Factors influencing men’s decisions whether or not to utilize sexual and reproductive health services in Low-Middle-Income countries: A narrative review

Factors influencing men’s decisions whether or not to utilize sexual and reproductive health services in Low-Middle-Income countries: A narrative review | 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 Help Center Sign In Submit a Preprint Cite Share Download PDF Systematic Review Factors influencing men’s decisions whether or not to utilize sexual and reproductive health services in Low-Middle-Income countries: A narrative review Mpumelelo Nyalela, Thembelihle Dlungwane This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-1418093/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Low-Middle-Income countries (LMIC) present with a high aversion to the utilization of Sexual and Reproductive Health (SRH) services by men. Nevertheless, in both Low-Middle-Income and High-Income countries, low SRH utilization is mainly related to men's poor Health Seeking Behaviour (HSB). Identifying SRH inhibitors and facilitators remains an essential approach to improve SRH utilization and avert higher mortality and earlier morbidity associated with poor HSB among men. This literature review identifies factors contributing to men's decisions not to utilize SRH services, particularly to inform a conceptual model illustrating men's SRH utilization in LMIC. Methods In this narrative review, we searched articles published between 2004 and 2021 from international databases, including Google Scholar, Science Direct, EBSCOhost, Scopus, PubMed, Medline, and reference lists of retrieved published articles. Results A total of 2219 articles were retrieved, from which 51 articles met the inclusion criteria. We reveal lack of access and availability of SRH services, poor health-seeking behavior among men and, SRH facilities often not being seen as "male-friendly” spaces and not providing men's services under one roof as the underlying factors contributing to the poor uptake of SRH services by men. Further influences to decline in SRH utilization by men included lack of focus on adult men's sexual and reproductive health; the lack of inclusion of men in a meaningful way; and the insufficient evidence about large-scale and implementable approaches to address men’s SRH needs. Our reviews reveal that dealing with negative or inhibiting factors to manage low utilization of SRH services had improved men's SRH utilization where this was carried out. We conclude by proposing a framework to illustrate men's engagement with SRH services. Epidemiology Men Sexual and Reproductive Health services factors influencing SRH service utilization factors facilitating the SRH service utilization factors inhibiting SRH service utilization Figures Figure 1 Figure 2 Plain English Sexual and Reproductive Health service utilization refers to accessibility, affordability, availability, and quality of sexual health services that are provided in a convenient and suitable manner. The utilization of SRH services provides a state of physical, mental, and emotional well-being. SRH services include assistance with contraception, prevention and treatment of HIV/AIDS and other Sexually Transmitted Infections (STIs), Medical Male Circumcision (MMC), condom use, psychosocial interventions such as sexual health counseling and education, Vasectomy, prevention and treatment of male cancers such as prostate and testicular, infertility services, sexual dysfunction developmental anomalies, malignancy, trauma, developmental and lifecycle issues, sexual identity and orientation, and partnership issues. We have found that there is a lack of literature investigating factors associated with adult men’s utilization of SRH. To our knowledge, this is the only review that comprehensively focuses on adult men’s utilization of SRH services. Empirical evidence indicates the enormous under-utilization of SRH services by men. Very few men are reported to be accessing and utilizing SRH services. Consequently, men die from curable SRH problems that can be prevented, contributing to higher mortality and earlier morbidity among men. The factors influencing men’s decision to utilize SRH services include cultural, religious, psychosocial, economic, and socio-demographic characteristics. We conducted a systematic review of articles between 2004 and 2021 and identified an initial 2219 papers, of which 51 were included in the analysis and then analyzed narratively. We extracted information about the factors influencing SRH service utilization among adult men from published and unpublished peer-reviewed literature. Identifying SRH inhibitors and facilitators remains an essential approach to improve SRH utilization. Background Sexual and Reproductive Health (SRH) is a global public health concern [ 1 , 2 ]. SRH problems account for major health challenges and constitute almost 14% of the disease burden which contributes to higher mortality and earlier morbidity in men [ 3 ]. Globally, SRH is one of the fundamental human rights for every individual [ 1 ], but only less than one-quarter of men report accessing and utilizing SRH services [ 4 ]. The utilization of SRH services refers to having suitable and convenient access to these services [ 5 , 10 ]. The services provide a state of physical, mental, and emotional well-being related to sexuality and reproduction, and are essential for the socio-economic development of communities and countries [ 2 , 6 – 8 ]. SRH services include providing contraception, prevention and treatment of mental disorders, communicable and non-communicable diseases, medical male circumcision, and psychosocial interventions such as sexual health counseling, [ 5 , 8 – 12 ]. Under-utilization of SRH services is evident despite several international conventions and adopted programmes and policies that seek to engage men and boys in the context of reproductive health services [ 11 ]. The Lancet Commission (2018) posited that 4.3 billion people of reproductive age would inadequately utilize sexual and reproductive health services throughout their lives. The Commission further stated that two million people were newly infected with HIV while more than 350 million men and women needed treatment for curable STIs [ 2 ]. Factors influencing men's under-utilization are multifaceted. These factors include the lack of focus on men's SRH by international programmes such as Sustainable Development Goals (SDGs) and Family Planning 2020 (FP2020), which largely focus on women and youth [ 14 – 17 ]. Furthermore, SRH service provision is often fragmented or poorly structured to address men's health needs, and is mostly needlessly expensive [ 3 , 17 , 18 ]. The purpose of the review is to synthesize available evidence on factors contributing towards adult men's engagement with SRH services in LMICs. The review focused on LMICs because of resource constraint challenges that largely lead to relative poorer access to and higher unmet need for SRH services. The literature review was conducted as part of a doctoral research project. These findings contribute to the development of appropriate interventions to guide men's engagement with SRH services. Methodology The systematic quantitative literature review method was followed to search and identify relevant literature. The search included published peer-reviewed articles, reports, and grey literature. Peer-reviewed articles were searched in the following databases: Google Scholar, Science Direct, Scopus, and EBSCOhost. Additionally, electronic databases: CINHAL, PubMed, Medline, Academic Search Complete, Health Source - Consumer Edition, Health Source: Nursing/Academic Edition and MEDLINE, electronic journals, and reference lists of retrieved published articles were also searched. The following MESH terms were used to retrieve relevant articles for this review: "sexual and reproductive health services", "men", "factors influencing / inhibiting / facilitating SRH service utilization", "Utilization of Sexual and Reproductive Health services by adult men". To cover comprehensive SRH services, studies were also searched by individual SRH services, e.g., utilization of condoms. Studies that investigated Health Care Workers’ (HCW) knowledge and perceptions about men's use of SRH services were also included. Studies conducted in 2004 were sourced because the World Health Organisation (WHO) recognized the immense global health burden (including extensive mortality and morbidity) associated with sexual and reproductive health conditions and poor quality of care for people's sexual and reproductive health in 2004 [ 12 ]. The database was constructed to extract important dimensions of factors influencing SRH service utilization. We extracted only relevant results about populations eligible for inclusion in this narrative review. For example, where data was collected for males and females, we extracted only data presented on males. Eligibility criteria This review included quantitative and qualitative papers published in English between 2004 and 2021. Studies reporting exclusively on the factors influencing SRH service utilization among adolescents or women were excluded. Studies reporting on the interventions and the evaluation of interventions to improve SRH utilization; clinical decision-making algorithms; studies conducted in HICs; and studies not reporting on barriers or facilitators of SRH utilization were also not considered. Assessment of Publications The database search generated 2219 records which were grey literature, health services reports, research reports, theses, and dissertations. The Principal Investigator assessed titles and abstracts for inclusion. On a review of titles, 2042 were excluded because they were duplicates unrelated to this narrative review topic or exclusively focused on adolescents and women. On a review of abstracts, 96 papers were excluded because they reported on the evaluation of SRH services, management of SRH problems, or male involvement in partner family planning. These were policies and documents that did not report on factors facilitating or hindering SRH service utilization. The latter were systematic reviews. Of 73 potentially relevant full-text papers, 22 were excluded because results did not yield factors hindering or facilitating SRH service utilization. Fifty-one papers met the inclusion criteria and were captured in the database. Secondary to the heterogeneity of papers, we present a narrative synthesis describing study characteristics and key findings. We further summarize overarching themes and the consistency of key findings. Discussions between team members were used to build consensus on the narrative synthesis. Constructing the database A database was constructed to summarise the studies identified for the review. The following information was captured in the database (Table 1): author (s), year of publication, the country(s) where the study was conducted, the age and target population for the study, the study design, barriers to and facilitators of the utilization of SRH services, and SRH issues investigated. Figure 1 presents the search algorithm indicating the number of identified studies, included and excluded studies, and reasons for exclusion. Results A total of 2219 articles were retrieved, from which 51 studies met the inclusion criteria for review. Table 1 presents the author, year of publication and study location, participant characteristics (age and gender), and study design. Table 2 presents barriers, facilitators, and sexual and reproductive health issues. All articles (qualitative and quantitative studies) extracted from the literature were descriptive. The results are summarized narratively. Description of included studies 1. Study location Most of the studies were conducted in South Africa (22%) [21-31], and five (10%) of studies were conducted in Kenya [32-36], Uganda [37-41], and Ghana [42-46]. Four (8%) studies were published in Zimbabwe [47-50]. Three (6%) studies were conducted in Nigeria [51-53] and Nepal [54-56]. In Rwanda [57, 58], there were two (4%) studies identified, whilst only one (2%) study each conducted in Swaziland [59], Papua New Guinea [60], Tanzania [61], Zambia [62], Botswana [63], Lesotho [64], Mexico [65], Philippines [66], Ethiopia [67], Egypt [68], Myanmar [69], Lao [70] and one both in Zimbabwe and South Africa [71]. 2. Age and gender The studies included all targeted adult men. In studies that mixed male and females, as well as those which included younger ages, we only extracted information pertaining to adult men. The majority (55%) of studies identified exclusively targeted men [22-26, 28, 30, 31, 33, 35, 37, 39, 41, 43, 44, 45, 48, 49, 53, 57, 59, 60, 62, 63-66, 71]. The balance (45%) focused on both men and women [21, 27, 29, 32, 34, 36, 38, 40, 42, 46, 47, 50-52, 54-56, 58, 61, 67-70]. The majority (86%) of studies targeted adults 26 years and above [21-39, 41-44, 46-51, 53, 57-66, 71]. Studies which targeted adolescents were excluded, however those targeting youth or young adults age between 15-25 years (14%) were included [40, 45, 52, 54-56, 67-70]. 3. Study design The majority (55%) of studies that met the inclusion criteria were conducted qualitatively, and employed either Focus Group Discussions (FGDs) (16%) or In-depth Interviews (IDIs) (18%), and some both FGDS and IDIs (24%) [22, 24, 26 ,28, 31-34, 36, 38, 39-41, 45-47, 49, 50, 52, 56, 59, 60-62, 65, 67, 68, 70, 71]. Twenty-five percent of quantitative studies employed cross-sectional study design [23, 25, 27, 29, 42, 43, 45, 51, 53, 54, 57, 58, 69], and two (4%) employed National Health and Demographic Survey (NHDS) [35, 66]. The later (16%) used mixed [21, 30, 37, 44, 48, 55, 63, 64]. There was only one mixed study that included Randomized Control Trial (RCT). 4. Study setting Forty-nine percent of studies were conducted in both urban and rural settings. In some studies, the exact locations where data was collected were not specified [33, 34, 40, 43, 45, 46, 56, 59, 60, 61, 63, 65-68, 70]. Some of the studies were conducted in public and private-sector health facilities (clinics and hospitals) [24, 25, 29, 58, 64]; private rooms or offices in community centres; Non-Governmental Organizations sites [27, 32, 35], and households in towns and rural villages [28, 48, 69]. In studies conducted exclusively in urban settings (27%), data was collected in towns and townships in which households were visited. Some participants were recruited on the streets [21, 23, 30, 47], district health offices [26], hospital and clinical settings [36, 38, 44, 53, 62], and there were two unspecified studies [42, 54]. Studies solely conducted in rural settings (24%) approached households in villages [22, 37, 39, 41, 49, 51, 52, 55, 57, 71], traditional healers’ places, school and community halls, community tuck-shops, faith-based organizations’ premises, hospital and clinic waiting rooms. [31, 50]. 