Exploring Sexual Health Communication Challenges and Opportunities Between Men Living with Diabetes and Healthcare Providers in Five Selected Districts in Ghana

Exploring Sexual Health Communication Challenges and Opportunities Between Men Living with Diabetes and Healthcare Providers in Five Selected Districts in Ghana | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Exploring Sexual Health Communication Challenges and Opportunities Between Men Living with Diabetes and Healthcare Providers in Five Selected Districts in Ghana Mawuli Kushitor, PhD, Mercy Adjei Adumatta, Wisdom Mejida Zinnya Mahama, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8221827/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 8 You are reading this latest preprint version Abstract Background: Diabetes mellitus remains a major global health concern with profound biomedical and psychosocial implications. In Ghana, the intersection between diabetes and sexual health is poorly understood and rarely discussed within clinical settings, largely due to sociocultural taboos and limited provider competence. This study explored the lived experiences of male diabetes patients regarding sexual health and examined the barriers and facilitators to sexual health communication between patients and healthcare providers. Methods: A phenomenological and exploratory qualitative design was adopted, involving in-depth interviews with 26 male diabetes patients and 14 healthcare providers across five hospitals in four regions of Ghana. Participants were purposively selected, and data collection continued until thematic saturation was reached. Interviews were audio-recorded, transcribed verbatim, and analyzed using conventional qualitative content analysis with the aid ATLAS.ti 7.5.7 software. Results: Sexual health communication between healthcare providers and male diabetes patients was limited by shyness, cultural taboos, and fear of judgment. Patients rarely disclosed sexual concerns unless in a calm, private, and supportive environment. Many male patients preferred discussing sexual issues with male providers and avoided such conversations with female staff. Healthcare providers reported lacking the skills and confidence to initiate sexual health discussions, leaving patients to self-manage sexual dysfunction through ineffective herbal and spiritual remedies. These gaps contributed to delayed care-seeking, marital strain, and worsening diabetes-related sexual dysfunction. Conclusion: The study reveals a significant communication gap between diabetes patients and healthcare providers concerning sexual health. Addressing this requires culturally sensitive training for healthcare workers, improved privacy in consultation settings, and patient-centered communication strategies that normalize sexual health discussions within diabetes care. Integrating sexual health into routine diabetes management will not only enhance patient-provider trust but also improve overall health outcomes and quality of life for individuals living with diabetes. Diabetes Sexual health Communication Barriers Facilitators Healthcare providers Ghana Qualitative study Introduction Diabetes has become an increasingly prevalent public health concern across many African countries and is strongly associated with sexual health complications, particularly among men ( 1 – 3 ). The most common of these is Erectile Dysfunction (ED), defined as the persistent or recurrent inability to achieve or maintain an erection sufficient for satisfactory sexual activity ( 4 , 5 ). Among men living with diabetes, ED results from a complex interplay of neurogenic, vasogenic, and psychological factors ( 6 ). Despite its high prevalence, the management of ED is often neglected in routine diabetes care. This neglect persists even though evidence shows that ED is one of the most treatable complications of diabetes, with therapeutic success rates exceeding 95% ( 7 ). Since introducing phosphodiesterase type 5 (PDE5) inhibitors nearly three decades ago, global treatment outcomes for ED have significantly improved ( 8 – 10 ). However, many men in African settings do not access professional help for ED ( 11 ). Evidence from Nigeria, for instance, shows that men rarely seek hospital-based treatment and often avoid discussing sexual difficulties with their physicians ( 12 , 13 ) instead, they commonly turn to herbal remedies rather than biomedical management ( 2 ). This communication gap around sexual health has allowed misconceptions about male sexuality and treatment to proliferate, enabling unregulated herbal markets to dominate ED care ( 2 ). While such remedies are easily accessible, they may harm men’s overall health. The reluctance to seek biomedical care for ED in African contexts is often attributed to culturally inhibited sexual communication. Both clients and healthcare workers experience discomfort discussing sexual issues ( 14 ), a barrier that needs to be addressed with cultural sensitivity. Yet research suggests that the problem extends beyond individual uneasiness to deeper systemic barriers. Diabetes clinics, for example, are typically overcrowded, leaving little privacy for sensitive discussions ( 15 ). Referrals to specialist care often involve additional costs or travel, creating further barriers to care. Moreover, most hospitals lack adequate infrastructure, staff, and training ( 16 ) to address sexual health needs comprehensively ( 17 , 18 ). As a result, healthcare providers rarely initiate conversations about sexuality, leaving patients with unanswered concerns. This neglect undermines men’s quality of life, relationships, and adherence to diabetes management plans. Previous research on ED and sexual dysfunction (SD) in Africa has predominantly focused on prevalence, aetiology, or pharmacological interventions, with limited attention to the dynamics of patient–provider communication. Where such studies exist, they often focus on single healthcare facilities, limiting the generalizability of findings. The present study addresses this gap by exploring sexual health communication related to ED and SD across multiple healthcare facilities in Ghana. Specifically, it examines five districts across four culturally distinct regions representing Ghana’s major ethnolinguistic groups. The study further investigates the opportunities and constraints faced by healthcare providers in engaging male clients about sexual health in a sexually conservative context, where men may find it particularly difficult to discuss such concerns, especially with providers of the opposite sex. Study Objectives This study seeks to examine how sexual health communication—specifically regarding erectile dysfunction (ED) and sexual dysfunction (SD)—is addressed within diabetes care in Ghana. It aims to explore the extent to which healthcare providers engage male clients in discussions about sexual health, the challenges that constrain such interactions, and the contextual factors that shape these dynamics. By analysing interactions across multiple healthcare facilities, the study highlights the systemic and cultural factors influencing the management of ED among men with diabetes. More specifically, the study pursues the following objectives: To explore the experiences and perspectives of men living with diabetes regarding sexual health communication within healthcare settings. To examine how healthcare providers perceive and address sexual health issues, particularly ED and SD, among their clients. To identify structural, cultural, and interpersonal barriers that hinder effective dialogue on sexual health in diabetes management. To assess opportunities for strengthening provider–patient communication and integrating sexual health discussions into diabetes care in Ghana’s culturally diverse contexts. Through these objectives, the study aims to generate insights that can inform the development of culturally sensitive, patient-centered strategies to improve the sexual health component of diabetes management in Ghana and similar settings across Africa. By focusing on the experiences and perspectives of men living with diabetes and healthcare providers, the study aims to bridge the gap in sexual health communication and enhance the quality of care. Methodology Study design This study adopted a phenomenological and exploratory qualitative design to examine the lived experiences of male diabetes patients regarding sexual health, its impact on daily life, and its management. Additionally, the study explored communication practices, facilitators, and barriers between patients and healthcare providers, as well as structural constraints within the healthcare system, from healthcare givers perspective. Study Sites and Context Data were collected from diabetes clinics in five districts across four regions of Ghana, representing the country’s major cultural and linguistic zones; Legon Hospital (Ayawaso District, Greater Accra Region), Margaret Marquart Catholic Hospital (Kpando Municipality, Volta Region), Sandema Hospital (Builsa North Municipality, Upper East Region), War Memorial Hospital (Kassena Nankana Municipal, Upper East Region), and Walewale Municipal Hospital (North East Region). These regions were purposively selected to ensure diversity in social norms, language, and healthcare delivery systems. The selected sites included both urban and rural health facilities, encompassing regional hospitals, district hospitals, and primary health centres. This multi-site design enabled the study to capture patient–provider communication variations across different institutional and cultural settings. Study Population and Sampling The study population comprised two main groups: Men living with diabetes, aged 30 years and above, who had attended diabetes clinics for at least six months. Healthcare providers, including physicians, nurses, diabetes educators, and counsellors, routinely engage with diabetic clients A purposive sampling technique was employed to recruit participants with direct experience relevant to the study. Among the male diabetes patients, 10 were from Kpando Municipality, 8 from Ayawaso District, and 8 from Builsa North Municipality. For healthcare providers, 10 were from Kassena Nankana Municipal and four from Walewale Municipal.The saturation method was used to determine the final sample size. Data collection continued until no new insights emerged, ensuring that additional data would not contribute significant value to the study. Saturation was identified through the interview and observation process, confirming the adequacy of the data collected for analysis and conclusions. Data Collection Methods Data was collected through in-depth face-to-face interviews using a semi-structured interview guide. The guide covered key areas, including participant demographics, diabetic sexual health challenges and their impact, and facilitators and barriers to sexual health communication. The interview guide was adapted from the RODAM qualitative protocols developed by Aikins et al. in 2012, ( 19 ). All interviews were conducted in a calm, private environment, suitable for patients and healthcare providers' consulting offices. The interview process involved probing questions such as “Can you elaborate more on this? Can you clarify this further? What experiences have you had in this regard?” to facilitate a clearer understanding of the concept for both the researcher and the participants. Two audio recorders were used during each interview session to ensure accuracy and completeness. Additionally, handwritten notes were taken to capture key points and serve as a backup in case of the recorders' technical malfunctions. This dual-recording approach also allowed for cross-verification of data accuracy. The duration of interviews ranged from 30 to 45 minutes each. Box 1. Key areas of the interview guide. Sexual Health and Communication Perspectives from diabetic men 1. Overall sexual health experiences (and its effects on daily life and intimate relationships) 2. Challenges with sexual communication 3. Management of sexual health communication 4. Sexual health disclosure (confidential people, preferred healthcare provider, reasons for disclosure and preferred healthcare setting for sexual health communication) Perspectives from healthcare providers 5. Management of sexual health communication 6. Facilitators to sexual health communication 7. Barriers to sexual health communication (patients and institutional barriers to sexual health communication) Data Analysis Data were analysed using conventional content analysis, allowing themes and categories to emerge inductively from the participants’ narratives. The collected data were transcribed verbatim to facilitate textual analysis, after which the transcripts were read multiple times to ensure familiarity with the content. An iterative coding process was applied, where similar findings were grouped to form initial codes. These codes were then categorised into sub-themes based on shared patterns, and from these sub-themes, main themes emerged, reflecting broader aspects of the findings. Where necessary, some themes were merged or refined to establish well-defined patterns of shared meaning with a central idea. A descriptive narrative of themes, analytical interpretations, and data extracts were used to provide depth to the findings. Thematic analysis was conducted using ATLAS.ti version 7.5.7 (ATLAS.ti GmbH, Berlin) to ensure a systematic approach to coding, categorisation, and pattern recognition within the dataset. Ethical Considerations Ethical approval was obtained from the Research Ethics Committee of the University of Health and Allied Sciences (UHAS-REC). The School of Public Health, UHAS, secured a formal introduction letter to seek institutional permission for data collection at the selected hospitals. Informed consent was obtained from all participants before their involvement in the study. To ensure anonymity and confidentiality, participants were assigned unique identification codes instead of using their real names, and no personally identifiable information was recorded. Participation was entirely voluntary, and participants were informed of their right to withdraw at any time without consequence. Results The results reveal sexual health communication experiences and perspectives from both diabetic men and healthcare providers. The results are presented in order of dominating and consensual themes, followed by minority themes. Areas of conflict and contradiction are presented where these occur in respondents’ narratives. Quotes that best capture shared or unique ideas are presented for illustration. Respondents are identified by letters and numbers, corresponding to the detailed respondent profiles in Tables 3 and 4 in the appendix. We present a comparison of barriers and facilitators to sexual health communication from the perspectives of both study participants and providers in table 2. Detailed overall thematic table for this study