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Sexual and reproductive health (SRH) services are rarely designed specifically to meet men’s needs. There is a general consensus among clinicians that males need access to SRH services. Studies have reported that men are often hesitant to go to health facilities because they feel uncomfortable being served by female providers. The study sought to determine whether men who participate in SRH services have specific preference for the gender of health workers for consultation on different types of services. A mixed-method design was employed. A combination of stratified proportional sampling of facilities and criterion purposive sampling of participants were used. Questionnaires were used to collect data from 390 participants, which were complemented with 10 in-depth interviews. Chi-square analysis with post hoc comparisons were used to determine whether there were significant differences in gender preference for specific services. Based on the data, Batswana males did not have any gender preference of the health provider for consultation on SRH services. The gender of the provider is of minor importance compared with other characteristics such as competence and confidentiality. However, the gender of the provider seems to be more important to younger men for delivery, sexually transmitted infections, voluntary counselling, and testing services. Further research is needed because the study was conducted in the city and the participants’ characteristics may be unique to an urban setting. Preferences for providers among demographic groups can be useful in informing resource prioritization and help direct program efforts to reach different subgroups of males.
The International Conference on Population and Development of 1994 called on organizations that historically provided reproductive health services to women to engage the male sector of the population in sexual and reproductive health (SRH) services (Kalmuss & Tatum, 2007; United Nations Fund for Population Activities, 1994). Since the International Conference on Population and Development, reproductive health programs are seeking better ways to understand men, to communicate with them, engage them in SRH activities, and to help them better take care of themselves and their partners (Jamu & Schaan, 2005; Peacock, 2003; Salem, 2004; Sonfield, 2004).
SRH services are rarely designed specifically to meet men’s needs. However, there is a general consensus among clinicians and SRH program managers that males need access to SRH services (Char, Saavala, & Kulmala, 2011; Koster, Kemp, & Offei, 2001). Some studies reported that men, particularly younger ones, are often hesitant to go to health facilities because they feel uncomfortable being served by multiple providers, especially females (Hulton, Cullen, & Khalokho, 2000; Johnson, Schnatz, Kelsey, & Ohannesian, 2005; Koster et al., 2001). Health workers may be trained to treat both men and women, but it is not known if all men feel comfortable being served by female providers. Training of health workers in reproductive health cannot be one size fits all (Schimid, Hall, & Roter, 2007). Providers should obtain specific training on female and male sexual issues and should be aware that the gender of the provider may alter clients’ expectations (Lindberg, Lewis-Spruill, & Crownover, 2006).
Women’s preference for gender of health providers has widely been documented, but there is limited comparable data regarding men’s preference of the gender of health workers, especially on consultation of SRH services. Most studies identified that patients generally do not have gender preference, but some do have gender preferences with percentages that vary from study to study (Johnson et al., 2005). For example, Adudu and Adudu (2007) observed that 53% of Nigerian patients cared about gender of the attending doctor with 42% of them preferring male doctors and 11% preferring females. The remaining 47% had no gender bias because they were satisfied that both male and female doctors possessed similar professional knowledge and were equally competent. Howell, Gardiner, and Concato (2002) reported that 34% of respondents had preference for female obstetricians, 7% male obstetricians, and 58% had no preference. The limited studies on men’s preference have concentrated on gender preference for specific male health services. None of these studies have investigated gender preference for SRH services received by men and their partners.
The purpose of the current study was to determine men’s gender preference for consultation on SRH services they and their partners receive, namely pregnancy (antenatal care), family planning (FP), delivery (childbirth), child care, infertility, sexually transmitted infections (STIs), cancers of the male and female reproductive systems, prevention of mother to child transmission (PMTCT), and voluntary counselling and testing (VCT). The author hypothesized that there is a significant difference in the preference for gender of SRH provider for consultation on different types of SRH services by age, marital status, educational level, presence of children, number of children, and residence with them. The subhypotheses were the following:
Some studies reported that just like women, men in general have a preference for a provider of their own gender (Umar, Mandalazi, Jere, & Muula, 2013). Researchers reported inconsistent results, particularly, when males are seeking help for intimate health services (Adudu & Adudu, 2007). An American study on preference for gender of health provider in the management of erectile dysfunction reported that 57% of men indicated no gender preference of the provider because they believed there is no difference between male and female providers (Carrejo, Balla, &Tan, 2007). Among those who had preferences, 75% preferred males because they believed that male health care providers are better trained to manage erectile dysfunction than females. The authors reported that although routine male genital examinations are much less intrusive than women’s examinations, between 30% and 50% of men preferred males for urological examinations. A Malawian study reported that male participants experienced discomfort and embarrassment when attended by a female clinician during male circumcision (Umar et al., 2013). Umar et al. (2013) reported that embarrassment was not only experienced by circumcised men but also by the attending female health worker.
