Article: Community Health Workers ‘s perspectives on healthcare accessibility and utilisation by adult men in the City of Mbombela, Mpumalanga Province, South Africa

Article: Community Health Workers ‘s perspectives on healthcare accessibility and utilisation by adult men in the City of Mbombela, Mpumalanga Province, South Africa | 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 Short Report Article: Community Health Workers ‘s perspectives on healthcare accessibility and utilisation by adult men in the City of Mbombela, Mpumalanga Province, South Africa Jonas Mahlapahlapa Langa, Tshifhiwa Sinky Netshapapame, Daniel Ter Goon This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8287737/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 11 You are reading this latest preprint version Abstract Objective: Men in the city of Mbombela, face persistent barriers to healthcare access, driven by socio-cultural norms and systemic challenges. Community Health Workers (CHWs) are well-positioned to understand these barriers yet remain underrepresented in health system planning. This study aimed to explore CHWs’ perceptions of the obstacle’s adult men (18-60 years) encounter when seeking care and to identify feasible strategies to improve engagement within differentiated service delivery models. Results: We conducted five focus group discussions with 63 CHWs using a semi-structured guide. Thematic analysis identified that men’s health-seeking behaviour is constrained by harmful masculinity norms, HIV-related stigma, financial hardship, and inflexible clinic hours. CHWs reported playing key roles in awareness-raising and linkage to care but noted limited resources and training to effectively engage men. Participants proposed practical solutions, including mobile clinics, workplace-based services, male peer support groups, and gender-sensitive counseling. Findings suggest that integrating CHWs into male-targeted, community-based care models, while addressing both structural and cultural barriers could enhance men’s access and retention in health services. CHWs men’s health healthcare access qualitative research FGDs City of Mbombela 1. Introduction South Africa’s healthcare setting, while strengthened by progressive policy commitments, continues to experience important gaps in adult men’s engagement with primary healthcare services, especially in rural and peri-urban contexts. Research consistently illustrates a distinct pattern of adult men frequently delay seeking care, and when they do engage the health system, it is often at an advanced stage of illness. This underutilization stem from social norms around masculinity, stigma associated with certain illnesses, economic pressures, and persistent distrust toward formal healthcare providers [ 1 ]. These factors intertwine to substitute reluctance, resulting in missed opportunities for preventive interventions and delayed treatment[ 2 ]. CHWs have emerged as essential facilitators of healthcare access in underserved settings, acting as frontline liaisons due to their community proximity and cultural competence. Their role is regarded as particularly effective in navigating the complex barriers faced by adult men, leveraging both trust and contextually relevant communication [ 3 ]. However, even with CHWs positioned positively within their communities, structural and attitudinal barriers still hinder adult men’s access and utilization of healthcare services. For example, men often report discomfort with healthcare settings perceived as female-oriented or unwelcoming, and many experiences logistical challenges, such as conflicting work schedules, transportation hurdles, and negative past interactions with health personnel[ 4 ] Societal attitudes around masculinity further compound these barriers. In many communities, norms that compare health seeking mainly for preventative or non-acute care with weakness, discourage men from proactively engaging with health services [ 5 ]. Stigma surrounding illnesses like HIV, tuberculosis, and mental health disorders intensifies this hesitancy, especially where CHWs report that disclosure or open discussion is culturally troubled [ 6 ]. Moreover, in some focus group findings from similar contexts, men expressed scepticism about the confidentiality of community-based health workers, fearing breaches of privacy in tight-knit rural areas [ 7 ].Despite these obstacles, CHWs have made notable steps in building trust and enhancing men’s participation through tailored interventions. Successful strategies include door-to-door outreach, peer-led educational campaigns, and the integration of health services into male-dominated community spaces, such as sports leagues or workplaces [ 1 ]. These approaches help reshape health-seeking behaviors and gradually wear away gendered stereotypes about care utilisation. CHWs also highlight the value of involving male community leaders and role models in their advocacy efforts, finding that these collaborations increase men’s receptivity to health messaging[ 8 ]. Persistent systemic barriers, however, highlight the need for broader, multi-sectoral changes. Limited transportation options in rural areas impose physical barriers to service access, while inflexible clinic hours often clash with work commitments, making healthcare less accessible to working-aged men[ 9 ]. Additional challenges include a shortage of male CHWs, whose presence could normalize engagement and address gender-specific concerns more effectively [ 10 ]. As such, the perspectives of CHWs point toward a double approach on addressing deeply rooted socio-cultural norms while implementing pragmatic structural changes. Recommendations include expanding community-based service delivery, increasing flexibility in health system scheduling, investing in male-targeted health promotion, and sustaining ongoing community dialogues to challenge stigma and gender norms[ 4 ]. Ultimately, a participatory and context-sensitive strategy that builds on CHWs’ local knowledge stands as the most promising way to improve adult men’s healthcare access and utilization in the City of Mbombela’s rural and peri-urban in Mpumalanga Province, aiming to inform strategies that enhance service delivery and engagement[ 3 ]. 2. Methods Study Design and Setting This exploratory qualitative study was conducted to capture the perspectives and lived experiences of CHWs regarding men’s access to healthcare services in the City of Mbombela. The study aimed to explore the depth and complexity of barriers affecting men’s health-seeking behaviors and service utilization. A qualitative descriptive approach was employed to provide a contextual understanding of the structural and social factors influencing these behaviors. CHWs were encouraged to share their experiences in their own words, offering rich, nuanced insights into the challenges they encounter in their outreach work. This design enable deeper engagement with participants through attentive observation and listening, ensuring accurate documentation of their perceptions, practices, and counselling experiences. Data were collected through semi-structured focus group discussions (FGDs), and thematic analysis was used to identify key themes and subthemes from the transcripts. Study Population The study population comprised CHWs who met the inclusion criteria and were actively providing community-based outreach services for more than a year at healthcare facilities within the City of Mbombela, South Africa. Sampling Strategy and Sample Size Purposive sampling was used to recruit CHWs who were available and met the study criteria. This non-probability sampling method was chosen to ensure that participants had relevant experience and awareness aligned with the study objectives. Data saturation was defined as the point at which no new information or themes emerged was reached after five FGDs, each involving 10–12 participants, resulting in a total sample size of 63 CHWs. Data