is presented in table 5 in appendix. Sociodemographic Characteristics Tables 1 present the summary sociodemographic characteristics of the study participants, including healthcare providers and male patients with diabetes recruited from various healthcare facilities across Ghana. Table 3 details the 14 healthcare providers, including their gender, age, educational background, professional roles, healthcare facility, and years of experience. The participants comprised doctors, physician assistants, nurses, and senior nursing officers, with years of experience ranging from 1 to 12 years. Most were from War Memorial Hospital (Kassena Nankana Municipal) and Walewale Municipal Hospital, representing diverse professional experiences in diabetes management. Table 4 presents the detailed sociodemographic characteristics of the 26 male patients with diabetes, including age, educational background, marital status, occupation, religion, ethnicity, district, treatment facility, and duration of diabetes. The participants were recruited from the University of Ghana Hospital, Margaret Marquart Catholic Hospital, Sandema Government Hospital, and other facilities. Most participants had a secondary or tertiary education, and their occupations ranged from teaching and farming to business, civil service, and technical professions. The duration of diabetes varied, with some newly diagnosed patients (3–6 months) and others living with the condition for over 20 years. Table 3 and 4 are presented in the appendix. Table 1: Sociodemographic of participants Variables (men living with diabetes) Total number of respondents (n=26) AGE 45 and below 17 Above 45 9 Educational Level JHS 1 SHS 9 Tertiary 16 Marital Status Married 18 Not married 8 Years With Condition Below 10 21 10 and above 5 District Kpando 10 Builsa North Municipal 8 Ayawaso District (Accra) 8 Healthcare providers Total number of respondents (n=14) Males 11 Females 3 Years Of Experience 5 and below 10 Above 5 4 Facility War Memorial Hospital 10 Walewale municipal Hospital 4 Table 2. Barriers and Facilitators of Sexual Health Communication Barriers Patients’ experiences Healthcare provider’s experiences Convergent Lack of privacy Opposite gender of healthcare provider No need to disclose Sexual matters are secret It can’t be managed by the hospital Shyness Opposite gender of healthcare providers Lack of privacy Client’s misconceptions on sexual health and clinical management Trust issues Lack of privacy Opposite gender of healthcare provider Client’s misconceptions Institutional Barriers Diabetes healthcare providers not being competent enough to handle sexual health issues. Long queues leading to limited consultation time Facilitators Patients’ experiences Healthcare provider’s experiences Convergent Privacy Same gender healthcare provider Friendly, calm and conducive room For solution Privacy Same gender healthcare provider Friendly, calm and conducive room Healthcare provider initiating sexual health conversation Clients overwhelmed of the condition and intimate relationship challenges Privacy Same gender healthcare provider Friendly, calm and conducive room For solution FACILITATORS TO SEXUAL HEALTH COMMUNICATION Several factors were found to facilitate sexual health communication, most of which centered on creating an enabling environment. Both the physical setting and the nature of human interaction shaped sexual communication. Participants emphasised the importance of having a private and comfortable space within the hospital—one that provided the right atmosphere for open discussion about sexual health. Nearly all participants emphasised the importance of a calm and conducive setting, a view echoed by healthcare providers who identified such an environment as crucial for meaningful conversations. The gender of the provider also played a significant role: many men reported discomfort in discussing sexual health concerns with female doctors or nurses, describing it as particularly difficult to talk about issues related to sexual performance. Across all discussions, confidentiality and an empathetic, engaging healthcare provider emerged as the most critical factors enabling open sexual health communication in clinical settings. Health system-related facilitators/structure of the healthcare system Preferred Setting for Sexual Health Discussions: Many participants expressed a preference for discussing sexual health matters in a private setting, such as a doctor’s office, where confidentiality could be maintained. Healthcare providers affirmed this view, noting that patients feel more at ease and open in a calm, comfortable, and welcoming consulting room. Quotes from participants illustrate this point. Private setting " Private place. No, no, no, no. I can't expose myself in public like that. Oh. But when you go to the doctor, I can discuss with.” (farmer, 67yrs) " at first, they use to do the consulting at this place, that place is not secretive, but today they have moved to this room, that one is okay, the inner room. But I don’t know if the diabetic people treat sexual weakness. But if they also treat sexual weakness, then I think they should use the inner room” (teacher, 42yrs) Privacy, conducive and friendly environment “Until recently, there was an elderly man, middle-aged, that came with erectile dysfunction. In fact, he actually did not come straight. He started going around, giving different complaints. And then when he realized that the place was calm for him to talk, then after he finished saying what was not important, then he came back to what actually brought him that his thing is not working.” (Female physician assistant, S1) “Anywhere that I meet the doctor. Anywhere that is or his office, so I want it to be his or her office, private. You know, when you have one-on-one with your doctor, where, you see the doctor, you see him personally. So, you can tell her or him that my sister or my doctor, I'm having this problem. How can you help me? So, we can discuss it. Like the woman here, the female doctor here. She is very free. So, when I go, we talk, we talk at length. She ask me questions and I answer. So, such a person, I can express myself to her and she will advise me. because, they are our mothers.” (retired teacher, 45yrs) “The sexual problems, people tend to shrink, but they prefer one-on-one than to have nurses hanging around. And so they feel.., some are not able to talk about it. But when they see that the place is calm and they are reassured that they can continue to talk, their information will not go out, then they can express. So it's a two-way kind of, depending on the situation”. (Female physician assistant, S1) The quotations above indicate that although sexual weakness is a significant concern for many men, bringing up the issue with a healthcare provider can be influenced by various contextual and interpersonal factors within the hospital setting. As a result, some patients may endure the condition silently for extended periods, either because they feel uneasy discussing it with their provider or because the environment does not encourage such conversations. Patient-related factors Trust and confidence in the healthcare provider Trust and confidence were identified as key enablers of effective communication. Patients who had multiple encounters with the same healthcare provider and established a rapport over time were more likely to feel comfortable sharing sensitive issues. This familiarity fostered a sense of trust that encouraged openness and honesty in discussing personal health concerns. A nurse narrated: “Well, sometimes before some of these patients will tell you their sexual needs, they should have had some trust and built some confidence in you before they will say it. Some will visit you several times before they feel safe to discuss with you. So, the system, I don't know whether it's the system or the individual, most of them do not freely tell you their sexual problems until they build trust and confidence in you” (male nurse, S9) Preferred Healthcare Provider for Sexual Health Discussions: Most male participants preferred discussing sexual health issues with male doctors, believing that men would better understand their struggles and would not judge them, also because they would not be so shy since their of the same gender. However, only one participant had a different view: "I will tell the female doctor, The women, they enjoy sex so much. So, if you involve them, they will tell you what to do." (retired teacher, 45yrs) “Yeah, some openly discuss. For male to male, they easily discuss, they are open. Because when they come and you welcome them, and you have a good communication with them, they openly tell you that, oh, they don't have erection.” (male physician assistant, S5) “Yes, the male, actually when they come, they feel free. When they see you as a male clinician, they feel free to discuss anything with you. Unlike the female.” (male nurse, S10) " I would like to take it to the male doctors. Okay. Maybe old people who are in the community. Maybe there is a way that they can also help you.” (teacher, 35yrs) “Male doctor. As today, when I... The woman was questioning me, the doctor. I told her that this is nothing to me. The issue. So she just advised me that I shouldn't worry because of my age. I'm getting to 70, So, my brother, don't worry. Don't do this, do this. That's what she told me” (farmer, 67yrs) “When it comes to communication, because I'm a female, coming in contact with a female client, most of them open up. They will tell you, oh madam, these days I have, when I'm to sleep with my husband, the vagina is always dry. So the females open up. But the males usually don't want to open up to we the females” (female doctor, S2) Confidentiality in other people: Participants were generally cautious about whom they confided in regarding their sexual health concerns. Male participants tended to share such issues only with their wives, brothers, close male friends, or colleagues who had experienced similar problems. While some felt comfortable opening up to trusted individuals within these circles, others chose to keep their challenges entirely private. Participants narrated: " why not? She's my wife. I have to discuss with her. And also one of my friends that I travel to do business with.” (farmer, 40yrs) “Maybe a colleague male diabetic patient. Yeah, I asked one person, he said yes, it normally has effect on your sexual your sexual health.” (teacher, 42yrs) " oh apart from my wife, no one. I can only confide in someone who also has the problem, so that he can give me an advice since he also have experience"(navy pensioner, 72yrs) Reasons for Disclosing: The main motivations for sharing sexual health challenges were to seek possible solutions and to prevent conflicts or misunderstandings within their marriages.These are some perspectives from patients: “I discussed with my junior brother. Though if you tell your problems to people, you will get solutions, but this one de3, if I go and tell people that I cant have sex with my wife, someone will come and take my wife. Because its not everything that you should disclose to people” (unemployed, 40yrs) " I let her know that this is what is happening to me and she should not be worried or try to go to any other person. Sometimes we worry about it”. (Priest, 46yrs) However, some healthcare providers observed that patients tend to open up about their sexual health problems only when the situation becomes overwhelming—particularly when it starts to take a psychological toll or creates tension within their marriage. “I would not say trust anyway, but they normally feel that, no, I just have to express my feelings. So, it's like they are always trying to express themselves, maybe the way I take it, out of maybe anger or frustration. So, in that sense, they don't actually see it as they build some confidence in you, that is why they are saying. But then, they are actually always looking so furious, that is what makes them to discuss their issues, some of their issues, sexual issues with me” (Male Nurse, S3) “They come with complaints that they cannot perform and they are having issues in their marriage and relationships. When you go further, it's either the interest is not there or they are unable to get sustained erection.” ((Male Nurse, S9) BARRIERS TO SEXUAL HEALTH COMMUNICATION Healthcare providers highlighted several obstacles that limit effective discussions about sexual health between diabetic patients and medical professionals. Most of these challenges were linked to the broader health system. Key barriers included the lack of privacy, long waiting times resulting in brief consultations, a shortage of sexual health specialists, limited availability of necessary medications, and inadequate training or preparedness among healthcare providers. Many providers emphasised the need for specialised training to enhance their capacity to address sexual health concerns. In addition, patient-related barriers—such as shyness, fear of being judged, lack of privacy, cultural constraints, mistrust of healthcare providers, gender differences between patients and providers, and misconceptions about sexual health—were also identified. Notably, many of these issues aligned closely with the challenges reported by patients themselves. Health System-related barriers/ structure of the healthcare system Lack of Privacy: A key obstacle to effective sexual health communication was the lack of privacy. Patients reported feeling uneasy discussing intimate matters in open spaces or when other people were present during consultations. Unfortunately, most diabetes clinics lack the level of privacy required for men to talk about such issues comfortably. Even in cases where private spaces exist, they are often shared with nurses or other staff, making them unsuitable for confidential discussions. Additionally, the high patient turnout on clinic days creates time pressure for healthcare providers, meaning that even when physical space is available, limited consultation time often prevents meaningful conversations. One physician assistant noted: “Not all the time. Sometimes when there's pressure, there are a lot of people around. There are other conditions that nurses are there to help with. The sexual problems, people tend to shrink, but they prefer one-on-one rather than having nurses hanging around the consulting room. And so they feel.., some are not able to talk about it” (female physician assistant, S1) Long Queues Leading to Limited Consultation Time: Because diabetic clinics often serve a large number of patients, healthcare providers struggle to devote enough time to discuss sexual health concerns in depth. Due to shyness or embarrassment, many patients need time to gather confidence before opening up about such sensitive issues. However, the limited consultation time and the pressure to attend to many patients make it difficult for these conversations to take place. These