重庆市男性生殖健康需求及社会—心理—行为因素的流行病学调查和防治策略研究
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摘要
传统意义上,生殖健康(Reproductive health)主要是针对女性。1994年“国际人口发展会议(即开罗会议)”把生殖健康的关注焦点转向了男性生殖健康。世界卫生组织确定了每年的10月28日为“世界男性健康日”,同时,还在每年的“世界男性健康日”到来之即,要求世界各国加大对男性健康的宣传力度,呼吁整个社会再多一点对男性健康的关注、呼吁每个家庭再多一点对男性健康的关爱。男性性和生殖健康受到越来越多的关注。目前很多研究结果都证明世界范围的男性生殖健康在下降。但是男性生殖健康有关的研究还不多,特别是发展中国家,男性生殖健康的主要问题和需求还没有得到很好认识和理解。
我国男性生殖健康也同样呈现出下降趋势。有关调查发现25%的男性有性功能障碍或性心理障碍,男性不育率在3-11%,个别地区高达13-14%。很多研究表明1980-2010年我国有生育能力的男性的精液质量有明显的下降:1981- 1996间我国有生育能力的男性的所有精液指标都呈下降趋势;1980-2005年间中国有生育力男性精液参数中精子密度和精子总数呈现下降;1985-2010间我国正常生育力男子的精子密度呈下降趋势。我国政府近年来已经开始重视男性生殖健康。自从2000年起,为了提高男性健康意识,将每年的10月28日确定为男性健康日。中国是世界范围内确定了“男性健康日”的少数几个国家之一。国家人口计生委办公厅每年发布通知,确定当年男性健康日活动主题,部署男性健康日宣传活动。
在地处中国大西南的重庆,目前有关男性生殖健康的调查研究较少,现有研究已经表明其男性生殖健康也不容乐观。2005-2006年的调查发现重庆不育率为5.5%。也有调查发现重庆男性不育症发生率约为3%。我们前期的研究表明,按照1999年WHO的精液标准,在重庆超过60%的男性精液至少有一项指标不达标,但是其危险因素还有待进一步的深入研究。
研究目的:采用多种卫生服务研究方法,调查重庆市男性生殖健康需求,剖析影响男性生殖健康的社会-心理-行为因素,提出改善重庆市男性生殖健康的策略建议。
研究方法:
本研究采用参与式研究(participatory research method)、文献分析、个人深入访谈(in-depth interview)、现有资料分析等方法,对重庆市男性生殖健康需求(主要健康问题、影响因素和服务需求等)进行快速评价。通过系统评价(systemic review)和文献荟萃分析(meta-analysis)、横断面调查和病例对照研究,对重庆市男性精液质量的社会-心理-行为危险因素进行深入剖析。在此基础上,结合文献分析,提出改善重庆市男性生殖健康的对策建议。
主要研究结果:
一、重庆市男性生殖健康的需求评估
1.主要的男性生殖健康问题
通过对16位男性进行定性研究(个人深入访谈)和5位男性进行参与式研究(排序法)发现:性传播性疾病、前列腺疾病和性功能障碍是男性前三位的生殖健康问题。
2.男性生殖健康的有关影响因素
社会重视不够。个人深入访谈、现有资料分析和文献研究都反映了当前全国范围政府普遍对男性生殖健康重视程度还不够。传统意义上,生殖健康主要针对女性。从国家到地方,有专业针对女性健康的卫生机构(如妇幼保健院、妇幼保健站),各大医院都设有妇产科。各地的计划生育指导站(中心)也主要为妇女提供有关服务。但是到目前为止,重庆市很少设立专门的男性健康有关卫生机构,很多综合性医院没有设置专门的男科科室。虽然现有资料表明政府在每年的“男性健康日”都组织了各种各样的男性健康有关的宣传活动,但是本次调查中所有男性都反应从未见到过这类宣传活动。
男性健康知识缺乏,健康意识较差。个人深入访谈发现大部分男性健康意识较差,对男性生殖健康有关的健康知识相当缺乏。虽然大多数男性比较关心自己的男性健康,但是有部分人表现出完全不关心。不少人从来没有听说过男性生殖健康;绝大多数人对男性生殖健康的理解仅仅是“性健康”。对于性病的认识,大多数都或多或少听说过性病,但是对于具体的体征/症状以及传播途径不太清楚。安全性行为对于1/4的人都很陌生,只有少数人了解部分症状。绝大多数人对男性更年期的认识不足,不少人从来没有听说过男性更年期,大多数人对男性更年期的症状完全不了解。
男性就医行为不良。个人深入访谈发现怀疑有生殖健康疾病时,绝大多数都认为应该直接去医院,但是少数人自己会先处理(觉得不严重),实在不好再去医院。有人因为工作太忙,没有时间去医院看病,就干脆不管。
3.急需的男性生殖健康有关的卫生服务项目
个人深入访谈、参与式研究和文献研究的结果都表明目前主要卫生服务需求包括:设立男科诊所或医院成立专门的男性科室,方便男性就医;加强健康教育,给予健康知识普及;对常见的男性生殖健康疾病定期进行检查/筛查;提供男性生殖健康方面的专业咨询服务。
二、精液危险因素的系统评价和meta-分析
1.纳入57篇合格的文献,包括来自26个国家和地区的29914研究对象(4516有生育能力的男性和13001不育男性)。
2.共调查了精液质量和13个因素的关系:年龄、BMI,心理因素、吸烟、饮酒、喝咖啡、被动吸烟,久坐、洗热水澡/桑拿,穿紧身裤,喝绿茶,使用电热毯和个人卫生习惯。
3.根据资料提取结果,最后对六个因素与精液质量的关系进行了meta-分析。结果提示吸烟是精液量、精子密度、精子总数、精子运动能力和精子形态的危险因素(合并均数差分别为: -0.25, -7.07, -32.20, -1.85, -4.92, P<0.05);年龄大于40岁者精液量比40岁以下减少(合并均数差分别为:-0.57,P<0.05);长期饮酒时会减少精液量(合并MD为:-0. 30,P<0.05);心里压力可以降低精子密度和向前运动的精子比例,增加精子形态畸形的比例(合并均数差分别为: -23.01, -6.49 and 7.43, P<0.05).
