Abstract
This study examines the extent to which age, fatherhood, relationship status, self-control of birth control method, and the use of birth control influence young Native American men’s intention to use family planning services. Data were collected for this study during in-depth interviews with 112 Native American men between the ages of 18 and 24 years. The mean age reported was 21. Thirty-eight percent of the young men reported having children. Almost 70% of the young men reported being in a steady relationship. Eighty-eight percent reported that it was very important that they have self-control of the type of birth control that they use. In addition, 88% of the young men reported that they would use some type of birth control within the next year to prevent a pregnancy with their partner. Logistic regression analysis indicated that as age increased, young men were less likely to seek family planning services for birth control. The young men who reported being fathers were more likely than the young men who did not report being fathers to seek family planning services for birth control. Findings from this study suggest that public health efforts to educate Native American men about family planning services are most effective in their adolescence, before they transition into young adulthood. Fatherhood may also be considered a protective factor that may increase the likelihood that young Native American men will seek family planning services for birth control. Public health efforts that address reproductive health among young Native American men may be effective with Native American men in adolescence, prior to their transition to young adulthood. Family planning services that provide outreach education and care to Native American fathers may also be effective.
Introduction
Only 4% of Title X Family Planning clients are males, with less than 1% of these men being Native American, indicating that young Native American males are not seeking out and using family planning services as a means to understand and address their sexual and reproductive health needs (Alan Guttmacher Institute, 2002). In addition, unintended fatherhood and sexually transmitted infections (STIs) are higher among young men from racially and ethnically underrepresented populations (Centers for Disease Control and Prevention, 2003). Specifically, compared with the national average, young Native American men are more likely than any other racial or ethnic group to have sexual intercourse and contract an STI. They are less likely to use contraceptives and condoms to prevent pregnancy than any other racial or ethnic group. The incidence of Native American teen fatherhood is also higher than the national average (Kaiser Family Foundation, 2004). The STI and teen pregnancy disparities in native male populations persist despite research suggesting that sexual and reproductive health in Native American populations is related to myriad psychosocial, emotional, and historical issues; and there continues to be a paucity of research conducted with Native American male populations that examines their specific sexual and reproductive health needs.
Despite a growing awareness of sexual and reproductive health and the factors that contribute to young people being sexually active in the United States, little is known about the factors that contribute to sexual and reproductive health among Native American men, how to approach sexual and reproductive health issues in Native American communities, or how to design effective, culturally sensitive family planning prevention and intervention strategies for Native American men (Sonenstein, Punja, & Scarcella, 2004). Furthermore, a large proportion of Native American men live in rural, frontier, and reservation environments, which are characterized by heterogeneous communities sparsely spread across diverse landscapes where access to family planning services and contraception may be challenging.
The purpose of this article is to present some of the findings from the Fort Peck Sexual Health Study. The Fort Peck Sexual Health Study was a 2-year investigation conducted from September 2007 to October 2009 among Native American men aged 18 to 24 years living on the Fort Peck Reservation. The Fort Peck Sexual Health Study examined the individual, social, and environmental factors that had the greatest influence on Native American men’s sexual and reproductive health and their use of family planning services. The overall goal of the study was to provide recommendations for designing innovative and culturally relevant family planning services that will foster systems change: increasing access to family planning services for Native American men and, thereby, reducing the sexual and reproductive health disparities among Native Americans in rural frontier communities. Specifically, the findings presented in this article address the demographic relationship and birth control characteristics most likely to influence the intent to use family planning services among Native American males aged 18 to 24 years.
