AIDS and Behavior

, Volume 13, Supplement 1, pp 92–102

Male Involvement in PMTCT Services in Mbeya Region, Tanzania

Authors

    • Institute of Tropical Medicine and International HealthCharité University Medicine
  • Paulina Mbezi
    • PMTCT Programme Mbeya Region, Ministry of Health and Social Welfare
  • Hebel Luvanda
    • PMTCT Programme Mbeya Region, Ministry of Health and Social Welfare
  • Brigitte Jordan-Harder
    • Institute of Tropical Medicine and International HealthCharité University Medicine
  • Andrea Kunz
    • Institute of Tropical Medicine and International HealthCharité University Medicine
  • Gundel Harms
    • Institute of Tropical Medicine and International HealthCharité University Medicine
Original Paper

DOI: 10.1007/s10461-009-9543-0

Cite this article as:
Theuring, S., Mbezi, P., Luvanda, H. et al. AIDS Behav (2009) 13: 92. doi:10.1007/s10461-009-9543-0

Abstract

Throughout all stages of programmes for the prevention of mother-to-child-transmission of HIV (PMTCT), high dropout rates are common. Increased male involvement and couples’ joint HIV counselling/testing during antenatal care (ANC) seem crucial for improving PMTCT outcomes. Our study assessed male attitudes regarding partner involvement into ANC/PMTCT services in Mbeya Region, Tanzania, conducting 124 individual interviews and six focus group discussions. Almost all respondents generally supported PMTCT interventions. Mentioned barriers to ANC/PMTCT attendance included lacking information/knowledge, no time, neglected importance, the services representing a female responsibility, or fear of HIV-test results. Only few perceived couple HIV counselling/testing as disadvantageous. Among fathers who had refused previous ANC/PMTCT attendance, most had done so even though they were not perceiving a disadvantage about couple counselling/testing. The contradiction between men’s beneficial attitudes towards their involvement and low participation rates suggests that external barriers play a large role in this decision-making process and that partner’s needs should be more specifically addressed in ANC/PMTCT services.

Keywords

TanzaniaANCPMTCTMale involvementPartner involvement

Introduction

Programmes for the prevention of mother-to-child transmission of HIV (PMTCT) respond to three of the most challenging problem areas of international health: combatting HIV/AIDS, reducing child mortality and improving maternal health. Those health topics, also voiced in the United Nation’s Millennium Development Goals (United Nations 2007), have been calling attention worldwide in the past years. Accordingly, PMTCT programmes have now broadly been established in HIV-affected countries, especially in sub-Saharan Africa, where HIV prevalence in pregnant women is exorbitantly high in some regions.

The widespread approach, consisting of comprehensive counselling and subsequent HIV-testing followed by the offer of single-dosed nevirapine for seropositive mothers and their newborns, as well as referring HIV-positive mothers and their families to antiretroviral therapy (ART) programmes, has been reported to be convincing in terms of feasibility and effectiveness (Rely et al. 2003; Stringer et al. 2003). However, service uptake often turned out to be the critical point of PMTCT programmes (Manzi et al. 2005; Stringer et al. 2003). Although PMTCT interventions are usually embedded into antenatal care (ANC) services, which are frequented by most pregnant women at least once during pregnancy (Van Eijk et al. 2006), entering the PMTCT procedure seems to be of a still high threshold for many ANC clients. Dropout rates during the different steps of intervention follow a cascade-like pattern (Dardian 2003), resulting in reduced numbers of participation at each of those steps, including HIV-counselling, HIV-testing, post-test counselling, programme enrolment, drug intake of the mother, drug administration to the child, adherence to feeding recommendations and follow-up visits.

Reasons for programme refusal or later-on dropout are multifaceted. Previous research found that social support plays a crucial role in enabling women to take on the required serial decisions and adhere to the course of the intervention. Especially male partners, key decision makers in questions of sexual and reproductive health (SRH) in many societies, are attributed to a high potential of impact on pregnant women’s behaviour (Biratu and Lindstrom 2006; Sarker et al. 2007; Semrau et al. 2005), and unsupportive partner attitudes are likely to create a barrier to women’s programme participation. It has been shown that fear of the partner’s reaction in case of positive serostatus disclosure is a major obstacle for women to participate in voluntary counselling and testing and further programme enrolment (Antelman et al. 2001; Medley et al. 2004). Joint counselling and HIV-testing for couples seems to be a key to success here. As demonstrated in earlier studies (Farquhar et al. 2004; Painter 2001; Semrau et al. 2005), in women who underwent couple’s voluntary HIV-counselling and testing (CVCT), PMTCT programme uptake and adherence were significantly improved. The male role has to be considered as a major player and contributor to community acceptance of PMTCT services (Burke et al. 2004).

