Expectations Toward a Novel Male Fertility Control Method and Potential User Types: Results of a Multinational Survey‡

Hormonal male fertility control (MFC) has already been under investigation for decades, and several surveys have been conducted in this field in recent years. But still knowledge on the attitudes and expectations in males concerning MFC is limited. About one-third of all couples worldwide rely on male-dependent contraception methods, and the importance of the male contribution has often been underscored (Ringheim, 1996; Drenman, 1998). There have been many surveys about attitudes toward and practice of contraception in general, but only a few concerning males opinions (Keith et al, 1975; Davidson et al, 1985; Ringheim, 1993; Ezeh et al, 1996; Hulton and Falkingham, 1996; Drenman, 1998). First impressions have been achieved in some clinical studies (Bebb et al, 1996; Handelsman et al, 1996; Merrigola and Bremner, 1997; Sjörgen and Gottlieb, 2001). A few surveys showed results on knowledge, attitudes, and acceptability of male fertility control (Grady et al, 1996). A recent one showed variability within countries and ethnic groups (Glasier et al, 2000; Martin et al, 2000). Now an MFC method is at an advanced stage of development, and more extensive research on a multinational base has had to be conducted. The MFC study was conducted in 9 countries and 4 continents, and over 9000 males were included. Based on the data collected, this paper tries to describe factors associated with MFC and perceived positively and negatively and aggregate all the information into a potential characteristic of an MFC user as expected several years before a commercial drug is launched. The methods used for the international survey have been published elsewhere (Heinemann et al, 2005). In brief, the objectives of the large cross-cultural survey were as follows: 1) We prepared a comparative survey to provide details about the awareness, attitudes, and acceptability of male fertility control in various methods of administration on a multinational level. Some of the results have been published elsewhere (Heinemann et al, 2005). 2) We analyzed determinants for differences among various groups and described types of potential users in order to draw conclusions concerning further studies. A total of 9342 men aged 18 to 50 were recruited, based on population panels or quota samples. The participating countries were Argentina, Brazil, France, Germany, Indonesia, Mexico, Spain, Sweden, and the United States. In Europe (except for Sweden) and North America, study participants were selected by a random sampling males aged 18 to 50 from existing community panels. These panels have been in wide use for years in the countries concerned; are representative of the overall populations with respect to age, sex, regional structure, and social status (eg, educational, income levels); and in some cases include medical history parameters as well. The methodology has been described elsewhere (Potthoff et al, 2004). In Latin America and Indonesia, the study questionnaires were distributed by interviewers on the basis of a quota sample. Interviewers were sent from house to house in selected regions, recruiting men of the required age group who were willing to participate in this study. When a total of 1000 men had been interviewed in each country, the study was considered complete. The survey was designed as a structured, standardized interview, with identical questions, answers, and sequences in all countries. All questions were multiple-choice, except for 2 open-ended questions. The respondents were questioned about their knowledge of and their general attitude toward existing fertility control methods as well as toward a new male contraception method. The field work started in waves in March 2002. Field work and data entry were completed by the end of June 2002. The cleaned and validated data set was then transformed into an SPSS format, documented with variable labels and value labels, and consequently saved in a general SPSS file, where the access to the individual countries is made possible via a specific country code. Factor analyses and cluster analyses were mainly carried out with the SPSS® for Windows 10.0 statistical package. Additionally, a STATA® 6.0 database was set up for other univariate and multivariate analyses. The sample description will be published elsewhere (Heinemann et al, 2005). In brief, The median age of the participants ranged from 29 years (Mexico) to 40 years (United States). In all the participating countries except for Indonesia the vast majority of the respondents belonged to a Christian religion. Most of the Indonesian participants were Islamic. The percentage of married or cohabiting respondents ranged from 82.1% (Germany) to 62.7% (Argentina). The median number of children was 2 across all centers, but varied markedly between 1 and 20 in some countries. Low education ranged between 7.7% (United States) and 61.3% (Germany) according to our definition (basic education or less). The highest education level (university level) was between 8.4% (Brazil) and 47.3% (United States). It should be stressed that this comparison is biased because of different educational classifications, which could not be overcome. The proportion of the lower third income category (self-assessed) varied between 15% (France) and 55% (Argentina), for the upper third between 2% (Mexico, Argentina, and Indonesia) and 23% (United States). The aim of this paper was to analyze determinants for differences among various groups and to describe types of potential users in order to draw conclusions about the need for specific studies. The statistical method of cluster analysis was used to derive the potential user groups based on the attributes which