Introduction

Major gender gaps exist in the uptake of HIV services despite increased service availability across South Africa. Uptake of HIV testing and treatment remains lower amongst males compared to females, resulting in poorer clinical outcomes, and presenting a significant barrier to achieving the UNAIDS 95-95-95 targets [1]. Achieving these targets calls for inclusive people-centered approaches towards the HIV response. Engaging men as agents of change is a critical component of HIV prevention and care [2, 3].

Several factors contribute to lower uptake of HIV testing, prevention, and treatment services among men, including stigma, confidentiality concerns, inconvenient clinic operating hours, fear of an HIV-positive test result, and long-waiting times [4–6]. Moreover, women have more regular contact with formal health services than men do, either for their own health (for example for contraception or antenatal services) or for their children [7]. This increases their likelihood of accessing other HIV services compared to men who have less regular contact. Novel approaches and strategies are needed to increase men’s routine utilization of health services. Maternal, neonatal and child health services (MNCH) present an opportunity to improve male engagement with routine health services and subsequent uptake of integrated HIV care.

Men play a crucial role in MNCH as their influence on decision making and provision of material support can impact their partner’s health care seeking behavior and access to services [8, 9]. In the context of HIV/AIDS, evidence indicates that male partners influence their partners’ utilization of HIV prevention services and adherence to antiretroviral treatment [10–13]. Men’s involvement in MNCH services is not only beneficial for men’s partners and children but is also beneficial to their own health. Through MNCH services, men can access HIV services and other male-related services. In addition, MNCH services are strategically positioned to affirm responsible roles men can play in their families and help them realize how self-care can positively influence their role as fathers [14, 15].

Fatherhood is an important phase in a man’s life and is often central to their identity. In most societies, fatherhood remains a valued social role [16]. Fatherhood has been found to have a positive impact on men’s sense of responsibility, self-worth, mental/emotional health, and confidence [17]. Research studies with fathers in various settings revealed that fatherhood brings significant changes to men’s lives, men reported making multiple lifestyle changes when they became fathers: new priorities, a change in masculinity, reorientation of time, increased responsibility, a shift in values, altered sense of purpose, increased problem solving abilities, and improved emotional regulation [18, 19]. Fathers also reported becoming more mature, confident, secure, and empathic [18]. Paternal commitments have also been linked to improved men’s health and religious participation [20]. Research indicates that men strongly desire to be involved in their children’s lives and are unhappy when they are marginally or not involved [21]. MNCH is therefore a strategic option to harness men’s desire to be involved in their children’s lives through active involvement in MNCH services.

Considerable efforts have been made to involve men in MNCH services, however the focus has mainly been on how their involvement can improve MNCH outcomes [11, 22–25]. Extensive research has been conducted on barriers and facilitators to men’s involvement in MNCH services, and efforts have been made to address some of the barriers, however, men’s involvement in MNCH services remains low [26]. New approaches and perspectives of increasing men’s involvement in MNCH services are therefore needed. The links between male engagement in MNCH and its benefits to their own health and well-being are not well documented. In addition, the positive role that fatherhood can play in improving men’s engagement in MNCH services is not well explored. Leveraging on men’s roles as fathers, and their interest in building healthy families, may have the potential to motivate them to utilize MNCH and, subsequently, HIV services and this needs to be further researched as a possible approach to close the HIV gender gap.

This study explored the concept of fatherhood and how fatherhood and other factors influence men’s involvement in MNCH services, with the aim of contributing to the design of programmes to encourage male involvement in both MNCH and HIV services.

Methods

Results

Demographic characteristics of participants

Table 1 summarizes the demographic characteristics of the participants.

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Table 1. Profile of the participants.

https://doi.org/10.1371/journal.pone.0296955.t001

The ages of the participants ranged from 25–74 years. The majority of participants (12) were in the age group of 35–44 years. The majority of participants (22) were employed while nine (9) of the participants were unemployed. All the participants identified as Black African. Twelve (12) of the participants reported that they had 1–2 biological children, another 12 participants reported that they had 2–4 biological children and only one participant reported not having biological children. The majority of participants (16) reported having non-biological children. All participants (31) considered themselves to be involved fathers. The majority of participants (24) reported residing with their children. Participants were of mixed ethnic backgrounds, including Zulu, Xhosa, Sepedi, Venda and Tsonga.

