Adapting health systems to men’s realities: An intersectional exploration of men’s barriers to TB care in Nigeria’s peri-urban communities

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This research explored how masculinities combine with layers of disadvantage among men in peri-urban communities to limit their access to TB services. We conducted 20 in-depth interviews among 12 men and 8 women with presumptive or confirmed TB, 3 focus group discussions among 24 men in their workplaces, and interviews with 12 key informants exploring experiences of TB symptoms and care seeking. Audio recordings were transcribed and analysed using a reflexive thematic approach. Findings suggest many men in peri-urban settlements could not afford TB symptoms due to strict masculine gender expectations and norms (Theme 1), while official TB information was not tailored to reach them (Theme 2). When developing symptoms presumptive of TB, men negotiated the least disruptive way to wellbeing (Theme 3). After TB diagnosis, female healthcare workers used strategies such as baiting and negotiating to engage and retain men in care (Theme 4). In conclusion, health systems need to address the compounded barriers different groups of men in peri-urban settlements in Nigeria highlighted by this study and leverage existing community resources to create scalable adaptations to care that make services more responsive to their realities. Infectious Diseases Healthcare access masculinities intersectionality Tuberculosis Nigeria peri-urban settlement Figures Figure 1 Introduction Tuberculosis (TB) is a disabling and dispiriting disease enabled by poverty and deprivation that affected 10.8 million globally in 2023 ( 1 ). Nigeria, where this research is based, ranks 6th globally and 1st in Africa for its TB burden of about 500,000 estimated TB incidences in the same year ( 1 ). In most parts of the world, including Nigeria, TB is highly gendered. Men have constituted the majority of people diagnosed and treated for TB for as long as WHO has kept track( 2 ). Globally, 55% of people who developed TB in 2023 were men followed by women (33%) and children (12%)( 1 ). In Nigeria, TB incidence in men is two-fold that in women (751 [95% CI: 538–965] vs 359 [95% CI: 213–505] cases per 100,000 population)( 3 ). Whilst globally about 8.2 million people with TB were correctly diagnosed and treated in 2023, more than 2.6 million were left undiagnosed, unreported or untreated( 1 ). Nigeria is among the 5 countries that account for over half of people with TB who miss out on care( 1 ). Numerous prevalence surveys, reflective of true population burden, have shown that globally and in sub-Saharan Africa, two out of every three people with TB who miss out on care are men( 4 ). Differences in Nigeria’s TB prevalence notification ratio (7.25 in men vs 4.63 in women) reveal men’s delay in TB diagnosis and care ( 4 ). 3.1 Gendered nature of TB burden The gender pattern observed in TB is due to an interplay of biological, socio-cultural, and environmental factors. Whilst acknowledging women’s greater likelihood to develop extra-pulmonary TB ( 5 ) and face socio-cultural barriers to TB care due to lack of decision-making power ( 6 ) and access to resources ( 7 ), this manuscript focusses on the gendered burden of TB among men. Biological male sex is inherently associated with a higher risk of acquiring TB disease ( 8 ) and developing recurrence ( 9 ). Men tend to transmit TB more easily than women due to men’s better developed pectoral muscles that produce stronger cough expelling more bacilli ( 10 ) and men’s social mixing pattern ( 11 ). In many settings, men suffer longer delays before reaching care ( 3 ) and among people who get on treatment, men are more likely to drop out of care, experience treatment failure, and death ( 1 ) thus remain infectious for longer periods. 3.2 Health in peri-urban settings About half of Nigeria’s 120 million urban population are affected by unsafe water, poor sanitation, crowding, poor housing, insecure tenure ( 12 ). These include people living in peri-urban settlements who lack access to urban privileges and amenities common in the affluent, well-planned cities nearby. Peri-urban suburbs accommodate highly mobile and transient populations of low socio-economic status reside in search of a living. Pollution, poor urban planning, high taxation of small-scale informal businesses ( 13 ), limited employment, and food and economic insecurity heighten survival pressure among peri-urban dwellers, while overcrowded and poorly ventilated living spaces make TB transmission easy ( 14 ). Despite the presence of public primary healthcare centres, informal health providers such as patent medicine vendors thrive in these suburbs. Tertiary healthcare is absent. 3.3 Importance of TB in achieving global and national health goals TB is the highest cause of deaths from an infection globally ( 1 , 15 ), taking the lives of 1.3 million people globally, and over 67,000 in Nigeria in 2023. TB contributes significantly to disability and reduction in the quality of life( 16 ), including through post-TB lung disease ( 17 , 18 ). Many people with TB face catastrophic costs (71% in Nigeria), stigma, and mental health challenges, including depression, which affects their livelihoods, families and communities( 21 ). With its chronic sequalae on the quality of life and livelihoods of affected individuals, families and communities, TB epitomizes the deleterious effect of the dual burden of diseases on low- and middle-income countries with shorter life expectancies than affluent countries ( 15 ). As a signatory to the End TB strategy, Nigeria has recorded notable progress; the proportion of people with TB who access TB diagnosis and treatment (treatment coverage) improved from 27% in 2019 to 74% in 2023 ( 1 , 22 ), widening the gender gap (91% coverage for women and 65% for men) ( 1 ). The excess disease risk and its negative consequences in men carries population-wide implications for men as well as women and children sharing households, workplaces and neighbourhoods with them. Despite exposure to disease ( 23 ) in informal peri-urban settlements, recovery is complicated by limited access to healthcare and the precarities of urban existence for the poor ( 14 ). Approaches that ease care access for men with TB are crucial for the country’s progress towards eliminating TB as a public health challenge ( 3 ). This understanding is imperative for effective planning and implementation of TB services to fast-track the country on its path to achieving the goals of the End TB strategy. 3.4 Aim This research seeks to explore how masculinities combine with multiple layers of disadvantage connected to the identities of men in peri-urban communities to inflex their access to TB services. Methods This research is part of “Developing and Evaluating gender-responsive TB Interventions for communities in Nigeria” (DESTINE), a mixed methods implementation study affiliated with the “Leaving no one behind; transforming gendered pathways to health for TB” (LIGHT) Consortium ( 15 ). LIGHT is a six-year cross-disciplinary global health research programme led by a UK-based institution in collaboration with partners in Kenya, Malawi, Nigeria, Uganda, and the UK. LIGHT aims to support policy and practice in transforming gendered pathways to health for people with TB in urban settings ( 24 ). Here we report DESTINE’s exploratory qualitative cross-sectional study on men’s barriers to TB care. 4.1 Conceptual framework Masculinities can be viewed as a system of power constructed within historical, cultural and political milieu ( 25 ). Within it, hegemonic masculinities define aspirations and privileges for men imposing restrictive norms on men and marginalizing those who do not conform ( 26 ). Rooted in Black feminist scholarship( 27 ), intersectionality offers a framework for examining how interlocking social identities and structures of power such as race, gender, and class shape unequal health outcomes among marginalized people. Its adaptation to men’s health research( 28 ) enables a deeper understanding of how race, masculinity, and structural inequities intersect to influence the health of Black and African men. This perspective shows how masculinities intersect with other systemic inequalities to influence men’s access to health services. Our research considers the social identities, positions and conditions of men in peri-urban communities in Nigeria that affect their access to TB services and the gendered systems of power that shape health systems in these contexts( 29 ). The WHO intersectional gender analysis framework ( 30 ) guided out research design, data collection and analysis. 4.2 Research context Our research was conducted in purposively selected peri-urban areas, Karu, in North-central and Okpoko, in South-east Nigeria. Karu local government area (LGA) is on the western border of Nasarawa state, in proximity with Nigeria’s Federal Capital Territory (FCT), Abuja ( 32 ). Created in 1991, the FCT emerged as the fastest growing city in Africa, being the home of 4 million people, becoming the fourth most populous city in Nigeria behind Lagos, Kano, and Ibadan ( 33 ). Between 2003 and 2007, the FCT development authority demolished unapproved structures and evicted their residents ( 34 ) to reduce pressures that the escalating population put on the city’s social amenities, sanitation, water, and aesthetics ( 35 ). Subsequently, poorly planned settlements sprung up around Nigeria’s FCT, as thousands of displaced households were unable to afford officially approved prime property within the city. Karu is one of these peri-urban areas, designated as FCT’s sub-urban districts ( 36 , 37 ), characterised by rapid population growth, high-population density, limited water supply, poor sanitation, and unsustainable housing ( 35 – 37 ). Similarly, Okpoko in Anambra state is a densely populated peri-urban settlement adjacent to the bustling city of Onitsha ( 38 ). Although Onitsha had been a trade hub for centuries due to its location along river Niger, its influence in the region was propelled when the British colonial government set up a trade post in 1857 ( 39 ). Onitsha main market has grown to become the largest market in west Africa ( 40 ), enjoying patronage from local and international traders and attracting a high influx of migrants. In response to the escalating demand for affordable housing around the commercial powerhouse, Okpoko emerged as one of Nigeria’s most populous peri-urban settlements( 41 ). It suffers persistent flooding due to its proximity to the Niger, unregulated development and congestion, historical underinvestment in infrastructure, poor waste disposal systems, predisposing Okpoko to frequent disease outbreaks ( 23 , 38 , 42 ). 4.3 Research team An interdisciplinary team of researchers conducted the study. Author1, a male medical doctor and doctoral researcher from Nigeria, designed the study in consultation with his male supervisors, author5 and author6, UK-based senior researchers and consultants specialised in TB, and author4, a consultant community medicine physician in Nigeria. Author1 and author2, a female PhD social scientist from Nigeria, led community entry, recruitment, and data collection. Author3, a female German post-doctoral researcher with a UK institution based in Uganda, supported data analysis. 