Stage 1—Eliciting the program theory.

Interventions are theory incarnate [32]; they say that if we deliver these services or this intervention in this way, we will get this outcome [30, 33]. And like all theories, they are open to being supported or refuted. In realist review, the program theory is an articulation of how a given intervention is expected to work and acts as the hypothesis that is being tested. By developing a clear understanding of how a program is expected to work, we give ourselves the best opportunity to compare what is expected to what is actually happening [33]. Hence, realist review begins with development of a program theory to be refined throughout the research [30]. Realist program theories are presented as ‘CMO’ configurations which describe the causal relationships being investigated [32].

To build the initial program theory we conducted an initial ‘scoping review’ of the literature’ [33]. This process involved informally exploring the literature, including both peer-reviewed and grey literature, to establish an initial understanding of the theory of how MI is expected to improve uptake of PMTCT interventions for pregnant women in low and middle-income countries. Numerous sources were used in this process, including reports from international organisations such as UNAIDS and World Health Organisation, existing published research around barriers to the uptake of PMTCT interventions by pregnant women, as well as research around MI in PMTCT programs. Academic literature was sourced through informal searches of Ovid MEDLINE, Cochrane Database of Systematic Reviews and Google scholar using simple combinations of search terms ‘male involvement’, ‘hiv’, ‘antenatal care’, and ‘PMTCT’. This broad reading set the foundation to build a preliminary program theory. The preliminary program theory is presented as a series of context, mechanism, outcome (CMO) configurations to be tested throughout the review (see Table 1). These were developed by theorising reasons that a woman may not progress through each of the steps required to prevent MTCT (Fig 1). Each of these potential missteps was translated into a CMO theory.

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Table 1. Preliminary program theory.

https://doi.org/10.1371/journal.pone.0240087.t001

Stage 2—Search strategy.

Following development of the initial program theory, the next step was to locate relevant evidence to inform the CMO configuration review. Following the lead of Rycroft-Malone et al. [31] and groups that have completed rapid realist reviews [34], we deviated from pure realist methodology [30] and began a formal search strategy with an electronic database search. This formal search differs from the initial scoping searches in that the scoping search is effectively a process of broad reading to learn about the intervention and context while the formal search is a reproducible and unbiased collection of sources with which you can test your program theory [30]. To ensure an inclusive search, a medical librarian was consulted to improve keyword search strategies and database identification (see S1 Appendix for search terms and strategy). Our initial search was concluded on the 29^th of May 2017. As we were aware that our formal search would likely be our only significant gathering of data, we chose to make it as inclusive as possible by choosing a broad selection of databases [30]. This formal search included the databases Ovid MEDLINE, Embase, CINAHL, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Scopus, Web of Science and ProQuest. Due to a delay in publication, the search was repeated on 12/06/2020 to ensure the most recent data was also included prior to publishing (see S2 Appendix for the search terms and strategy of the repeated search).

Stage 3—Study selection criteria.

In realist review the traditional hierarchical approach to evidence is rejected because the rich picture you hope to produce requires input from many different forms and sources of evidence [30]. For example, in realist review a randomised control trial is not considered a more reliable source of evidence than a cross sectional study as we aren’t looking for good proof that an intervention works, we are looking for how the intervention seemed to be working in that context and how individuals were responding to it. As one can imagine, qualitative papers with interviews and quotes are particularly valuable in this process whereas in traditional review methodology they would be considered less useful than a randomised control trial. Studies used in a realist review should be diverse, and judgements on the value of a piece of research should not be strictly based on study design but rather on how well it informs the program theory [32]. In selecting literature for this review, we assessed both relevance and rigour. Decisions around relevance of an article were made based on whether it was related to the topic of interest and whether it could contribute to theory building, while our assessment of rigour evaluated whether a particular piece of work was credible and trustworthy [33]. It is important to understand that while a study would not be excluded based on the type of study, it was removed if it was of poor quality [30].

