`Real men’ do not need healthcare: men and treatment seeking in Malawi

Control, struggle, and emergent masculinities: a qualitative study of men's care-seeking determinants for chronic cough and tuberculosis symptoms in Blantyre, Malawi.

Chikovore J, Hart G, Kumwenda M, Chipungu GA, Desmond N, Corbett L.BMC Public Health. 2014 Oct 9;14:1053. doi: 10.1186/1471-2458-14-1053.

Background: Men's healthcare-seeking delay results in higher mortality while on HIV or tuberculosis (TB) treatment, and implies contribution to ongoing community-level TB transmission before initiating treatment. We investigated masculinity's role in healthcare-seeking delay for men with TB-suggestive symptoms, with a view to developing potential interventions for men.

Methods: Data were collected during March 2011 - March 2012 in three high-density suburbs in urban Blantyre. Ten focus group discussions were carried out of which eight (mixed sex = two; female only = three; male only = three) were with 74 ordinary community members, and two (both mixed sex) were with 20 health workers. Individual interviews were done with 20 TB patients (female =14) and 20 un-investigated chronic coughers (female = eight), and a three-day workshop was held with 27 health stakeholder representatives.

Results: An expectation to provide for and lead their families, and to control various aspects of their lives while facing limited employment opportunities and small incomes leaves men feeling inadequate, devoid of control, and anxious about being marginalised as men. Men were fearful about being looked at as less than men, and about their wives engaging in extramarital sex without ability to detect or monitor them. Control was a key defining feature of adequate manhood, and efforts to achieve it also led men into side-lining their health. Articulate and consistent concepts of men's bodily strength or appropriate illness responses were absent from the accounts.

Conclusions: Facilitating men to seek care early is an urgent public health imperative, given the contexts of high HIV/AIDS prevalence but increasingly available treatment, and the role of care-seeking delay in TB transmission. Men's struggles trying to achieve ideal images seem to influence their engagement with their health. Ambiguous views regarding some key masculinity representations and the embrace of less harmful masculinities raise questions about some common assumptions that guide work with men. Apparent 'emergent masculinities' might be a useful platform from which to support the transformation of harmful masculinity. Finally, the complex manifestations of masculinity indicate the need for interventions targeting men in health and TB control to assume supportive, multidimensional and long-term outlooks.

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Editor’s notes: The differences between men and women’s willingness to seek healthcare have been described in many different settings. This paper sets out the detailed results from a cross-sectional qualitative study looking at men’s care seeking practices for tuberculosis/chronic cough in Malawi. As well as describing perceptions of how a man should behave in society, and what this means for managing health, the authors examine how masculinity influences ill-health responses. Some men delay treatment seeking, because it is not manly to give in to symptoms. Men should publicly show an ability to put up with poor health or employ alcohol or exercise to chase away sickness. While the focus of this paper is on treatment seeking for tuberculosis, the authors draw parallels with the emerging literature on masculinity and HIV-treatment access. Making treatment available will not be enough; efforts have to be made to develop programmes to support and sustain men on treatment.

Avoid TB deaths
Africa
Malawi
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