Background
Conceptual framework
Methods
Study design
The setting of the study
Sample size
Selection of study participants
Data collection
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Would you please describe the roles of male partners in PMTCT services?
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Would you please describe the services that are required by men in PMTCT services?
Data analysis
Results
Socio-demographic characteristics of the participants
Demographic characteristics of male participants
Demographic characteristics of health care workers
Demographic characteristics of village headmen
Findings
Subjective norms that shape the roles of men in PMTCT
Supportive roles
The health care workers also confirmed the role of a man to provide for his pregnant partner and this is shared with a pregnant woman as a list of items that a man ought to provide in preparation for the birth of the baby.“As a man, I have a role to fund all the activities that may be needed, finding money for my wife to start antenatal care; for transportation; and buying necessary things for labour and delivery. Yes, that is my role.” (Man 1, involved in PMTCT)
Health workers expect men to accompany their pregnant partners for antenatal services, delivery including under-five clinics. Health workers expect a man’s presence at every interface with the health system by the wife so that he is well informed.“The man has to buy wrappers for the woman, to buy basins, soap for bathing and washing when the woman delivers. A man has that responsibility so he needs to find money to buy all that and other things like the food at home.” (Health Worker, 2)
Although men are expected at every interface a woman makes with the health system as expressed by health care workers, the men in the study found this concept to be new and contended that it needs wider implementation in the health services for it to be normalized as a man’s role which will facilitate acceptability of it among women, men and health care workers. Male involvement is not fully implemented despite being recommended in health facilities.“The role of the husband is to accompany his wife to the PMTCT clinic. This makes the wife feel comfortable and relaxed which helps the baby to grow healthily.” (Health worker 2)
In other cases, men are more motivated to accompany their partners when it is medically beneficial to them which cements that their action is primarily influenced by the belief in the output of the service. In instances where there is partner referral, men tend to show up to access the services and this was confirmed by both men and health care workers mainly because the medical condition normalizes their presence in a woman’s domain.“This issue just started sometime back, that men should be available when their wives are giving birth, I wish this issue was being implemented in our hospitals so that as men we should experience what our wives encounter. I just believe that if this happened we would have a common understanding with our wives and health care workers.” (Man 1, involved in PMTCT)
Village headmen also shared their experiences and stated that they are in support of men attending health care services with their partners.“Honestly, I find it hard to accompany my wife to get tested for HIV, like today I came to receive medication because my wife tested positive for syphilis yesterday when she came for antenatal services.” (Man 6, involved in PMTCT)
Implementation of supportive roles, particularly accompanying a woman to the health facility is deterred because, at the community level, it is not an acceptable norm. Men reported that they will be laughed at for escorting their partners because pregnancy and its related issues are traditionally a woman’s domain and if men are lingering there, they are deemed to be charmed, under a spell, or bewitched. There was a lack of consistency between what a community and individuals accept as a norm. The need to belong and behave as a community expects dissuades men from supporting their partners.“We tell men to take their babies when they fall sick and most of them do that in this community. They are motivated because they do not wait for long hours, they are assisted early, so because of that men in this community play that role as well.” (Village headman 4)
Despite stating that men ought to accompany their partners, health care workers also acknowledged the lack of congruence between what is promoted by health care workers and what is socially accepted for men to do. When we probed on social underpinnings on male involvement, village headmen in both sites denied the presence of social norms in their communities that hinder men from accompanying their wives to ANC services.“Do you think it is easy (to escort a wife to a health facility)? All men and women in this community laugh at a man who seems to be too busy with his wife and children, they mock you and segregate you to the point that you cannot have friends … .hmmm here you don’t dare, they speak when they have seen you … .(Man 2, not involved in PMTCT)
Seemingly a male partner may easily support his partner within the confines of their home and in more discrete tasks that will not be viewed against the norms in a community or that will not induce ridicule. Men and health workers agreed that male partners have the role of reminding their wives to attend antenatal care visits. However, the men who are not involved in PMTCT and the village headmen at both sites remained silent on this issue.“There is no negative social influence that can stop a man from participating in the program. In this community we teach them that a man should love his wife whether at peace or not, we tell them to love their wives all the time and everyone has to abide by that’ (Village headman 2)
There was no agreement as far as household chores are concerned with Village headmen and men who were not involved in PMTCT emphasizing that such chores are for women, while some men who were involved stated that they participate in the chores.“A husband has to remind the wife, right. When it is time to take drugs, she may be hesitant, he has to make sure that his wife is taking drugs.” (Health Worker 5)
“In our community, all the household chores are considered to be for women, there let me not lie, for as long as you are married, if by any chance they see you washing, even your clothes, it is taken as a taboo, and the relatives of the woman do not allow that.” (Village headman 1)
HIV prevention behaviour roles
However, men who are not involved in PMTCT viewed faithfulness as responsibility for both partners“The role of the man is to make sure that he does not engage in promiscuous behaviours, he should not have extramarital affairs and he has to faithful to his wife to prevent from contracting the virus be it when the mother is not pregnant, is pregnant or breastfeeding.” (Man3, involved in PMTCT).