4.目前的研究还不能提供足够的证据证明以下生活习惯对精子质量有影响:被动吸烟、久坐、洗热水澡、穿紧身裤、喝绿茶、使用电热毯和个人卫生习惯。还需要有更好设计的研究对这些关联进行进一步的验证。
三、影响重庆市男性精液质量的社会-心理-行为因素
1.横断面调查
对重庆市六个区县的1346位的20-40岁健康男性的精液质量的16个社会-心理-行为影响因素进行了横断面调查。结果显示年龄和经常穿化纤内裤与精子形态呈负相关(beta系数分别为: 0.69和0.83, P<0.01);职业分级与精子密度和精子向前运动呈负相关(beta系数分别为: 0.79和0.81, P=0.02和0.04);与心理压力大的男性相比,心理压力小的男性的精子总数和精子形态正常的比例要高(beta系数分别为: 1.19和1.25, P=0.02和0.04)。值得关注的是,有规律的参加适度的体育运动与精液的pH呈负相关。此外,我们观察到在不同年龄阶段、不同文化程度、不同收入水平和职业的男性参加体育运动的情况不一样。文化程度与穿化纤内裤的行为有关。年龄、文化程度和职业与心理压力有关。这些因素可以通过影响行为而间接影响精液质量。
2.病例对照研究
通过对重庆市沙坪坝区212位男性进行病例对照研究(83病例和129对照)发现:精液的PH值与洗热水澡、多个性伴侣和嫖娼行为呈负相关(Beta系数分别为: 0.51、0.54、0.51;P= 0.006、0.015、0.008 );精液量和不幸的婚姻呈负相关(Beta系数: 0.65;P: 0.008);精子密度与年龄、吸烟和过去3个月穿紧身裤呈负相关(Beta系数分别为: 0.51、0.61、0.49;P: 0.036、0.036、0.003);精子总数与不幸的婚姻和过去12个月穿化纤内裤呈负相关(Beta系数分别为: 0.69、2.05;P: 0.026、0.003);精子快速向前运动和年龄和饮酒呈负相关(Beta系数分别为: 0.69、0.50;P: 0.026、0.003);精子快速运动和年龄、饮酒以及首次性行为小于18岁呈负相关(Beta系数分别为: 0.57、0.72、0.44、0.57;P: 0.001,0.046,0.001、0.040)。此外,本研究分析了社会经济因素对精液有关的行为的影响。发现男性的文化程度、职业和贫困状态和他们的性行为有关;婚姻状况、教育程度、职业和贫困状况与行为/生活方式(饮酒、泡热水澡的习惯、穿化纤内裤的习惯)有关。这些社会经济因素可以通过这些行为间接影响精液质量。
四、重庆市男性生殖健康促进策略建议
1.高度重视男性生殖健康。国际上,男性参与生殖健康已经成为生殖健康项目和政策制定的重要内容。但是,在发达国家男性生殖健康至今主要还是输精管结扎和推广安全套使用。计划生育和妇幼保健系统工作都是针对女性,缺乏主要针对男性的有关政策和保健服务机构,使得男性生殖健康问题日益严重。政府有关部门和政策制定者需要更加关注男性生殖健康,在制定和完善有关政策和设计计划生育和生殖健康有关项目时强调和纳入男性;政府需要对男性生殖健康加大资金投入,如投资成立有关专门的机构,培训专业卫生人员队伍,提供有关卫生服务等。
2.组织机构和能力建设。健康需求结果表明目前缺乏为男性生殖健康服务的专业机构和专业人员。因此需要大力加强机构和能力的建设。一方面,可以设置男性健康专门的机构,配备专业的、具备有关知识和技能的卫生人员。另一方面,也可以将男性生殖健康和女性生殖健康服务相结合。利用现有的成熟妇幼保健机构,设置男性健康科室,配备有关卫生人员和培训有关男性生殖健康的知识和技能。此外,为了提高男性的男性健康意识,通过各种途径进行男性健康的宣传,建设男性健康的文化氛围也是非常重要。
3.提供男性生殖健康的卫生服务①健康教育:男性生殖健康需求评估发现男性普遍缺乏有关知识,对知识的需求很迫切。为了提高社区、家庭和大众能对健康教育的可及性,健康教育可以通过多种途径进行,通过各种大众媒体和大家喜爱的方式进行。考虑到上班人员,可以通过发放资料或在单位组织有关健康教育活动。此外,知识宣传也可以通过义诊咨询和热线电话的形式进行。②咨询服务:由经过正规培训的合格咨询人为男性提供专业的咨询服务可以预防有关健康问题。开展优质的咨询服务需要注意:咨询服务首先应该可及性好,费用能负担,适合文化背景和咨询对象的年龄、语言和健康需求;提供服务的方式可以通过义诊、热线,或者将咨询和其它为生服务相结合;注意保密,让咨询者建立信任,以便交流;咨询服务提供者应该热情和友好,让咨询者能够自然交流自己的健康问题。③常规的健康检查和质量:有关专业机构定时组织男性常见疾病的健康检查,以早期发现、早期治疗。一旦患病,最急需的就是有专业的机构提供有效的治疗。为了提高治疗的有效性,提供治疗时应该注意为患者保密、治疗费用能够承担。
4.进一步推广100%安全套策略。100%安全套策略在亚洲和全世界都已经推广。在中国已经经过长期的试点证明在预防性传播疾病和艾滋病方面是有明显效果。本次调查发现相当多的人即使从事危险的性行为时也没有使用安全套。因此,100%安全套策略还有待进一步推广。
5.干预不健康的性行为。在中国,随着经济发展,改革开放,人们的性观念发生了很大改变,性行为发生了巨大的变化,不健康性行为广泛存在。为了促进健康的性行为,为所有人群,特别是青少年提供综合性性健康教育。
6.对未来研究工作的建议。首先,加强男性健康问题预防措施的研究,预防比治疗更有效。其次,促进男性生殖健康领域的交叉学科的研究。第三,为了弄清男性生殖健康问题的原因,还需要长期开展良好设计的流行病学研究;最后,应该在男性生殖健康方面开展国际国内合作研究。
结论
男性生殖健康长期以来被忽略和边缘化,近年来在国际上受到广泛关注。本研究采用了多种卫生服务研究方法相结合的方法,对重庆市男性生殖健康需求和男性精液质量的社会-心-行为因素进行了深入研究.重庆市男性生殖健康需求还远没有得满足。影响男性生殖健康和精液质量的社会-心理-行为因素广泛存在:男性的年龄、婚姻状况、职业、心理压力、吸烟、饮酒、缺乏体育锻炼、穿紧身裤和化纤内裤的习惯、洗热水澡习惯、以及不安全性行为等)。近年来,我国对男性生殖健康逐渐受到关注,但是为了促进男性生殖健康,目前还有长的路要走。为了促进重庆市男性生殖健康,政府需要进一步重视男性生殖健康,成立专门的卫生机构或部门提供有关卫生服务,加强100%安全套推广,干预不良性行为和开展进一步的研究等措施很关键.