However, it has turned out to be a challenging endeavour to integrate men into those services (Farquhar et al. 2004). ANC has a long tradition of representing a female realm, and where CVCT is offered in the frame of ANC, the participation rates of male partners often remain negligible. Hence, male partner involvement has developed to a major target point for the successful implementation of PMTCT as well as of other SRH programmes.

In this context, a number of studies aiming to define women’s attitudes towards partner integration into reproductive health services, partner status disclosure and CVCT can be found (Maman et al. 2003; Medley et al. 2004; Semrau et al. 2005; USAID/Synergy 2004). On contrary, limited research has been performed so far in order to understand the male perspective on ANC or SRH services and barriers to participation in those services. When reviewing recent literature in this regard, it becomes evident that most of the existing knowledge presented on men’s perceptions has been gained and derived from research conducted among women. However, as postulated by Nzioka (2001), an in-depth understanding of men’s attitudes is crucial when intending to increase partner involvement, and it can only be obtained through male-focussed research. Studies that did try to explore male perspectives on ANC or SRH service participation include insights from eastern and southern Africa (e.g., Adeleye and Chiwuzie 2007; Kunene et al. 2004; Muia et al. 2000; Nzioka 2000; Peacock 2003), or from southern Asia (e.g., Mullany 2006; Saha et al. 2007; Sharma 2002). Many of those studies had in common that men tended to express a general concern for their female partner’s health and rather positive attitudes towards their own participation in SRH services; thus, as pointed out by Peacock (2003), they do provide room for some optimism. However, research performed in this context has mostly not primarily focussed on the male point of view, but rather used it for comparison or triangulation with female perspectives, and oftentimes it concentrated largely on partner participation in issues like family planning, but less on actual service attendance. In-depth studies with a primary focus on men, supplying evidence of male attitudes and opinions on involvement and on participation barriers are rare and specifically in the context of PMTCT virtually unavailable.

The aim of this study was to fill the existing gap on male-focussed research and to learn about men’s perspectives on and experiences with ANC and PMTCT services in Mbeya Region, Tanzania, in order to identify strategies for increasing partner participation rates in those services.

Methods

Study Setting

The United Republic of Tanzania is among the poorest countries in the world, and also among the hardest-hit countries with regards to the HIV epidemic, although the nationwide adult prevalence rate has decreased to now about 7% over the past years (UNAIDS 2007). Since 2001, the German government through the German Agency for Development and Technical Co-operation (GTZ) has been supporting a comprehensive nevirapine-based PMTCT programme in Mbeya Region (Harms et al. 2007). The study was conducted within the frame of this programme, which is embedded into the existing ANC services of about 60 health facilities in the peripheric, rural setting of Mbeya Region. This region represents one of Tanzania’s most heavily HIV-affected areas (WHO/UNAIDS 2006). Average HIV prevalence in pregnant women frequenting the programme has been 12% in 2007 (health centres range: 4–20%). The intervention procedure of this PMTCT programme envisages that women are offered voluntary counselling and HIV-testing at first encounter with the PMTCT-offering ANC services. Positive-tested women may then enrol in a single-dosed nevirapine prophylaxis programme, receiving a maternal drug dose in gestational week 28 with the instruction to take it at the onset of labour. Newborns receive a drug dose within 72 h after birth in the health facilities. Women first-time encountering the PMTCT programme at delivery are offered intra- or postpartum counselling, testing and subsequent drug administration in case of a positive test result. The programme also involves postnatal counselling on safe infant feeding and other relevant health issues, as well as a referral system for HIV treatment and care. Partners are encouraged to participate in the programme. Especially CVCT had been made widely available from the beginning of the programme by being offered in all ANC/PMTCT facilities and also being permanently emphasised in public awareness campaigns, but nonetheless, partner participation rates have remained low. Even though an upward trend from 4 to 7% could be observed between the first and the third quarter of 2007, those numbers underlie strong fluctuations and still require significant improvement.

Study Participants

Individual interviews were conducted among a convenience sample of men in reproductive age during a 1 week agricultural exhibition and community event in Mbeya Region in August 2007. A random selection procedure was applied by asking every tenth male exhibition visitor for his consent to answer the questionnaire. Fifteen out of 139 approached men rejected participation (rejection rate 11%), all of those explained this was because they were in a hurry due to the ongoing exhibition. The so-obtained sample consisted of 124 men within an age range of 22–59 years. Out of these, 71% belonged to the age group of 20–40 years, hence the most relevant age group regarding reproduction, and 29% belonged to the age group 40+, a distribution which is in compliance with the age profile of Mbeya Region as described in the Population and Housing Census (National Bureau of Statistics Tanzania 2002). It might be considered as a limitation of the study sample that it also incorporated some men of the 50+ age group, while at the same time these are less likely to be still involved in family planning and reproduction. However, it was deemed that older men have a high potential of being influential towards men in younger age groups, for example within extended family structures, and thus their attitudes and perceptions deserved to be taken into account as well.