would—according to the respondents—positively or negatively influence the decision to use the new MFC method. To use the cluster analysis, the attributes used to create the clusters must not be intercorrelated. A factor analysis should be conducted in order to reduce highly correlated attributes to independent factors (Berekoven et al, 1993). The respondents were given a list with 14 parameters that could potentially have a positive influence on the decision to use a new MFC (eg, low side effects, increased libido, etc). They were asked to decide how important each of these parameters was. The same was done for 14 parameters with a potentially negative influence (eg, low efficacy, decrease in sexual potency). Factorial analyses were performed to characterize patterns that positively or negatively influence the decision to use a new MFC method. Each of the mathematically determined factors describes variables that are closely linked according to the data. The 9 factors we found can be understood as largely independent constructs, explaining the total variance in the answers of all survey respondents with regard to the decision to use MFC. Factorial analyses done on the country level did not show material differences in the internal structure of the factors in the different countries. The aim of the factor analysis was to find the best describable groups of interlinked variables explaining an underlying common ground. For the 14 variables with a positive influence on the decision to use the new MFC, these best describable groups were found when 4 factors were created (Table 1). To make the difference among the 4 factors more visible, only high correlations with the respective factors (over 0.5) were depicted in Table 1. The aim of the naming process was to find a memorable name that describes the prominent patterns (variables of the questionnaire) characterizing the factor best. The sex-oriented pattern (first factor) involved all the variables related to sex life—such as enhancement of masculinity, sexual desire, improvement of sexual performance—and which variables would have a positive influence on the decision to use such a new MFC method. A potential positive impact was also observed for increase in muscle strength. However, 1 weighting of more than 0.5 was also found with factor 3 pointing at limited independence between factor 1 and 3. The second factor was called pattern of independent safe and easy way of contraception. This factor embraces variables related to primary fertility control parameters such as efficacy, confidence in contraception, easy handling, quick onset time, reversibility, and few side effects. To a lesser extent, this factor is correlated with desired independence from the women concerning the contraception, which is more explicit with factor 3. Factor 3 was named narcissist after the variables with the highest correlation. The positive influences that formed this factor include positive effects on the appearance of the user, namely, the positive influence on body frame and the increase of muscle strength. Factor 4 of the positively influencing variables is the improvement of well being. This very general construct explains the second biggest share of the total variation in the answers and formed an independent factor. It did not really correlate with any of the other variables or overlap with the other factors. For factors with a negative influence on the decision to use the new MFC method, 5 factors have been determined even though it was a little harder to find good descriptive and memorable names for them. The exact numbers of the weightings that indicated a type of correlation of the 14 subquestions with the 5 calculated factors are shown in Table 2. The first factor (worry about safety and efficacy) involves attitudes concerning primary fertility control parameters that could negatively influence the decision to use such a new MFC method. A potential low efficacy and nonexisting long-term data on safety belong to these concerns, as well as fear of adverse side effects or fear of sexual hormones in general. The fear of tumors such as liver or gynecological tumors associated with hormones (Heinemann et al, 2000, 2003) played an increasing role in the last decade and led to several crises of hormonal treatment with extensive media coverage. This was also recognized by males. Factor 2, religious-dominated refusal, consisted of negative attitudes due to religious reasons, due to objections against any male fertility control, and due to a general disapproval of drugs. The religious reasons showed the highest correlation to the factor. Whether the general disapproval of drugs and the negative attitude toward any male fertility control have a religious background is not clear, but they clearly belong to the same factor as the religious reasons. So a partly religious background was at least assumed. In the third factor, which was named general rejection, attitudes are combined that concentrate more on the new male fertility control directly. Seeing a doctor regularly—which would be necessary with the new method—and the opinion that the already existing male contraception methods are good enough—a new method is not necessary—have a negative influence on the willingness to use such a new method. Another component of this factor was the attitude that contraception is the responsibility of the females. This was closely related to the opinion that there are enough other methods of contraception. Two of the 14 subquestions were dealing with fears concerning the sex life—the possible negative impact on sexual satisfaction and on sexual potency. These 2 formed their own, fourth factor: sex-oriented fears. In the last and fifth factor—not another drug please—2 subquestions were highlighted, both of