Discussion

Our study has shown that men value the fatherhood role, with it being a central component of their identity. All participants appreciated their role as fathers and expressed a strong desire to be involved in their children’s lives. Participants also narrated the concerted efforts they were making to be involved fathers. MNCH services can seize the opportunity of men’s desire to be involved fathers, and harness that to increase service utilization, and affirm that taking care of their own health would allow them to provide and care for their children. MNCH services are well positioned to build on men’s roles as fathers, develop their capacity as fathers, provide knowledge, skills, and confidence to be more involved with their children. However, the challenge is that the HCWs offering these services lack the skills to do so. Although men are already involved in different ways in MNCH, the involvement is mostly “facilitative”, for example, escorting their partners to the health facility and providing financial resources for transport costs and any medical expenses. MNCH services need to enable men to move beyond the “facilitative” role towards active involvement.

Existing literature indicates that fear of HIV testing is a primary barrier to men’s utilization of HIV services [5, 28, 29]. Moreover, men may be afraid to test with their partners due to fear that a positive HIV test could expose hidden infidelity, be blamed for being responsible for bringing HIV into the relationship, resulting in marital or relationship tension. Although men in our FGDs did not mention fear of HIV testing as a barrier to involvement in MNCH services, anecdotally, women participating in our MNCH programmes highlighted that their partners were reluctant to accompany them to MNCH due to fear of HIV testing. Even though MNCH services are a strategic entry point for HIV services for men, the efforts to get men involved in these services should be thoughtful not to be identified and perceived by men as a strategy to lure them for HIV testing and linkage to HIV services. Such perceptions can adversely impact on men’s utilization of MNCH services. HCWs should therefore be sensitive to this when providing services. HCWs should rather focus on creating rapport and educating men on the benefits of self-care on fatherhood and manhood. The rapport and awareness would ease men’s fears and encourage them to test for HIV and utilize integrated HIV services as they build up trust in the health services they are accessing. This is also applicable to HIV services; careful messaging is needed for men to understand the personal benefits of utilizing the services. It is important to help men realize that their involvement in HIV services allows them to regain their health, restore masculinity compromised by HIV, and provide for their families, particularly their children. These are key elements to men and can therefore be powerful motivators for engagement in care [6].

Barriers and facilitators to men’s involvement in MNCH services need to be considered in the adaptation of services, and implementation of interventions to increase male engagement. Our findings show that men’s involvement in MNCH is affected by socio-economic and healthcare system related factors which should be considered to create a more inclusive health services environment. Male engagement in economic activities to fulfill their role as family providers seem to be in tension with their desire to participate in MNCH services and family life in general. The findings indicate that employment schedules often infringe on family life, hindering men from being involved in MNCH services. The findings reveal the central role that work plays in men’s identity and how it occupies much of their time. Timing and scheduling of services would, therefore, be critical to improving men’s involvement in MNCH services and health services in general.

The findings clearly show that men’s utilization of MNCH services is greatly influenced by socio-cultural norms. Socially constructed gender roles limit men’s participation in MNCH services. The study findings are consistent with previous research studies which have highlighted that gender stereotyping of MNCH as women’s primary activity discourage men from being involved MNCH services [11–13, 30]. In addition, MNCH services are predominantly occupied by females (female health workers and clients) making men feel alienated. Historically, MNCH services have been directed primarily at women which could have reinforced the perception of the services as women affairs. Engaging communities and HCWs should be considered to transform cultural norms that discourage men from accessing MNCH services. Working with community structures such as men forums and churches is crucial to transforming ingrained cultural norms which hinder men’s involvement in MNCH services.

Participants noted that one of the key facilitators to involve men in MNCH services is increasing the visibility of male HCWs. It should be noted that the organizational structure of the healthcare system reflects gender imbalances in the healthcare professions. Men remain underrepresented in the nursing profession, a structural challenge which is unlikely to change soon. This is because healthcare professions like many other professions reflect prevailing societal power and social relations. In most societies, nursing is still considered to be a female career because of gender stereotyping norms which consider caregiving to be a role for women. Even though socio-cultural norms are dynamic, it might take some time to witness a significant increase of men joining the nursing profession. Given this structural deficiency of the healthcare system, innovative approaches should be used to improve the visibility of male HCWs in MNCH services. This could involve enlisting male clinicians and non-clinicians (general support staff and peer supporters) to support MNCH services, for example through facilitating health talks during the waiting time for services and becoming male champions for MNCH services. The role of mentor fathers would also be useful in this regard. Mentor fathers would play a similar role as mentor mothers, a cadre enrolled in PMTCT programmes to provide psychosocial and other support to pregnant and post-partum women living with HIV. Mentor mothers have been found to enhance maternal-infant outcomes [31].