Other studies reported varying results with no preference for gender of the provider but preference for other characteristics. For example, a study involving adolescents aged 10 to 19 years from Kenya and Zimbabwe reported that confidentiality and friendly staff were rated as the most important factors when seeking services than the gender of the provider (Biddlecom, Munthali, Singh, & Woog, 2007). Other variables include the age of the patient with a majority of young women preferring same gender care in higher numbers than older women who have generally become accustomed to being cared for by males (Noula, Leontzini, Anastasiadis, & Ifanti, 2010). Reasons for gender preference of health providers vary across nations. In developed countries, preference is based on attributes such as technical expertise, communication style, and experience, while in developing countries, such as Nigeria, emphasis is more of cultural and socially related factors (Onyemocho et al., 2014).
The administration, delivery, and oversight of health services in Botswana is under the Ministry of Health (MoH). The MoH is also responsible for setting national policies and standards, planning, direction, and technical supervision of the entire health system. The responsibility of overseeing delivery of SRH services falls under the SRH Unit in the MoH, while delivery of services rests with hospitals, clinics, health posts, and mobile clinics (MoH, 2002). While Botswana has an impressive network of reproductive health services and facilities widely available throughout the country, male-oriented reproductive health programs are out-numbered by those serving females (United Nations Fund for Population Activities, 2007). In Botswana, SRH services are provided at primary care level mostly by female providers who out-number their male counterparts (MoH, 2009). This implies that men presenting at SRH clinics are most likely to be attended to by female providers.
In 2002, the Botswana Government shifted focus from Maternal Child Health and FP to SRH approach (MoH, 2002). The Maternal Child Health/FP initiative almost exclusively focused on women and children, taking little account of the social and cultural realities of women’s reproductive lives and their subordinate status in the decision-making process. There were limited efforts to involve males, which subsequently led to passive male participation in SRH services (Central Statistics Office, 1996, 2006; MoH, 2002). The SRH approach emphasizes male involvement in all components of SRH to increase their participation in SRH matters (MoH, 2004; United Nations Fund for Population Activities, 2007).
Previous studies on male involvement in SRH services in Botswana revealed limited data on male participation in SRH services compared with data on females (Mookodi, Maundeni, & Kapunda, 2007). Available literature revealed that males who are involved in SRH services have expressed concerns regarding the services they receive. For example, Moyo, Motlhanka, and Letamo (2007) reported that Batswana men expressed discomfort in discussing sexual issues with female providers. Nair and Rakgoasi (2009) reported that Batswana men’s involvement in SRH services is strongly influenced by traditional stereotypes and misconceptions about different roles of men and women in reproductive health. None of these studies have investigated gender preference of men who actually participate in SRH services. There appears to be a paucity of information documenting men’s preference for the gender of SRH providers in Botswana. The current study sought to determine whether men who participate in SRH services have specific preference for the gender of health workers for consultation on different types of SRH services, and whether the preferences may be a factor in influencing their participation in SRH services.
A mixed-method (quantitative and qualitative) design was selected for this study because the designs complemented each other (Andrew & Halcomb, 2009). While the quantitative data helped isolate and identify correlations between preference of gender of provider and the characteristics of male users, the qualitative aspect provided unique insights into understanding reasons for men’s preferences of gender for consultation on SRH services.
