Background
Male Involvement (MI) in the Prevention of Mother to Child Transmission (PMTCT) of Human Immunodeficiency Virus (HIV) services is essential in a patriarchal society where men are key decision makers as in most African countries [
1‐
4]. A household head, who is usually a husband, greatly influences the woman’s ability to seek health care, implement health practices and interventions [
5‐
7]. Male partners have a role in the woman’s risk of acquiring HIV [
8‐
11], the uptake of HIV testing and interventions for reducing perinatal HIV transmission [
8‐
12]. Success in the prevention of vertical transmission of HIV largely depends on the cooperation between partners [
8] where a pregnant woman’s uptake of an HIV test is directly related to her husbands’ approval of the service [
8,
13,
14]. Involvement of male partners in their partner’s PMTCT programme, in Tanzania and Kenya, led to more HIV infected women receiving Nevirapine during their antenatal follow up visits, avoidance of breastfeeding in their babies, adherence to infant feeding method chosen and a reported higher condom use than those whose partners were not involved [
11,
13].
Although there is positive impact on the uptake and adherence to PMTCT regimens especially when men accompany their partners, evidence indicates that only a few men accompany their female partners for antenatal care (ANC) and participate in PMTCT programmes [
13] with rates of 3.2% in Malawi [
15], 12.5% in Tanzania [
11] and 16% in Kenya [
16]. Efforts to involve men in ANC services, where PMTCT takes place, have only resulted in a few husbands being involved [
13,
17,
18]. Prevention of Mother to Child Transmission services have been criticized for only focusing on females and sidelining males who are the primary support unit to the woman [
19]. Barriers to MI in PMTCT services are categorized into: Health systems, community level and personal and family factors. Health system barriers include the clinic set up, using women to convey messages to men, service costs [
20], distance to the clinic [
21,
22], and health workers’ attitudes [
20,
23]; Community level barriers are founded on traditional gender roles and cultural factors that regard pregnancy and its related aspects as solely a woman’s responsibility [
2,
11,
20,
24‐
26] and polygamous cultures that render MI challenging [
27,
28]. Personal and family level barriers may include the unwillingness and fear of a man knowing his HIV status [
12,
20,
22,
26], lack of knowledge [
21‐
23,
29‐
31], fear of stigma [
22], a woman’s fear of violence [
22,
32] and socioeconomic factors [
19,
20].
Similarly, barriers to MI in PMTCT in Malawi have been categorized into personal and family and health system factors. Personal and family factors comprise unwillingness of men to know their HIV status [
17], marriage instability [
17], men’s lack of knowledge about the services [
1], fear of potential dissolution of marriage consequent to HIV infected status [
1,
33], lack of perceived benefits of HIV services when one is healthy, lack of proper communication between partners and fear of stigmatization [
34]. Barriers related to the health system were: health delivery system [
35] such as services offered in an area traditionally viewed as a woman’s domain [
17] and health centres being non-conducive for MI and cultural conformity to the traditionally gender defined roles [
36].
Factors that promote MI in PMTCT are categorized at different levels as follows: personal and family, health facility and community. Personal and family level involves continuous discussions on MI at home and within the community [
37]. Health facility level include: creating male-friendly environments [
24], considering gender relations in the programme [
38], offering adequate and private clinic space for male partners and accessibility of services [
23]. Aligning clinic opening hours to men’s work schedule by opening over the weekends [
11,
19] or clinics that open for longer hours [
4] and clinics that are geographically located closer to the targeted population [
20] promotes MI. Streamlining of services for men or for pregnant couples only [
39] through provision of services such as couple counseling [
40‐
42] and sexual reproductive health services to boys and men [
43] promotes MI. Even the term “prevention of Mother to Child Transmission” implies that responsibility of HIV transmission is solely on the mother. Activists and researchers have proposed a change on the term to “prevention of parents to child transmission” (PPTCT) to promote MI into the programme [
44]. This proposition may benefit both the community and male partners.