The shift in focus on men's reproductive health was influenced by the 1994 Cairo (ICPD) Action Plan to promote gender equality and equity. Recently, men's needs in sexual and reproductive health and health care are receiving increased attention. The present evidences proved that male reproductive health is declining worldwide. However, to date not much is known about reproductive health problems and health care needs in men from developing countries.
Male reproductive health in China also is declining. WHO together MOH in China organized an investigation in male reproductive health in China. Results showed that 25% men had sex disorder, infertility rate ranged between 3% and 11%, individual place reached 14%. Many studies consistently found that semen quality of fertile men decreased between 1980 and 2010. Male reproductive health has drawn attention in China. October 28 in every year is designed as“Man Health Day”in order to raise public awareness about male reproductive health care. China is one of a few countries to set aside a special day highlighting male health.
In Chongqing, southwest of China, the investigation between 2005 and 2006 found that the infertility rate was 5.5%. Our previous study found 61.1% of healthy males in Chongqing had at least one sperm parameter below normal threshold values compared with the WHO criteria. However, there is no study to comprehensively explore the male reproductive health needs and risk factors for male reproductive health in this area.
Aim: This thesis focus on investigating health needs of male reproductive health in Chongqing, exploring the risk factors for male reproductive health (particularly socio- psycho-behavioral factors) widely in this area, and identifying the possible strategies for male reproductive health promotion by utilizing interdisplinary methods. Methods: This investigation used mixed research methods such as in-depth interview, participatory research method, questionnaire survey, literature analysis, second data analysis, and meta-analysis and etc.
Main results:
1. Health needs assessment on male reproductive health in Chongqing
1.1 Main reproductive health problems
Through in-depth interviews of 16 males and ranking of 5 males, STDs prevention and control, prostate diseases control, sexual disorders were identified as the first three priorities of reproductive health problems in males in Chongqing.
1.2 Determinants related to male reproductive health
Little Attention form government: Traditionally main attention to reproductive health was given to female and men were marginalized. There is no a professional clinic or health sectors for male reproductive health. Though there was some kind of health propagandas on“Man Health Day”in each year, yet all males in the in-depth interviews reflected they never access to any professional health service(including health propagandas) for male’s health.
Lack of awareness and health knowledge in male: In-depth interviews found that male’s health awareness need improve. Though the vast majorities(14/16)cared about male reproductive health, yet individual male didn’t mind male reproductive health. Generally speaking, males were rather lack of knowledge related to male reproductive health. Quite a few males(6/16)never heard of male reproductive health. The vast majorities only heard of STDs, but have no knowledge of symptoms or sign, or the route of transmission. Safe sexual behaviors and risk sexual behaviors were strange for around 1/4 males. Many men didn’t hear of male menopause and majorities have no knowledge on any symptoms of it. It is notably, number of male didn’t know any information about the places to get condom or its use; vast majorities thought condom was only used for contraception.
Risk behaviors related to male reproductive health when they suspect they have reproductive health problems, the vast majorities (12/16) would see doctors directly, but minorities (4/16) of them would take self-treatment and then would see doctor when they feel it is difficult to recover by itself. Some men even just let it alone just because they were busy with work.
1.3 Urgent health needs of male reproductive health
The In-depth interviews and ranking reflected that urgent health services reported by men included setting up professional clinics for male reproductive health, strengthening health information dissemination, screening reproductive diseases and provided various consultation services.
2. Meta-analysis on risk factors for male semen quality
2.1 Fifty seven eligible articles were identified altogether including 29914 subjects (including 4516 fertile people, 13001 infertile people, 9080 healthy people and 3317 men from general population) from more than 26 countries and regions.
2.2 13 Factors were investigated: age, BMI, psychological stress, smoking, alcohol and coffee consumption, passive smoking, sedentary posture, hot bath/sauna, wearing tight pants, tea drinking, electric blanket utilization, and genitalia washing.