5. SRH issues The SRH issues identified were Vasectomy; Family Planning (FP); Medical Male Circumcision (MMC); condom use; management and prevention of STIs; HIV services; Prostate Cancer (PC) screening; and Erectile Dysfunction (FD). 6. Barriers to men’s decisions to utilize or not utilize Sexual and Reproductive Health Services Several barriers have been associated with the decision to utilize or not utilize S.R.H. services. These can be summarized into individual/personal factors, knowledge, socio-cultural and religious, socio-economic factors, geographical, and health service system factors, as detailed below. Individual / personal factors In this review, individual/personal factors are described as behavior and characteristics demonstrated by participants which determined whether they utilized SRH services or not. Individual factors presented as barriers to SRH utilization were identified. Fear emerged as a barrier to utilizing SRH services. Among the studies focused on PC screening, fear of post-operative complications such as pain, delayed recovery, infections, morning erections, as well as the post-procedure abstinence period deterred most men from undergoing MMC [21,23, 32, 33, 39, 48, 49, 53, 57, 61-64, 59,71]. The requirement to do HIV testing before getting circumcised deterred most men from undergoing Medical Male Circumcision (MMC). They feared the possibility of testing positive, and hence death related to HIV complications. because of self-knowledge of reckless lifestyles. Men also feared the stigma associated with HIV, and the possibility of being blamed and rejected by significant others such as partners, family members, and friends, as well as the pressure from employees to quit the job after being diagnosed [24, 26, 27,31, 43, 47-52, 64, 69]. Post circumcision myths such as the inability to sexually satisfy partners, less natural lubrication, and decreased penile sensitivity on a circumcised penis also deterred individual men [21, 22, 33, 37, 39, 46, 59]. Factors associated with barriers involving Condom use included poor quality of condoms and embarrassment to buy condoms [28, 44, 66, 70]. Furthermore, the perception of low-risk also hindered men from using condoms and undergoing MMC [32, 33, 50, 57, 69, 70]. In Hassan's (2015) study, some men in Nigeria were reluctant to screen for Prostate Cancers they perceived it as a low-risk since there was no family history [53]. Lack of Knowledge Men's underutilization of SRH services was associated with a lack of awareness of disease screening services such as HIV and prostate cancer, and the lack of knowledge of the existence of SRH services. Consequently, some men did not know where to go for SRH services [27, 35, 46, 53-56, 67, 69, 70]. Lack of knowledge and understanding of HIV was evident when men often inferred their status from their female partners' results [27, 31, 52]. As a result of this lack of knowledge and of reliable information, men claimed less or no benefits of MMC if they were already HIV-positive, had good hygiene, were already practising other HIV prevention methods such as the ‘Abstinence’ ‘Be faithful’ ‘Condomise’ (ABC) method, or their partner(s) was sexually satisfied [33, 49]. Furthermore, in non-circumcising communities in South Africa, men did not know that the MMC service was offered for free at the local clinic or hospital [21]. Furthermore, some men associated infertility with circumcision [39, 48]. In addition to lack of knowledge, myths resulted in men opting not to use condoms after getting circumcised, citing reasons such as the circumcised penis would tear a condom; or putting a condom on an exposed circumcised penis would cause pain [47]. Furthermore, misconceptions such as the nutritional benefit from sperm, condom porousness, lubricant related infections, and the belief that white men had infected condoms with HIV hindered Condom use [28, 40, 45, 50, 56, 70]. Men often confused Vasectomy with castration and wrongly associated it with loss of libido, decreased sexual activity, and loss of masculinity [46, 66]. Socio-cultural and religious factors Factors associated with culture, such as the threat to masculinity, prevented men from undergoing MMC as non-circumcising communities presumed circumcision to be an alien culture or part of a foreign religion [21, 23, 30, 39, 45, 47, 49, 59, 60]. Some men alluded to undergoing MMC as tampering with God's creation [33, 47, 49, 59]. Most cultural and religious practices consider discussing sexual matters a taboo. Therefore, the sensitivity of discussing SRH issues had hindered most men from accessing psychosocial health therapy and counseling [35, 42, 45, 46, 55, 56, 67]. Socio-economic factors SRH service utilization was hindered by the perceived high costs of SRH products such as condoms, particularly in rural areas [40, 56, 67]. In addition, the inaccessibility and unavailability of condoms due to fewer shops contributed to low utilization [23, 25, 29, 30, 44, 45, 69]. Fear of losing income (work) due to long-period off work due to pain or post-procedure healing period deterred some men from undergoing MMC [21, 32, 33, 39, 61, 62]. Traveling costs to healthcare establishments also emerged as a major deterrent [27]. Geographical factors In most LMICs, health facilities are concentrated in the urban area, whereas most men in these populations reside in rural areas [67, 56, 63]. Consequently, long distances and poor transport (especially in rural areas) to the health facility became barriers to accessing and utilizing SRH services [29, 33, 40, 42, 54, 69]. The distance of health centres from men's workplaces often leads to men failing to utilize SRH services. Furthermore, poor transport infrastructure can prevent access to services in rural areas [30]. Health service system (Physical accessibility, availability, accessibility, affordability) Poor quality of the services and lack of materials such as condoms and medicines hindered the utilization of SRH services by men [29, 42, 54, 55, 63, 67, 68, 70]. Inconvenient service hours or limited opening hours at the delivery point were also barriers to SRH services utilization [27, 36, 40, 54, 55, 67, 68]. The inconvenience of the location of the SRH services at the local clinic seems to be a barrier to accessing the SRH care, especially for young men [44, 67]. Long waiting times because of queues influenced men's decisions to avoid coming to a healthcare centre [29, 30, 36, 40, 42, 50, 63, 64, 67]. Some studies revealed that most health care providers lack the necessary training and knowledge to make men feel comfortable discussing SRH issues [36, 56, 67]. Physicians indicated discomfort in counseling on sexuality and safer sex for unmarried youth [68]. Lack of privacy, respect, and potential breaches of confidentiality from the health care workers at the health facilities deterred men from utilizing SRH services [25, 36, 40, 41, 44, 55, 67, 70]. Men avoided utilization of SRH services due to hostile and judgmental attitudes from female health service providers [27, 29, 30, 40, 45, 56], especially towards young and unmarried men. There is still much sensitivity needed regarding pre-marital sexuality [26, 29, 36, 56, 67, 69, 70]. Consequently, the non-availability of same-sex health workers was a barrier since some men felt embarrassed to discuss their health issues and be examined by female health workers [30, 33, 45, 55, 64, 68]. Frequently changing HIV prevention programmes led to distrust in the health system, discouraging men from testing and treating HIV [49, 59]. A further deterrent was partial protection of condoms and lack of empirical efficacy of MMC for HIV prevention as people can die even after circumcision [39]. 7. Facilitators to men’s engagement with Sexual and Reproductive Health Services There was a limited number of studies that focused on factors facilitating the utilization of SRH services. Facilitators to men's decisions to utilize SRH services are summarized into individual/personal issues, knowledge, socio-cultural and religious factors, socio-economic factors, and health service system factors as detailed below. Individual / personal factors Some studies discussed above concluded that men were reluctant to undergo MMC due to poor sexual performance. Conversely, other studies found that sexual appeal and satisfying women motivated men to perform MMC sexually. Men believe that post circumcision, they better satisfy women as they last longer before ejaculating, and also wearing condoms was much easier after the foreskin was removed [21, 22, 33, 38, 47, 60, 61, 64, 59]. Curiosity to feel the difference between sex with an uncircumcised penis and a circumcised one motivated some men [47]. Furthermore, personal gain or prestige from research activities such as free medical care for ailments, financial incentives, and a sense of being responsible by participating and contributing to research, motivated men to undergo MMC [27, 39, 50]. Role modeling positive HIV status disclosure and adherence to Anti-Retroviral Therapy (ART) motivated men to engage in HIV treatment initiatives [24, 27]. Furthermore, an individual desire to limit family size encouraged some men to undergo a Vasectomy since it was perceived as a permanent method with a low risk of complications, thus limiting the side effects of other female-controlled hormonal methods [58]. Knowledge Knowing the benefits of undergoing MMC, such as protection against diseases and improved hygiene motivated most men to perform the procedure [21, 33, 34, 37-39, 47, 48, 57, 60-62, 64, 59,]. Some men were motivated by myths such as the increased size of the penis post circumcision (Humphries 2015). Socio-economic factors Financial constraints motivated undergoing a Vasectomy [58]. The fact that some SRH services are provided at no cost, also motivated men [38]. Health service system (Physical accessibility, availability, accessibility, affordability) Health workers' welcoming friendly attitudes, and respect for men's privacy and confidentiality motivated men to access and utilize SRH services [55, 63, 68]. Access to the right information about SRH services via advertisements such as pamphlets and radio/television programmes [27, 63] and the support from healthcare providers also played a vital role in encouraging SRH service use by men [24, 41, 50]. Discussion This literature review aimed to establish the factors that influence men's decisions to utilize or not to utilize SRH services. In this review, only studies conducted in LMICs were included for synthesis. Identified studies were conducted mostly in the Africa regions (Southern, Eastern, and Western regions), and ten percent in South-Asia. Although studies were conducted in either rural or urban or in both rural and urban areas, findings in these settings remained comparable. Qualitative methods were the most used methods, either employed Focus Group Discussions (FGDs) or In-depth Interviews (IDIs) and some utilized both FGDS and IDIs. All studies included in this review targeted adult men. In studies that mixed males and females, as well as those that included younger ages, we only extracted information pertaining to adult men. Adult men were targeted because the literature review revealed less focus on studies investigating SRH service utilization among adult men. The most prevalent SRH issues identified incorporated Medical Male Circumcision, management and prevention of STIs, HIV/AIDS services, Family Planning (FP), and condom use. Less noted were Prostate Cancer (PC) screening, and Erectile Dysfunction (ED), and Vasectomy surgeries. This may be because services for these SRH issues are expensive, and most men in LMICs cannot afford them and sometimes they are against their cultures and religious beliefs [ 46 , 58 ]. The identified barriers and facilitators of SRH service utilization encompassed individual or personal factors, lack of knowledge, socio-cultural and religious factors, socio-economic factors, geographical and health service systems. The most prevalent barrier identified was the personal perceptions (personal factors) in which men largely demonstrated embarrassment, insecurity (which have to do with their self-esteem and reputation), and fear. Fear played a vital role in inhibiting men’s use of SRH services. Consequently, men were discouraged to utilize SRH services such as MMC, Vasectomy services, family planning, STI / HIV services, screening for prostate cancer, and Condom use [ 23 , 26 , 27 , 33 , 42 , 43 , 46 , 47 , 49 , 50 , 59 , 63 , 64 , 66 ]. Some studies revealed that men were largely deterred by fear of MMC post-procedure complications [ 32 , 33 , 39 , 61 , 62 ]. Most men find it embarrassing to go to SRH services and consider it a very negative experience when they are seen, ridiculed, and disrespected by people known to them [ 28 , 44 , 66 , 70 ]. These negative experiences may motivate men not to go back to the clinic. Under-utilization of SRH services was associated with a range of cultural barriers. Most studies indicated that socio-cultural factors inhibited men's utilization of SRH services. For example, cultural and religious backgrounds that perceived discussing sexual matters as a taboo deterred men's engagement with SRH services [ 35 , 42 , 45 , 46 , 55 , 56 , 67 ]. The threat to masculinity was also a major barrier, and was associated with post MMC or Vasectomy procedure misconceptions and myths. These are beliefs about the inability to produce more children, the loss of manhood, and infertility [ 48 , 39 , 40 ]. Despite the availability of services, poor utilization was associated with limited knowledge of the availability of the different SRH services. Lack of knowledge or awareness of the existence of SRH services such as vasectomies, screening for prostate cancer, STI / HIV testing, MMC, centres for counseling, and provision