The study was conducted in Gaborone, the capital city of Botswana. According to the 2011 Botswana population census, Gaborone hosted 11% (231,592) of the total population, which is the second largest city in the country. Almost half (49%) of the population was male (Central Statistics Office, 2011). The population increases constantly as people migrate from rural areas to the city seeking better socioeconomic prospects. Gaborone was considered an appropriate environment for the study because it constitutes different groups with diverse educational, socioeconomic, and cultural backgrounds. It also has the largest population of males compared with other cities in Botswana and more SRH facilities where men accessing SRH services could be found.
Stratified proportional sampling was employed to select facilities. All the 15 public facilities in Gaborone were listed and stratified according to high, medium, and low case load based on the total number of SRH clients attending during 2012. Proportions of sample size per stratum and per facility were calculated based on SRH usage and a total sample size of 390 participants was divided proportionally among the 15 clinics. In Botswana, facilities do not keep a record of male clients who access or accompany their partners for SRH services, therefore there was no sampling frame. Criterion purposive sampling was used to select men of age 21 years and above who reported to have participated individually or with their partners in any of the SRH services.
Data were collected using a survey instrument specifically designed for this study. It was developed in both English and Setswana languages. Some questions were adapted from a national SRH study by Moyo et al. (2007). A pilot study was conducted in two SRH clinics which were not included in the main study. The pilot study was done to assess appropriateness and quality of the items in the instruments and to test the interview procedures. The survey was completed by 390 men with prior use of SRH services. Men with prior SRH use were selected because they were assumed to be more experienced about the SRH services and they engaged better than those with no experience of such services. The quantitative data were complemented with semistructured questions where each question ended with an open-ended probe to encourage participants to reflect on pertinent aspects influencing their responses. In addition, 10 in-depth interviews with men who had participated in three or more SRH services were conducted. Data were analyzed using the Statistical Package for the Social Sciences version 19 with level of significance set at <.05. Chi-square analysis was done to contrast proportions of men by their marital status, age, education, and number of children. Post hoc analyses were done to identify specific differences. Analysis of variance was done to assess the relation between men’s demographic characteristics and their level of SRH use. Interviews were analyzed through constant comparative method to determine emerging themes (Glasser & Strauss, 1967).
Ethical approval was obtained from the University of Botswana (Office of Research and Development Ethics Committee) and Health Research Unit in the MoH. Permission for the study was also granted by the heads of the different facilities. Written consent was obtained from participants following a detailed explanation of the purpose of the study and that their participation was voluntary. Participants’ initials were used instead of their real names for confidentiality purposes. For the in-depth interviews, participants were requested to consent to audiotaping of the discussion.
Participants were a community sample of 390 men with a mean age 35.0 and a standard deviation of 9.4. Thirty-eight percent (149) of respondents were aged between 21 and 30 years, 39% (151) between 31 and 40 years, and 23% (90) were 41 years and above. About 76% (297) of the respondents identified themselves as Christians. Regarding marital status, 34% (126) of them were in a relationship but not yet married, 25% (90) were married, and 22% (80) cohabited with partners. About 19% (71) were single and not in a relationship. A majority of respondents, 75% (291) had at least one child, with 85% (248) reporting having less than three children. About 33% (130) had secondary school education, followed by 20% (78) with university education up to PhD level. Diploma holders constituted 17% (67) followed by 12% (48) with primary education and 10% (37) with certificate. The smallest percentage (8%; 30) of respondents had never attended school. A majority of respondents (74%; 288) were employed (Table 1).
The findings demonstrated significant difference in the gender preference of health workers for delivery services with older men having no gender preference for delivery services as compared with younger men, χ2(1, N = 239) = 11.37, p < .05. There was an expressed preference for a female health provider by 39.9% (59) of younger men compared with 22.5% (20) of older men for delivery services, χ2(1, N = 237) = 6.80, p < .05. Forty-seven percent (17) of younger men expressed preference for a female provider and 39% (13) preferred a male provider on consultation for VCT services (Table 2). There was no statistically significant difference in gender preference of health worker by age for consultation on pregnancy, FP, child care, PMTCT, VCT, STIs, or female and male cancers of the reproductive system.