There was a discordance in the views expressed by men and health care workers’ overuse of condoms when a woman is pregnant. Health care workers emphatically specified initiation of condom use by men as a critical role for men to avoid infection especially when a couple is HIV infected, however, men viewed condoms as only necessary for family planning methods“We both have to be faithful, I mean a man and wife, we should trust each other and rely on each other. We should be open to each other to meet the needs of each other.” (Man 2, not involved in non-PMTCT)
“So, the man has a responsibility to initiate the use of the condoms in the family when the family is HIV positive, be it during the time the wife is not pregnant, or is pregnant or is breastfeeding.” (Health worker 8)
Decision making roles for the family
Again, this decision is founded on the economic responsibility vested on a man as stated below:“ [HIV] Testing should not wait for a woman to become pregnant, the role of a man, as the head of the family, is to decide on how often the couple should be tested to prevent the child from the virus.” (Village headman 2)
“We have to decide where our wives should attend ANC services because even though in Malawi these services are free, we still have to think that how will my wife reach there? What about during the rainy season how will she travel to reach there? So that she has to attend at the convenient possible hospital to prevent absenteeism.” (Man 3, involved in PMTCT)
Attitudes towards male-specific services required in the PMTCT programme
Health care workers reported that men expect to be attended to and be given health advice as appropriate.“If the health care workers are willing to help, I would love to have my blood pressure checked.” (Man 2, involved in PMTCT)
However, some men who were involved and some who were not involved in PMTCT services had different opinions from other participants and emphasized that they do not require services that would benefit them directly. The choice of services could be stemming from their cultural beliefs on PMTCT being a woman’s domain. They insisted that they are just escorting their wives and that it is time-consuming for the healthcare workers to provide some services to the men.“They expect to be asked if they are doing fine and given time to explain the problems that they may have. When men come to the antenatal clinic, they become our clients and we need to listen to their complaints and attend to them and refer if the need arises. We always have clinicians whom we work with, those should also be consulted.” (Health worker 2)
“We men are here just to escort our wives, so when you are just escorting you cannot request for anything. Antenatal is for pregnant women to should see how much the unborn baby weighs, therefore for us to be tested for no reason is impossible. Besides it is time-consuming for the health care workers.” (Man 6, involved in PMTCT)
Delivery of health assessment services
Re-arrangement of clinic activities-targeted services
However, the opinions of some male participants involved in PMTCT and village headmen were contrary to what was suggested as follows:“You know what? At the ANC clinic, they sing songs and clap hands, I don’t like that. How do you expect me to sing songs in the presence of a large group of women, who are strangers for that matter?” (Man 2, not involved in PMTCT)
“The hospitals are just ok, the services are also ok, there is nothing wrong with how they offer their services, as long as they receive the care they were supposed to, that is enough. Some men are just stubborn, they don’t need to be listened to.” (Village headman 1)
Couple specific structural services
“I feel shy when I sit together with strange women; I don’t become open. I would love if they can provide a space for couples only.” (Man 2, involved in PMTCT)
Privacy and confidentiality in service provision
“I expect to find a hospital that has rooms that provide privacy, and not only inside but also outside so that when entering into the room, people should not see you entering into the room where HIV testing is done. That is what I expect!” (Man 1, involved in PMTCT)
Safeguarding confidentiality becomes paramount in instances where health workers and men know one another as explained below:“I think sometimes they (health workers) also need to be discreet, men should not hear from anywhere about the treatment that they have received at the hospital.” (Health worker 2)
