Two to Tango: How Men’s Health-Seeking Behaviors May Influence the Spread of Zika in the Caribbean
On February 1, 2016, the World Health Organization (WHO) declared Zika virus a Public Health Emergency of International Concern (PHEIC) (I) after information surfaced that linked Zika virus infections with clusters of microcephaly and other neurological complications. While not new (1), the virus began to rapidly spread across the Americas after first being recorded in 2015. By February 4, 2016, 26 countries reported Zika virus infections (II).
Excerpts from the WHO’s Interim Recommendations (September 2016)
1. In regions with active Zika transmission
a. All people (male and female) with Zika virus infection and their sexual partners (particularly pregnant women) receive information about the risks of sexual transmission of Zika virus.
b. Men and women also get counselling on safer sexual practices and be offered condoms.
c. Pregnant women should practice safer sex or abstain from sexual activity for at least the whole duration of the pregnancy. Their partners should also be informed about this recommendation.
2. In regions with no active Zika transmission
a. Men and women returning from areas where transmission of Zika virus is known to occur should adopt safer sex practices or consider abstinence for at least 6 months upon return.
b. Sexual partners of pregnant women, returning from areas where transmission of Zika virus is known to occur, should be advised to practice safer sex a or abstain from sexual activity for at least the whole duration of the pregnancy.
Though primarily transmitted through the bite of the Aedes mosquito, rare instances of sexual transmission of Zika virus had been previously documented (2). On February 2, 2016, one day after the PHEIC news, the United States reported the first case of sexual transmission in this most recent epidemic (III). This information was pivotal as Zika virus infection during pregnancy was known to be associated with adverse outcomes for infants and children, such as microcephaly and Guillain-Barré syndrome among others. What followed was guidance from the WHO warning women to delay pregnancy and couples to seek counseling; several country governments in the Latin America and Caribbean region joined suit, including Jamaica (IV).
Here’s what we know about sexual transmission of Zika virus according to the Centers for Disease Control and Prevention (CDC) (V):
• Zika virus can be passed through sex (3) from a person with Zika to his or her partners.
• Zika virus can be passed through sex even if those persons are in a committed relationship.
• The timeframes that men and women can pass Zika through sex are different because Zika virus can stay longer in a man’s semen (4) than in other bodily fluids (5).
• Infected persons can pass Zika through sex even when they don’t have symptoms (and many people won’t have symptoms or only mild ones and may not know they are infected).
While well-intended, the WHO guidelines potentially overestimate a woman’s control in having sex and possibly underestimate a partner’s desire to seek out health services.
The Eastern and Southern Caribbean, like everywhere in the world, has its unique perspectives and opinions on what it means to be a man or woman, a boy or girl, and how individuals should behave, act, do, and be. Under the USAID ASSIST Project, partner WI-HER has led efforts to identify and explore gender-based barriers that may limit uptake in health services. Recent learning from health and education providers in Antigua, Dominica, St. Kitts and Nevis, and St. Vincent and the Grenadines helps shed light on why and how societal beliefs influence health outcomes, and can make or break response efforts in the context of Zika.
"Learning Sessions,” an integral part of the collaborative learning and adaptation plan of the ASSIST project, were held in November and December 2018 to convene health and early childhood education - decision-makers, doctors, nurses, registered midwives, community health aides, educators - for the purpose of information exchange and knowledge transfer. As part of these activities, partner WI-HER led participatory gender sensitization sessions and informal group discussions with 180 health care workers and government representatives (9 men and 171 women) from the representative Caribbean islands, to better understand the societal and cultural expectations of men and women, and identify and address any gender-based constraints that may be potential barriers to health care and service uptake.
We asked health and education providers....
What does “act like a man” mean to you?
Expectations of men can influence whether or not they seek personal health services.
