A total of 2219 articles were retrieved, from which 51 studies met the inclusion criteria for review. Table 1 presents the author, year of publication and study location, participant characteristics (age and gender), and study design. Table 2 presents barriers, facilitators, and sexual and reproductive health issues. All articles (qualitative and quantitative studies) extracted from the literature were descriptive. The results are summarized narratively.
Description of included studies
1. Study location
Most of the studies were conducted in South Africa (22%) [21-31], and five (10%) of studies were conducted in Kenya [32-36], Uganda [37-41], and Ghana [42-46]. Four (8%) studies were published in Zimbabwe [47-50]. Three (6%) studies were conducted in Nigeria [51-53] and Nepal [54-56]. In Rwanda [57, 58], there were two (4%) studies identified, whilst only one (2%) study each conducted in Swaziland , Papua New Guinea , Tanzania , Zambia , Botswana , Lesotho , Mexico , Philippines , Ethiopia , Egypt , Myanmar , Lao  and one both in Zimbabwe and South Africa .
2. Age and gender
The studies included all targeted adult men. In studies that mixed male and females, as well as those which included younger ages, we only extracted information pertaining to adult men. The majority (55%) of studies identified exclusively targeted men [22-26, 28, 30, 31, 33, 35, 37, 39, 41, 43, 44, 45, 48, 49, 53, 57, 59, 60, 62, 63-66, 71]. The balance (45%) focused on both men and women [21, 27, 29, 32, 34, 36, 38, 40, 42, 46, 47, 50-52, 54-56, 58, 61, 67-70]. The majority (86%) of studies targeted adults 26 years and above [21-39, 41-44, 46-51, 53, 57-66, 71]. Studies which targeted adolescents were excluded, however those targeting youth or young adults age between 15-25 years (14%) were included [40, 45, 52, 54-56, 67-70].
3. Study design
The majority (55%) of studies that met the inclusion criteria were conducted qualitatively, and employed either Focus Group Discussions (FGDs) (16%) or In-depth Interviews (IDIs) (18%), and some both FGDS and IDIs (24%) [22, 24, 26 ,28, 31-34, 36, 38, 39-41, 45-47, 49, 50, 52, 56, 59, 60-62, 65, 67, 68, 70, 71]. Twenty-five percent of quantitative studies employed cross-sectional study design [23, 25, 27, 29, 42, 43, 45, 51, 53, 54, 57, 58, 69], and two (4%) employed National Health and Demographic Survey (NHDS) [35, 66]. The later (16%) used mixed [21, 30, 37, 44, 48, 55, 63, 64]. There was only one mixed study that included Randomized Control Trial (RCT).
4. Study setting
Forty-nine percent of studies were conducted in both urban and rural settings. In some studies, the exact locations where data was collected were not specified [33, 34, 40, 43, 45, 46, 56, 59, 60, 61, 63, 65-68, 70]. Some of the studies were conducted in public and private-sector health facilities (clinics and hospitals) [24, 25, 29, 58, 64]; private rooms or offices in community centres; Non-Governmental Organizations sites [27, 32, 35], and households in towns and rural villages [28, 48, 69]. In studies conducted exclusively in urban settings (27%), data was collected in towns and townships in which households were visited. Some participants were recruited on the streets [21, 23, 30, 47], district health offices , hospital and clinical settings [36, 38, 44, 53, 62], and there were two unspecified studies [42, 54]. Studies solely conducted in rural settings (24%) approached households in villages [22, 37, 39, 41, 49, 51, 52, 55, 57, 71], traditional healers’ places, school and community halls, community tuck-shops, faith-based organizations’ premises, hospital and clinic waiting rooms. [31, 50].
5. SRH issues
The SRH issues identified were Vasectomy; Family Planning (FP); Medical Male Circumcision (MMC); condom use; management and prevention of STIs; HIV services; Prostate Cancer (PC) screening; and Erectile Dysfunction (FD).
6. Barriers to men’s decisions to utilize or not utilize Sexual and Reproductive Health Services
Several barriers have been associated with the decision to utilize or not utilize S.R.H. services. These can be summarized into individual/personal factors, knowledge, socio-cultural and religious, socio-economic factors, geographical, and health service system factors, as detailed below.