The process of appraisal and selection of studies to be included began with initial screening of title and abstract. The inclusion criteria for this initial screen was as follows

1. Study is published in English with full text available
2. Research focused on low or middle-income country/ies
3. Addresses MI in ANC and/or PMTCT

While these were treated as strict criteria, in the initial stages we tended towards inclusion when the title and abstract appeared to be relevant to ensure good evidence was not missed. Due to the overwhelming number of results from the initial search, we focused on articles published from 2010, with the proviso that if we could return to the pre-2010 results if required (this ended up not being necessary as there was sufficient good quality evidence published after 2010 to reach a point of ‘saturation’ as described by Pawson et al. [30]). Full text of the remaining articles were assessed for rigour using a series of standardised critical appraisal tools from the Joanna Briggs Institute [35] and The Critical Appraisals Skills Programme [36]. These tools provided an objective checklist of criteria for each different type of study design that papers could be marked against. To ensure a manageable number of articles during our data extraction process we strictly removed any articles that did not meet a high-quality standard determined as a score greater than 80% on the appropriate critical appraisal tool.

Stage 4—Data extraction.

After removing all articles that did not meet the rigour standard, the remaining 38 articles were read in full thoroughly and iteratively to find evidence that related to the initial program theories. The software program NVivo 11 was used to manage the data. A hybrid deductive and inductive thematic analysis was conducted. Articles were searched for evidence that proved or disproved the initial program theory and to identify any new possibilities, and all potentially relevant data was coded into NVivo. This process was undertaken by the lead researcher and to avoid bias was reviewed by a second member of the research team, any and all disagreements were discussed with the team as a whole to be rectified. Following review of all articles the coding structure was reviewed and themes relating to contexts, mechanisms and outcomes were drawn out and sorted.

Stage 5—Data analysis and synthesis.

The goal in synthesis is to use the data extracted to refine the initial program theory [31]. Realist analysis of data collected requires a combination of not just deductive and inductive reasoning, but also the more abstract abductive and retroductive reasoning [37, 38]. That is, the researcher does not just look for data that proves of disproves their initial theory. They must acknowledge all data available and instead of proving or disproving a theory, they use the data to alter the theory to come to a most likely description of what may be occurring. The data collected in stage 4 was compared to the initial program theory and then used to alter the initial program theory to produce a refined program theory of how context effects the mechanisms that work and result in desired outcomes of MI in PMTCT programs.

CMO1—The nature of a couple’s relationship influences whether they are likely to participate in PMTCT programs together or not.

From the review it is clear that MI in PMTCT works best for couples in monogamous [14, 15, 50, 56, 57], trusting [13], and safe [13, 16, 23, 39, 40] relationships. The degree to which these aspects are perceived by the couple directly relates to the likelihood of being willing to attend ANC with a partner.

There were several factors that seemed to influence how willing an individual would be to disclose their status to their partner, male or female. The more committed they were in a relationship, the more likely they were to participate in couples voluntary counselling and testing (CVCT) as a part of ANC.

“Women, who perceived their relationship as supportive, loving and trusting would disclose without fear of rejection or abandonment” [41] pg 264

Non-monogamous couples were not as willing as monogamous couples [54] to attend for CVCT.

Being married increased a couple’s likelihood of participating in CVCT [12, 50, 60], although infidelity was repeatedly mentioned as a barrier to MI in any ANC or subsequent CVCT [14, 15, 52]. If either partner had participated in extramarital sexual relationships, the likelihood they would agree to participate in CVCT as a part of ANC was reduced [48, 50]. This included women refusing a test if they knew their partner had been unfaithful as they did not want to bring a positive test home and risk taking the blame [46]. In contrast, men who had been faithful to their pregnant partners reported willingness to participate in a HIV test if it were offered to them [15].

“If you engaged in sex with other men and suspect yourself to be HIV positive, you wouldn’t like to come with your partner in the clinic because it might cause misunderstandings in the home.”– 33-year-old pregnant woman attending ANC alone [14] pg 1557

“For those women who have a good, open and honest relationship with their husband it’s fine to bring their husband. For those who are married to the … euhm the typical macho man, it’s difficult, they are not open, there is no trust. They are scared to invite their husband, to bring her husband … They are scared to be accused of HIV infection.” Female provider, age group 30–40, Provider FGD [48] pg 7.