Human resource related factors that would promote MI include providing ongoing education to the midwives, adequate staffing, improving the welfare of the health workers [
20], empowering health care providers through precise policies and job descriptions on MI in PMTCT [
23]. At community level, promotions that can be done include “mass campaigns” on couple HIV testing, use of key and influential people to promote MI [
19,
45], mass media campaigns such as television programmes [
45] on MI, community mobilization [
39] and involvement [
26], male peers reaching to other men [
46] and community based programme and support [
26].
Male involvement, although it is important for uptake of PMTCT interventions, is low. In Malawi, male involvement is encouraged however there has been suboptimal involvement with self-reported rates by women ranging from 3.2% to 23% [
15,
36,
47]. Understanding of the factors that influence MI may assist in developing strategies that will involve men better in the programme thereby improving the uptake of PMTCT services by women and may provide an HIV testing and treatment service for men. The main purpose of this study was to identify the factors that promote and those that hinder MI in PMTCT services in antenatal care services in Blantyre, Malawi.
Discussion
The main findings of this study on factors that influence MI in PMTCT show that the factors are interrelated among and within individual, community and health facility factors, such that a successful MI programme requires a multifaceted and multilevel approach that includes all the factors involved. The current study findings validate and augment on what has been reported by other studies in this area.
The individual factors that hinder MI as highlighted in this study remain consistent with other studies. A man’s lack of knowledge on the relevance and his role in PMTCT services limits his participation [
17]. Additionally, lack of knowledge on pregnancy and its associated factors contributed to lack of MI in the PMTCT programme [
2,
17,
22,
23,
52,
53]. The lack of information also included men being unaware of the; existence of PMTCT services, the benefits and the role of a man in PMTCT services [
23], not knowing the wife’s HIV status [
54] and rationale for testing when they had no signs of sickness [
55]. Low formal education in men further limits a man’s understanding of issues on HIV and AIDS [
54]. As reported in other studies, due to inadequate information on HIV and AIDS, men have used their wives HIV test results as a proxy for their own HIV status [
28,
39,
56]. Conversely, educating men in antenatal care aspects yielded positive results in birth preparedness and postnatal visit compliance [
29].
The fear of learning one’s HIV status following attendance of PMTCT services prevents men from attending the service as has been reported by other studies [
17,
23,
28]. In Lilongwe Malawi, lack of MI in PMTCT was reported to arise from men’s fear of HIV testing [
57] while in Zimbabwe men perceived HIV as a threat to their manhood and they discouraged their partners in accessing ART services to avoid learning their HIV status indirectly [
26]. Equally, women have also expressed the fear of learning their HIV status as a barrier to their participation in PMTCT programme [
58]. However with the current opt out policy of HIV testing; women are rarely refusing an HIV test in Malawi as evidenced by the high rates of HIV testing antenatally [
59].
A man’s lack of knowledge on PMTCT issues [
55], his fear of learning his HIV status fear [
17], and traditional gender roles and cultural norms [
2,
60] partially explain the unwillingness of men or lack of interest by men with the PMTCT programmme as expressed in this study, thereby, hindering their involvement. These results are congruent with reports from Tanzania where 74.6% of men were unwilling to participate in PMTCT programs [
61] while in Zambia men had low motivation for MI [
52,
54] and others were uninterested in the service [
62]. This study also showed that some women are unwilling to have their partners involved in ANC, probably because they want to retain the decision making and control on their reproductive health [
62] or they may not have a male partner.
