Family planning and men's health from nurses' perspective

Objective: This study aims to know nurses' views on men's use of family planning services in the regional health of municipalities in Rio Grande do Sul, Brazil. Methods: It is a qualitative study, carried out from July 2009 to October 2009 through semi-structured interviews with 22 nurses. Results: The results produced the following categories: 'Men and the limiting factors to their access to family planning services', and 'Men and their reasons for accessing family planning services'. The results showed that men seek those services looking for condoms or diagnosis of pathologies, sexual-related or not. Conclusion: The idea of men as being invulnerable or of family planning as being women's responsibility might be associated with men's disengagement from the services, but barriers to healthcare access and the unavailability of some services might be the greatest hindrance.


INTRODUCTION
The public policies on health care, throughout history, privilege specific population groups, such as women, children, adolescents and the elderly and spreading the idea that the health services, particularly primary care, is to meet the demands of these populations 1 .However, not always, these privileged populations have their rights guaranteed in terms of access to services quality healthcare.
Regarding the Family Planning, the policies for a long time, devoted mainly to women, which are responsible for the choice of contraceptive methods, of unplanned pregnancies and other acts in relation to family planning decision.The fact is that, giving visibility and power to women in directing the actions of Family Planning, left the men in uncertain situation 2 , causing some myths from a macho culture, consolidate it in society.Today, including male involvement in health care becomes a major challenge for health professionals 3 .
Only in August 2008, the Ministry of Health of Brazil, launched officially, the first public health policy that specifically addresses the health of Man 2,4 .The National Policy for Integral Care To Men's Health (PNAISH) recognizes that health is a basic social and citizenship rights of all Brazilian and "[...] aims to guide the actions and health services for the male population with completeness and equity focused on humane approach" 4:35 .
The PNAISH emphasizes issues of gender, stating that paradigm changes are necessary, to the male population, in relation to health care and the health of their family.Besides educational aspects, among other actions/activities, public health services need to welcome and make the man feel part of them.The implementation of PNAISH should occur associated with other existing policies, following the hierarchy of health care in which primary care is the gateway to the SUS 4 .
With regard to family planning and reproductive and sexual rights, it is necessary to overcome the diminished responsibility of contraceptive practices on women, assuring to men the right to participate in the regulation of fertility and reproduction.Thus, parenting is not perceived only from the point of view of a legal obligation or a duty, but as a human right to participate in the entire process, including the decision to have children or not, how and when to have them as well as the monitoring of pregnancy, childbirth, postpartum and education in children 4 .In the comprehension of the current policy of the man, before seen as an obligation and men tended to escape, now it is a right 2 .Issues of reproductive and sexual health are on a first thematic area in actions of human health 3 .
Brazilian scientific production, published from 2005, indexed in BIREME database (SciELO, LILACS and BDENF), searching in June 2010 by using the descriptor Men's Health, we identified 22 studies.Of these 22 studies, 10 mentioned the production of knowledge and the politics of healthcare for the man; five were about male sexual health, including behavior in the Sexually Transmitted Diseases (STDs); three studies were about cancer in men; one study about the profile of male mortality; two studies about cardiovascular disease; and a search was on male subjectivity.In fact, indexed studies were not found, in the bases that include Family Planning as focus of men's health, even with five research about to human sexuality.Thus, we perceive a large existing in knowledge production in relation to the theme of the actions of Family Planned in men's health, involving the activities of nursing.
Based on the above, this study aimed to know the nurses' view about the search of equity and family planning services for men in the municipalities of a regional health state of Rio Grande do Sul.

