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RESEARCH ARTICLE (Open Access)

Men’s use of sexual health and HIV services in Swaziland: a mixed methods study

Joelle Mak A C , Susannah H. Mayhew A , Ariane von Maercker A , Integra Research Team B and Manuela Colombini A
+ Author Affiliations
- Author Affiliations

A London School of Hygiene & Tropical Medicine, Faculty of Public Health & Policy, Department of Global Health & Development, 15–17 Tavistock Place, London WC1H 9SH, UK.

B The Integra research team includes staff from the London School of Hygiene & Tropical Medicine, Population Council and International Planned Parenthood Federation.

C Corresponding author. Email: joelle.mak@lshtm.ac.uk

Sexual Health 13(3) 265-274 https://doi.org/10.1071/SH15244
Submitted: 18 December 2015  Accepted: 10 February 2016   Published: 31 March 2016

Journal Compilation © CSIRO Publishing 2016 Open Access CC BY-NC-ND

Abstract

Background: Over one-quarter of the adult population in Swaziland is estimated to be HIV positive. Men’s use of sexual health (SH) services has significant implications for HIV prevention. This study aimed to understand Swazi men’s health-seeking behaviours in relation to SH and HIV services. Methods: A household survey was conducted in Manzini (n = 503), complemented by 23 semi-structured interviews and two focus group discussions (with a total of 10 participants). Results: One-third of male survey participants used SH services in the past year, most commonly HIV testing (28%). Service users were more likely to be sexually active (aOR 3.21, 95% CI: 1.81–5.68 for those with one partner; and aOR 2.35, 95% CI: 1.25–4.41 for those with multiple partners) compared with service non-users. Service users were less likely to prefer HIV services to be separated from other healthcare services (aOR 0.50, 95% CI: 0.35–0.71), or to agree with travelling further for their HIV test (aOR 0.52, 95% CI: 0.33–0.82) compared with non-users, after controlling for age-group and education. Men avoided SH services because they feared being stigmatised by STI/HIV testing, are uncomfortable disclosing SH problems to female healthcare providers, and avoided HIV testing by relying on their wife’s results as a proxy for their own status. Informal providers, such as traditional healers, were often preferred because practitioners were more often male, physical exams were not required and appointments and payment options were flexible. Conclusion: To improve men’s uptake of SH services, providers and services need to be more sensitive to men’s privacy concerns, time restrictions and the potential stigma associated with STI/HIV testing.

Additional keywords: health services, health-seeking behaviours, HIV testing, men, STIs.


References

[1]  UNAIDS. Swaziland HIV and AIDS Estimates 2013. Available online at: http://www.unaids.org/sites/default/files/epidocuments/SWZ.pdf [verified 24 April 2015].

[2]  Central Statistical Office. Swaziland demographic and health survey 2006–07. Mbabane, Swaziland: (CSO) [Swaziland] and Macro International Inc.; 2008.

[3]  Staveteig SE, Wang S, Head SK, Bradley SE, Nybro E. Demographic patterns of HIV testing uptake in sub-Saharan Africa. Maryland: ICF International; 2013.

[4]  Cockcroft A, Andersson N, Ho-Foster A, Marokoane N, Mziyako B. What happened to multiple sexual partnerships in Swaziland? Analysis of five linked national surveys between 2002 and 2008. AIDS Care 2010; 22 955–60.
What happened to multiple sexual partnerships in Swaziland? Analysis of five linked national surveys between 2002 and 2008.Crossref | GoogleScholarGoogle Scholar | 20544415PubMed |

[5]  Buseh AG, Glass LK, McElmurry BJ. Cultural and gender issues related to HIV/AIDS prevention in rural Swaziland: a focus group analysis. Health Care Women Int 2002; 23 173–84.
Cultural and gender issues related to HIV/AIDS prevention in rural Swaziland: a focus group analysis.Crossref | GoogleScholarGoogle Scholar | 11868964PubMed |

[6]  Courtenay WH. Constructions of masculinity and their influence on men’s well-being: a theory of gender and health. Soc Sci Med 2000; 50 1385–401.
Constructions of masculinity and their influence on men’s well-being: a theory of gender and health.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BD3c3gtlKiuw%3D%3D&md5=7c834028d97d83e9383902e2608cc0fdCAS | 10741575PubMed |