of information, hindered men's utilization [ 27 , 35 , 46 , 53 – 56 , 67 , 69 , 70 ]. Cost-related issues prevented access to and utilization of SRH services such vasectomies, condoms, HIV testing. Although most SRH services are provided for free in LMICs, some men, especially those from rural areas, alluded to cost as a hindrance to accessing SRH services [ 40 , 56 , 67 ]. Such difficulties in accessing SRH services may be due to unemployment. In rural areas, most health facilities are far from the communities. As a result, people in rural communities have to walk long distances due to a lack of money and transport. In the health service system, health care workers' conduct significantly influenced men's decisions to utilize or not to utilize SRH services. Predominantly, men’s utilization of SRH services was deterred by bad health workers' attitudes and lack of privacy and confidentiality. The review identified only a few studies that focused on factors facilitating the SRH service utilization by men. Among studies that investigated SRH facilitating factors, virility was found to have motivated men to undergo MMC. Having done MMC, some men claimed to be stronger sexually, and that wearing condoms was much easier [ 21 , 22 , 33 , 38 , 47 , 60 , 61 , 64 , 59 ]. Conversely, some studies found that men were reluctant to undergo MMC in case it resulted in poor sexual performance. Barriers to SRH service were prevalent among societies who did not regard MMC as part of life, whereas, facilitators to SRH service utilization were predominant among those who embraced MMC. Individual factors such as curiosity motivated SRH utilization. For example, some men were inquisitive about the differences experienced during the sexual act with an uncircumcised penis as compared to a circumcised one [ 47 ]. Moreover, personal gain from research activities cannot be ruled out as most men showed interest in financial incentives post MMC [ 27 , 39 , 50 ]. Knowledge was instrumental in encouraging SRH service utilization. Men who understood the benefits of undergoing MMC were motivated to perform the procedure [21, 33, 34, 37–39, 47, 48, 57, 60–62, 64, 59,]. Bad attitudes from healthcare workers can be a barrier to SRH service utilisation, however, professional and good treatment from healthcare workers was found to facilitate SRH service utilization [ 55 , 63 , 68 ]. This review of the literature revealed a limited number of studies conducted exclusively in the area of adult men's SRH service utilization. More studies that focus on adult men need to be conducted, especially in LMICs. Given the lack of focus on men's SRH by international programmes such as SDGs and Family Planning 2020 (FP2020) [ 14 – 17 ], research focusing on men may bring about evidence-based knowledge that can be utilized by policy makers to ensure accessibility and availability of SRH services for adult men. Subsequently, high morbidity and mortality among men adult men may decrease. The analysis also reveals that men generally ignore the warning signs of sexual health problems, and are reluctant to seek and engage with SRH services for anything other than severe illness [ 67 , 41 ]. Nevertheless, if factors influencing men’s decisions to seek and utilize SRH services are known and understood comprehensively and in the local context, men's engagement with SRH services could improve. Furthermore, this analysis can be used by policymakers, service administrators, and service providers who want to identify the barriers experienced by men to make services more accessible. Strengths of the review This review consolidated knowledge about barriers and facilitators that influence men's decisions to utilize SRH services. While reviews conducted in past decades have identified barriers and facilitators to SRH services, this current systematic review is the first to focus on adult men only and to comprehensively focus on all SRH services. The findings from this review have implications for clinical practice and policy. Limitations of the review This review restricted the inclusion criteria to studies conducted in LMICs. Therefore, findings may not be generalizable to other settings. However, during analysis, the authors extracted findings of adult men only. The writers of the review also restricted the criteria only to include studies published in English due to a lack of resources for translation. This may limit how findings from this review can be transferable to all low and middle-income countries. Another limitation of this review is that data extraction was not performed in duplicate, which could result in bias results. We did not do additional study quality assessments or remove studies based on the risk of bias, given our goal to describe the relevant studies identified. Conclusion Despite the need for SRH utilization by men, there is little evidence suggesting the implementation of proposed interventions. Consequently, low SRH utilization has become a major concern regarding men's health. Men's SRH service utilization needs to be investigated comprehensively to comprehend men's problems fully. None of the identified studies comprehensively investigated SRH issues. There is also a lack of studies investigating vasectomies and their influence on infertility. Furthermore, most papers identified described adolescents and young adults, predominantly focusing on barriers rather than facilitators. There is, therefore, a need to explore the utilization of SRH services among adult men. There is a need to motivate men to participate in SRH services so that the high level of morbidity and mortality among men can be averted. Although SRH includes mental health issues, little is known about mental health issues related to sexual health. The same applies to the impact of physical disabilities and chronic illnesses on sexual well-being. Further research may be warranted in this regard. Governments need to increase the awareness and education of the public to fight against myths and misconceptions linked to the utilization of SRH services and to improve the capacity of the healthcare providers to engage men better. Men perceive many hindrances in obtaining SRH services from the time they access the services until they leave. These hurdles must be reduced as they could prevent them from even initiating seeking advice or care. Some obstacles (e.g., access, service delivery) are easier to remove than others (e.g., living place issues). There is a need to advertise the services widely, to indicate who can seek these, and to offer convenient opening hours. Abbreviations SRH Sexual and Reproductive Health LMICs Low- and Middle-Income countries HSB Health Seeking Behaviour HIV Human Immunodeficiency Virus AIDS Acquired Immunodeficiency Disease Syndrome STI Sexually transmitted infection UNFPA United Nations Population Fund WHO World Health Organization HCW Healthcare worker MMC Medical Male Circumcision PC Prostate Cancer ED Erectile Dysfunction FP Family Planning IPPF International Planned Parenthood Federation S.D.G.s Sustainable Development Goals F.G.D.s Focus Group Discussions I.D.I.s In-depth Interviews. Declarations Acknowledgements Not applicable. Authors’ contributions M.N. conceived the study and developed the design of this review with valuable contributions from T.D. M.N. performed the searches, conducted the title and abstract screening and the full-text screening, and performed the data abstraction and thematic analysis. M.N. drafted the first manuscript. T.D. oversaw the project and contributed valuable feedback to the manuscript. All authors read and gave approval of the final manuscript. Funding The author(s) received no financial support for this article's research, authorship, and publication. Availability of data and materials Not applicable. Ethics approval and consent to participate Not applicable. Consent for publication Not Applicable. Competing interests The authors declare that they have no competing interests. Author details Mpumelelo Nyalela (MPH), Lecturer. Email: [email protected] Thembelihle Dlungwane (PhD), Senior Lecturer. Email: [email protected] References Jobson M. Structure of the health system in South Africa. 2015. South Africa Khulumani Support Group. Starrs AM, Ezeh AC, Barker G, Basu A, Bertrand JT, et al. Accelerate progress—sexual and reproductive health and rights for all: report of the Guttmacher–Lancet Commission. The Lancet. 2018 Jun 30;391(10140):2642–92. De Silva VP. 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DOI: 10.1080/13691058.2013.807519 Tables Table 1: Author, year of publication and study location, participant characteristics (age and gender), study design and study setting Authors Year Study location Participant characteristics (age and gender) Study design Study setting (Urban or Rural) Hoffman et al. 2015 South Africa Men and women 18 and above Mixed - analytical cross-sectional study design Urban Humphries et al. 2015 South Africa Men 18-54 Qualitative - FGDs Rural Lissouba et al. 2011 South Africa Men 15-49 Quantitative - Community-based cross-sectional study Urban Zissette et al. 2016 South Africa Men 24-80 Qualitative – IDIs Urban Khan et al. 2014 South Africa Men 18-50 Survey questionnaire Urban Mambanga et al. 2016 South Africa Men 18 and above Qualitative - semi-structured interviews Urban Mohlabane et al. 2016 South Africa Men and women 16 and above Quantitative – cross-sectional survey (semi-structured questionnaire) Urban and Rural Stern et al. 2014 South Africa Men 18-55 Qualitative – FGDs Urban and Rural Morison et al. 2016 South Africa Men and women 20-90 Quantitative – Survey - A Healthcare User questionnaire Urban and Rural Mthembu et al. 2015 South Africa Men 18 and above Quantitative - Survey questionnaire Qualitative - IDIs Urban Chikovore et al. 2016 South Africa Men 17-64 Qualitative - IDIs, FGDs Rural Evens et al. 2014 Kenya Men and women 18-35 Qualitative - FGDs, IDIs Urban and Rural Herman-Roloff et al. 2011 Kenya Men 18-40 Qualitative - FGDs Urban and Rural Macintyre et al. 2014 Kenya Men and women 25-49 Qualitative - FGDs, IDIs Urban and Rural Withers et al. 2015 Kenya Men 15-64 Quantitative - Kenya Demographic and Health Survey (KDHS). Urban and Rural Godia et al. 2013 Kenya Men and women 27-50 Qualitative – FGDs, IDIs Urban and Rural Mbonye et al. 2016 Uganda Men 18-35 Mixed: Quantitative - interim serosurvey; Qualitative - IDIs Rural Muhamadi et al. 2013 Uganda Men and women 18 and above Qualitative - IDIs, FGDs Urban Ssekubugu et al. 2013 Uganda Men 15-49 Quantitative - RCT Qualitative - FGDs Rural Nalwadda et al. 2010 Uganda Men and women 15-25 Qualitative - FGDs Urban and Rural Siu et al. 2013 Uganda Men 27-51 Qualitative - IDIs Rural Sunnu et al. 2016 Ghana Men and women 15-65 Quantitative - cross-sectional survey Urban Dako-Gyeke et al. 2014 Ghana Men 15-49 Quantitative - cross-sectional survey Urban and Rural Leblanc et al. 2015 Ghana Men 18 and above Mixed: Quantitative – self-administered structured questionnaire. Qualitative – IDIs, FGDs Urban Addo et al. 2016 Ghana Men and women 15-25 Quantitative - cross-sectional survey Urban and Rural Adongo et al. 2014 Ghana Men and women 18 and above Qualitative – IDIs, FGDs Urban and Rural Chikutsa et al. 2015 Zimbabwe Men and women 18-49 Qualitative - FGDs, IDIs Urban Hatzold et al. 2014 Zimbabwe Men 15-49 Mixed: Quantitative - National, population-based survey, Qualitative - FGDs Urban and Rural Moyo et al. 2015 Zimbabwe Men 15-79 Qualitative - FGDs Rural Skovdal et al. 2011 Zimbabwe Men and women 18 and above Qualitative - IDIs, FGDs Rural Thomas et al. 2015 Nigeria Men and women 18-30 Quantitative - interview schedule - pre-tested questionnaire (scale) Rural Jones et al. 2017 Nigeria Men and women 18-24 Qualitative - IDIs Rural Hassan et al. 2015 Nigeria Men 25-60 Quantitative - descriptive cross-sectional Urban Tamang et al. 2017 Nepal Men and women 15-24 Quantitative - cross-sectional household survey Urban Gautam et al. 2018 Nepal Men and women 15-24 Qualitative - IDIs Rural Regmi et al. 2010 Nepal Men and women 18-22 Qualitative - IDIs and FGDs Urban and Rural Gasasira et al. 2012 Rwanda Men 15-59 Quantitative - cross sectional study Rural Shattuck et al. 2014 Rwanda Men and women 24-45 Quantitative - cross-sectional descriptive Urban and Rural Adams et al. 2015 Swaziland Men 18-49 Qualitative – FGDs, IDIs, participant observation Urban and Rural Kelly et al. 2012 Papua New Guinea Men 16 and above Qualitative – FGDs, IDIs Urban and Rural Plotkin et al. 2013 Tanzania Men and women 18-39 Qualitative - FGDs Urban and Rural Price et al. 2014 Zambia Men 18 and above Qualitative - semi-structured interviews Urban Sabone et al. 2013 Botswana Men 18 and above Mixed: Quantitative - survey was cross-sectional, - Qualitative – IDIs, FGDs Urban and Rural Skolnik et al. 2014 Lesotho Men 18 and above Mixed: Quantitative – cross-sectional Qualitative - FGDs Urban and Rural Yabeny et al. 2018 Mexico Men 20-39 Qualitative - IDIs Urban Parcon et al. 2010 Philippines (Western Visayas) Men 15-54 Quantitative - National Health and Demographic Survey (NDHS) Urban and Rural Muntean et al. 2015 Ethiopia Men and women 15-24 Qualitative - IDIs Urban and Rural Oraby et al. 2013 Egypt Men and women 15-24 Qualitative – IDIs, FGDs Urban and Rural Thongmixay et al. 2019 Lao Men and women 15-25 Qualitative - IDIs Urban and Rural Zaw et al. 2012 Myanmar Men and women 15-24 Quantitative - cross-sectional study Urban and Rural Khumalo-Sakutukwa et al. 2013 Zimbabwe, South Africa Men 18 and above Qualitative – IDIs, FGDs Rural Table 2: Barriers, Facilitators, and SRH issues Authors Barriers Facilitators SRH issues Hoffman et al. Intra and Post and procedure complications Low-risk perception, Lack of social support High costs Fear HIV test Protection against diseases (HIV, STIs, cancers) acquisition Hygiene Virility Good societal standing MMC Humphries et al. Post-procedure complications Low-risk perception Virility Social support MMC Lissouba et al. Intra-procedure complications Non-culture High costs Safety Social support MMC Zissette et al. Threat to masculinity (stigma around HIV) Fear of losing manhood Social support Good standing example HIV testing and management Khan et al. Lack of confidentiality High costs HIV counselling and testing (HCT) Mambanga et al. Fear HIV test (stigma around HIV) Cultural practices preference Low-risk perception None HIV counselling