hormonal methods. Questionnaire-based structured interviews were administered to men in Edinburgh, Cape Town, Shanghai and Hong Kong. Approximately 450 men were interviewed in Edinburgh, Shanghai and Hong Kong, and a slightly larger group (n = 493) in Cape Town to give samples (n > 150) of black, coloured and white men. Knowledge of existing male and female methods of contraception was high in all centres and groups. The majority of men welcomed a new hormonal method of contraception, 44–83% stating that they would use a male contraceptive pill. Overall, a pill was more acceptable than an injectable form (most popularly given at 3–6 month intervals); long-acting implants were least so except in Shanghai. Familiarity with comparable female methods appeared to influence acceptability, for both oral and injectable methods. Hong Kong was the only centre where a male method (condom) was currently the most commonly used; men there appeared to rate the convenience of condoms highly while being least likely to think that they provided effective protection against pregnancy compared to other centres, and were least enthusiastic about novel male methods. The acceptability of potential male hormonal methods of contraception was high in some groups but showed wide variability, determining factors including cultural background and current contraceptive usage. These results suggest that the emerging emphasis that men should have greater involvement in family planning will be substantiated when appropriate contraceptive methods become available.

Key words: acceptability/attitudes/cultural setting/knowledge/male contraception


    Introduction
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 References
 
Access to a wide range of effective methods of contraception is an important element of reproductive health. The development of new methods of contraception, such as the combined oral contraceptive pill in the 1960s and more recently medicated intrauterine devices (IUD) and long term implants, has been mainly female-directed. Despite this one-sided approach to contraceptive provision, a third of couples practising contraception world-wide use a male method (United Nations, 1994Go). Lack of demand for more advanced reversible male methods is frequently advocated as a reason for limiting the already meagre research effort in this field (Potts, 1996Go). The widespread usage of male methods, however, suggests that any lack of demand is more perceived than real, but there are limited data on this subject (Ringheim, 1993Go).

The prospect of a clinically available hormonal male contraceptive has been considerably advanced in recent years. The contraceptive efficacy of a prototype, testosterone-based, method has been demonstrated [World Health Organization (WHO), 1996]. Combinations of testosterone with a progestogen (Bebb et al., 1996Go; Handelsman et al., 1996Go; Meriggiola and Bremner, 1997Go) may show more rapid and consistent suppression of spermatogenesis, and long-acting testosterone preparations are becoming available (Behre et al., 1995Go). Formulations may therefore include oral, injectable and implant preparations.

In view of this divergence between perceived need and actual usage, we have investigated men's attitudes to contraception. The progress in development of potential methods allows inclusion of likely specific formulations to address their potential impact, and the wide global variations in contraceptive usage necessitate that this be addressed in different cultures.


    Materials and methods
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 References
 
The participating centres in this study were Edinburgh, UK; Cape Town, South Africa; Shanghai and Hong Kong, People's Republic of China. A total of 1829 men (~450 per centre) was recruited between October 1995 and December 1996. The study group was recruited from (i) new or expectant fathers (exclusively new fathers in Shanghai); (ii) fire-fighters in Edinburgh, Hong Kong and Shanghai and army personnel in Cape Town; and (iii) men attending Blood Transfusion Services to donate blood. These groups were selected to achieve a sample population at different stages of their reproductive careers, and which would allow similar groups of men in the different centres to be compared. Equal numbers of men were recruited from these three groups except in Cape Town: very few black men were recruited from Blood Transfusion; thus, to ensure approximately equal numbers from the coloured, black and white ethnic groups, additional men were recruited from the other two groups.

Data were collected through structured interviews using a questionnaire filled in by a trained interviewer. The questionnaire took ~30 min to complete. In each centre the questionnaire was translated from English to the appropriate local language by a fluent interpreter and checked by back-translation. Interviews were conducted in the subject's first language: English in Edinburgh, English, Afrikaans or Xhosa in Cape Town, Mandarin in Shanghai, and Cantonese in Hong Kong. In each centre, permission to conduct the study was granted from the local ethical committee. Informed consent was given by all subjects before interview.

The questionnaire aimed to assess the attitudes of men to currently available male methods of contraception and their opinion about oral, injectable and implant preparations which may become available in the future. The questionnaire therefore covered three main areas: (i) sociodemographic data, including religious beliefs; (ii) knowledge of contraception and current use; (iii) attitudes towards hormonal methods for men.