High levels of trust and stability in a relationship were associated with increased likelihood of participating in CVCT [39, 46, 48, 59, 65]. Distrustful or unstable relationships were associated with decreased willingness to participate for both men and women [17]. While disclosure has been suggested to not significantly increase rates of domestic violence or relationship breakdown [62, 64], the fear of these is a very real barrier to MI in PMTCT. If a woman has any fear that disclosure will lead to domestic violence or abandonment it is very likely that she will not disclose [16, 17, 21, 39, 55–57, 62]. It is evident that the more secure a couple feel in their relationship the more willing they are to be tested for HIV together [17, 39].

“As to why some men did go for couple HIV testing, the men we interviewed speculated that these were men who had a good relationship with their wives, and had marriages marked by mutual love, trust, and understanding.” [43] pg 4

In relation to CMO1, we theorise that relationship characteristics that lead to high levels of mutual trust, intimacy, commitment, safety, security and ownership encourages willingness to disclose ones’ HIV status and therefore increases a couple’s willingness to participate in CVCT as a part of ANC.

CMO2—How ‘male friendly’ the ANC space is influences how likely male partners are to attend.

Men tend to prefer not to attend ANC services that are dominated by women and increase their involvement when male friendly adjustments are made to services. Comments from male participants from a range of studies reaffirmed their current dissatisfaction with ANC and offered suggestions on how to improve men’s engagement with ANC [12, 17, 21, 25, 45, 65].

Across multiple studies men and women alike refer to ANC as women’s business [12–22, 28, 47]. This idea has been so strongly engrained, it has led to ANC being labelled as “unmanly” in many cultures [15–17, 22, 25, 28, 46–48, 65]. There is strong social pressures around this in countries where patriarchal norms dominate with men risking ridicule and judgement for attending a “women’s clinic” [28, 46–48].

“Even the songs we always sing at the antenatal clinic, we always mention the woman, not a man, so the men feel ashamed to be together with their wives, they feel that they are not part of it”. Key informant [21] pg7

“Men who accompanied their wives to the clinic were called ‘kana-kodona’ (women’s rivals) or ‘bakana’ which means ‘man-woman’; suggesting that the man exhibits female tendencies.” [28] pg6

“They come fetch you up saying "Let´s go for a walk. Why are you being commanded by your wife?” (Man, 20, bike taxi driver, Gonhane)” [46] pg 7

“Providing support to a pregnant partner, including accompaniment to an ANC appointment, meant that men had to endure the heckling and mocking of their friends. Providing physical or emotional support to a pregnant partner implied male weakness.” [46] pg 6

ANC being considered a women’s space is a significant barrier to MI in PMTCT programs [23]. In the female dominated ANC clinic, those men who do attend feel out of place, unwelcome and unnecessary [12, 17, 45, 51].

“Attending the antenatal clinic was seen as “unmanly” to the extent that men feared being socially stigmatized if they accompanied their wives to the antenatal clinic” [13] pg 9

Men tend to prefer receiving VCT in ‘friendlier’ spaces outside of the ANC setting [16, 17] and are more likely than women to request home-based testing over ANC-based testing [53]. As well as men not feeling as though they belong in the ANC space, it is often reported that they are not treated as though they are welcome in the space [22].

“many of the men implied that the prenatal care clinic was not inviting” [25] pg 11

Throughout multiple studies, men reported that staff were unfriendly to them [15, 19, 28, 47, 64], that they were not included in the appointment [14, 19, 22, 25, 41, 43, 45, 48], even that they were asked to leave the clinic [16, 19, 20, 22, 28, 44, 52], all of which discouraged the men from returning to the ANC clinic.

“Sometimes, the nurses are always so harsh and they don’t want to see a man (husband) inside the maternity ward.” [22] pg 8

The review identified that male participation increased at clinics that made “male friendly” adjustments to their usual practice [13, 45, 51]. These included providing incentives for male partners to attend, formally inviting male partners to attend, and employing male staff members. Incentives included preferential treatment for women who attended with their male partner to reduce wait times [21, 27, 39, 47, 49], providing health checks for the male partners [12, 21], providing parenting advice for the male partners [12, 20, 51], even providing gifts for couples who attended together [21]. The act of formally inviting male partners into the ANC space appeared to have a significant effect on how willing the male partner was to attend ANC [12, 17, 23, 47, 49, 51, 54, 62, 65].