Collection Procedures Data collection was conducted on pre-arranged days at selected healthcare facilities. The researcher arrived early to prepare a comfortable and private setting conducive to open dialogue. Rapport was established through informal conversation before the interviews began. The researcher introduced herself, explained the purpose and procedures of the study, and obtained informed consent from participants. Semi-structured interview guides were used to explore both observable and non-observable variables, including CHWs’ knowledge, perceptions, and experiences related to men’s healthcare access and utilization. While the guides provided structure, flexibility was maintained to allow for deeper exploration of emerging themes. Probing questions were used to clarify and expand on responses. Each FGD was conducted in a quiet room within the health facility to ensure privacy. Discussions were facilitated in Siswati and English, depending on participants’ preferences. Non-verbal cues such as facial expressions, gestures, and tone of voice were noted, and field notes were taken to document group dynamics and contextual factors. The researcher facilitated the sessions, encouraging participants to speak freely and share their experiences beyond the scope of the interview guide. Data Analysis Data were collected, transcribed verbatim, and analyzed using inductive thematic approach, to understand patterns and themes. An independent coder was engaged for professional guidance and validation of codes and themes. Data analysis followed Braun and Clarke's six-step framework, to ensure a logical process. The data was manually coded with relevant features using ATLAS.ti version 23.0.0. software. Codes were studied to ascertain patterns and themes addressing the research question. Themes were refined, defined, and named to capture the data's substance. Findings were written up, combining rich examples to support themes. A complete audit trace was continued, documenting analytical decisions, data collection, and methodological choices, improving dependability. 3. Results The study findings report that a total of 63 CHWs participated in five FGDs. Thematic analysis was conducted using ATLAS.ti software, version 23.0.0, allowing for the identification of key themes, categories, and subcategories. Results are presented in both tabular format Table 1 on sociodemographic characteristics and Table 2 through direct quotations to enhance credibility and give voice to participants. 3.1. The sociodemographic characteristics Table 1. Descriptive characteristics of CHWs Age 18–24 years 0 0.00 25–49 years 34 53.97 > 50 years 29 46.03 Gender Female 62 98.41 Male 1 1.59 Marital Status Never Married 40 63.49 Married 23 36.51 Education Below Matric 38 60.32 Matric 23 36.51 Above Matric 2 3.17 Religion Christian 62 98.41 Islam 1 1.59 3.2 Key Findings The CHWs provided insights into the challenges adult men face in accessing healthcare services. They highlighted systemic barriers such as long waiting times, lack of privacy, and limited clinic hours, as well as cultural and societal factors including stigma, masculinity norms, and reliance on traditional healing practices. CHWs emphasized their role in addressing these barriers through awareness, support, and tailored counselling. Strategies proposed included community-based support groups, mobile unit clinics, and direct service delivery to improve accessibility and reduce stigma. Thematic analysis revealed four overarching themes: CHWs’ awareness and support, cultural influences, systemic barriers, and proposed strategies for improvement on summarized in the Table 2. Table 2: Summary of theme, subthemes, and categories Theme Subthemes Categories CHWs’ Awareness, Support, and Counselling Non-disclosure and reluctance to seek help. Limited health knowledge Fear of judgment Fear of HIV testing Embarrassment Cultural Influences Masculinity and stigma Preference for traditional healing Social norms Traditional remedies Systemic Barriers Long waiting times Financial constraints Inconvenient clinic hours Slow clinic processes Transport costs Fear of being seen Proposed Strategies Enhancing access Supportive programs Service delivery improvements CHW trust-building Medication delivery by CHWs Male-led support groups , Theme 1: CHWs’ Awareness, Support, and Counselling CHWs highlighted that men often avoid healthcare services due to non-disclosure and reluctance to seek help, primarily driven by fear of judgment and embarrassment. Limited health knowledge further compounds this issue, as men lack adequate understanding of HIV prevention and treatment. Participants supported this: Quotations “Many men openly admit that they feel deeply embarrassed about visiting clinics because they believe others will judge them harshly. They worry that even the nurses or other patients will assume they are sick or HIV-positive, which makes them avoid healthcare altogether.” – Female CHW, 51 “Men often tell us that the idea of HIV testing terrifies them. They fear what a positive result would mean for their reputation, their relationships, and their sense of masculinity. This fear is so strong that they would rather stay away from clinics completely than face the possibility of knowing their status.” – Female CHW, 30 These quotes illustrate how stigma and fear act as psychological barriers, preventing men from accessing essential health services. Theme 2: Cultural Influences Cultural norms around masculinity and stigma significantly influence men’s health-seeking behavior. Many men perceive seeking healthcare as a sign of weakness, and some prefer traditional remedies over clinical treatment, masculinity and stigma. Participants supported this: “In our communities, many men strongly believe in traditional medicine and see it as a safer, more private option compared to clinics. They say that going to a clinic makes them look weak or dependent, while using herbs or consulting a traditional healer feels more aligned with cultural expectations of strength and resilience.” – Female CHW, 28 This reflects deeply rooted cultural beliefs that hinder engagement with formal healthcare systems. Theme 3: Systemic Barriers Structural challenges such as long waiting times, inconvenient clinic hours, and financial constraints were repeatedly mentioned by CHWs as major deterrents such as slow clinic processes, fear of being seen and judged and fear of being seen, judged and transport costs: Participants supported this: Quotations “Men complain that clinic visits take too long—sometimes they wait for hours just to be seen. For someone who works or has responsibilities, this feels like wasted time. After one bad experience, they often decide not to return because they feel the system doesn’t respect their time.” – Female CHW, 49 “Men often tell us they avoid clinics because they don’t want anyone in the community to see them there. They fear gossip and judgment, especially in small villages where everyone knows each other. Just being seen at a clinic can lead to rumours about HIV or other illnesses.” – Female CHW, 14 “For men living far from clinics, the cost of transport is a big barrier. Some say they would rather spend that money on food or family needs than on a trip to the clinic. When combined with long waiting times, the whole process feels expensive and inconvenient.” – Female CHW, 38 These systemic issues create practical obstacles that discourage men from consistent healthcare engagement. Theme 4: Proposed Strategies CHWs suggested practical interventions to improve men’s access to healthcare, including trust-building, medication delivery by CHWs, and male-led support. Participants supported this: Quotations “When I approach men, I make sure to introduce myself properly and explain why I’m there. This simple step helps break the ice and shows that I’m not there to judge them but to support them. Once they understand my role, they open up more easily.” – Female