Semistructured and in-depth interviews revealed that participants did not have any specific gender preference and they pointed out that what matters is the health worker’s competence which they believed both male and female providers possess. Some men preferred female providers for delivery services because they (men) are not comfortable with a male midwife or doctor attending to their partner. For example, LE, a 29-year-old aptly captured this view in these words:
I prefer to be served by a woman because I would not like a man seeing me when I am at my weakest moment. I cannot imagine another man in the same room with my wife naked. It does not feel right.
A female provider was also preferred for VCT because females are considered patient, good listeners, and focus more on feelings than men. Females are also considered to have a motherly spirit and are considered more understanding of and experienced in female issues such as childbirth and care. MBS, a 56-year-old married man said:
Female nurses are gentler when handling women because they understand the pain other women go through when they give birth. They have a soft spot . . . I honestly feel that women have a natural thing to deal with these issues compared to men. Men just do quick quick and give you your card back.
When asked why they prefer male health workers, participants indicated that unlike their female counterparts men are able to keep information confidential. They also reported that they feel less embarrassed on exposure of the body during examination by male providers.
There was a statistically significant difference in gender preference of health workers for PMTCT services, χ2(6, N = 385) = 12.08, p < .05, and STI services, χ2(6, N = 385) = 12.54, p < .05 (Table 3). A higher proportion, 79.4% (100), of single men (in a relationship), χ2(1, N = 206) = 4.50, p < .05, than married men, χ2(1, N = 188) = 8.34, p < .05, did not have any gender preference for STI services. Though the majority of men did not have preference for any gender, this study also demonstrated that 11% (12) of married men and 22% (23) of single men (single in and not in a relationship) preferred male providers for STI services, χ2(1, N = 198) = 4.60, p < .05. There was no statistically significant difference by marital status in gender preference of health workers on consultation of pregnancy, FP, delivery, child care, VCT, or female and male cancers of reproductive systems.
When asked to elaborate on their preferences, some men indicated that they do not have a problem being attended to by female providers for other services except for intimate services such as screening and treatment of STIs. MF, a single 49-year-old man, summed up his position by saying, “I think same sex people can serve each other better because they understand each other. When you tell a person of an opposite sex what you are going through they may not understand what you mean.”
As illustrated in Table 4, there was a statistically significant difference in gender preference of health workers for delivery, χ2(2, N = 390) = 6.07, p < .05, and infertility services, χ2(2, N = 389) = 9.01, p < .05. Sixty-two percent (179) of men who had at least one child, 61.5% compared with those who did not have a child, 20.8% (47) did not have a preference of any gender of health worker for delivery services, χ2(1, N = 366) = 10.89, p < .05. Also, 29.6% (86) of men who had at least one child or more compared with those without a child preferred a female health worker for delivery services, χ2(1, N = 390) = 4.21, p < .05. A very small percentage, 12.8% (37), of men who have children compared with 24.2% (24) of those without a child preferred a female health worker, χ2(1, N = 389) = 6.52, p < .05, for infertility services. There was no statistically significant difference in gender preference of health workers by presence of children for consultation on pregnancy, FP, child care, PMTCT, VCT, STIs, or female and male cancers of the reproductive system.
Regarding residence with children (see Table 3), 72.3% (138) of men who were residing with their children compared with 62.2% (120) of those who were not residing with their children did not have any gender preference for consultation of female cancers, χ2(1, N = 389) = 3.98, p < .05. About 17.8% (34) of men who were residing with children compared with 31.6% (61) of those who were not residing with children preferred a female health worker for consultation of female cancers of the reproductive system, χ2(1, N = 384) = 9.10, p < .05. Differences in proportions in gender preference of health worker by number of children were also statistically significant for infertility services, χ2(4, N = 384) = 10.49, p < .05. Semistructured and in-depth interviews confirmed nonpreference of any gender of health workers by participants. This was illustrated in these words by MTG, a father of five:
For me, it does not really matter whether female or male. They are the same. When my wife was pregnant with our fourth child, the nurse here was a female nurse, she was good. With my last born it was a male nurse in the clinic. He was also very good. He delivered my wife and handled her with respect.