METHOD
It is an exploratory, descriptive study with qualitative approach 5,6 .This article is part of a research entitled: "Family planning: actions and services of nursing/health".
This study was in the municipalities covered by a regional health of the state of Rio Grande do Sul, which comprises 22 municipalities, totaling 871,025 inhabitants.The coordinators of services nurses of Nursing primary care of these municipalities and/or nurses' coordinators of family planning activities participated of the study, totaling just 22 nurses.
The study followed the principles of Resolution 196/86 of the National Health Council.First, the study design was for consideration by the Association of Secretaries and Directors of Health, Southern Region -SOUTH ASSEDISA.After approval of the project by the institution, we sent it for consideration by Committee for Research Ethics of the Nursing University, of the Federal University of Pelotas, and approved in accordance with Opinion Nº 32/2009.In order to preserve the anonymity of the study subjects, these were identified by the letter N (Nurse) followed by an Arabic number, according to the order of the interviews.
Data collection was through semi-structure interviews 7 , in the period from July 27 to October 6, 2009.To ensure the credibility and integrity of the data collected, we recorded on digital media and then immediately transcribed all the interviews.After that, it was a fluent reading of the material aiming to capture the relevant aspects and identification of the topics in order to provide authors impregnating of content and dialogue with the data.
We worked with data carrying out the clippings, codification and subsequent categorization, as the recurrence data.However, the organization of the material and the formation of the corpus were by the completeness, considering all aspects in the script; the representativeness, considering the perspective

Family planning and men's health
Casarin ST, Siqueira HCH of the intended universe; by homogeneity, following the precise criteria for choice of the topic and technical partners; and relevance, analyzing the lines taking into account the objectives of the study 5 .
In their analysis 5 , there was the exploration of the material, i.e., there was the search of categories for understanding the text.This phase consisted in the identification of significant units of record by topic.In this study, one of the categories that emerged from the macro study: Men in family planning; as well as two sub-categories: Men and factors limiting their access to family planning and Men and their reasons for seeking to family planning services.
The term category refers to a concept that incorporates elements or aspects with common characteristics, or which relate to each other, being expressed around a concept that can encompass the whole 5 .

Men in Family planning
The discussion about the factors that separate the men from the units of primary health care, and especially of family planning services offered by these units needs to be focused on the issue in the debate about gender 1,8,9 .These issues should be "seen as a major factor in the pattern of the health risks of men and how they perceive and use their bodies" 3:15 .
We understood, therefore, that gender are in built differences, within a given society as it implies being a man and being a woman and the relations that are structured in such differences.We do not deny the biological aspects of the differences between the sexes, but we highlight the sociocultural aspects 10 and that is crucially important to think about the relationships between men and women and their behavior 8 .
Therefore, in this study, gender is the construction throughout history and societies about the differences associated with male and female.Thus, we expect different attitudes and behaviors for men and women at different times in history that go beyond the biological.Men and women have their peculiarities and only through knowledge that these will have a "better approach immediately relational form of male-female, ensuring greater awareness of the specific density of each pole interaction" 3:8 .

Men and factors limiting their access to family planning
The nurses interviewed said that in general, men are hardly a client that seeks the Basic Health Unit (BHU) for family planning, reproductive and sexual health, as reflected in the speeches of N3, NE5, N6, N9, N10, N11, N12, N14, N15, N19, N20 and N22: No, here is more difficult [...] (N3).

Men do not seek (N9).
Very little; the search of man here in the center is minimum.(N10).

Men do not come, I do not see them [...] (N11).
Very little, very little; sometimes; we have done some vasectomies; but men seek very little (N12).
So far no one came to me in that part.Yeah, that part is more complicated (N14).
That's difficult.I think that if he had the vasectomy program here, it would not have any demand, it is very difficult (N15).

