Health care workers’ internal bias toward men as HIV clients in Malawi and Mozambique: A qualitative study

Abstract

Background: Men are underrepresented in HIV services throughout sub-Saharan Africa. Little is known about health care worker (HCW) perceptions of men as clients, which may directly affect the quality of care provided, and HCWs’ buy-in for male-specific interventions. Methods: Focus group discussions (FGDs) were conducted in 2016 with HCWs from 15 facilities across Malawi and Mozambique, and were originally conducted to evaluate barriers to universal treatment (not gender or internal bias). FGDs were conducted in local languages, recorded, translated to English, and transcribed. For this study, we focused on HCW perceptions of men as HIV clients, using inductive and deductive coding in Atlas.ti v.8, and analyzed codes using constant comparison methods. Findings: 20 FGDs with 154 HCWs working in HIV treatment clinics were included. Median age was 30 years, 59% were female, and 43% were providers versus support staff. HCWs held strong implicit bias against men as clients. Most HCWs believed men could easily navigate HIV services due to their elevated position within society, regardless of facility-level barriers faced. Men were described in pejorative terms as ill-informed and difficult clients who were absent from health systems. Men were largely seen as “bad clients” due to assumptions about men’s ‘selfish’ and ‘prideful’ nature, resulting in little HCW sympathy for men’s poor use of care. Interpretation: Our study highlights a strong implicit bias against men as HIV clients, even when gender and implicit bias were not the focus of data collection. As a result, HCWs may have little motivation to implement male-specific interventions or improve provider-patient interactions with men. Framing men as problematic places undue responsibility on individual men while minimizing institutional barriers that uniquely affect them. Implicit bias in local, national, and global discourses about men must be immediately addressed.

Implementing a male‐specific ART counselling curriculum: a quality assessment with healthcare workers in Malawi

“…Methods for developing and piloting the male‐centred counselling curriculum are described in detail elsewhere [ 47 ]. Briefly, we adapted the Malawi Ministry of Health (MoH) standard HIV Testing and Counselling curriculum to include key topics identified as important to men in Malawi, based on prior literature and formative qualitative research with men and HCWs [ 10 , 43 , 48 , 49 , 50 , 51 , 52 ]. The curriculum aligned with person‐centred counselling and motivational interviewing principles [ 53 , 54 ], whereby counselling was meant to facilitate identifying how treatment can contribute to men's priorities/goals, identifying challenges to treatment success and developing tailored strategies to overcome challenges, in order to facilitate highly interactive counselling sessions tailored to clients’ individual needs [ 21 ].…”

“…There may be additional barriers to person‐centred counselling for men specifically. HCWs have perceived men as difficult and stubborn clients responsible for their own experiences of treatment interruption [ 42 , 43 ] which can limit HCW buy‐in to tailored interventions and may negatively impact the provision of high‐quality, person‐centred counselling for male clients. Reciprocal poor experiences between men and HCWs [ 44 ] mean there is a lack of established patient‐provider communication for men that may otherwise help to improve experiences of HIV services.…”

Interventions to improve men’s engagement in HIV and other key services in sub-Saharan Africa: a scoping review

“…[107][108][109] HCWs often describe men as "difficult", "too powerful" and simply unable to be "good clients." 107 Misconceptions and implicit bias stem from a lack of understanding, experience, and professional skills/tools to engage a client population well. This can change.…”

“…Emerging evidence shows that equitable, positive, and trusting HCW interactions are critical to men's continued use of services, as well as men's satisfaction with services. 100,103,104 Recent studies suggest that positive interactions with peer HCWs and HIV messaging that resonates with men's priorities can lead to positive ART retention outcomes 105,106 and should be explored for other health services. Further research is needed to understand how to best support positive interactions with HCWs and equip HCWs to interact with men well.…”

“…Across the region, HCWs report implicit bias toward men as clients, misunderstand men and are unsure how to engage men well. [107][108][109] HCWs often describe men as "difficult", "too powerful" and simply unable to be "good clients." 107 Misconceptions and implicit bias stem from a lack of understanding, experience, and professional skills/tools to engage a client population well.…”