4.4 Sampling and recruitment of participants We purposively sampled 20 community members for in-depth interviews (IDIs), 24 men for focus group discussions (FGDs), and 12 key stakeholders for interviews (KIIs), as shown in Table 1 . Given the higher burden of TB amongst men, we sampled more men than women. Table 1 Summary of participants recruited into the study Method Type of Participant Number Participants by gender Mode of Recruitment Purpose of recruitment IDIs Community members 20 12 Men 8 Women Snowball sampling To understand factors shaping individuals’ experiences of care FGD Men in workplaces 3 24 Men Criteria-based sampling of men in their workplaces To seek men’s views about their access to TB care KIIs Policymakers and TB actors 12 (shown below) 6 Men 6 Women Key informant sampling To reflect community views on factors affecting access to TB care, and seek solutions Patient advocates and civil society leaders 2 1 Man 1 Woman Purposively selected based on leadership in TB advocacy NGO based actors 4 2 Men 2 Women Purposively selected based on experience in active case finding State and LGA policymakers 4 2 Men 2 Women Purposively selected based on expertise in TB programmes at state level (n = 2) and LGA level (n = 2) Patent medicine vendors 2 1 Man 1 Woman Snowball sampling of patent medicine vendors rendering TB care in the communities Note. LGA = Local Government Area; NGO = non-governmental organisation; TB = tuberculosis. The 20 community members (12 men and 8 women) were selected through snowball sampling for IDIs to conceptualize the factors affecting access to TB services through individual experiences. We identified the initial participants (n = 12, men = 6, women = 6) who had presented with symptoms presumptive of TB to local Primary Health Centres from TB service register. Subsequently, participants linked us to other similarly symptomatic members of their communities, including five people (men = 3, women = 2) who had attempted (unsuccessfully) to seek care for their symptoms, one man who had been declared lost to follow up on a previous treatment cycle, and two people who had never sought care. Most men were employed in the informal sector including one migrant worker (from a minority ethnic group), one identified as unemployed but engaged in subsistence farming. Most women and men were married while two men were single, and two women were single parents (one widowed, the other separated). One woman was living with a disability on account of a neglected tropical disease. FGDs sought to understand collective views of what seeking and accessing TB care meant for men in selected occupations in peri-urban settlements and how they navigated the health challenges encountered. Three male-specific FGDs focused on men’s lived experiences and customs around gender. We purposively sampled occupational groups based on anticipated TB exposure and health care barriers to include commercial tricycle operators ( keke napep drivers) (n = 8); bus drivers and conductors (n = 8); and artisans (n = 8). Information about the research was explained to the prospective IDI and FGD participants including voluntary participation and confidentiality of information. All provided written informed consent. Twelve health system actors were recruited for KIIs to discuss community views on access to TB care. They comprised two local government TB supervisors, two patient advocates (one leads a community-based support organization), two regional leads and two country leads in NGOs, two State TB Programme Managers, and two patent medicine vendors involved in TB screening initiatives. We invited them via emails and phone calls and shared the participant information and informed consent sheets by email. Some preferred to have the information and consent giving process in-person. We scheduled interviews with participants at their convenience within a fortnight. 4.5 Data collection Data were collected from April to August 2022. Semi-structured topic guides were informed by the research objectives and intersectionality framework, involving 13 questions for IDIs and 9 questions for FGDs, to elicit in-depth data in the direction participant’s narratives whilst iteratively referring back to the topic guide with opportunities for probing ( 43 ). The IDI topic guide was pre-tested amongst two community members (one man and one woman) who did not participate in the research. Afterwards, author1 and supervisors modified all guides, simplifying the language and modifying the flow. Author1 and author2 conducted IDIs with research assistants as note takers and timekeepers. All IDIs were conducted in offices at health facilities that provided sufficient audio-visual privacy and lasted 30 to 50 minutes. Author1 facilitated the FGDs with men in their workplaces, including motor-parks and a stall for artisans. A research assistant functioned as the rapporteur timekeeper, administering a quality assessment checklist reflexively during FGDs to ensure adherence to FGD steps and engaging discussion. Each FGD lasted 50 to 60 minutes. Findings from the community members were synthesized and fed into the KIIs to understand their perspectives on the mechanisms behind IDI and FGD findings and possible ways forward. Most KIIs occurred in participant’s offices. Due to acute fuel scarcity and hike in fuel prices at the time, we conducted three KIIs virtually via zoom. All IDIs, FGDs, and KIIs were conducted in English, Pidgin, Igbo, or Hausa (the researchers are native speakers). Participant were compensated for their time (₦2,000/ $ 4.80). Individual and group discussions were audio recorded with participants’ permission. The research team took reflective notes and held weekly (virtual) meetings to reflect on experiences, interview process, emerging issues and themes. 4.6 Data management and analysis Author1 and a trained research assistant transcribed all audio recordings (n = 35), using a naturalized transcription approach ( 44 ). Reductions were minimal but important to enhance readability whilst preserving participants’ original expressions. Our analysis considered all data collected among men as well as data collected among women and stakeholders that referred to the realities of men. We used the reflexive thematic analysis approach, following Braun and Clarke ( 45 ) six stages: (i) Familiarization with the data: authors1,2,3, and 6 spent ample time listening to the audio recordings and/or reading the transcripts to become thoroughly familiar with the data and compare observations between those who collected data and those who did not. (ii) Generation of initial codes: authors1,2, and 6 coded five transcripts individually, labelling ideas contained in the data. In virtual meetings, they harmonised coding and grouped codes, addressing similar underlying thoughts, as descriptive second order codes and later as interpretive third order codes, keeping them close to participant’s very words. This coding framework was applied to all remaining transcripts. (iii) Searching for initial themes: authors1,2, and 3 observed the clusters of codes, identified underlying threads of meaning running through them, and coalesced into themes. Abstraction of themes occurred at both inductive and deductive levels. (iv) Review of the themes: author1 interpreted the data pursuing first an inductive course and reflecting upon the gender-related factors affecting access to care for TB presented in the data. Thereafter, he interpreted themes within the context drawing on intersectionality theory ( 27 ). (v) Defining and naming the themes: authors1 and 3 reviewed the initial ‘bucket’ themes, renamed and conceptualised themes to clarify how they linked to each other and to the sub-themes. (vi) Report writing: author1 wrote the initial draft in accordance with COREQ standards( 46 ). 4.7 Ethical approval The research protocol was reviewed and approved by global north REC (21-099) and the global south REC (NHREC/21/05/2005/00867). We sought approval from community leaders prior to recruitment with support from Community Health Extension Workers in each study site. We explained the objectives and importance of the research and voluntariness of participation to the community leaders who endorsed the study. Results Figure 1 summarises men’s intersectional gendered experiences of TB symptoms, health seeking, and TB care in peri-urban areas in Nigeria. Data illustrate how masculinities intersected with other factors such as informality of work, occupation, education, socio-economic status, migration, and family situations to create systemic barriers to TB care among men. Due to strict masculine gender expectations and norms, many men in peri-urban settlements could not afford TB symptoms (Theme 1) while official TB information was not tailored to reach them (Theme 2). When developing symptoms presumptive of TB, men negotiated the least disruptive way to wellbeing within health systems viewed as feminine (Theme 3). After TB diagnosis, female healthcare workers used innovative strategies to engage and retain men in care within gender-blind health systems (Theme 4). 5.1 Men cannot afford TB symptoms Men in both peri-urban settlements experienced social and economic pressures that put them in positions where they cannot afford to show TB symptoms. Societal masculinity expectations of men as the primary ‘breadwinners’ created pressure for men to continue working despite illness. Many worked without formal contracts to earn daily wages as bus and Keke napep drivers, itinerant artisans, miners, and scrap metal collectors, among others. Their work offered little to no job security, no paid leave, and no health benefits. Time spent away from work, including for health, directly impacted their income. Social nets to safeguard households from precarities of ill health were non-existent. These men risked jeopardising food for their household when seeking healthcare. “The people you came to see today are keke napep drivers…Most of us don’t own the keke, it was given to us on hi-po (hire-purchase). We are supposed to pay a huge amount of money every day to the owners of the keke. Within one year, we are to pay back double the total cost of buying the keke. How do you now tell your boss that you didn’t make your daily return because you went to the hospital for cough? They will collect the thing (keke) from you and give it to a more serious person”. (FGD Keke napep drivers, Participant 5 Male) Men endured symptoms without seeking proper medical help. Scarce job opportunities in Okpoko’s artisan sector, employing only the strongest, created competition between local and migrant labourers, generally perceived to be better in mining and masonry than locals. Men artisans had to normalise illness to maintain masculine competence as they would not be hired if they showed weakness. Worsening severity of symptoms threatened men’s livelihoods and forced some to resort to lower-paying jobs. “I worked a lot yesterday and the day before yesterday. Today I feel tired and decided to rest. Tomorrow I will regain my strength and continue. I will not show my sickness because like when companies use to hire us, if someone is not all that healthy, the person will not get work and will… forget about anything money for that day” (FGD Artisans Participant 2 Male) “…the work I was doing, furniture work, gives money but it requires strength. But for scrap (picking scrap metals), you will have no money. So, because of my sickness (TB), I no longer have the strength to do it, so I now do scrap work. It affected my family, it affected them very well their feeding, everything even their school fees. I will not be able to go back to furniture because it requires money to start again” (IDI 06 Male) TB was portrayed as a deadly disease no one wanted to be associated with. Men with TB usually faced stigma and discrimination including within families and households. TB symptoms – unrelenting cough and dramatic weight loss – attracted the wrong kind of attention for the men. Once diagnosed and on treatment, TB medicines caused an embarrassing discolouration of urine. Men on treatment avoided using public male urinals at work for fear of being found out and labelled unfit or sick. “I urinated at elephant house (a public urinal near the market where he sells). Someone saw the colour of my urine which was like blood. They went and met my brothers and told them to find out what is wrong with me. By the time I got home, my brothers were asking me what was wrong with me, that I was urinating blood. I explained to them that I was taking a drug that changes the colour of my urine, and they calmed down. But those drugs can cause embarrassment to someone, if you want to urinate, you have to go to a hidden place.” (IDI 01 Male) Men’s gender roles and economic pressures, harsh labour conditions, and TB stigma in peri-urban settings created an environment which prevented men from showing TB symptoms and seeking care early. 