and testing (HCT) Mohlabane et al. Fear of HIV test (stigma around HIV) Staff attitudes Lack of knowledge (testing sites, understanding HIV) Inconvenient opening hours Fear of death Ignorance (lack of condom use) Low-risk perception High costs (traveling) Lack of social support Knowledge Incentives for those who test for HIV Good staff attitudes Role modes Stern et al. Condom use– Virility (sex interruption, incontrollable sexual urge) Lack of knowledge of HIV transmission Substance abuse Low-risk perception None Condom use Morison et al. Long waiting times Unavailability of medicines and equipment Staff attitudes Lak of privacy and confidentiality High costs (traveling) None HCT Family Planning Condoms use HIV and STI treatment and counselling Mthembu et al. Staff attitudes Long waiting times High costs Absence of male health workers HCT Chikovore et al. Fear HIV test Low-risk perception Preference of traditional medicine None HCT and management Evens et al. Myths (circumcised penis would tear a condom) Nonculture / Nonreligion Lack of trust in government witchcrafts beliefs Low-risk perception Fear HIV test Virility MMC Herman-Roloff et al. Fear of losing a job Noncultural, nonreligious Intra and Post procedure complications Lack of knowledge Vulnerability to ignorance Distance to health facilities Female service providers Hygiene Social acceptance Virility Protection against diseases Convenience (easier to use condom) MMC Macintyre et al. Nonculture, nonreligion Low-risk perception Hygiene Protection against diseases Social support MMC Withers et al. Lack of knowledge or awareness Religious prohibition Unvirility Hindrance to community development None Family planning Godia et al. Limited knowledge and competency of HSP Staff attitudes Lack of medicines and equipment Lack of confidentiality and privacy Long waiting times High costs. Inconvenient hours None Family Planning STI/HIV services, Condom use Mbonye et al. Post-procedure compilations Fear HIV test Protection against diseases Hygiene MMC Muhamadi et al. None Protection against diseases Hygiene Social support Virility MMC Ssekubugu et al. Post-procedure compilations Fear HIV test Myths (infertility) Partial protection against diseases Long waiting times Fear of losing a job Protection against diseases Hygiene Social support Incentives. MMC Nalwadda et al. Myths (infertility, porous and infectious condoms) Virility Low-risk perception Incontrollable sexual urge Staff attitudes Lack of privacy and confidentiality, Lack medicines and equipment High costs Long distance to health facilities Inconvenient opening hours, Long waiting times None Family Planning STI/HIV services, Condom use Siu et al. Threat to masculinity Fear HIV test Long waiting times Lack of confidentiality and privacy None HIV services Sunnu et al. Lack social support Nonreligious, noncultural Staff attitudes Distance to health facilities None Family planning Dako-Gyeke et al. Fear HIV test None HCT Leblanc et al. Cultural beliefs (non-condom use) Embarrassment Desire for children Fear of HIV test (stigma) High costs Lack of confidentiality None HIV services Condom use Yeboah et al. Embarrassment High costs Female health Staff attitudes Religious doctrines None Family planning STI services Adongo et al. Lack of social support Unvirility Vulnerability to ignorance Intra and Post procedure complications Lack of knowledge Religious doctrines None Vasectomy Condom use Chikutsa et al. Myths (circumcised penis would tear a condom, foreskin may be used in satanic rituals.) Nonculture, nonreligion Lack of trust in government Low-risk perception Fear HIV test Virility Protection against diseases MMC Hatzold et al. Intra procedure complications Low-risk perception Lack of social support, High costs Fear of an HIV test Myths (infertility) Protection against diseases Hygiene, Virility Set good example MMC Moyo et al. Lack of knowledge Fear of HIV testing Myths (foreskin to be used in witchcraft) Lack of trust in government Threat to masculinity Female health care provider Unvirility None MMC Skovdal et al. Fear of HIV test Stigma Embarrassment Threat to masculinity Low-risk perception Lack of knowledge Social support Role models HIV services Thomas et al. Fear of HIV test Stigma Nonculture None HIV services Jones et al. Stigma Inaccessibility Lack of knowledge Inaccessibility Low-risk perception None HIV services Hassan et al. Low-risk perception Lack of time Intra procedure complications Fear of PC test outcome Lack of knowledge None Prostate Cancer screening Tamang et al. Embarrassment Poor health services Lack of knowledge Inaccessibility None Condom use Family planning Gautam et al. Embarrassment Lack of knowledge Staff attitudes Lack of privacy and confidentiality Lack of medicines and equipment None All Regmi et al. Embarrassment Poor health services Lack of knowledge Substance abuse Inaccessibility High costs None Condom use Gasasira et al. Low-risk Intra procedure complications Protection against diseases Hygiene MMC Shattuck et al. None Financial relief (limit family size) Complications of other family plaining methods Permanent method Low-risk of complications Vasectomy services Adams et al. Threat to masculinity Virility Intra and post procedure complications Partially protective against diseases Lack of trust in government Noncultural, nonreligious Lack of knowledge Myths (foreskins used for witchcraft) Virility Protection against diseases Convenience (wearing condoms) MMC Kelly et al. Vulnerable to ignorance Noncultural, nonreligious Protection against diseases Hygiene Culturally appropriate Virility MMC Plotkin et al. Post procedure complications Fear of losing job Protection against diseases Hygiene Social support Virility MMC Price et al. Intra and post procedure complications Lack of time Social support Hygiene Protection against diseases MMC Sabone et al. Lack of medicines and equipment Long waiting times Poor transport to health facilities Post procedure complications Advertisement Social support Right staff attitudes MMC Skolnik et al. Intra procedure complications Fear of HIV test High costs Female health workers Long waiting times Protection against diseases Hygiene Social support Virility MMC Yabeny et al. Low-risk perception Fear of illness Mistrust in relationship Condom use Parcon et al. Lack of knowledge Myths (loss of libido) Unvirility decreased sexual activity, loss of vitality, Inconvenience Embarrassment Protection against diseases Vasectomy Condom use Muntean et al. High costs Long distance to the health facility Staff attitudes Inconvenient location of facilities Inconvenient hours Lack of privacy and confidentiality Embarrassment Lack of knowledge Noncultural None All Oraby et al. Inaccessibility Absence of male health workers None All Thongmixay et al. Lack of medicines and equipment Low-risk perception Lack of knowledge Lack of privacy and confidentiality Substance abuse Noncultural, nonreligious Embarrassment High costs Protection against diseases Social acceptance Condom use Family planning Zaw et al. High costs Lack of confidentiality Lack of transport Staff attitudes Fear of HIV test Embarrassment Lack of knowledge None Family planning HIV services Condom use Khumalo-Sakutukwa et al. Noncultural Intra and post procedure complications None MMC Cite Share Download PDF Status: Posted Version 1 posted 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. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies 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-1418093","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Systematic Review","associatedPublications":[],"authors":[{"id":88208897,"identity":"c8252c85-96d6-4d7e-8cdb-a8c15cf48971","order_by":0,"name":"Mpumelelo Nyalela","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA4ElEQVRIie3SsWoCQRDG8U8OtBnYlKbyFUauCDb3IjYLC3uNC1cKFi4IsRHS7mMogdR7LOQaH+DKq6wsDmxSpNA2zZ12Afdfz2+mGSAW+58NPApAYPiA8WDg1T5M2N9L3saq8S1n87TW6lIgm0CEppPMnObSsTJftfapg5pafHMn4VpyIE5uJLeKkEgMbB/J2/DLa/PpchsIa4lk1PaQBQdwMPuxLjeEIDGknivHc1HuuDLueFIJcTV9Jyq6SZUfmp/lynxsdXqh5WoiRLXvJHiRfzbgjicQvnckFovFnr0rP3ZGH0vgRqYAAAAASUVORK5CYII=","orcid":"","institution":"University of Kwa-Zulu Natal","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Mpumelelo","middleName":"","lastName":"Nyalela","suffix":""},{"id":88209064,"identity":"58a51225-a386-4141-becb-48b158284641","order_by":1,"name":"Thembelihle Dlungwane","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA4klEQVRIiWNgGAWjYDCC4zAGewMzkVoOwxg8B0jWIpFApBa+wzxmD7+22eXxS74xNvy5g0Gev4H94Qd8WiQP85gby7YlF0vOzjFOkDzDYDjjAEOyBD4tBkBbpCW3MSduuJ1jfMCwjYFxAwPDAWK01Cfuv3nG+EBiG4P9BgbG5h+EtEh+3HY4cYMEj3HCwTaGxA0MzGx4bZE8zFYmzfjveOKMM2nFho1tEskzDrOxWeDTwne8eZvkjzPVif3thzdL/myzse1vb398A58WEGDmQbCBTiImehjx+nYUjIJRMApGAQBrcUWpzCl1rQAAAABJRU5ErkJggg==","orcid":"","institution":"University of Kwa-Zulu Natal","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Thembelihle","middleName":"","lastName":"Dlungwane","suffix":""}],"badges":[],"createdAt":"2022-03-04 07:54:34","currentVersionCode":1,"declarations":{"humanSubjects":true,"vertebrateSubjects":false,"conflictsOfInterestStatement":true,"humanSubjectEthicalGuidelines":true,"humanSubjectConsent":true,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false,"coiExplicitlySet":false},"doi":"10.21203/rs.3.rs-1418093/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-1418093/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":18953221,"identity":"d90824ac-1fc6-4af7-80c7-2597e5945f5d","added_by":"auto","created_at":"2022-03-07 23:12:25","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":110890,"visible":true,"origin":"","legend":"\u003cp\u003eFlow chart mapping out the number of articles identified, screened, excluded together with reasons for exclusion\u003c/p\u003e","description":"","filename":"ScreenShot20220307at1.32.48PM.png","url":"https://assets-eu.researchsquare.com/files/rs-1418093/v1/b64143074293326d556987f8.png"},{"id":18953411,"identity":"11020575-7e46-46b0-b92d-1adbe75abb43","added_by":"auto","created_at":"2022-03-07 23:15:25","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":188551,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003e\u003cu\u003eConceptual Framework\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Fig.jpg","url":"https://assets-eu.researchsquare.com/files/rs-1418093/v1/b7e9b47aa259a33480f980e8.jpg"},{"id":18953412,"identity":"b367fcef-a999-4cdf-9eca-65bfd55413f5","added_by":"auto","created_at":"2022-03-07 23:15:28","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":750511,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-1418093/v1/ddeef55f-8235-4237-a547-122ca6b3d6ad.pdf"}],"financialInterests":"","formattedTitle":"\u003cp\u003eFactors influencing men’s decisions whether or not to utilize sexual and reproductive health services in Low-Middle-Income countries: A narrative review","fulltext":[{"header":"Plain English","content":"\u003cp\u003eSexual and Reproductive Health service utilization refers to accessibility, affordability, availability, and quality of sexual health services that are provided in a convenient and suitable manner. The utilization of SRH services provides a state of physical, mental, and emotional well-being. SRH services include assistance with contraception, prevention and treatment of HIV/AIDS and other Sexually Transmitted Infections (STIs), Medical Male Circumcision (MMC), condom use, psychosocial interventions such as sexual health counseling and education, Vasectomy, prevention and treatment of male cancers such as prostate and testicular, infertility services, sexual dysfunction developmental anomalies, malignancy, trauma, developmental and lifecycle issues, sexual identity and orientation, and partnership issues.\u003c/p\u003e \u003cp\u003eWe have found that there is a lack of literature investigating factors associated with adult men\u0026rsquo;s utilization of SRH. To our knowledge, this is the only review that comprehensively focuses on adult men\u0026rsquo;s utilization of SRH services. Empirical evidence indicates the enormous under-utilization of SRH services by men. Very few men are reported to be accessing and utilizing SRH services. Consequently, men die from curable SRH problems that can be prevented, contributing to higher mortality and earlier morbidity among men. The factors influencing men\u0026rsquo;s decision to utilize SRH services include cultural, religious, psychosocial, economic, and socio-demographic characteristics.\u003c/p\u003e \u003cp\u003eWe conducted a systematic review of articles between 2004 and 2021 and identified an initial 2219 papers, of which 51 were included in the analysis and then analyzed narratively. We extracted information about the factors influencing SRH service utilization among adult men from published and unpublished peer-reviewed literature. Identifying SRH inhibitors and facilitators remains an essential approach to improve SRH utilization.