Individual / personal factors
In this review, individual/personal factors are described as behavior and characteristics demonstrated by participants which determined whether they utilized SRH services or not. Individual factors presented as barriers to SRH utilization were identified. Fear emerged as a barrier to utilizing SRH services. Among the studies focused on PC screening, fear of post-operative complications such as pain, delayed recovery, infections, morning erections, as well as the post-procedure abstinence period deterred most men from undergoing MMC [21,23, 32, 33, 39, 48, 49, 53, 57, 61-64, 59,71]. The requirement to do HIV testing before getting circumcised deterred most men from undergoing Medical Male Circumcision (MMC). They feared the possibility of testing positive, and hence death related to HIV complications. because of self-knowledge of reckless lifestyles. Men also feared the stigma associated with HIV, and the possibility of being blamed and rejected by significant others such as partners, family members, and friends, as well as the pressure from employees to quit the job after being diagnosed [24, 26, 27,31, 43, 47-52, 64, 69]. Post circumcision myths such as the inability to sexually satisfy partners, less natural lubrication, and decreased penile sensitivity on a circumcised penis also deterred individual men [21, 22, 33, 37, 39, 46, 59].
Factors associated with barriers involving Condom use included poor quality of condoms and embarrassment to buy condoms [28, 44, 66, 70]. Furthermore, the perception of low-risk also hindered men from using condoms and undergoing MMC [32, 33, 50, 57, 69, 70]. In Hassan's (2015) study, some men in Nigeria were reluctant to screen for Prostate Cancers they perceived it as a low-risk since there was no family history .
Lack of Knowledge
Men's underutilization of SRH services was associated with a lack of awareness of disease screening services such as HIV and prostate cancer, and the lack of knowledge of the existence of SRH services. Consequently, some men did not know where to go for SRH services [27, 35, 46, 53-56, 67, 69, 70]. Lack of knowledge and understanding of HIV was evident when men often inferred their status from their female partners' results [27, 31, 52]. As a result of this lack of knowledge and of reliable information, men claimed less or no benefits of MMC if they were already HIV-positive, had good hygiene, were already practising other HIV prevention methods such as the ‘Abstinence’ ‘Be faithful’ ‘Condomise’ (ABC) method, or their partner(s) was sexually satisfied [33, 49]. Furthermore, in non-circumcising communities in South Africa, men did not know that the MMC service was offered for free at the local clinic or hospital . Furthermore, some men associated infertility with circumcision [39, 48].
In addition to lack of knowledge, myths resulted in men opting not to use condoms after getting circumcised, citing reasons such as the circumcised penis would tear a condom; or putting a condom on an exposed circumcised penis would cause pain . Furthermore, misconceptions such as the nutritional benefit from sperm, condom porousness, lubricant related infections, and the belief that white men had infected condoms with HIV hindered Condom use [28, 40, 45, 50, 56, 70]. Men often confused Vasectomy with castration and wrongly associated it with loss of libido, decreased sexual activity, and loss of masculinity [46, 66].
Socio-cultural and religious factors
Factors associated with culture, such as the threat to masculinity, prevented men from undergoing MMC as non-circumcising communities presumed circumcision to be an alien culture or part of a foreign religion [21, 23, 30, 39, 45, 47, 49, 59, 60]. Some men alluded to undergoing MMC as tampering with God's creation [33, 47, 49, 59]. Most cultural and religious practices consider discussing sexual matters a taboo. Therefore, the sensitivity of discussing SRH issues had hindered most men from accessing psychosocial health therapy and counseling [35, 42, 45, 46, 55, 56, 67].
SRH service utilization was hindered by the perceived high costs of SRH products such as condoms, particularly in rural areas [40, 56, 67]. In addition, the inaccessibility and unavailability of condoms due to fewer shops contributed to low utilization [23, 25, 29, 30, 44, 45, 69]. Fear of losing income (work) due to long-period off work due to pain or post-procedure healing period deterred some men from undergoing MMC [21, 32, 33, 39, 61, 62]. Traveling costs to healthcare establishments also emerged as a major deterrent .