2.3 There were six factors including age, body mass index, psychological stress, smoking, alcohol, and coffee consumption that were included in this meta-analysis. The results showed that smoking can deteriorate all of the sperm parameters (the pooled mean differences were -0.25, -7.07, -32.20, -1.85, -4.92, respectively, P<0.05); higher age and alcohol consumption are risk factors for lower semen volume (the pooled mean differences were -0.57 and -0. 30, respectively, P<0.05); psychological stress can lower sperm density and sperm progressive motility and increase abnormal sperm (the pooled mean differences were -23.01, -6.49 and 7.43, respectively, P<0.05).
2.4 We did not identify enough data for a meta-analysis on the relationship between the rest factors and semen quality. But, the effect of tea drinking, electric blanket use, passive smoking, sedentary posture, and wearing tight pants on semen quality were implicated in the qualitative analysis in a few present studies. Great efforts should be needed to examine their role on semen quality with a better study design.
3. Socio-psycho-behaviour factors associated with male semen quality in Chongqing
3.1 Cross-sectional study
This cross-sectional study investigated the association between 16 socio-psycho-behaviour factors and semen quality of 1346. Results indicated that age and often wearing fiber underwear were negatively associated with sperm morphology (beta coefficient: 0.69 and 0.83 respectively, P<0.01); occupation class was negatively correlated with sperm density and sperm progressive motility (beta coefficient: 0.79 and 0.81 respectively, P=0.02 and 0.04 respectively); men with less stress had higher total sperm count and percentage of morphologically normal sperm(beta coefficient: 1.19 and 1.25 respectively, P=0.02 and 0.04 respectively). Noticeably, regular physical exercise was negatively correlated with semen pH value. In addition, we observed that regular physical exercise participation was significantly different among different age groups, years of education, occupation classes and level of income (P=0.000). Age, education and income were significantly associated with fiber underwear wearing (p=0.005, 0.000, 0.01 and 0.036 respectively). Age, education and occupation were associated with psychological stress (p=0.036, 0.003 and 0.004 respectively).
3.2 Case-controls study
This case-control study found that semen PH was negatively associated with habit of taking hot bath, having multiple sexual partners and visiting prostitute(Beta: 0.51, 0.54 and 0.51 respectively; P: 0.006,0.015 and 0.008 respectively); semen volume was negatively related to divorce/separate or winded marital status(Beta: 0.65; P: 0.008); age, smoking, tight pants wearing in past 3 month decreased significantly sperm density (Beta: 0.51, 0.61 and 0.49 respectively; P:0.036, 0.036 and 0.003 respectively);total sperm count was negatively associated with divorce/separate or winded marital status, and fiber underwear wearing in past 12 months (Beta: 0.69 and 0.50 respectively; P: 0.026 and 0.003 respectively); rapid progressive motility was negatively influenced by age and alcohol(Beta: 0.002 and 0.50 respectively; P: 0.00 and 0.006 respectively); progressive motility was negatively affected by age, alcohol drinking, and age at sex initiation(Beta: 0.57, 0.72, 0.44 and 0.57 respectively; P: 0.001,0.046,0.001 and 0.040 respectively). Besides, we explored socio-economic factors indirect associated with semen quality and found that education level, occupation and poverty influence sexual behaviours; marital status, education, occupation and poverty did influenced alcohol drinking, habit of taking hot bath and wearing fiber underwear.
4. Strategies suggestions for improvement of male reproductive health in Chongqing
4.1 To attract attention to male reproductive health from government Up to date, in developing countries, the tendency is still to exclude men from reproductive health work other than vasectomy or condom distribution. Health needs assessment also indicated that policy makers was expect to give high light to male involvement in family planning and reproductive health when they make or perfect related policy; government should gradually increase financial input in every aspect of male reproductive health, such as organisational and environmental development, training and skills development of health workers, provision of health services.
4.2 Organizational capacity building It is important to set up professional health sectors for male reproductive health and to staff a group of professional health workers with essential knowledge and skill. Another one choice is to combine female reproductive health service with male reproductive in existing family planning networks, and to staff and train health workers in this network. Besides, in order to improve awareness, it is of great significance to build cultural environment through widely health education by TV, broadcast, newspaper, propaganda column.
4.3 Provision of health services for men reproductive health Health needs assessment discovered that men are thirty for accessible health education, providing counselling, regular examination. Accordingly, following measures can be considered: Regular publicity activities should be conducted through public media or other popular means so that local communities, families and the public can benefit and form healthy lifestyle/behaviours; professional health education programs can be conducted in local communities or work units; knowledge can also be disseminated by giving volunteer medical consultation or hotline. Professional, accessible, affordable, acceptable, counselling by qualified counsellors should be provided in free-standing counselling services, by hotline or by integrating it into other health services. Regular examinations for some common male reproductive diseases can be organized by related health sectors. Besides, provision of treatment is another one need because once males meet any reproductive health problem, accessible treatment is of great importance.
4.4 Strengthening 100% CUP strategy The 100% CUP strategy is now recommended to implement in Asian countries and worldwide. It has also been proven effective to in reducing the prevalence of STI and HIV/AIDS in China. Therefore, it is important to emphasize the importance of 100% using condom in establishments and provide skills-building services on condom use.
4.5 Unhealthy sexual behavioural interventions With social and economic development, unhealthy sexual behaviours are increasing largely in China and Chongqing. Providing comprehensive sex education for youth and improving access to health care are important strategies to help individuals achieve and maintain good sexual health.
4.6 Implications for research: Firstly, target research efforts should address prevent/minimize the occurrence of disorders rather than develop drug treatment. Secondly, strengthen interdisciplinary, translational research in male reproductive health issues. Thirdly, implementing long-term, epidemiology studies aimed at better understanding the causes and effects of male reproductive disorders. Besides, national/international exchanges and cooperation, collaborative research in the field of male reproductive health should be improved.