\u003c/p\u003e"},{"header":"Background","content":"\u003cp\u003eSexual and Reproductive Health (SRH) is a global public health concern [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. SRH problems account for major health challenges and constitute almost 14% of the disease burden which contributes to higher mortality and earlier morbidity in men [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Globally, SRH is one of the fundamental human rights for every individual [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], but only less than one-quarter of men report accessing and utilizing SRH services [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe utilization of SRH services refers to having suitable and convenient access to these services [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. The services provide a state of physical, mental, and emotional well-being related to sexuality and reproduction, and are essential for the socio-economic development of communities and countries [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. SRH services include providing contraception, prevention and treatment of mental disorders, communicable and non-communicable diseases, medical male circumcision, and psychosocial interventions such as sexual health counseling, [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan additionalcitationids=\"CR9 CR10 CR11\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eUnder-utilization of SRH services is evident despite several international conventions and adopted programmes and policies that seek to engage men and boys in the context of reproductive health services [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. The Lancet Commission (2018) posited that 4.3\u0026nbsp;billion people of reproductive age would inadequately utilize sexual and reproductive health services throughout their lives. The Commission further stated that two million people were newly infected with HIV while more than 350\u0026nbsp;million men and women needed treatment for curable STIs [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Factors influencing men's under-utilization are multifaceted. These factors include the lack of focus on men's SRH by international programmes such as Sustainable Development Goals (SDGs) and Family Planning 2020 (FP2020), which largely focus on women and youth [\u003cspan additionalcitationids=\"CR15 CR16\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Furthermore, SRH service provision is often fragmented or poorly structured to address men's health needs, and is mostly needlessly expensive [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe purpose of the review is to synthesize available evidence on factors contributing towards adult men's engagement with SRH services in LMICs. The review focused on LMICs because of resource constraint challenges that largely lead to relative poorer access to and higher unmet need for SRH services. The literature review was conducted as part of a doctoral research project. These findings contribute to the development of appropriate interventions to guide men's engagement with SRH services.\u003c/p\u003e"},{"header":"Methodology","content":"\u003cp\u003eThe systematic quantitative literature review method was followed to search and identify relevant literature. The search included published peer-reviewed articles, reports, and grey literature. Peer-reviewed articles were searched in the following databases: Google Scholar, Science Direct, Scopus, and EBSCOhost. Additionally, electronic databases: CINHAL, PubMed, Medline, Academic Search Complete, Health Source - Consumer Edition, Health Source: Nursing/Academic Edition and MEDLINE, electronic journals, and reference lists of retrieved published articles were also searched.\u003c/p\u003e \u003cp\u003eThe following MESH terms were used to retrieve relevant articles for this review: \"sexual and reproductive health services\", \"men\", \"factors influencing / inhibiting / facilitating SRH service utilization\", \"Utilization of Sexual and Reproductive Health services by adult men\". To cover comprehensive SRH services, studies were also searched by individual SRH services, e.g., utilization of condoms. Studies that investigated Health Care Workers\u0026rsquo; (HCW) knowledge and perceptions about men's use of SRH services were also included.\u003c/p\u003e \u003cp\u003eStudies conducted in 2004 were sourced because the World Health Organisation (WHO) recognized the immense global health burden (including extensive mortality and morbidity) associated with sexual and reproductive health conditions and poor quality of care for people's sexual and reproductive health in 2004 [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. The database was constructed to extract important dimensions of factors influencing SRH service utilization. We extracted only relevant results about populations eligible for inclusion in this narrative review. For example, where data was collected for males and females, we extracted only data presented on males.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eEligibility criteria\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis review included quantitative and qualitative papers published in English between 2004 and 2021. Studies reporting exclusively on the factors influencing SRH service utilization among adolescents or women were excluded. Studies reporting on the interventions and the evaluation of interventions to improve SRH utilization; clinical decision-making algorithms; studies conducted in HICs; and studies not reporting on barriers or facilitators of SRH utilization were also not considered.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAssessment of Publications\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe database search generated 2219 records which were grey literature, health services reports, research reports, theses, and dissertations. The Principal Investigator assessed titles and abstracts for inclusion. On a review of titles, 2042 were excluded because they were duplicates unrelated to this narrative review topic or exclusively focused on adolescents and women. On a review of abstracts, 96 papers were excluded because they reported on the evaluation of SRH services, management of SRH problems, or male involvement in partner family planning. These were policies and documents that did not report on factors facilitating or hindering SRH service utilization. The latter were systematic reviews.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOf 73 potentially relevant full-text papers, 22 were excluded because results did not yield factors hindering or facilitating SRH service utilization. Fifty-one papers met the inclusion criteria and were captured in the database. Secondary to the heterogeneity of papers, we present a narrative synthesis describing study characteristics and key findings. We further summarize overarching themes and the consistency of key findings. Discussions between team members were used to build consensus on the narrative synthesis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConstructing the database\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA database was constructed to summarise the studies identified for the review. The following information was captured in the database (Table 1): author (s), year of publication, the country(s) where the study was conducted, the age and target population for the study, the study design, barriers to and facilitators of the utilization of SRH services, and SRH issues investigated.\u003c/p\u003e\n\u003cp\u003eFigure 1 presents the search algorithm indicating the number of identified studies, included and excluded studies, and reasons for exclusion.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 2219 articles were retrieved, from which 51 studies met the inclusion criteria for review. Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e presents the author, year of publication and study location, participant characteristics (age and gender), and study design. Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e presents barriers, facilitators, and sexual and reproductive health issues. All articles (qualitative and quantitative studies) extracted from the literature were descriptive. The results are summarized narratively.\u003c/p\u003e \u003cp\u003e \u003cb\u003eDescription of included studies\u003c/b\u003e \u003c/p\u003e\u003cp\u003e\u003cstrong\u003e1. Study location\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMost of the studies were conducted in South Africa (22%) [21-31], and five (10%) of studies were conducted in Kenya [32-36], Uganda [37-41], and Ghana [42-46]. Four (8%) studies were published in Zimbabwe [47-50]. Three (6%) studies were conducted in Nigeria [51-53] and Nepal [54-56]. In Rwanda [57, 58], there were two (4%) studies identified, whilst only one (2%) study each conducted in Swaziland [59], Papua New Guinea [60], Tanzania [61], Zambia [62], Botswana [63], Lesotho [64], Mexico [65], Philippines [66], Ethiopia [67], Egypt [68], Myanmar [69], Lao [70] and one both in Zimbabwe and South Africa [71].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2. Age and gender\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe studies included all targeted adult men. In studies that mixed male and females, as well as those which included younger ages, we only extracted information pertaining to adult men. The majority (55%) of studies identified exclusively targeted men [22-26, 28, 30, 31, 33, 35, 37, 39, 41, 43, 44, 45, 48, 49, 53, 57, 59, 60, 62, 63-66, 71]. The balance (45%) focused on both men and women [21, 27, 29, 32, 34, 36, 38, 40, 42, 46, 47, 50-52, 54-56, 58, 61, 67-70]. The majority (86%) of studies targeted adults 26 years and above [21-39, 41-44, 46-51, 53, 57-66, 71]. Studies which targeted adolescents were excluded, however those targeting youth or young adults age between 15-25 years (14%) were included [40, 45, 52, 54-56, 67-70].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eStudy design\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe majority (55%) of studies that met the inclusion criteria were conducted qualitatively, and employed either Focus Group Discussions (FGDs) (16%) or In-depth Interviews (IDIs) (18%), and some both FGDS and IDIs (24%) [22, 24, 26 ,28, 31-34, 36, 38, 39-41, 45-47, 49, 50, 52, 56, 59, 60-62, 65, 67, 68, 70, 71]. Twenty-five percent of quantitative studies employed cross-sectional study design [23, 25, 27, 29, 42, 43, 45, 51, 53, 54, 57, 58, 69], and two (4%) employed National Health and Demographic Survey (NHDS) [35, 66]. The later (16%) used mixed [21, 30, 37, 44, 48, 55, 63, 64]. There was only one mixed study that included Randomized Control Trial (RCT). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4. Study setting\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eForty-nine percent of studies were conducted in both urban and rural settings. In some studies, the exact locations where data was collected were not specified [33, 34, 40, 43, 45, 46, 56, 59, 60, 61, 63, 65-68, 70]. Some of the studies were conducted in public and private-sector health facilities (clinics and hospitals) [24, 25, 29, 58, 64]; private rooms or offices in community centres; Non-Governmental Organizations sites [27, 32, 35], and households in towns and rural villages [28, 48, 69]. In studies conducted exclusively in urban settings (27%), data was collected in towns and townships in which households were visited. \u0026nbsp;Some participants were recruited on the streets [21, 23, 30, 47], district health offices [26], hospital and clinical settings [36, 38, 44, 53, 62], and there were two unspecified studies [42, 54]. Studies solely conducted in rural settings (24%) approached households in villages [22, 37, 39, 41, 49, 51, 52, 55, 57, 71], traditional healers\u0026rsquo; places, school and community halls, community tuck-shops, faith-based organizations\u0026rsquo; premises, hospital and clinic waiting rooms. [31, 50].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e5. SRH issues\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe SRH issues identified were Vasectomy; Family Planning (FP); Medical Male Circumcision (MMC); condom use; management and prevention of STIs; HIV services; Prostate Cancer (PC) screening; and Erectile Dysfunction (FD).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e6.\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eBarriers to men\u0026rsquo;s\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003edecisions to utilize or not\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;utilize Sexual and Reproductive Health Services\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSeveral barriers have been associated with the decision to utilize or not utilize S.R.H. services. These can be summarized into individual/personal factors, knowledge, socio-cultural and religious, socio-economic factors, geographical, and health service system factors, as detailed below.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eIndividual / personal factors\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn this review, individual/personal factors are described as behavior and characteristics demonstrated by participants which determined whether they utilized SRH services or not. Individual factors presented as barriers to SRH utilization were identified. Fear emerged as a barrier to utilizing SRH services. Among the studies focused on PC screening, fear of post-operative complications such as pain, delayed recovery, infections, morning erections, as well as the post-procedure abstinence period deterred most men from undergoing MMC [21,23, 32, 33, 39, 48, 49, 53, 57, 61-64, 59,71]. The requirement to do HIV testing before getting circumcised deterred most men from undergoing Medical Male Circumcision (MMC). They feared the possibility of testing positive, and hence death related to HIV complications. because of self-knowledge of reckless lifestyles. Men also feared the stigma associated with HIV, and the possibility of being blamed and rejected by significant others such as partners, family members, and friends, as well as the pressure from employees to quit the job after being diagnosed [24, 26, 27,31, 43, 47-52, 64, 69]. Post circumcision myths such as the inability to sexually satisfy partners, less natural lubrication, and decreased penile sensitivity on a circumcised penis also deterred individual men [21, 22, 33, 37, 39, 46, 59].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFactors associated with barriers involving Condom use included poor quality of condoms and embarrassment to buy condoms [28, 44, 66, 70]. Furthermore, the perception of low-risk also hindered men from using condoms and undergoing MMC [32, 33, 50, 57, 69, 70]. In Hassan\u0026apos;s (2015) study, some men in Nigeria were reluctant to screen for Prostate Cancers they perceived it as a low-risk since there was no family history [53].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eLack of Knowledge\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMen\u0026apos;s underutilization of SRH services was associated with a lack of awareness of disease screening services such as HIV and prostate cancer, and the lack of knowledge of the existence of SRH services. Consequently, some men did not know where to go for SRH services [27, 35, 46, 53-56, 67, 69, 70]. Lack of knowledge and understanding of HIV was evident when men often inferred their status from their female partners\u0026apos; results [27, 31, 52]. As a result of this lack of knowledge and of reliable information, men claimed less or no benefits of MMC if they were already HIV-positive, had good hygiene, were already practising other HIV prevention methods such as the \u0026lsquo;Abstinence\u0026rsquo; \u0026lsquo;Be faithful\u0026rsquo; \u0026lsquo;Condomise\u0026rsquo; (ABC) method, or their partner(s) was sexually satisfied [33, 49]. Furthermore, in non-circumcising communities in South Africa, men did not know that the MMC service was offered for free at the local clinic or hospital [21]. Furthermore, some men associated infertility with circumcision [39, 48].