The understanding of what it means to be a man permeates Caribbean societies not only for men, but for women too. If a man doesn’t meet these expectations for himself, his peers or his partners, he may be judged, considered weak, labeled a “sissy”, and made to feel ”less than.” Ironically, it is some of these same characteristics that make a man feel “more like a man” that may hinder his access and utilization of health services.
Top Reasons Providers Believe Men Evade Health Facilities (6):
Men see health as a “woman thing”. Through a gallery walk exercise that included identifying gendered differences in health seeking behaviors, participants shared that men seem to value strength and some men consider themselves (and their immune system) to be stronger than a woman. This belief drives certain men to think they don’t need health care.
Men see health as a “woman thing.” Men consider they are stronger. No need health care. – Group Discussion, St. Kitts and Nevis
Males see themselves as strong. – Group Discussion, Antigua
Men wait to go to until the last minute. During a focus group with 12 health providers in St. Vincent and gallery walk in Dominica, it was discussed that men prefer home remedies as a first line of defense and often only go to health centers and hospitals when they are very sick, and their illness becomes unbearable. While experiencing prolonged symptoms, men may not even choose to go themselves to a health facility but are rather encouraged by their spouse or mother to seek medical attention.
Men don’t usually seek help. They go to the health center when they are very ill, when it’s overbearing. Supposedly, men don’t like to go to the doctor. Men prefer to try a home remedy first. – Focus Group Discussion, St. Vincent and the Grenadines
Men don’t usually seek medical help until things are really bad, and young men delay unless it is a STI which causes difficulty passing urine. – Individual Response, Dominica
Men are too busy. Through the gallery walk, providers shared that there is the perception that men are very busy working and earning a living that they lack the patience to sit and wait to see a medical professional. Though the majority of providers stated that men and women are treated the same in health facilities, it was also accepted that sometimes a man would be attended to first because he likely had to return to work.
Men are too busy working, less self-awareness. – Group Discussion, St. Kitts and Nevis
Lack of patience will stop a male from visiting doctors to have to sit and wait to see the doctor. – Group Discussion, St. Kitts and Nevis
Men actively avoid “well-care” check-ups.
Men Are Welcome!
Though men may prefer not to go to health facilities, their presence is welcomed. They are not discriminated against in any way. When bringing in their children for visits (with or without a female partner or family member) they are afforded the same consideration as other clients and are not given any special treatment; but they are sometimes praised. Despite ease of access, few men visit health facilities and utilize services. We’ve identified this as an issue to tackle, especially with regards to well-baby care. – Summary of Individual Responses, St. Kitts and Nevis
Through the St. Vincent focus group and gallery walk in St. Kitts, providers identified that men dodge their prostate exam and any other procedures involving the rectal area. Men, it seems, overwhelmingly prefer to see female doctors and shy away from male ones, especially for sensitive medical assessments.
The men don’t want to be examined by a male doctor, especially if it’s something related the prostate. They shy away from the rectal examination. A lot of men prefer to go to female doctor to do their rectum…. That is the biggest problem that keeps men away. – Focus Group Discussion, St. Vincent and the Grenadines
Women will access health care facility to have their annual pap smear while men are reliant to have their prostate screening done. – Group Discussion, St. Kitts and Nevis
Men are afraid of health care providers. Through the gallery walk exercise and activity discussion, participants revealed that some men don’t trust younger health professionals who potentially lack the experience and are fearful of older staff who may no longer be able to perform medical tasks.
Men are afraid to visit health providers. Fear of older staff/don’t trust younger staff. – Group Discussion, St. Kitts and Nevis
Both genders, especially men, fear result outcomes. – Group Discussion, Antigua
We learned from providers that men aren’t going to health facilities as often as they should and some of the reasons behind this, but why is this relevant to the context of Zika? The simple answer is sex. The majority of health providers we spoke to in every island shared that they believe men should not have sexual relations outside of a relationship if his partner doesn’t know; though background research and confirmation from the providers present concluded that it is often a cultural practice. From the perspective of the providers, it is considered disrespectful, cheating, against religious teachings, and (relevant to this conversation) can increase the risk of infections that can be transmitted by sex (like Zika). Yet despite this belief and the negative sentiments associated with infidelity, research (VI) and reinforcing statements from Learning Session participants reveal that being a man in the Caribbean is also founded on the idea of having multiple partners.