[7]  Galdas PM, Cheater F, Marshall P. Men and health help-seeking behaviour: literature review. J Adv Nurs 2005; 49 616–23.
Men and health help-seeking behaviour: literature review.Crossref | GoogleScholarGoogle Scholar | 15737222PubMed |

[8]  Leichliter JS, Paz-Bailey G, Friedman AL, Habel MA, Vezi A, Sello M, Farirai T, Lewis DA. ‘Clinics aren’t meant for men’: sexual health care access and seeking behaviours among men in Gauteng province, South Africa. SAHARA-J: J Social Aspects of HIV/AIDS 2011; 8 82–8.
‘Clinics aren’t meant for men’: sexual health care access and seeking behaviours among men in Gauteng province, South Africa.Crossref | GoogleScholarGoogle Scholar |

[9]  Venables E, Stadler J. ‘The study has taught me to be supportive of her’: empowering women and involving men in microbicide research. Cult Health Sex 2012; 14 181–94.
‘The study has taught me to be supportive of her’: empowering women and involving men in microbicide research.Crossref | GoogleScholarGoogle Scholar | 22085043PubMed |

[10]  Skovdal M, Campbell C, Madanhire C, Mupambireyi Z, Nyamukapa C, Gregson S. Masculinity as a barrier to men’s use of HIV services in Zimbabwe. Global Health 2011; 7 13
Masculinity as a barrier to men’s use of HIV services in Zimbabwe.Crossref | GoogleScholarGoogle Scholar | 21575149PubMed |

[11]  Reece M, Hollub A, Nangami M, Lane K. Assessing male spousal engagement with prevention of mother-to-child transmission (pMTCT) programs in western Kenya. AIDS Care 2010; 22 743–50.
Assessing male spousal engagement with prevention of mother-to-child transmission (pMTCT) programs in western Kenya.Crossref | GoogleScholarGoogle Scholar | 20461572PubMed |

[12]  Warren C, Mayhew SH, Vassall A, Kimani JK, Church K, Obure CD, Friend du-Preez N, Abuya T, Mutemwa R, Colombini M, Birdthistle I, Aksew I, Watts C. Study protocol for the Integra Initiative to assess the benefits and costs of integrating sexual and reproductive health and HIV services in Kenya and Swaziland. BMC Public Health 2012; 12 973
Study protocol for the Integra Initiative to assess the benefits and costs of integrating sexual and reproductive health and HIV services in Kenya and Swaziland.Crossref | GoogleScholarGoogle Scholar | 23148456PubMed |

[13]  Mak J, Birdthistle I, Church K, Friend du-Preez N, Kivunaga J, Kikuvi J, Masuka R, Integra Research Team Mayhew SH. Need, demand and missed opportunities for integrated reproductive health-HIV care in Kenya and Swaziland: evidence from household surveys. AIDS 2013; 27 S55–63.
Need, demand and missed opportunities for integrated reproductive health-HIV care in Kenya and Swaziland: evidence from household surveys.Crossref | GoogleScholarGoogle Scholar | 24088685PubMed |

[14]  Alli F, Maharaj P, Vawda MY. Interpersonal relations between health care workers and young clients: barriers to accessing sexual and reproductive health care. J Community Health 2013; 38 150–5.
Interpersonal relations between health care workers and young clients: barriers to accessing sexual and reproductive health care.Crossref | GoogleScholarGoogle Scholar | 22782338PubMed |

[15]  Morfaw F, Mbuagbaw L, Thabane L, Rodrigues C, Wunderlich A-P, Nana P, Kunda J. Male involvement in prevention programs of mother to child transmission of HIV: a systematic review to identify barriers and facilitators. Syst Rev 2013; 2 5
Male involvement in prevention programs of mother to child transmission of HIV: a systematic review to identify barriers and facilitators.Crossref | GoogleScholarGoogle Scholar | 23320454PubMed |

