Addressing Gaps in Men's Health Literacy and Health Seeking in Mozambique: A Case for Differentiated Care for HIV and CVD

As in other parts of the world, men are more likely to delay health care seeking and drop out of care than women in Southern Africa. There is evidence for men's gaps in health care for tuberculosis and HIV, and increasingly for non-communicable diseases (NCD) such as diabetes and hypertension which are on the rise in the region. However, due to emphasis on women and children in the global health agenda, men's health gaps have been neglected and there is limited regional data on their awareness, decision-making, and actions with regards to seeking health care. In this project, we focus on the case of cardiovascular disease (CVD) in HIV-positive men in Mozambique, a country where poverty, conflict, and migration for work have influenced men's health and their vulnerability to disease. Our project aims to contribute data for the development of 'differentiated' care strategies, that is models of care that are responsive to men's health needs and adapted to local systems processes and resource constraints. Mozambique has a high burden of infectious diseases (ID) as well as a growing burden of NCD, and men have lower levels of awareness, control, and uptake of treatment for both ID and NCD. Our project is based in a large urban district of Maputo and will use a range of qualitative and quantitative methods to explore aspects of men's health literacy and health-seeking. A literature review and mapping of men's health interventions in Mozambique will examine current approaches and assumptions. Facility-based observations and interviews with health providers and male patients with HIV and CVD will look at how their pathways to care are influenced by social, structural, and systems-related factors. A community-based survey and a nested qualitative study will use different measures to compare data on health literacy, self-perceived health and household influences on men's health seeking behaviour. Data from these different sources will be used to develop models of processes and pathways to care for men. Finally, we will consult with our project partners, researchers and stakeholders in the fields of health and gender to share findings and discuss how these can potentially inform strategies to strengthen men's engagement with HIV and CVD services. We expect to deliver timely insights for the systems response to HIV/CVD co-morbidity in men. Further, our partnership will provide a solid interdisciplinary platform for the development of a larger proposal that can implement and evaluate health systems strategies to address the chronic health needs of male migrants and mobility across borders in the Southern African region.

Men are more likely to disengage with health services than women in Southern Africa, a gap worsened with the rise of non-communicable diseases (NCD) and complex patterns of co-morbidity. There is little regional data on men's health literacy, health-seeking behaviour, and experiences of receiving care in health systems. Using the tracer of cardiovascular disease (CVD) in HIV+ men in Mozambique, this project aims to strengthen the evidence base for differentiated health systems strategies to promote men's health literacy and health-seeking in Southern Africa. Mozambique has a high burden of infectious diseases (ID) with steady increase in NCD since the early 2000s. Retention of men in HIV care remains challenging; emerging evidence indicates that men have lower levels of awareness, control, and uptake of treatment for NCDs including CVD risk factors. Our mixed-method observational and cross-sectional study will is based in a large urban district of Maputo and has four phases: 1) A scoping review and mapping exercise will examine current approaches to men's health; 2) facility-based observations and interviews with health providers and male patients will situate illness trajectories within social, structural, and systems context; 3) a community-based survey and a nested qualitative study will triangulate data on health literacy, self-perceived health and household influences on men's health seeking behaviour and 4) participatory systems modelling techniques and stakeholder consultation will inform potential strategies to strengthen men's engagement with HIV and CVD services. We expect to deliver timely insights for the systems response to HIV/CVD co-morbidity in men. The partnership will further generate a solid interdisciplinary platform for the development of a larger proposal that can implement and evaluate health systems strategies to address the chronic health needs of male migration and mobility across borders in the Southern African region.

In Mozambique, one of the poorest countries in Southern Africa, a continued high burden of infectious disease coincides with the rise in non-communicable diseases (NCD) and cardiovascular disease (CVD) events. Men are more likely to present late at health services and drop out of care, a trend observed across the Southern African region. Though national coverage of antiretroviral therapy (ART) is 54%, only 39% of men living with HIV are on ART. Of the 1.4 million people with CVD, most are aged 40 years or younger with a male to female ratio of 2:1. The dual burden of disease has significant social, economic, and health systems implications. Vertical programming for HIV has meant that NCD have received limited policy attention to date, and awareness of NCD risk factors and prevention in the population remains low. Men's late presentation in health services for HIV and CVD is compounded by social and structural vulnerabilities that hinder or dissuade care-seeking. At the same time, the country is only just beginning to develop systems for monitoring and profiling NCD and yet to implement strategies for integrating NCD care at primary level, and within HIV services.

Our partners at MIHER are on the pulse of current health policy and systems thinking and national priorities in the country, and our tracer reflects real-time concerns and challenges for the Mozambican health system. Our project is poised to make a timely contribution the national NCD programme agenda and a new strategic focus on men's health by the Mozambican Ministry of Health (MISAU). We will contribute to theoretical and methodological innovations in social sciences and health systems research. Our data will provide implementers and policy makers concrete, relevant information to develop feasible and affordable strategies to engage and retain men in care in Mozambique. Through the creation of a strong research partnership, the study will also promote the exchange of expertise across disciplines and will generate capacity building for junior researchers and early career academics.

Overall, this study responds to very recent calls for attention to the men's health disparities that have failed to feature on global health agendas, supporting formulation of novel strategies to support men's literacy and health-seeking trajectories in the context of their lives and specific gendered vulnerabilities. The project will stimulate and enhance policy and programmatic dialogue across sectors by bringing together key stakeholders as participants in the research process and dialogue. Finally, this project will seek to inform sustainable policy and programme changes in Mozambique and in similar settings in Southern Africa.