HCWs’ conduct and attitudes towards patients play a central role in patients’ utilization of services. A growing body of literature has shown the impact of staff attitudes on patient service satisfaction and utilization of services [32–35]. Negative staff attitudes are contrary to the ideals and ethical code of the health profession. Negative attitudes of HCWs in South Africa have been widely reported [35, 36], making it an area of concern requiring urgent redress to improve patient care and restore patient trust in the healthcare system. It is important to note that negative staff attitudes are due to multiple factors, including burnout, inadequate staff training, conformity to socio-cultural norms, work overload, lack of resources and lack of management support. These factors need to be considered when developing interventions to increase male involvement in MNCH services. Engaging HCWs is important to shift their attitudes around gender norms.

Our findings indicate that men are less likely to use health services when services lack privacy, are offered at inconvenient hours, and involve long waiting times. Enlisting men’s involvement in MNCH services requires creating male-friendly and targeted interventions in terms of convenience, privacy, and positive patient–provider interactions. Our findings indicate failure of the health care system to adapt services to suit men’s needs. Consequently, failure of the healthcare system to adapt accordingly has an impact on utilization of services and health outcomes. In broader terms, the rigidity and lack of responsiveness of healthcare systems to address male health needs has significant public health cost. In the absence of adaptation of HIV services to encourage men’s uptake of the services, men will remain missing in the continuum. Consciously considering the needs and preferences of men has the potential to improve men’s attitudes towards MNCH services. To improve accessibility of services, healthcare services should consider the needs and preferences of all their service users in line with a person-centered approach. Such considerations are likely to benefit men as well as other groups who face access challenges.

It was evident from the discussions that participants were unhappy with the current structure of services and how they were offered. Re-orientation of services towards a family-centered approach is likely to provide a favorable environment for men, encouraging them to attend MNCH services. The restructuring towards a family-centered approach might require allocation of additional resources to create more “family friendly” MNCH spaces. Making waiting areas and consultation rooms comfortable for families will require investments in resources, for example, additional spaces, provision of appropriate information, education, and communication materials. However, simple steps such as shifting the language used in MNCH spaces and by HCWs towards family-based language could have a positive impact on service utilization by men. Other initiatives include training of health workers on the delivery and promotion of family-centered services.

Recommendations

More work remains to be done to improve men’s engagement with MNCH and HIV services. Further efforts in both research and practice should focus on other strategies which can be used to motivate male engagement in MNCH and HIV services. Possible strategies which can be explored further include a) use of mobile applications; b) issuing a patient card to men who are expecting and/or with children attending Expanded Programme on Immunization (EPI) services; and c) collaboration with community men’s forums. The patient card would serve as official documentation men could use to request time-off in their workplaces and a reminder of the appointment dates when they were expected at the health facility. Partnerships with existing community forums such as churches and other social and cultural organizations provide sustainable opportunities which are not costly. Interactive multimedia mobile applications are widely used, convenient and not bound in time and space making them a powerful tool to engage men in MNCH services. Family-centered approaches and principles provide exciting new directions to pursue in rethinking service delivery and have the potential to increase men’s involvement in MNCH and HIV services. Implementation science approaches should be applied to understand how these interventions can be operationalized and, where they have been implemented, assess their effectiveness in improving men’s engagement with MNCH services and subsequent uptake of HIV services.

Limitations

The transferability of the study findings may be limited to men who are not interacting with health or community services. However, the findings offer valuable insights for strengthening MNCH services and integration with HIV services. The small number of FGDs conducted and limitations of the sampling approach may influence perspectives on fatherhood and engagement in MNCH services.

Conclusions

Our study highlights that poor service utilization and male engagement remain persistent challenges in HIV programmes, resulting in poor outcomes for men and making it difficult to achieve the 95-95-95 targets. Male engagement in MNCH could become an important strategic entry point for promoting men’s health and effectively reaching men with integrated HIV services. Men in South Africa are willing to be involved in MNCH services but there is a need to address the barriers which hinder their involvement. In addition, men strongly desire to be involved fathers and the healthcare system should harness this desire through active engagement of men in MNCH services. In broader terms, increasing men’s utilization of health services will require the healthcare system to be more responsive to men’s needs and to adapt and/or design services to meet those needs and rebuild men’s trust in the healthcare services on offer.

Supporting information

Acknowledgments

We thank all the participants who participated in this research.