are what healthcare providers said: "Most of them don’t get the time to express their problems with us because we want to hurry up. There are so many clients, and you need to attend to almost everybody. So that time is not there" (female doctor, S2, 35 YRS). "One client can sit and wants to engage you for like two hours, but we have long queues. So, we are forced to cut the session short, and the person may not get to fully talk about their sexual problems" (male nurse, S10, 36 YRS). Healthcare Providers Not Being Fully Equipped or Trained: Nearly all healthcare providers admitted that they had not received specialised training on how to initiate or manage discussions about sexual health concerns among diabetic patients. These are some highlights of what they stated: "I will need more knowledge on handling such cases. This has to do more with psychological support, and we are not adequately trained for that" (female doctor, S2, 35 YRS). “As for the sexual health concerns, I would say no. Per our setting, I think we are not adequately equipped. We may be able to handle their medical aspect. But when it comes to the sexual aspect, although we recommend some medication, but we may need more expertise or specialists to engage in the clinic to be able to assess their sexual problems and possibly find long-lasting solutions, physically, psychologically, socially, all that, to be able to let them go with their needs” (male physician assistant, S6, 39yrs). Inadequate Essential Medical Equipment at Facilities: Many healthcare facilities lack the essential diagnostic tools and medical equipment required to properly evaluate and manage sexual dysfunction among diabetic patients. Participants narrated: "We still need more equipment because most of the modern tools that can be used to detect certain dysfunctions are lacking" (male snr. Nursing officer, M1, 39 YRS). "There is no gynaecologist here for sexual health. Many patients require specialised attention, but we don’t have the equipment or experts to handle it" (male nurse, M4, 32 YRS). Inadequate Necessary Medications at Facilities: Many healthcare facilities face challenges in ensuring a consistent supply of medications needed to treat sexual dysfunction associated with diabetes.They emphasised: "Even though their medication is given free, it is not all the time that we always have medications available for them. Sometimes, some of them come disappointed because the medication is not there for them to take" (male nurse, S3, 36 YRS). "When they come, the medicines are not there, so we have to write for them to go and buy. Whether they can afford it or not, we cannot tell" (male physician assistant, S8, 36 YRS) Healthcare Providers' Requests: About 10 of the 14 healthcare providers interviewed expressed the need for specialised training to improve their ability to discuss and manage sexual health concerns in diabetes care. Quotes from a doctor and a nurse: “No. I will need more knowledge on handling such cases. Okay, because this has to do more with psychology. You talk to them, you prepare them psychologically, then they will be able to open up”. (female doctor, S2, 35 Yrs) “Sincerely, we are not competent in that area as we would have wished. And I think that is one thing our professionals, you are a student, so you should be advocating for that. Nurses should be trained more on that, to be able to attend to the sexual health needs of clients. For that, sincerely, we are not that much equipped” (male snr. Nursing officer, M2, 37yrs) Patient-related barriers Shyness, cultural restrictions and fear of judgment: The main barrier to sexual health communication identified in this study was patients’ hesitation to openly express their concerns, mainly due to shyness, cultural taboos, and fear of being judged. Many patients—especially women—avoided discussing sexual health matters because of deep-rooted cultural norms that discourage open dialogue about sexuality. Among men, disclosure was often tentative and indirect, with participants initially avoiding or speaking around the topic before eventually acknowledging their difficulties. Below are some quotes from healthcare providers; “As for the males, they do. Yes, like I said, recently that man who came, yes. But I've not had any complaint from the females. Maybe because of our culture, women feel shy to talk about sexuality. Unlike men, women have it as a necessary part of their life. They cannot live, so they tend to complain” (female physician assistant, S1) “Not actively engaged. Because there are some that will not even open up to you out of shyness or whatever it is. So, it’s not something that is well-discussed. But it’s few people that will open up." (male doctor, S7). “But because usually we engage with marriage clients, sometimes some of them feel shy to come out to actually discuss their sexual needs to us. But then just a few of them sometimes are bold enough to just tell us what they are experiencing” (male nurse, S3) “Sometimes, I remember I had one, a very elderly man. And when he also came, he was going around the bush. And finally, at a point, he said, My daughter, I see that you may be feeling like at my age, I shouldn't talk about this, but this is my problem. And so he also mentioned it. Initially, they always had that reservation. They don't know what possibly you will say or think of them. But when they now start interacting and they see that, oh, they can say their main issue, then they will say it” (female physician assistant, S1) Trust issues: Trust between patients and healthcare providers proved to be a key factor influencing the disclosure of sexual health concerns. Some patients were willing to share their experiences because they trusted their providers. In contrast, others chose to remain silent out of fear or lack of confidence in the provider’s ability to keep their sexual issues confidential. A female doctor believed: “Yes and no. Few trust me. That's those that are open up. Because when you talk to them and they understand, they know that you want to help them. They do tell us certain problems they are facing. But some will not even open up to tell you the problem. So, in that case, why will they trust me?” (female doctor, S2) Gender difference in healthcare providers: The gender of healthcare providers significantly influenced communication about sexual health. Female patients were generally more comfortable discussing sensitive issues—such as vaginal dryness—with female providers, whereas male patients often hesitated or withheld information when their healthcare provider was female. Another practitioner said: “When it comes to communication, because I'm a female, coming in contact with a female client, most of them open up. They will tell you, oh madam, these days I have, when I'm to sleep with my husband, the vagina is always dry. So the females open up. But the males usually don't want to open up to we the females” (female doctor, S2) Misconceptions about sexual issues: Some diabetic patients attributed their sexual health problems to supernatural causes, leading them to believe that such issues could not be treated in a hospital setting. This belief often hindered open communication and delayed proper medical care. Additionally, some patients held misconceptions that prescribed medications were intended to cause infertility. The quotes below illustrate these points. “Some of the misconceptions are that there are others who believe it is spiritual. They don't believe that it is actually a natural medical condition. So, you see a lot of them. And then there are others who also believe that there is a deliberate intention to render some people impotent. And for that matter, they are given the medication. That is why some of them don't get sexual erection” (male nurse, S3) Misconnection on sexual health medication: “And then some, when they are enrolled into the medication, they feel or they have the misconception that the whites are always having the intention or the mind that we blacks, we reproduce much. So they want to do all means that they can to reduce the childbearing aspects of we, the blacks. So there are the misconceptions some of them are having” (male nurse, M4) Discussion Although effective treatments for sexual dysfunction exist, communicating these needs remains a substantial challenge for men living with diabetes in Ghana. Consistent with findings across sub-Saharan Africa, men in this study struggled to discuss sexual health concerns with healthcare providers, a barrier that prevents timely help-seeking for conditions that are both distressing and debilitating ( 3 ). The hospital environment itself emerged as a significant constraint, shaped by both systemic and personal factors. Similar to earlier Ghanaian work documenting communication barriers within overstretched outpatient clinics ( 20 ), our participants emphasised that men were more willing to disclose sexual concerns only when they perceived the clinical space as private, supportive, and confidential. Unfortunately, many of the facilities represented in this study did not provide such an ambience. Diabetes clinics in Ghana frequently operate under heavy caseloads often with hundreds of patients in a single clinic session making it almost impossible to guarantee the privacy required for sensitive discussions ( 20 ). This aligns with evidence from other African countries showing that overcrowded clinics and compromised confidentiality deter patients from discussing sexual dysfunction with clinicians ( 21 ). A systematic model for addressing male sexuality within routine diabetes care may therefore be required. Structural innovations such as designating specific clinic days for men, reorganizing client flow, or integrating psychosocial specialists such as clinical psychologists could allow for more comprehensive, client-centered conversations on sexual health. Such approaches parallel successful gender-sensitive interventions reported in Kenya and South Africa, where tailored clinic sessions improved men’s engagement with sexual and reproductive health services ( 22 ). The reluctance to discuss sexual health was consistent across all study regions, irrespective of religious or cultural background. Whether in predominantly Muslim northern communities or largely Christian southern contexts, men expressed similar difficulties initiating sexual health conversations. This finding reflects wider African literature describing how male sexual performance is closely tied to masculinity, identity, and social status, making disclosure of sexual dysfunction particularly stigmatizing ( 21 , 23 ). As a result, many men silently endure difficulties with erectile function, libido, or performance issues that have profound consequences for psychological wellbeing, marital stability, and adherence to diabetes management. Across Ghana and other African nations, men fear the social consequences of being labelled sexually weak, leading many to suppress concerns or seek alternative, often unsafe, remedies ( 22 ). This echoes the experiences documented in this study, where several participants described suffering in silence, turning to herbal or spiritual options, or self-managing complications in secret. The health system must therefore recognise male sexuality as a sensitive but integral component of diabetic care, not merely a secondary symptom of hyperglycemia. A particularly important implication arises from healthcare providers’ reports that they seldom initiate sexual-health conversations. This finding mirrors earlier Ghanaian research showing that providers feel undertrained, overburdened, and insufficiently equipped to manage sexual dysfunction in chronic-disease settings ( 16 ). A lack of provider-initiated dialogue has been associated with reduced treatment uptake, poor glycemic control, and deteriorating quality of life among men with diabetes. In settings where patients hesitate to start such conversations due to stigma, the absence of clinician engagement deepens the communication gap. Enhancing provider skills, particularly around sensitive communication, confidentiality, and culturally grounded counselling may therefore improve the detection and management of diabetes-related sexual dysfunction. Findings from this multi-regional Ghanaian study echo broader African evidence showing that sexual dysfunction among men with diabetes is both common and under-discussed, largely due to cultural expectations of masculinity, inadequate clinic environments, and limited provider capacity. Addressing these barriers requires targeted policy attention, including structural adjustments to clinic organization, integration of psychosocial support, and robust training programs enabling healthcare providers to confidently initiate and manage sexual-health conversations. Such reforms are essential to ensuring that sexual wellbeing is fully integrated into holistic diabetes care in Ghana. Limitations of the study Given the sensitive nature of sexual health, some participants, particularly male patients may have been reluctant to fully disclose their experiences due to cultural norms, fear of judgement, or embarrassment, potentially leading to underreporting. Additionally, as the study was conducted in selected public healthcare facilities, the transferability of the findings to private or tertiary healthcare settings may be limited. Conclusion This study demonstrates that the current structure and environment of diabetes clinics in Ghana do not adequately support open discussions about sexual health among male patients. Overcrowded clinic spaces, limited privacy, and the absence of calm and confidential consultation settings prevent men from disclosing sensitive sexual concerns. Participants consistently emphasized that a more conducive, private, and supportive environment would greatly facilitate such conversations. Although healthcare providers recognize the importance of addressing diabetes-related sexual dysfunction, many do not initiate discussions because they lack the necessary skills and confidence in sexual health communication. Targeted training is therefore essential to equip providers with the competencies required for effective sexual health assessment and management. To better respond to the sexual health needs of men with diabetes, we recommend the introduction of specialized clinic days dedicated solely to sexual health management within diabetes care. Such a model, combined with improved provider training and enhanced clinic environments, has the potential to strengthen communication, improve early identification of sexual dysfunction, and ultimately enhance the quality of diabetes care and patient well-being. Abbreviations ED Erectile Dysfunction SD Sexual Dysfunction Declarations Ethics approval and consent to participate Ethical approval for this study was obtained from the University of Health and Allied Sciences Research Ethics Committee (UHAS-REC) . (Approval No: UHAS-REC B.10 [147]24–25). All participants provided written informed consent before taking part in the study. Confidentiality and anonymity were strictly maintained throughout the research process. All methods were performed in accordance with relevant guidelines and regulations. Competing interests The authors declare that they have no competing interests. Authors’ information (optional) MK is a population scientist with an interest in population health and health systems. Specifically, the burden and management of Non-Communicable Diseases (NCDs) in urban cities in Africa. Key aspects of his research have led to important community level interventions for hypertension and diabetes in some cities. The author is intrigued by the intricate relationship between the built environment and the risk of cardiovascular disease (CVD) among the urban poor. Over the years he has developed the necessary competence in doing this kind of research. M.A.A. is a Public Health Nutrition Officer and researcher with expertise in non-communicable diseases and qualitative health research. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Author Contribution MK and MAA jointly conceived and designed the study. Both authors contributed to data analysis, interpretation of findings, and drafting of the manuscript. MAA and MK critically revised the paper for important intellectual content.WM, SAA, DBN, LQ, SRUA, and NJK did all the interviews with the study’s participants and generated the data.HKA reviewed the draft manuscript and gave feedback for improvement.All authors read and approved of the final manuscript. Acknowledgement The authors extend sincere appreciation to the healthcare providers and diabetes patients who willingly shared their experiences. We also thank the staff of the participating hospitals for their cooperation and support during data collection. Data Availability The datasets generated and analyzed during the current study are not publicly available due to confidentiality restrictions involving qualitative interview data. However, de-identified audios and transcripts may be obtained from the corresponding author upon reasonable request. References Kaya SP, Bilgehan T, ASSESSMENT OF THE RELATIONSHIP BETWEEN SEXUAL SATISFACTION, AND DIABETES SELF-MANAGEMENT IN ADULTS WITH DIABETES AND THE FACTORS INFLUENCING THIS RELATIONSHIP. Ankara Med J. 2025;(1):80–95. Kang WH, Sithik MNM, Khoo JK, Ooi YG, Lim QH, Lim LL. Gaps in the management of diabetes in Asia: A need for improved awareness and strategies in men’s sexual health. J Diabetes Investig [Internet]. 2022;13(12):1945–57. Available from: https://doi.org/10.1111/jdi.13903 Owiredu WKBA, Amidu N, Alidu H, Sarpong C, Gyasi-sarpong CK. Determinants of sexual dysfunction among clinically diagnosed diabetic patients. Reprod Biol Endocrinol [Internet]. 2011;9(70). Available from: http://www.rbej.com/content/9/1/70 Pellegrino F, Sjoberg DD, Tin AL, Benfante NE, Briganti A, Montorsi F et al. Relationship Between Age, Comorbidity, and the Prevalence of Erectile Dysfunction. Eur Urol Focus [Internet]. 2023;9(1):162–7. Available from: https://doi.org/10.1016/j.euf.2022.08.006 Odubia JS, Olalere CI, Ukanwa CM, Ogunjinmi LM, Adesina FO, Oyediran MO, et al. A Multidimensional Analysis of Erectile Dysfunction Etiology: The Interplay of Lifestyle, Comorbidity, and Age. Scicom J Med Appl Med Sci. 2025;4(1):58–70. Maiorino MI, Bellastella G, Esposito K. Diabetes and sexual dysfunction: current perspectives. Diabetes, Metab Syndr Obes Targets Ther [Internet]. 2014;7:Pages 95–105. Available from: https://doi.org/10.2147/DMSO.S36455 McMahon CG. Current diagnosis and management of erectile dysfunction. Med J Aust [Internet]. 2019;210(10):469–76. Available from: https://doi.org/10.5694/mja2.50167 Tsertsvadze A, Fink HA, Yazdi F, MacDonald R, Bella AJ, Ansari MT et al. Oral Phosphodiesterase-5 Inhibitors and Hormonal Treatments for Erectile Dysfunction: A Systematic Review and Meta-analysis. Ann Intern Med [Internet]. 2009;151(9). Available from: https://doi.org/10.7326/0003-4819-151-9-200911030-00150%0A RAINA R, LAKIN MM, SHARMA AGARWALA, GOYAL R, MONTAGUE KK. Long-term effect of sildenafil citrate on erectile dysfunction after radical prostatectomy: 3-year follow-up. ADULT Urol. 2003;4295(03):0–5. Nobili S, Lucarini E, Murzilli S, Vanelli A, Mannelli LDC, Ghelardini C. Efficacy Evaluation of Plant Products in the Treatment of Erectile Dysfunction Related to Diabetes. 2021;13(12). Available from: https://doi.org/10.3390/nu13124520 Nyalile KB, Mushi EHP, Moshi E, Leyaro BJ, Msuya SE, Mbwamo O. Prevalence and factors associated with erectile dysfunction among adult men in Moshi municipal, Tanzania : community- based study. Basic abd Clin Androl [Internet]. 2020;30(1):20. Available from: https://doi.org/10.1186/s12610-020-00118-0 Adebusoye LA, Olapade-olaopa OE, Ladipo MM, Owoaje ET. Prevalence and Correlates of Erectile Dysfunction among Primary Care Clinic Attendees in Nigeria. Glob J Health Sci [Internet]. 2012;4(4):107–17. Available from: http://dx.doi.org/10.5539/gjhs.v4n4p107 Okonkwo JEN, Uwakwe R, Obionu C, OKONKWO CV. Communication and sexuality in a Nigerian community. 1999;(1):61–8. Mgopa LR, Rosser BRS, Ross MW, Lukumay GG, Mohammed I, Massae AF et al. Cultural and clinical challenges in sexual health care provision to men who have sex with men in Tanzania: a qualitative study of health professionals ’ experiences and health students ’ perspectives. BMC Public Health [Internet]. 2021;1–12. Available from: https://doi.org/10.1186/s12889-021-10696-x Pretorius D, CouperProf I, Mlambo M. Sexual History Taking: Perspectives on Doctor-Patient Interactions During Routine Consultations in Rural Primary Care in South Africa. Sex Med [Internet]. 2021; Available from: http://creativecommons.org/licenses/ by-nc-nd/4.0/ Yin J, Rämgård M, Wangel AM. Sexual health in diabetes care is a ‘ hot topic ’– ­ A qualitative study with Diabetes Specialist Nurses. J Clin Nurs [Internet]. 2023;7568–77. Available from: https://onlinelibrary.wiley.com/doi/ 10.1111/jocn.16832 Mbanya JC, Ramiaya K et al. Diabetes Mellitus. In: Jamison DT, Feachem RG, Makgoba MW, Bos ER, Baingana FK, Hofman KJ, editors. Disease and Mortality in Sub-Saharan Africa [Internet]. 2nd ed. Washington, DC: The International Bank for Reconstruction and Development / The World Bank; 2006. Available from: https://www.ncbi.nlm.nih.gov/books/NBK2291/?utm Laar AS, Harris ML, Thomson C, Loxton D. Perspectives on barriers to traditional sources of sexual and reproductive health information and services: Are mHealth technologies the answer? Heal Promot Perspect [Internet]. 2024;14(3):258–267. Available from: https://www.ncbi.nlm.nih.gov/articles/PMC11612345/ Aikins AG. RODAM Work Package 7: Assessment of Perception and Knowledge of Obesity and T2D – Focus Group Discussion and Interview Protocols. Accra; 2012. Maghsoudi Z, Sadeghi A, Oshvandi K, Ebadi A, Tapak L. Barriers to Treatment Adherence Among Older Adults With Type 2 Diabetes: A Qualitative Study. J Gerontol Nurs [Internet]. 2023;49(1):42–49. Available from: https://doi.org/10.3928/00989134-20221206-04 Buzi RS, Smith PB, Access to Sexual and Reproductive Health Care Services. : Young Men ’ s Perspectives. J Sex Marital Ther [Internet]. 2014;40(2):149–57. Available from: http://dx.doi.org/10.1080/0092623X.2012.736923 PLEASE. Ngidi ND. In: Bhana D, Skovdal M, Govender K, editors. Young Masculinities and Sexual Health in Southern Africa. 1 ed. London: Routledge / Taylor & Francis; 2025. p. 322. Ouma-Odero M. That is somebody’s husband: Face-saving Strategies in Doctor–Patient Interaction in a Public Health Facility in Kenya. An Interdiscip J Heal Ethics Soc [Internet]. 2025; Available from: https://doi.org/10.3138/cam-2024-0021%0A Tables Table 3 to 5 are available in the Supplementary Files section. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8221827","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":580652949,"identity":"9ef5a0dc-47ec-4063-8edc-05e743904f4a","order_by":0,"name":"Mawuli Kushitor, PhD","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA5klEQVRIie3PsQrCMBCA4ZNAXU7nlGh9AiESiIM+TEVwcujkaqdOda9vIQjOgqBLi6vgojjqIHRxyGDUzSHaTSQ/HISDjyMANtsvhgAEuH6UQ+e1WT42n4k2uCxEHmeo/yVpxqnIg0B57elFHm4KvOrOJ+fAQGQWS5ZwLmr7Ybs1iUC4O9/pJCayRUmQ817ChpJWQujNNBFoJiJ/EjeVrlIw/kyymLMnoSgZOuBz/ZeTkaTrkSZCUByMWD2irWl6jIiZ9Oc5Ks+j5dXCvahuo7rpr3ITeY/qKUW0gHhFroWJzWaz/XN3/l9E3oJ+5WEAAAAASUVORK5CYII=","orcid":"","institution":"University of Health and Allied Sciences","correspondingAuthor":true,"prefix":"","firstName":"Mawuli","middleName":"","lastName":"Kushitor","suffix":"PhD"},{"id":580652951,"identity":"3dd339ed-3525-4ee7-87ba-948fc0be25cc","order_by":1,"name":"Mercy Adjei Adumatta","email":"","orcid":"","institution":"University of Health and Allied Sciences","correspondingAuthor":false,"prefix":"","firstName":"Mercy","middleName":"Adjei","lastName":"Adumatta","suffix":""},{"id":580652952,"identity":"84f37f36-0be2-451a-8357-b5e6891aef7f","order_by":2,"name":"Wisdom Mejida Zinnya Mahama","email":"","orcid":"","institution":"University of Health and Allied Sciences","correspondingAuthor":false,"prefix":"","firstName":"Wisdom","middleName":"Mejida Zinnya","lastName":"Mahama","suffix":""},{"id":580652953,"identity":"90d3d5dc-c16b-4937-b9a9-4eb4947ad498","order_by":3,"name":"Sophia Ayabalie Adala","email":"","orcid":"","institution":"University of Health and Allied Sciences","correspondingAuthor":false,"prefix":"","firstName":"Sophia","middleName":"Ayabalie","lastName":"Adala","suffix":""},{"id":580652954,"identity":"98ec469d-9d06-4f6f-89ab-c27ae1f8524c","order_by":4,"name":"David Binpi Nayiden","email":"","orcid":"","institution":"University of Health and Allied Sciences","correspondingAuthor":false,"prefix":"","firstName":"David","middleName":"Binpi","lastName":"Nayiden","suffix":""},{"id":580652955,"identity":"dd72b117-db6b-4dad-9660-7a91fedc5cb8","order_by":5,"name":"Linda Quainoo","email":"","orcid":"","institution":"University of Health and Allied Sciences","correspondingAuthor":false,"prefix":"","firstName":"Linda","middleName":"","lastName":"Quainoo","suffix":""},{"id":580652956,"identity":"97f4ed3c-8a5d-4146-83ba-8c803fa7ba70","order_by":6,"name":"Sukpen Reuben Uwumbor Apak","email":"","orcid":"","institution":"University of Health and Allied Sciences","correspondingAuthor":false,"prefix":"","firstName":"Sukpen","middleName":"Reuben Uwumbor","lastName":"Apak","suffix":""},{"id":580652957,"identity":"c7d0f105-17a9-49ec-ac16-4230d4f9c10a","order_by":7,"name":"Naab Joseph Kologbire","email":"","orcid":"","institution":"University of Health and Allied Sciences","correspondingAuthor":false,"prefix":"","firstName":"Naab","middleName":"Joseph","lastName":"Kologbire","suffix":""},{"id":580652958,"identity":"9d5a8efe-6cd3-48bd-8f73-d2fa428852b8","order_by":8,"name":"Helen K. Arkorful, PhD","email":"","orcid":"","institution":"University of Professional Studies","correspondingAuthor":false,"prefix":"","firstName":"Helen","middleName":"K.","lastName":"Arkorful","suffix":"PhD"}],"badges":[],"createdAt":"2025-11-27 12:08:18","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8221827/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8221827/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":102298507,"identity":"8521424b-c418-4ef3-90ed-0ad5bd6dce9d","added_by":"auto","created_at":"2026-02-10 10:41:07","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":894183,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8221827/v1/4b1f2394-5c3b-455e-a3c1-157e0e65da13.pdf"},{"id":101311716,"identity":"53e3921c-84ff-453c-885b-1dae4ab6de1a","added_by":"auto","created_at":"2026-01-28 11:04:38","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":24861,"visible":true,"origin":"","legend":"","description":"","filename":"APPENDEX.docx","url":"https://assets-eu.researchsquare.com/files/rs-8221827/v1/9e5cf819e76e8230390e2626.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Exploring Sexual Health Communication Challenges and Opportunities Between Men Living with Diabetes and Healthcare Providers in Five Selected Districts in Ghana","fulltext":[{"header":"Introduction","content":"\u003cp\u003eDiabetes has become an increasingly prevalent public health concern across many African countries and is strongly associated with sexual health complications, particularly among men (\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e–\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). The most common of these is Erectile Dysfunction (ED), defined as the persistent or recurrent inability to achieve or maintain an erection sufficient for satisfactory sexual activity (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Among men living with diabetes, ED results from a complex interplay of neurogenic, vasogenic, and psychological factors (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Despite its high prevalence, the management of ED is often neglected in routine diabetes care. This neglect persists even though evidence shows that ED is one of the most treatable complications of diabetes, with therapeutic success rates exceeding 95% (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Since introducing phosphodiesterase type 5 (PDE5) inhibitors nearly three decades ago, global treatment outcomes for ED have significantly improved (\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e–\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eHowever, many men in African settings do not access professional help for ED (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Evidence from Nigeria, for instance, shows that men rarely seek hospital-based treatment and often avoid discussing sexual difficulties with their physicians (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e) instead, they commonly turn to herbal remedies rather than biomedical management (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). This communication gap around sexual health has allowed misconceptions about male sexuality and treatment to proliferate, enabling unregulated herbal markets to dominate ED care (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). While such remedies are easily accessible, they may harm men’s overall health.\u003c/p\u003e \u003cp\u003eThe reluctance to seek biomedical care for ED in African contexts is often attributed to culturally inhibited sexual communication. Both clients and healthcare workers experience discomfort discussing sexual issues (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e), a barrier that needs to be addressed with cultural sensitivity. Yet research suggests that the problem extends beyond individual uneasiness to deeper systemic barriers. Diabetes clinics, for example, are typically overcrowded, leaving little privacy for sensitive discussions (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Referrals to specialist care often involve additional costs or travel, creating further barriers to care. Moreover, most hospitals lack adequate infrastructure, staff, and training (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e) to address sexual health needs comprehensively (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). As a result, healthcare providers rarely initiate conversations about sexuality, leaving patients with unanswered concerns. This neglect undermines men’s quality of life, relationships, and adherence to diabetes management plans.