Men rarely come looking for us. What I see women who come here are worried because their husbands are sick; or they come to know about vasectomy; but they, it is difficult [...] (N22).
The N2 nurse observed the fact that the repressed demand, however, she attributes this to a low demand:

Men, I think there is a very repressed demand. It is, I think, because they do not want (N2).
The literature confirms what nurses said, and several studies showed that men in general accesses health services very poor, particularly primary care, and they are intended for children, women and elderly 1,3,9,11,12 .Therefore, the literature suggests that this fact is due to "a characteristic of masculine identity related to their socialization process" 1:106 , i.e., men undervalue the self-care and attach little importance to his health 3,9 or then seek other health services such as pharmacies and emergency rooms, which would respond with greater objectivity to their demands 9 .
The literature indicates that the understanding of people about what is it being a man is one of the factors that influence the demand for the health services 8,12,11 .In the ideology of the population, being a man is invulnerable, strong and manly, and these characteristics are incompatible with the demonstration of signs of fear, weakness, anxiety and insecurity, represented by the demand for health services.This fact would jeopardize masculinity approaching the representations of femininity 9 .

Family planning and men's health
Casarin ST, Siqueira HCH The perception that BHU is like a feminized space, primarily composed of professional women and frequented by mainly women, also showed in the literature as a barrier to men 9 "that it would create in men a sense of not belonging to that space" 1:106 .
Considering that the search for health and family planning services are connected to the imaginary of what is being a man connected to invulnerability, strength and virility 9,11,12 , the N7, N8, N13 and N21 nurses, refer to factors as shame, fear and prejudice seen as vulnerable are the things that turn away men from seeking family planning: Well, men, it is a very big taboo that who comes to take condoms; often it the women; but then we have a lot of men without planning, for sure (N7).
It is more difficult for men; they have a big fear.It's very rarer even [...] they have more ashamed to come here to talk; but they do not come (N8).

[...] That prejudice of impotence. So, look, it's very complicated (N21).
The fear of discovering that something is not right with the health or live with the uncertainty of cure 13 and shame to show 8,9 and the belief that is invulnerable 14 are some of the factors that drive men of health services, especially because this is not a male prerogative.The fact is that to discover that men have some disease, like an STD, can bring up how are vulnerable and fragile when not adopting measures to prevent these diseases, or boost their health.
Nurses still remember the mistakes and biases are greater barriers when it comes to the demand for surgical sterilization: For vasectomy?For some time now we had here [...] we had to go to radio to do promotion and here is an area, so that machismo is very strong.Then the men said, they were so afraid of being powerless [...] (N13).

No, we have nothing. I think it would very prejudice (N15).
The N13 and N15 nurses cite sexism and prejudice as difficulties.These facts suggest that the communities served by the regional health agreeing with the idea that man is invulnerable 13 , and virility is an essential feature in the constitution of the ideals of being a man, in that aggression, the power and the initiative constitute sexual uncontrolled sexual male identity 8 .Aspects of the culture of a patriarchal society imposed on women the responsibility for the maternity, household and domestic tasks of the family, getting men the responsibility for the outside world 14 .
In the literature reviewed are records of men who seek a vasectomy and consequently the fatherhood, seeking their existence freedom 14 .Thus, we considered the gender perspective in areas of primary care.The image that health services are feminized spaces must be transformed to include the health needs of men 1 ; in this particular case, the need for family planning.It is urgent a change in professional attitude, to show greater sensitivity to the interactions between gender conceptions and demands brought by men in service use.
Even on the male surgical sterilization, another point that draws attention is the fact that, in the municipalities, the procedure is not offered by the SUS to its users, as mentioned N15, speech above, and verbalized N11:

Particular vasectomy I know who do it, but by SUS, no. And it is also not common, from what I see, what I observe (N11).
In this view, even if the opinion that the vasectomy as a cause of impotence, was worked to bring greater instrumentation for the male, demystifying this prejudice, if health services are not organized to provide the procedure, the efforts of nurses will be better.
It is worth remembering that sterilization is voluntary and legally permitted in: "[...] men and women with full civil capacity and over twenty-five years old, or at least two living children, since complied with the minimum period sixty days of the manifestation of the will and surgery, which the person will be afforded access to fertility regulation services, including counseling by a multidisciplinary team in order to discourage early sterilization" 15 .Therefore, in order to comply with the law, municipalities need to be organized to provide the procedure by SUS for clients, a fact that is not true in some of the cities studied.
It is also necessary to consider as N11 remember that, in the municipalities of the regional study of health, men's health is not yet discussed, or is not seen as a priority issue within public health policies:

No, I put that to the staff. Men's health does not have here, is not yet in [name of city]. Now we're entering with the worker's health, but the health of man, thus directed to the man, no, it has nothing (N11).
Although the actions of Family Planned are not directed to human health, some nurses seek to integrate them in BHU: When I attend, we ask for the husband to come together to choose the method, but we know that it does not work very well, they do not come (N17).

Family planning and men's health
Casarin ST, Siqueira HCH

Men's health is kind of complicated. You know we invited them to participate in family planning [...] (N16). [...] We try to do it, but they are not adhering very well [...] (N20).
There are also reports of the existence of campaigns for the prevention of penis and prostate cancer, but even so, the demand was small: [...]Last year, we had a campaign like this, for men to go; the test was performed; until the rectal examination was done; but there was not a lot of people.They will not [..

.] (N20).
As N20, observing that men have not joined the campaign for the detection of prostate cancer and penis in their city, this fact is associated with fear, and especially to shame.Exposed to another man or another woman is also an explanation to avoid searching for health care by men and possibly by the lack of habit that they have to seek health services; unlike the woman who, throughout the history of health sciences, has always had her exposed body, especially in the fertile period 9 .
The speeches denote the lack of guidance that the male population has in relation to their sexual health, since men prefer not to seek health services for prevention activities to develop a type of cancer, absolutely curable if detected in early stages.The literature indicates that, every day, in many different ways, men receive some guidance for the fact of the importance of preventive measures and early diagnosis, but still exposing themselves naively to easily preventable diseases 13 .Thus, it is necessary that nurses prepare themselves to instruct their clients, directing their actions also to men, since only women are primary prevention actions to focus cancers.Accurate targeted actions aimed at questioning of male problems involving these issues are important, because it is not enough just to include men without discussing the inequalities between men and women when talking about family planning.
It is also worth mentioning the issues of accessibility of health services and how they are organized to meet and understand the specifics of male demands.One of them is the work activity of man, which is alluded to in bibliographies as a barrier to seeking the primary care services 9,11,12 .The opening hours of most BHU coincides with the work schedule and thus the professional activities are first on the list of men's priorities, especially when it comes to men with low purchasing power, since "the association between provider and be a man is still very present in the social imaginary" 9:569 .
Another important fact is for the low frequency of male users at BHU corresponding to the perspective of those having other impediments such as the need to get into queues, which means lost time for work; the lack of programs or activities directed specifically to their needs first, and also the lack of specialized health units in men's health 9 .
The regional health where the study was conducted is characterized by the large distance between the municipalities and the predominance of the rural area as a nurse reminded N4: [...] So condoms, they do not come to pick up because, well, it is far from the settlements, sometimes someone comes there and takes it personally or they pick them on the day of attendance.At least once a month there is service in all locations (N4).
The distance in the communities to the basic units and vice versa, constitutes a barrier that needs to be transposed by both users, as by health professionals.It is understood that the municipalities of the regional health have an extensive rural area, and some of them do not exist BHU.Thus, the distance is one of the major obstacles faced by users of SUS in these municipalities.Thus, health services need to adapt to meet these locations and meet their demands; of these forms is the displacement of professionals with mobile units.
It is understood that, for greater adherence to masculine Family Planning, it is necessary that the services become more convenient for men, through educational programs on sexual and reproductive health.It is necessary to involve both sexes in the discussion of this topic, achieving thus more participatory and responsible men.
It is necessary to organize the work of health professionals, with the intention of strengthening actions before men, who are also users of the Unified Health System, as well as seek resolution and equity, given the health needs of these users 16 .