5.2 TB information does not reach men Many men in both locations lacked access to the necessary information about TB and related services contributing to delayed help seeking for their symptoms. Health education in peri-urban settings was typically scheduled during working hours and delivered in the community or health facilities, not workplaces. Many men in informal employment worked long hours to maximise income and could not afford to take time off work for such activities. Men’s lack of TB awareness was coupled with misconceptions attributing TB to witchcraft or heredity. “Before I started the medication, I did not know anything about the TB. When I got sick, people thought it was witchcraft or that I was poisoned while others thought it was HIV infection. It was a man who saw me and recommended that I go for a TB test.” (IDI 11 Male) Migrant workers unfamiliar with local customs faced additional barriers to health education due to language and culture. Most men in peri-urban settlements had limited knowledge about availability, cost, and location of TB services. Whilst TB services are free, they nursed speculative concerns about high costs of tests and treatment. Lack of awareness and fear of cost could delay healthcare seeking even among relatively affluent men in the peri-urban setting and prolong chances of transmission within affected households. “All we are saying now seems to be only about money, but one of our brothers had tuberculosis. We were worried about the doctor’s prescriptions thinking that they will charge us a lot of money, but all those things were given to us free of charge. So, the challenge is that people fear the money, but the whole thing is free. It is the fear of money [laughs]” (FGD Artisans Participant 4 Male) Nigeria’s National TB programme prioritised formal communication channels for the dissemination of TB information through TB campaigns and training for media experts during World TB Day. However, many men within underserved peri-urban settlements mistrusted these formal channels as sources of health information especially after the Covid-19 infodemic. “The TB programme and the partners are doing quite a lot to ensure that information about TB is well disseminated in the country. We conduct annual capacity building for all our media partners in TV, radio and print media organisations. This year we also added social media influencers. This year alone across platforms we trained nearly one thousand, give them the correct information on TB and how to write correct news report on TB.” (KII 01 Policymaker Woman) “Like during Covid…every time they announce in the radio and everywhere… if you call a number (state emergency toll free number) they will tell you what to do, but many people said the number was not working. And they said, ‘don’t shake hands’, ‘don’t greet people’, ‘don’t take holy communion’, even ‘don’t go to church’. In the end, those things did not work. Everything we hear in the radio or TV, I take it as government trying to create confusion and make people afraid using propaganda.” (FGD 03 Participant 6) Participants made frequent references to suboptimal links between TB programmes and community-based institutions. Religious platforms and leaders emerged as trusted local agencies moulding opinion and role-modelling behaviour. Traditional leaders, market organisations, and football teams could also be leveraged as valuable resources to enhance TB messaging for men. TB survivors could play a critical role as advocates, with some participants identifying as survivors themselves. “…if you tell a sick person to go to hospital, he will tell you he has been prayed for … so we need to carry this message to churches and mosques, inside markets, motor parks, places where men gather, where they play football in the morning. Once people see the bishop doing the test and he gives approval…everybody will follow suit. While sensitizing them… you know… things are hard, so also inform them that the test is free.” (IDI 09 Man) “Toward the end of last year, I carried a man that was very sick. He was so weak and coughing persistently and was looking so thin that his bones were seen. I took him to the TB clinic at the local government… where I was treated and cured of TB some years ago. They later diagnosed him with TB. This year around January, he came to this our keke park here to look for me and I was very surprised when I saw him because he added weight and looked like a human being. I did not recognize him and asked why he was looking for me, until he explained that he was the man I picked from head bridge that was sick last year.” (FGD Keke napep drivers Participant 5 Man) Keke napep operators also signalled limited engagement with TB programmes as they often encountered people with persistent cough. Although many felt obligated to help, they were unaware of where to refer such individuals for assistance. “…for me I have carried not one, not two, not even three passengers with cough. The most painful one was when I carried someone beside me in the front seat of my keke. The person coughed to the point that he almost fell down from my tricycle. The second time he coughed, I threw my face to the opposite side, and we nearly had an accident… I didn’t know what it was…you know that was when COVID-19 was serious… It made me realize that I didn’t know any health professional that I can refer him to. How I wish I knew the treatment hospitals at that time.” (FGD Keke napep Participant 3 Man) Men in peri-urban settings missed out on TB messaging because TB programmes did not consider men’s economic obligations and social spaces for health education at the local level and often prioritised formal platforms over well-trusted community-based communication channels and champions. 5.3 Men negotiate the least disruptive pathway to wellbeing Faced with economic constraints, social pressures, and limited TB information, men in the peri-urban settlements often sought the least disruptive way to manage their health. Many avoided formal healthcare facilities, which they perceived as time-consuming, costly, and inaccessible. As a first choice, men often resorted to informal providers, like traditional healers or patent medicine vendors, who offered quick, low-cost alternatives that aligned better with men’s work schedules and economic realities. By using informal pathways, men attempted to maintain a sense of control over their well-being without disrupting their responsibilities to family and work. “If I go to the district hospital, I will spend the whole day, what will happen to my work? But I can easily buy drugs from the chemist even in the night to stop the cough even though the tiredness may continue. But I can manage once the cough reduces.” (FGD 3 Participant 4) Most men viewed public health facilities as rigid and primarily catering to women and children. If symptoms persisted, men preferred healthcare from private providers for their convenience and flexibility.. Men and policymakers understood the convenience private clinics offered remaining open with full services beyond official hours, accommodating working men and treating clients with dignity. “Men tend to patronize the private sector more because of the convenience and flexibility. They don’t have closing hours, they work on weekends, so working men could come after five or six (in the evening) and still see a doctor. Nobody will look at them somehow and tell them they were late. As long as that hospital has a doctor on call, they would want to make money…” (KII 01 Policymaker Woman) Private informal providers were more affordable but both informal and formal private healthcare providers in the peri-urban settings frequently lacked the necessary capacity to diagnose TB. Whilst aiming to save money, men incurred repeated visits and additional costs. “We went to three different hospitals that we felt were big hospitals. But after everything, nothing came out of it. All they did was charge us huge amounts of money. But thank God for Dr. O, he was the one that insisted we must do chest X-ray, he also interpreted the result by himself. I don’t really think private hospitals have the equipment to handle TB, because I was ready to do anything to ensure my daughter and I were treated.” (IDI 01 TB Patient Man) Men’s tendency to negotiate care pathways across parallel health systems reflected a pragmatic approach to health. Many prioritized immediate responsibilities over their long-term health needs. Being disadvantaged by employment and limited economic opportunities, they made calculated trade-offs prioritising short-term gains of convenient services for temporary symptom relief and financial contributions to their dependents over formal diagnosis and treatment for their own health and economic stability in the long run. 5.4 Baiting and negotiation to engage and retain men in care Frontline female healthcare workers, especially in Okpoko, observed that initiating and successfully retaining men in TB care often took additional work compared to women. From their perspective, men required extra time to build trust, greater resources to support care, more comprehensive information to foster collaborative decision-making, and more flexible service delivery to continue treatment. “If you have both male and female diagnosed, and you have their results with you, it is much easier to enroll women on treatment, and it is easier to manage them. Most times you will be calling the men, and they will continue to give you excuses… even throughout the course of treatment, you continue to pamper them and give them more attention to ensure that they complete their treatment.” (KII 09 Woman Healthcare worker 2) Healthcare workers had to be flexible and innovative to adapt standard care and tailor services to each man's needs. Occasionally they initiated services at men’s homes or workplaces and frequently baited and negotiated with men to encourage clinic attendance. “We diagnosed a furniture maker who was very weak but said he did not have time to come to our facility for enrolment except we bring the drugs to his shop. I refused… But each time I pass his shop, I see his workers and children and I know they are at risk of getting TB… So, one day I took some medicines and weighing balance and went to enrol him in his shop… Later I told him that some of the other tests (HIV test) cannot be done there at his shop. The next day, he called me by himself and came to our clinic.” (KII 04 Woman Healthcare worker 1) Healthcare workers' ability, agency and autonomy to identify and respond to men’s needs during care varied. Some exhibited what was seen as insensitive and stigmatizing behaviour towards men whereas others called the men regularly and supported them through the process. Men recognised and appreciated the extra level of care which motivated them to respond positively to treatment and behaviour change education that would redound to overall better health and post-TB quality of life. “Sometimes they (healthcare workers at the TB clinic) called me on phone saying, ‘Mr. E how is your health? Are you taking your medication? How are you feeling? Keep taking it. If you don’t take it for even a day, you will be affected’. Not like the nurses at the district hospital who dodge you like a bullet and talk harshly…These women here are really helping us. I have even stopped smoking and drinking. I used to be very stubborn but now, when you bring a cigarette near me, I begin to cough.” (IDI 011 TB Patient Man) The changes healthcare workers made required commitment beyond official job expectations as there were no formal guidance or additional resources to support these service adaptations. Discussion We set out to understand how male gender intersects with other inequalities to shape men’s access to TB services in two peri-urban communities. Data suggest men in these settings must navigate social expectations, economic precarities, and health system limitations and rely on their community to access health information and care. Disadvantages associated with informal work, lack of education, and, in some cases, migrant status on top of the expectations towards men in the peri-urban context do not simply add up but interact in ways that amplify vulnerabilities of men in need of healthcare. An unwittingly dismissive attitude towards cough coupled with TB stigma, inaccessible TB information, prohibitive costs of taking time away from work for healthcare, and fear of hospital bills posed significant impediments among men in this context. When men sought care, they resorted to community-embedded informal providers, prolonging their time-lag before reaching proper TB care in formal healthcare settings. What is frequently referred to as men’s late care seeking reflects an accumulation of several attempts and trials at care seeking from healthcare providers where proper TB care was unavailable. Taken together, our findings demonstrate that men’s delayed TB care is not simply a function of individual choice but a product of intersecting social, economic, and health system constraints. Men’s economic and social pressures are determinants of their TB care access. This aligns with research from precarious urban settings in eastern and southern Africa (47,48) where daily struggles for survival are gendered (49–53). Dominant masculine ideals emphasise strength, self-reliance, and breadwinning, and condescend healthcare seeking as a sign of weakness (25). Like in southern Africa, men in this study feared losing their livelihoods and social standing if they sought care. The exploitation of informal workers, like keke napep drivers and artisans, underscored how restrictive gender norms intersect with weak protective labour laws in peri-urban settlements to create economic and health inequalities for men. Recent steps by the Nigeria TB Programme, disaggregating routine healthcare data by sex, made men’s TB burden and TB care gaps visible(54). However, male-specific strategies to address TB gender gaps are lacking (55). Rigid operation hours of public health facilities, clashing with men’s working hours and insecure employment, posed a structural barrier to TB care among men. This is consistent with evidence (11) that showed men working in precarious jobs lack the flexibility to attend health services during conventional clinic hours. As elsewhere (48), many of our participants sought care from informal providers such as patent medicine vendors, despite their limited capacity to diagnose and manage TB effectively. Reliance on informal healthcare can lead to inadequate treatment, increasing chances of TB transmission and worsening health outcomes including lifelong disability, post-TB lung disease, and mortality (56). Men’s preference for private or informal health providers due to convenience and respect, reinforce the need for TB programs to integrate these providers into formal care pathways (57). Men use both informal and formal healthcare providers depending on symptoms and their financial fears. Although the strength and weakness of different systems were