The Department of Health and Human Services/Office of Population Affairs funded five family planning grantees in 2009 to expand male reproductive health services via staff and clinic innovation interventions within both the clinics and the surrounding community. As a project grantee, Family Health Centers (FHCs) of San Diego, CA, included 15 clinics that provided family planning, reproductive health, or STI-related services. Of these, we enrolled two family planning clinic programs as intervention sites and also identified five other FHC family planning programs with similar client populations and family planning service models to serve as comparison sites. Intervention sites were chosen in collaboration with FHC management and factored in medical director support and staff capacity to commit to training and intervention activities. Five interventions, described in the following section, were initiated beginning in 2010, at the two intervention clinics:

In-reach: Clinic staff members were trained on using in-reach strategies with their female clients by encouraging women to inform male partners, friends, and relatives about reproductive health services. Promotoras, middle-aged women who were well-respected community members, were used at one intervention site in a predominantly Hispanic community. These part-time volunteers approached males and couples in the clinic waiting room and at the building entrance to inform them about the availability of male reproductive health services. For males expressing interest, the promotoras arranged clinic appointments and shared contact information with the project coordinator, who proceeded to make reminder calls in advance of scheduled appointments. At the second intervention site, the clinic’s outreach worker provided community outreach and clinic in-reach. For the latter, the worker approached male clients in the waiting area. If interested, the worker would suggest having a further confidential conversation about STI services in a separate room, as needed.

For primary analyses, we accessed all 20,711 de-identified male family planning client clinic visit records from the administrative client information system for the seven participating clinics in FHC’s network (i.e., two interventions and five comparisons) from 2007 through 2012. In addition, we accessed 85,803 de-identified clinic visit records for female clients aged 15–24 years from the same clinics for the same years. This age range selected for female clients represents a priority clinical population for prevention of both STIs and unintended pregnancies [17,18]. Two periods were compared between intervention and comparison clinics: (1) 2007–2009, before interventions were implemented and (2) 2010–2012, during and after interventions were implemented (herein referred to as “preintervention” and “postintervention”) periods, respectively. Computerized visit records were extracted by agency information managers and routed to the coordinating center (Cardea Services, Seattle, WA) via secure and encrypted electronic file transfer. Measures included clinic identifier, visit calendar quarter and year (recoded as preintervention vs. postintervention period), and condition (comparison vs. intervention clinic); client demographic and visit characteristics (sex, age, and race/ethnicity, federal poverty level [Client federal poverty level is based on self-reported annual income that is then compared with the most recent HHS guidelines. Unemancipated minors who wish to receive services on a confidential basis must be considered according to their own resources.]), insurance status, and client visit status (new or continuing client [A new client visit was defined as an individual who had not been to any FHC clinic nor received any FHC health program services prior to that family planning visit; a continuing visit indicated that the individual had had one or more prior visits for any type of health service anywhere in the FHC system of clinics.]); chlamydia test performed; and chlamydia test results. We developed a joint race/ethnicity measure [19] where records identified as Hispanic ethnicity–regardless of race–were assigned to race/ethnicity’s Hispanic category.

Descriptive statistics were calculated for all measures. We compared male and female client volume by intervention status and period. STI service delivery, operationalized as chlamydia testing, was stratified by client demographics, visit characteristics, intervention status, and period. We used Pearson’s chi-squared test or Fisher’s exact tests to assess differences in proportions. Bivariate and multivariate log-binomial regression procedures were used to assess the relationship between chlamydia testing and client demographic and visit characteristics, intervention status, and time period [20,21]. Multivariate procedures were implemented separately for visit records within preintervention and postintervention periods. Covariates (age, race/ethnicity, poverty, insurance coverage, and client visit status) for multivariate analyses were selected based on bivariate results. Prevalence ratios (PRs) and 95% confidence intervals (CIs) were calculated to evaluate factors associated with chlamydia testing. A two-sided p value < .05 was considered statistically significant. We performed analyses using SPSS, version 19 (Chicago, IL) [22].

Overall study procedures were approved by the Washington State Institutional Review Board and, locally, by the University of California, San Diego, Human Research Protections Program. The study was based on an analysis of de-identified data from the administrative and client information systems of the FHCs. Protocols for informed consent were not required.

Of 7,826 reproductive health visits by males to family planning clinics operated by FHCs before intervention, total visit volume by males between comparison and intervention clinics was comparable (Table 1). Overall, most visits were by males who were adolescents or young adults (aged < 30 years), Hispanic, residing in households below 100% of the federal poverty level and lacking health insurance. Visits at intervention clinics relative to comparison clinics were less common among men aged < 20 years (5% vs. 18%) and those who were insured (12% vs. 27%). Rates of chlamydia testing were comparable between comparison and intervention (37% vs. 35%) clinics.