CHW, 20 “Many men tell us they feel more comfortable getting their medication from us rather than going to the clinic. It saves them time and avoids the embarrassment of being seen at a health facility. They trust us because we come to them discreetly and respect their privacy.” – Female CHW, 34 “I believe that support groups led by men themselves can make a big difference. When men see other men talking openly about health issues, it reduces stigma and creates a safe space for sharing. It helps them realize they’re not alone and encourages them to seek care.” – Female CHW, 40 4. Discussion Our finding demonstrated that CHWs strongly highlighted systemic obstacles such as long waiting times, inadequate privacy, and inflexible clinic hours as central barriers for men. These findings align with multiple studies from various African contexts, where health system inefficiencies and structural constraints have been shown to particularly hinder men’s engagement with healthcare [ 9 ]. Men are also affected by economic pressures and logistical burdens, with transport costs and loss of work time acting as powerful deterrents to attending clinics [ 5 ]. This is especially true in rural and peri-urban settings, where facilities may be distant and public transport options limited. Concerns over privacy and confidentiality also emerged, as men reported reluctance to be seen attending clinics for fear of community judgment or breaches of confidentiality. Such findings are consistent with broader literature, where confidentiality concerns are a recognized barrier to healthcare utilization among men, fuelling doubts and avoidance behaviors[ 7 , 11 ].CHWs repeatedly referenced deeply entrenched masculinity norms that discourage men from acknowledging vulnerability, seeking preventive care, or disclosing health problems. In sub-Saharan Africa, health-seeking is often constructed as a feminine activity, and men may perceive clinic attendance as incompatible with ideals of strength and patience[ 5 , 12 ]. The literature consistently demonstrates that masculine identity preservation contributes to late presentation and underutilization of healthcare among men [ 13 ]. Stigma especially relating to HIV, tuberculosis, and sexual health was frequently cited as a critical barrier. Men’s discretion to engage with clinics often comes from fear of being labelled, both within their peer groups and at the broader community level[ 14 , 15 ]. Furthermore, CHWs noted the appeal of traditional healing practices among men, whom they observed to prefer traditional remedies over biomedical interventions in some cases[ 16 ].Despite these challenges, CHWs play a vital role as mediator, using personal introduction and clear communication to gain men’s trust and facilitate care. Their proximity and insider status within communities allow them to tailor services and provide culturally sensitive counselling, which literature identifies as essential for overcoming gendered barriers and increasing men’s healthcare engagement[ 3 ]. However, the feminization of the CHW workforce may limit their impact with male clients, underlining a need for more gender-balanced staffing and specialized training in male-targeted outreach[ 10 ]. Strategies proposed by CHWs including community mobile unit clinics, direct home medication delivery, and peer-led support group that reflect evidence-based recommendations in the literature. Community-based interventions, particularly those leveraging trusted male peers or integrating care into male-dominated communal spaces, have proven successful in shifting norms and addressing access barriers among men[ 8 , 17 ]. Peer-led and male-support groups, highlighted in both qualitative research and intervention trials, build community around health while eroding stigma and boosting uptake of testing and treatment [ 17 , 18 ]. Strengths and limitations The study offers valuable awareness into CHWs perspectives on the barriers and challenges men encounter when seeking healthcare services. A key strength lies in its qualitative design, which enables an in-depth understanding of the underlying factors influencing men’s health-seeking behaviors. Furthermore, the research is context-specific, reflecting the realities of a particular local municipality, which makes the findings highly relevant for designing interventions tailored to the community’s needs. However, the study also presents notable limitations. The small sample size may not adequately represent the broader population of CHWs in the City of Mbombela, limiting the generalizability of the findings to other settings. Cultural, social, and economic characteristics unique to the study area further restrict the applicability of results to different populations. Additionally, reliance on self-reported data introduces potential biases, including social desirability effects. The use of a single data collection method, focus group discussion may also limit the comprehensiveness of the findings, as incorporating multiple methods could provide a more holistic understanding of the topic. 5. Conclusion It is evident that the multifaceted nature of barriers to healthcare access among adult men, encompassing cultural beliefs, systemic inefficiencies, and social stigma. CHWs identified practical strategies such as mobile clinics, direct medication delivery, and male-led support groups as promising interventions. Empowering CHWs through training and resources can enhance their capacity to engage men effectively. Future interventions should prioritize integrating CHWs into broader health system planning to ensure sustainable and inclusive healthcare access for all. Abbreviations CHWs Community Health Workers. FGDs Focus Group Discussions SAMRC South African Medical Research Council Declarations Acknowledgement : This is part of Langa J.M.’s PhD thesis. The authors wish to thank all of the responded who participated in the study: The Mpumalanga Health Department and Research Unit, University of Limpopo. the participants for participating in the study; the Mpumalanga Department of Heath for granting permission to conduct the study in selected health facilities in the City of Mbombela; and the Research assistants for their assistance in data collection. Author Contributions: JML contributed to conceptualization, methodology, data curation, and writing of the original draft. TSN was responsible for formal analysis, writing review and editing, and supervision. DTG contributed to investigation, validation, and writing review, editing and Co-supervision. All authors confirm that all stages of the research and manuscript preparation were conducted collaboratively and that they fully support the results. Funding: The work reported herein was made possible through funding by the South African Medical Research Council through its Division of Research Capacity Development. The content hereof is the sole responsibility of the authors and does not necessarily represent the official views of the SAMRC. Data availability: The datasets used and analysed during the current study available from the corresponding author upon reasonable request. Conflicts of Interest: The authors declare no conflicts of interest. Institutional Review Board Statement : The study was conducted in accordance with the Declaration of Helsinki and Ethical approval was obtained from University of Limpopo Ethics Committee with the code (TREC/110/2024:PG) on 20 May 2024. Informed Consent Statement : Informed consent was obtained from all the participants involved in the study. References Kohrt BA, Asher L, Bhardwaj A, Fazel M, Jordans MJ, Mutamba BB, et al. The role of communities in mental health care in low-and middle-income countries: a meta-review of components and competencies. 2018;15(6):1279. Matovu JK, Mbita G, Hamilton A, Mhando F, Sims WM, Thompson N, et al. Men’s comfort in distributing or receiving HIV self-test kits from close male social network members in Dar Es Salaam, Tanzania: baseline results from the STEP project. 