known, linkages between these systems are weak. Men’s experiences highlight this disconnect as well as the potential for collaboration and linkages through strengthened referral systems to improve overall quality of care and reduce diagnostic delays(58). Similarly, conventional TB messaging failed to reach men effectively because health system actors and communities trusted different health information providers. Whereas the TB programme primarily engaged formal media channels, many men in peri-urban communities distrusted such channels. Our findings align with previous research highlighting the need for community-driven and context-specific TB communication strategies (59). TB programs should prioritize informal channels (60) like religious institutions, markets, workplace gatherings, and survivor-led advocacy, among others. TB-related stigma emerged as a significant constraint to care among men who must constantly prove their manhood in workplaces and communities. TB stigma, associated with contagion, poverty, irresponsibility, and weakness (20,61), is highly gendered. Evidence elsewhere suggests men are more likely than women to internalize stigma in ways that hinder help-seeking (62). In our study, masculinity norms in peri-urban Nigeria reinforced TB stigma making men conceal TB symptoms (cough and weakness), medication and treatment side effects, like urine discolouration. Gendered TB stigma can limit men’s access to and retention in TB care, thus there is need for stigma reduction messaging to address harmful gender norms. Whilst we set out to understand men’s gendered experiences, data also revealed the voluntary, unpaid, and often invisible extra labour provided by women frontline healthcare workers. They recognised and responded to needs of men and adapted their services at personal cost to retain men in care exemplifying how local innovation can help overcome health system limitations. Gender dynamics within healthcare settings have been shown to influence treatment adherence (63). In southern Africa, female partners and relatives have been reported to help men acknowledge symptoms, reach health facilities, and navigate losses through emotional and material support to become healthy again (64,65). Our study highlights the ability of female healthcare workers to build rapport, provide emotional support, and negotiate easier care pathways is crucial for retaining men in treatment. These efforts remained largely unrecognized and unrewarded within the health system that is heavily masculine at decision-making levels but relies on the unpaid or underpaid labour of women to compensate for systemic inefficiencies (66). In a sense, TB programmes appear to be gender blind, with barriers for poor men and non-recognition of adaptations by frontline women healthcare workers. Recommendations Addressing compounded issues affecting men’s access to TB care in the peri-urban context requires systemic multi-layered solutions (67) and gender-responsive health system changes. Targeted, male-focused health communication is essential to close information gaps and improve access to TB care among men. Tackling stigma requires reframing TB narratives within peri-urban communities and engaging trusted figures such as religious and traditional leaders to normalize care-seeking. Community-led awareness must be coupled with accessible diagnostic services to bring TB screening closer to men. Advancing TB care for men should also include support for local innovations and fair compensation for unpaid frontline work, predominantly undertaken by women. Expanding TB services for men in peri-urban areas requires integrating community-based informal and formal private providers into the TB care network. These cadres could be trained and incentivized to identify and refer individuals with presumptive TB to nearby clinics, minimizing missed opportunities for early diagnosis. Broader measures, such as improving labour protections, access to education, and legal or language support for migrants, can further enhance men’s and their families’ well-being while ensuring more sustainable access to TB care. Limitations Our study had some limitations. The cost-of-living crisis, driven by fuel scarcity and price hikes during data collection, created challenges for both participants and the research team while amplifying existing inequalities in peri-urban settings. Underreporting of challenges related to TB stigma cannot be ruled out. To enhance participation and data quality, native interviewers conducted interviews in participants’ preferred languages, researchers received training on rapport building and sensitivity, topic guides were pre-tested, and reflective debriefings were held to refine techniques. An intersectional lens informed sampling and data collection, engaging diverse groups of men. However, due to time and budget constraints, we could not include other male-dominated populations facing compounded barriers, such as refugees, garbage collectors, sanitation workers, and men experiencing homelessness. Future studies should ensure equitable participation of marginalized men to enhance shared learning and practice. Although our geographical focus may limit generalizability, intensive engagement with local histories, economies, and health systems strengthens the depth and transferability of our findings. Conclusion Men’s TB care experiences reflected the intersecting effects of poverty, social expectations, occupational risk, and institutional barriers. Their delayed care-seeking was shaped not only by masculine norms but also by socioeconomic insecurity, peer scrutiny, and structural gaps within the health system—revealing overlapping systems of disadvantage. Current TB services often overlook both men’s gendered barriers and women’s local innovations that could help address them if scaled. Furthermore, limited use of community assets constrains the spread of TB information and services in informal settlements, perpetuating suboptimal access and ongoing transmission. Health systems must therefore recognize the layered barriers men face and leverage community resources to design more inclusive, adaptable, and gender-responsive TB services. References Global Tuberculosis Report 2024 [Internet]. [cited 2025 Apr 22]. 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08:31:41","extension":"html","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":147177,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7866183/v1/c91ce01e82f45ec2f250fda1.html"},{"id":93662963,"identity":"828e6900-2b17-40fd-9173-36dfe79aba9b","added_by":"auto","created_at":"2025-10-16 08:31:41","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":547614,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eThematic summary of intersectional gendered barriers facing men in peri-urban communities\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7866183/v1/12ea8d863cfa6788108e91bc.png"},{"id":93665567,"identity":"be6cffc8-d638-4983-981a-c543c94228fa","added_by":"auto","created_at":"2025-10-16 08:55:42","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1314410,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7866183/v1/9f3dae61-cd30-4e47-92e6-854cff4a7cb5.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003eAdapting health systems to men’s realities: An intersectional exploration of men’s barriers to TB care in Nigeria’s peri-urban communities\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eTuberculosis (TB) is a disabling and dispiriting disease enabled by poverty and deprivation that affected 10.8\u0026nbsp;million globally in 2023 (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Nigeria, where this research is based, ranks 6th globally and 1st in Africa for its TB burden of about 500,000 estimated TB incidences in the same year (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). In most parts of the world, including Nigeria, TB is highly gendered. Men have constituted the majority of people diagnosed and treated for TB for as long as WHO has kept track(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Globally, 55% of people who developed TB in 2023 were men followed by women (33%) and children (12%)(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). In Nigeria, TB incidence in men is two-fold that in women (751 [95% CI: 538\u0026ndash;965] vs 359 [95% CI: 213\u0026ndash;505] cases per 100,000 population)(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eWhilst globally about 8.2\u0026nbsp;million people with TB were correctly diagnosed and treated in 2023, more than 2.6\u0026nbsp;million were left undiagnosed, unreported or untreated(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Nigeria is among the 5 countries that account for over half of people with TB who miss out on care(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Numerous prevalence surveys, reflective of true population burden, have shown that globally and in sub-Saharan Africa, two out of every three people with TB who miss out on care are men(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Differences in Nigeria\u0026rsquo;s TB prevalence notification ratio (7.25 in men vs 4.63 in women) reveal men\u0026rsquo;s delay in TB diagnosis and care (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003cdiv id=\"Sec2\" class=\"Section2\"\u003e\u003ch2\u003e3.1 Gendered nature of TB burden\u003c/h2\u003e\u003cp\u003eThe gender pattern observed in TB is due to an interplay of biological, socio-cultural, and environmental factors. Whilst acknowledging women\u0026rsquo;s greater likelihood to develop extra-pulmonary TB (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) and face socio-cultural barriers to TB care due to lack of decision-making power (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e) and access to resources (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e), this manuscript focusses on the gendered burden of TB among men. Biological male sex is inherently associated with a higher risk of acquiring TB disease (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e) and developing recurrence (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Men tend to transmit TB more easily than women due to men\u0026rsquo;s better developed pectoral muscles that produce stronger cough expelling more bacilli (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e) and men\u0026rsquo;s social mixing pattern (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). In many settings, men suffer longer delays before reaching care (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) and among people who get on treatment, men are more likely to drop out of care, experience treatment failure, and death (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) thus remain infectious for longer periods.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003e3.2 Health in peri-urban settings\u003c/h2\u003e\u003cp\u003eAbout half of Nigeria\u0026rsquo;s 120\u0026nbsp;million urban population are affected by unsafe water, poor sanitation, crowding, poor housing, insecure tenure (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). These include people living in peri-urban settlements who lack access to urban privileges and amenities common in the affluent, well-planned cities nearby. Peri-urban suburbs accommodate highly mobile and transient populations of low socio-economic status reside in search of a living. Pollution, poor urban planning, high taxation of small-scale informal businesses (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e), limited employment, and food and economic insecurity heighten survival pressure among peri-urban dwellers, while overcrowded and poorly ventilated living spaces make TB transmission easy (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Despite the presence of public primary healthcare centres, informal health providers such as patent medicine vendors thrive in these suburbs. Tertiary healthcare is absent.