Interview Procedures and Analysis

The local research coordinator identified capable interviewers for the study, taking into consideration possible influence of the interviewers’ sex. Presuming that female interviewers would be unlikely to cause less valid reporting because in the study region, female health personnel is highly common and respected, and men can generally be expected to be accustomed to and confiding in female health workers, it was agreed on a team of one male and three female interviewers. The subsequently chosen interviewers, four local health workers of the programme, were trained in quantitative and qualitative data collection methods regarding the conduction of questionnaire-based individual interviews as well as the conduction of focus group discussions (FGDs).

The standardised, Kisuahili-translated questionnaire included both close-ended and open-ended questions and was pretested before starting the survey. It requested demographic information and general knowledge on PMTCT at the outset. Having general knowledge on PMTCT was defined as being aware of the fact that HIV could be transmitted from mother to child, that a drug intervention and safe feeding could prevent transmission, and that services for this purpose existed. Men who were aware of MTCT and the fact that it was preventable, but did not further know how or where this could be done, were considered as having partial knowledge on PMTCT. In case a respondent had no or partial knowledge on it, the interviewer was instructed to give a brief explanation of the PMTCT concept before asking further questions. Even though the study targeted PMTCT services, most questions did also focus on ANC, which represents the entry point to PMTCT and thus was critical in this context. Therefore, the combined expression “ANC/PMTCT services”, meaning “ANC and/or PMTCT services” was used. The questionnaire further on asked for experiences with the services, obstacles impeding attendance, the perceived paternal role, attitudes towards CVCT and possible incentives for male participation. Interviews were led in Kisuahili, but answers written down directly in English by the bilingual interviewers.

For analysis of non-standardised, open-ended questions, data was segmented and manually organised in categories for coding based on a grounded theory approach. Codes were initially generated by two different coders (a local research team member and the first author) to compare for consistency, and were in the further process refined into an exhaustive coding scheme. A standard statistical package was applied for classifying and analysing quantifiable data, e.g., in terms of frequency distribution and cross-tabulation of variables.

Focus Group Discussions

To complement insights from the interviews, six FGDs comprising 6–13 individuals were conducted by the local health workers in four different peripheral, mostly rurally located health facilities (Uyole, Iyela, Kiwanjampaka and Mbeya Regional). Discussions were primarily led in male groups, but also in some female groups for data triangulation. FGD participants had partly been identified and invited prior to the discussions, partly they were recruited from waiting areas in the health facilities’ outpatient clinics. Confidentiality was guaranteed to the participants and assured by anonymising names. Discussions were guided around issues raised in the questionnaire and lasted for around 45 min each. They were tape recorded and, immediately after the session, transcribed or summarised for analysis. FGDs were evaluated manually by the authors by applying an inductive coding scheme, which was developed and refined in the process of data analysis, and then compared to the codes having emerged from individual interviews.

Results

One-hundred and twenty-four individual interviews were conducted among male community members. In addition, six FGDs were conducted, four of those among men and two more among women.

The 124 respondents of individual interviews had a median age of 35 years. 103 (83%) of them were married, out of which 36 (35%) stated to be married less than 5 years, 30 (29%) stated to be married for a period between 5 and 10 years, and 26 (25%) stated to be married for more than 10 years. Ninety-nine out of 124 interviewees (80%) did have children. From those, 51 stated to have children in the age group below 5 years, and 27 stated all their children were older than 5 years. Twenty-one fathers had not made a statement on their children’s age. The average number of children was 2.4 (range 1–8). Primary education was the highest completed educational level in 79 (64%) of the responents, secondary education in 26 (21%), higher secondary education or tertiary education was completed by eight interviewees (6%). Nine interviewees (7%) did not have any completed educational level. Out of all respondents, 104 (84%) were Christians, 11 (9%) Muslims and 9 (7%) had another religious denomination.

General Attitude Towards PMTCT

Out of 124 interview respondents, 85 (68%) stated to know what PMTCT is. 32 (26%) declared that they did not know and seven (6%) stated to partly know what it was. Almost all respondents (123 out of 124 persons, 99%) stated that they generally approved of PMTCT interventions. 102 (82%) stated they would also approve of infant feeding alternatives to breastfeeding in order to save a baby from infection, while 16 respondents (13%) did not agree on this, and 6 (5%) were undecided. From those 22 respondents not providing a positive answer on infant feeding support, more than three quarters were married and had children.