In Edinburgh, 80 men refused to complete the questionnaire, 34 refused in Hong Kong and 76 men in Cape Town, mainly due to lack of time. There were 45 refusals in Shanghai mainly because these men objected to the idea of a questionnaire about contraception.

Statistical methods
All data were returned to Edinburgh for analysis. In general, completeness of data was high, typically 98–100%, with the exception of black Cape Town men for questions concerned with attitudes to contraceptive methods where completeness was ~93%. Associations between pairs of variables were tested by t-tests, {chi}2 or Spearman rank correlation tests as appropriate.

Multivariate linear regression was used to analyse the likelihood of men using novel hormonal male methods (5-point score ranging from `definitely would' to `definitely would not' use). Multivariate logistic regression was used to analyse men's first choice between condoms, a daily pill, injection or implant. For both linear and logistic regressions, the following factors were assessed for significance: age, having children (yes/no), wanting children in the future (yes/no), married/co-habiting (yes/no), and having a higher qualification (yes/no). Variables were selected for the model using forward selection with age given priority over the other variables since age was likely to affect other variables rather than vice versa. The analysis of men's first choice tested whether current contraceptive method influenced their preference.

Preliminary analysis demonstrated that there were only minor differences in attitudes between the three sources of recruitment (new and expectant fathers, blood donors and firemen/soldiers), thus these groups were combined.


    Results
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 References
 
Characteristics of study population
In Cape Town, 493 men were interviewed (153 black, 171 white and 169 coloured), 450 men in Hong Kong and Shanghai and 436 in Edinburgh. Demographic details and reproductive status are shown in Table IGo. Men in Shanghai were older than in the other centres and the majority (70%) had completed their families. Only a small number of men declared no interest in having a family at any stage (2–6%).


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Table I. Demographic details of participating centres
 
Current contraceptive usage
Table IIGo shows the current contraceptives used by men or their partners in the four centres, excluding new or expectant fathers who would not have a current contraceptive requirement. There were marked differences (P < 0.001) between centres and between ethnic groups in Cape Town. The majority of men, other than black men, were using some form of contraception: 74% overall, 41% among black men. Female hormonal methods were the most widely used method of contraception in Edinburgh and all ethnic groups in Cape Town. Very few partners of Edinburgh men, white Cape Town men or Chinese men were using injectable methods. The IUD was the most common method in Shanghai, and uncommon in other centres. Only one couple in Shanghai was relying on female hormonal methods. Condoms were the most common method in Hong Kong, and the second or third most common method in other groups, accounting for 17–62% of current usage. Vasectomy was relatively common among white men in Cape Town and in Edinburgh, particularly in comparison with female sterilization, but was used very little in the other centres.


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Table II. Current contraception (excluding new or expectant fathers)
 
Knowledge of and attitudes to existing contraceptive methods
Men were asked to give as many female and male contraceptive methods as they could think of, without prompting. Table IIIGo shows the proportions of men who recalled the major current female and male methods, and the proportions of men who had used those methods.


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Table III. Contraceptive knowledge and past usage
 
There was a highly significant difference (P < 0.001) between centres and ethnic groups with respect to knowledge of current male contraceptive methods. While knowledge was generally high, black men in Cape Town were unlikely to recall other than commonly used methods (condom, pill, and injection). Shanghai men had the greatest knowledge of methods of which they had no direct experience.

There were differences between centres in men's views on condoms for effectiveness (P < 0.001) and convenience (P < 0.001) but less so for decreasing sexual satisfaction (P < 0.01) (Table IVGo). Men in Edinburgh were most likely to regard condoms as effective but least likely to find them convenient to use whereas the opposite was found for Hong Kong men, where usage was highest: men there were least likely to think them effective for preventing pregnancy but most likely to regard them as convenient. This difference between Hong Kong and other centres also applied to men who were current condom users rather than just the group overall: only 72% of Hong Kong current users agreed that condoms were effective for preventing pregnancy compared to 92–95% of users in the other centres.


