Socio-demographic characteristics of the participants
Demographic Characteristics of Male participants
The age of the men ranged from 21 to 46 years; seven were married, seven were Christians, seven were unemployed, four had some primary education and two had secondary school education.
Demographic Characteristics of Health care workers
There were eight health care workers aged 29 to 65 years, five were female, four were nurses, one medical assistant, one HIV diagnostic assistant and the PMTCT coordinator.
Demographic Characteristics of Village Headmen
These were four village head men, two from each of the study sites. They were all menwith age range of 49–70 years old. Two had attended primary school education and two never attended any formal education but were able to read and write.
Roles of male partners in PMTCT services
The roles that men play in PMTCT services were categorized into: Supportive, HIV Prevention Behavior and Decision-making Roles (Table 1).
Participants stated that the role of the man in PMTCT services is to provide support and the support varied as follows:
Men are expected to financially provide for their families irrespective of a wife being pregnant or not and are expected to ensure that the family has food. When a wife or partner is pregnant then men are to provide for all necessary materials in preparation of the pregnancy and delivery.
“It is the duty of the man 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 food at home.” (Health Worker, 2)
“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)
b. Participation during Pregnancy, Delivery and Child care Activities
Men are to accompany their pregnant partners for antenatal services, delivery including clinics for children under the age of five. Additionally, when a child is sick, men are to seek medical attention for the baby including reminding the wives to take the child for other related health activities.
“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 healthy. But also knowing what the wife will get inside [in the consulting or delivery rooms], eeeh, that is the responsibility of the husband so that he too should know that my wife is going through this and this.” (Health worker 2)
“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 encounters. I just believe that if this happens we will have a common understanding with our wives and health care workers.” (Man 1, involved in PMTCT)
One Village headman shared what is impressed on men in their settings and what he had observed being done in response. He narrated the experience as below:
“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)
Furthermore, participants expected men to offer companionship which is expressed by assisting a wife with household chores. This is illustrated in the quote below:
"I don’t know if men do assist but they can help the pregnant mother to wash the clothes when the pregnancy has reached term or even cooking. This has an advantage because it gives time to rest and when the mother has given birth, it helps her to have more time to breast feed her baby exclusively.” (Health worker5)
Male partners have a role of reminding their wives to attend antenatal care/PMTCT visits however the men who are not involved in PMTCT and the village headmen at both sites remained silent on this issue.
Health care workers and male partners described another aspect of reminders like reminding a woman on activities around PMTCT such as taking of ARV drugs and taking the baby for early infant diagnosis of HIV services and receipt of cotrimoxazole because they believe that on their own women tend to forget appointment dates
“………the 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)
“… so, it is the role of the father to remind mother to take the child at for this procedure (Early Infant Diagnosis of HIV services) in time.” (Health Worker 4)
“You know women very well, they tend to forget things easily, they are fond of making mistakes. Like for my wife if I don’t keep the date of her next appointment, I tell you here, she will not go and surely, she will miss that visit I tell you’ how then will we know that our baby is growing well?” (Man 6, involved in PMTCT)
2.HIV Prevention Behavior Roles
In the context of PMTCT, men are expected to take up HIV prevention strategies to ensure that their families are protected. These roles include behavioral practices such as faithfulness to one’s partner and using condoms in the presence of HIV Infection.
a. Faithfulness to One’s Partner
Men are to remain faithful to their wives whether the woman is not pregnant, or pregnant and is breastfeeding and whether the family is HIV positive or not, the role of the man is to be faithful to their wives
“Men have a large responsibility in this programme although they may not know, but they should make sure that they do not infect the wife with the HIV virus.” (Health worker 1)
However, men who are not involved in PMTCT viewed faithfulness as a responsibility for both partners
"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)
b. Initiation of condom use
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.
"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)
3. Decision making roles
Men are key in deciding on uptake of health services as follows. Participants specified various time points within PMTCT services where men make decisions.
a. Uptake of HIV testing by the family
Men decide whether a couple and their children will undertake an HIV test or not. A village headman explained that a man should decide on an HIV test outside the context pf PMTCT. He narrated as follows:
" [HIV] Testing should not wait for a woman to become pregnant, the role of a man as a head of the family is to make decision on how often the couple should be tested in relation to prevent the child from the virus.” (Village headman 2)
b. Antenatal Clinic Attendance, Place and mode of delivery.
Men are culturally expected to decide on when a pregnant partner is to initiate antenatal services. A village headman stated as follows:
“In our Malawian culture men are heads of the family, so the role of the father is to make a decision on when to start the antenatal clinic visits.” (Village headman 4)
A man who was involved in PMTCT services further stated that the role often extends to deciding on the facility where a pregnant partner will deliver.
“… as a decision makers they are supposed to decide on where his wife will deliver. Again, he has to decide on the mode of delivery, … on when to go to the hospital to await labour.” (Man1, involved in PMTCT)
Health care workers asserted that men have to decide on the infant feeding practices a couple would follow since they provide financially for the family.