Timidity with involvement in a domain that is traditionally regarded as a woman’s responsibility was highlighted as a barrier in this study which remains congruent with other studies [
2,
28,
39]. Similarly reviews of studies have reported that fear of societal stigma and ridicule [
63,
64] as barriers. Timidity may stem from intrinsic factors or be perpetuated by traditional mindset [
54] as well as community beliefs [
28,
65] and is further compounded with the term “PMTCT” which excludes men in the program [
19]. Timidity may also be aggravated by the manner in which services are rendered for instance in this study the songs sung in the antenatal clinic deter men from involvement. This resonates with findings by Kang’ona in Lilongwe, Malawi where men shunned PMTCT services because they were embarrassed to sing along at the antenatal clinics with their partners [
57]. Timidity may also stem from notions of masculinity that propel the supremacy of a man.
The belief that a man is the head of the family who may not be influenced by his partner deters them from involvement in PMTCT services especially when invites come through his partner. This finding remains consistent with Tanzanian and Ugandan studies where women could not ask their partners for HIV tests because they had no authority over them [
39,
55] and was also concluded as a limiting factor for MI in maternal health services in Mwanza, Malawi [
66]. Superiority norms held by men led to men shunning of any HIV related clinics for fear of being regarded as weak [
65] or less masculine [
39]. Furthermore in this study, participants regarded a man who follows what his wife tells him, to have unknowingly taken a local herb called “Khuzumule” which renders him a “puppet”. A similar nomenclature regarding men who are involved in pregnancy and its associated aspects has been previously reported as follows: in Lilongwe, Malawi such men were regarded as fools [
57], in Nepal, such men were regarded as “
joitingre” or “hen-pecked” [
22] and in India they were regarded as “sissies” [
62]. Furthermore, in Tanzania men stated that it was against their culture to be involved in female affairs [
61]. It could be argued that for a successful MI in PMTCT service; cultural aspects, gender roles and dynamics of marital relationship need to be explored and incorporated in the development and implementation of the programme [
62]. Conversely, a study by Tshibumbu in Zambia found that men did not regard, a man who escorted his partner for PMTCT services as bewitched [
27]. We argue that as a head of the family a man should take responsibility and take a leading role in the health of his family.
Time constraints, such as balancing the need to provide for the family versus attendance to antenatal clinic and negotiating time off from work, is a barrier to MI in this study. This builds upon findings from other studies that identified socioeconomic demands [
20], poverty [
52] and job responsibilities [
13,
19,
22,
23,
28,
39,
53,
54,
62,
67] as a barrier to MI in PMTCT. Additionally, other studies on MI in sexual reproductive health reported that men prioritized social obligations [
2] and other personal issues [
54,
61] than supporting their partners’ attendance to antenatal care. Time constraints also prevented men from listening to radio or reading brochure messages on MI in PMTCT [
54]. As a way of averting this problem, countries may consider legitimizing MI in PMTCT for men that are formally employed while those in informal employment may utilize their free days to attend to the service.
Health system related factors highlighted in this study are similar with those reported in earlier studies such as services located in an antenatal clinic, non-male friendly environment there by marginalizing men [
54,
62,
68,
69], organization of the PMTCT programme [
39], lack of supportive hospital policies on MI, and inadequate space [
20,
22,
62].
According to our study, as also shown in others, human resource related barriers such as health care workers negative attitude [
20,
53,
54,
61] and shortage of health care workers [
22,
55] are a barrier to MI. Our findings remain consistent with a study in Lilongwe, Malawi that reported that men failed to participate in PMTCT services because of the health care workers’ rudeness [
57]. However in our study, health care attitudes were reported as barriers by health care workers only. Nonetheless, health care workers’ attitude has been cited by women as a barrier for PMTCT services in Botswana [
58]. Contrary to other studies [
53,
61] the fact that the majority of health care staff involved in PMTCT are females was not a barrier in this study. We argue that perhaps most men in this setting have not attended PMTCT services therefore they have no reference point or because traditionally the majority of health care workers in Malawi are females hence men are used to being attended to by women. Another factor that was not cited in the present study is the non-flexible opening hours [
19,
61] which has been cited by several studies as a barrier to MI. This may possibly be secondary to non-involvement as most men have not encountered it as a problem but it may also portray the flexibility of men with time. Furthermore distance [
19,
20,
55] and cost of getting to the health centre as reported in other studies [
19,
55] was not mentioned as a direct barrier in this study.