\u003c/p\u003e \u003cp\u003ePrevious research on ED and sexual dysfunction (SD) in Africa has predominantly focused on prevalence, aetiology, or pharmacological interventions, with limited attention to the dynamics of patient–provider communication. Where such studies exist, they often focus on single healthcare facilities, limiting the generalizability of findings. The present study addresses this gap by exploring sexual health communication related to ED and SD across multiple healthcare facilities in Ghana. Specifically, it examines five districts across four culturally distinct regions representing Ghana’s major ethnolinguistic groups. The study further investigates the opportunities and constraints faced by healthcare providers in engaging male clients about sexual health in a sexually conservative context, where men may find it particularly difficult to discuss such concerns, especially with providers of the opposite sex.\u003c/p\u003e\n\u003ch3\u003eStudy Objectives\u003c/h3\u003e\n\u003cp\u003eThis study seeks to examine how sexual health communication—specifically regarding erectile dysfunction (ED) and sexual dysfunction (SD)—is addressed within diabetes care in Ghana. It aims to explore the extent to which healthcare providers engage male clients in discussions about sexual health, the challenges that constrain such interactions, and the contextual factors that shape these dynamics. By analysing interactions across multiple healthcare facilities, the study highlights the systemic and cultural factors influencing the management of ED among men with diabetes.\u003c/p\u003e \u003cp\u003eMore specifically, the study pursues the following objectives:\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eTo explore the experiences and perspectives of men living with diabetes regarding sexual health communication within healthcare settings.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eTo examine how healthcare providers perceive and address sexual health issues, particularly ED and SD, among their clients.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eTo identify structural, cultural, and interpersonal barriers that hinder effective dialogue on sexual health in diabetes management.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eTo assess opportunities for strengthening provider–patient communication and integrating sexual health discussions into diabetes care in Ghana’s culturally diverse contexts.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003cp\u003e\u003c/p\u003e \u003cp\u003eThrough these objectives, the study aims to generate insights that can inform the development of culturally sensitive, patient-centered strategies to improve the sexual health component of diabetes management in Ghana and similar settings across Africa. By focusing on the experiences and perspectives of men living with diabetes and healthcare providers, the study aims to bridge the gap in sexual health communication and enhance the quality of care.\u003c/p\u003e"},{"header":"Methodology","content":"\u003cp\u003eStudy design\u003c/p\u003e\u003cp\u003eThis study adopted a phenomenological and exploratory qualitative design to examine the lived experiences of male diabetes patients regarding sexual health, its impact on daily life, and its management. Additionally, the study explored communication practices, facilitators, and barriers between patients and healthcare providers, as well as structural constraints within the healthcare system, from healthcare givers perspective.\u003c/p\u003e\u003cp\u003eStudy Sites and Context\u003c/p\u003e\u003cp\u003eData were collected from diabetes clinics in five districts across four regions of Ghana, representing the country’s major cultural and linguistic zones; Legon Hospital (Ayawaso District, Greater Accra Region), Margaret Marquart Catholic Hospital (Kpando Municipality, Volta Region), Sandema Hospital (Builsa North Municipality, Upper East Region), War Memorial Hospital (Kassena Nankana Municipal, Upper East Region), and Walewale Municipal Hospital (North East Region). These regions were purposively selected to ensure diversity in social norms, language, and healthcare delivery systems. The selected sites included both urban and rural health facilities, encompassing regional hospitals, district hospitals, and primary health centres. This multi-site design enabled the study to capture patient–provider communication variations across different institutional and cultural settings.\u003c/p\u003e\u003cp\u003eStudy Population and Sampling\u003c/p\u003e\u003cp\u003eThe study population comprised two main groups:\u003c/p\u003e\u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eMen living with diabetes, aged 30 years and above, who had attended diabetes clinics for at least six months.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eHealthcare providers, including physicians, nurses, diabetes educators, and counsellors, routinely engage with diabetic clients\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e\u003cp\u003eA purposive sampling technique was employed to recruit participants with direct experience relevant to the study. Among the male diabetes patients, 10 were from Kpando Municipality, 8 from Ayawaso District, and 8 from Builsa North Municipality. For healthcare providers, 10 were from Kassena Nankana Municipal and four from Walewale Municipal.The saturation method was used to determine the final sample size. Data collection continued until no new insights emerged, ensuring that additional data would not contribute significant value to the study. Saturation was identified through the interview and observation process, confirming the adequacy of the data collected for analysis and conclusions.\u003c/p\u003e\u003cp\u003eData Collection Methods\u003c/p\u003e\u003cp\u003eData was collected through in-depth face-to-face interviews using a semi-structured interview guide. The guide covered key areas, including participant demographics, diabetic sexual health challenges and their impact, and facilitators and barriers to sexual health communication. The interview guide was adapted from the RODAM qualitative protocols developed by Aikins et al. in 2012, (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). All interviews were conducted in a calm, private environment, suitable for patients and healthcare providers' consulting offices. The interview process involved probing questions such as “Can you elaborate more on this? Can you clarify this further? What experiences have you had in this regard?” to facilitate a clearer understanding of the concept for both the researcher and the participants. Two audio recorders were used during each interview session to ensure accuracy and completeness. Additionally, handwritten notes were taken to capture key points and serve as a backup in case of the recorders' technical malfunctions. This dual-recording approach also allowed for cross-verification of data accuracy. The duration of interviews ranged from 30 to 45 minutes each.\u003c/p\u003e\u003cp\u003eBox 1. Key areas of the interview guide. Sexual Health and Communication\u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e\u003ccolgroup cols=\"1\"\u003e\u003c/colgroup\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePerspectives from diabetic men\u003c/p\u003e \u003cp\u003e1. Overall sexual health experiences (and its effects on daily life and intimate relationships)\u003c/p\u003e \u003cp\u003e2. Challenges with sexual communication\u003c/p\u003e \u003cp\u003e3. Management of sexual health communication\u003c/p\u003e \u003cp\u003e4. Sexual health disclosure (confidential people, preferred healthcare provider, reasons for disclosure and preferred healthcare setting for sexual health communication)\u003c/p\u003e \u003cp\u003ePerspectives from healthcare providers\u003c/p\u003e \u003cp\u003e5. Management of sexual health communication\u003c/p\u003e \u003cp\u003e6. Facilitators to sexual health communication\u003c/p\u003e \u003cp\u003e7. Barriers to sexual health communication (patients and institutional barriers to sexual health communication)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/table\u003e\u003c/div\u003e\u003ch2\u003eData Analysis\u003c/h2\u003e\u003cp\u003eData were analysed using conventional content analysis, allowing themes and categories to emerge inductively from the participants’ narratives. The collected data were transcribed verbatim to facilitate textual analysis, after which the transcripts were read multiple times to ensure familiarity with the content. An iterative coding process was applied, where similar findings were grouped to form initial codes. These codes were then categorised into sub-themes based on shared patterns, and from these sub-themes, main themes emerged, reflecting broader aspects of the findings. Where necessary, some themes were merged or refined to establish well-defined patterns of shared meaning with a central idea. A descriptive narrative of themes, analytical interpretations, and data extracts were used to provide depth to the findings. Thematic analysis was conducted using ATLAS.ti version 7.5.7 (ATLAS.ti GmbH, Berlin) to ensure a systematic approach to coding, categorisation, and pattern recognition within the dataset.\u003c/p\u003e\u003cp\u003eEthical Considerations\u003c/p\u003e\u003cp\u003e Ethical approval\u003c/strong\u003e was obtained from the Research Ethics Committee of the University of Health and Allied Sciences (UHAS-REC). The School of Public Health, UHAS, secured a formal introduction letter to seek institutional permission for data collection at the selected hospitals.\u003c/p\u003e\u003cp\u003e Informed consent\u003c/strong\u003e was obtained from all participants before their involvement in the study. To ensure anonymity and confidentiality, participants were assigned unique identification codes instead of using their real names, and no personally identifiable information was recorded. Participation was entirely voluntary, and participants were informed of their right to withdraw at any time without consequence.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe results reveal sexual health communication experiences and perspectives from both diabetic men and healthcare providers. The results are presented in order of dominating and consensual themes, followed by minority themes. Areas of conflict and contradiction are presented where these occur in respondents\u0026rsquo; narratives. Quotes that best capture shared or unique ideas are presented for illustration. Respondents are identified by letters and numbers, corresponding to the detailed respondent profiles in Tables 3 and 4 in the appendix. We present a comparison of barriers and facilitators to sexual health communication from the perspectives of both study participants and providers in table 2. Detailed overall thematic table for this study is presented in table 5 in appendix.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSociodemographic Characteristics\u003c/p\u003e\n\u003cp\u003eTables 1 present the summary sociodemographic characteristics of the study participants, including healthcare providers and male patients with diabetes recruited from various healthcare facilities across Ghana.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 3 details the 14 healthcare providers, including their gender, age, educational background, professional roles, healthcare facility, and years of experience. The participants comprised doctors, physician assistants, nurses, and senior nursing officers, with years of experience ranging from 1 to 12 years. Most were from War Memorial Hospital (Kassena Nankana Municipal) and Walewale Municipal Hospital, representing diverse professional experiences in diabetes management.\u003c/p\u003e\n\u003cp\u003eTable 4 presents the detailed sociodemographic characteristics of the 26 male patients with diabetes, including age, educational background, marital status, occupation, religion, ethnicity, district, treatment facility, and duration of diabetes. The participants were recruited from the University of Ghana Hospital, Margaret Marquart Catholic Hospital, Sandema Government \u0026nbsp;Hospital, and other facilities. Most participants had a secondary or tertiary education, and their occupations ranged from teaching and farming to business, civil service, and technical professions. The duration of diabetes varied, with some newly diagnosed patients (3\u0026ndash;6 months) and others living with the condition for over 20 years. Table 3 and 4 are presented in the appendix.