Table A3.
Constructs from meta‐synthesis of qualitative studies on men's engagement in HIV care
| Third‐order constructs | Second‐order constructs | Summary definition | First‐order constructs | Source(s) | ||
|---|---|---|---|---|---|---|
| Perceived social norms | Barriers | Femininity of healthcare and HIV | Health facilities as feminine spaces | Perception that healthcare facilities are primarily oriented towards addressing the needs of women and children. Also, the staff at clinics are mostly women, which makes it harder for men to feel comfortable discussing their concerns. | It is difficult because the other problem is that virtually all the nurses and counsellors at the clinic are women and thus men are not comfortable discussing their issues with women. We men prefer talking to other men if we have health problems and thus it is hard to go to the clinic for help. [Fleming, p. 7] | Adams 2017, Adeagbo 2019, Camlin 2016, Chikovore 2016, Fleming 2016, Lavender 2019, Mak 2016, Martínez Pérez 2016, Mburu 2014, Orr 2017, Osingada 2019, Rankin‐Williams 2017, Tibbels 2019, Zissette 2016 |
| HIV as a feminine issue | Perception that women are responsible for “managing” HIV in a relationship. This includes testing so that men can know their status by proxy, which, therefore, makes it unnecessary for men to test if their female partner already has tested. | What [men] like to say is that once I have tested, he had already tested too. (Woman in focus group) [DiCarlo, p. 15] | Camlin 2016, DiCarlo 2014, Lavender 2019, Mak 2016 | |||
| HIV as a threat to social norms | Health, strength and sexuality | Men fear being seen as weak if seen involved in HIV care. They also fear that HIV and HIV treatment could lead to sexual dysfunction and/or take away from a strong and attractive physical appearance. | From the culture, [to be a man] means to be strong, to have a family. To have your things. Cattles. To get a house. The problem about this, it's never been discussed health issues about men. The only health issue they know is going to the bush [circumcision ceremony] and they come out as man… That they are HIV, it's still a taboo, they hear it in the radio, they see in the TV… [Martínez Pérez, p. 6] | Adams 2017, Chikovore 2016, DiCarlo 2014, Fleming 2016, Hendrickson 2019, Jennings 2017, Mak 2016, Martínez Pérez 2016, Mooney 2017, Naugle 2019, Ndyabakira 2019, Okal 2020, Orr 2017, Osingada 2019, Rankin‐Williams 2017, Russell 2019, Sileo 2019b, Skovdal 2019, Wamoyi 2017 | ||
| Livelihood | Belief that HIV as well as engaging in HIV care takes away from men's ability to earn a livelihood and support their family. | I had spent a long time without testing because I am always busy looking for money so one would not get time even to go to [nearest health center] get tested. [Ndyabakira, p. 3] | Chikovore 2016, Naugle 2019, Ndyabakira 2019 | |||
| Social standing | Fear that HIV and being seen engaging in HIV care will take away from a man's social and family standing. | When you suffer from some of these illnesses [HIV], you find that you do not spend enough time with other men as you have to constantly go to the hospital. Your absence from other men may make you feel less masculine… (South Africa, Age 62) [Fleming, p. 7] | Adams 2017, Camlin 2016, Chikovore 2016, DiCarlo 2014, Fleming 2016, Lavender 2019, Mantell 2019, Martínez Pérez 2016, Mburu 2014, Naugle 2019, Russell 2019, Sileo 2019b, Wamoyi 2017, Zissette 2016 | |||
| Lifestyle | Fear that HIV and engagement in HIV care will make life less fun for men because of HIV stigma in the community and the need to take treatment. | For us, men, HIV is the end of your fun, the end of your joy… it's like you are condemned. When you do not have AIDS, you go to bars, you drink your beer, you find a girl, you go and enjoy…But once you have it, in your neighborhood, if people say you have it, they will point fingers at you. (Man in focus group, age 25–34) [Naugle, p. 6] | Chikovore 2016, Conserve 2019, DiCarlo 2014, Hendrickson 2019, Naugle 2019, Ndyabakira 2019, Orr 2017, Rankin‐Williams 2017, Sileo 2019b, Zissette 2016 | |||
| Facilitators | Coping skills | Appearance of health and strength | Belief that engaging in HIV care is a way to maintain and enhance physical appearance, health, strength and sexuality. | In the past there was so much fear [about HIV] …[but now] I drink my beer and I tell the people around that I am HIV infected, and I am proud…I show off because I look good. (Man with HIV) [Russell, p. 1203] | Brown 2019, Camlin 2016, Graham 2018, Hendrickson 2019, Russell 2019, Sandfort 2015, Sileo 2019b | |