In most LMICs, health facilities are concentrated in the urban area, whereas most men in these populations reside in rural areas [67, 56, 63]. Consequently, long distances and poor transport (especially in rural areas) to the health facility became barriers to accessing and utilizing SRH services [29, 33, 40, 42, 54, 69]. The distance of health centres from men's workplaces often leads to men failing to utilize SRH services. Furthermore, poor transport infrastructure can prevent access to services in rural areas .
Health service system (Physical accessibility, availability, accessibility, affordability)
Poor quality of the services and lack of materials such as condoms and medicines hindered the utilization of SRH services by men [29, 42, 54, 55, 63, 67, 68, 70]. Inconvenient service hours or limited opening hours at the delivery point were also barriers to SRH services utilization [27, 36, 40, 54, 55, 67, 68]. The inconvenience of the location of the SRH services at the local clinic seems to be a barrier to accessing the SRH care, especially for young men [44, 67]. Long waiting times because of queues influenced men's decisions to avoid coming to a healthcare centre [29, 30, 36, 40, 42, 50, 63, 64, 67].
Some studies revealed that most health care providers lack the necessary training and knowledge to make men feel comfortable discussing SRH issues [36, 56, 67]. Physicians indicated discomfort in counseling on sexuality and safer sex for unmarried youth . Lack of privacy, respect, and potential breaches of confidentiality from the health care workers at the health facilities deterred men from utilizing SRH services [25, 36, 40, 41, 44, 55, 67, 70].
Men avoided utilization of SRH services due to hostile and judgmental attitudes from female health service providers [27, 29, 30, 40, 45, 56], especially towards young and unmarried men. There is still much sensitivity needed regarding pre-marital sexuality [26, 29, 36, 56, 67, 69, 70]. Consequently, the non-availability of same-sex health workers was a barrier since some men felt embarrassed to discuss their health issues and be examined by female health workers [30, 33, 45, 55, 64, 68]. Frequently changing HIV prevention programmes led to distrust in the health system, discouraging men from testing and treating HIV [49, 59]. A further deterrent was partial protection of condoms and lack of empirical efficacy of MMC for HIV prevention as people can die even after circumcision .
7. Facilitators to men’s engagement with Sexual and Reproductive Health Services
There was a limited number of studies that focused on factors facilitating the utilization of SRH services. Facilitators to men's decisions to utilize SRH services are summarized into individual/personal issues, knowledge, socio-cultural and religious factors, socio-economic factors, and health service system factors as detailed below.
Individual / personal factors
Some studies discussed above concluded that men were reluctant to undergo MMC due to poor sexual performance. Conversely, other studies found that sexual appeal and satisfying women motivated men to perform MMC sexually. Men believe that post circumcision, they better satisfy women as they last longer before ejaculating, and also wearing condoms was much easier after the foreskin was removed [21, 22, 33, 38, 47, 60, 61, 64, 59]. Curiosity to feel the difference between sex with an uncircumcised penis and a circumcised one motivated some men . Furthermore, personal gain or prestige from research activities such as free medical care for ailments, financial incentives, and a sense of being responsible by participating and contributing to research, motivated men to undergo MMC [27, 39, 50].
Role modeling positive HIV status disclosure and adherence to Anti-Retroviral Therapy (ART) motivated men to engage in HIV treatment initiatives [24, 27]. Furthermore, an individual desire to limit family size encouraged some men to undergo a Vasectomy since it was perceived as a permanent method with a low risk of complications, thus limiting the side effects of other female-controlled hormonal methods .
Knowing the benefits of undergoing MMC, such as protection against diseases and improved hygiene motivated most men to perform the procedure [21, 33, 34, 37-39, 47, 48, 57, 60-62, 64, 59,]. Some men were motivated by myths such as the increased size of the penis post circumcision (Humphries 2015).
Financial constraints motivated undergoing a Vasectomy . The fact that some SRH services are provided at no cost, also motivated men .
Health service system (Physical accessibility, availability, accessibility, affordability)
Health workers' welcoming friendly attitudes, and respect for men's privacy and confidentiality motivated men to access and utilize SRH services [55, 63, 68]. Access to the right information about SRH services via advertisements such as pamphlets and radio/television programmes [27, 63] and the support from healthcare providers also played a vital role in encouraging SRH service use by men [24, 41, 50].