Those general attitudes to PMTCT services were also mirrored in FGD statements:

I know about PMTCT, it is about how a child can be prevented from HIV infection, although I am not sure how the service is carried out···I agree that it is very important for a mother to take antiretrovirals in order to protect her baby. (Male discussant, Kiwanjampaka)

It is important for the HIV positive mother to be helped and assisted to get services for PMTCT, otherwise she will not go for the services and the child will be infected. (Male discussant, Mbeya Regional)

General Perception of Obstacles to Attending ANC/PMTCT Services

All interviewees, irrespective of their experiential background, were asked to name obstacles which in their perception could generally prevent men from attending ANC/PMTCT services. The most frequently mentioned points included “lack of information/knowledge on the existence of the services or the necessity to go there” (mentioned by 61 persons, 49%); “being too busy/no time” (mentioned by 46 persons, 37%); “neglected importance of attending the services” (mentioned by 42 persons, 34%); “general cultural or traditional habits” (mentioned by 37 persons, 30%); “services are a female domain/female responsibility” (mentioned by 36 persons, 29%), and “fear of the results of an HIV-test” (mentioned by 25 persons, 20%). When restricting perceived participation barriers to those men who had children, the displayed picture and the hierarchy of barriers remained almost equal.

The mentioned obstacles were further explained in the FGDs:

Men do not attend these clinics because it is not their role. They only do so when their wives are not feeling well. (Male discussant, Uyole)

Due to difficulties of life it is better to go and seek money for the family, instead of attending clinics which were designed for women only. (Male discussant, Uyole)

A lot of men when told about the service, they don’t give attention to it, as they see it is to do with women and children. After all, the women are thought to be capable to handle the situation. Because of economic hardships and constraints caused by the time he will be there, he may loose time to work. Also, they don’t know what they are being called for. Men are afraid of testing. (Male discussant, Kiwanjampaka)

Individual Experiences with ANC/PMTCT Services

Asking for personal experiences among the 99 respondents who were having children, 46 (46%) had attended ANC/PMTCT services before, and 53 (54%) had never attended ANC/PMTCT services. Disaggregating fathers with respect to child age groups did not endorse a wide discrepancy in attendance rates: among 51 more recent fathers (defined as having children aged five or younger), 22 had visited ANC/PMTCT before and 29 had not done so (43 vs. 57%). Among 27 nonrecent fathers (having only children older than 5 years), 13 had visited services and 14 had not done so (48 vs. 52%).

Among the men who had attended ANC/PMTCT, 37 (80%) had made an overall positive experience, seven (15%) had made both positive and negative experiences, and one person had made an overall negative experience (one answer missing). Positive experiences by majority included that the men felt they were met with a kind reception at the services and that the services felt valuable to them:

When I attended ANC/PMTCT, I felt good about it. We were counselled together and got knowledge on important issues. The providers were very polite with me. (Male discussant, Iyela)

Specific negative experiences included majorly feeling shy as a man in presence of many women (mentioned by nine respondents, 20%). Eight respondents (17%) declared that they were not allowed to enter the room with their wife or were made wait outside during the wife’s examination. One FGD participant expressed this amibiguous situation:

I heard that in case you have escorted your wife to the services, you will be told to wait outside the clinic room, so why should I go and end up waiting outside? (Male discussant, Mbeya Regional)

Those 53 fathers who had never attended ANC/PMTCT services were asked for individual reasons which made them reject the services. Those essentially included “lack of knowledge/information on existence of services or on request to go there” (mentioned by 25 persons, 46%); “neglected importance of attending services” and “lack of time/too busy” (both mentioned by 13 persons, 24%); and general “cultural or traditional habits” (mentioned by seven persons, 13%). Disaggregating for recent and nonrecent fatherhood, it turned out that in both groups the most frequently mentioned reason was “lack of knowledge” (45% in recent fathers, 36% in nonrecent fathers). The recent fathers then named “lack of time” (35%), “neglected importance” (21%), only 3% mentioned “cultural/traditional reasons”. On contrary, in nonrecent fathers, the second most frequently mentioned rejection reason was both “neglected importance” and “cultural/traditional reasons” (21% each); “no time” was mentioned by only 14%.

Attendance and Perception of VCT and CVCT

Fifty-seven of all interviewees (46%) stated to have undergone VCT of any provider before. From the 66 persons (53% of all, one missing answer) who had not undergone counselling and testing so far, 54 (82%) stated a general willingness to attend counselling and testing, and 12 (18%) said they were not willing to do so.