“Involve us in the registration, antenatal check-up, getting drugs and all the processes to make us feel that we are also important people in the clinic.” (Man accompanying partner, age 32) [14] pg 1559

“If the doctor sent me an invitation, I cannot refuse to answer. I'll be going to know my HIV status.” (Male FGD participant) [49] pg 5

It seemed the formality of the process made men feel invited and welcome [25], made them feel the process was legitimate [43] and reassured them that they had a role to play in the ANC space [27].

“Few of the participants added a condition that their presence must be needed at the clinic before they could accompany their wife.” [18] pg 4

“Health care providers involved with the couple counselling activities at the Vientiane MCHH said that most of the men who are invited do come along to these special sessions, suggesting that men are interested to receive information if they feel welcome.” [45] pg 306

In addition to men being more likely to accept a formal invitation from the clinic, women preferred having a formal invitation to legitimise their request of their partner’s attendance [13, 14, 43, 46, 51]. It is not uncommon for women to feel intimidated in asking their partners to attend ANC, and so a formal invitation from the clinic also reduces this anxiety for the pregnant woman [13, 14, 43, 51].

“I think, for a man to believe that the wife’s message is true; there should be a written notification. … Not much will be said on the paper, the letter ought to be stamped with a hospital stamp. When the man sees the stamp he will know that he is wanted.” [23] pg 5

The incorporation of male staff and volunteers attempts to balance gender in a female dominated space [12, 14, 26, 39, 46, 47]. This strategy seems to normalise the presence of men in the ANC setting [39] and the longer the male staff/volunteers are involved, the more acceptable MI seems to become for the community [26]. This normalisation is further reinforced as men continue to attend the clinic [20, 66].

In relation to CMO2, men in low and middle-income countries respond to being invited into ANC and are more willing to participate in CVCT and PMTCT as a part of ANC when the space is more ‘male friendly’.

CMO3—The health literacy of a couple and their community influences how likely they are to participate in PMTCT programs.

General awareness and knowledge of PMTCT increases how likely an individual is to willingly participate in PMTCT strategies including CVCT. It was clear from the evidence that health literacy around HIV and PMTCT was generally low [12–15, 17, 18, 21, 25, 41, 42, 49, 54], which acted as a barrier to men participating in ANC and PMTCT programs.

Men’s incorrect beliefs around contraceptive and condom use [13, 14, 41] and particularly beliefs around the pregnant woman’s HIV status automatically being the same as her husbands [12, 13, 15, 17, 21, 25, 41], fed the belief that the male partner did not need to attend ANC or participate in PMTCT strategies. Men were less likely to have received any targeted education about HIV or prevention strategies and were subsequently more likely to hold these incorrect beliefs compared to women [25, 42]. Comparatively, men who had participated in ANC previously or had previous experience with HIV testing or treatment had greater understanding of the process and its importance and were as a result more willing to participate in PMTCT programs again [17, 20, 49, 52, 54, 56, 58, 59, 61, 63, 64].

“The findings … show that expectant fathers need and want more information so that they can better protect the health of their partners and babies during and after pregnancy, and that they are willing to attend antenatal care when invited” [45] pg 307

An individual’s level of general education was also an indicator of how willing they were to participate in ANC and PMTCT programs. Higher levels of education of the male or female partner was associated with higher levels of participation in PMTCT [12, 16, 24, 49, 51, 52, 57, 58]. Being young and living in urbanised areas were factors associated with receiving higher levels of education, and subsequently having a greater awareness and appreciation of why PMTCT programs were important [22].

“The problem is that there are many men … especially in rural areas who have no formal education. Such men do not always understand the risks involved in getting pregnant and giving birth” (Male Participant, FGD) [22] pg 10

As well as increasing an individual’s knowledge of PMTCT being important, when thinking about male partners it is also important to consider how that knowledge can be increased. For male partners, strategies to increase health literacy around PMTCT that were led by men were particularly successful. These included male community leaders publicly advocating for PMTCT [21, 23, 28, 48, 49], and male employees and volunteers in the ANC clinic acting as educators and peer supports [21, 22, 26, 46]. Men also suggested that they would appreciate hearing from other men who had experience with HIV as role models [43].

Evidence for CMO3 suggest that having greater health literacy around HIV and PMTCT strategies and, for men in particular, having respected sources to learn from, increases an individual’s willingness to participate in PMTCT programs.