\u003c/p\u003e\n\u003cp\u003eIn addition to lack of knowledge, myths resulted in men opting not to use condoms after getting circumcised, citing reasons such as the circumcised penis would tear a condom; or putting a condom on an exposed circumcised penis would cause pain [47]. Furthermore, misconceptions such as the nutritional benefit from sperm, condom porousness, lubricant related infections, and the belief that white men had infected condoms with HIV hindered Condom use [28, 40, 45, 50, 56, 70]. Men often confused Vasectomy with castration and wrongly associated it with loss of libido, decreased sexual activity, and loss of masculinity [46, 66].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eSocio-cultural and religious factors\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFactors associated with culture, such as the threat to masculinity, prevented men from undergoing MMC as non-circumcising communities presumed circumcision to be an alien culture or part of a foreign religion [21, 23, 30, 39, 45, 47, 49, 59, 60]. Some men alluded to undergoing MMC as tampering with God\u0026apos;s creation [33, 47, 49, 59]. Most cultural and religious practices consider discussing sexual matters a taboo. Therefore, the sensitivity of discussing SRH issues had hindered most men from accessing psychosocial health therapy and counseling [35, 42, 45, 46, 55, 56, 67].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eSocio-economic factors\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSRH service utilization was hindered by the perceived high costs of SRH products such as condoms, particularly in rural areas [40, 56, 67]. In addition, the inaccessibility and unavailability of condoms due to fewer shops contributed to low utilization [23, 25, 29, 30, 44, 45, 69]. Fear of losing income (work) due to long-period off work due to pain or post-procedure healing period deterred some men from undergoing MMC [21, 32, 33, 39, 61, 62]. Traveling costs to healthcare establishments also emerged as a major deterrent [27].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eGeographical factors\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn most LMICs, health facilities are concentrated in the urban area, whereas most men in these populations reside in rural areas [67, 56, 63]. Consequently, long distances and poor transport (especially in rural areas) to the health facility became barriers to accessing and utilizing SRH services [29, 33, 40, 42, 54, 69]. The distance of health centres from men\u0026apos;s workplaces often leads to men failing to utilize SRH services. Furthermore, poor transport infrastructure can prevent access to services in rural areas [30].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eHealth service system\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003e(Physical accessibility, availability, accessibility, affordability)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePoor quality of the services and lack of materials such as condoms and medicines hindered the utilization of SRH services by men [29, 42, 54, 55, 63, 67, 68, 70]. Inconvenient service hours or limited opening hours at the delivery point were also barriers to SRH services utilization [27, 36, 40, 54, 55, 67, 68]. The inconvenience of the location of the SRH services at the local clinic seems to be a barrier to accessing the SRH care, especially for young men [44, 67]. Long waiting times because of queues influenced men\u0026apos;s decisions to avoid coming to a healthcare centre [29, 30, 36, 40, 42, 50, 63, 64, 67].\u003c/p\u003e\n\u003cp\u003eSome studies revealed that most health care providers lack the necessary training and knowledge to make men feel comfortable discussing SRH issues [36, 56, 67]. Physicians indicated discomfort in counseling on sexuality and safer sex for unmarried youth [68]. Lack of privacy, respect, and potential breaches of confidentiality from the health care workers at the health facilities deterred men from utilizing SRH services [25, 36, 40, 41, 44, 55, 67, 70].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMen avoided utilization of SRH services due to hostile and judgmental attitudes from female health service providers [27, 29, 30, 40, 45, 56], especially towards young and unmarried men. \u0026nbsp;There is still much sensitivity needed regarding pre-marital sexuality [26, 29, 36, 56, 67, 69, 70]. Consequently, the non-availability of same-sex health workers was a barrier since some men felt embarrassed to discuss their health issues and be examined by female health workers [30, 33, 45, 55, 64, 68]. Frequently changing HIV prevention programmes led to distrust in the health system, discouraging men from testing and treating HIV [49, 59]. A further deterrent was partial protection of condoms and lack of empirical efficacy of MMC for HIV prevention as people can die even after circumcision [39].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e7. Facilitators to men\u0026rsquo;s engagement with Sexual and Reproductive Health Services\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere was a limited number of studies that focused on factors facilitating the utilization of SRH services. Facilitators to men\u0026apos;s decisions to utilize SRH services are summarized into individual/personal issues, knowledge, socio-cultural and religious factors, socio-economic factors, and health service system factors as detailed below.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eIndividual / personal factors\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSome studies discussed above concluded that men were reluctant to undergo MMC due to poor sexual performance. Conversely, other studies found that sexual appeal and satisfying women motivated men to perform MMC sexually. Men believe that post circumcision, they better satisfy women as they last longer before ejaculating, and also wearing condoms was much easier after the foreskin was removed [21, 22, 33, 38, 47, 60, 61, 64, 59]. Curiosity to feel the difference between sex with an uncircumcised penis and a circumcised one motivated some men [47]. Furthermore, personal gain or prestige from research activities such as free medical care for ailments, financial incentives, and a sense of being responsible by participating and contributing to research, motivated men to undergo MMC [27, 39, 50].\u003c/p\u003e\n\u003cp\u003eRole modeling positive HIV status disclosure and adherence to Anti-Retroviral Therapy (ART) motivated men to engage in HIV treatment initiatives [24, 27]. Furthermore, an individual desire to limit family size encouraged some men to undergo a Vasectomy since it was perceived as a permanent method with a low risk of complications, thus limiting the side effects of other female-controlled hormonal methods [58].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eKnowledge\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eKnowing the benefits of undergoing MMC, such as protection against diseases and improved hygiene motivated most men to perform the procedure [21, 33, 34, 37-39, 47, 48, 57, 60-62, 64, 59,]. Some men were motivated by myths such as the increased size of the penis post circumcision (Humphries 2015).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eSocio-economic factors\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFinancial constraints motivated undergoing a Vasectomy [58]. The fact that some SRH services are provided at no cost, also motivated men [38].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eHealth service system (Physical accessibility, availability, accessibility, affordability)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHealth workers\u0026apos; welcoming friendly attitudes, and respect for men\u0026apos;s privacy and confidentiality motivated men to access and utilize SRH services [55, 63, 68]. Access to the right information about SRH services via advertisements such as pamphlets and radio/television programmes [27, 63] and the support from healthcare providers also played a vital role in encouraging SRH service use by men [24, 41, 50].\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis literature review aimed to establish the factors that influence men's decisions to utilize or not to utilize SRH services. In this review, only studies conducted in LMICs were included for synthesis. Identified studies were conducted mostly in the Africa regions (Southern, Eastern, and Western regions), and ten percent in South-Asia. Although studies were conducted in either rural or urban or in both rural and urban areas, findings in these settings remained comparable. Qualitative methods were the most used methods, either employed Focus Group Discussions (FGDs) or In-depth Interviews (IDIs) and some utilized both FGDS and IDIs. All studies included in this review targeted adult men. In studies that mixed males and females, as well as those that included younger ages, we only extracted information pertaining to adult men. Adult men were targeted because the literature review revealed less focus on studies investigating SRH service utilization among adult men.\u003c/p\u003e \u003cp\u003eThe most prevalent SRH issues identified incorporated Medical Male Circumcision, management and prevention of STIs, HIV/AIDS services, Family Planning (FP), and condom use. Less noted were Prostate Cancer (PC) screening, and Erectile Dysfunction (ED), and Vasectomy surgeries. This may be because services for these SRH issues are expensive, and most men in LMICs cannot afford them and sometimes they are against their cultures and religious beliefs [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe identified barriers and facilitators of SRH service utilization encompassed individual or personal factors, lack of knowledge, socio-cultural and religious factors, socio-economic factors, geographical and health service systems. The most prevalent barrier identified was the personal perceptions (personal factors) in which men largely demonstrated embarrassment, insecurity (which have to do with their self-esteem and reputation), and fear. Fear played a vital role in inhibiting men\u0026rsquo;s use of SRH services. Consequently, men were discouraged to utilize SRH services such as MMC, Vasectomy services, family planning, STI / HIV services, screening for prostate cancer, and Condom use [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e, \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e, \u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e, \u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e, \u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e]. Some studies revealed that men were largely deterred by fear of MMC post-procedure complications [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e, \u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e]. Most men find it embarrassing to go to SRH services and consider it a very negative experience when they are seen, ridiculed, and disrespected by people known to them [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e, \u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e]. These negative experiences may motivate men not to go back to the clinic.\u003c/p\u003e \u003cp\u003eUnder-utilization of SRH services was associated with a range of cultural barriers. Most studies indicated that socio-cultural factors inhibited men's utilization of SRH services. For example, cultural and religious backgrounds that perceived discussing sexual matters as a taboo deterred men's engagement with SRH services [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e, \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e, \u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e]. The threat to masculinity was also a major barrier, and was associated with post MMC or Vasectomy procedure misconceptions and myths. These are beliefs about the inability to produce more children, the loss of manhood, and infertility [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. Despite the availability of services, poor utilization was associated with limited knowledge of the availability of the different SRH services. Lack of knowledge or awareness of the existence of SRH services such as vasectomies, screening for prostate cancer, STI / HIV testing, MMC, centres for counseling, and provision of information, hindered men's utilization [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan additionalcitationids=\"CR54 CR55\" citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e, \u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e, \u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e, \u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCost-related issues prevented access to and utilization of SRH services such vasectomies, condoms, HIV testing. Although most SRH services are provided for free in LMICs, some men, especially those from rural areas, alluded to cost as a hindrance to accessing SRH services [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e, \u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e]. Such difficulties in accessing SRH services may be due to unemployment. In rural areas, most health facilities are far from the communities. As a result, people in rural communities have to walk long distances due to a lack of money and transport. In the health service system, health care workers' conduct significantly influenced men's decisions to utilize or not to utilize SRH services. Predominantly, men\u0026rsquo;s utilization of SRH services was deterred by bad health workers' attitudes and lack of privacy and confidentiality.