Men and their reasons for seeking to family planning services
Some nurses report that demand for men to BHU is when they are already ill: Men's kind of complicated.The men will only go to the cener when they are sick (N20).
Or search for specific medical care for STDs:

[...]
There is a doctor who is a urologist who treats a lot of STDs.They come to him, as well, but looking method thus contraceptive, no.They come because they're an STD, or because they're sexual problem, sexual dysfunction, not for the method.They even look for the condom (N19).

Family planning and men's health
Casarin ST, Siqueira HCH Or for exams or medical care because they cannot, as shown by N22: [...] the search of men here, for nursing is to get tested for HIV.Like I said, who does pre and post-test and the collection here, are nurses.Then they come.Sometimes they cannot get to the doctor and come to us because they are with any genital lesion [...] (N22).
The N17 nurse states that men access to the BHU for the condoms only; This fact is also observed in the speech of N3 and N22: They come for a condom [...] (N17).
[...] Funny, some even come in the unit, but it is more for consultation.Some come get condoms, but they are not many (N3).

Regarding the methods, what I observe is seeking a condom, and this has greatly increased, but no one ever comes here asking for vasectomy, or follow the companion comes to receiving guidance on other methods [...] (N22).
When discussing male participation in contraception, there are a limited number of methods available solely to the decision of men; i.e., that man makes use of coitus interruptus, or undergoes vasectomy and use of condom.The literature points to the fact that male participation in contraception is more frequent in support of women, and the methods of periodic abstinence or agree with the use of methods considered high efficacy (hormonal, tubal ligation and Intrauterine Device) 17 ."The emptying of the options of contraception prevents men from living their sexuality free of tensions and fears of an unwanted pregnancy" 14:80 .Furthermore, cultural aspects structure topics with the absence of males, and studies have focused on the man concentrated on the issue of sexuality 3 .
The fact that men are appearing at BHU to withdraw the barrier method may be signaling to a new reality, that is, men are going beyond the comfortable situation to support partners in relation to family planning.In this sense, the search for the exercise of a right, begin planning their family.This fact points to the need for health professionals be alert and aware of it, calling these users to other activities against family planning, among them educational.Furthermore, they can take the opportunity to create more this playing field of nursing actions.

FINAL CONSIDERATIONS
The study results showed that in the cities studied nurses identify that men seek actions and family planning services along with guidance for sexual and reproductive health; to have access to condoms; because they are with any demand concerning the prevention and diagnosis of STDs or require some other medical service for which could not care.
The results also point to the fact that the imagination of man is to be invulnerable and virile might be one of the factors that drive men to seek family planning and the myths and beliefs about sexual impotence and fear of getting sick too are involved.However, barriers to access, as the unavailability of services related to the SUS, like vasectomy, or related to primary health services (adequacy of schedules, long lines and distance of residence and/or work) make it impossible that men seek for family planning.
The study shows how limiting the impossibility of being able to identify whether the provision of family planning services are sufficient or insufficient, for men, in the cities studied, but it is emphasized that male demands for family planning are urgent and cannot be ignored.However, is not enough to meet the biological demands for curative and preventive activities; you need to think primarily in the actions of health promotion.It is necessary to call the men to health teams, even moving them to the communities, since the distance of rural localities in relation to health services was one of the barriers.
It is understood that, for greater adherence to masculine Family Planning, it is necessary that the services become more appropriate for men.It is necessary to make use of dialog, to address the issues of human health and, in particular, issues related to Family Planning.Moreover, it is necessary, through creative actions, educational and motivational programs for sexual and reproductive health, engage in a participatory way, both sexes, taking into account gender differences.
The awakening of a more shared vision among men and encouraging demystifying fears and prejudices can be planned educational activities for nursing, in order to contribute to a more effective and responsible participation of men in family planning.These demands must be in the perspective of gender, respecting their differences.