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Table IV. Men's views on male methods
 
Attitudes to potential contraceptive methods
Men were asked a series of questions about male methods which may be available in the future, i.e. a daily pill and injectable/implant contraceptives, and their answers were compared to their views on condoms (Table IVGo). In the introduction to the questions on proposed male methods, subjects were told that these methods would provide reliable contraception, would not carry significant risk of side-effects and would take 3–4 months to become effective. Questions were therefore designed to assess men's attitudes to these novel preparations separate from concerns about safety and efficacy although questions regarding these issues were included. Despite these reassurances, many men appeared to remain sceptical about the safety and efficacy of the proposed methods although there were large differences between centres. Thus there were differences between centres for perceived contraceptive efficacy, convenience, reduction in sexual satisfaction and reduction in masculinity (P < 0.001 in each case for both a male pill and an injectable contraceptive). This was particularly the case with Hong Kong men, of whom only 36% and 38% felt that a male pill and injection respectively would be effective at preventing pregnancy. As discussed above, however, Hong Kong men also had doubts as to the efficacy of condoms (only 60% believing them to be effective) despite the finding that they were the most widely used form of contraception in that centre and that 79% of condom users were happy with their current form of contraception.

Men had more positive attitudes to the convenience of novel male methods. The male pill was regarded as more convenient to use than condoms in Edinburgh and in Cape Town. Men in the Chinese centres, however, regarded condoms as more convenient, particularly in Shanghai where only 38% of men thought a male pill would be convenient compared to 61% for condoms. Similar results were obtained when men were asked whether a male pill or injectable form would be inconvenient to obtain, with a minority (23–34%) of men in Edinburgh and Cape Town stating that an injectable form would be inconvenient, whereas 64% of men in Hong Kong and 46% in Shanghai felt it would be inconvenient.

Condoms were consistently regarded as decreasing sexual satisfaction in all centres (by 48–63% of men). While both a male pill and an injectable form were thought to be more satisfactory in this respect, 16–34% of black men in Cape Town and in the Chinese centres thought that a new hormonal pill or injection would decrease their sexual desire or masculinity. Men in all centres regarded condoms as safer for health reasons: this question was deliberately phrased in a non-specific manner to allow the subject to interpret it as they wished.

The preferred frequency of administration of potential injectable methods was investigated (Table IVGo). Proposed frequencies varied from monthly injections to implants lasting 3 years. The most popular intervals were 3 and 6 months except in Shanghai where 42% said they would prefer implants which lasted 3 years.

Men were asked whether they would use the proposed novel male methods (Table IVGo). Despite the above reservations, a majority of men said they would definitely or probably use a male pill (from 44% in Hong Kong to 83% among white Cape Town men). Responses to the same question regarding an injectable form were less positive in all groups, varying from 32% in Edinburgh and Hong Kong to 62% among white Cape Town men. There was a strong correlation (r = 0.76; P < 0.001) in all centres between men's willingness to use a pill and an injectable form, with nearly all men willing to use a male injection also willing to use a pill. Factors considered in Table IVGo were closely related to whether men thought they would use a novel male method. The strongest predictor for both pill and injectable methods was found to be whether the men thought their partner would wish them to use that method (P < 0.001 in all groups in each case with the sole exception of black Cape Town men for prediction of pill use, n.s.). Concern that novel methods would affect sexual desire was found to be a predictor of use of a male pill in Edinburgh, among black men in Cape Town and in Shanghai (P < 0.01 in each case) and for an injectable form in all groups (P < 0.01 except for black and white men in Cape Town, P < 0.05).

Relationships between demographic data and likely usage were investigated. In Edinburgh older men were more likely to consider a male pill (P = 0.023) whereas younger men in Hong Kong and white men in Cape Town were more likely to consider a male pill (P < 0.001 and P = 0.026 respectively). Edinburgh men were more likely to consider using an injectable contraceptive if they did not have a higher qualification (P = 0.004) whereas in Hong Kong men with a higher qualification (P = 0.033) were more likely to consider this method. Although there was no relationship between strength of religious belief (on a 5-point scale) and likelihood of using novel methods in any centre/group, all three ethnic groups in Cape Town were more likely to say that they would use a male pill if they attended religious services (P = 0.003, P = 0.022, and P = 0.040 for black, coloured and white men respectively). There was no such relationship in the other centres.