2021;21(1):1739. Pascoe L, Peacock D, Stemple L. Reaching men: addressing the blind spot in the HIV response. 2018;1(SP1):e57–70. Njeru MK, Blystad A, Nyamongo IK, Fylkesnes K. 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Cuco RMM, Munguambe K, Osman NB, Sidat MM, Degomme O, Temmerman M. Male partners’ involvement in prevention of mother-to-child HIV transmission in sub-Saharan Africa: a systematic review. 2015;12(1):87–105. Kelly G, Mrengqwa L, Geffen L. “They don’t care about us”: older people’s experiences of primary healthcare in Cape Town, South Africa. 2019;19(1):98. Camlin CS, Cassels S, Seeley J. Bringing population mobility into focus to achieve HIV prevention goals. 2018;21(Suppl Suppl 4):e25136. Bergman AJ, McNabb KC, Mlandu K, Akumbom A, Flores DD. Identity management in the face of HIV and intersecting stigmas: A metasynthesis of qualitative reports from sub-Saharan Africa. 2023;3(2):e0000706. Rotheram-Borus MJ, Tomlinson M, Mayekiso A, Bantjes J, Harris DM, Stewart J, et al. Gender-specific HIV and substance abuse prevention strategies for South African men: study protocol for a randomized controlled trial. 2018;19(1):417. Additional Declarations No competing interests reported. Supplementary Files JMLANGAFocusgroupinterviewguideforCommunityHealthWorkers.pdf Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 03 Feb, 2026 Reviews received at journal 26 Jan, 2026 Reviews received at journal 21 Jan, 2026 Reviewers agreed at journal 15 Jan, 2026 Reviewers agreed at journal 14 Jan, 2026 Reviewers agreed at journal 13 Jan, 2026 Reviewers invited by journal 07 Jan, 2026 Editor assigned by journal 05 Jan, 2026 Editor invited by journal 11 Dec, 2025 Submission checks completed at journal 11 Dec, 2025 First submitted to journal 11 Dec, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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07:21:06","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":74813,"visible":true,"origin":"","legend":"","description":"","filename":"JMLANGAFocusgroupinterviewguideforCommunityHealthWorkers.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8287737/v1/efced5c8ff163af8a123f8ad.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Article: Community Health Workers ‘s perspectives on healthcare accessibility and utilisation by adult men in the City of Mbombela, Mpumalanga Province, South Africa","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eSouth Africa\u0026rsquo;s healthcare setting, while strengthened by progressive policy commitments, continues to experience important gaps in adult men\u0026rsquo;s engagement with primary healthcare services, especially in rural and peri-urban contexts. Research consistently illustrates a distinct pattern of adult men frequently delay seeking care, and when they do engage the health system, it is often at an advanced stage of illness. This underutilization stem from social norms around masculinity, stigma associated with certain illnesses, economic pressures, and persistent distrust toward formal healthcare providers [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. These factors intertwine to substitute reluctance, resulting in missed opportunities for preventive interventions and delayed treatment[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eCHWs have emerged as essential facilitators of healthcare access in underserved settings, acting as frontline liaisons due to their community proximity and cultural competence. Their role is regarded as particularly effective in navigating the complex barriers faced by adult men, leveraging both trust and contextually relevant communication [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. However, even with CHWs positioned positively within their communities, structural and attitudinal barriers still hinder adult men\u0026rsquo;s access and utilization of healthcare services. For example, men often report discomfort with healthcare settings perceived as female-oriented or unwelcoming, and many experiences logistical challenges, such as conflicting work schedules, transportation hurdles, and negative past interactions with health personnel[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eSocietal attitudes around masculinity further compound these barriers. In many communities, norms that compare health seeking mainly for preventative or non-acute care with weakness, discourage men from proactively engaging with health services [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Stigma surrounding illnesses like HIV, tuberculosis, and mental health disorders intensifies this hesitancy, especially where CHWs report that disclosure or open discussion is culturally troubled [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Moreover, in some focus group findings from similar contexts, men expressed scepticism about the confidentiality of community-based health workers, fearing breaches of privacy in tight-knit rural areas [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].Despite these obstacles, CHWs have made notable steps in building trust and enhancing men\u0026rsquo;s participation through tailored interventions. Successful strategies include door-to-door outreach, peer-led educational campaigns, and the integration of health services into male-dominated community spaces, such as sports leagues or workplaces [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. These approaches help reshape health-seeking behaviors and gradually wear away gendered stereotypes about care utilisation. CHWs also highlight the value of involving male community leaders and role models in their advocacy efforts, finding that these collaborations increase men\u0026rsquo;s receptivity to health messaging[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Persistent systemic barriers, however, highlight the need for broader, multi-sectoral changes. Limited transportation options in rural areas impose physical barriers to service access, while inflexible clinic hours often clash with work commitments, making healthcare less accessible to working-aged men[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Additional challenges include a shortage of male CHWs, whose presence could normalize engagement and address gender-specific concerns more effectively [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. As such, the perspectives of CHWs point toward a double approach on addressing deeply rooted socio-cultural norms while implementing pragmatic structural changes. Recommendations include expanding community-based service delivery, increasing flexibility in health system scheduling, investing in male-targeted health promotion, and sustaining ongoing community dialogues to challenge stigma and gender norms[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Ultimately, a participatory and context-sensitive strategy that builds on CHWs\u0026rsquo; local knowledge stands as the most promising way to improve adult men\u0026rsquo;s healthcare access and utilization in the City of Mbombela\u0026rsquo;s rural and peri-urban in Mpumalanga Province, aiming to inform strategies that enhance service delivery and engagement[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cp\u003e \u003cb\u003eStudy Design and Setting\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThis exploratory qualitative study was conducted to capture the perspectives and lived experiences of CHWs regarding men\u0026rsquo;s access to healthcare services in the City of Mbombela. The study aimed to explore the depth and complexity of barriers affecting men\u0026rsquo;s health-seeking behaviors and service utilization. A qualitative descriptive approach was employed to provide a contextual understanding of the structural and social factors influencing these behaviors. CHWs were encouraged to share their experiences in their own words, offering rich, nuanced insights into the challenges they encounter in their outreach work. This design enable deeper engagement with participants through attentive observation and listening, ensuring accurate documentation of their perceptions, practices, and counselling experiences. Data were collected through semi-structured focus group discussions (FGDs), and thematic analysis was used to identify key themes and subthemes from the transcripts.