Thirty-nine persons (32%) had undergone counselling and testing jointly with their partner. From the ones who had not undergone CVCT, only 35 persons (41%) affirmed a general willingness for it, while 45 persons (53%) refused their general willingness to participate in CVCT (five missing answers). Some FGD statements exemplify the sometimes hesitant willingness to get tested with one’s partner:

Yes, I am willing to go to CVCT, but I need time to be prepared for testing just because I have heard a lot about it. Some say you will end up with uncontrolled worries which could shorten your life. (Male discussant, Kiwanjampaka)

It is important to go together for testing, although we haven’t done so, but we are on the way to do so. If one of us is HIV positive, the other one will be responsible to take care of the diseased partner and will stop having sexual relationships. (Male discussant, Kiwanjampaka)

Interviewees were asked on their general opinion on joint counselling and testing of couples, irrespective of having experienced it or not. 116 individuals (94%) could find at least one advantage in CVCT. The major perceived advantages of attending CVCT were “clearness on both partners’ HIV status” (68 persons, 55%); “general knowledge on HIV and its prevention” (46 persons, 37%); “know how to live in case of HIV infection” (42 persons, 34%); “plan for the future of the couple/of the family” (32 persons, 26%); “strengthen partnership if HIV-negative” (25 persons, 20%); and “prevent conflicts in partnership” (18 persons, 15%).

Twenty respondents (16%) did perceive at least one disadvantage of CVCT, while 104 (84%) did not see any specific disadvantage about it. Named disadvantages included general “worries and no peace” (10 persons, 8%); “conflicts in partnership” (seven persons, 6%) and “conflict in case of serodiscordant status” (six persons, 5%).

Just looking at those men who had experienced CVCT before, it turned out that only three of them (8%) were aware of a disadvantage, while 36 (92%) did not associate disadvantages with CVCT.

The mentioned perceptions of the joint counselling and testing procedure, including the issue of disclosure, were also described in the FGDs:

If you go for testing together with your partner and found negative, you will be very happy and ensure faithfulness between you two. (Male discussant, Kiwanjampaka)

But in case only one partner is positive, especially when it is the wife, there will be very little peacefulness in the house. (Male discussant, Kiwanjampaka)

In couple testing, there will be no time for preparation to tell your partner how you have become HIV- positive. (Male discussant, Kiwanjampaka)

However I see there are very few disadvantages compared to advantages. (Male discussant, Kiwanjampaka)

In case they were not together, it will be difficult to share the results for a couple, the one who tested first will be blamed that he or she was the one bringing the disease at home. If it is the woman who is positive, no question a divorce will be the answer. But in case it is the man who is HIV positive, there will be negation. (Male discussant, Iyela)

In the group of fathers who had never attended the services with their female partners, 20% did see a disadvantage linked with CVCT, whereas 80% had neglected previous ANC/PMTCT attendance while at the same time they were not perceiving a disadvantage about CVCT.

Comparing Women’s Opinions from Female FGDs

The results of the FGDs with female groups showed that women were in accordance with the assumption that men should accompany them to the health facility for ANC. The opportunity of starting a dialogue on difficult topics was considered extremely valuable. At the same time, the lacking willingness of men to attend services was mentioned by numerous discussants:

Just walking with my husband to the clinic will make me happy, we will be able to discuss our concerns throughout the way to the clinic. It will encourage us to make use or put into practice the advice from the counsellor. (Female discussant, Uyole)

I am really willing to go for a test with my husband, but the problem is that many men dislike to be tested with their wives. We told them that going to the clinic won’t be a problem. (Female discussant, Uyole)

You may tell your husband that you are not feeling well, so you need him to accompany to the health facility for medication. There, you could have arranged with a counsellor who will do the counselling before seeing a doctor for medication. (Female discussant, Uyole)

I will arrange with the counsellor to write a calling message to my husband. (Female discussant, Uyole)

Another important issue mentioned by the women in the discussions were the negative events in case the partner came along for HIV testing and they would test positive.

A disadvantage will be either to loose your husband in case you test HIV-positive, but in case both of you are HIV-positive, he might blame you for bringing the disease into the family. In such situation I will ask the counsellor to help me how to face my husband as many marriages collapse due to conflicts concerning the HIV status. (Female discussant, Uyole)

I won’t tell my husband if I have tested positive, if I do he will divorce me. (Female discussant, Uyole)

Perceptions of Father’s Role

When being asked who in a family would carry the responsibility for a (unborn) baby’s health, the vast majority of interviewees stated that both parents would share the responsibility (112 persons, 91%). Six persons (5%) named the mother as being responsible, five persons (4%) named the father.