Method
Community-Based Participatory Research
The research study design was rooted in a community-based participatory research (CBPR) approach. Sexual and reproductive health data on Native Americans are often not reported in national surveillance and survey reports, and research studies investigating sexual and reproductive health have focused on African Americans, Hispanics, and Whites (Gaydos et al., 2006; Hellerstedt, Peterson-Hickey, Rhodes, & Garwick, 2006; Levine et al., 2003). Also, Native Americans have, historically, been reluctant to participate in research projects because traditional research methods, which emphasize the researcher as “the expert,” have not engaged Native Americans in the design and implementation of the research project (Hellerstedt et al., 2006). CBPR has been identified as an effective and essential strategy for conducting research with Native Americans because of its emphasis on participation of the community and empowering the community to address their health disparities (Holkup, Tripp-Reimer, Salois, & Weinert, 2004). In this study, the CBPR approach engaged the Fort Peck Tribes and outside researchers as full and equal partners. A Community Advisory Board was formed, consisting of three members to work with researchers and Fort Peck Tribal Health Department personnel to implement the project. The role of the Community Advisory Board was to provide oversight and guidance for the project, including input into the research design, research participant recruitment, interpretation of the results, and dissemination of the research findings. Institutional review board approval for the study was received by Montana State University, Indian Health Services and through tribal resolution with the Fort Peck Tribal Council.
Participants and Procedures
The primary target population for this project was Native American men aged 18 to 24 years from the Assiniboine and Sioux tribes who live on the Fort Peck Reservation in northeastern Montana. Montana is a rural frontier state with seven reservations and 11 federally recognized tribes. Counties in Montana that report STI rates substantially higher than the national average are counties that contain reservation lands. The teen pregnancy and fertility rates for the Native American population in Montana are higher than for the nonnative population (Montana Department of Public Health and Human Services, 2008). The Fort Peck Reservation is located in a high plains prairie environment and spans approximately 2,093,310 acres. Approximately 12,000 enrolled members of the Assiniboine and Sioux nations live on the reservation. Of the 12,000 enrolled members of the Assiniboine and Sioux tribes, 5,221 are men, 578 of whom are men between the ages of 18 and 24 years. In this study, 112 Native American men, representing 20% of the target population, were interviewed. This sample size, estimated for the finite, age-specific population size for the Fort Peck Reservation, provided an estimated 10% prevalence with 95% confidence intervals (CI) and 5% precision (Daniel, 1999).
Eligible research participants were Native American men between the ages of 18 and 24 years who were living on the Fort Peck Reservation and were members of the Assiniboine or Sioux tribes. The participants were recruited for this study using purposive sampling techniques by partnering with community organizations such as the Fort Peck Tribal Health, the Fort Peck Reservation Indian Health Services, the Fort Peck Community College, and the Roosevelt County Health Department. These organizations assisted in informing the men in the community who met the eligibility criteria. The project advertised via flyers, posters, presentations, community gatherings, advertisement on the Indian Health Services marquee, and word of mouth. Interviewers conducted the majority of the in-depth interviews with the Fort Peck men.
The study’s investigators trained the interviewers in interviewing techniques, protocols, and subject matter. Interviewers were male tribal members and slightly older than the study population. The interviews took place in a private setting, either in the space provided by the project’s partnering agencies or in another private setting agreed on by the interviewer and interviewee and lasted anywhere from 45 minutes to 1.5 hours. When appropriate, transportation was provided to the research participants to reduce logistical barriers. Study participants were provided a $25.00 gift certificate to one of two local convenience stores as compensation for their time.
Measures
The measures used in this analysis are described below.
Age
Age was measured as a continuous variable and ranged from 18 to 24 years.
Children
Research participants were asked if they had children, using a yes/no dichotomous variable with yes = 1 and no = 0.
Relationship type
Research participants were asked to describe their relationships with a partner with whom they had sexual intercourse within the past 3 months. Relationship categories included the following: just friends, dating her only, dating her and other people also, just a “one-night stand” or “a fling,” engaged, and married. Because of thin cell counts in several of the categories, just friends, dating her and other people also, and just a “one-night stand” or “fling” were collapsed into one category referenced to as casual relationship. Dating her only, engaged, and married were collapsed into another category referred to as steady relationship.