\u003c/p\u003e \u003cp\u003e \u003cb\u003eStudy Population\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe study population comprised CHWs who met the inclusion criteria and were actively providing community-based outreach services for more than a year at healthcare facilities within the City of Mbombela, South Africa.\u003c/p\u003e \u003cp\u003e \u003cb\u003eSampling Strategy and Sample Size\u003c/b\u003e \u003c/p\u003e \u003cp\u003ePurposive sampling was used to recruit CHWs who were available and met the study criteria. This non-probability sampling method was chosen to ensure that participants had relevant experience and awareness aligned with the study objectives. Data saturation was defined as the point at which no new information or themes emerged was reached after five FGDs, each involving 10\u0026ndash;12 participants, resulting in a total sample size of 63 CHWs.\u003c/p\u003e \u003cp\u003e \u003cb\u003eData Collection Procedures\u003c/b\u003e \u003c/p\u003e \u003cp\u003eData collection was conducted on pre-arranged days at selected healthcare facilities. The researcher arrived early to prepare a comfortable and private setting conducive to open dialogue. Rapport was established through informal conversation before the interviews began. The researcher introduced herself, explained the purpose and procedures of the study, and obtained informed consent from participants. Semi-structured interview guides were used to explore both observable and non-observable variables, including CHWs\u0026rsquo; knowledge, perceptions, and experiences related to men\u0026rsquo;s healthcare access and utilization. While the guides provided structure, flexibility was maintained to allow for deeper exploration of emerging themes. Probing questions were used to clarify and expand on responses. Each FGD was conducted in a quiet room within the health facility to ensure privacy. Discussions were facilitated in Siswati and English, depending on participants\u0026rsquo; preferences. Non-verbal cues such as facial expressions, gestures, and tone of voice were noted, and field notes were taken to document group dynamics and contextual factors. The researcher facilitated the sessions, encouraging participants to speak freely and share their experiences beyond the scope of the interview guide.\u003c/p\u003e \u003cp\u003e \u003cb\u003eData Analysis\u003c/b\u003e \u003c/p\u003e \u003cp\u003eData were collected, transcribed verbatim, and analyzed using inductive thematic approach, to understand patterns and themes. An independent coder was engaged for professional guidance and validation of codes and themes. Data analysis followed Braun and Clarke's six-step framework, to ensure a logical process. The data was manually coded with relevant features using ATLAS.ti version 23.0.0. software. Codes were studied to ascertain patterns and themes addressing the research question. Themes were refined, defined, and named to capture the data's substance. Findings were written up, combining rich examples to support themes. A complete audit trace was continued, documenting analytical decisions, data collection, and methodological choices, improving dependability.\u003c/p\u003e"},{"header":"3. Results","content":"\u003cp\u003eThe study findings report that a total of 63 CHWs participated in five FGDs. Thematic analysis was conducted using ATLAS.ti software, version 23.0.0, allowing for the identification of key themes, categories, and subcategories. Results are presented in both tabular format Table 1 on sociodemographic characteristics and Table 2 through direct quotations to enhance credibility and give voice to participants.\u003c/p\u003e\n\u003cp\u003e3.1. \u003cstrong\u003eThe sociodemographic characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 1. Descriptive characteristics of CHWs\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 29px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 29px;\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e18\u0026ndash;24 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e25\u0026ndash;49 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22px;\"\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e53.97\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e\u0026gt; 50 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22px;\"\u003e\n \u003cp\u003e29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e46.03\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 29px;\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22px;\"\u003e\n \u003cp\u003e62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e98.41\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e1.59\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 29px;\"\u003e\n \u003cp\u003eMarital Status\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003eNever Married\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22px;\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e63.49\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22px;\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e36.51\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 29px;\"\u003e\n \u003cp\u003eEducation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003eBelow Matric\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22px;\"\u003e\n \u003cp\u003e38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e60.32\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003eMatric\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22px;\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e36.51\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003eAbove Matric\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e3.17\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 29px;\"\u003e\n \u003cp\u003eReligion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003eChristian\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22px;\"\u003e\n \u003cp\u003e62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e98.41\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003eIslam\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e1.59\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e3.2 Key Findings\u003c/p\u003e\n\u003cp\u003eThe CHWs provided insights into the challenges adult men face in accessing healthcare services. They highlighted systemic barriers such as long waiting times, lack of privacy, and limited clinic hours, as well as cultural and societal factors including stigma, masculinity norms, and reliance on traditional healing practices. CHWs emphasized their role in addressing these barriers through awareness, support, and tailored counselling. Strategies proposed included community-based support groups, mobile unit clinics, and direct service delivery to improve accessibility and reduce stigma. Thematic analysis revealed four overarching themes: CHWs\u0026rsquo; awareness and support, cultural influences, systemic barriers, and proposed strategies for improvement on summarized in the Table 2.\u003c/p\u003e\n\u003cp\u003eTable 2: Summary of theme, subthemes, and categories\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"610\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTheme\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSubthemes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCategories\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCHWs\u0026rsquo; Awareness, Support, and Counselling\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cul\u003e\n \u003cli\u003eNon-disclosure and reluctance to seek help.