Among fathers, all but one respondent stated that they wished to generally play a more active role during pregnancy, childbirth and child care (97 persons, 98%; one answer missing). When asked for specification, the understanding of an active paternal role turned out to target mainly the general ensurance of daily subsistence and surviving of the family, i.e., food supply, security and broad aspects of health. The concept of an actively involved father remained rather vague. Support for the woman especially in pregnancy was considered important, for example in the form of support in housework (23 persons, 24%).

One hundred of all men (81%) thought that women would not need male consent in health decision making, while 22 (18%) did think that this consent was indeed needed. This is being illustrated by several FGD statements:

The woman needs consent from her husband because the husband is the one who can incure all costs needed for their health if they arise. (Male discussant, Mbeya Regional)

I think it is not necessary for the mother to get permission, because sometimes, the father may not be present and the baby is required to be taken to the clinic, for how long will the mother wait for the father to come? (Male discussant, Mbeya Regional)

I believe the woman should obtain permission from her husband for the child’s health; this will effectively help to take care of their child together. (Male discussant, Uyole)

No, it is not necessary for the mother to get permission, after all it is her responsibility to take care of the children, whether in her husband’s presence or absence. (Male discussant, Uyole)

Incentives for Male ANC/PMTCT Attendance

When asked on their approval of different ways to overcome men’s barriers, the highest affirmation was expressed for special CVCT hours within ANC services (91 persons, 73%), followed by a special waiting area for men/couples (75 persons, 61%), an invitation letter from the health facility delivered to men by their wifes (58 persons, 47%) and an official letter excusing from work for ANC attendance (53 persons, 43%). 80 interviewees (65%) suggested to offer CVCT in ANC services not only during working days to enable male partners to attend. Regarding other strategies for male attendance, a large proportion of the interviewed men (56 persons, 45%) suggested to increase education and knowledge on the importance of ANC and PMTCT services which was too low in their opinion.

Discussion

The study aimed at understanding male perspectives regarding their involvement into the female domain of ANC/PMTCT services. This understanding constitutes a critical step for developing strategies to increase partner participation.

In general, our findings suggest that conducive attitudes towards partner involvement into ANC/PMTCT services are existent to a great extent among male community members in Mbeya Region. This complies with the results of other surveys on attitudes towards male involvement from varying cultural settings, such as Botswana, South Africa (Peacock 2003) or Nepal (Mullany 2006), where men also by majority demonstrated favourable positions regarding participation in ANC or undergoing an HIV test as a couple. However, the contradiction between men’s beneficial attitudes on one side and low male participation rates in ANC facilities on the other side requires explanation.

Interviewees of the study expressed an overwhelmingly high overall approval of PMTCT measures. Still a vast majority stated to support safe feeding options like formula feeding or early weaning for the purpose of PMTCT; however, this number was yet lower as compared to the almost unanimous general approval of PMTCT (82 vs. 99%). It is imaginable that the overall supportive attitude is suffering to some extent when it comes to more tangible aspects the intervention might request, highlighting the importance of scrutinising generally expressed supportive attitudes to the degree of their veracity not only in theory, but in daily life practice.

A principal goal of the study was to uncover major obstacles for men to attend ANC/PMTCT services and to identify approaches enabling to come up against those obstacles. Overall, the interviewed men did not so much feature a general intrinsic refusal to participate, but rather referred to external, i.e., structural, institutional or organisational obstacles. A similar finding was obtained from the study of Muia et al. (2000), where, when investigating contraints for men to participate in SRH services, it was concluded that “institutional barriers seemed more overwhelming than cultural barriers”.

It is necessary to distinguish between external and internal barriers and their respective implications to develop appropriate problem solving approaches. Overcoming internal barriers, often led by entrenched, complex cultural and traditional beliefs or by strong emotions like fear, is an assumedly difficult and long-winded process. Striving for rapid behaviour changes, it seems more practicable to first address external barriers. By slowly increasing the amount of ANC-attending partners and thereby the perceived level of normality, improved external conditions might at long sight also influence traditional paradigms and intrinsic motivations towards higher service participation.

The primary external barrier found from the survey was a “lack of knowledge and information”, mentioned by almost half of the respondents. While part of the interviewees showed a general knowledge deficit regarding ANC/PMTCT services, a much larger group seems to possess this general knowledge but to lack the particular information that men are called upon attending those services with their wifes. This gives reason to reanalyse the focus and direction of PMTCT-related information, education and communication (IEC) strategies, which numerously have been in place in the past decade in Tanzania. Knowledge campaigns can only be effective when information is systematically taylored to target recipients’ needs and transported to the right locations. Hence, beyond assuring that general information on ANC/PMTCT services is made available to men, it should specifically and strongly address the necessity for male partner participation. This is underscored by Waltson (2005) in a similar analysis in Cambodia, who recommended that not only current education campaigns should be reviewed to assess their value in promoting male involvement, but also that effective ways to deliver education messages to the male population need to be established. One way of delivering those messages and filling in the obvious information gap could be the distribution of personal invitation letters for men on behalf of health facilities, handed out to all women presenting for ANC without their partner (Homsy et al. 2006). Previous experiences with invitation letters have been extremely promising in terms of increased rates of partner participation in ANC (Bolu et al. 2007). Also in this study, a high level of affirmation among men was detected with regard to contact letters.