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1: Sociodemographic of participants\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 324px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariables (men living with diabetes)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 300px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal number of respondents (n=26)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 324px;\"\u003e\n \u003cp\u003eAGE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 300px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 324px;\"\u003e\n \u003cp\u003e45 and below\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 300px;\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 324px;\"\u003e\n \u003cp\u003eAbove 45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 300px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 324px;\"\u003e\n \u003cp\u003eEducational Level\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 300px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 324px;\"\u003e\n \u003cp\u003eJHS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 300px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 324px;\"\u003e\n \u003cp\u003eSHS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 300px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 324px;\"\u003e\n \u003cp\u003eTertiary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 300px;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 324px;\"\u003e\n \u003cp\u003eMarital Status\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 300px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 324px;\"\u003e\n \u003cp\u003eMarried \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 300px;\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 324px;\"\u003e\n \u003cp\u003eNot married\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 300px;\"\u003e\n \u003cp\u003e8 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 324px;\"\u003e\n \u003cp\u003eYears With Condition\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 300px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 324px;\"\u003e\n \u003cp\u003eBelow 10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 300px;\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 324px;\"\u003e\n \u003cp\u003e10 and above\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 300px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 324px;\"\u003e\n \u003cp\u003eDistrict\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 300px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 324px;\"\u003e\n \u003cp\u003eKpando\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 300px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 324px;\"\u003e\n \u003cp\u003eBuilsa North Municipal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 300px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 324px;\"\u003e\n \u003cp\u003eAyawaso District (Accra)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 300px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 324px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHealthcare providers\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 300px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal number of respondents (n=14)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 324px;\"\u003e\n \u003cp\u003eMales\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 300px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 324px;\"\u003e\n \u003cp\u003eFemales\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 300px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 324px;\"\u003e\n \u003cp\u003eYears Of Experience\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 300px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 324px;\"\u003e\n \u003cp\u003e5 and below\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 300px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 324px;\"\u003e\n \u003cp\u003eAbove 5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 300px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 324px;\"\u003e\n \u003cp\u003eFacility\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 300px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 324px;\"\u003e\n \u003cp\u003eWar Memorial Hospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 300px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 324px;\"\u003e\n \u003cp\u003eWalewale municipal Hospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 300px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 324px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 300px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable 2. Barriers and Facilitators of Sexual Health Communication\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"768\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eBarriers\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePatients\u0026rsquo; experiences\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 216px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHealthcare provider\u0026rsquo;s experiences\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 240px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eConvergent\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003eLack of privacy\u003c/p\u003e\n \u003cp\u003eOpposite gender of healthcare provider\u003c/p\u003e\n \u003cp\u003eNo need to disclose\u003c/p\u003e\n \u003cp\u003eSexual matters are secret\u003c/p\u003e\n \u003cp\u003eIt can\u0026rsquo;t be managed by the hospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 216px;\"\u003e\n \u003cp\u003eShyness\u003c/p\u003e\n \u003cp\u003eOpposite gender of healthcare providers\u003c/p\u003e\n \u003cp\u003eLack of privacy\u003c/p\u003e\n \u003cp\u003eClient\u0026rsquo;s misconceptions on sexual health and clinical management\u003c/p\u003e\n \u003cp\u003eTrust issues\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 240px;\"\u003e\n \u003cp\u003eLack of privacy\u003c/p\u003e\n \u003cp\u003eOpposite gender of healthcare provider\u003c/p\u003e\n \u003cp\u003eClient\u0026rsquo;s misconceptions\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 216px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eInstitutional Barriers\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 216px;\"\u003e\n \u003cp\u003eDiabetes healthcare providers not being competent enough to handle sexual health issues.\u003c/p\u003e\n \u003cp\u003eLong queues leading to limited consultation time\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFacilitators\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePatients\u0026rsquo; experiences\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 216px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHealthcare provider\u0026rsquo;s experiences\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 240px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eConvergent\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 219px;\"\u003e\n \u003cp\u003ePrivacy\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eSame gender healthcare provider\u003c/p\u003e\n \u003cp\u003eFriendly, calm and conducive room\u003c/p\u003e\n \u003cp\u003eFor solution\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 216px;\"\u003e\n \u003cp\u003ePrivacy\u003c/p\u003e\n \u003cp\u003eSame gender healthcare provider\u003c/p\u003e\n \u003cp\u003eFriendly, calm and conducive room\u003c/p\u003e\n \u003cp\u003eHealthcare provider initiating sexual health conversation\u003c/p\u003e\n \u003cp\u003eClients overwhelmed of the condition and intimate relationship challenges\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 240px;\"\u003e\n \u003cp\u003ePrivacy\u003c/p\u003e\n \u003cp\u003eSame gender healthcare provider\u003c/p\u003e\n \u003cp\u003eFriendly, calm and conducive room\u003c/p\u003e\n \u003cp\u003eFor solution\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eFACILITATORS TO SEXUAL HEALTH COMMUNICATION\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSeveral factors were found to facilitate sexual health communication, most of which centered on creating an enabling environment. Both the physical setting and the nature of human interaction shaped sexual communication. Participants emphasised the importance of having a private and comfortable space within the hospital\u0026mdash;one that provided the right atmosphere for open discussion about sexual health. Nearly all participants emphasised the importance of a calm and conducive setting, a view echoed by healthcare providers who identified such an environment as crucial for meaningful conversations. The gender of the provider also played a significant role: many men reported discomfort in discussing sexual health concerns with female doctors or nurses, describing it as particularly difficult to talk about issues related to sexual performance. Across all discussions, confidentiality and an empathetic, engaging healthcare provider emerged as the most critical factors enabling open sexual health communication in clinical settings.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHealth system-related facilitators/structure of the healthcare system\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePreferred Setting for Sexual Health Discussions:\u003c/p\u003e\n\u003cp\u003eMany participants expressed a preference for discussing sexual health matters in a private setting, such as a doctor\u0026rsquo;s office, where confidentiality could be maintained. Healthcare providers affirmed this view, noting that patients feel more at ease and open in a calm, comfortable, and welcoming consulting room. \u0026nbsp;Quotes from participants illustrate this point. \u0026nbsp;\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003ePrivate setting\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u0026quot; Private place. No, no, no, no. I can\u0026apos;t expose myself in public like that. Oh. But when you go to the doctor, I can discuss with.\u0026rdquo; (farmer, 67yrs)\u003c/p\u003e\n\u003cp\u003e\u0026quot; at first, they use to do the consulting at this place, that place is not secretive, but today they have moved to this room, that one is okay, the inner room. But I don\u0026rsquo;t know if the diabetic people treat sexual weakness. But if they also treat sexual weakness, then I think they should use the inner room\u0026rdquo; (teacher, 42yrs)\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003ePrivacy, conducive and friendly environment\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u0026ldquo;Until recently, there was an elderly man, middle-aged, that came with erectile dysfunction. In fact, he actually did not come straight. He started going around, giving different complaints. And then when he realized that the place was calm for him to talk, then after he finished saying what was not important, then he came back to what actually brought him that his thing is not working.\u0026rdquo; (Female physician assistant, S1)\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Anywhere that I meet the doctor. Anywhere that is or his office, so I want it to be his or her office, private. You know, when you have one-on-one with your doctor, where, you see the doctor, you see him personally. So, you can tell her or him that my sister or my doctor, I\u0026apos;m having this problem. How can you help me? So, we can discuss it. Like the woman here, the female doctor here. She is very free. So, when I go, we talk, we talk at length. She ask me questions and I answer. So, such a person, I can express myself to her and she will advise me. because, they are our mothers.\u0026rdquo; (retired teacher, 45yrs)\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;The sexual problems, people tend to shrink, but they prefer one-on-one than to have nurses hanging around. And so they feel.., some are not able to talk about it. But when they see that the place is calm and they are reassured that they can continue to talk, their information will not go out, then they can express. So it\u0026apos;s a two-way kind of, depending on the situation\u0026rdquo;. (Female physician assistant, S1)\u003c/p\u003e\n\u003cp\u003eThe quotations above indicate that although sexual weakness is a significant concern for many men, bringing up the issue with a healthcare provider can be influenced by various contextual and interpersonal factors within the hospital setting. As a result, some patients may endure the condition silently for extended periods, either because they feel uneasy discussing it with their provider or because the environment does not encourage such conversations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePatient-related factors\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTrust and confidence in the healthcare provider\u003c/p\u003e\n\u003cp\u003eTrust and confidence were identified as key enablers of effective communication. Patients who had multiple encounters with the same healthcare provider and established a rapport over time were more likely to feel comfortable sharing sensitive issues. This familiarity fostered a sense of trust that encouraged openness and honesty in discussing personal health concerns. A nurse narrated:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Well, sometimes before some of these patients will tell you their sexual needs, they should have had some trust and built some confidence in you before they will say it. Some will visit you several times before they feel safe to discuss with you. So, the system, I don\u0026apos;t know whether it\u0026apos;s the system or the individual, most of them do not freely tell you their sexual problems until they build trust and confidence in you\u0026rdquo; (male nurse, S9)\u003c/p\u003e\n\u003cp\u003ePreferred Healthcare Provider for Sexual Health Discussions:\u003c/p\u003e\n\u003cp\u003eMost male participants preferred discussing sexual health issues with male doctors, believing that men would better understand their struggles and would not judge them, also because they would not be so shy since their of the same gender. However, only one participant had a different view:\u003c/p\u003e\n\u003cp\u003e\u0026quot;I will tell the female doctor, The women, they enjoy sex so much. So, if you involve them, they will tell you what to do.\u0026quot; (retired teacher, 45yrs)\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Yeah, some openly discuss. For male to male, they easily discuss, they are open. Because when they come and you welcome them, and you have a good communication with them, they openly tell you that, oh, they don\u0026apos;t have erection.\u0026rdquo; (male physician assistant, S5)\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Yes, the male, actually when they come, they feel free. When they see you as a male clinician, they feel free to discuss anything with you. Unlike the female.\u0026rdquo; (male nurse, S10)\u003c/p\u003e\n\u003cp\u003e\u0026quot; I would like to take it to the male doctors. Okay. Maybe old people who are in the community. Maybe there is a way that they can also help you.\u0026rdquo; (teacher, 35yrs)\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Male doctor. As today, when I... The woman was questioning me, the doctor. I told her that this is nothing to me. The issue. \u0026nbsp; So she just advised me that I shouldn\u0026apos;t worry because of my age. I\u0026apos;m getting to 70, So, my brother, don\u0026apos;t worry. Don\u0026apos;t do this, do this. That\u0026apos;s what she told me\u0026rdquo; (farmer, 67yrs)\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;When it comes to communication, because I\u0026apos;m a female, coming in contact with a female client, most of them open up. They will tell you, oh madam, these days I have, when I\u0026apos;m to sleep with my husband, the vagina is always dry. So the females open up. But the males usually don\u0026apos;t want to open up to we the females\u0026rdquo; (female doctor, S2)\u003c/p\u003e\n\u003cp\u003eConfidentiality in other people:\u003c/p\u003e\n\u003cp\u003eParticipants were generally cautious about whom they confided in regarding their sexual health concerns. Male participants tended to share such issues only with their wives, brothers, close male friends, or colleagues who had experienced similar problems. While some felt comfortable opening up to trusted individuals within these circles, others chose to keep their challenges entirely private. Participants narrated:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026quot; why not? She\u0026apos;s my wife. I have to discuss with her. And also one of my friends that I travel to do business with.\u0026rdquo; (farmer, 40yrs)\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Maybe a colleague male diabetic patient. Yeah, I asked one person, he said yes, it normally has effect on your sexual your sexual health.