[16]  Sudhinaraset M, Ingram M, Lofthouse HK, Montagu D. What is the role of informal healthcare providers in developing countries? A systematic review. PLoS One 2013; 8 e54978
What is the role of informal healthcare providers in developing countries? A systematic review.Crossref | GoogleScholarGoogle Scholar | 1:CAS:528:DC%2BC3sXivFGqs7k%3D&md5=aed542e06a9d4d48f858e59b0acdd208CAS | 23405101PubMed |

[17]  Hsieh EJ, Garcia PJ, Roca SL. Male midwives: preferred managers of sexually transmitted infections in men in developing countries? Pan American Journal of Public Health. 2008; 24 271–5.
Male midwives: preferred managers of sexually transmitted infections in men in developing countries?Crossref | GoogleScholarGoogle Scholar | 19133176PubMed |

[18]  Char A, Saavala M, Kulmala T. Provider bias or organizational limitations? Female and male health care workers’ interaction with men in reproductive health programmes in rural central India. J Fam Welf 2011; 57 1–11.

[19]  Hawkes S. Why include men? Establishing sexual health clinics for men in rural Bangladesh. Health Policy Plan 1998; 13 121–30.
Why include men? Establishing sexual health clinics for men in rural Bangladesh.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DyaK1czhsVarsA%3D%3D&md5=a7721bbda94b0612e2dd7ef39e3fa153CAS | 10180400PubMed |

[20]  Leal AF, dos Santos Figueiredo W, Nogueira-da-Silva GS. Charting the Brazilian Comprehensive Healthcare Policy for Men (PNAISH), from its formulation through to its implementation in local public health services. Cien Saude Colet 2012; 17 2607–16.
Charting the Brazilian Comprehensive Healthcare Policy for Men (PNAISH), from its formulation through to its implementation in local public health services.Crossref | GoogleScholarGoogle Scholar | 23099748PubMed |

[21]  Mills E, Singh S, Wilson K, Peters E, Onia R, Kanfer I. The challenges of involving traditional healers in HIV/AIDS care. Int J STD AIDS 2006; 17 360–3.
The challenges of involving traditional healers in HIV/AIDS care.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BD28zgslKrsA%3D%3D&md5=ec09288c3d7bc8ee78ccef27ea47c063CAS | 16734953PubMed |

[22]  UNAIDS. Collaboration with traditional healers in HIV/AIDS prevention and care in sub-Saharan Africa. A literature review. Geneva: UNAIDS; 2000.

[23]  Furin J. The role of traditional healers in community-based HIV care in rural Lesotho. J Community Health 2011; 36 849–56.
The role of traditional healers in community-based HIV care in rural Lesotho.Crossref | GoogleScholarGoogle Scholar | 21374087PubMed |

[24]  Tobias BQ. A descriptive study of the cultural mores and beliefs toward HIV/AIDS in Swaziland, Southern Africa. Int J Adv Couns 2001; 23 99–113.
A descriptive study of the cultural mores and beliefs toward HIV/AIDS in Swaziland, Southern Africa.Crossref | GoogleScholarGoogle Scholar |

[25]  Ditekemena J, Koole O, Engmann C, Matendo R, Tshefu A, Ryder R, Colebunders R. Determinants of male involvement in maternal and child health services in sub-Saharan Africa: a review. Reprod Health 2012; 9 32
Determinants of male involvement in maternal and child health services in sub-Saharan Africa: a review.Crossref | GoogleScholarGoogle Scholar | 23171709PubMed |

[26]  Hawkins C, Chalamilla G, Okuma J, Spiegelman D, Hertzmark E, Aris E, Ewald T, Mugusi F, Mtasiwa D, Fawzi W. Sex differences in antiretroviral treatment outcomes among HIV-infected adults in an urban Tanzanian setting. AIDS 2011; 25 1189–97.
Sex differences in antiretroviral treatment outcomes among HIV-infected adults in an urban Tanzanian setting.Crossref | GoogleScholarGoogle Scholar | 1:CAS:528:DC%2BC3MXmt1yltrw%3D&md5=61c3f7ae90ce1a013b89b9549325c7c9CAS | 21505309PubMed |