The WHO guidelines (reviewed above) state that men should 1) get information about Zika, 2) get counselling on safer sexual practices and condoms, and 3) consider abstinence with their partner. But if men aren’t going to the health facility in the first place, how can these recommendations be followed? With limited utilization of services, men miss opportunities to speak with providers, receive necessary and correct health education, and better understand the implications of a Zika virus infection for themselves, their partners, and future children.
Ultimately, for the Zika response to be fully successful, programs must work to reach men and get them into health facilities as much as they target women.
Understanding men’s health-seeking behaviors and working to address them can help suppress the transmission of Zika and other infections through sex and positively affect health outcomes for men, women, and children. Through learning opportunities supported by its partnership with ASSIST, WI-HER has helped to build the capacity of health providers to recognize gender-related barriers to service uptake and advocate for regular well-health visits with its clientele. For men, early or routine service utilization can greatly improve opportunities to gain awareness of potential health threats, discover infirmities like sexually transmitted infections, access treatments (where possible), and start preventive measures to stay additional spread. As we continue to respond to the lingering impacts of the Zika epidemic, we must remember that women are not in this alone, and men are the equal part of the solution
From 2012-2017, the USAID ASSIST (Applying Science to Strengthen and Improve Systems) Project fostered improvements in 38 countries in a range of health care processes through the application of modern improvement methods by host-country providers and managers and build the capacity of host-country systems to improve effectiveness, efficiency, client-centeredness, safety, accessibility, and equity of the health services they provide. In a two-year extension from 2017-2019, ASSIST applies quality improvement methods to health systems strengthening efforts in Zika-affected countries, including Antigua and Barbuda, Dominica, Dominican Republic, Ecuador, El Salvador, Guatemala, Honduras, Jamaica, Nicaragua, Paraguay, Peru, St. Kitts and Nevis, and St. Vincent and the Grenadines.
WI-HER, LLC (Women Influencing Health, Education and Rule of Law) is a woman-owned small business that partners with international donors, national governments, non-governmental organizations and others to identify and implement creative solutions to complex development challenges to achieve better, healthier lives for women, men, girls, and boys. Founded by Dr. Taroub Harb Faramand in 2011, WI-HER, LLC works to integrate gender through contextualized, adaptable, and systems strengthening methods that can be seamlessly integrated into ongoing and new programs. WI-HER is committed to ensuring equal opportunities for women, men, girls, and boys, as well as all other vulnerable groups, including LGBTQI+ people.
(1) The first human cases of Zika were detected in Uganda and Tanzania in 1952.
(2) In 2008, a US scientist who was working in Senegal caught Zika. When he returned home, his wife became infected in what is said to be the first documented case of sexual transmission of the infection. In 2013, a patient recovering from Zika virus in French Polynesia seeks treatment for bloody sperm; Zika was isolated from his semen.
(3) Sex refers to vaginal, anal, oral, and the sharing of sex toys.
(4) WHO guidance now recommends males with or without symptoms returning from areas with active Zika to practice safe sex 6 months. The previous recommendation for asymptomatic males was 8 weeks. Safe sex refers to the use of male or female condoms correctly and consistently, non-penetrative sex, reducing the number of sexual partners, and postponing sexual debut.
(5) Other bodily fluids include, the female genital tract, saliva, and urine (as reported to the WHO). Instances of Zika virus passing via these avenues are rare.
(6) As shared by health and early childhood education practitioners during the gender sensitization training components of the USAID ASSIST Project’s November and December 2018 Learning Sessions. While men were present at each country’s sessions, the majority of participants were women