\u003c/p\u003e \u003cp\u003eThe review identified only a few studies that focused on factors facilitating the SRH service utilization by men. Among studies that investigated SRH facilitating factors, virility was found to have motivated men to undergo MMC. Having done MMC, some men claimed to be stronger sexually, and that wearing condoms was much easier [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e, \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e, \u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e, \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e]. Conversely, some studies found that men were reluctant to undergo MMC in case it resulted in poor sexual performance. Barriers to SRH service were prevalent among societies who did not regard MMC as part of life, whereas, facilitators to SRH service utilization were predominant among those who embraced MMC.\u003c/p\u003e \u003cp\u003eIndividual factors such as curiosity motivated SRH utilization. For example, some men were inquisitive about the differences experienced during the sexual act with an uncircumcised penis as compared to a circumcised one [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. Moreover, personal gain from research activities cannot be ruled out as most men showed interest in financial incentives post MMC [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]. Knowledge was instrumental in encouraging SRH service utilization. Men who understood the benefits of undergoing MMC were motivated to perform the procedure [21, 33, 34, 37\u0026ndash;39, 47, 48, 57, 60\u0026ndash;62, 64, 59,]. Bad attitudes from healthcare workers can be a barrier to SRH service utilisation, however, professional and good treatment from healthcare workers was found to facilitate SRH service utilization [\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e, \u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e, \u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis review of the literature revealed a limited number of studies conducted exclusively in the area of adult men's SRH service utilization. More studies that focus on adult men need to be conducted, especially in LMICs. Given the lack of focus on men's SRH by international programmes such as SDGs and Family Planning 2020 (FP2020) [\u003cspan additionalcitationids=\"CR15 CR16\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], research focusing on men may bring about evidence-based knowledge that can be utilized by policy makers to ensure accessibility and availability of SRH services for adult men. Subsequently, high morbidity and mortality among men adult men may decrease.\u003c/p\u003e \u003cp\u003eThe analysis also reveals that men generally ignore the warning signs of sexual health problems, and are reluctant to seek and engage with SRH services for anything other than severe illness [\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. Nevertheless, if factors influencing men\u0026rsquo;s decisions to seek and utilize SRH services are known and understood comprehensively and in the local context, men's engagement with SRH services could improve.\u003c/p\u003e \u003cp\u003eFurthermore, this analysis can be used by policymakers, service administrators, and service providers who want to identify the barriers experienced by men to make services more accessible.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eStrengths of the review\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis review consolidated knowledge about barriers and facilitators that influence men\u0026apos;s decisions to utilize SRH services. While reviews conducted in past decades have identified barriers and facilitators to SRH services, this current systematic review is the first to focus on adult men only and to comprehensively focus on all SRH services. The findings from this review have implications for clinical practice and policy.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLimitations of the review\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis review restricted the inclusion criteria to studies conducted in LMICs. Therefore, findings may not be generalizable to other settings. However, during analysis, the authors extracted findings of adult men only. The writers of the review also restricted the criteria only to include studies published in English due to a lack of resources for translation. This may limit how findings from this review can be transferable to all low and middle-income countries. Another limitation of this review is that data extraction was not performed in duplicate, which could result in bias results. We did not do additional study quality assessments or remove studies based on the risk of bias, given our goal to describe the relevant studies identified.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eDespite the need for SRH utilization by men, there is little evidence suggesting the implementation of proposed interventions. Consequently, low SRH utilization has become a major concern regarding men's health. Men's SRH service utilization needs to be investigated comprehensively to comprehend men's problems fully. None of the identified studies comprehensively investigated SRH issues. There is also a lack of studies investigating vasectomies and their influence on infertility.\u003c/p\u003e \u003cp\u003eFurthermore, most papers identified described adolescents and young adults, predominantly focusing on barriers rather than facilitators. There is, therefore, a need to explore the utilization of SRH services among adult men. There is a need to motivate men to participate in SRH services so that the high level of morbidity and mortality among men can be averted. Although SRH includes mental health issues, little is known about mental health issues related to sexual health. The same applies to the impact of physical disabilities and chronic illnesses on sexual well-being. Further research may be warranted in this regard. Governments need to increase the awareness and education of the public to fight against myths and misconceptions linked to the utilization of SRH services and to improve the capacity of the healthcare providers to engage men better.\u003c/p\u003e \u003cp\u003eMen perceive many hindrances in obtaining SRH services from the time they access the services until they leave. These hurdles must be reduced as they could prevent them from even initiating seeking advice or care. Some obstacles (e.g., access, service delivery) are easier to remove than others (e.g., living place issues). There is a need to advertise the services widely, to indicate who can seek these, and to offer convenient opening hours.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSRH\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSexual and Reproductive Health\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLMICs\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eLow- and Middle-Income countries\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHSB\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHealth Seeking Behaviour\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHIV\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHuman Immunodeficiency Virus\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAIDS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAcquired Immunodeficiency Disease Syndrome\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSTI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSexually transmitted infection\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eUNFPA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eUnited Nations Population Fund\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eWHO\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eWorld Health Organization\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHCW\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHealthcare worker\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMMC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMedical Male Circumcision\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eProstate Cancer\u003c/p\u003e \u003c/div\u003e \u003c/div\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\"\u003eFP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eFamily Planning\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIPPF\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eInternational Planned Parenthood Federation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eS.D.G.s\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSustainable Development Goals\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eF.G.D.s\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eFocus Group Discussions\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eI.D.I.s\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eIn-depth Interviews.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eM.N. conceived the study and developed the design of this review with valuable contributions from T.D. M.N. performed the searches, conducted the title and abstract screening and the full-text screening, and performed the data abstraction and thematic analysis. M.N. drafted the first manuscript. T.D. oversaw the project and contributed valuable feedback to the manuscript. All authors read and gave approval of the final manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author(s) received no financial support for this article\u0026apos;s research, authorship, and publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot Applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor details\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMpumelelo Nyalela (MPH), Lecturer. \u0026nbsp;Email: [email protected]\u003c/p\u003e\n\u003cp\u003eThembelihle Dlungwane (PhD), Senior Lecturer. Email: [email protected]\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eJobson M. Structure of the health system in South Africa. 2015. South Africa Khulumani Support Group.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStarrs AM, Ezeh AC, Barker G, Basu A, Bertrand JT, et al. Accelerate progress\u0026mdash;sexual and reproductive health and rights for all: report of the Guttmacher\u0026ndash;Lancet Commission. The Lancet. 2018 Jun 30;391(10140):2642\u0026ndash;92.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDe Silva VP. World Book of Family Medicine:Sexual and Reproductive Health in Primary Care: Where Do We Go from Here?. Wonca Europe: Iberoamericana Edition. 2016;26:1\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSame RV, Bell DL, Rosenthal SL, Marcell AV. Sexual and reproductive health care: Adolescent and adult men\u0026rsquo;s willingness to talk and preferred approach. 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Academic Journal of Interdisciplinary Studies. 2014 Jun 29;3(4):239-.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLeblanc NM, Andes KL. An exploration of men's knowledge, attitudes, and perceptions of HIV, HIV risk, and willingness to test for HIV in Yendi District, Northern Ghana. Journal of the Association of Nurses in AIDS Care. 2015 May 1;26(3):281 \u0026ndash; 95.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAddo IY, Gyamfuah AI. Utilization of reproductive health services among young people in Sawua, Ghana. Clinical Medicine Reviews in Patient Care. 2015 Aug 9;2015(3):1\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAdongo PB, Tapsoba P, Phillips JF, Tabong PT, Stone A, Kuffour E, Esantsi SF, Akweongo P. \u0026ldquo;If you do vasectomy and come back here weak, I will divorce you\u0026rdquo;: a qualitative study of community perceptions about vasectomy in Southern Ghana. BMC International Health and Human Rights. 2014 Dec;14(1):1\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAdongo PB, Tapsoba P, Phillips JF, Tabong PT, Stone A, Kuffour E, Esantsi SF, Akweongo P. \u0026ldquo;If you do vasectomy and come back here weak, I will divorce you\u0026rdquo;: a qualitative study of community perceptions about vasectomy in Southern Ghana. BMC International Health and Human Rights. 2014 Dec;14(1):1\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHatzold K, Mavhu W, Jasi P, Chatora K, Cowan FM, Taruberekera N, et al. Barriers and motivators to voluntary medical male circumcision uptake among different age groups of men in Zimbabwe: results from a mixed methods study. 2014;9(5):e85051.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMoyo S, Mhloyi M, Chevo T, Rusinga O. Men's attitudes: A hindrance to the demand for voluntary medical male circumcision\u0026ndash;A qualitative study in rural Mhondoro-Ngezi, Zimbabwe. Global public health. 2015 Jul 3;10(5\u0026ndash;6):708\u0026ndash;20. DOI:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1080/17441692.2015.1006241\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSkovdal M, Campbell C, Madanhire C, Mupambireyi Z, Nyamukapa C, Gregson SJG, et al. Masculinity as a barrier to men's use of HIV services in Zimbabwe. 2011;7(1):13.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThomas KA. HIV/AIDS Voluntary Counselling and Testing (VCT): Perspectives of Rural Youths in Oyo State, Nigeria. International Journal of Agricultural Economics and Rural Development. 2015 Nov 1;7(1):52 \u0026ndash; 8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJones OO. Factors affecting the uptake of voluntary counselling and testing among youth in rural Nigeria. University of Lethbridge (Canada); 2017.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHassan R. Knowledge, Perception, Risk Factors and Utilization of Prostate Cancer Screening Services among male staff of the University College Hospital, Ibadan, Nigeria. 2015. (Doctoral dissertation).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTamang L, Raynes-Greenow C, McGeechan K, Black KI. Knowledge, experience, and utilisation of sexual and reproductive health services amongst Nepalese youth living in the Kathmandu Valley. Sexual \u0026amp; Reproductive Healthcare. 2017 Mar 1;11:25\u0026ndash;30.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGautam P, Soomro MH, Sapkota S, Gautam KR, Kasaju A. Barriers to utilization of sexual health services among young people in district dang Nepal: A qualitative study. Journal of Medicine. 2018 Jul 10;19(2):79\u0026ndash;83.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRegmi PR, Van Teijlingen E, Simkhada P, Acharya DR. Barriers to sexual health services for young people in Nepal. Journal of health, population, and nutrition. 2010 Dec;28(6):619.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGasasira RA, Sarker M, Tsague L, Nsanzimana S, Gwiza A, Mbabazi J, Karema C, Asiimwe A, Mugwaneza P. Determinants of circumcision and willingness to be circumcised by Rwandan men, 2010. BMC public health. 