Conclusion:
This thesis primarily investigated health needs of male reproductive health and socio-psycho-behavioural risk factors associated with semen quality of males in Chongqing. Health needs of men health was far from fulfilling. Many socio-psycho-behavioural factors associated with male reproductive and semen quality. Increasing attention had been given to male reproductive health, but there is still a long way to go. Attention from government, organization capacity and environment building, health service provision (including health education, counselling, regular examination and treatment), strengthening 100% CUP, interventions on unhealthy sexual behaviours, further research are major strategies for male reproductive health improvement in Chongqing.
我国男性生殖健康也同样呈现出下降趋势。有关调查发现25%的男性有性功能障碍或性心理障碍,男性不育率在3-11%,个别地区高达13-14%。很多研究表明1980-2010年我国有生育能力的男性的精液质量有明显的下降:1981- 1996间我国有生育能力的男性的所有精液指标都呈下降趋势;1980-2005年间中国有生育力男性精液参数中精子密度和精子总数呈现下降;1985-2010间我国正常生育力男子的精子密度呈下降趋势。我国政府近年来已经开始重视男性生殖健康。自从2000年起,为了提高男性健康意识,将每年的10月28日确定为男性健康日。中国是世界范围内确定了“男性健康日”的少数几个国家之一。国家人口计生委办公厅每年发布通知,确定当年男性健康日活动主题,部署男性健康日宣传活动。
在地处中国大西南的重庆,目前有关男性生殖健康的调查研究较少,现有研究已经表明其男性生殖健康也不容乐观。2005-2006年的调查发现重庆不育率为5.5%。也有调查发现重庆男性不育症发生率约为3%。我们前期的研究表明,按照1999年WHO的精液标准,在重庆超过60%的男性精液至少有一项指标不达标,但是其危险因素还有待进一步的深入研究。
研究目的:采用多种卫生服务研究方法,调查重庆市男性生殖健康需求,剖析影响男性生殖健康的社会-心理-行为因素,提出改善重庆市男性生殖健康的策略建议。
研究方法:
本研究采用参与式研究(participatory research method)、文献分析、个人深入访谈(in-depth interview)、现有资料分析等方法,对重庆市男性生殖健康需求(主要健康问题、影响因素和服务需求等)进行快速评价。通过系统评价(systemic review)和文献荟萃分析(meta-analysis)、横断面调查和病例对照研究,对重庆市男性精液质量的社会-心理-行为危险因素进行深入剖析。在此基础上,结合文献分析,提出改善重庆市男性生殖健康的对策建议。
主要研究结果:
一、重庆市男性生殖健康的需求评估
1.主要的男性生殖健康问题
通过对16位男性进行定性研究(个人深入访谈)和5位男性进行参与式研究(排序法)发现:性传播性疾病、前列腺疾病和性功能障碍是男性前三位的生殖健康问题。
2.男性生殖健康的有关影响因素
社会重视不够。个人深入访谈、现有资料分析和文献研究都反映了当前全国范围政府普遍对男性生殖健康重视程度还不够。传统意义上,生殖健康主要针对女性。从国家到地方,有专业针对女性健康的卫生机构(如妇幼保健院、妇幼保健站),各大医院都设有妇产科。各地的计划生育指导站(中心)也主要为妇女提供有关服务。但是到目前为止,重庆市很少设立专门的男性健康有关卫生机构,很多综合性医院没有设置专门的男科科室。虽然现有资料表明政府在每年的“男性健康日”都组织了各种各样的男性健康有关的宣传活动,但是本次调查中所有男性都反应从未见到过这类宣传活动。
男性健康知识缺乏,健康意识较差。个人深入访谈发现大部分男性健康意识较差,对男性生殖健康有关的健康知识相当缺乏。虽然大多数男性比较关心自己的男性健康,但是有部分人表现出完全不关心。不少人从来没有听说过男性生殖健康;绝大多数人对男性生殖健康的理解仅仅是“性健康”。对于性病的认识,大多数都或多或少听说过性病,但是对于具体的体征/症状以及传播途径不太清楚。安全性行为对于1/4的人都很陌生,只有少数人了解部分症状。绝大多数人对男性更年期的认识不足,不少人从来没有听说过男性更年期,大多数人对男性更年期的症状完全不了解。
男性就医行为不良。个人深入访谈发现怀疑有生殖健康疾病时,绝大多数都认为应该直接去医院,但是少数人自己会先处理(觉得不严重),实在不好再去医院。有人因为工作太忙,没有时间去医院看病,就干脆不管。
3.急需的男性生殖健康有关的卫生服务项目
个人深入访谈、参与式研究和文献研究的结果都表明目前主要卫生服务需求包括:设立男科诊所或医院成立专门的男性科室,方便男性就医;加强健康教育,给予健康知识普及;对常见的男性生殖健康疾病定期进行检查/筛查;提供男性生殖健康方面的专业咨询服务。
二、精液危险因素的系统评价和meta-分析
1.纳入57篇合格的文献,包括来自26个国家和地区的29914研究对象(4516有生育能力的男性和13001不育男性)。
2.共调查了精液质量和13个因素的关系:年龄、BMI,心理因素、吸烟、饮酒、喝咖啡、被动吸烟,久坐、洗热水澡/桑拿,穿紧身裤,喝绿茶,使用电热毯和个人卫生习惯。
3.根据资料提取结果,最后对六个因素与精液质量的关系进行了meta-分析。结果提示吸烟是精液量、精子密度、精子总数、精子运动能力和精子形态的危险因素(合并均数差分别为: -0.25, -7.07, -32.20, -1.85, -4.92, P<0.05);年龄大于40岁者精液量比40岁以下减少(合并均数差分别为:-0.57,P<0.05);长期饮酒时会减少精液量(合并MD为:-0. 30,P<0.05);心里压力可以降低精子密度和向前运动的精子比例,增加精子形态畸形的比例(合并均数差分别为: -23.01, -6.49 and 7.43, P<0.05).