Self-control of birth control
A 5-point Likert-type scale was used to assess how important or unimportant it was to the Native American men to use a birth control method that they could control. The research participants were asked, “How important or unimportant is it to you to use a birth control method that you control? By control, I mean that you can choose to use a method independent of your partner.” Responses included 1 = not important, 2 = slightly important, 3 = moderately important, 4 = very important, and 5 = extremely important. Based on skewed response distributions, self-control of birth control was dichotomized into 0 = not important and 1 = very important.
Use of birth control to prevent pregnancy
The use of birth control to prevent a pregnancy was measured using the following question: “Over the next year, how likely or unlikely is it that you will use some form of birth control to prevent pregnancy?” Responses were measured on a 5-point Likert-type scale ranging from 1 = not at all likely to 5 = extremely likely. Because of a skewed distribution in the cells, with the majority of the respondents indicating that they were very likely or extremely likely to use some form of birth control to prevent pregnancy within the next year, the variable was collapsed into two categories: 0 = not at all likely and 1 = very likely.
Intent to use family planning services
Intention to use family planning services was measured by asking the study participants, “How likely is it that you will seek birth control services in the next year?” Responses were measured using a 5-point Likert-type scale with 1 = not at all likely, 2 = a little likely, 3 = moderately likely, 4 = very likely, and 5 = extremely likely. The variable was dichotomized into two categories, 0 = not at all likely and 1 = very likely, because of thin cell counts.
Analysis
Descriptive statistics was conducted on the independent and dependent variables in the study. Logistic regression was used to examine the extent to which demographics, relationship type, and use of birth control to prevent pregnancy influence young Native American men’s intention to use family planning services. STATA Version 9 was used to perform the analysis (STATA, 2003). Significant levels were set at p < .05, p < .01, and p < .001. Once data analysis was completed, the results were reviewed with the project’s Community Advisory Board, Fort Peck Tribal Health Department personnel, and researchers to interpret them.
Results
The frequency distributions for demographics, relationship type, self-control of birth control, use of birth control to prevent a pregnancy, and intention to use family planning services are presented in Table 1. The average age of the Native American men in the study was 21 years, with a standard deviation of 1.9 and range of 18 to 24 years. Fatherhood was reported by 38.2% of the men. Almost 70% of the men reported that they were in a steady relationship. Eighty-eight percent of the men reported that it was very important to them to use a form of birth control that they could control themselves. The use of birth control to prevent pregnancy within the next year was reported as very likely by 88% of the men. Intention to use family planning services for birth control within the next year was reported as very likely by 88% of the Native American men.
Demographics, Relationship, Birth Control, and Family Planning Characteristics
Logistic regression results are presented in Table 2. Age was found to have a statistically significant influence on Native American men’s intention to use family planning services for birth control within the next year. As age increased, the study participants reported that they were less likely to seek family planning services within the next year for birth control (odds ratio [OR] = 0.62, CI = 0.46-0.88, p < .01). Native American men who reported having children were over five times more likely to seek family planning services within the next year for birth control than Native American men who reported not having children (OR = 5.7, CI = 1.4-22.4, p < .01). Relationship type, the importance of self-control of birth control, and the use of birth control to prevent pregnancy within the next year were found to not be statistically significant in this study.
Factors Influencing Intent to Use Family Planning Services
p < .05. **p < .01. ***p < .001.