Contraceptive preference
The data in Table IVGo suggest that all groups would prefer to use a pill than an injectable form, particularly in Edinburgh where twice as many men would consider using a pill than a injection. The order of preference was tested more directly by asking men to rank condoms, a daily pill, a 3-monthly injection and a long-term implant (Table VGo). The proportion of men rating each method as first choice varied significantly between centres (P < 0.001 for all four methods). Condoms were first choice for over 60% of men in both Chinese centres, other methods being first choice for less than 20% of men. Condoms were also the first choice of 44% of black Cape Town men, but novel methods were first choice for men in Edinburgh and for coloured and white men in Cape Town. Edinburgh men showed a preference for a male pill (33% first choice), although this centre showed the most even distribution between methods. A 3-monthly injection was the most prevalent first choice for both coloured and white Cape Town men (41 and 39% respectively), with a pill being second choice in both groups. A 3-monthly injection was second most prevalent choice with black men. A longer acting implant was the least prevalent first choice among all groups except in Shanghai, but it was still only first choice with 17% of men in that centre.


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Table V. Contraceptive preference
 
Factors associated with contraceptive method of first choice were obtained by multivariate logistic regression. Condoms were more likely to be the choice of younger men in Edinburgh, white men in Cape Town, Hong Kong and Shanghai (P < 0.05 in each case). Black men in Cape Town were more likely to pick this option if they wanted (more) children in the future (P < 0.01). Current users of condoms were more likely to choose condoms except in Edinburgh and coloured men in Cape Town (P < 0.01 for black and white men in Cape Town, P < 0.05 for Hong Kong and Shanghai).

In Edinburgh, having a higher qualification was the only factor associated with ranking the male pill as the first choice (P < 0.05). For black and coloured men in Cape Town, none of the factors investigated show a significant correlation with choosing the pill. Current pill usage was predictive for this choice among white men in Cape Town and in Hong Kong (P < 0.01). This cannot be assessed in Shanghai as only one man indicated that his current method of contraception was the pill; however, men who were using methods other than the two main methods in that centre (condom and IUD) were more likely to choose the male pill.

An injectable form was more likely to be chosen by those men who were married or cohabiting in Edinburgh and among black and white Cape Town (P < 0.05 for Edinburgh and white men in Cape Town, P < 0.01 for black Cape Town men). This was not a predictive factor in Hong Kong, where current use of methods other than condoms was associated with men being more likely to pick this option. Not wanting any (more) children was a strong predictive factor among black Cape Town men (P < 0.001). No significant associations were found between any of the factors investigated and choosing this option among men in Shanghai.

Age was the main factor associated with first choice of an implant. Thus being older in Edinburgh, Hong Kong (P < 0.01) and Shanghai (P < 0.05) and having children in Edinburgh (P < 0.01) showed significant positive associations with this method. Current contraceptive usage was also a significant predictive factor for IUD users in Hong Kong and Shanghai (P < 0.05 and P < 0.01 respectively), using the pill in Edinburgh (P < 0.01) and among coloured Cape Town men (P < 0.01), and using injectable forms among black men in Cape Town (P < 0.05). These factors, however, did not show significant associations among white men in Cape Town.

Sharing responsibility
The sharing of contraceptive decision-making was investigated. In all centres the majority of men reported that decisions regarding contraceptive usage were made jointly, varying from 54% in Hong Kong to 80% of white men in Cape Town (Table VGo). A majority of men in all centres except Edinburgh thought that the responsibility for contraception fell too much on women.

The need for semen analysis and delay in onset of efficacy
It is likely that the use of male hormonal contraception will require analysis of one or more semen samples, therefore men were asked whether the necessity to supply a semen sample would be acceptable to them (Table VGo). There were significant differences between centres, men in Cape Town being most likely to find this acceptable and Chinese men in Shanghai and Hong Kong least likely (P < 0.001). Similar results were obtained when men were asked about the acceptability of a 3–4 month delay before the method became effective, with the exception of Cape Town where this was regarded as less acceptable than the need for semen analysis by all three ethnic groups.