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003e3.3 Importance of TB in achieving global and national health goals\u003c/h2\u003e\u003cp\u003eTB is the highest cause of deaths from an infection globally (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e), taking the lives of 1.3\u0026nbsp;million people globally, and over 67,000 in Nigeria in 2023. TB contributes significantly to disability and reduction in the quality of life(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e), including through post-TB lung disease (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Many people with TB face catastrophic costs (71% in Nigeria), stigma, and mental health challenges, including depression, which affects their livelihoods, families and communities(\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). With its chronic sequalae on the quality of life and livelihoods of affected individuals, families and communities, TB epitomizes the deleterious effect of the dual burden of diseases on low- and middle-income countries with shorter life expectancies than affluent countries (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAs a signatory to the End TB strategy, Nigeria has recorded notable progress; the proportion of people with TB who access TB diagnosis and treatment (treatment coverage) improved from 27% in 2019 to 74% in 2023 (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e), widening the gender gap (91% coverage for women and 65% for men) (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). The excess disease risk and its negative consequences in men carries population-wide implications for men as well as women and children sharing households, workplaces and neighbourhoods with them. Despite exposure to disease (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e) in informal peri-urban settlements, recovery is complicated by limited access to healthcare and the precarities of urban existence for the poor (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Approaches that ease care access for men with TB are crucial for the country\u0026rsquo;s progress towards eliminating TB as a public health challenge (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). This understanding is imperative for effective planning and implementation of TB services to fast-track the country on its path to achieving the goals of the End TB strategy.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003e3.4 Aim\u003c/h2\u003e\u003cp\u003eThis research seeks to explore how masculinities combine with multiple layers of disadvantage connected to the identities of men in peri-urban communities to inflex their access to TB services.\u003c/p\u003e\u003c/div\u003e"},{"header":"Methods","content":"\u003cp\u003eThis research is part of \u0026ldquo;Developing and Evaluating gender-responsive TB Interventions for communities in Nigeria\u0026rdquo; (DESTINE), a mixed methods implementation study affiliated with the \u0026ldquo;Leaving no one behind; transforming gendered pathways to health for TB\u0026rdquo; (LIGHT) Consortium (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). LIGHT is a six-year cross-disciplinary global health research programme led by a UK-based institution in collaboration with partners in Kenya, Malawi, Nigeria, Uganda, and the UK. LIGHT aims to support policy and practice in transforming gendered pathways to health for people with TB in urban settings (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). Here we report DESTINE\u0026rsquo;s exploratory qualitative cross-sectional study on men\u0026rsquo;s barriers to TB care.\u003c/p\u003e\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003e4.1 Conceptual framework\u003c/h2\u003e\u003cp\u003eMasculinities can be viewed as a system of power constructed within historical, cultural and political milieu (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Within it, hegemonic masculinities define aspirations and privileges for men imposing restrictive norms on men and marginalizing those who do not conform (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Rooted in Black feminist scholarship(\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e), intersectionality offers a framework for examining how interlocking social identities and structures of power such as race, gender, and class shape unequal health outcomes among marginalized people. Its adaptation to men\u0026rsquo;s health research(\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e) enables a deeper understanding of how race, masculinity, and structural inequities intersect to influence the health of Black and African men. This perspective shows how masculinities intersect with other systemic inequalities to influence men\u0026rsquo;s access to health services. Our research considers the social identities, positions and conditions of men in peri-urban communities in Nigeria that affect their access to TB services and the gendered systems of power that shape health systems in these contexts(\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). The WHO intersectional gender analysis framework (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e) guided out research design, data collection and analysis.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003e4.2 Research context\u003c/h2\u003e\u003cp\u003eOur research was conducted in purposively selected peri-urban areas, Karu, in North-central and Okpoko, in South-east Nigeria. Karu local government area (LGA) is on the western border of Nasarawa state, in proximity with Nigeria\u0026rsquo;s Federal Capital Territory (FCT), Abuja (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). Created in 1991, the FCT emerged as the fastest growing city in Africa, being the home of 4\u0026nbsp;million people, becoming the fourth most populous city in Nigeria behind Lagos, Kano, and Ibadan (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). Between 2003 and 2007, the FCT development authority demolished unapproved structures and evicted their residents (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e) to reduce pressures that the escalating population put on the city\u0026rsquo;s social amenities, sanitation, water, and aesthetics (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). Subsequently, poorly planned settlements sprung up around Nigeria\u0026rsquo;s FCT, as thousands of displaced households were unable to afford officially approved prime property within the city. Karu is one of these peri-urban areas, designated as FCT\u0026rsquo;s sub-urban districts (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e), characterised by rapid population growth, high-population density, limited water supply, poor sanitation, and unsustainable housing (\u003cspan additionalcitationids=\"CR36\" citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eSimilarly, Okpoko in Anambra state is a densely populated peri-urban settlement adjacent to the bustling city of Onitsha (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e). Although Onitsha had been a trade hub for centuries due to its location along river Niger, its influence in the region was propelled when the British colonial government set up a trade post in 1857 (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e). Onitsha main market has grown to become the largest market in west Africa (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e), enjoying patronage from local and international traders and attracting a high influx of migrants. In response to the escalating demand for affordable housing around the commercial powerhouse, Okpoko emerged as one of Nigeria\u0026rsquo;s most populous peri-urban settlements(\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e). It suffers persistent flooding due to its proximity to the Niger, unregulated development and congestion, historical underinvestment in infrastructure, poor waste disposal systems, predisposing Okpoko to frequent disease outbreaks (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\u003ch2\u003e4.3 Research team\u003c/h2\u003e\u003cp\u003eAn interdisciplinary team of researchers conducted the study. Author1, a male medical doctor and doctoral researcher from Nigeria, designed the study in consultation with his male supervisors, author5 and author6, UK-based senior researchers and consultants specialised in TB, and author4, a consultant community medicine physician in Nigeria. Author1 and author2, a female PhD social scientist from Nigeria, led community entry, recruitment, and data collection. Author3, a female German post-doctoral researcher with a UK institution based in Uganda, supported data analysis.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\u003ch2\u003e4.4 Sampling and recruitment of participants\u003c/h2\u003e\u003cp\u003eWe purposively sampled 20 community members for in-depth interviews (IDIs), 24 men for focus group discussions (FGDs), and 12 key stakeholders for interviews (KIIs), as shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Given the higher burden of TB amongst men, we sampled more men than women.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eSummary of participants recruited into the study\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMethod\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eType of Participant\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNumber\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eParticipants by gender\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eMode of Recruitment\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003ePurpose of recruitment\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIDIs\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCommunity members\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e12 Men\u003c/p\u003e\u003cp\u003e8 Women\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eSnowball sampling\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eTo understand factors shaping individuals\u0026rsquo; experiences of care\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFGD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMen in workplaces\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e24 Men\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eCriteria-based sampling of men in their workplaces\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eTo seek men\u0026rsquo;s views about their access to TB care\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e\u003cp\u003eKIIs\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePolicymakers and TB actors\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e12 (shown below)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6 Men\u003c/p\u003e\u003cp\u003e6 Women\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eKey informant sampling\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"4\" rowspan=\"5\"\u003e\u003cp\u003eTo reflect community views on factors affecting access to TB care, and seek solutions\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePatient advocates and civil society leaders\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1 Man\u003c/p\u003e\u003cp\u003e1 Woman\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ePurposively selected based on leadership in TB advocacy\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNGO based actors\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2 Men\u003c/p\u003e\u003cp\u003e2 Women\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ePurposively selected based on experience in active case finding\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eState and LGA policymakers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2 Men\u003c/p\u003e\u003cp\u003e2 Women\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ePurposively selected based on expertise in TB programmes at state level (n\u0026thinsp;=\u0026thinsp;2) and LGA level (n\u0026thinsp;=\u0026thinsp;2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePatent medicine vendors\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1 Man\u003c/p\u003e\u003cp\u003e1 Woman\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eSnowball sampling of patent medicine vendors rendering TB care in the communities\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"6\"\u003eNote. LGA\u0026thinsp;=\u0026thinsp;Local Government Area; NGO\u0026thinsp;=\u0026thinsp;non-governmental organisation; TB\u0026thinsp;=\u0026thinsp;tuberculosis.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe 20 community members (12 men and 8 women) were selected through snowball sampling for IDIs to conceptualize the factors affecting access to TB services through individual experiences. We identified the initial participants (n\u0026thinsp;=\u0026thinsp;12, men\u0026thinsp;=\u0026thinsp;6, women\u0026thinsp;=\u0026thinsp;6) who had presented with symptoms presumptive of TB to local Primary Health Centres from TB service register. Subsequently, participants linked us to other similarly symptomatic members of their communities, including five people (men\u0026thinsp;=\u0026thinsp;3, women\u0026thinsp;=\u0026thinsp;2) who had attempted (unsuccessfully) to seek care for their symptoms, one man who had been declared lost to follow up on a previous treatment cycle, and two people who had never sought care. Most men were employed in the informal sector including one migrant worker (from a minority ethnic group), one identified as unemployed but engaged in subsistence farming. Most women and men were married while two men were single, and two women were single parents (one widowed, the other separated). One woman was living with a disability on account of a neglected tropical disease.\u003c/p\u003e\u003cp\u003e FGDs sought to understand collective views of what seeking and accessing TB care meant for men in selected occupations in peri-urban settlements and how they navigated the health challenges encountered. Three male-specific FGDs focused on men\u0026rsquo;s lived experiences and customs around gender. We purposively sampled occupational groups based on anticipated TB exposure and health care barriers to include commercial tricycle operators (\u003cem\u003ekeke napep\u003c/em\u003e drivers) (n\u0026thinsp;=\u0026thinsp;8); bus drivers and conductors (n\u0026thinsp;=\u0026thinsp;8); and artisans (n\u0026thinsp;=\u0026thinsp;8). Information about the research was explained to the prospective IDI and FGD participants including voluntary participation and confidentiality of information. All provided written informed consent.