Discussion
Overall, the results of this study suggest that young Native American men are interested in their reproductive health. In this study, the average age of the young men was 21 years. The results from this study demonstrate that as the young men transition from late adolescence into their early 20s, they are less likely to consider it important to use family planning services to practice birth control. These findings are consistent with previous research, which demonstrates that as young men enter into young adulthood they are less likely to seek family planning services (Kalmuss & Tatum, 2007). This is important to highlight because males tend to be at risk of contracting STIs and causing unintended pregnancy during their adolescence more so than during young adulthood (Marcell, Ford, Pleck, & Sonenstein, 2007). Strategies for outreach to the adolescent male population, and in this case Native American male adolescents, to provide education and services regarding their reproductive health may ensure responsible and safe decision making regarding birth control use. This finding supports previous research with young men in urban clinical settings, which found that adolescent males reported wanting more knowledge about their sexual and reproductive health but health care agencies lacked the training to meet the specific health care needs of adolescent males (Marcell & Halpern-Felsher, 2004).
In this study, fatherhood appeared to be an important factor influencing young Native American men’s intention to use family planning services. Almost 40% of the young Native American men reported having children. Fatherhood was also associated with an increased likelihood of seeking family planning services for birth control. These findings suggest that young Native American men who are fathers may be more interested in preventing, planning, or delaying future pregnancies with their partner than young Native American men who are not fathers. Given that the average age of the study participants was 21, this finding is worth emphasizing because it suggests that these men had already experienced fatherhood at an early age. It may be that because Native American men are having children at a young age they want to delay or prevent having more children until they are older and perhaps more economically stable or have completed education beyond high school so that they can economically support their families better. Providing information regarding birth control methods and the importance of receiving family planning services while Native American men are in their adolescence may be of value for pregnancy prevention and planning efforts to assist young Native American men in making decisions about when they want to have children. This finding is supported by research conducted by Garwick, Rhodes, Peterson-Hickey, and Hellerstedt (2008), which found that Native American teenagers recommended school- and community-based programs to provide education and training on reproductive health topics to Native youth in order to prevent and/or delay pregnancy.
Being in a steady relationship was reported by 68.6% of the study participants. Although this finding did not show a statistically significant influence on young Native American men’s intentions to seek family planning services, it does demonstrate that these young men perceive that they are in committed relationships with their partners. This finding, which demonstrates a level of dedication in an intimate sexual relationship, provides further support for incorporating men in community-based reproductive health education and family planning services as equal partners in reproductive choices in intimate relationships. Previous research has found that in committed relationships young men felt it important to use condoms when having sex, to encourage their partner to go to the doctor in order to keep her healthy, and to be honest and trustworthy in the relationship (Marcell, Raine, & Eyre, 2003). Thus, public health efforts aimed at providing reproductive health education and services to young Native American men may warrant inclusion of discussion about relationship status and how to keep one’s partner healthy. Moreover, encouraging Native American women to bring their partner with them on family planning visits to their heath care provider may also be an effective strategy for increasing Native American men’s use of reproductive health care services. Finally, although it is reassuring that the majority of young Native American men in this study perceive that they are in a steady relationship, those young Native American men in a casual relationship should not be forgotten in reproductive health outreach education efforts or clinical services as previous research has found that men in casual relationships appear to be at the same risk level for STIs and unplanned pregnancy as those in exclusive relationships (Eisenberg, Ackard, Resnick, & Neumark-Sztainer, 2009).
Eighty-eight percent of the young Native American men reported that it was very important to them to have self-control over their birth control method and that they would use some type of birth control method within the next year to prevent a pregnancy with their partner. Neither of these findings demonstrated a statistically significant influence on young Native American men’s intentions to use family planning services. However, these findings do suggest that young Native American men have the intention and the desire to take responsibility for contraception. These findings are consistent with other research that demonstrates joint decision making and control over condom use in culturally diverse sexual relationships (Kraft et al., 2007).