| Responsibility for family | HIV can serve as an impetus to help men realize the importance of taking care of themselves so that they are able to take care of their family. Men also described testing in order to start a serious relationship or get married. | My children are a reason to fight for my life so I can take care of them…[before HIV] I did not know how to save money or even budget, and used [money] for things that did not matter, but ever since I was told that I am HIV positive, I realized that I had to plan… (Man with HIV) [Russell, p. 1204] | Brown 2019, Camlin 2016, Hendrickson 2019, Mak 2016, Okal 2020, Russell 2019, Sandfort 2015, Schatz 2018, Sileo 2019a, Sileo 2019b, Wamoyi 2017 | |||
| Power over HIV | A sense of control over HIV and a desire to fight the diagnosis by engaging in care. | They gave me ARVs as treatment and therefore I have no reason to be afraid. When someone gives you an instrument like a shield to fight with in a war, do you say that I am afraid? You have to fight. (Man with HIV) [Russell, p. 1207] | Hendrickson 2019, Osingada 2019, Russell 2019, Sileo 2019a, Sileo 2019b | |||
| New social support | Men with HIV serve as friends and role models for other men with HIV, helping them to see how HIV and masculinity can be compatible. Men also benefit from support from other friends, family and community members. | Before being diagnosed with HIV, I used to fall sick all the time, yet I know of friends who have already initiated on ART therapy. So, my friends would advise me that why don't you go to a health facility such that you can be checked. (Fisherman, age 23) [Sileo, p. 781] | Daniels 2019, Graham 2018, Hill 2018, Mburu 2014, Mooney 2017, Osingada 2019, Rosen 2020, Russell 2019, Sileo 2019b, Wamoyi 2017, Zissette 2016 | |||
| Health system challenges | Barriers | Low‐resourced clinics | Lack of materials, medications and/or staff | Frustration that health facilities have long waiting times, unavailable providers, and unavailable testing kits and/or ART. | When I come, [the provider gives me advice, he tells me to take my medication. I tell him yes I will take the medication, but often when I come there is no medication. So when there's no medication like that, I am discouraged. [Tibbels, p. 8] | Adams 2017, Adeabgo 2019, Daniels 2019, Krakowiak 2020, Lavender 2019, Mak 2016, Ndyabakira 2019, Ogunbajo 2018, Okal 2020, Tibbels 2019, Tsang 2019, Zissette 2016 |
| Mistrust and misinformation about HIV | Doubt accuracy of test results | Mistrust that testing results are valid, as well as the ability or motivation of providers to correctly interpret and communicate results. | I do not doubt the reliability of the test, the test we all know that it is reliable, but sometimes the person who does the test can be wrong. (Man in focus group, age 35–49) [Tibbels, p. 6] |
Graham 2018, Jennings 2017, Martínez Pérez 2016, Ogunbajo 2018, Okal 2020, Osingada 2019, Sandfort 2015, Tibbels 2019 |
||
| Misinformation about HIV | False beliefs including that it is impossible to survive with HIV, that HIV is man‐made or that one's personal risk is low despite high‐risk activities. | Some [men] get involved [in HIV care] while others fear because they think if I am found positive, I would die quickly, so they better go when they are already bedridden. [Ndyabakira, p. 6] | Adams 2017, Camlin 2016, DiCarlo 2014, Jennings 2017, Mak 2016, Martínez Pérez 2016, Mooney 2017, Ndyabakira 2019, Ogunbajo 2018, Rankin‐Williams 2017, Russell 2019 | |||
| Unwanted disclosure | Lack of confidentiality given clinic layout and procedures | Concern that the lack of confidential spaces and procedures within the clinical setting leads to unwanted disclosure. | … At the hospital there is a bench for those with HIV. When you sit there, you wait for medication, people know that you have HIV. The person has so much fear of this, so much shame, that the person will not go there. [Tibbels, p. 7] | Adams 2017, Adeagbo 2019, Fleming 2016, Hendrickson 2019, Mak 2016, Mantell 2019, Martínez Pérez 2016, Ogunbajo 2018, Okal 2020, Orr 2017, Rankin‐Williams 2017, Rosen 2020, Sandfort 2015, Tibbels 2019, Van Heerden 2015, Zissette 2016 | ||
| Anticipated and enacted stigma | Enacted and anticipated stigma towards persons with HIV | Experienced of expected judgement from healthcare staff and others towards people with HIV. | When you get to the hospital, you feel as if you have failed, being sick…When they discover it is HIV, they give you a weird look. When your back is turned, the staff laughs…. I lived it yesterday and it hurt me. (Man with HIV, age 25–34) [Tibbels, p. 5] | Adams 2017, Adeagbo 2019, Chikovore 2016, Daniels 2019, DiCarlo 2014, Hendrickson 2019, Mak 2016, Mantell 2019, Micheni 2017, Mooney 2017, Naugle 2019, Ndyabakira 2019, Ogunbajo 2018, Okal 2020, Orr 2017, Osingada 2019, Rankin‐Williams 2017, Rosen 2020, Russell 2019, Sandfort 2015, Skovdal 2019, Tibbels 2019, Tsang 2019, Zissette 2016 | ||