Finally, we assessed the impact of male-centered interventions at FHC clinics on clinic visit volume and rate of chlamydia testing among female clients aged 15–24 years. Between the preintervention and postintervention periods, the number of family planning visits by female clients aged 15–24 years declined 39% at comparison clinics (pre: 21,800 visits; post: 13,202 visits) and 35% at intervention clinics (pre: 30,830; post: 19,971). Beyond visit volume, at comparison clinics the likelihood of chlamydia testing among visits for new female clients aged 15–24 years remained stable from preintervention to postintervention period (26% vs. 28%, respectively; p = .175 for difference in percent increase between periods) but increased significantly at intervention clinics between periods (pre: 18%; post: 36%; p < .001).

Future research regarding the design and implementation of program innovations could build on four lessons learned from this study. First, routine administrative information systems are underutilized but highly cost-efficient sources of information that can be used to assess intervention effectiveness. These systems are also limited to existing client demographics and service outputs, such as the number and type of STI tests performed. Having easily accessible, de-identified data on client demographics and receipt of clinical services will become increasingly important as health care systems shift from simply monitoring service delivery to evaluating the effectiveness of programs and interventions.

Second, future work could enhance the measures available in administrative information systems for monitoring client health and informing program direction. Where feasible, the focus on client characteristics and services could be further expanded to include client sexual history and recent sexual behaviors (e.g., number of recent sex partners, condom and contraceptive use).

Third, although the intervention was not designed to address female chlamydia screening, we observed that chlamydia testing increased significantly during adolescent and young adult female family planning visits within the two clinics where interventions emphasized STI testing for male clients. While this shift cannot be directly attributed to innovations focused on male client service delivery, this unexpected finding reinforces the need to monitor how changes in male family planning service delivery might impact the volume of female clients and their access to STI services.

Fourth, based on our assessment of project implementation, future efforts to expand male family planning clients and STI services must recognize that implementing systemic changes require commitment from management and front line personnel, ongoing communication, and significant shifts in agency culture to address challenges. Potential challenges range from staff concerns about how female clients would view the increased presence of male clients on-site to the need for additional training on male genital exams. These efforts are part of a broad and empirically based effort to improve reproductive health services for male and female clients across current and potential providers of family planning services in the United States (Program managers interested in replicating our study’s clinic assessment and intervention activities to increase male family planning clients can find the project toolkit at: http://www.cardeaservices.org/resourcecenter/getting-ready-for-male-reproductive-health-services.) [25].

Our findings are subject to at least five limitations. First, we relied on the agency’s existing administrative information system, which lacked key measures related to use of family planning services such as sexual orientation, clinical exam findings, or sexual risk behaviors. In addition, data were collected at the visit level and could not be aggregated to client summaries; thus, we were unable to account for the effect of repeat visits by clients. Second, we did not measure the amount or intensity of male-centered interventions–either at clinics where they were implemented or at comparison clinics. Third, the nonrandomized observational design limits our ability to conclusively attribute intervention effects to project interventions [26]. Fourth, we could not determine which of the intervention’s five components may have accounted for changes in male client volume or STI testing. Finally, our work was limited to a single set of family planning clinics in San Diego and may not be generalizable to other family planning clinics or the general population.

Several strengths of the study design should be noted. First, the reliance on a single health care agency within a relatively small geographic area with common protocols and administrative information systems to identify intervention and comparison clinics strengthened the rigor of our approach. Second, we were able to utilize existing administrative information systems to efficiently assess client characteristics and services over an extended timeframe. Third, since our evaluation used de-identified administrative data, it involved neither active consent by clients nor the opportunity for nonparticipation, which reduced threats to external validity, as biases related to clients’ awareness of participating in a field study were avoided [27]. Fourth, the use of routinely collected information allowed us to assess the impact of study interventions on female family planning client volume and receipt of services post hoc, in addition to male services. Monitoring female clients’ receipt of STI services is also critical in the context of the mission of maintaining women’s access to reproductive health services.

Family planning clinics within San Diego’s FHCs implemented program and community innovations that showed significant increases in the frequency of male reproductive health client visits and STI testing, particularly among adolescent and young adult males. As important, these results did not adversely affect female family planning visit volume or receipt of chlamydia testing. For family planning programs, particularly those embedded in larger health care agencies, the tested interventions may be a promising approach to increasing male clinic attendance and STI testing. However, further research is needed to assess the efficacy of specific elements in our multiple-component intervention.