4.目前的研究还不能提供足够的证据证明以下生活习惯对精子质量有影响:被动吸烟、久坐、洗热水澡、穿紧身裤、喝绿茶、使用电热毯和个人卫生习惯。还需要有更好设计的研究对这些关联进行进一步的验证。
三、影响重庆市男性精液质量的社会-心理-行为因素
1.横断面调查
对重庆市六个区县的1346位的20-40岁健康男性的精液质量的16个社会-心理-行为影响因素进行了横断面调查。结果显示年龄和经常穿化纤内裤与精子形态呈负相关(beta系数分别为: 0.69和0.83, P<0.01);职业分级与精子密度和精子向前运动呈负相关(beta系数分别为: 0.79和0.81, P=0.02和0.04);与心理压力大的男性相比,心理压力小的男性的精子总数和精子形态正常的比例要高(beta系数分别为: 1.19和1.25, P=0.02和0.04)。值得关注的是,有规律的参加适度的体育运动与精液的pH呈负相关。此外,我们观察到在不同年龄阶段、不同文化程度、不同收入水平和职业的男性参加体育运动的情况不一样。文化程度与穿化纤内裤的行为有关。年龄、文化程度和职业与心理压力有关。这些因素可以通过影响行为而间接影响精液质量。
2.病例对照研究
通过对重庆市沙坪坝区212位男性进行病例对照研究(83病例和129对照)发现:精液的PH值与洗热水澡、多个性伴侣和嫖娼行为呈负相关(Beta系数分别为: 0.51、0.54、0.51;P= 0.006、0.015、0.008 );精液量和不幸的婚姻呈负相关(Beta系数: 0.65;P: 0.008);精子密度与年龄、吸烟和过去3个月穿紧身裤呈负相关(Beta系数分别为: 0.51、0.61、0.49;P: 0.036、0.036、0.003);精子总数与不幸的婚姻和过去12个月穿化纤内裤呈负相关(Beta系数分别为: 0.69、2.05;P: 0.026、0.003);精子快速向前运动和年龄和饮酒呈负相关(Beta系数分别为: 0.69、0.50;P: 0.026、0.003);精子快速运动和年龄、饮酒以及首次性行为小于18岁呈负相关(Beta系数分别为: 0.57、0.72、0.44、0.57;P: 0.001,0.046,0.001、0.040)。此外,本研究分析了社会经济因素对精液有关的行为的影响。发现男性的文化程度、职业和贫困状态和他们的性行为有关;婚姻状况、教育程度、职业和贫困状况与行为/生活方式(饮酒、泡热水澡的习惯、穿化纤内裤的习惯)有关。这些社会经济因素可以通过这些行为间接影响精液质量。
四、重庆市男性生殖健康促进策略建议
1.高度重视男性生殖健康。国际上,男性参与生殖健康已经成为生殖健康项目和政策制定的重要内容。但是,在发达国家男性生殖健康至今主要还是输精管结扎和推广安全套使用。计划生育和妇幼保健系统工作都是针对女性,缺乏主要针对男性的有关政策和保健服务机构,使得男性生殖健康问题日益严重。政府有关部门和政策制定者需要更加关注男性生殖健康,在制定和完善有关政策和设计计划生育和生殖健康有关项目时强调和纳入男性;政府需要对男性生殖健康加大资金投入,如投资成立有关专门的机构,培训专业卫生人员队伍,提供有关卫生服务等。
2.组织机构和能力建设。健康需求结果表明目前缺乏为男性生殖健康服务的专业机构和专业人员。因此需要大力加强机构和能力的建设。一方面,可以设置男性健康专门的机构,配备专业的、具备有关知识和技能的卫生人员。另一方面,也可以将男性生殖健康和女性生殖健康服务相结合。利用现有的成熟妇幼保健机构,设置男性健康科室,配备有关卫生人员和培训有关男性生殖健康的知识和技能。此外,为了提高男性的男性健康意识,通过各种途径进行男性健康的宣传,建设男性健康的文化氛围也是非常重要。
3.提供男性生殖健康的卫生服务①健康教育:男性生殖健康需求评估发现男性普遍缺乏有关知识,对知识的需求很迫切。为了提高社区、家庭和大众能对健康教育的可及性,健康教育可以通过多种途径进行,通过各种大众媒体和大家喜爱的方式进行。考虑到上班人员,可以通过发放资料或在单位组织有关健康教育活动。此外,知识宣传也可以通过义诊咨询和热线电话的形式进行。②咨询服务:由经过正规培训的合格咨询人为男性提供专业的咨询服务可以预防有关健康问题。开展优质的咨询服务需要注意:咨询服务首先应该可及性好,费用能负担,适合文化背景和咨询对象的年龄、语言和健康需求;提供服务的方式可以通过义诊、热线,或者将咨询和其它为生服务相结合;注意保密,让咨询者建立信任,以便交流;咨询服务提供者应该热情和友好,让咨询者能够自然交流自己的健康问题。③常规的健康检查和质量:有关专业机构定时组织男性常见疾病的健康检查,以早期发现、早期治疗。一旦患病,最急需的就是有专业的机构提供有效的治疗。为了提高治疗的有效性,提供治疗时应该注意为患者保密、治疗费用能够承担。
4.进一步推广100%安全套策略。100%安全套策略在亚洲和全世界都已经推广。在中国已经经过长期的试点证明在预防性传播疾病和艾滋病方面是有明显效果。本次调查发现相当多的人即使从事危险的性行为时也没有使用安全套。因此,100%安全套策略还有待进一步推广。
5.干预不健康的性行为。在中国,随着经济发展,改革开放,人们的性观念发生了很大改变,性行为发生了巨大的变化,不健康性行为广泛存在。为了促进健康的性行为,为所有人群,特别是青少年提供综合性性健康教育。
6.对未来研究工作的建议。首先,加强男性健康问题预防措施的研究,预防比治疗更有效。其次,促进男性生殖健康领域的交叉学科的研究。第三,为了弄清男性生殖健康问题的原因,还需要长期开展良好设计的流行病学研究;最后,应该在男性生殖健康方面开展国际国内合作研究。
结论
男性生殖健康长期以来被忽略和边缘化,近年来在国际上受到广泛关注。本研究采用了多种卫生服务研究方法相结合的方法,对重庆市男性生殖健康需求和男性精液质量的社会-心-行为因素进行了深入研究.重庆市男性生殖健康需求还远没有得满足。影响男性生殖健康和精液质量的社会-心理-行为因素广泛存在:男性的年龄、婚姻状况、职业、心理压力、吸烟、饮酒、缺乏体育锻炼、穿紧身裤和化纤内裤的习惯、洗热水澡习惯、以及不安全性行为等)。近年来,我国对男性生殖健康逐渐受到关注,但是为了促进男性生殖健康,目前还有长的路要走。为了促进重庆市男性生殖健康,政府需要进一步重视男性生殖健康,成立专门的卫生机构或部门提供有关卫生服务,加强100%安全套推广,干预不良性行为和开展进一步的研究等措施很关键.