Limitations
This study provides a unique examination of the extent to which age, fatherhood, relationship status, self-control of birth control, and intention to use birth control influence whether or not young Native American men seek family planning services. This study only focused on young Native American men living in a rural frontier environment on one reservation in Montana. Thus, the results from this study cannot be generalizable to other tribes and reservations in Montana, reservations in other parts of the United States, or Native American men living in an urban environment. Data were also derived from self-reports, which may be restricted to opinions or feelings rather than based on facts or evidence. In addition, young Native American men may not be accustomed to talking about their reproductive health within a research context, which may have restricted the young men who agreed to participate in the study. In this analysis, the study participants were not asked questions regarding their self-efficacy in using the type of birth control they prefer to use with their partners. This may make it difficult to assess how much the concept of controlling one’s own choice of birth control method is based on one’s comfort level with one’s skill and ability to use that birth control method effectively and how much it is based on a conceptual and philosophical belief that one should always have control over the choice of birth control method used. This analysis also did not include questions regarding why young Native American men think it important to use some form of birth control to prevent or plan a pregnancy. Future research may warrant examination of what facilitates or hinders young Native American men’s use of birth control. Similarly, the study participants were not asked questions about what gets in the way of or supports their going to see a health care provider for family planning services. Such questions may provide insights into ways in which public health programs and family planning services may be designed to meet the needs of young Native American men’s reproductive health.
Conclusion
Previous research on sexual and reproductive health among Native populations suggests several barriers that impede Native American men from seeking family planning services. First, family planning services have not historically been grounded in a social, cultural, or theoretical framework that meets the needs of Native American men (Garwick et al., 2008). Second, the emotional and psychological needs of Native men, such as their opinions or feelings about fatherhood and/or their intimate relationships with their sex partner or partners, have not been taken into consideration when designing prevention services (Kaufman et al., 2004; Kaufman et al., 2007). Third, despite efforts to include men in family planning services, the practice of sexual and reproductive health care services continues to primarily focus on women (Kalmuss & Tatum, 2007; Kraft et al., 2007). This is particularly apparent in India, where the majority of family planning services are provided to women and young mothers through Indian Health Services or Tribal Health Departments. Thus, Native American men may not feel comfortable seeking family planning services because they may not feel that they have an important role in a couple’s decision to prevent, delay, or plan a pregnancy.
The findings in this study support the need to provide reproductive health care services to Native American men. Because almost 40% of Native American men between the ages of 18 and 24 years reported already having children, reproductive health education, outreach, and services for Native American men in adolescence and young adulthood are warranted. To meet the needs of young Native American men, schools, community-based organizations, and family planning services should provide culturally relevant information and skills training in birth control methods, communication, and sexual decision making to men in their teenage years and in their early 20s that can meet their reproductive health needs. In addition, the majority of the young Native American men in this study reported being in a steady relationship. This finding highlights the importance of including partners in reproductive health services, working with couples, and encouraging women to bring their male partners on family planning visits to discuss birth control, pregnancy prevention and planning, and overall sexual health. In this study, young Native American men reported the importance of having control over the type of birth control they use with their partner. Educating young Native American men and empowering them with the knowledge and the skills to use birth control effectively in their intimate sexual relationships is necessary. Importantly, the intention reported by the study participants to use some form of birth control to prevent or plan a pregnancy and to seek family planning services demonstrates a desire by young Native American men to be responsible for their reproductive health. This positive intention on the part of young Native American men should be explored further as it may be that although the intention is there to seek reproductive health care services for birth control, other issues, such as lack of knowledge about where to go and whom to speak with or embarrassment about discussing one’s own reproductive health with a health care provider, may act as a barrier for young Native American men in their desire to be sexually responsible. Thus, future research is needed to understand the factors that motivate and/or impede young Native American men in the utilization of family planning services.
Footnotes
Acknowledgements
Special thanks are given to James Melbourne, the Fort Peck Tribal Health Department Director, the Fort Peck Tribal Council, and the study’s Community Advisory Board. Their guidance, support, and wisdom throughout the study have been greatly appreciated. Most important, thanks are given to the young men of the Fort Peck tribes for their thoughtful responses and participation in the study.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was funded by the U.S. Office of Population Affairs (R03: #FPRPA006028-01-01; Principal investigator—Elizabeth Rink).