Incentivizing couples that report together for PMTCT services is a promoting factor for MI reported in this study. Incentives, a part of behavioural economics, have a potential in increasing uptake and retention in PMTCT programmes [
70]. This strategy, although reported in Mwanza Malawi, was regarded as unsustainable as it was dependent on donor funded incentives [
66]. Nonetheless, in a PMTCT programme in Lilongwe Malawi, retention and appointment keeping were linked to nutrition and hygiene incentives that mothers received [
71]. Other forms of incentives may be provision of transport to a PMTCT centre [
55].
Having an all-male clinic or a pregnant couple clinic was suggested as a promoting factor for MI as also suggested in earlier studies [
11,
23,
39,
54]. Ensuring that a couple attends the initial antenatal visit together partially remains consistent with studies that have advocated for couple attendance to VCT/PMTCT or ANC [
54]. The difference in this study is that participants only emphasized male attendance on the initial visit alone as opposed to all antenatal visits as they were cognizant of the socioeconomic demands on the man and most participants felt that major activities on PMTCT are covered on the initial visit. Making antenatal care attendance by men obligatory is a way of ensuring greater rates of MI in maternal health services in general [
72]. This recommendation promotes the aspect of couple counselling which has been recommended by several studies [
13,
62] as a way of eliminating women only ANC and PMTCT services [
62].
Creation of a male friendly environment within the antenatal clinics would promote MI. This finding remains consistent with earlier findings on ensuring a male friendly environment [
73]. offering privacy [
11,
23,
53‐
55,
74] and an environment that handles men’s sexual and reproductive health matters [
2]. A male peer approach as stated in this study was also advocated in PMTCT services [
17,
19,
55] and other maternal health services [
53,
55,
66]. Additionally, this approach would be culturally appropriate as men will be advised by fellow men [
68] as opposed to being advised by women. Furthermore, this approach would offer a live personal communication which is deemed beneficial for increased understanding in men [
55]. In a program in Lilongwe, Malawi, peer education through drama and male friendly hospital infrastructures were recommended as a way of promoting MI in PMTCT [
75].
Clarification and education on the meaning and importance of PMTCT coupled with a change in name from PMTCT to Prevention of Parental transmission of HIV to child (PPTCT) has potential in promoting MI in the service. This finding is consistent with studies that showed that educating men on their role and relevance to PMTCT and including them in the programme would increase their involvement [
17,
19,
20,
23,
27,
76] and further supports what Msellati recommended on changing the term PMTCT to PPTCT as a way of accommodating men in the programme [
44]. Another study proposed a change from voluntary testing to routine testing so that most couples get tested [
77]. Currently in Malawi, as in most countries, Voluntary Counselling and Testing (VCT) changed to HIV Testing and Counselling (HTC).
Training of health care workers on MI in PMTCT services and incorporation of it in their job description and policies has potential in promoting MI. Similarly other studies have suggested training of health care workers at all levels [
2,
53‐
55] sensitizing employers and having a PMTCT friendly work policy [
20,
54,
74]. We propose development of a MI in PMTCT policy in Malawi. Additionally, improving the attitude of health care workers and instilling maintenance of confidentiality as expressed in this study remains consistent with findings from other studies [
54,
55] that proposed integration of services as a measure of ensuring confidentiality [
54].
Extending invites to men as expressed in other studies is also a way of promoting MI [
20,
23,
53]. A review of literature concluded that MI requires a multimethod approach such as invitation letter accompanied by community education and mass media campaigns [
78]. Ensuring consistent supply of resources remains consistent with a study by Mohlala that reported availability of ARVs as a promoting factor [
79] for MI.