“The other role of the father is to help the mother decide on the feeding choice of her baby and decide on when she can stop breastfeeding to avoid contracting the virus.” (Health worker 2)
B. Male specific services required in PMTCT programme
The specific services men require are classified under two broader themes and these are: Health Assessment and Health Promotion Services. The participants further outlined how the services can be organized and delivered at both the health facility and community level (Table 2)
Theme 1: Health Assessment Services
The health assessment services men expected from a PMTCT service were Physical Assessment and Medical Consultation services.
a. Physical Assessments Services
Male partners and health care workers at both sites suggested that men should have targeted health care services. Such services include: checking blood pressure, body weight and blood sugar.
“If the health care workers are willing to help, I would love to be checked blood pressure.” (Man 2, involved in PMTCT)
“…if the man comes what he most benefits is the free testing for HIV, but if we integrate with those of non-communicable disease and check their blood pressure, blood sugar, or even their weight” (Health worker 2)
b. Medical Consultation Services
Health care workers reported that men expect to be attended to and be given health advice as appropriate.
“They expect to be asked if they are doing fine and given time to explain their problems that they may have. When men come at the antenatal clinic, they become our clients and we need to listen to their complaints and attend to them and refer if need arises. We always have clinicians whom we work with, those ones should also be consulted.” (Health worker 2)
However, some men who are both involved and not involved in PMTCT services had different opinions from other participants and emphasized that they do not require services that would benefit them directly. 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.
“Because we men are here just to escort our wives, heh, so when you are just escorting you cannot request for anything. When antenatal is for pregnant women, so that they should see how much the unborn baby weighs, so for us to be tested for no reason that is impossible, besides it is time consuming for the health care workers.” (Man 6, involved in PMTCT)
Delivery of Health Assessment Services
Participants further explained how the services they require could be organized and delivered at the Health Facility and Community.
1. Delivery of Health Assessment Services at a Health Facility
Men asserted that they expect the services and staff to be male friendly. Their understanding of male friendly facilities and services emphasized on organization of services like HIV testing, Blood pressure monitoring and information. Male friendly health services entail: Clinic Flow rearrangement, Privacy and confidentiality, personalized and integrated services, couple services and services with positive customer care attribute
a. Re-arrangement of Clinic Activities-Targeted services
Health care workers and men from both sites agreed that most men advocate for omission of antenatal clinic songs and allow the health care workers to proceed with sharing the necessary information directly with the recipients
“You know what? At the ANC clinic they sing songs and clap hands, aaaah 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)
Health care workers corroborated the men’s expectation on the songs that are part of Antenatal services:
“Men want to receive counseling based on their condition, so sitting them down and telling them to sing songs, which is a waste of time… They just want the information to be given out directly.” (Health worker 8)
However, the opinions of some male participants involved in PMTCT and village headmen were contrary to what was suggested as follows:
"I only expect to be given assistance that is all, even if they tell us to sing songs, I can sing without any problems.” (Man 4, involved in PMTCT)
“The hospitals are just ok, the services are also ok, there is nothing wrong with how they offer, 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)
b. Couple Specific Structural Services
Both health care workers at both sites and men who are involved in PMTCT advocated for a designated reception area for couples only. This strategy will avert non-attendance at the services due to shyness stemming from services being offered in the presence of other women.
“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)
“A hospital should have a space which can be used to receive couples only, and test [HIV] a wife and a husband together, while those women who came alone should also have another reception." (Health worker 5)
c. Privacy and confidentiality in Service Provision
As a measure of achieving male friendly health services, especially with HIV services that men may access through PMTCT services, men and health care workers reported that the services have to be offered in rooms that maintain privacy. Men who are involved in PMTCT, health care workers and some village chiefs at both sites also highlighted that male partners expect privacy because they feel relaxed in a closed environment
“I expect to find a hospital which 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)
“These men expect to be treated privately; no one should be suspicious of them when something has gone wrong (HIV Infected result outcome), but in our facility, almost everybody knows that the couple has come for HIV testing and this makes a lot of men to shun away from coming here.” (Health worker 2)
Furthermore, participants suggested that the health care workers must be able to keep the information of people and services accessed confidential, to allow participants to be more open to them.
“The health care workers must keep the information confidential, for example one person has HIV or both of us are positive, it is not good for them to be telling other people about it, we shouldn’t hear about it anywhere.” (Man 6, involved in PMTCT)
“I think sometimes they (health workers) also need us to be discreet, men should not hear from anywhere about the treatment that they have received at the hospital.” (Health worker 2)
Preserving confidentiality becomes paramount in instances where health workers and men know one another as explained below:
“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)
d. Personalized and Integrated Services
Only men who are involved in PMTCT reiterated that men expect to be assisted by one health care worker who would provide all the necessary services without referrals from one health care worker to the other.