\u0026rdquo; (teacher, 42yrs)\u003c/p\u003e\n\u003cp\u003e\u0026quot; oh apart from my wife, no one. I can only confide in someone who also has the problem, so that he can give me an advice since he also have experience\u0026quot;(navy pensioner, 72yrs)\u003c/p\u003e\n\u003cp\u003eReasons for Disclosing:\u003c/p\u003e\n\u003cp\u003eThe main motivations for sharing sexual health challenges were to seek possible solutions and to prevent conflicts or misunderstandings within their marriages.These are some perspectives from patients:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;I discussed with my junior brother. Though if you tell your problems to people, you will get solutions, but this one de3, if I go and tell people that I cant have sex with my wife, someone will come and take my wife. Because its not everything that you should disclose to people\u0026rdquo; (unemployed, 40yrs)\u003c/p\u003e\n\u003cp\u003e\u0026quot; I let her know that this is what is happening to me and she should not be worried or try to go to any other person. Sometimes we worry about it\u0026rdquo;. (Priest, 46yrs)\u003c/p\u003e\n\u003cp\u003eHowever, some healthcare providers observed that patients tend to open up about their sexual health problems only when the situation becomes overwhelming\u0026mdash;particularly when it starts to take a psychological toll or creates tension within their marriage.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;I would not say trust anyway, but they normally feel that, no, I just have to express my feelings. So, it\u0026apos;s like they are always trying to express themselves, maybe the way I take it, out of maybe anger or frustration. So, in that sense, they don\u0026apos;t actually see it as they build some confidence in you, that is why they are saying. But then, they are actually always looking so furious, that is what makes them to discuss their issues, some of their issues, sexual issues with me\u0026rdquo; (Male Nurse, S3)\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;They come with complaints that they cannot perform and they are having issues in their marriage and relationships. When you go further, it\u0026apos;s either the interest is not there or they are unable to get sustained erection.\u0026rdquo; ((Male Nurse, S9)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBARRIERS TO SEXUAL HEALTH COMMUNICATION\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHealthcare providers highlighted several obstacles that limit effective discussions about sexual health between diabetic patients and medical professionals. Most of these challenges were linked to the broader health system. Key barriers included the lack of privacy, long waiting times resulting in brief consultations, a shortage of sexual health specialists, limited availability of necessary medications, and inadequate training or preparedness among healthcare providers. Many providers emphasised the need for specialised training to enhance their capacity to address sexual health concerns. In addition, patient-related barriers\u0026mdash;such as shyness, fear of being judged, lack of privacy, cultural constraints, mistrust of healthcare providers, gender differences between patients and providers, and misconceptions about sexual health\u0026mdash;were also identified. Notably, many of these issues aligned closely with the challenges reported by patients themselves.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHealth System-related barriers/ structure of the healthcare system\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLack of Privacy:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA key obstacle to effective sexual health communication was the lack of privacy. Patients reported feeling uneasy discussing intimate matters in open spaces or when other people were present during consultations. Unfortunately, most diabetes clinics lack the level of privacy required for men to talk about such issues comfortably. Even in cases where private spaces exist, they are often shared with nurses or other staff, making them unsuitable for confidential discussions. Additionally, the high patient turnout on clinic days creates time pressure for healthcare providers, meaning that even when physical space is available, limited consultation time often prevents meaningful conversations.\u003c/p\u003e\n\u003cp\u003eOne physician assistant noted:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Not all the time. Sometimes when there\u0026apos;s pressure, there are a lot of people around. There are other conditions that nurses are there to help with. The sexual problems, people tend to shrink, but they prefer one-on-one rather than having nurses hanging around the consulting room. And so they feel.., some are not able to talk about it\u0026rdquo; (female physician assistant, S1)\u003c/p\u003e\n\u003cp\u003eLong Queues Leading to Limited Consultation Time:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBecause diabetic clinics often serve a large number of patients, healthcare providers struggle to devote enough time to discuss sexual health concerns in depth. Due to shyness or embarrassment, many patients need time to gather confidence before opening up about such sensitive issues. However, the limited consultation time and the pressure to attend to many patients make it difficult for these conversations to take place. These are what healthcare providers said:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026quot;Most of them don\u0026rsquo;t get the time to express their problems with us because we want to hurry up. There are so many clients, and you need to attend to almost everybody. So that time is not there\u0026quot; (female doctor, S2, 35 YRS).\u003c/p\u003e\n\u003cp\u003e\u0026quot;One client can sit and wants to engage you for like two hours, but we have long queues. So, we are forced to cut the session short, and the person may not get to fully talk about their sexual problems\u0026quot; (male nurse, S10, 36 YRS).\u003c/p\u003e\n\u003cp\u003eHealthcare Providers Not Being Fully Equipped or Trained:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNearly all healthcare providers admitted that they had not received specialised training on how to initiate or manage discussions about sexual health concerns among diabetic patients. These are some highlights of what they stated:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026quot;I will need more knowledge on handling such cases. This has to do more with psychological support, and we are not adequately trained for that\u0026quot; (female doctor, S2, 35 YRS).\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;As for the sexual health concerns, I would say no. Per our setting, I think we are not adequately equipped. We may be able to handle their medical aspect. But when it comes to the sexual aspect, although we recommend some medication, but we may need more expertise or specialists to engage in the clinic to be able to assess their sexual problems and possibly find long-lasting solutions, physically, psychologically, socially, all that, to be able to let them go with their needs\u0026rdquo; (male physician assistant, S6, 39yrs).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eInadequate Essential Medical Equipment at Facilities:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMany healthcare facilities lack the essential diagnostic tools and medical equipment required to properly evaluate and manage sexual dysfunction among diabetic patients. \u0026nbsp;Participants narrated:\u003c/p\u003e\n\u003cp\u003e\u0026quot;We still need more equipment because most of the modern tools that can be used to detect certain dysfunctions are lacking\u0026quot; (male snr. Nursing officer, M1, 39 YRS).\u003c/p\u003e\n\u003cp\u003e\u0026quot;There is no gynaecologist here for sexual health. Many patients require specialised attention, but we don\u0026rsquo;t have the equipment or experts to handle it\u0026quot; (male nurse, M4, 32 YRS).\u003c/p\u003e\n\u003cp\u003eInadequate Necessary Medications at Facilities:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMany healthcare facilities face challenges in ensuring a consistent supply of medications needed to treat sexual dysfunction associated with diabetes.They emphasised:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026quot;Even though their medication is given free, it is not all the time that we always have medications available for them. Sometimes, some of them come disappointed because the medication is not there for them to take\u0026quot; (male nurse, S3, 36 YRS).\u003c/p\u003e\n\u003cp\u003e\u0026quot;When they come, the medicines are not there, so we have to write for them to go and buy. Whether they can afford it or not, we cannot tell\u0026quot; (male physician assistant, S8, 36 YRS)\u003c/p\u003e\n\u003cp\u003eHealthcare Providers\u0026apos; Requests:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAbout 10 of the 14 healthcare providers interviewed expressed the need for specialised training to improve their ability to discuss and manage sexual health concerns in diabetes care. Quotes from a doctor and a nurse:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;No. I will need more knowledge on handling such cases. Okay, because this has to do more with psychology. You talk to them, you prepare them psychologically, then they will be able to open up\u0026rdquo;. (female doctor, S2, 35 Yrs)\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Sincerely, we are not competent in that area as we would have wished. And I think that is one thing our professionals, you are a student, so you should be advocating for that. Nurses should be trained more on that, to be able to attend to the sexual health needs of clients. For that, sincerely, we are not that much equipped\u0026rdquo; (male snr. Nursing officer, M2, 37yrs)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePatient-related barriers\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eShyness, cultural restrictions and fear of judgment:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe main barrier to sexual health communication identified in this study was patients\u0026rsquo; hesitation to openly express their concerns, mainly due to shyness, cultural taboos, and fear of being judged. Many patients\u0026mdash;especially women\u0026mdash;avoided discussing sexual health matters because of deep-rooted cultural norms that discourage open dialogue about sexuality. Among men, disclosure was often tentative and indirect, with participants initially avoiding or speaking around the topic before eventually acknowledging their difficulties. \u0026nbsp;Below are some quotes from healthcare providers;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;As for the males, they do. Yes, like I said, recently that man who came, yes. But I\u0026apos;ve not had any complaint from the females. Maybe because of our culture, women feel shy to talk about sexuality. Unlike men, women have it as a necessary part of their life. They cannot live, so they tend to complain\u0026rdquo; (female physician assistant, S1)\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Not actively engaged. Because there are some that will not even open up to you out of shyness or whatever it is. So, it\u0026rsquo;s not something that is well-discussed. But it\u0026rsquo;s few people that will open up.\u0026quot; (male doctor, S7).\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;But because usually we engage with marriage clients, sometimes some of them feel shy to come out to actually discuss their sexual needs to us. But then just a few of them sometimes are bold enough to just tell us what they are experiencing\u0026rdquo; (male nurse, S3)\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Sometimes, I remember I had one, a very elderly man. And when he also came, he was going around the bush. And finally, at a point, he said, My daughter, I see that you may be feeling like at my age, I shouldn\u0026apos;t talk about this, but this is my problem. And so he also mentioned it. Initially, they always had that reservation. They don\u0026apos;t know what possibly you will say or think of them. But when they now start interacting and they see that, oh, they can say their main issue, then they will say it\u0026rdquo; (female physician assistant, S1)\u003c/p\u003e\n\u003cp\u003eTrust issues:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTrust between patients and healthcare providers proved to be a key factor influencing the disclosure of sexual health concerns. Some patients were willing to share their experiences because they trusted their providers. In contrast, others chose to remain silent out of fear or lack of confidence in the provider\u0026rsquo;s ability to keep their sexual issues confidential. A female doctor believed:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Yes and no. Few trust me. That\u0026apos;s those that are open up. Because when you talk to them and they understand, they know that you want to help them. They do tell us certain problems they are facing. But some will not even open up to tell you the problem. So, in that case, why will they trust me?\u0026rdquo; (female doctor, S2)\u003c/p\u003e\n\u003cp\u003eGender difference in healthcare providers:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe gender of healthcare providers significantly influenced communication about sexual health. Female patients were generally more comfortable discussing sensitive issues\u0026mdash;such as vaginal dryness\u0026mdash;with female providers, whereas male patients often hesitated or withheld information when their healthcare provider was female. Another practitioner said:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;When it comes to communication, because I\u0026apos;m a female, coming in contact with a female client, most of them open up. They will tell you, oh madam, these days I have, when I\u0026apos;m to sleep with my husband, the vagina is always dry. So the females open up. But the males usually don\u0026apos;t want to open up to we the females\u0026rdquo; (female doctor, S2)\u003c/p\u003e\n\u003cp\u003eMisconceptions about sexual issues:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSome diabetic patients attributed their sexual health problems to supernatural causes, leading them to believe that such issues could not be treated in a hospital setting. This belief often hindered open communication and delayed proper medical care. Additionally, some patients held misconceptions that prescribed medications were intended to cause infertility. The quotes below illustrate these points.