\u003c/li\u003e\n \u003cli\u003eLimited health knowledge\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cul\u003e\n \u003cli\u003eFear of judgment\u003c/li\u003e\n \u003cli\u003eFear of HIV testing\u003c/li\u003e\n \u003cli\u003eEmbarrassment\u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCultural Influences\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cul\u003e\n \u003cli\u003eMasculinity and stigma\u003c/li\u003e\n \u003cli\u003ePreference for traditional healing\u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cul\u003e\n \u003cli\u003eSocial norms\u003c/li\u003e\n \u003cli\u003e\u0026nbsp;Traditional remedies\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSystemic Barriers\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cul\u003e\n \u003cli\u003eLong waiting times\u003c/li\u003e\n \u003cli\u003e\u0026nbsp;Financial constraints\u003c/li\u003e\n \u003cli\u003e\u0026nbsp;Inconvenient clinic hours\u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cul\u003e\n \u003cli\u003eSlow clinic processes\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eTransport costs\u003c/li\u003e\n \u003cli\u003eFear of being seen\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eProposed Strategies\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cul\u003e\n \u003cli\u003eEnhancing access\u003c/li\u003e\n \u003cli\u003eSupportive programs\u003c/li\u003e\n \u003cli\u003e\u0026nbsp;Service delivery improvements\u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cul\u003e\n \u003cli\u003eCHW trust-building\u003c/li\u003e\n \u003cli\u003eMedication delivery by CHWs\u003c/li\u003e\n \u003cli\u003eMale-led support groups\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e,\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme 1: CHWs\u0026rsquo; Awareness, Support, and Counselling\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCHWs highlighted that men often avoid healthcare services due to non-disclosure and reluctance to seek help, primarily driven by fear of judgment and embarrassment. Limited health knowledge further compounds this issue, as men lack adequate understanding of HIV prevention and treatment. Participants supported this:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eQuotations\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Many men openly admit that they feel deeply embarrassed about visiting clinics because they believe others will judge them harshly. They worry that even the nurses or other patients will assume they are sick or HIV-positive, which makes them avoid healthcare altogether.\u0026rdquo; \u0026ndash; Female CHW, 51\u003cbr\u003e\u0026nbsp;\u0026ldquo;Men often tell us that the idea of HIV testing terrifies them. They fear what a positive result would mean for their reputation, their relationships, and their sense of masculinity. This fear is so strong that they would rather stay away from clinics completely than face the possibility of knowing their status.\u0026rdquo; \u0026ndash; Female CHW, 30\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThese quotes illustrate how stigma and fear act as psychological barriers, preventing men from accessing essential health services.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme 2: Cultural Influences\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCultural norms around masculinity and stigma significantly influence men\u0026rsquo;s health-seeking behavior. Many men perceive seeking healthcare as a sign of weakness, and some prefer traditional remedies over clinical treatment,\u0026nbsp;masculinity and stigma.\u0026nbsp;Participants\u0026nbsp;supported this:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;In our communities, many men strongly believe in traditional medicine and see it as a safer, more private option compared to clinics. They say that going to a clinic makes them look weak or dependent, while using herbs or consulting a traditional healer feels more aligned with cultural expectations of strength and resilience.\u0026rdquo; \u0026ndash; Female CHW, 28\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis reflects deeply rooted cultural beliefs that hinder engagement with formal healthcare systems.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme 3: Systemic Barriers\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStructural challenges such as long waiting times, inconvenient clinic hours, and financial constraints were repeatedly mentioned by CHWs as major deterrents such as slow clinic processes, fear of being seen and judged and fear of being seen, judged and transport costs: Participants supported this:\u003c/p\u003e\n\u003cp\u003eQuotations\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Men complain that clinic visits take too long\u0026mdash;sometimes they wait for hours just to be seen. For someone who works or has responsibilities, this feels like wasted time. After one bad experience, they often decide not to return because they feel the system doesn\u0026rsquo;t respect their time.\u0026rdquo; \u0026ndash; Female CHW, 49\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Men often tell us they avoid clinics because they don\u0026rsquo;t want anyone in the community to see them there. They fear gossip and judgment, especially in small villages where everyone knows each other. Just being seen at a clinic can lead to rumours about HIV or other illnesses.\u0026rdquo; \u0026ndash; Female CHW, 14\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;For men living far from clinics, the cost of transport is a big barrier. Some say they would rather spend that money on food or family needs than on a trip to the clinic. When combined with long waiting times, the whole process feels expensive and inconvenient.\u0026rdquo; \u0026ndash; Female CHW, 38\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThese systemic issues create practical obstacles that discourage men from consistent healthcare engagement.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme 4: Proposed Strategies\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCHWs suggested practical interventions to improve men\u0026rsquo;s access to healthcare, including trust-building, medication delivery by CHWs, and male-led support. Participants supported this:\u003c/p\u003e\n\u003cp\u003eQuotations\u003cbr\u003e\u003cem\u003e\u0026ldquo;When I approach men, I make sure to introduce myself properly and explain why I\u0026rsquo;m there. This simple step helps break the ice and shows that I\u0026rsquo;m not there to judge them but to support them. Once they understand my role, they open up more easily.\u0026rdquo; \u0026ndash; Female CHW, 20\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Many men tell us they feel more comfortable getting their medication from us rather than going to the clinic. It saves them time and avoids the embarrassment of being seen at a health facility. They trust us because we come to them discreetly and respect their privacy.\u0026rdquo; \u0026ndash; Female CHW, 34\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I believe that support groups led by men themselves can make a big difference. When men see other men talking openly about health issues, it reduces stigma and creates a safe space for sharing. It helps them realize they\u0026rsquo;re not alone and encourages them to seek care.\u0026rdquo; \u0026ndash; Female CHW, 40\u003c/em\u003e\u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eOur finding demonstrated that CHWs strongly highlighted systemic obstacles such as long waiting times, inadequate privacy, and inflexible clinic hours as central barriers for men. These findings align with multiple studies from various African contexts, where health system inefficiencies and structural constraints have been shown to particularly hinder men\u0026rsquo;s engagement with healthcare [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Men are also affected by economic pressures and logistical burdens, with transport costs and loss of work time acting as powerful deterrents to attending clinics [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. This is especially true in rural and peri-urban settings, where facilities may be distant and public transport options limited.