    Discussion
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 References
 
Although a third of all couples world-wide rely on a male-dependent method of contraception (United Nations, 1994Go; Ringheim, 1996Go), there is an emerging emphasis that men should be involved in family planning (ICPD, 1994). The use of male methods also appears to be increasing in many developing countries (Drennam, 1998Go). Although many knowledge, attitudes and practice surveys relating to contraception have been carried out, few contain comparable data on men in different countries (Ezeh et al., 1996Go; Drennam, 1998Go). This survey therefore sought to investigate men's attitudes to novel hormonal forms of contraception which would provide effective male-dependent methods. While it is acknowledged that intention may not predict behaviour (Keller, 1979Go), the information obtained may be of value in the design of future products by biomedical scientists and the eventual introduction of a real method.

The recruitment of men from approximately the same three sources in the four different centres was designed to increase comparability between the centres. This design was adopted in preference to attempting to recruit a random sample from the local population. Blood donors and firemen/soldiers would not be expected to reflect the views of the wider population, but the third group, recent fathers, would be more likely to do so. Importantly, we did not find significant differences between the three recruitment groups in any of the centres, strengthening the validity of these data as representative of the population from which they are drawn. Although there will inevitably be differences between such diverse populations, the demographic details shown in Table IGo show considerable similarities in the composite variable of `reproductive status', i.e. whether the men had or were planning children, or whose families were complete. Men in Shanghai, however, tended to be older, and consequently were more likely to have completed their families. The overall similarity in the responses of men in Hong Kong and Shanghai compared to the other two centres indicates that this had little impact, in agreement with the result of the detailed analysis showing the generally modest influence of reproductive status.

The major finding of this study is that the majority of men surveyed welcomed new hormonal methods of contraception even though they were mostly happy with their current method. Indeed 44–83% said that they would definitely or probably use a male pill. Attitudes to existing and novel methods, however, differed greatly between centres. Hong Kong was the only centre where a male-directed method (condom) was the main method currently used, and men in that centre were least keen on novel methods despite the high prevalence of reduction in sexual satisfaction with condoms (52%, similar to other centres) and low belief in their contraceptive efficacy (60%, lower than all other centres). Lack of belief in contraceptive efficacy also extended to novel hormonal methods despite being assured of this in the introduction to those sections of the interview. Condoms, however, were highly regarded for convenience. Conversely, men in Edinburgh were least likely to regard condoms as convenient although most likely to regard them as effective. These data therefore illustrate differences in factors influencing contraceptive usage in different societies. Thus the finding that a male pill was regarded as more convenient than condoms in Edinburgh and among all ethnic groups in Cape Town but not in Hong Kong or Shanghai may indicate large differences in potential usage. Similarly an injectable form was regarded as more inconvenient in Hong Kong and Shanghai than Edinburgh and Cape Town.

In addition to convenience, concern over interference with sexual functioning and partner's attitudes were strong predictors of potential use of novel methods. Both a male pill and an injectable form were perceived as having a much lower impact on sexual desire/satisfaction than condoms in all centres, particularly in Edinburgh and among coloured and white men in Cape Town. Similar differences between centres were apparent for concern as to whether novel methods would affect self-perceptions of `masculinity'. However, compared to all other factors tested (Table IVGo), anticipated endorsement by the man's partner of usage of both oral and injectable novel methods was the most powerful predictor of potential usage.

Men's knowledge of both male and female existing contraceptive methods was generally high. The only exception was that knowledge among black men in Cape Town was largely restricted to past or present usage of methods. Conversely men in Shanghai had the widest knowledge. There are thus differences not only in knowledge and usage in different cultural settings, but also in the relationship between them. The high prevalence of men's knowledge of both male and female methods found here is consistent with an analysis of men's and women's knowledge and usage in 10, mostly African, countries (Hulton and Falkingham, 1996Go). In that study, usage of male methods was generally low, e.g. the highest rate of ever-use of condoms was 35% (in Ghana) compared to the lowest figure from the current data of 49% among black Cape Town men.

Relationships between age and willingness to use novel methods varied greatly between centres. Thus older men were more likely to use a male pill in Edinburgh, while this was more likely among younger men in Hong Kong who were also more likely to use an injectable form. Having a higher qualification also showed variable correlations, being less likely in Edinburgh men who would use an injectable form but more likely among such Hong Kong men. Age and level of education have frequently been found to have a significant influence on the acceptability of family planning methods in demographic and health surveys carried out in developing countries (Drennam, 1998Go). Reproductive status was generally not an important predictor of potential usage of a novel method in any centre. These findings demonstrate the importance of local and specific investigation of factors influencing uptake of family planning methods.