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Some of the misconceptions are that there are others who believe it is spiritual. They don\u0026apos;t believe that it is actually a natural medical condition. So, you see a lot of them. And then there are others who also believe that there is a deliberate intention to render some people impotent. And for that matter, they are given the medication. That is why some of them don\u0026apos;t get sexual erection\u0026rdquo; (male nurse, S3)\u003c/p\u003e\n\u003cp\u003eMisconnection on sexual health medication:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;And then some, when they are enrolled into the medication, they feel or they have the misconception that the whites are always having the intention or the mind that we blacks, we reproduce much. So they want to do all means that they can to reduce the childbearing aspects of we, the blacks. So there are the misconceptions some of them are having\u0026rdquo; (male nurse, M4)\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eAlthough effective treatments for sexual dysfunction exist, communicating these needs remains a substantial challenge for men living with diabetes in Ghana. Consistent with findings across sub-Saharan Africa, men in this study struggled to discuss sexual health concerns with healthcare providers, a barrier that prevents timely help-seeking for conditions that are both distressing and debilitating (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). The hospital environment itself emerged as a significant constraint, shaped by both systemic and personal factors. Similar to earlier Ghanaian work documenting communication barriers within overstretched outpatient clinics (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e), our participants emphasised that men were more willing to disclose sexual concerns only when they perceived the clinical space as private, supportive, and confidential.\u003c/p\u003e \u003cp\u003eUnfortunately, many of the facilities represented in this study did not provide such an ambience. Diabetes clinics in Ghana frequently operate under heavy caseloads often with hundreds of patients in a single clinic session making it almost impossible to guarantee the privacy required for sensitive discussions (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). This aligns with evidence from other African countries showing that overcrowded clinics and compromised confidentiality deter patients from discussing sexual dysfunction with clinicians (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). A systematic model for addressing male sexuality within routine diabetes care may therefore be required. Structural innovations such as designating specific clinic days for men, reorganizing client flow, or integrating psychosocial specialists such as clinical psychologists could allow for more comprehensive, client-centered conversations on sexual health. Such approaches parallel successful gender-sensitive interventions reported in Kenya and South Africa, where tailored clinic sessions improved men\u0026rsquo;s engagement with sexual and reproductive health services (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe reluctance to discuss sexual health was consistent across all study regions, irrespective of religious or cultural background. Whether in predominantly Muslim northern communities or largely Christian southern contexts, men expressed similar difficulties initiating sexual health conversations. This finding reflects wider African literature describing how male sexual performance is closely tied to masculinity, identity, and social status, making disclosure of sexual dysfunction particularly stigmatizing (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). As a result, many men silently endure difficulties with erectile function, libido, or performance issues that have profound consequences for psychological wellbeing, marital stability, and adherence to diabetes management.\u003c/p\u003e \u003cp\u003eAcross Ghana and other African nations, men fear the social consequences of being labelled sexually weak, leading many to suppress concerns or seek alternative, often unsafe, remedies (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). This echoes the experiences documented in this study, where several participants described suffering in silence, turning to herbal or spiritual options, or self-managing complications in secret. The health system must therefore recognise male sexuality as a sensitive but integral component of diabetic care, not merely a secondary symptom of hyperglycemia.\u003c/p\u003e \u003cp\u003eA particularly important implication arises from healthcare providers\u0026rsquo; reports that they seldom initiate sexual-health conversations. This finding mirrors earlier Ghanaian research showing that providers feel undertrained, overburdened, and insufficiently equipped to manage sexual dysfunction in chronic-disease settings (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). A lack of provider-initiated dialogue has been associated with reduced treatment uptake, poor glycemic control, and deteriorating quality of life among men with diabetes. In settings where patients hesitate to start such conversations due to stigma, the absence of clinician engagement deepens the communication gap. Enhancing provider skills, particularly around sensitive communication, confidentiality, and culturally grounded counselling may therefore improve the detection and management of diabetes-related sexual dysfunction.\u003c/p\u003e \u003cp\u003eFindings from this multi-regional Ghanaian study echo broader African evidence showing that sexual dysfunction among men with diabetes is both common and under-discussed, largely due to cultural expectations of masculinity, inadequate clinic environments, and limited provider capacity. Addressing these barriers requires targeted policy attention, including structural adjustments to clinic organization, integration of psychosocial support, and robust training programs enabling healthcare providers to confidently initiate and manage sexual-health conversations. Such reforms are essential to ensuring that sexual wellbeing is fully integrated into holistic diabetes care in Ghana.\u003c/p\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eLimitations of the study\u003c/h2\u003e \u003cp\u003e Given the sensitive nature of sexual health, some participants, particularly male patients may have been reluctant to fully disclose their experiences due to cultural norms, fear of judgement, or embarrassment, potentially leading to underreporting. Additionally, as the study was conducted in selected public healthcare facilities, the transferability of the findings to private or tertiary healthcare settings may be limited.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study demonstrates that the current structure and environment of diabetes clinics in Ghana do not adequately support open discussions about sexual health among male patients. Overcrowded clinic spaces, limited privacy, and the absence of calm and confidential consultation settings prevent men from disclosing sensitive sexual concerns. Participants consistently emphasized that a more conducive, private, and supportive environment would greatly facilitate such conversations. Although healthcare providers recognize the importance of addressing diabetes-related sexual dysfunction, many do not initiate discussions because they lack the necessary skills and confidence in sexual health communication. Targeted training is therefore essential to equip providers with the competencies required for effective sexual health assessment and management. To better respond to the sexual health needs of men with diabetes, we recommend the introduction of specialized clinic days dedicated solely to sexual health management within diabetes care. Such a model, combined with improved provider training and enhanced clinic environments, has the potential to strengthen communication, improve early identification of sexual dysfunction, and ultimately enhance the quality of diabetes care and patient well-being.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eED\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eErectile Dysfunction\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSexual Dysfunction\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e \u003cp\u003eEthical approval for this study was obtained from the \u003cb\u003eUniversity of Health and Allied Sciences Research Ethics Committee (UHAS-REC)\u003c/b\u003e. (Approval No: UHAS-REC B.10 [147]24\u0026ndash;25). All participants provided written informed consent before taking part in the study. Confidentiality and anonymity were strictly maintained throughout the research process. All methods were performed in accordance with relevant guidelines and regulations.\u003c/p\u003e \u003ch2\u003eCompeting interests\u003c/h2\u003e \u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e \u003ch2\u003eAuthors\u0026rsquo; information (optional)\u003c/h2\u003e \u003cp\u003eMK is a population scientist with an interest in population health and health systems. Specifically, the burden and management of Non-Communicable Diseases (NCDs) in urban cities in Africa. Key aspects of his research have led to important community level interventions for hypertension and diabetes in some cities. The author is intrigued by the intricate relationship between the built environment and the risk of cardiovascular disease (CVD) among the urban poor. Over the years he has developed the necessary competence in doing this kind of research.\u003c/p\u003e \u003cp\u003eM.A.A. is a Public Health Nutrition Officer and researcher with expertise in non-communicable diseases and qualitative health research.\u003c/p\u003e \u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eMK and MAA jointly conceived and designed the study. Both authors contributed to data analysis, interpretation of findings, and drafting of the manuscript. MAA and MK critically revised the paper for important intellectual content.WM, SAA, DBN, LQ, SRUA, and NJK did all the interviews with the study\u0026rsquo;s participants and generated the data.HKA reviewed the draft manuscript and gave feedback for improvement.All authors read and approved of the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThe authors extend sincere appreciation to the healthcare providers and diabetes patients who willingly shared their experiences. We also thank the staff of the participating hospitals for their cooperation and support during data collection.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets generated and analyzed during the current study are not publicly available due to confidentiality restrictions involving qualitative interview data. 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An Interdiscip J Heal Ethics Soc [Internet]. 2025; Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3138/cam-2024-0021%0A\u003c/span\u003e\u003cspan address=\"10.3138/cam-2024-0021%0A\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 3 to 5 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Diabetes, Sexual health, Communication, Barriers, Facilitators, Healthcare providers, Ghana, Qualitative study","lastPublishedDoi":"10.21203/rs.3.rs-8221827/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8221827/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e \u003cp\u003eDiabetes mellitus remains a major global health concern with profound biomedical and psychosocial implications. In Ghana, the intersection between diabetes and sexual health is poorly understood and rarely discussed within clinical settings, largely due to sociocultural taboos and limited provider competence. This study explored the lived experiences of male diabetes patients regarding sexual health and examined the barriers and facilitators to sexual health communication between patients and healthcare providers.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e \u003cp\u003eA phenomenological and exploratory qualitative design was adopted, involving in-depth interviews with 26 male diabetes patients and 14 healthcare providers across five hospitals in four regions of Ghana. Participants were purposively selected, and data collection continued until thematic saturation was reached. Interviews were audio-recorded, transcribed verbatim, and analyzed using conventional qualitative content analysis with the aid ATLAS.ti 7.5.7 software.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e \u003cp\u003eSexual health communication between healthcare providers and male diabetes patients was limited by shyness, cultural taboos, and fear of judgment. Patients rarely disclosed sexual concerns unless in a calm, private, and supportive environment. Many male patients preferred discussing sexual issues with male providers and avoided such conversations with female staff. Healthcare providers reported lacking the skills and confidence to initiate sexual health discussions, leaving patients to self-manage sexual dysfunction through ineffective herbal and spiritual remedies. These gaps contributed to delayed care-seeking, marital strain, and worsening diabetes-related sexual dysfunction.\u003c/p\u003e\u003ch2\u003eConclusion:\u003c/h2\u003e \u003cp\u003eThe study reveals a significant communication gap between diabetes patients and healthcare providers concerning sexual health. Addressing this requires culturally sensitive training for healthcare workers, improved privacy in consultation settings, and patient-centered communication strategies that normalize sexual health discussions within diabetes care. Integrating sexual health into routine diabetes management will not only enhance patient-provider trust but also improve overall health outcomes and quality of life for individuals living with diabetes.\u003c/p\u003e","manuscriptTitle":"Exploring Sexual Health Communication Challenges and Opportunities Between Men Living with Diabetes and Healthcare Providers in Five Selected Districts in Ghana","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-28 11:04:32","doi":"10.21203/rs.3.rs-8221827/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-02-13T10:08:00+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"62959317707522334360365554959075455563","date":"2026-02-01T13:19:23+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"282960076740670537805411014764430163901","date":"2026-01-30T08:03:58+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-23T15:46:05+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-12-20T16:27:05+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-12-16T19:12:12+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-16T17:52:54+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2025-12-15T22:37:05+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"32b0a708-aa02-49bd-ad47-940742f2a3fb","owner":[],"postedDate":"January 28th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-01-28T11:04:32+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-28 11:04:32","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8221827","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8221827","identity":"rs-8221827","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}