\u003c/p\u003e \u003cp\u003eConcerns over privacy and confidentiality also emerged, as men reported reluctance to be seen attending clinics for fear of community judgment or breaches of confidentiality. Such findings are consistent with broader literature, where confidentiality concerns are a recognized barrier to healthcare utilization among men, fuelling doubts and avoidance behaviors[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].CHWs repeatedly referenced deeply entrenched masculinity norms that discourage men from acknowledging vulnerability, seeking preventive care, or disclosing health problems. In sub-Saharan Africa, health-seeking is often constructed as a feminine activity, and men may perceive clinic attendance as incompatible with ideals of strength and patience[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. The literature consistently demonstrates that masculine identity preservation contributes to late presentation and underutilization of healthcare among men [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eStigma especially relating to HIV, tuberculosis, and sexual health was frequently cited as a critical barrier. Men\u0026rsquo;s discretion to engage with clinics often comes from fear of being labelled, both within their peer groups and at the broader community level[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Furthermore, CHWs noted the appeal of traditional healing practices among men, whom they observed to prefer traditional remedies over biomedical interventions in some cases[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].Despite these challenges, CHWs play a vital role as mediator, using personal introduction and clear communication to gain men\u0026rsquo;s trust and facilitate care. Their proximity and insider status within communities allow them to tailor services and provide culturally sensitive counselling, which literature identifies as essential for overcoming gendered barriers and increasing men\u0026rsquo;s healthcare engagement[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. However, the feminization of the CHW workforce may limit their impact with male clients, underlining a need for more gender-balanced staffing and specialized training in male-targeted outreach[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eStrategies proposed by CHWs including community mobile unit clinics, direct home medication delivery, and peer-led support group that reflect evidence-based recommendations in the literature. Community-based interventions, particularly those leveraging trusted male peers or integrating care into male-dominated communal spaces, have proven successful in shifting norms and addressing access barriers among men[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Peer-led and male-support groups, highlighted in both qualitative research and intervention trials, build community around health while eroding stigma and boosting uptake of testing and treatment [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cb\u003eStrengths and limitations\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe study offers valuable awareness into CHWs perspectives on the barriers and challenges men encounter when seeking healthcare services. A key strength lies in its qualitative design, which enables an in-depth understanding of the underlying factors influencing men\u0026rsquo;s health-seeking behaviors. Furthermore, the research is context-specific, reflecting the realities of a particular local municipality, which makes the findings highly relevant for designing interventions tailored to the community\u0026rsquo;s needs.\u003c/p\u003e \u003cp\u003eHowever, the study also presents notable limitations. The small sample size may not adequately represent the broader population of CHWs in the City of Mbombela, limiting the generalizability of the findings to other settings. Cultural, social, and economic characteristics unique to the study area further restrict the applicability of results to different populations. Additionally, reliance on self-reported data introduces potential biases, including social desirability effects. The use of a single data collection method, focus group discussion may also limit the comprehensiveness of the findings, as incorporating multiple methods could provide a more holistic understanding of the topic.\u003c/p\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eIt is evident that the multifaceted nature of barriers to healthcare access among adult men, encompassing cultural beliefs, systemic inefficiencies, and social stigma. CHWs identified practical strategies such as mobile clinics, direct medication delivery, and male-led support groups as promising interventions. Empowering CHWs through training and resources can enhance their capacity to engage men effectively. Future interventions should prioritize integrating CHWs into broader health system planning to ensure sustainable and inclusive healthcare access for all.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCHWs \u0026nbsp; \u0026nbsp; \u0026nbsp; Community Health Workers.\u003c/p\u003e\n\u003cp\u003eFGDs \u0026nbsp;\u0026nbsp; \u0026nbsp; \u0026nbsp; Focus Group Discussions\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSAMRC \u0026nbsp; South African Medical Research Council\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgement\u003c/strong\u003e: This is part of Langa J.M.\u0026rsquo;s PhD thesis. The authors wish to thank all of the responded who participated in the study: The Mpumalanga Health Department and Research Unit, University of Limpopo. the participants for participating in the study; the Mpumalanga Department of Heath for granting permission to conduct the study in selected health facilities in the City of Mbombela; and the Research assistants for their assistance in data collection.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions:\u0026nbsp;\u003c/strong\u003eJML contributed to conceptualization, methodology, data curation, and writing of the original draft. TSN was responsible for formal analysis, writing review and editing, and supervision. DTG contributed to investigation, validation, and writing review, editing and Co-supervision. All authors confirm that all stages of the research and manuscript preparation were conducted collaboratively and that they fully support the results.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e \u003cem\u003e\u0026nbsp;\u003c/em\u003eThe work reported herein was made possible through funding by the South African Medical Research Council through its Division of Research Capacity Development. The content hereof is the sole responsibility of the authors and does not necessarily represent the official views of the SAMRC.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability:\u003c/strong\u003e The datasets used and analysed during the current study available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of Interest:\u0026nbsp;\u003c/strong\u003eThe authors declare no conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInstitutional Review Board Statement\u003c/strong\u003e: The study was conducted in accordance with the Declaration of Helsinki and Ethical approval was obtained from University of Limpopo Ethics Committee with the code (TREC/110/2024:PG) on 20 May 2024.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed Consent Statement\u003c/strong\u003e: Informed consent was obtained from all the participants involved in the study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eKohrt BA, Asher L, Bhardwaj A, Fazel M, Jordans MJ, Mutamba BB, et al. The role of communities in mental health care in low-and middle-income countries: a meta-review of components and competencies. 