The results demonstrated a statistically significant difference in gender preference of health workers for infertility services χ2(6, N = 389) = 13.97, p < .05. More men, 89.6% (43), with primary education compared with 63.8% (83) of those with secondary education did not have any gender preference of a health worker for infertility services, χ2(1, N = 178) = 10.02, p < .05. There was no statistically significant difference in gender preference of health workers by education on consultation of pregnancy, FP, delivery, child care, PMTCT, VCT, STI, or cancers of the female and male reproductive systems. Data from semistructured and in-depth interviews also supported nonpreference of health workers by educational background. For example, 56-year-old BGS with primary school education said, “Both male and female health workers are the same. I only have a problem with those health workers who do not have respect for elders.” However, some men prefer being served by females because they (men) believe that female health workers are competent in providing specific SRH services such as delivery and child care services because of their experience in dealing with children and females have a motherly spirit and are naturally designed to care for children.
Overall, the hypothesis that there is a significant difference in the preference for gender of SRH provider for consultation on different types of SRH services by age, marital status, educational level, number of children, and residence with them was supported for delivery services by age, PMTCT and STI services by marital status, delivery and infertility services by presence of children, infertility by number of children and education, and female cancers by residence with children. However, the hypothesis was rejected for pregnancy, FP, and VCT services by any of the above demographic variables.
Since in public health facilities clients are not given the choice of selecting a provider, participants were asked if they ever consulted for specific or intimate male services such as screening and treatment of STIs and cancers of the male reproductive system in the past 24 months and if so, which gender of provider assisted them. Out of the 188 who answered “yes” to the question on STIs, 79% (148) were consulted by female providers and 21% by male providers. Out of the 78 who consulted for cancer screening and treatment, 45% (35) were consulted by male providers who were mostly doctors and 55% (43) by female providers. In an effort to understand how gender preference might or might not be strongly held, a follow-up question was asked on whether they would like to have a choice of provider and for which services? Interestingly, 52% of men indicated they would like to be given an opportunity to choose a provider of their own for treatment of STIs with the highest (27%) being younger men and 57% for screening of cancers of the male reproductive system.
To determine if participants’ demographic characteristics could be associated with men’s use of SRH services, analysis of variance was done. There was a statistically significant difference in the level of SRH use by men’s age, F(2, 38) = 8.99, p < .05 (Table 5). A post hoc comparison using Bonferroni test indicated that older men (M = 2.33, SD = 0.66) utilized SRH services more than younger men (M = 2.05, SD = 0.65), p < .05, t(292) = −3.945, p < .05. Middle-aged men (31-40 years; M = 2.33, SD = 0.55) reported higher level of use of SRH services than younger men (M = 2.05, SD = 0.65), p < .05, t(229) = −3.040, p < .05. Married men (M = 2.43, SD = 0.61) reported higher participation in SRH services than single men in a relationship (M = 2.40, SD = 0.59), t(229) = −4.35, p < .05. Men who had children (M = 2.37, SD = 0.67) reported higher use of SRH services than those who did not have children (M = 1.81, SD = 0.49), t(210.91) = −9.218, p < .05.
The purpose of the current study was to investigate preferences of men regarding the gender of SRH provider as well as factors related to these preferences. In the study, it was indicated that older, married, and more educated men with children did not have any preference of gender of the provider for SRH consultation of delivery, STI, and infertility services. The gender of the SRH provider seems to be of minor importance to older and married participants and they perceived access issues to be more important than gender of provider.
The findings may suggest that the expressed preference for both sexes is closely related to men’s previous experience of consulting health workers for services. Men may be more familiar with the process of screening and treatment of STIs and cancers of reproductive system and perhaps their previous engagement with SRH services was successful regardless of the gender of provider. The finding is consistent with the results of a study by Carrejo et al. (2007) and Johnson et al. (2005) who reported that for most men regardless of age, race, and ethnicity, the gender of the provider is not an issue. Similarly, Speizer and Bollen (2000) observed that important determinants of perceptions of quality among women and men include perceived travel time to the facility and availability of SRH services and not the gender of provider. Adudu and Adudu (2007) also noted that Nigerian patients viewed both male and female doctors as possessing the same professional knowledge and were equally competent. Consistent with the current study findings also are those observed among American adult females and males by Johnson et al. (2005) who reported that there was no gender preference of attending providers.
