Journal of Reproductive Health and Contraception

Keywords

Contraception; Men; Knowledge; Couple; Tunisia

Introduction

Contraception is defined by the World Health Organization (WHO) as the use of agents, methods or procedures to reduce the risk of conception or avoid it totally [1,2].

In general, family planning units prioritize women-centered care and surveys on contraception are mainly aimed women. However, there is a growing recognition of the importance of the men’s personal perspective in the implementation of reproductive health care, decreasing unwanted pregnancy and avoiding the abortion complications.

Given that men, often, have significant influences on a couple’s family planning, research suggests that male involvement can increase uptake and garant observance of the use of contraceptive methods [3-5]. Unfortunately, few studies are focusing on assessing men beliefs, knowledge, attitudes and uses of modern contraceptives methods in order to identify the personal, cultural and social barriers impeding their support and uptake of family planning services [6-8].

Tunisia was the first country in the Arab and African world which created an official policy in 1964 “The National Institute of Family Planning” whose goal is to reduce the high rate of births.

To our knowledge, until today, no study has been conducted to evaluate Tunisian men attitude toward contraception or to assess their involvement degree in family planning issues. Thus, the aim of our study is to assess the knowledge and capture the circumstances and sources from which men in Tunisia gain knowledge about contraception and their subsequent perceptions of different contraceptive methods.

Materials and Methods

A descriptive cross-sectional study was performed, including 122 men between 20 and 57 years old from different regions in Tunisia (Mahdia, Monastir, Sousse…).

Our study was spread over a period of one year, from January 2021 to December 2021.

Inclusion criteria were men aged 20 to 57 who accepted to be included in our study. Exclusion criteria were men over 57, under 20 and those who do not wish to participate in our study. A 20-question questionnaire was used for data collection. It was validated by a pre-test with 5 men who did not participate in the study, allowing to estimate the duration of the questionnaire and to observe the reactions and possible misunderstandings of the questions.

The questionnaire was produced in electronic form using Google Forms for internet distribution through social networks (especially Facebook) and it was filled anonymously in Arabic. We examined participant profile, major sources of knowledge about contraception, perceptions of contraceptive side effects among Tunisian men and the factors influencing the level of knowledge of contraception.

Our study does not pose any ethical problem because it does not involve any risk for the participants. Indeed, a moral consent is obtained from the participants who agreed to answer our questionnaire. During our research, anonymity and confidentiality are preserved.

Results

The average age of the participants was 31.3+/-8.7 years with extremes ranging from 20 to 57 years. 65.6% of our participants had a tertiary education, 21.3% were in training while 71.3% were employees. Half of the respondents were married, 34.4% were single and 13.9% were in a couple (Table 1). More than half of the participants (51.6%) had children and 45.4% wanted to have a child in the near future.

Table 1: Socio-demographic and professional characteristics of participants.

The occurrence of an unwanted pregnancy was observed in 21.3% of respondents. Our study revealed that only 15.6% of participants discussed contraception with their doctor and 47.5% did not discuss it with their partners. 70.5% of respondents declared that the responsibility for contraception should be shared within the couple, while 26.2% believed that it is rather the woman’s responsibility. Only 3.3% of participants considered the man is responsible for contraception. Contraception can interfere with the couple's sex life according to 45.1% of the participants. It’s considered a constraint to sexuality for 27% of them.

The internet was the first source of knowledge for participants about contraception (61.5%), followed by the doctor (25.4%), friends (25.4%) and school (24.6%) (Table 2). The majority of respondents (44, 3%) felt insufficiently informed about contraception. Only 13.9% of our population felt fully informed about this subject.

Table 2: Participants’ source of knowledge about contraception.

The male condom is the most known method among men of our population (59.0%), followed by pills (31%) and the IUD (21.3%).

Our study shows a lack of knowledge of other contraceptive such as diaphragm, implant, patch, female condom, injectable progesterone, spermicide, male sterilization (respectively 62,3%; 54,1%; 62,3%, 43,4%; 44,3%; 55,7%; 56,6%) (Table 3). Half of respondents had no knowledge about the emergency contraception and only 14.8% used it at least once.

Table 3: Evaluation of participants’ level of knowledge of the different contraceptive methods.

The condom was the preferred method of male contraception (37.7%). The majority of respondents disagreed with the use of other methods of male contraception (Injectable progesterone, the withdrawal method, male sterilization, male hormone pill; respectively 54.9%; 57.4%; 63.1%; 54.9%) (Table 4).

Table 4: Evaluation of participants’ perception of male contraceptive methods.

Almost a third of participants (30.3%) are currently using contraception (female or male). The male condom was used by almost all of our population. The pill and the IUD are also frequently used (76%, 30% respectively).

Our study reveals a statistically significant relationship between the level of education and the level of knowledge of contraception: 64.2% of participants with a tertiary level of education knew contraception sufficiently/perfectly versus 10.5% of participants with a baccalaureate level and 22.7% of participants with primary or secondary education (p<0.001). Another statistically significant relationship was highlighted between the level of knowledge and the desire for a child: 55.2% of men who wanted a child knew enough/perfectly about contraception versus 40% of those who did not want a child (p=0.032) (Table 5).

Table 5: Study of the level of knowledge of contraception according to socio-demographic and professional factors.

Our study shows that the participants who considered the woman to be solely responsible for contraception had a low level of knowledge of contraception compared to those who considered the couple or the man to be responsible for it (p=0.042).

