Male involvement/participation factors
In our review we identified three categories of factors associated with male involvement/participation (MIP):
1) Socio-demographic factors
A. Age and marital status: Most studies reported that older age and cohabiting were associated with male involvement [8, 10–13, 42–44]. Our group conducted a study in Kinshasa and found male involvement was 1.2 times higher among men whose female partners were 25 years or older. Monogamous partners and co-habiting men were twice and 1.6 times respectively more likely to be involved . In contrast, Nkuoh et al. reported that Cameroonian men in polygamous relationships showed higher involvement .
B. Education: A study in Uganda found that men who had completed 8 or more years of education were twice more often involved compared with those with less than 8 years of education (OR =1.9; 95% CI: 1.1-3.3; p≤ 0.05) . This was not confirmed in our study in Kinshasa where the level of education of pregnant women or their male partner did not influence male participation .
C. Profession: In Uganda, taxi drivers and “Bodaboda” riders (motorbike taxi riders) were less likely to participate than men with other professions such as farmers or construction workers (OR =0.3; 95% CI: 0.1-0.9; p≤ 0.05) . Other authors have corroborated these findings. Reece et al. reported that Kenyan men having only an occasionally job were less likely to participate in MCH services . Another study from Rwanda reported that men with a well-paid job were more likely to participate in PMTCT interventions compared to those not well paid .
2) Health service- related factors
A. Harsh, critical behavior and language use: Byamugisha et al. reported that harsh, critical language directed at Ugandan women from skilled health professionals was a barrier to male participation . Harsh treatment of men by health providers discouraged them from returning or participating in PMTCT activities . Furthermore, some providers did not allow men access to ANC settings .
B. Financial constraints: Financial constraints of clients and health facilities have been identified as impacting health services uptake and male participation [3, 12–14, 46, 47]. A Ugandan study reported that some health providers charged extra beyond the official ANC fees to bridge their own financial gaps  while other authors have identified low health providers’ salaries as limiting factors for male involvement [47, 48].
C. Venue and space constraints: In our study in the DRC, men were invited for voluntary counseling and testing (VCT) in three venues: a bar, a health center or a church. Male involvement in VCT was higher in the bar (26, 4%, p < 0,001) and church (20,8%, p = 0,163) compared with the health center (18,2%) . These results suggest that more friendly and convenient venues for men are needed . The lack of space to accommodate male partners in ANC clinics was also reported to adversely impact male involvement . Clinics are often unable to concurrently accommodate pregnant women and their partners because of a lack of space. Gender specific services to address uniquely male issues do not exist. Targeted interventions for men, such as tailored messages, specific health education sessions, and innovative strategies to identify male friendly venues would be valuable for increasing male involvement .
D. Waiting time: Frequently women have to wait for a long time before receiving ANC services because of burdensome administrative procedures which result in poor patient/client through-put in health facilities. Men, who frequently are in the paid workforce, are often not in a position to spend virtually the entire day participating in ANC services .
E. Quality of care: In a study in Rwanda it was shown that essential PMTCT services were often not proposed by health providers thus contributing to the weak PMTCT ARV prophylaxis uptake among clients . Health services providers are often overworked, stressed, and have to work in an infrastructure with severely limited resources. In such context, the quality of services is compromised and taking care of participating male partners is considered an additional burden [47, 48].
F. Time of day for providing PMTCT services: Increased male participation in VCT and couple testing occurred in Kinshasa when the MCH services are open in the evenings between 5:00 – 8:00 pm and at weekends . Most health facilities offer these services only on weekday mornings, when the majority of men are at work. Yet several studies have identified ANC opening hours as a limiting factor for male involvement [13, 14, 48]. Permanent PMTCT services would facilitate the services’ uptake even for men with difficult work schedules [10, 12]. Geographical constraints impact health services uptake and male participation [3;9;12–14;47]. Lack of decentralized services is a reason for low health services uptake and limited male involvement . A qualitative study conducted in western Kenya by Reece et al. found that the distance that the male partners have to travel to the clinics for participating in the education, HIV tests and counseling, the costs of the transport to the clinics and the amount of time per appointment at the clinic were identified as barriers to male involvement . Data from another study from Uganda showed that majority of participants said that the health facilities were few and located far from the people, making the health services such as HIV testing and counseling inaccessible . Most of the male partners and men in general wanted the health services to be implemented and extended to their villages or close to their homes in order to save them the costs of time and travel fee .
3) Sociologic factors
A. Cultural: In several studies cultural standards were identified as barriers for male involvement [11–14]. Several studies have reported negative perceptions towards men attending ANC services. In one report, men who accompanied their wives to ANC services were perceived as being dominated by their wives. Frequently men perceive that ANCs services are designed and reserved for women, thus are embarrassed to find themselves in such “female” places [11, 26, 27]. Certain women too, do not like to be seen with their male partner attending the ANC service [12, 26]. A study conducted in Kenya showed that certain male clients trust traditional healers but not hospitals and therefore do not attend ANC clinics .
B. Male attitudes and beliefs: Fear of receiving an HIV positive result and confidentiality concerns prevent some men from coming for VCT. In many studies men were mentioned being concerned about HIV-associated stigma and disclosure [12, 49, 50]. Men may be afraid of HIV status disclosure in a health system facility, in the context of weak health system .
C. Female attitudes and considerations: Several studies showed that women at ANC clinics fear violence from their partners who attend ANC clinics with them. These women fear that discovery of a positive HIV test result may lead to abandonment, rejection or being perceived by their husband as being responsible for bringing HIV into the couples’ relationship [18, 39–41, 44, 52]. Gender-based violence is another cause of low male involvement [18, 42, 49, 53, 54]. Victims of gender-based violence may be afraid to ask their partner to be tested for HIV. Reinforcement of women’s’ power for negotiation would be a major asset [14, 55]. Msuya reported from the study conducted in Tanzania that male partners of women with higher income were more likely to participate in HIV testing and counseling. Also, women with higher education were more likely to have discussed HIV and reproductive health issues with their male partners (94.3% versus 88.3%; p<0.001) . Alcohol use was identified as another factor for non-participation of men [27, 44–54]. Daily overconsumption of alcohol by male partners maybe particularly implicated as a catalytic event for physical violence towards women. In similar regard, Karamagi reported alcohol as one of reasons for 54% of lifetime partner’s violence and 14% of physical violence in Uganda . Ntanganira found the 35.1% of intimate violence in the last year; physical violence was twice likely to occur if a woman was HIV positive than negative .
D. Communication: Poor communication between men and their female partners was associated with poor male involvement. On the other hand, good couple communication was associated with high HIV status disclosure and support between husband and wife .