However, the study findings contradict those of a Malawian study by Umar et al. (2013) which revealed a strong preference for male providers for male circumcision. Findings of a similar study in Botswana by Moyo et al. (2007) reported that males were hesitant to go to health facilities because they felt uncomfortable discussing sexual issues with female providers and being attended to by multiple providers, especially females. The findings of this study could be different from Moyo’s because of methodological issues. Moyo et al. (2007) focused on the general population of men who did not necessarily have experience in using SRH services and might not have been used to being served by women for consultation on male sexual issues. The current study focused on males who have actually participated in SRH issues and are already used to being served by females. Men with experience of SRH services seem to be more comfortable working with female health workers.
Despite the nonpreference for gender of the provider on consultation for the majority of SRH services, the current study has demonstrated that the gender of the provider seems to be more important to younger men for specific services such as delivery and VCT services. It is possible that the sensitive nature of these services may make younger men follow some stereotypes in their preference of gender of provider. This is an important factor because this age group has the highest risk and the challenge would be that their discomfort with certain providers can influence their satisfaction level, compliance to services, health-seeking behavior, and consequently their health care outcomes. The implication is that services for younger men may need to be specifically designed for them to address their different concerns such as privacy and confidentiality.
Similar findings were observed in a study by Onyemocho et al. (2014) who reported that demographic characteristics such as age, marital status, religion, and ethnicity of Nigerian women had a significant relationship to the preference of gender for health providers. The results are also similar to those observed by Noula et al. (2010) who reported that the gender of the doctor is important to younger women who do not have children. An important observation in the current study is that younger men tend to use SRH services less than older men. The results could mean that gender preference may be a factor in influencing SRH utilization. Therefore, SRH program managers need to appropriately target services to different subgroups of males.
Regarding attributes of providers, some men expressed preference for female providers because they (female providers) were perceived to be gentle, patient, good listeners, devote more time to patients, and focus on their clients’ feelings than their male counterparts. Female providers are also considered more knowledgeable on issues such as childbirth and care because they are naturally born to provide such services. This finding is similar to that of a study by Carrejo et al. (2007) conducted among adult females who reported preference for female providers for services such as cervical cancer and breast examination because female providers were considered to be more experienced in dealing with these issues. Consistent with these findings are those of Adudu and Adudu (2007), Janssen and Lagro-Janssen (2012), and Onyemocho et al. (2014) who highlighted that females were preferred because of their better communication style.
Some men had preference for male providers particularly for consultation on STIs. The preference could be related to their feeling of discomfort from being examined by female health workers (Moyo et al., 2007). Reasons for preferences of male providers were also associated with the general belief that male health workers are less likely to divulge confidential information as opposed to their female counterparts. This implies that men would be less likely to share information or access services with female providers if they feel that what they disclose would not be treated confidentially. In their studies, Akarro, Deonisia, and Sichona (2011) and Noula et al. (2010) observed that men prefer male health providers because they tend not to divulge confidential information.
The current study used purposive sampling and therefore the results cannot be generalized to the general population of males. The study was conducted in the city and the participants had a set of characteristic that may be unique to an urban setting.
The data revealed that Batswana men do not have a gender preference of health provider for consultation of SRH services. The gender of providers is of minor importance compared with other characteristics. For those who have a preference, the gender of the provider is largely determined by the type of service and perceived qualities of the provider. For example, male providers are preferred for intimate services such as consultation of STIs or screening and treatment of cancers of the male reproductive system. Male providers are perceived to maintain confidentiality and men feel less embarrassed when examined by male providers. Female providers are preferred for delivery services because they are perceived to be gentle, good listeners, and are considered more knowledgeable on issues such as childbirth and care. Qualities such as patience and being good listeners are critical in assisting SRH providers to become better practitioners. Gender preferences among demographic groups can be useful in informing resource prioritization and helping direct program efforts to reach different subgroups of males. To address participants’ concern that female providers tend to divulge confidential information, health workers need to uphold confidentiality when dealing with clients. Further research should be carried out in the rural and periurban locations of Botswana to examine men’s gender preference of providers.
Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.