\u003c/p\u003e\u003cp\u003eTwelve health system actors were recruited for KIIs to discuss community views on access to TB care. They comprised two local government TB supervisors, two patient advocates (one leads a community-based support organization), two regional leads and two country leads in NGOs, two State TB Programme Managers, and two patent medicine vendors involved in TB screening initiatives. We invited them via emails and phone calls and shared the participant information and informed consent sheets by email. Some preferred to have the information and consent giving process in-person. We scheduled interviews with participants at their convenience within a fortnight.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003e4.5 Data collection\u003c/h2\u003e\u003cp\u003eData were collected from April to August 2022. Semi-structured topic guides were informed by the research objectives and intersectionality framework, involving 13 questions for IDIs and 9 questions for FGDs, to elicit in-depth data in the direction participant\u0026rsquo;s narratives whilst iteratively referring back to the topic guide with opportunities for probing (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e). The IDI topic guide was pre-tested amongst two community members (one man and one woman) who did not participate in the research. Afterwards, author1 and supervisors modified all guides, simplifying the language and modifying the flow.\u003c/p\u003e\u003cp\u003eAuthor1 and author2 conducted IDIs with research assistants as note takers and timekeepers. All IDIs were conducted in offices at health facilities that provided sufficient audio-visual privacy and lasted 30 to 50 minutes.\u003c/p\u003e\u003cp\u003eAuthor1 facilitated the FGDs with men in their workplaces, including motor-parks and a stall for artisans. A research assistant functioned as the rapporteur timekeeper, administering a quality assessment checklist reflexively during FGDs to ensure adherence to FGD steps and engaging discussion. Each FGD lasted 50 to 60 minutes.\u003c/p\u003e\u003cp\u003eFindings from the community members were synthesized and fed into the KIIs to understand their perspectives on the mechanisms behind IDI and FGD findings and possible ways forward. Most KIIs occurred in participant\u0026rsquo;s offices. Due to acute fuel scarcity and hike in fuel prices at the time, we conducted three KIIs virtually via zoom.\u003c/p\u003e\u003cp\u003eAll IDIs, FGDs, and KIIs were conducted in English, Pidgin, Igbo, or Hausa (the researchers are native speakers). Participant were compensated for their time (₦2,000/\u003cspan\u003e$\u003c/span\u003e4.80). Individual and group discussions were audio recorded with participants\u0026rsquo; permission. The research team took reflective notes and held weekly (virtual) meetings to reflect on experiences, interview process, emerging issues and themes.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003e4.6 Data management and analysis\u003c/h2\u003e\u003cp\u003eAuthor1 and a trained research assistant transcribed all audio recordings (n\u0026thinsp;=\u0026thinsp;35), using a naturalized transcription approach (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e). Reductions were minimal but important to enhance readability whilst preserving participants\u0026rsquo; original expressions.\u003c/p\u003e\u003cp\u003eOur analysis considered all data collected among men as well as data collected among women and stakeholders that referred to the realities of men. We used the reflexive thematic analysis approach, following Braun and Clarke (\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e) six stages: (i) Familiarization with the data: authors1,2,3, and 6 spent ample time listening to the audio recordings and/or reading the transcripts to become thoroughly familiar with the data and compare observations between those who collected data and those who did not. (ii) Generation of initial codes: authors1,2, and 6 coded five transcripts individually, labelling ideas contained in the data. In virtual meetings, they harmonised coding and grouped codes, addressing similar underlying thoughts, as descriptive second order codes and later as interpretive third order codes, keeping them close to participant\u0026rsquo;s very words. This coding framework was applied to all remaining transcripts. (iii) Searching for initial themes: authors1,2, and 3 observed the clusters of codes, identified underlying threads of meaning running through them, and coalesced into themes. Abstraction of themes occurred at both inductive and deductive levels. (iv) Review of the themes: author1 interpreted the data pursuing first an inductive course and reflecting upon the gender-related factors affecting access to care for TB presented in the data. Thereafter, he interpreted themes within the context drawing on intersectionality theory (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). (v) Defining and naming the themes: authors1 and 3 reviewed the initial \u0026lsquo;bucket\u0026rsquo; themes, renamed and conceptualised themes to clarify how they linked to each other and to the sub-themes. (vi) Report writing: author1 wrote the initial draft in accordance with COREQ standards(\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\u003ch2\u003e4.7\u0026nbsp; \u0026nbsp;Ethical approval\u003c/h2\u003e\n\u003cp\u003eThe research protocol was reviewed and approved by global north REC (21-099) and the global south REC (NHREC/21/05/2005/00867). We sought approval from community leaders prior to recruitment with support from Community Health Extension Workers in each study site. We explained the objectives and importance of the research and voluntariness of participation to the community leaders who endorsed the study.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eFigure 1 summarises men\u0026rsquo;s intersectional gendered experiences of TB symptoms, health seeking, and TB care in peri-urban areas in Nigeria. Data illustrate how masculinities intersected with other factors such as informality of work, occupation, education, socio-economic status, migration, and family situations to create systemic barriers to TB care among men. Due to strict masculine gender expectations and norms, many men in peri-urban settlements could not afford TB symptoms (Theme 1) while official TB information was not tailored to reach them (Theme 2). When developing symptoms presumptive of TB, men negotiated the least disruptive way to wellbeing within health systems viewed as feminine (Theme 3). After TB diagnosis, female healthcare workers used innovative strategies to engage and retain men in care within gender-blind health systems (Theme 4).\u003c/p\u003e\n\u003cp\u003e5.1 \u0026nbsp; Men cannot afford TB symptoms\u003c/p\u003e\n\u003cp\u003eMen in both peri-urban settlements experienced social and economic pressures that put them in positions where they cannot afford to show TB symptoms. Societal masculinity expectations of men as the primary \u0026lsquo;breadwinners\u0026rsquo; created pressure for men to continue working despite illness. Many worked without formal contracts to earn daily wages as bus and \u003cem\u003eKeke napep\u003c/em\u003e drivers, itinerant artisans, miners, and scrap metal collectors, among others. Their work offered little to no job security, no paid leave, and no health benefits. Time spent away from work, including for health, directly impacted their income. Social nets to safeguard households from precarities of ill health were non-existent. These men risked jeopardising food for their household when seeking healthcare.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;The people you came to see today are keke napep drivers\u0026hellip;Most of us don\u0026rsquo;t own the keke, it was given to us on hi-po (hire-purchase). We are supposed to pay a huge amount of money every day to the owners of the keke. Within one year, we are to pay back double the total cost of buying the keke. How do you now tell your boss that you didn\u0026rsquo;t make your daily return because you went to the hospital for cough? They will collect the thing (keke) from you and give it to a more serious person\u0026rdquo;.\u0026nbsp;\u003c/em\u003e(FGD \u003cem\u003eKeke napep\u003c/em\u003e drivers, Participant 5 Male)\u003c/p\u003e\n\u003cp\u003eMen endured symptoms without seeking proper medical help. Scarce job opportunities in Okpoko\u0026rsquo;s artisan sector, employing only the strongest, created competition between local and migrant labourers, generally perceived to be better in mining and masonry than locals. Men artisans had to normalise illness to maintain masculine competence as they would not be hired if they showed weakness. Worsening severity of symptoms threatened men\u0026rsquo;s livelihoods and forced some to resort to lower-paying jobs.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I worked a lot yesterday and the day before yesterday. Today I feel tired and decided to rest. Tomorrow I will regain my strength and continue. I will not show my sickness because like when companies use to hire us, if someone is not all that healthy, the person will not get work and will\u0026hellip; forget about anything money for that day\u0026rdquo;\u0026nbsp;\u003c/em\u003e(FGD Artisans Participant 2 Male)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;the work I was doing, furniture work, gives money but it requires strength. But for scrap (picking scrap metals), you will have no money. So, because of my sickness (TB), I no longer have the strength to do it, so I now do scrap work. It affected my family, it affected them very well their feeding, everything even their school fees. I will not be able to go back to furniture because it requires money to start again\u0026rdquo;\u003c/em\u003e (IDI 06 Male)\u003c/p\u003e\n\u003cp\u003eTB was portrayed as a deadly disease no one wanted to be associated with. Men with TB usually faced stigma and discrimination including within families and households. TB symptoms \u0026ndash; unrelenting cough and dramatic weight loss \u0026ndash; attracted the wrong kind of attention for the men. Once diagnosed and on treatment, TB medicines caused an embarrassing discolouration of urine. Men on treatment avoided using public male urinals at work for fear of being found out and labelled unfit or sick.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I urinated at elephant house (a public urinal near the market where he sells). Someone saw the colour of my urine which was like blood. They went and met my brothers and told them to find out what is wrong with me. By the time I got home, my brothers were asking me what was wrong with me, that I was urinating blood. I explained to them that I was taking a drug that changes the colour of my urine, and they calmed down. But those drugs can cause embarrassment to someone, if you want to urinate, you have to go to a hidden place.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(IDI 01 Male)\u003c/p\u003e\n\u003cp\u003eMen\u0026rsquo;s gender roles and economic pressures, harsh labour conditions, and TB stigma in peri-urban settings created an environment which prevented men from showing TB symptoms and seeking care early.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003e5.2 \u0026nbsp; TB information does not reach men\u003c/h2\u003e\n\u003cp\u003eMany men in both locations lacked access to the necessary information about TB and related services contributing to delayed help seeking for their symptoms. Health education in peri-urban settings was typically scheduled during working hours and delivered in the community or health facilities, not workplaces. Many men in informal employment worked long hours to maximise income and could not afford to take time off work for such activities. Men\u0026rsquo;s lack of TB awareness was coupled with misconceptions attributing TB to witchcraft or heredity.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Before I started the medication, I did not know anything about the TB. When I got sick, people thought it was witchcraft or that I was poisoned while others thought it was HIV infection. It was a man who saw me and recommended that I go for a TB test.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(IDI 11 Male)\u003c/p\u003e\n\u003cp\u003eMigrant workers unfamiliar with local customs faced additional barriers to health education due to language and culture. Most men in peri-urban settlements had limited knowledge about availability, cost, and location of TB services. Whilst TB services are free, they nursed speculative concerns about high costs of tests and treatment. Lack of awareness and fear of cost could delay healthcare seeking even among relatively affluent men in the peri-urban setting and prolong chances of transmission within affected households.