A second question to assess the potential impact of novel methods involved asking men to rank condoms and three novel methods: a daily pill, an injectable form lasting 3 months, and a long-acting implant. The most consistent finding was of the rejection of novel male methods in the two Chinese centres, with <15% of men ranking a pill or injection first choice. In contrast a significant proportion of men in Edinburgh and Cape Town would choose a pill, injection or implant demonstrating that, as in female contraception, user satisfaction is most likely to occur when a range of methods is available. Injectable methods appeared to be relatively more popular than a pill, in contrast to when men were directly asked whether they would use either method. This may be because in this section men were asked to rank four methods, none of which might have been acceptable. Current use and familiarity with comparable female methods appeared to affect acceptability, similarly to findings in the accompanying study of the acceptability of novel male methods to women (Glasier et al., 2000Go): thus female pill use was highest in partners of Edinburgh and white Cape Town men, where potential male pill usage was also highest. Similar relationships were also apparent for injectable method use, with both current female usage and proposed male usage highest in Cape Town. Current contraceptive usage was dominated by a single method in the two Chinese centres, over 60% using condoms in Hong Kong and IUD in Shanghai, and men in these centres were markedly less interested in novel male methods. Perhaps related to familiarity with the IUD, long-duration methods were relatively popular among Shanghai men: the lowest frequency of administration was most popular and an implant was rated as first choice by 17%.

One potentially valuable area of information from acceptability studies such as this is the identification of barriers to widespread usage of a method. Two relevant areas to novel male methods are the need for semen analysis to confirm azoo- or severe oligozoospermia, and the delay before adequate suppression of spermatogenesis is achieved. The need for semen analysis was regarded as acceptable by a small majority in Cape Town, but by only 17 and 27% in the two Chinese centres. These figures are lower than the proportions of men, even in the Chinese centres, who indicated that they would use a male pill or injection. As the question of semen analysis was raised towards the end of the questionnaire, it is possible that if it had been included earlier, it might have reduced the apparent acceptability of the methods. Men, however, were told that there would be a delay of 3 months before the methods would become effective in the introduction to the questions on each method. This was also regarded as a significant disadvantage to a novel method. It therefore appears that both a delay in onset of effectiveness and a need for semen samples would be significant barriers to the introduction of novel male methods of contraception. These are also key features of vasectomy, however, and do not preclude its widespread use.

Partners' attitudes to novel methods were a strong influence on acceptability to men, and the majority of men in all centres agreed that decisions about family planning should be taken jointly. This finding is in agreement with other studies in a variety of settings (Keith et al., 1975Go; Davidson et al., 1985Go; Grady et al., 1996Go; Drennam, 1998Go) and emphasizes the importance of our finding of very positive attitudes to hormonal male methods in a parallel study in women (Glasier et al., 2000Go). The addition of further contraceptive options potentially adds to the total of contraceptive use, and the female partner's encouragement has been a major factor in men's willingness to volunteer for prototype male contraceptive trials (Ringheim, 1995Go). This finding, from participants in mostly Western urban locations of WHO studies, complements findings from developing countries of the importance of women as the principal sources of information about contraception for their partners (Ringheim, 1993Go).

While acceptability is recognized to be culture specific, failure to find new methods acceptable should not be attributed to cultural bias until access to the method is observed to be easy and appropriate education and information channels have been used to best effect (Ringheim, 1993Go). However, the present results suggest a major dichotomy between the acceptability of hormonal male methods in the two Chinese centres compared to the other centres. The similarity in the responses to this questionnaire between Hong Kong and Shanghai is despite major differences in current contraceptive usage as well as in economic/political terms, as this study was conducted shortly before Hong Kong became part of the People's Republic of China. The acceptability of novel methods among black Cape Town men was relatively high despite the finding that they had the lowest knowledge of current male methods, and is encouraging as to the potential widespread applicability of such methods.

Female-dependent methods have been the subject of considerable scientific advance, offering effective and male-independent contraception. Recent advances in the field of hormonal male contraception provide models for the characteristics of hypothetical preparations and although they remain experimental, the recent announcements of intent by major pharmaceutical companies adds credence to their successful development. The acceptability of potential male hormonal methods of contraception was generally high but showed significant variability between centres, determining factors including cultural background and current contraceptive usage. These results suggest that the current emphasis that men should have greater involvement in family planning will be substantiated when appropriate contraceptive methods are made available.