[27]  Risher K, Adams D, Sithole B, Ketende S, Kennedy C, Mnisi Z, Mabusa Z, Bural SD. Sexual stigma and discrimination as barriers to seeking appropriate healthcare among men who have sex with men in Swaziland. J Int AIDS Soc 2013; 16 18715
Sexual stigma and discrimination as barriers to seeking appropriate healthcare among men who have sex with men in Swaziland.Crossref | GoogleScholarGoogle Scholar | 24242263PubMed |

[28]  Amnesty International UK. Mapping anti-gay laws in Africa 2015. Available online at: http://www.amnesty.org.uk/lgbti-lgbt-gay-human-rights-law-africa-uganda-kenya-nigeria-cameroon#.VfbDltJVhBd [verified 10 September 2015].

[29]  Fay H, Baral SD, Trapence G, Motimedi F, Umar E, Iipinge S, Dausab F, Wirtz A, Beyrer C. Stigma, health care access, and HIV knowledge among men who have sex with men in Malawi, Namibia, and Botswana. AIDS Behav 2011; 15 1088–97.
Stigma, health care access, and HIV knowledge among men who have sex with men in Malawi, Namibia, and Botswana.Crossref | GoogleScholarGoogle Scholar | 21153432PubMed |

[30]  Byamugisha R, Tumwine JK, Semiyaga N, Tylleskar T. Determinants of male involvement in the prevention of mother-to-child transmission of HIV programme in Eastern Uganda: a cross-sectional survey. Reprod Health 2010; 7 12
Determinants of male involvement in the prevention of mother-to-child transmission of HIV programme in Eastern Uganda: a cross-sectional survey.Crossref | GoogleScholarGoogle Scholar | 20573250PubMed |

[31]  van Rooyen H, McGrath N, Chirowodza A, Joseph P, Fiamma A, Gray G, Richter L, Coates T. Mobile VCT: reaching men and young people in urban and rural South Africa pilot studies (NIMH Project Accept, HPTN 043). AIDS Behav 2013; 17 2946–53.
Mobile VCT: reaching men and young people in urban and rural South Africa pilot studies (NIMH Project Accept, HPTN 043).Crossref | GoogleScholarGoogle Scholar | 23142856PubMed |

[32]  Matovu JK, Wanyenze RK, Wabwire-Mangen F, Nakubulwa R, Sekamwa R, Masika A, Todd J, Serwadda D. ‘Men are always scared to test with their partners… it is like taking them to the Police’: motivations for and barriers to couples’ HIV counselling and testing in Rakai, Uganda: a qualitative study. J Int AIDS Soc 2014; 17 19160
‘Men are always scared to test with their partners… it is like taking them to the Police’: motivations for and barriers to couples’ HIV counselling and testing in Rakai, Uganda: a qualitative study.Crossref | GoogleScholarGoogle Scholar | 25239379PubMed |

[33]  Ditekemena J, Matendo R, Koole O, Colebunders R, Kashamuka M, Tshefu A, Kilese N, Nanlele D, Ryder R. Male partner voluntary counselling and testing associated with the antenatal services in Kinshasa, Democratic Republic of Congo: a randomized controlled trial. Int J STD AIDS 2011; 22 165–70.
Male partner voluntary counselling and testing associated with the antenatal services in Kinshasa, Democratic Republic of Congo: a randomized controlled trial.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BC3MvgvFaqsw%3D%3D&md5=621ef10926aeaa6f24ba71f6b3d595d1CAS | 21464455PubMed |

[34]  Simelane B, Plattner L, Mkhabela T, End A, Thwala-Tembe M, Mojapele M, Adams A, Okello V. Swaziland: male involvement in addressing the HIV epidemic. Exchange on HIV and Aids, Sexuality and Gender. Amsterdam: Royal Tropical Institute; 2012.

[35]  Dageid W, Govender K, Gordon SF. Masculinity and HIV disclosure among heterosexual South African men: implications for HIV/AIDS intervention. Cult Health Sex 2012; 14 925–40.
Masculinity and HIV disclosure among heterosexual South African men: implications for HIV/AIDS intervention.Crossref | GoogleScholarGoogle Scholar | 22943462PubMed |