The shift in focus on men's reproductive health was influenced by the 1994 Cairo (ICPD) Action Plan to promote gender equality and equity. Recently, men's needs in sexual and reproductive health and health care are receiving increased attention. The present evidences proved that male reproductive health is declining worldwide. However, to date not much is known about reproductive health problems and health care needs in men from developing countries.
Male reproductive health in China also is declining. WHO together MOH in China organized an investigation in male reproductive health in China. Results showed that 25% men had sex disorder, infertility rate ranged between 3% and 11%, individual place reached 14%. Many studies consistently found that semen quality of fertile men decreased between 1980 and 2010. Male reproductive health has drawn attention in China. October 28 in every year is designed as“Man Health Day”in order to raise public awareness about male reproductive health care. China is one of a few countries to set aside a special day highlighting male health.
In Chongqing, southwest of China, the investigation between 2005 and 2006 found that the infertility rate was 5.5%. Our previous study found 61.1% of healthy males in Chongqing had at least one sperm parameter below normal threshold values compared with the WHO criteria. However, there is no study to comprehensively explore the male reproductive health needs and risk factors for male reproductive health in this area.
Aim: This thesis focus on investigating health needs of male reproductive health in Chongqing, exploring the risk factors for male reproductive health (particularly socio- psycho-behavioral factors) widely in this area, and identifying the possible strategies for male reproductive health promotion by utilizing interdisplinary methods. Methods: This investigation used mixed research methods such as in-depth interview, participatory research method, questionnaire survey, literature analysis, second data analysis, and meta-analysis and etc.
Main results:
1. Health needs assessment on male reproductive health in Chongqing
1.1 Main reproductive health problems
Through in-depth interviews of 16 males and ranking of 5 males, STDs prevention and control, prostate diseases control, sexual disorders were identified as the first three priorities of reproductive health problems in males in Chongqing.
1.2 Determinants related to male reproductive health
Little Attention form government: Traditionally main attention to reproductive health was given to female and men were marginalized. There is no a professional clinic or health sectors for male reproductive health. Though there was some kind of health propagandas on“Man Health Day”in each year, yet all males in the in-depth interviews reflected they never access to any professional health service(including health propagandas) for male’s health.
Lack of awareness and health knowledge in male: In-depth interviews found that male’s health awareness need improve. Though the vast majorities(14/16)cared about male reproductive health, yet individual male didn’t mind male reproductive health. Generally speaking, males were rather lack of knowledge related to male reproductive health. Quite a few males(6/16)never heard of male reproductive health. The vast majorities only heard of STDs, but have no knowledge of symptoms or sign, or the route of transmission. Safe sexual behaviors and risk sexual behaviors were strange for around 1/4 males. Many men didn’t hear of male menopause and majorities have no knowledge on any symptoms of it. It is notably, number of male didn’t know any information about the places to get condom or its use; vast majorities thought condom was only used for contraception.
Risk behaviors related to male reproductive health when they suspect they have reproductive health problems, the vast majorities (12/16) would see doctors directly, but minorities (4/16) of them would take self-treatment and then would see doctor when they feel it is difficult to recover by itself. Some men even just let it alone just because they were busy with work.
1.3 Urgent health needs of male reproductive health
The In-depth interviews and ranking reflected that urgent health services reported by men included setting up professional clinics for male reproductive health, strengthening health information dissemination, screening reproductive diseases and provided various consultation services.
2. Meta-analysis on risk factors for male semen quality
2.1 Fifty seven eligible articles were identified altogether including 29914 subjects (including 4516 fertile people, 13001 infertile people, 9080 healthy people and 3317 men from general population) from more than 26 countries and regions.
2.2 13 Factors were investigated: age, BMI, psychological stress, smoking, alcohol and coffee consumption, passive smoking, sedentary posture, hot bath/sauna, wearing tight pants, tea drinking, electric blanket utilization, and genitalia washing.
2.3 There were six factors including age, body mass index, psychological stress, smoking, alcohol, and coffee consumption that were included in this meta-analysis. The results showed that smoking can deteriorate all of the sperm parameters (the pooled mean differences were -0.25, -7.07, -32.20, -1.85, -4.92, respectively, P<0.05); higher age and alcohol consumption are risk factors for lower semen volume (the pooled mean differences were -0.57 and -0. 30, respectively, P<0.05); psychological stress can lower sperm density and sperm progressive motility and increase abnormal sperm (the pooled mean differences were -23.01, -6.49 and 7.43, respectively, P<0.05).