“I expect to be assisted with 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 the pregnancy of my wife. 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 will be around.” (Man 4, involved in PMTCT)
Additionally, health care workers and men further described the process of rendering services. This was expressed in the quotes below
“They want to be warmly welcomed, 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)
“We expect to be taught in a loving manner, not like idiots.” (Man 1, not involved in PMTCT)
The health care workers affirmed that a receptive and respectful welcome would encourage more men to attend the PMTCT programme.
“If we welcome them [men] nicely when they come, when they go they will tell their friends, they too will come. Do not judge with the way they look. At times, we (health care workers) tend to judge saying they are too old, or maybe too young, you start saying: eeeh you should be using family planning, yes, saying you also came last year.” (Health care worker 5)
Village Headmen corroborated the receptive attitude by advocating for a non-judgmental attitude by health care workers
“They [men] expect that they will not be judged, the language should be courteous, the care in the hospital should be good, they should take care of the patient well, and do what is required, they should not mock them.” (Village headman 3)
2. Delivery of Health Assessment Services at a Community Level
a. Integration in other activities within a Community
Another way of providing services that was recommended by some men who are involved in PMTCT and health care workers is integrating PMTCT services in other activities, such as in sports because most men enjoy and patronize soccer events.
“Through soccer, before the game starts there should be an announcement to speak 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 other men who may be ignorant or not willing to participate.” (Man 6 involved in PMTCT)
Theme 2: Health Promotional Activities
The health promotion activities suggested were all on educating men on their role and services they can access from PMTCT services. Men suggested of having education sessions concerning their health as part of the services.
“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)
Men who are involved in PMTCT services suggested that the information should be staggered in phases unlike the current practice where participants are loaded with information on one visit.
"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)
Another health care worker shared the consequences of the current practice in sharing information with men:
“If we only counsel them once they will not remember for the whole nine months, until the 24th month.” (Health worker 2)
The healthcare workers at both sites asserted that sharing expectations with the male partners can bring behavior change among men, because they would know what is expected of them within PMTCT services. The quote below illustrates this:
“If we just leave them without telling them our expectations, they behave ignorantly and they don’t like it because they feel out of place.” (Health worker 6)
Delivery of Health Promotion Services
1. Delivery of Health Promotion Services at a Health Facility
a. Audio and visual Messages
The health care workers and men who are involved in PMTCT at both sites suggested sharing information using leaflets, brochures or charts so that men could be reading when they are at the waiting area in the antenatal clinic.
“If the hospital can buy leaflets that have information about PMTCT, the roles that they are supposed to play and some benefits, just as it is with the male circumcision leaflet which gives one the whole information about it and one does not need to ask about it” (Man 5, involved in PMTCT)
“We should hand out brochures or charts which explain the importance of men taking part, how a man can benefit, how a woman can benefit, even the baby because the man has taken part. That can be good because the message can reach a lot of people and a lot can ask for clarification.” (Health worker 1)
Additionally, men and health care workers recommended sharing of information on PMTCT services through television or a radio that are located within a health facility. This approach was deemed inclusive because it would cater for men that cannot read on their own.
“… If there is a radio or television, I see others like at the district hospital in children’s ward there is a radio or television. When they wait to be attended to, they could be watching or listening that, 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)
b. Health Education Sessions in all areas men patronize at a health facility
Giving health talks about the PMTCT services in areas where most men patronize, such as at Antiretroviral clinics and Outpatient Department is another way of delivering health promotional services. This approach was suggested by health care workers who noted that in most cases PMTCT education services are offered at the antenatal or under-five clinics where only a few men are in-attendance.
“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)
2. Delivery of Health Promotion Services at a Community Level
a. Creation of peer support groups
Village headmen and men involved in PMTCT services recommended creation of peer support groups as a mechanism for peer-education to fellow men on PMTCT services in the villages. The participants stated that peer-education is effective in relaying information to others.
“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 trained 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)
b. Stakeholders’ mapping and collaboration
Another form of sharing of information suggested was through collaboration with the community leaders such as traditional leaders, influential institutions such as religious leaders, family clan and employers to facilitate sensitization in community gatherings with the village headmen and existing community healthcare workers. This approach was suggested because cultural beliefs regarding pregnancy, child caring and roles of men towards the care of pregnancy are the ones hindering men from participating in PMTCT services hence the need to work with opinion leaders and key people within a community.
“Since the biggest issue is culture, this has to start in the community first. Our culture needs to accept that pregnancy is not solely a woman’s issue only but both men and women……” (Health care worker 3)
“Some cultures like some religions, they disregard these things, they don’t go to the hospital, it would be good if the message also reaches the church leaders, they should understand it very well so that they can teach their people.” (Village headman 3)
“The message must reach all the stakeholders including the employers in work places. We should all know how important this message (PMTCT Message) is to our men.” (Health worker 7)