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;All we are saying now seems to be only about money, but one of our brothers had tuberculosis. We were worried about the doctor\u0026rsquo;s prescriptions thinking that they will charge us a lot of money, but all those things were given to us free of charge. So, the challenge is that people fear the money, but the whole thing is free. It is the fear of money [laughs]\u0026rdquo;\u0026nbsp;\u003c/em\u003e(FGD Artisans Participant 4 Male)\u003c/p\u003e\n\u003cp\u003eNigeria\u0026rsquo;s National TB programme prioritised formal communication channels for the dissemination of TB information through TB campaigns and training for media experts during World TB Day. However, many men within underserved peri-urban settlements mistrusted these formal channels as sources of health information especially after the Covid-19 infodemic.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;The TB programme and the partners are doing quite a lot to ensure that information about TB is well disseminated in the country. We conduct annual capacity building for all our media partners in TV, radio and print media organisations. This year we also added social media influencers. This year alone across platforms we trained nearly one thousand, give them the correct information on TB and how to write correct news report on TB.\u0026rdquo;\u003c/em\u003e (KII 01 Policymaker Woman)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Like during Covid\u0026hellip;every time they announce in the radio and everywhere\u0026hellip; if you call a number (state emergency toll free number) they will tell you what to do, but many people said the number was not working. And they said, \u0026lsquo;don\u0026rsquo;t shake hands\u0026rsquo;, \u0026lsquo;don\u0026rsquo;t greet people\u0026rsquo;, \u0026lsquo;don\u0026rsquo;t take holy communion\u0026rsquo;, even \u0026lsquo;don\u0026rsquo;t go to church\u0026rsquo;. In the end, those things did not work. Everything we hear in the radio or TV, I take it as government trying to create confusion and make people afraid using propaganda.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(FGD 03 Participant 6)\u003c/p\u003e\n\u003cp\u003eParticipants made frequent references to suboptimal links between TB programmes and community-based institutions. Religious platforms and leaders emerged as trusted local agencies moulding opinion and role-modelling behaviour. Traditional leaders, market organisations, and football teams could also be leveraged as valuable resources to enhance TB messaging for men. TB survivors could play a critical role as advocates, with some participants identifying as survivors themselves.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;if you tell a sick person to go to hospital, he will tell you he has been prayed for \u0026hellip; so we need to carry this message to churches and mosques, inside markets, motor parks, places where men gather, where they play football in the morning. Once people see the bishop doing the test and he gives approval\u0026hellip;everybody will follow suit. While sensitizing them\u0026hellip; you know\u0026hellip; things are hard, so also inform them that the test is free.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(IDI 09 Man)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Toward the end of last year, I carried a man that was very sick. He was so weak and coughing persistently and was looking so thin that his bones were seen. I took him to the TB clinic at the local government\u0026hellip; where I was treated and cured of TB some years ago. They later diagnosed him with TB. This year around January, he came to this our keke park here to look for me and I was very surprised when I saw him because he added weight and looked like a human being. I did not recognize him and asked why he was looking for me, until he explained that he was the man I picked from head bridge that was sick last year.\u0026rdquo;\u003c/em\u003e (FGD Keke napep drivers Participant 5 Man)\u003c/p\u003e\n\u003cp\u003eKeke napep operators also signalled limited engagement with TB programmes as they often encountered people with persistent cough. Although many felt obligated to help, they were unaware of where to refer such individuals for assistance.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;for me I have carried not one, not two, not even three passengers with cough. The most painful one was when I carried someone beside me in the front seat of my keke. The person coughed to the point that he almost fell down from my tricycle. The second time he coughed, I threw my face to the opposite side, and we nearly had an accident\u0026hellip; I didn\u0026rsquo;t know what it was\u0026hellip;you know that was when COVID-19 was serious\u0026hellip; It made me realize that I didn\u0026rsquo;t know any health professional that I can refer him to. How I wish I knew the treatment hospitals at that time.\u0026rdquo;\u003c/em\u003e (FGD Keke napep Participant 3 Man)\u003c/p\u003e\n\u003cp\u003eMen in peri-urban settings missed out on TB messaging because TB programmes did not consider men\u0026rsquo;s economic obligations and social spaces for health education at the local level and often prioritised formal platforms over well-trusted community-based communication channels and champions.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003e5.3 \u0026nbsp; Men negotiate the least disruptive pathway to wellbeing\u003c/h2\u003e\n\u003cp\u003eFaced with economic constraints, social pressures, and limited TB information, men in the peri-urban settlements often sought the least disruptive way to manage their health. Many avoided formal healthcare facilities, which they perceived as time-consuming, costly, and inaccessible. As a first choice, men often resorted to informal providers, like traditional healers or patent medicine vendors, who offered quick, low-cost alternatives that aligned better with men\u0026rsquo;s work schedules and economic realities. By using informal pathways, men attempted to maintain a sense of control over their well-being without disrupting their responsibilities to family and work.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;If I go to the district hospital, I will spend the whole day, what will happen to my work? But I can easily buy drugs from the chemist even in the night to stop the cough even though the tiredness may continue. But I can manage once the cough reduces.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(FGD 3 Participant 4)\u003c/p\u003e\n\u003cp\u003eMost men viewed public health facilities as rigid and primarily catering to women and children. If symptoms persisted, men preferred healthcare from private providers for their convenience and flexibility.. Men and policymakers understood the convenience private clinics offered remaining open with full services beyond official hours, accommodating working men and treating clients with dignity.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Men tend to patronize the private sector more because of the convenience and flexibility. They don\u0026rsquo;t have closing hours, they work on weekends, so working men could come after five or six (in the evening) and still see a doctor. Nobody will look at them somehow and tell them they were late. As long as that hospital has a doctor on call, they would want to make money\u0026hellip;\u0026rdquo;\u003c/em\u003e (KII 01 Policymaker Woman)\u003c/p\u003e\n\u003cp\u003ePrivate informal providers were more affordable but both informal and formal private healthcare providers in the peri-urban settings frequently lacked the necessary capacity to diagnose TB. Whilst aiming to save money, men incurred repeated visits and additional costs.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;We went to three different hospitals that we felt were big hospitals. But after everything, nothing came out of it. All they did was charge us huge amounts of money. But thank God for Dr. O, he was the one that insisted we must do chest X-ray, he also interpreted the result by himself. I don\u0026rsquo;t really think private hospitals have the equipment to handle TB, because I was ready to do anything to ensure my daughter and I were treated.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(IDI 01 TB Patient Man)\u003c/p\u003e\n\u003cp\u003eMen\u0026rsquo;s tendency to negotiate care pathways across parallel health systems reflected a pragmatic approach to health. Many prioritized immediate responsibilities over their long-term health needs. Being disadvantaged by employment and limited economic opportunities, they made calculated trade-offs prioritising short-term gains of convenient services for temporary symptom relief and financial contributions to their dependents over formal diagnosis and treatment for their own health and economic stability in the long run.\u003c/p\u003e\n\u003ch2\u003e5.4 \u0026nbsp; Baiting and negotiation to engage and retain men in care\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eFrontline female healthcare workers, especially in Okpoko, observed that initiating and successfully retaining men in TB care often took additional work compared to women. From their perspective, men required extra time to build trust, greater resources to support care, more comprehensive information to foster collaborative decision-making, and more flexible service delivery to continue treatment.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;If you have both male and female diagnosed, and you have their results with you, it is much easier to enroll women on treatment, and it is easier to manage them. Most times you will be calling the men, and they will continue to give you excuses\u0026hellip; even throughout the course of treatment, you continue to pamper them and give them more attention to ensure that they complete their treatment.\u0026rdquo;\u003c/em\u003e (KII 09 Woman Healthcare worker 2)\u003c/p\u003e\n\u003cp\u003eHealthcare workers had to be flexible and innovative to adapt standard care and tailor services to each man\u0026apos;s needs. Occasionally they initiated services at men\u0026rsquo;s homes or workplaces and frequently baited and negotiated with men to encourage clinic attendance.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;We diagnosed a furniture maker who was very weak but said he did not have time to come to our facility for enrolment except we bring the drugs to his shop. I refused\u0026hellip; But each time I pass his shop, I see his workers and children and I know they are at risk of getting TB\u0026hellip; So, one day I took some medicines and weighing balance and went to enrol him in his shop\u0026hellip; Later I told him that some of the other tests (HIV test) cannot be done there at his shop. The next day, he called me by himself and came to our clinic.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(KII 04 Woman Healthcare worker 1)\u003c/p\u003e\n\u003cp\u003eHealthcare workers\u0026apos; ability, agency and autonomy to identify and respond to men\u0026rsquo;s needs during care varied. Some exhibited what was seen as insensitive and stigmatizing behaviour towards men whereas others called the men regularly and supported them through the process. Men recognised and appreciated the extra level of care which motivated them to respond positively to treatment and behaviour change education that would redound to overall better health and post-TB quality of life.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Sometimes they (healthcare workers at the TB clinic) called me on phone saying, \u0026lsquo;Mr. E how is your health? Are you taking your medication? How are you feeling? Keep taking it. If you don\u0026rsquo;t take it for even a day, you will be affected\u0026rsquo;. Not like the nurses at the district hospital who dodge you like a bullet and talk harshly\u0026hellip;These women here are really helping us. I have even stopped smoking and drinking. I used to be very stubborn but now, when you bring a cigarette near me, I begin to cough.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(IDI 011 TB Patient Man)\u003c/p\u003e\n\u003cp\u003eThe changes healthcare workers made required commitment beyond official job expectations as there were no formal guidance or additional resources to support these service adaptations.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eWe set out to understand how male gender intersects with other inequalities to shape men\u0026rsquo;s access to TB services in two peri-urban communities. Data suggest men in these settings must navigate social expectations, economic precarities, and health system limitations and rely on their community to access health information and care. Disadvantages associated with informal work, lack of education, and, in some cases, migrant status on top of the expectations towards men in the peri-urban context do not simply add up but interact in ways that amplify vulnerabilities of men in need of healthcare. An unwittingly dismissive attitude towards cough coupled with TB stigma, inaccessible TB information, prohibitive costs of taking time away from work for healthcare, and fear of hospital bills posed significant impediments among men in this context. When men sought care, they resorted to community-embedded informal providers, prolonging their time-lag before reaching proper TB care in formal healthcare settings. What is frequently referred to as men\u0026rsquo;s late care seeking reflects an accumulation of several attempts and trials at care seeking from healthcare providers where proper TB care was unavailable. Taken together, our findings demonstrate that men\u0026rsquo;s delayed TB care is not simply a function of individual choice but a product of intersecting social, economic, and health system constraints.