The participants who considered the contraception a discomfort to sexual life esteemed themselves having a good knowledge of contraceptive methods compared to those estimating the opposite (p=0.041) (Table 6).

Table 6: Study of the level of knowledge according to the perception of contraception.

The level of knowledge was considered insufficient by 51% (p=0.026) and 55% (p=0.033) of participants using the internet and friends respectively, as source of knowledge against 42%(p=0.043) of those consulting a doctor considered their knowledge sufficient (Table 7).

Table 7: Study of the level of knowledge according to the sources of knowledge.

Discussion

Almost the third of participants (30.3%) are currently using contraception.

It corresponds to the prevalence of the use of contraception estimated in Tunisia by the United Nations in 2020 (between 20 and 40%) [9]. The occurrence of an unwanted pregnancy was 21.3% in our population, lower than the worldwide rate of unintended pregnancies esteemed 44% between 2010-2014 [10].

In our study, 70.5% of respondents declared that the responsibility of contraception should be shared within the couple. These participants have a significantly higher level of knowledge about contraception compared to those who believed the woman to be solely responsible for it (p=0.042).

These finding reflects the level of awareness among Tunisian men regarding contraception and family planning.

Actually, in many developing countries, men are still the only main decisionâ??makers on matters such as family planning and contraception use [11].

Yet, male partners support and shared responsibility are proven to positively influence the uptake of family planning services and to promote the use and adherence to modern contraception methods.

The husband’s agreement on family planning was considered one of the most significant factors associated with the use of modern contraceptive methods among married women of reproductive age in rural Jordan.

Our study revealed a statistically significant relationship between the level of education and the level of knowledge of contraception (p<0.001). The association between the knowledge and use of contraception, and the high educational level has been shown by several studies [12,13]. This may explain the level of contraception awareness among our population since 65.6% of our participants had a tertiary education.

Our study tried to assess the use of male contraception among men of our population. Though, only 4 male contraceptives methods are actually commonly used: Condoms, periodic abstinence, withdrawal… [14].

The use of condom seems popular among Tunisian males; it was used by almost all of our respondents and it was the most preferred method of male contraception (37.7%).

Even though the withdrawal was the third most used method of contraception in northern Africa and western Asia according to data from Union Nations 2020; more than half of our population (57,4%) do not agree to the use of withdrawal as a mean of contraception. This finding underlines a good level of consciousness since the withdrawal is associated with high failure rate (19%).

Regarding vasectomy, it was known by 11% of respondents and only 5,7% agree to its use. A systematic review showed that men around the world are not well informed about this method and they keep having a negative image about it, even when they had access to consistent information from healthcare providers or an acquaintance who was satisfied by vasectomy. In the United States, the prevalence of vasectomy was 9% among men aged 20 to 49 in 2019 [15].

As for the hormonal male contraceptive methods, they still faces problems of adverse effects and there is a need for greater understanding of their action on the reproductive tract and other body systems.

The internet was the first source of knowledge for participants about contraception (61.5%), followed by the doctor (25.4%), friends (25.4%) and school (24.6%).

These findings are similar to the results of a local survey of the population of Tunis on knowledge about familial planning issues, published in 2020, traditional media and social networks were the first cited sources of information, followed by friends and health worker [16].

Still, the majority of men participants in our study (44,3%) felt insufficiently informed about contraception. In fact, the level of knowledge was considered insufficient by 51% (p=0.026) of respondents using the internet and 55% (p=0,033) of respondents consulting friends. This lack of knowledge is well illustrated by the lack of awareness about emergency contraception among half of our respondents leading to a great limitation in the use of this modern contraceptive method to only 14% of the participants, as well as the false belief that the contraception may be a hindrance to sexual life among 45.1% of the participants and even the respondents who esteemed themselves having a good knowledge of contraception considered it a discomfort to sexual life (p=0.041).

Though, nowadays, social networks are esteemed a valuable mean of diffusing of new concepts regarding family planning and promoting the use of modern contraception methods for it allowed greater privacy and people described being more comfortable talking about family planning issues online vs. inperson [17]. The impact of social networks was assessed through a study that used existing social groups and influential network actors to engage women and men in reflection dialogues about family planning. The social network intervention led to statistically significant increases in couple and network communication on fertility desires. Both women and men showed significant shifts in the acceptability of discussing of family planning issues in public which reduced the social barriers and helped to address the unmet need for family planning among couples [18]. This type of social network discussion can be a solution for the difficulty expressed by 47.5% of men participating in our study in broaching the subject of contraception with their partners.

The doctor is considered a trusted source of knowledge by our respondents since 42% of those consulting a doctor esteemed their knowledge sufficient (p=0.043). These results are consistent with other study, identifying the healthcare workers as the most trusted sources of family planning information.

In the local survey of the population of Tunisia on knowledge and attitudes regarding familial planning published in 2020, more than 70% of participants preferred health workers as primary sources of information. It then becomes important to promote their role in messages’ transmission, especially when we find only 15.6% of participants discussing contraception issues with their doctors.

Conclusions

Our study highlights Tunisian men's involvement in contraception through their willingness to participate in family planning with their partner and the use of the known and available male contraception methods. Still, measures must be taken to remedy to the lack of knowledge expressed by our respondents. We propose the use of the internet and the healthcare providers as means to achieve this purpose.

Conflict of Interest

The authors have no conflicts of interest.

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