| Enacted and anticipated stigma towards MSM, regardless of HIV status | Experienced or expected judgement from healthcare staff and others towards MSM, which intersects with stigma of HIV | If I went to a health facility the moment I meet you I can tell how homophobic you are or how friendly you are … I cannot access health care where there is stigma or a place where they are not sensitive to sexuality issues. (MSM age 22 years, ART‐naïve) [Graham, p. 100] | Daniels 2019, Graham 2018, Mak 2016, Micheni 2017, Sandfort 2015, Tsang 2019 | |||
| Facilitators | Convenient access to healthcare | Home testing | Home testing allows for a comfortable, private environment for testing and is enhanced by health counsellors. | I think men definitely would [home]‐test … because there is no place like home. It is where I know I can get all the support. [DiCarlo, p. 877] |
DiCarlo 2014, Krakowaik 2020, Martínez Pérez 2016, Ndyabakira 2019, Rankin‐Williams 2017, Van Heerden 2015 [118,125,131,139,190,193, 127,134,140,148,199,202, 128,135,141,149,200,203, 125,201,202, 127,134,140,148,199,202, 126,133,139,147,198,201, 124,131,137,145,196,199, 122,129,135,143,194,197, 121,128,134,142,193,196, 119,126,132,140,191,194, 120,127,133,141,192,195, 119,126,132,140,191,194, 118,125,131,139,190,193, 115,122,128,136,187,190, 113,120,126,134,185,188, 112,119,125,133,184,187, 111,118,124,132,183,186] |
|
| Self‐testing | Self‐testing gives men a sense of control, privacy and convenience. | Yeah, like none sees me while I test. And once I am done, I throw it to the dustbin. (Man, age 26) [Jennings, p. 5] | Adeagbo 2019, Jennings 2017, Osingada 2019 | |||
| Flexible clinic opening hours | Flexible facility hours help to accommodate busy work schedules. | …they should make these hospitals operate 24 hours because this one is a big hospital…. The reason why I'm saying that is because there are some people who work in daytime up to very late and when they come here they don't get services because the doctors and the nurses are gone. (Man with HIV, age 40) [Okal, p. 14] | Okal 2020 | |||
| Trust in health system | Belief in effectiveness of ART | Belief in ART effectiveness through clinical guidance, public advertisements and personal experience. | So I believe that this treatment is good because my skin was black, and I also lost weight, but I have recovered. People, they used to ask me what I am eating nowadays because I look healthy and my body has recovered, compared to last year. So I have started to realize that ART is helpful, and it's true. (Man with HIV, age 45–50) [Mooney, p. 279] | Brown 2019, DiCarlo 2014, Hendrickson 2019, Mooney 2017, Ogunbajo 2018, Okal 2020, Rankin‐Williams 2017, Russell 2019, Schatz 2018, Skovdal 2019 | ||
| Positive experiences with healthcare staff | Experiences in which healthcare staff have been especially helpful to men engaging in care. | When I went to the hospital, I didn't tell my parents and I did not have any money. The nurse that counseled me, she paid for my labs. I needed labs before they could put me on the medicine. The nurse I went to see paid for my labs and she is the one who made everything easier for me. [Ogunbajo, p. 836] | Brown 2019, Graham 2018, Mak 2016, Ogunbajo 2018 | |||
| Poverty | Barriers | Poverty | Direct unaffordability of seeking HIV care | Economic challenges, including transport costs, non‐subsidized medical expenses and costs for medical visits. The informal health system is perceived as more affordable. | Think that if they go to the hospital, the costs will be exorbitant. So they prefer to stay in their corners, do their traditional treatment. (Man in focus group, age 25–34) [Tibbels, p. 8] | Jennings 2017, Mak 2016, Micheni 2017, Ndyabakira 2019, Ogunbajo 2018, Schatz 2018, Sileo 2019b, Tibbels 2019 |
| Opportunity costs of care | HIV care takes time and money away from needing to seek employment, food and other needs. | You see the challenge that most of us have faced is that we are poor; the illness finds us in poverty. So, you have to strive hard to look for money and that involves use of a lot of energy, which is a very big challenge. (Boat operator, age 32) [Sileo, p. 780] | Adeabgo 2019, Camlin 2016, Jennings 2017, Krakowiak 2020, Mak 2016, Micheni 2017, Ndyabakira 2019, Ogunbajo 2018, Sileo 2019a, Tibbels 2019 | |||
| Facilitators | Affordability of care | Testing alternatives | Home and self‐testing perceived as more affordable because they cost less and they are quicker, so men lose less productive time. Home testing is preferred because men do not have to spend money to travel to clinics or hospitals. | The advantage [of HIV self‐testing kits] is there is no need to go to the hospital to take the test. And also, you save money because…in private hospitals you must pay to be tested. (Man, age 22) [Jennings, p. 5] | Adeagbo 2019, Camlin 2016, Jennings 2017, Krakowiak 2020, Mak 2016, Micheni 2017, Ndyabakira 2019, Ogunbajo 2018, Sileo 2019a, Tibbels 2019 |