\u003c/p\u003e\n\u003cp\u003eMen\u0026rsquo;s economic and social pressures are determinants of their TB care access. This aligns with research from precarious urban settings in eastern and southern Africa\u0026nbsp;(47,48)\u0026nbsp;where daily struggles for survival are gendered (49\u0026ndash;53). Dominant masculine ideals emphasise strength, self-reliance, and breadwinning, and condescend healthcare seeking as a sign of weakness\u0026nbsp;(25). Like in southern Africa, men in this study feared losing their livelihoods and social standing if they sought care. The exploitation of informal workers, like \u003cem\u003ekeke napep\u003c/em\u003e drivers and artisans, underscored how\u0026nbsp;restrictive gender norms\u0026nbsp;intersect with \u0026nbsp;weak protective labour laws in peri-urban settlements to create economic and health inequalities for men.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRecent steps by the Nigeria TB Programme, disaggregating routine healthcare data by sex, made men\u0026rsquo;s TB burden and TB care gaps visible(54). However, male-specific strategies to address TB gender gaps are lacking\u0026nbsp;(55). Rigid operation hours of public health facilities, clashing with men\u0026rsquo;s working hours and insecure employment, posed a structural barrier to TB care among men. This is consistent with evidence\u0026nbsp;(11)\u0026nbsp;that showed men working in precarious jobs lack the flexibility to attend health services during conventional clinic hours. As elsewhere\u0026nbsp;(48), many of our participants sought care from informal providers such as patent medicine vendors, despite their limited capacity to diagnose and manage TB effectively.\u0026nbsp;Reliance on informal healthcare can lead to inadequate treatment, increasing chances of TB transmission and worsening health outcomes including lifelong disability, post-TB lung disease, and mortality\u0026nbsp;(56).\u0026nbsp;Men\u0026rsquo;s preference for private or informal health providers due to convenience and respect, reinforce the need for TB programs to integrate these providers into formal care pathways\u0026nbsp;(57).\u003c/p\u003e\n\u003cp\u003eMen use both informal and formal healthcare providers depending on symptoms and their financial fears. Although the strength and weakness of different systems were known, linkages between these systems are weak. Men\u0026rsquo;s experiences highlight this disconnect as well as the potential for collaboration and linkages through strengthened referral systems to improve overall quality of care and reduce diagnostic delays(58).\u0026nbsp;Similarly, conventional TB messaging failed to reach men effectively because health system actors and communities trusted different health information providers. Whereas the TB programme primarily engaged formal media channels, many men in peri-urban communities distrusted such channels. Our findings align with previous research highlighting the need for community-driven and context-specific TB communication strategies (59). TB programs should prioritize informal channels (60) like religious institutions, markets, workplace gatherings, and survivor-led advocacy, among others.\u003c/p\u003e\n\u003cp\u003eTB-related stigma emerged as a significant constraint to care among men who must constantly prove their manhood in workplaces and communities. TB stigma, associated with contagion, poverty, irresponsibility, and weakness\u0026nbsp;(20,61), is highly gendered. Evidence elsewhere suggests men are more likely than women to internalize stigma in ways that hinder help-seeking\u0026nbsp;(62). In our study, masculinity norms in peri-urban Nigeria reinforced TB stigma making men conceal TB symptoms (cough and weakness), medication and treatment side effects, like urine discolouration. Gendered TB stigma can limit men\u0026rsquo;s access to and retention in TB care, thus there is need for stigma reduction messaging to address harmful gender norms.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWhilst we set out to understand men\u0026rsquo;s gendered experiences, data also revealed the voluntary, unpaid, and often invisible extra labour provided by women frontline healthcare workers. They recognised and responded to needs of men and adapted their services at personal cost to retain men in care exemplifying how local innovation can help overcome health system limitations. Gender dynamics within healthcare settings have been shown to influence treatment adherence (63). In southern Africa, female partners and relatives have been reported to help men acknowledge symptoms, reach health facilities, and navigate losses through emotional and material support to become healthy again (64,65). Our study highlights the ability of female healthcare workers to build rapport, provide emotional support, and negotiate easier care pathways is crucial for retaining men in treatment. These efforts remained largely unrecognized and unrewarded within the health system that is heavily masculine at decision-making levels but relies on the unpaid or underpaid labour of women to compensate for systemic inefficiencies (66). In a sense, TB programmes appear to be gender blind, with barriers for poor men and non-recognition of adaptations by frontline women healthcare workers.\u0026nbsp;\u003c/p\u003e"},{"header":"Recommendations","content":"\u003cp\u003eAddressing compounded issues affecting men\u0026rsquo;s access to TB care in the peri-urban context requires systemic multi-layered solutions (67) and gender-responsive health system changes. Targeted, male-focused health communication is essential to close information gaps and improve access to TB care among men. Tackling stigma requires reframing TB narratives within peri-urban communities and engaging trusted figures such as religious and traditional leaders to normalize care-seeking. Community-led awareness must be coupled with accessible diagnostic services to bring TB screening closer to men. Advancing TB care for men should also include support for local innovations and fair compensation for unpaid frontline work, predominantly undertaken by women.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eExpanding TB services for men in peri-urban areas requires integrating community-based informal and formal private providers into the TB care network. These cadres could be trained and incentivized to identify and refer individuals with presumptive TB to nearby clinics, minimizing missed opportunities for early diagnosis. Broader measures, such as improving labour protections, access to education, and legal or language support for migrants, can further enhance men\u0026rsquo;s and their families\u0026rsquo; well-being while ensuring more sustainable access to TB care.\u003c/p\u003e"},{"header":"Limitations","content":"\u003cp\u003eOur study had some limitations. The cost-of-living crisis, driven by fuel scarcity and price hikes during data collection, created challenges for both participants and the research team while amplifying existing inequalities in peri-urban settings. Underreporting of challenges related to TB stigma cannot be ruled out. To enhance participation and data quality, native interviewers conducted interviews in participants\u0026rsquo; preferred languages, researchers received training on rapport building and sensitivity, topic guides were pre-tested, and reflective debriefings were held to refine techniques. An intersectional lens informed sampling and data collection, engaging diverse groups of men. However, due to time and budget constraints, we could not include other male-dominated populations facing compounded barriers, such as refugees, garbage collectors, sanitation workers, and men experiencing homelessness. Future studies should ensure equitable participation of marginalized men to enhance shared learning and practice. Although our geographical focus may limit generalizability, intensive engagement with local histories, economies, and health systems strengthens the depth and transferability of our findings.\u003c/p\u003e\n"},{"header":"Conclusion","content":"\u003cp\u003eMen\u0026rsquo;s TB care experiences reflected the intersecting effects of poverty, social expectations, occupational risk, and institutional barriers. Their delayed care-seeking was shaped not only by masculine norms but also by socioeconomic insecurity, peer scrutiny, and structural gaps within the health system\u0026mdash;revealing overlapping systems of disadvantage. Current TB services often overlook both men\u0026rsquo;s gendered barriers and women\u0026rsquo;s local innovations that could help address them if scaled. Furthermore, limited use of community assets constrains the spread of TB information and services in informal settlements, perpetuating suboptimal access and ongoing transmission. Health systems must therefore recognize the layered barriers men face and leverage community resources to design more inclusive, adaptable, and gender-responsive TB services.\u003c/p\u003e\n"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eGlobal Tuberculosis Report 2024 [Internet]. [cited 2025 Apr 22]. Available from: https://www.who.int/teams/global-programme-on-tuberculosis-and-lung-health/tb-reports/global-tuberculosis-report-2024\u003c/li\u003e\n\u003cli\u003eGlobal Tuberculosis Reports 1997 to 2023 [Internet]. [cited 2025 Apr 22]. Available from: https://www.who.int/teams/global-programme-on-tuberculosis-and-lung-health/tb-reports\u003c/li\u003e\n\u003cli\u003eNational TB prevalence survey.pdf. \u003c/li\u003e\n\u003cli\u003eHorton KC, MacPherson P, Houben RMGJ, White RG, Corbett EL. 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Missing men with tuberculosis: the need to address structural influences and implement targeted and multidimensional interventions. 2020 May 1 [cited 2024 Oct 1]; Available from: https://gh.bmj.com/content/5/5/e002255.abstract\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Liverpool School of Tropical Medicine","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Healthcare access, masculinities, intersectionality, Tuberculosis, Nigeria, peri-urban settlement","lastPublishedDoi":"10.21203/rs.3.rs-7866183/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7866183/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eAlthough men bear the brunt of TB globally and in Nigeria, understanding of men\u0026rsquo;s barriers to TB care is limited, including in peri-urban settlements where the risk of TB exposure is high. This research explored how masculinities combine with layers of disadvantage among men in peri-urban communities to limit their access to TB services. We conducted 20 in-depth interviews among 12 men and 8 women with presumptive or confirmed TB, 3 focus group discussions among 24 men in their workplaces, and interviews with 12 key informants exploring experiences of TB symptoms and care seeking. Audio recordings were transcribed and analysed using a reflexive thematic approach. Findings suggest many men in peri-urban settlements could not afford TB symptoms due to strict masculine gender expectations and norms (Theme 1), while official TB information was not tailored to reach them (Theme 2). When developing symptoms presumptive of TB, men negotiated the least disruptive way to wellbeing (Theme 3). After TB diagnosis, female healthcare workers used strategies such as baiting and negotiating to engage and retain men in care (Theme 4). In conclusion, health systems need to address the compounded barriers different groups of men in peri-urban settlements in Nigeria highlighted by this study and leverage existing community resources to create scalable adaptations to care that make services more responsive to their realities.\u003c/p\u003e","manuscriptTitle":"Adapting health systems to men’s realities: An intersectional exploration of men’s barriers to TB care in Nigeria’s peri-urban communities","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-16 08:31:36","doi":"10.21203/rs.3.rs-7866183/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ad5166d3-7a72-457c-8f44-6931a718b570","owner":[],"postedDate":"October 16th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":56333139,"name":"Infectious Diseases"}],"tags":[],"updatedAt":"2025-10-16T08:31:36+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-16 08:31:36","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7866183","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7866183","identity":"rs-7866183","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}