Healthcare providers’ challenges in providing health services to men: a masculinities-framed study of TB-related care-seeking in Blantyre, Malawi J Chikovore 1 , G Hart 2 , MK Kumwenda 3 , N Desmond 3,4 , EL Corbett 3,5 1 Human Sciences Research Council, South Africa; 2 University College London; 3 Malawi Liverpool Wellcome Research Program; 4 Liverpool School of Tropical Medicine; 5 London School of Hygiene and Tropical Medicine Background: Tuberculosis burden and epidemiology for men In 2016, there were 10.4m cases of tuberculosis (TB) globally, with 10% being HIV-infected, of whom 74% were in Africa. The same year, 1.674m deaths occurred globally, and of these 0.374m were due to HIV. Even though the African continent has a population of 1.02bn, it had a quarter of global incident cases in 2016 (WHO, 2017). Tuberculosis in Africa is driven by HIV, weak health systems, rapid urbanization, and poor living conditions in fast-growing cities. Men are over-represented among people who are diagnosed with TB, and those who remain undiagnosed with disease in the community (WHO, 2017), despite which they are less well-researched in African settings compared to women. Men are also still overlooked by policy at both national and international levels. Moreover, even though men delay seeking healthcare (Orr et al, 2017), the TB control strategy in use in most settings relies mainly on individuals self-presenting for care at facilities (Ho et al, 2016). Study aim We aimed to understand the reasons for high levels of undiagnosed TB among men in the community in order to develop and explore preferences around candidate interventions for facilitating men to engage with healthcare. A sub-analysis of the data illuminated health system challenges related to providing healthcare services to men. “gender entails what women and men do towards each other and against what the other sex does, and as played out on world scale, interwoven with the history of colonialism and contemporary structural effects of globalisation … stresses the multiple, hierarchical, and contradictory nature of masculinity” (Connell 2012) Social constructionist perspective of gender & masculinity Methods 1. Independence is threatened by illness 2. Provider role is threatened by illness and seeking care “there wasn’t time. …time to go to the hospital (health facility)… and then also not having the courage to say ‘I should test’. Umm! Instead I’d tell myself ‘What I have is a mere cough?’” (29yr old man, TB patient) “If you have to consider pain, just remember then that … those depending on you for help] will as well know they’re just going to starve … You want to be able to tell people: ‘I went to such-such a place even with my body not well’ and they’ll be shocked” (31-yr old father of three, TB patient) 3. Health system challenges • Poor communication of algorithms, leaving men feeling emasculated and without control • Long waiting hours , which affect men differently than women • Absence of dedicated space for men • Lack of courtesy and privacy “If a man falls sick at night, just to get there and receive the medicine is difficult. There’s no space except for pregnant women. Pregnant women have an advantage because they sleep inside the fence. Those coming in the morning come with an advantage already, because there is a section for women and … under-five , but no special room for men” (Man in community mixed sex FGD) “Men don’t like crowding. They say ‘Should I go to the hospital where I scramble with women? Why not just get Panadol and avoid that place that’s filled with women?” (Woman in mixed community FGD) Conclusion Beyond staff and equipment shortages, and low remuneration which dishearten providers in many African settings, our study highlights other elements to factor into quality of care improvement efforts. Training in order to engender a respectful and collaborative atmosphere for men at healthcare facilities, and organising facilities so they are welcoming to men and accommodative of their time demands based on their roles, are indicated. Acknowledgments 1. Wellcome Trust Grant WT085411MA 2. Malawi Liverpool Wellcome Trust Research Programme (MLW) 3. HIT TB Hard Study Team at MLW References 1. WHO (2017) Global Tuberculosis Report, Geneva 2. Ho, J et al (2016) Int J Mycobacteriol 5(4): 374-8 3. Husbands, W et al (2017) Ethn & Health, 1-17. 4. Kumwenda, M. et al (2016), PLoS one, 11(4) 5. Chikovore, J et al (2015) Glob Health Action, 8(1) 6. Chikovore, J et al (2014) BMC Pub Health, 14(1) 7. Connell, R (2012) Soc scie med, 74(11): 1675-83. 8. Orr N et al.(2017) JAIDS, 74(Suppl 1):S69. A qualitative research collecting data using in-depth interviews, focus group discussions (FGDs) and a participatory workshop. Data sources Findings Theoretical framework