“Men are more selfish and proud”: healthcare workers' negative biases in sub-Saharan Africa

Healthcare workers’ negative attitudes towards men prevent them from acknowledging structural barriers and may create hostile environments for men wanting to access healthcare. Dr Kathryn Dovel of the University of California and colleagues did a secondary analysis of data collected with healthcare workers in Malawi and Mozambique. They found that healthcare workers framed men as problematic and “selfish”, which places an unfair responsibility on individual men while minimising barriers and challenges they face.

Background

While men have much lower rates of viral suppression and higher rates of advanced HIV, they are underrepresented in HIV services throughout sub-Saharan Africa, including Malawi and Mozambique. Ongoing HIV transmission is now driven by men who have not reached viral suppression. Generally, men have historically been absent from global HIV guidelines and priorities and previous research has highlighted how this bias has a detrimental effect on local  and national healthcare practice. Addressing gender disparities is key to reducing higher morbidity among men and incidence among women.

Dovel and colleagues looked again at data collected from focus groups with healthcare workers in 2016. The focus groups involved healthcare workers across 15 facilities in areas of HIV high prevalence in Malawi and Mozambique. The original study aimed to address barriers to universal treatment, not bias among healthcare staff, which was the focus of the secondary analysis.

The 20 focus groups involved 150 healthcare workers involved in HIV treatment, including 43% ART providers (mostly nurses and clinical officers) and 57% support staff (community health workers, counsellors and peer educators). The majority (59%) of the participants were female and the average age was 30 years old.

Women are vulnerable

Healthcare workers tended to focus on gender inequalities and power dynamics in heterosexual relationships. When talking of difficulties with adherence, they juxtaposed women’s vulnerability with men’s inadequacies and character flaws.

“There are wives [taking ART] in hiding, and this influences her treatment adherence. Other wives do not reveal [their status] because they fear that the partner will beat them or they will get divorced. Nowadays, when the men find out [about their partner’s positive status], they abandon the family.” – Support staff, Mozambique

“Most women fail to start ART because of challenges related to patriarchal dominancy. Most men out there still think in the outdated manner that they are superior than women and as such a woman is prevented from making an independent decision to start ART because she is afraid that she will risk breaking up her marriage.” – Support staff, Malawi

“While in men, the decision seems to be his own. . . Ahhh its easier for the men to start because the decision power he possesses. The woman, she understands. The woman understands the facts [about ART] very well, but the problem is in the power of decisions.” – Support staff, Mozambique

Men should be able to overcome structural barriers

The study participants shared explicit strong and negative views about male service users. Due to gender disparities and what they identified as an economic advantage, healthcare workers believed that men had enough power to overcome barriers, even structural ones. Although healthcare workers acknowledged that the time taken to attend healthcare appointments conflicted with men’s role as economic providers, few were sympathetic towards men’s dilemma. Some workers believed that men prioritised earning money over their own health (and subsequently their families’ health).

Healthcare workers tended to overlook multiple disadvantages that some men faced (such as poverty and sexuality) and viewed them all as having an elevated status in society, believing they brought poor health “upon themselves”.

“[Men are] pompous! Pompous! Because they feel themselves to be of higher social status, so when they are told about [HIV], they don’t see the negative impacts right away and they don’t want these issues to disturb their normal [work].” – ART provider, Malawi

“They are different, men and women. Women do accept their counselling very quickly compared to men. Men they sometimes become troublesome to accept their results, so it can be difficult . . . They are head of the family and head of their immune system [laughter].” – ART provider, Malawi

“Men refuse to start ART because they are selfish. Men are more selfish and proud than women are and as a result, they end up resisting ART. Most men are promiscuous and they have many extra-marital sexual affairs. However, they want to pretend to be good people to their wives and as such they are unwilling to come for testing.” – ART provider, Mozambique

Conclusion

Heterosexual African men are stereotyped in international and national policies, which influence local care. The authors write that “such stereotypes deserve immediate attention as they may negatively impact healthcare workers’ buy-in and implementation of male-specific interventions, and negatively impact patient-provider interactions.” Health workers should “embrace more nuanced, intersectional definitions of vulnerability which acknowledge that groups who are powerful in one social sphere may be vulnerable in another”.

Healthcare workers have limited exposure to men as clients and men have limited experience using healthcare services. Routine visits for family planning, antenatal care and services for children under five give women more opportunities to attend healthcare and receive information about HIV prevention, testing and treatment. In contrast, there are fewer opportunities for men to attend clinics, which means they have little exposure to health education, and attending clinics in itself raises suspicion about their HIV status.

Appropriate care will require healthcare workers to destigmatise male service users and address structural barriers. The authors suggest healthcare workers attend sensitisation workshops, and that clinics provide differentiated services including mentorship and counselling specifically for men, flexible appointments and shorter waiting times to accommodate men’s needs.