Another substantial external obstacle to male participation turned out to be the timely inflexibility of those men heavily burdened with earning a family’s subsistence. To accommodate this problem, it has been suggested to offer services after working hours or on weekends and to reduce waiting time for men/couples (Bolu et al. 2007). The proposed offer of Saturday or evening clinics was well received by the majority of interviewees in this study as well.

Special ANC service hours represent part of an act of making services more user-friendly for men in general, including also the improvement of privacy for male clients, e.g., through separate waiting areas for men or couples. A necessity for this is indicated by the fact that some interviewees had reported uncomfortable feelings, timidity or uneasiness on account of the female setting. Adjusting ANC facilities in a more male-friendly way (Walston 2005) might be a reasonable reaction to the predominant, obstructive societal assumption that ANC is an exclusively female domain. The cultural barriers precluding men from calling on women-oriented places could be mitigated to some extent by a male-sensitive revision of ANC settings, accommodating and respecting the needs of both male and female clients.

As one of the major internal, cultural barriers to male participation, the study revealed men’s disregard of importance concerning their involvement in ANC/PMTCT services, sometimes also reflected in describing ANC as a solely female responsibility. To a large extent, this can be explained by the widespread cultural female codification of all issues linked to reproductive health in general. On the other side, it must be noted that maternal/child health has become a main focus of community healthcare in the past decade, often following international endeavours to support vulnerable population groups and to overcome unequal sociocultural power structures regarding healthcare access. Institutionalising female health, for example by enforcing particular antenatal and maternity structures, has certainly brought great improval regarding women’s access to care; yet, it also might have contributed to an exclusion of men from participating in important health areas. While actually intending to protect health rights of women, those exclusive interventions can eventually result in less reproductive health equity than interventions including men (Dudgeon and Inhorn 2004; Walston 2005; Homsy et al. 2006). It must be recognized that the ever existent cultural/traditional barrier to male involvement in reproductive health services has been exacerbated by the tendency of health systems to structurally segregate men from reproductive issues. The circuit of reciprocal enhancement between cultural and structural conditions needs to be interrupted in order to open up SRH, ANC or PMTCT programmes for the male sex and, as Muia et al. (2000) put it more general, in order to defeminize reproductive health. This issue should be taken into serious consideration by health policy planners and decision makers.

The study also tried to shed light on individual male experiences with ANC/PMTCT services. Interviewees who had attended the services were rather satisfied and expressed positive experiences by majority. Yet, a number of men had been refused to enter consultation rooms with their female partners by health staff. Service provider attitudes emerged as a significant barrier to male ANC involvement here as well as in other studies (Muia et al. 2000; Peacock 2003). It is obvious that supportive policies and attitudes of health providers are central when strategies to increase male participation rates shall be effective. Especially ANC counsellors represent the crucial link between policy and practice of health services, and their attitudes and practices in giving advice will significantly influence the intervention’s outcome (DiPaoli et al. 2002). Further investigation on provider attitudes could be of high use in this context, and trainings for service providers regarding the importance of partner integration and the handling of CVCT represent an essential part of a strategy to raise male participation (Walston 2005). Guidelines to mainstream male involvement in ANC/PMTCT services, on regional or national level, would also be a very useful tool to align health provider policies, such as the guidelines on “Mainstreaming gender into HIV and AIDS” developed by WHO (2008). However, those guidelines, once established, need to be incorporated into working routine, for example by including them into terms of references of health workers (Amin et al. 2007).

The study appraised male perceptions of CVCT, which seems to be the quintessence of “male partner involvement in ANC/PMTCT services” when translating that term into practice: the shared participation of a couple in HIV-counselling and testing constitutes a foundation for all further decisions undertaken jointly with regard to HIV and PMTCT, like the decision to enrol in the PMTCT intervention.

CVCT did apparently not imply negative side effects for the majority of men in our study. Most interviewees did not see any disadvantage arising from it, while almost all expressed the perception of a benefit by mentioning at least one advantage of CVCT. Looking at the particular subgroup of fathers who had never attended ANC/PMTCT services before, only few stated to see a disadvantage in CVCT and through that actually expressed a clear intrinsic motivation for their attendance rejection, while the majority of the non-attendants did not express to see any disadvantage in CVCT.

