Gendered health institutions: examining the organization of health services and men’s use of HIV testing in Malawi

Kathryn Dovel, Shari L Dworkin, Morna Cornell, Thomas J. Coates, and Sara Yeatman

Introduction

Men in sub‐Saharan Africa are less likely to use HIV testing services than their female counterparts. Norms of masculinity are frequently cited as the main barrier to men’s use of HIV testing services, but very little is known about how health institutions are organized to facilitate or impede men’s care. We examined the organization of health institutions in Malawi, and implications for men’s use of HIV testing services.

Methods

A mixed methods ethnography was conducted in Malawi between October 2013 and September 2014. National Ministry of Health guidelines from 2012 to 2014 were analysed, counting the frequency of recommended preventative services by sex. In‐depth interviews were conducted with 18 healthcare workers and 11 national key informants (29 total). Five rural health facilities participated in direct observation and 52 observational journals were completed to document the structure and implementation of HIV services within local facilities. All data were analysed using the theory of gendered organization. Findings were grouped into one of the three theoretical levels of organization: (1) organizational policy; (2) organizational practice; and (3) structure of gendered expectations.

Results

Health institutions were gendered across three levels. Organizational policy : National guidelines omitted young and adult men’s health during reproductive years (176‐433 recommended visits for women vs. 32 visits for men). Health education strategies focused on reproductive and child health services, with little education strategies targeting men. Organizational practice : HIV testing was primarily offered during reproductive and child health services and located near female‐focused departments within health facilities. As these departments were women’s spaces, others could easily tell that men were using HIV services. Structure of gendered expectations : Clients who successfully accessed HIV testing services were perceived as exemplifying characteristics that were traditionally considered feminine: compliance (obeying instructions without explanation); deference (respecting providers regardless of provider behaviour); and patience (“waiting like a woman”).

Conclusions

Health institutions in Malawi were organized in ways that created substantial, multilevel barriers to men’s HIV testing and reinforced perceptions of absent, difficult men. Future research should prioritize a gendered organization framework to understand and address the complex realities of men’s constrained access to HIV services.

July 13, 2020
Year of publication
2020
Resource types
Journal and research articles
Countries
Tags
Gendered health institutions, HIV testing

Similar Resources

Sub-Saharan Africa bears more than two-thirds of the worldwide burden of HIV; however, data among transgender women from the region are sparse. Transgender women across the world face significant vulnerability to HIV.

This issue of the Southern African HIV Clinicians Society's "HIV Nursing Matters" online magazine focuses on vulnerable populations, including TB in prisons and intimate partner violence in the context of HIV.

This issue of the Southern African HIV Clinicians Society's "HIV Nursing Matters" online magazine focuses on key populations.

This article is featured in the SHARE Research Digest. Click here to learn more.

This article is featured in the SHARE Research Digest. Click here to learn more.

DREAMS is an ambitious $385 million partnership to reduce HIV infections among adolescent girls and young women in 10 sub-Saharan African countries. The goal of DREAMS is to help girls develop into Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe women.

In late 2015, the Linkages Across the Continuum of HIV Services for Key Populations (LINKAGES) project established a global acceleration initiative to fast-track and strengthen delivery of a comprehensive package of health services for key populations (KPs) at scale. In this context, “…

Gender-based power imbalances place women at significant risk for sexual violence, however, little research has examined this association among women living with HIV/AIDS.

A new study of the impact of cytotoxic T lymphocyte (CTL) escape mutations suggests that holes in the host immune repertoire contribute to poor disease outcomes, owing to a gradual deterioration of the host anti-HIV-1 immune response.

Gay, bisexual, and other men who have sex with men (MSM) continue to have disproportionately high burdens of HIV infection in countries of low, middle, and high income in 2016.