Community sensitization via open day functions, use of posters and use of influential people such as chiefs were suggested in this study as promoting factors. These findings remain consistent with other studies that suggested community mobilization [
39,
79] to enhance MI in PMTCT as well as use of community leaders through community outreach [
74], public meetings in places like churches, bars or shebeens as strategies for promoting MI [
53‐
55,
66]. Use of community support structures in PMTCT services yielded an increase in HTC with improved outcomes in HIV exposed infants [
80]. Community meetings have the potential of increasing uptake of couple counselling in PMTCT than radio messages because they provide a dialogue and men may have all their concerns addressed [
55]. This strategy needs to be explored with MI in PMTCT. A review of Demographic Health surveillance data from 8 countries in Africa, recommended the recognition of an association between uptake of HIV tests by men and the communities they live in thereby underscoring the importance of community factors such as educating communities in HIV programmes to increase male uptake of the programme [
81]. Another aspect of community mobilization for MI in PMTCT would be removing the gender differences that are embedded in raising children so that both boys and girls are raised without gender role boundaries which remain partially consistent with earlier findings MI [
62]. This suggestion needs to be cautiously taken because it may only work in selected roles. It could be argued that changing the upbringing of children will entail a change in the cultural pillars and gender norms which have been highlighted in this study as barriers. It also has the potential of eliminating timidity and embarrassment which were also expressed as barriers in this study.
Use of posters and radio messages as suggested in this study, remains consistent with findings from Khayelitsha South Africa [
53]. Additionally, TV programmes have been known to stir up conversation on HIV and AIDS between partners [
62]. A combination of clinic based health education, use of radio messages and television has potential in positively influencing women’s intentions with HIV testing [
82].
Other factors that promote MI that were not suggested by participants in this study were as follows: flexible opening hours [
4,
23,
53], and newspaper messages on relevance of MI [
53], possibly because of the population under study rarely has access to newspapers. Perceived benefits such as HIV free children [
19] were not cited as a motivator for MI in the current study; we are therefore not sure, of the communities understanding on the benefits and aim of PMTCT interventions.
Strengths
The strength with the study is the inclusion of responses from health care workers, men and pregnant women’s perception on the area under study. The information gathered in this study, presents consolidated reflections and views on the topic and represent men’s’ views better because of their involvement in the study.
Limitations
Use of FGDs may not have allowed other group members to verbalize all their concerns however the researcher encouraged all members to talk and assured them of confidentiality. Although the researcher does not work at SLHC, holding the discussions at the clinic could have resulted in other participants not fully expressing themselves or giving what they deemed as socially desirable responses. This was minimized by defining the groups according to gender and age groups to ensure that people of the same gender and within the same age range are in one group. The use of convenience sampling, though common in qualitative research, coupled with the small sample size limits result generalizations beyond the research site, however they provide information that can be explored further. Our study did not rank the barriers and facilitators in order of priority thereby posing a challenge with prioritizing interventions.
Competing interests
The opinions of the FGD participants and KIIs were very similar on the dilemma that arises between the need to provide for the family versus the demand for involvement in PMTCT services. Participants expressed that although some men are willing to be involved; they fail to participate in the programme because of work or business obligations in order for them to provide for their families. However, the participants also suggested measures that can be put in place to overcome this barrier.
“For some of us casual laborers if we attend antenatal care we lose time and will not be able to find food so a man may not show up”. Younger Male Focus Group (YM FG)
Health care workers were aware that some men are not involved in PMTCT of HIV services secondary to socioeconomic factors. In light of that, health care workers have put measures such as fast and immediate attendance to pregnant women who attend ANC with their male partners so that such men attend to their work commitments afterwards.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
ALN planned the study, developed study methods, interview guides and conducted the FGDs and KII, developed analysis plan, analysed the data and drafted the manuscript. ASM and AFC supervised the planning development of the methods, analysis plan, and data analysis and contributed and supervised the manuscript writing. All authors read and approved the final manuscript.