which were related to a negative attitude due to an already existing high amount of medication that has to be taken. People who suffer from a chronic illness usually also have to take some drugs, which is obviously in opposition to use of a new MFC method. The statistical method of cluster analysis was used to form different groups of users based on the role that single factors, which were created in the factor analysis, played for them. Here the goal is to identify homogeneous groups of people who are concerned about similar factors (Norusis, 1992). The clusters were named based on the factors that had the highest positive means in the respective cluster. These data are shown in Table 3. Very distinct or even exaggerated names were chosen to better understand and distinguish these 3 groups. These names are intended to be of a descriptive nature and by no means offensive or It has to be stressed that the in these clusters is not a single to 1 it not the factors that make up the 2 other clusters not an important role for It of better to the respective cluster than to the 2 factor another drug for has similar in 2 clusters of male The first cluster of respondents was called the sex-oriented A total of participants were in this group due to similar knowledge, attitudes, and The narcissist is mainly in a positive on sexual of libido, sexual and To the same is concerned that a new MFC method with sex or even factors that influence the of this cluster are the potentially positive effects on the body of muscle positive influence on body but also a attitude to male fertility methods and new drugs. The participants in this cluster would the new MFC method it were only a contraception method, but it and be willing to use it because of any positive effects they as The other factors that are to their high positive means in the respective describe the other 2 clusters also have positive value in this cluster. means they also a role in this user though a one with the other The second group was named the religious This cluster consisted of The religious has a negative attitude toward any male fertility control method. religious reasons for the Very high negative means could be found for the factors in safe and easy way of contraception and about safety and efficacy, which that for the of this cluster these are more or The third cluster was called the A total of of the respondents belong to this The is in safe and contraception, but also very concerned about potential and side effects as well as about a potentially low efficacy of the method. they are concerned about potential and side effects is by the third factor that influences the of this not another negative were found not for sex-oriented but also for general and religious attributes were for the The group was found in in and Table The group was of importance in the United States. The 3 participating countries from America the proportion of had the same as the in and the respective share was In Indonesia the did not the proportion was The religious played the important role This group was not very important in In the United 23% of the participants belonged to this cluster. showed the In the 2 other Latin countries the religious was a more important The sex-oriented narcissist was important in and important in and In the other countries the share of this cluster between and In the group a share of high participants could be found with the 2 other groups in the sex-oriented narcissist and in the religious Table The share of the educational level in the 3 clusters ranged between and religious the share of respondents was in the in the religious and in the sex-oriented of the group belonged to the high income level only of the sex-oriented narcissist and of the religious had high income Table The share of participants with a level income did not very between the 3 but only of the group belonged to the low income as with of the sex-oriented narcissist and of the religious The was by the information Table It was by The and of these 2 did not in the 3 in the were only in the and fifth The and the sex-oriented narcissist groups the as the third important of information for the religious were more For the group were the least important would information on the For the religious and the sex-oriented narcissist the was least The percentage of men who are any contraception method was in the group than in the 2 other clusters Table The share of men a was about the same in each cluster to The overall share of all study respondents who are willing or very willing to use the new method was 55% Table When into the 3 different this willingness of participants who belong to the group their willingness to use the MFC method, only of religious did The share of respondents who would of the method is more than as high in the religious as it is in the The sex-oriented narcissist showed only differences to the pattern of the The overall willingness to use such a new MFC varied between and across the participating to on survey found an of between and on the form and the country et al, 2000). when a and of the method are A number of questions have to be asked in order to find out there are specific groups for a new method among the end has to which factors and attitudes to which level for the MFC and there are positive or negative in these it possible to describe potential user groups based on these attitudes, groups who are more concerned about 1 set of attitudes than about and who show differences in their willingness to use the new are there any other differences in these groups which could to specific to or to their it would and would to results different as in our were used to describe user it was to a factor analysis Factor is a statistical used to identify a number of factors that can be used to