2018;15(6):1279.\u003c/li\u003e\n\u003cli\u003eMatovu JK, Mbita G, Hamilton A, Mhando F, Sims WM, Thompson N, et al. Men\u0026rsquo;s comfort in distributing or receiving HIV self-test kits from close male social network members in Dar Es Salaam, Tanzania: baseline results from the STEP project. 2021;21(1):1739.\u003c/li\u003e\n\u003cli\u003ePascoe L, Peacock D, Stemple L. Reaching men: addressing the blind spot in the HIV response. 2018;1(SP1):e57\u0026ndash;70.\u003c/li\u003e\n\u003cli\u003eNjeru MK, Blystad A, Nyamongo IK, Fylkesnes K. A critical assessment of the WHO responsiveness tool: lessons from voluntary HIV testing and counselling services in Kenya. 2009;9(1):243.\u003c/li\u003e\n\u003cli\u003eClark J, Sweet L, Nyoni S, Ward PR. Improving male involvement in antenatal care in low and middle-income countries to prevent mother to child transmission of HIV: a realist review. 2020;15(10):e0240087.\u003c/li\u003e\n\u003cli\u003eMantell JE, DiCarlo AL, Remien RH, Zerbe A, Morris D, Pitt B, et al. \u0026lsquo;There\u0026rsquo;s no place like home\u0026rsquo;: perceptions of home-based HIV testing in Lesotho. 2014;29(3):456\u0026ndash;69.\u003c/li\u003e\n\u003cli\u003eEvans MGB, Cloete A, Zungu N, Simbayi LC. HIV Risk Among Men Who Have Sex With Men, Women Who Have Sex With Women, Lesbian, Gay, Bisexual and Transgender Populations in South Africa: A Mini-Review. 2016 Apr 8;10(1):49.\u003c/li\u003e\n\u003cli\u003eZuma T, Seeley J, Sibiya LO, Chimbindi N, Birdthistle I, Sherr L, et al. The changing landscape of diverse HIV treatment and prevention interventions: experiences and perceptions of adolescents and young adults in rural KwaZulu-Natal, South Africa. 2019;7:336.\u003c/li\u003e\n\u003cli\u003eEvans MGB, Cloete A, Zungu N, Simbayi LC. HIV Risk Among Men Who Have Sex With Men, Women Who Have Sex With Women, Lesbian, Gay, Bisexual and Transgender Populations in South Africa: A Mini-Review. 2016 Apr 8;10(1):49.\u003c/li\u003e\n\u003cli\u003eHaldane V, Chuah FL, Srivastava A, Singh SR, Koh GC, Seng CK, et al. Community participation in health services development, implementation, and evaluation: A systematic review of empowerment, health, community, and process outcomes. 2019;14(5):e0216112.\u003c/li\u003e\n\u003cli\u003eRoudsari RL, Sharifi F, Goudarzi F. Barriers to the participation of men in reproductive health care: a systematic review and meta-synthesis. 2023;23(1):818.\u003c/li\u003e\n\u003cli\u003eWong V, Jenkins E, Ford N, Ingold H. To thine own test be true: HIV self‐testing and the global reach for the undiagnosed. 2019;22(Suppl Suppl 1):e25256.\u003c/li\u003e\n\u003cli\u003eKaiser N, Barstow CK. Rural transportation infrastructure in low-and middle-income countries: a review of impacts, implications, and interventions. 2022;14(4):2149.\u003c/li\u003e\n\u003cli\u003eCuco RMM, Munguambe K, Osman NB, Sidat MM, Degomme O, Temmerman M. Male partners\u0026rsquo; involvement in prevention of mother-to-child HIV transmission in sub-Saharan Africa: a systematic review. 2015;12(1):87\u0026ndash;105.\u003c/li\u003e\n\u003cli\u003eKelly G, Mrengqwa L, Geffen L. \u0026ldquo;They don\u0026rsquo;t care about us\u0026rdquo;: older people\u0026rsquo;s experiences of primary healthcare in Cape Town, South Africa. 2019;19(1):98.\u003c/li\u003e\n\u003cli\u003eCamlin CS, Cassels S, Seeley J. Bringing population mobility into focus to achieve HIV prevention goals. 2018;21(Suppl Suppl 4):e25136.\u003c/li\u003e\n\u003cli\u003eBergman AJ, McNabb KC, Mlandu K, Akumbom A, Flores DD. Identity management in the face of HIV and intersecting stigmas: A metasynthesis of qualitative reports from sub-Saharan Africa. 2023;3(2):e0000706.\u003c/li\u003e\n\u003cli\u003eRotheram-Borus MJ, Tomlinson M, Mayekiso A, Bantjes J, Harris DM, Stewart J, et al. Gender-specific HIV and substance abuse prevention strategies for South African men: study protocol for a randomized controlled trial. 2018;19(1):417. \u003c/li\u003e\n\u003c/ol\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-research-notes","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"resn","sideBox":"Learn more about [BMC Research Notes](http://bmcresnotes.biomedcentral.com)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/resn/default.aspx","title":"BMC Research Notes","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"CHWs, men’s health, healthcare access, qualitative research, FGDs, City of Mbombela","lastPublishedDoi":"10.21203/rs.3.rs-8287737/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8287737/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjective: \u003c/strong\u003eMen in the city of Mbombela, face persistent barriers to healthcare access, driven by socio-cultural norms and systemic challenges. Community Health Workers (CHWs) are well-positioned to understand these barriers yet remain underrepresented in health system planning. This study aimed to explore CHWs’ perceptions of the obstacle’s adult men (18-60 years) encounter when seeking care and to identify feasible strategies to improve engagement within differentiated service delivery models.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eWe conducted five focus group discussions with 63 CHWs using a semi-structured guide. Thematic analysis identified that men’s health-seeking behaviour is constrained by harmful masculinity norms, HIV-related stigma, financial hardship, and inflexible clinic hours. CHWs reported playing key roles in awareness-raising and linkage to care but noted limited resources and training to effectively engage men. Participants proposed practical solutions, including mobile clinics, workplace-based services, male peer support groups, and gender-sensitive counseling. Findings suggest that integrating CHWs into male-targeted, community-based care models, while addressing both structural and cultural barriers could enhance men’s access and retention in health services.\u003c/p\u003e","manuscriptTitle":"Article: Community Health Workers ‘s perspectives on healthcare accessibility and utilisation by adult men in the City of Mbombela, Mpumalanga Province, South Africa","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-09 10:10:56","doi":"10.21203/rs.3.rs-8287737/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-02-03T16:23:46+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-26T18:34:55+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-22T04:07:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"124583536292660078696179498725417962188","date":"2026-01-15T23:21:47+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"318652111493934169182359373248693820520","date":"2026-01-14T17:19:06+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"321654799169973070734379185288784426209","date":"2026-01-13T22:49:57+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-07T09:37:01+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-05T12:14:11+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-12-11T11:25:13+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-11T10:53:17+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Research Notes","date":"2025-12-11T10:31:28+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-research-notes","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"resn","sideBox":"Learn more about [BMC Research Notes](http://bmcresnotes.biomedcentral.com)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/resn/default.aspx","title":"BMC Research Notes","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"aeaf8f0c-9486-40e1-9d92-c919f3f28077","owner":[],"postedDate":"January 9th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-21T16:23:33+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-09 10:10:56","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8287737","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8287737","identity":"rs-8287737","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}