    Acknowledgments
 
This study was supported by the Medical Research Council and Department for International Development (Grant No. G9523250). We are grateful to Dr Paul van Look for his encouragement and support.


    Notes
 
6 To whom correspondence should be addressed at: MRC Reproductive Biology Unit, Centre for Reproductive Biology, University of Edinburgh, 37 Chalmers St, Edinburgh EH3 9ET, UK Back


    References
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 References
 
Bebb, R.A., Anawalt, B.D., Christensen, R.B. et al. (1996) Combined administration of levonorgestrel and testosterone induces more rapid and effective suppression of spermatogenesis than testosterone alone: a promising male contraceptive approach. J. Clin. Endocrinol. Metab., 81, 757–762.[Abstract]

Behre, H.M., Baus, S., Kleisch, S. et al. (1995) Potential of testosterone buciclate for male contraception: endocrine differences between responders and nonresponders. J. Clin. Endocrinol. Metab., 80, 2394–2403.[Abstract]

Davidson, A., Ahn, K.C., Chandra, S. et al. (1985) The acceptability of male fertility regulating methods: a multinational field survey. In Final Report to the Task Force on Psychosocial Research in Family Planning of the World Health Organization. World Health Organization, Geneva.

Drennam, M. (1998) Reproductive health: new perspectives on men's participation. Population Reports, Series J, no. 46.

Ezeh, A.C., Seroussi, M. and Raggers, H. (1996) Men's Fertility, Contraceptive Use, and Reproductive Preferences (DHS comparative studies no. 18). Macro International, Calverton, Maryland.

Glasier, A., Anakwe, R., Everington, D. et al. (2000) Would women trust their partners to use a male pill? Hum. Reprod., 15, 646–649.[Abstract/Free Full Text]

Grady, W.R., Tanfer, K., Billy, J.O. and Lincoln-Hanson, J. (1996) Men's perceptions of their roles and responsibilities regarding sex, contraception and childrearing. Fam. Plan. Perspect., 28, 221–226.[ISI][Medline]

Handelsman, D.J., Conway, A.J., Howe, C.J. et al. (1996) Establishing the minimum effective dose and additive effects of depot progestin in suppression of human spermatogenesis by a testosterone depot. J. Clin. Endocrinol. Metab., 81, 4113–4121.[Abstract]

Hulton, L. and Falkingham, J. (1996) Male contraceptive knowledge and practice: what do we know? Reprod. Health Matt., 7, 90–100.

ICPD; International Conference of Population and Development (1994) Programme of Action. United Nations, New York.

Keith, L., Keith, D., Bussell, R. and Wells, J. (1975) Attitudes of men toward contraception. Arch. Gynäkol., 220, 89–97.[ISI][Medline]

Keller, A. (1979) Contraceptive acceptability research: utility and limitations. Stud. Fam. Plan., 10, 230–237.[ISI]

Meriggiola, M.C. and Bremner, W.J. (1997) Progestin-androgen combination regimens for male contraception. J. Androl., 18, 240–244.[Free Full Text]

Potts, M. (1996) The myth of a male pill. Nature Med., 2, 398–399.[ISI][Medline]

Ringheim, K. (1993) Factors that determine prevalence of use of contraceptive methods for men. Stud. Fam. Plan., 24, 87–99.[ISI]

Ringheim, K. (1995) Evidence for the acceptability of an injectable hormonal method for men. Fam. Plan. Perspect., 27, 123–128.[ISI][Medline]

Ringheim, K. (1996) Whither methods for men? Emerging gender issues in contraception. Reprod. Health Matt., 7, 79–89.

United Nations (1994) World Contraceptive Use 1994. UN Department for Economic and Social Information and Policy Analysis, Population Division, New York (ST/ESA/SER.A/143).

World Health Organization Task Force on Methods for the Regulation of Male Fertility (1996) Contraceptive efficacy of testosterone-induced azoospermia and oligozoospermia in normal men. Fertil. Steril., 65, 821–829.[ISI][Medline]

Submitted on September 9, 1999; accepted on December 3, 1999.