“Some of the health workers who conduct HIV tests are our colleagues, so we tend to wonder what would happen if we are diagnosed with the virus. You see unless they are confidential enough but otherwise we can be everyone’s talk.” (Man 2, not involved in PMTCT)
Personalized and integrated services
Additionally, health care workers and men further described the process of rendering services which to an extent highlights the role of men as decision-makers and household heads. They are likely transferring the same position and expect it to apply even in PMTCT services. This was expressed in the quotes below“I expect to be assisted by one health care worker. Thus, when I arrive, he or she should educate me, counsel me and my wife, and do the check-up for my wife’s pregnancy. That should continue until when I come for the next visit, I should be booked the date that the healthcare worker who assisted me will be around.” (Man 4, involved in PMTCT)
The health care workers and Village headmen affirmed that a receptive and respectful welcome would encourage more men to attend the PMTCT programme.“They (men) want us to warmly welcome them, explain things about child preparation politely, they need to be helped fast so that they don’t have to wait for long hours at the clinic.” (Health worker 6)
At a community level, it was recommended that services should be integrated with sporting activities because they are an acceptable norm for men in most communities such that including health messages in them is desirable and will not be met with demeaning sentiments from others.“If we welcome them [men] nicely when they come, when they go home they will tell their friends and then they too will come. Do not judge the way they look. At times, we (health care workers) tend to judge saying they are too old, or maybe too young.” (Health care worker 5)
“Through soccer, before the game starts there should be an announcement to talk about the MI in PMTCT issue. Encourage questions and tell them where they can access the services. I believe this would help to reach out to other men who may be ignorant or unwilling to participate.” (Man 6 involved in PMTCT)
Men who are involved in PMTCT and health care workers services suggested that the information should be staggered in phases, unlike the current practice where participants are loaded with information on one visit.“Give us [men] health education concerning diseases such as malaria, STIs and how one can take care of oneself … because you may not know this from home but if you go to the hospital then you will know, and the health care providers should help with that.” (Man 5, involved in PMTCT)
“I expect a healthy baby, being born without HIV. But our concern is that the information is given just once when we come for the first visit, the information is not repeated when we return and we wonder if we are doing the right things that the health care workers expect us to do, for us to have a child who is not HIV infected.” (Man 2, involved in PMTCT)
Delivery of health promotion services
“The hospital can buy leaflets that have information about PMTCT, the roles that men are supposed to play and some benefits, just as it is with the male circumcision leaflet which gives a person the whole information about it and one does not need to ask about it” (Man 5, involved in PMTCT)
“ If there is a radio or television, like at the district hospital in the children’s ward there is a radio or television, while they wait to be attended to, men could be watching or listening to that (information on PMTCT services) then they will be enticed. For those who can read then we can make some charts so they can read, as they wait to be assisted.” (Health worker 2)
“In every opportunity that we have to meet men, at the hospital we should be able to give them the information. We can also find a way of spreading information about PMTCT, through OPD or ART. We tend to meet a lot of men in these areas at this hospital.” (Health worker 7)
“People love to learn from the people that they know, so if we agree to train some few men about PMTCT services so that they can be trained and train individuals … they will help the chief in advocating for this in the villages with other men. Then they will be helping the village headmen, I think this will be good if added.” (Village headman 2)
“Some cultures like some religions, disregard these things. They don’t go to the hospital, it would be good if the message also reaches the church leaders, and they should understand it very well so that they can teach their people.” (Village headman 3)