among of many It is used to identify the of such as or These not of variables that can be on but can be described by the underlying of these variables can be the description and the of these can be (Norusis, 1992). The of the factor analysis was to create an construct for a set of variables that to the description of the that will the process to use or to a new male fertility method. But it was not possible to describe potential differences or of the participants only with these factors. it had to be out which of the factors were important to which of the different were done to find factors that each include good describable groups of subquestions of both groups of variables The different groups of potential users could be determined the SPSS® cluster analysis These are the the sex-oriented and the religious The group is based on the different attitudes factors that would positively or negatively influence the willingness to use the new male fertility control method. The group is not but group also be concerned by factors that would belong to another cluster. This can be in the of participants in the 3 different The 3 groups in their but all of willing and of this study to the religious not form a homogeneous the other groups. all the religious would the new the of this cluster only similar concerns, which were to some related to religion. This not these men are not in the or the safety of the drug even though they the to be the other the of the 2 other clusters are positively by as for high efficacy and low side effects for the or an improvement of sexual or an increase of muscle for the sex-oriented but it not that all of would be willing to use the method even all these were in their and factors and in the factors and attributes that influence the of or not the new MFC are and will different for The group is in safe and contraception, but also very concerned about potential and side effects as well as about a potentially low efficacy of an MFC method. of this group need background information the of the efficacy, and about They also information concerning potential side effects of any this information is not this would influence their willingness to use such an MFC. The educational level in this group is with the 2 other groups. be the for the increased in more specific background information and also to a better of the and data. The educational level will also influence the which and are The a more important role for the group than for the 2 other groups. could that the group is more willing to for only information is for in the and the group in this of method, will for other information or the A specific on the could the to find information about the efficacy, study results side effects, and background information about the of and to questions to The group the the and to be more important information than the The 2 first are and questions and answers is in well a good about the and also concentrate on negative side effects. But with this the group not from the 2 other groups. The income level of the group is than the 2 other groups. the primary parameters of the new method are for the be more willing to a even positive effects of the are not for these effects would also to a The group is very important in in and Sweden, where it the group with the 2 other groups. In to the 2 other Latin group is also the important user even more important than in and In the United Mexico, and the group to the important in Indonesia this group is The sex-oriented narcissist is mainly in a positive on sexual of libido, sexual and to the same is concerned that this method with or even sex would be the new method had a positive impact on body such as an increase of muscle or a positive influence on body these positive side effects can be and are that will an increase in for the new contraception method in all 3 but for this group these attributes are the the other this group is also by a attitude toward male fertility methods and new drugs. It would be to of this group to use the new method even it had primary attributes as a very good the positive side effects in the the income level is lower in this group with the the potential user be willing to a good for that of fertility control can more than an fertility The sex-oriented narcissist about contraception in general with the The sex-oriented narcissist is the important user group in the United Mexico, and in The religious has a negative attitude toward any drug and any male fertility control method. reasons a role for the the of the 3 clusters is by no means The religious group also men who not have a religious to the method but were due to other factors that are important to and that best in this cluster. though this group a willingness to use the new method, that not that a sex of the method would not positively influence to use the new MFC method. In Indonesia the in the United Mexico, and also a very important is in the other participating countries. The religious has the educational and income level of all 3 groups and also the use of any contraception method. can that the effects and information about primary method attributes would not really and would also be the information for the religious but would than a to further and the is the least information for The results based on data in the MFC study the that there is a for MFC However, should be further considered before this method. In further studies should to the a method can be more very important that still has to be considered is the role of the in the The vast majority of male respondents that they would decide about the contraception method with their only 1 it is more the influence by women will make it necessary to more about their attitudes toward such new methods as well. studies among women should be in the of