2.4 We did not identify enough data for a meta-analysis on the relationship between the rest factors and semen quality. But, the effect of tea drinking, electric blanket use, passive smoking, sedentary posture, and wearing tight pants on semen quality were implicated in the qualitative analysis in a few present studies. Great efforts should be needed to examine their role on semen quality with a better study design.
3. Socio-psycho-behaviour factors associated with male semen quality in Chongqing
3.1 Cross-sectional study
This cross-sectional study investigated the association between 16 socio-psycho-behaviour factors and semen quality of 1346. Results indicated that age and often wearing fiber underwear were negatively associated with sperm morphology (beta coefficient: 0.69 and 0.83 respectively, P<0.01); occupation class was negatively correlated with sperm density and sperm progressive motility (beta coefficient: 0.79 and 0.81 respectively, P=0.02 and 0.04 respectively); men with less stress had higher total sperm count and percentage of morphologically normal sperm(beta coefficient: 1.19 and 1.25 respectively, P=0.02 and 0.04 respectively). Noticeably, regular physical exercise was negatively correlated with semen pH value. In addition, we observed that regular physical exercise participation was significantly different among different age groups, years of education, occupation classes and level of income (P=0.000). Age, education and income were significantly associated with fiber underwear wearing (p=0.005, 0.000, 0.01 and 0.036 respectively). Age, education and occupation were associated with psychological stress (p=0.036, 0.003 and 0.004 respectively).
3.2 Case-controls study
This case-control study found that semen PH was negatively associated with habit of taking hot bath, having multiple sexual partners and visiting prostitute(Beta: 0.51, 0.54 and 0.51 respectively; P: 0.006,0.015 and 0.008 respectively); semen volume was negatively related to divorce/separate or winded marital status(Beta: 0.65; P: 0.008); age, smoking, tight pants wearing in past 3 month decreased significantly sperm density (Beta: 0.51, 0.61 and 0.49 respectively; P:0.036, 0.036 and 0.003 respectively);total sperm count was negatively associated with divorce/separate or winded marital status, and fiber underwear wearing in past 12 months (Beta: 0.69 and 0.50 respectively; P: 0.026 and 0.003 respectively); rapid progressive motility was negatively influenced by age and alcohol(Beta: 0.002 and 0.50 respectively; P: 0.00 and 0.006 respectively); progressive motility was negatively affected by age, alcohol drinking, and age at sex initiation(Beta: 0.57, 0.72, 0.44 and 0.57 respectively; P: 0.001,0.046,0.001 and 0.040 respectively). Besides, we explored socio-economic factors indirect associated with semen quality and found that education level, occupation and poverty influence sexual behaviours; marital status, education, occupation and poverty did influenced alcohol drinking, habit of taking hot bath and wearing fiber underwear.
4. Strategies suggestions for improvement of male reproductive health in Chongqing
4.1 To attract attention to male reproductive health from government Up to date, in developing countries, the tendency is still to exclude men from reproductive health work other than vasectomy or condom distribution. Health needs assessment also indicated that policy makers was expect to give high light to male involvement in family planning and reproductive health when they make or perfect related policy; government should gradually increase financial input in every aspect of male reproductive health, such as organisational and environmental development, training and skills development of health workers, provision of health services.
4.2 Organizational capacity building It is important to set up professional health sectors for male reproductive health and to staff a group of professional health workers with essential knowledge and skill. Another one choice is to combine female reproductive health service with male reproductive in existing family planning networks, and to staff and train health workers in this network. Besides, in order to improve awareness, it is of great significance to build cultural environment through widely health education by TV, broadcast, newspaper, propaganda column.
4.3 Provision of health services for men reproductive health Health needs assessment discovered that men are thirty for accessible health education, providing counselling, regular examination. Accordingly, following measures can be considered: Regular publicity activities should be conducted through public media or other popular means so that local communities, families and the public can benefit and form healthy lifestyle/behaviours; professional health education programs can be conducted in local communities or work units; knowledge can also be disseminated by giving volunteer medical consultation or hotline. Professional, accessible, affordable, acceptable, counselling by qualified counsellors should be provided in free-standing counselling services, by hotline or by integrating it into other health services. Regular examinations for some common male reproductive diseases can be organized by related health sectors. Besides, provision of treatment is another one need because once males meet any reproductive health problem, accessible treatment is of great importance.
4.4 Strengthening 100% CUP strategy The 100% CUP strategy is now recommended to implement in Asian countries and worldwide. It has also been proven effective to in reducing the prevalence of STI and HIV/AIDS in China. Therefore, it is important to emphasize the importance of 100% using condom in establishments and provide skills-building services on condom use.
4.5 Unhealthy sexual behavioural interventions With social and economic development, unhealthy sexual behaviours are increasing largely in China and Chongqing. Providing comprehensive sex education for youth and improving access to health care are important strategies to help individuals achieve and maintain good sexual health.
4.6 Implications for research: Firstly, target research efforts should address prevent/minimize the occurrence of disorders rather than develop drug treatment. Secondly, strengthen interdisciplinary, translational research in male reproductive health issues. Thirdly, implementing long-term, epidemiology studies aimed at better understanding the causes and effects of male reproductive disorders. Besides, national/international exchanges and cooperation, collaborative research in the field of male reproductive health should be improved.
Conclusion:
This thesis primarily investigated health needs of male reproductive health and socio-psycho-behavioural risk factors associated with semen quality of males in Chongqing. Health needs of men health was far from fulfilling. Many socio-psycho-behavioural factors associated with male reproductive and semen quality. Increasing attention had been given to male reproductive health, but there is still a long way to go. Attention from government, organization capacity and environment building, health service provision (including health education, counselling, regular examination and treatment), strengthening 100% CUP, interventions on unhealthy sexual behaviours, further research are major strategies for male reproductive health improvement in Chongqing.
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