The finding that most interviewed men did not see a disadvantage in being couple counselled and tested displays an interesting contrast to the female perspective on this issue. As it turned out during FGDs among females, women do perceive existential fears when it comes to serostatus partner disclosure, which is inevitably linked to CVCT. Disclosing a positive HIV serostatus by many women was sensed as a potential source of adverse consequences, and particularly as a risk for their marital future. This has been affirmed in many studies conducted among women in developing countries, as subsumed by WHO (2004) in a review paper on gender dimensions of HIV status disclosure. At the same time, many women in the FGDs mentioned to see a chance in disclosing their status in presence of a counsellor, from whom they expect to serve as an intermediator in the couple’s disclosing process. Presumably, inner-relational or marital problems, which are named as disadvantages of CVCT most frequently, represent much more of a threat to women, who often have to suffer severe social and economic consequences from marital disruption. By contrast, male partners as the intra-family authority instance are less likely to fear and experience such drastic impacts when revealing a positive HIV-test, which could explain why they perceive CVCT disadvantages to a lesser extent than women. Yet, up to now, social consequences for men arising from serostatus disclosure have hardly been explored at all, and further research in this field would certainly be interesting.

However, the promising fact that most men in our study did perceive CVCT as advantageous nevertheless did not seem to positively influence their service-attending behaviour. The decision of whether to attend ANC/PMTCT services appears to be reached independently from the perceived level of benefit attained through CVCT. Not attending ANC services with the female partner while not explicitly rejecting CVCT might mirror the aforementioned significance of external causes, but, beyond this, could also stand for a general neglect or disregard of the issue. Both of those suggestions are endorsed by interviewee’s statements regarding partner participation barriers.

The study also tried to comprehend the interviewee’s perception of a father’s role. In fact, study participants did largely express their will to play an active role as a father. When asked to further explain this role, they referred to broad traditional paternal attributes such as assuring family health and protection. Clearly, men need to understand that in order to substantiate those vague concepts of paternal responsibility, their practical support is needed by female partners. In this context, it could be of great value trying to turn cultural attributes of masculinity to account as potential positive forces, as it has been suggested by Mullany (2006). If the common understanding of paternalism was channelled into an increased perception of paternal liability and commitment, appealing to men as responsible partners, this could offer a chance for targeting men in health interventions. It is important to help men redefine their masculinity to encompass a wider social role, as it has been pointed out by Montgomery et al. (2006). In this regard, stressing positive rolemodels of responsible fathers and partners should be a major emphasis in public awareness and IEC measures to increase partner involvement in ANC/PMTCT. Responsible fatherhood-campaigns do already exist in some countries, e.g., the “Fatherhood Project” in South Africa, aiming at influencing social expectations and perceptions about men’s roles, encouraging men’s positive responses to family care, and creating a sense of shared responsibility among fathers and mothers. The project expects to exert societal impact by providing information, generating public discourse and by encouraging policy-makers to include fatherhood-related activities in their programming (Richter et al. 2004).

This study has attempted to describe men’s perceptions of partner integration into ANC/PMTCT services in a rural Tanzanian region. Attitudes among men regarding their involvement were found to be beneficial by majority. However, it is important to keep in mind that attitudes concerning sensitive issues such as gender roles and reproductive health are to be seen in their particular background, and findings might not be transferrable to different contextual settings (Dudgeon and Inhorn 2004; Mullany 2006).

A number of barriers to partner participation as well as a number of strategies to overcome those barriers have been identified. Future challenges now seem to lay in establishing policies and implementing practices which respond adequately to the needs of male partners, and thereby help women-centred healthcare settings to integrate both sexes. The exigence of this integration is obvious. As stated by Montgomery et al. (2006), men’s involvement represents a “largely untapped resource for families affected by HIV/AIDS”. Male integration and participation in PMTCT, ANC and SRH services is a crucial gateway to bring forward their effectiveness.

The magnitude and complexity of men’s influence on health and wellbeing of their female partners and families has been well recognised in the public in the past years. Yet, it seems the required paradigm shift is still going further than that: male partners need to be viewed and treated not only as a powerful influencing factor, but as a constituent part of reproductive health, and can no longer be excluded from any debate surrounding issues like pregnancy or HIV/AIDS.

Acknowledgments

The authors would like to express their gratitude to all staff and clients of the involved health facilities in Mbeya Region, Tanzania. Special thanks are owed to Ms. Anna Kipera, Beauty Lwesya and Modesta Kiona, nursing officers at Mbeya Regional Hospital, who were greatly involved in the interviews and discussions. This study was conducted as a part of the GTZ Sector Project “Strengthening the German Contribution to the Global AIDS Response”.

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© Springer Science+Business Media, LLC 2009