2012 Dec;12(1):1\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShattuck D, Wesson J, Nsengiyumva T, Kagabo L, Bristow H, Zan T, Ngabo F. Who chooses vasectomy in Rwanda? Survey data from couples who chose vasectomy, 2010\u0026ndash;2012. Contraception. 2014 Jun 1;89(6):564 \u0026ndash; 71.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAdams A, Moyer E. Sex is never the same: Men's perspectives on refusing circumcision from an in-depth qualitative study in Kwaluseni, Swaziland. Global Public Health. 2015 Jul 3;10(5\u0026ndash;6):721 \u0026ndash; 38. DOI: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1080/17441692.2015.1004356\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKelly A, Kupul M, Fitzgerald L, Aeno H, Neo J, Naketrumb R, Siba P, Kaldor JM, Vallely A. \" Now we are in a different time; various bad diseases have come.\" understanding men's acceptability of male circumcision for HIV prevention in a moderate prevalence setting. BMC Public Health. 2012 Dec;12(1):1\u0026ndash;3.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePlotkin M, Castor D, Mziray H, K\u0026uuml;ver J, Mpuya E, Luvanda PJ, Hellar A, Curran K, Lukobo-Durell M, Ashengo TA, Mahler H. \u0026ldquo;Man, what took you so long?\u0026rdquo; Social and individual factors affecting adult attendance at voluntary medical male circumcision services in Tanzania. Global Health: Science and Practice. 2013 Mar 1;1(1):108 \u0026ndash; 16.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePrice JE, Phiri L, Mulenga D, Hewett PC, Topp SM, Shiliya N, Hatzold K. Behavior change pathways to voluntary medical male circumcision: narrative interviews with circumcision clients in Zambia. PLoS One. 2014 Nov 6;9(11):e111602.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSabone M, Magowe M, Busang L, Moalosi J, Binagwa B, Mwambona J. Impediments for the uptake of the Botswana government's male circumcision initiative for HIV prevention. The Scientific World Journal. 2013 Jan 1;2013.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSkolnik L, Tsui S, Ashengo TA, Kikaya V, Lukobo-Durrell M. A cross-sectional study describing motivations and barriers to voluntary medical male circumcision in Lesotho. BMC public health. 2014 Dec;14(1):1\u0026ndash;0.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYabeny TE. Assessing Condom Use among Navajo Men in the Southwest. 2018. (Doctoral dissertation, Walden University).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eParcon CR. MEN, FAMILY PLANNING AND CONTRACEPTIVE USE IN WESTERN VISAYAS. 2010.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMuntean N, Kereta W, Mitchell KR. Addressing the sexual and reproductive health needs of young people in Ethiopia: an analysis of the current situation. African journal of reproductive health. 2015 Sep 1;19(3):87\u0026ndash;99.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOraby DM. Sexual and reproductive health among young people in Egypt: the role and contribution of youth-friendly services. Sex Education. 2013 Jul 1;13(4):470-7. DOI:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1080/14681811.2012.756810\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThin Zaw PP, Liabsuetrakul T, Htay TT, McNeil E. Equity of access to reproductive health services among youths in resource-limited suburban communities of Mandalay City, Myanmar. BMC health services research. 2012 Dec;12(1):1\u0026ndash;2.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThongmixay S, Essink DR, Greeuw TD, Vongxay V, Sychareun V, Broerse JE. Perceived barriers in accessing sexual and reproductive health services for youth in Lao People\u0026rsquo;s Democratic Republic. PLoS One. 2019 Oct 29;14(10):e0218296.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKhumalo-Sakutukwa G, Lane T, van-Rooyen H, Chingono A, Humphries H, Timbe A, Fritz K, Chirowodza A, Morin SF. Understanding and addressing socio-cultural barriers to medical male circumcision in traditionally non-circumcising rural communities in sub-Saharan Africa. Culture, health \u0026amp; sexuality. 2013 Oct 1;15(9):1085 \u0026ndash; 100. DOI: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1080/13691058.2013.807519\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1: Author, year of publication and study location, participant characteristics (age and gender), study design and study setting\u003c/p\u003e\n\u003ctable border=\"1\" cellpadding=\"0\" cellspacing=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"18.556701030927837%\"\u003e\n \u003cp\u003e\u003cstrong\u003eAuthors\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.278350515463918%\"\u003e\n \u003cp\u003e\u003cstrong\u003eYear\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.402061855670103%\"\u003e\n \u003cp\u003e\u003cstrong\u003eStudy location\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.77319587628866%\"\u003e\n \u003cp\u003e\u003cstrong\u003eParticipant characteristics (age and gender)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003e\u003cstrong\u003eStudy design\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003e\u003cstrong\u003eStudy setting (Urban or Rural)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"18.556701030927837%\"\u003e\n \u003cp\u003eHoffman et al.\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.278350515463918%\"\u003e\n \u003cp\u003e2015\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.402061855670103%\"\u003e\n \u003cp\u003eSouth Africa\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.77319587628866%\"\u003e\n \u003cp\u003eMen and women\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e18 and above\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eMixed - analytical cross-sectional study design\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eUrban\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"18.556701030927837%\"\u003e\n \u003cp\u003eHumphries et al.\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.278350515463918%\"\u003e\n \u003cp\u003e2015\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.402061855670103%\"\u003e\n \u003cp\u003eSouth Africa\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.77319587628866%\"\u003e\n \u003cp\u003eMen\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e18-54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eQualitative - FGDs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eRural\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"18.556701030927837%\"\u003e\n \u003cp\u003eLissouba et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.278350515463918%\"\u003e\n \u003cp\u003e2011\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.402061855670103%\"\u003e\n \u003cp\u003eSouth Africa\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.77319587628866%\"\u003e\n \u003cp\u003eMen\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e15-49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eQuantitative - Community-based cross-sectional study\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eUrban\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"18.556701030927837%\"\u003e\n \u003cp\u003eZissette et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.278350515463918%\"\u003e\n \u003cp\u003e2016\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.402061855670103%\"\u003e\n \u003cp\u003eSouth Africa\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.77319587628866%\"\u003e\n \u003cp\u003eMen\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e24-80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eQualitative \u0026ndash; IDIs\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eUrban\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"18.556701030927837%\"\u003e\n \u003cp\u003eKhan et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.278350515463918%\"\u003e\n \u003cp\u003e2014\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.402061855670103%\"\u003e\n \u003cp\u003eSouth Africa\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.77319587628866%\"\u003e\n \u003cp\u003eMen\u003c/p\u003e\n \u003cp\u003e18-50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eSurvey questionnaire\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eUrban\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"18.556701030927837%\"\u003e\n \u003cp\u003eMambanga et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.278350515463918%\"\u003e\n \u003cp\u003e2016\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.402061855670103%\"\u003e\n \u003cp\u003eSouth Africa\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.77319587628866%\"\u003e\n \u003cp\u003eMen\u003c/p\u003e\n \u003cp\u003e18 and above\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eQualitative - semi-structured interviews\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eUrban\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"18.556701030927837%\"\u003e\n \u003cp\u003eMohlabane et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.278350515463918%\"\u003e\n \u003cp\u003e2016\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.402061855670103%\"\u003e\n \u003cp\u003eSouth Africa\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.77319587628866%\"\u003e\n \u003cp\u003eMen and women\u003c/p\u003e\n \u003cp\u003e16 and above\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eQuantitative \u0026ndash; cross-sectional survey (semi-structured questionnaire)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eUrban and Rural\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"18.556701030927837%\"\u003e\n \u003cp\u003eStern et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.278350515463918%\"\u003e\n \u003cp\u003e2014\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.402061855670103%\"\u003e\n \u003cp\u003eSouth Africa\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.77319587628866%\"\u003e\n \u003cp\u003eMen\u003c/p\u003e\n \u003cp\u003e18-55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eQualitative \u0026ndash; FGDs\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eUrban and Rural\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"18.556701030927837%\"\u003e\n \u003cp\u003eMorison et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.278350515463918%\"\u003e\n \u003cp\u003e2016\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.402061855670103%\"\u003e\n \u003cp\u003eSouth Africa\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.77319587628866%\"\u003e\n \u003cp\u003eMen and women\u003c/p\u003e\n \u003cp\u003e20-90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eQuantitative \u0026ndash; Survey - A Healthcare User questionnaire\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eUrban and Rural\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"18.556701030927837%\"\u003e\n \u003cp\u003eMthembu et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.278350515463918%\"\u003e\n \u003cp\u003e2015\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.402061855670103%\"\u003e\n \u003cp\u003eSouth Africa\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.77319587628866%\"\u003e\n \u003cp\u003eMen\u003c/p\u003e\n \u003cp\u003e18 and above\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eQuantitative - Survey questionnaire\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eQualitative - IDIs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eUrban\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"18.556701030927837%\"\u003e\n \u003cp\u003eChikovore et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.278350515463918%\"\u003e\n \u003cp\u003e2016\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.402061855670103%\"\u003e\n \u003cp\u003eSouth Africa\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.77319587628866%\"\u003e\n \u003cp\u003eMen\u003c/p\u003e\n \u003cp\u003e17-64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eQualitative - IDIs, FGDs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eRural\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"18.556701030927837%\"\u003e\n \u003cp\u003eEvens et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.278350515463918%\"\u003e\n \u003cp\u003e2014\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.402061855670103%\"\u003e\n \u003cp\u003eKenya\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.77319587628866%\"\u003e\n \u003cp\u003eMen and women\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e18-35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eQualitative - FGDs, IDIs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eUrban and Rural\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"18.556701030927837%\"\u003e\n \u003cp\u003eHerman-Roloff et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.278350515463918%\"\u003e\n \u003cp\u003e2011\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.402061855670103%\"\u003e\n \u003cp\u003eKenya\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.77319587628866%\"\u003e\n \u003cp\u003eMen\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e18-40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eQualitative - FGDs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eUrban and Rural\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"18.556701030927837%\"\u003e\n \u003cp\u003eMacintyre et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.278350515463918%\"\u003e\n \u003cp\u003e2014\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.402061855670103%\"\u003e\n \u003cp\u003eKenya\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.77319587628866%\"\u003e\n \u003cp\u003eMen and women\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e25-49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eQualitative - FGDs, IDIs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eUrban and Rural\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"18.556701030927837%\"\u003e\n \u003cp\u003eWithers et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.278350515463918%\"\u003e\n \u003cp\u003e2015\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.402061855670103%\"\u003e\n \u003cp\u003eKenya\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.77319587628866%\"\u003e\n \u003cp\u003eMen\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e15-64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eQuantitative - Kenya Demographic and Health Survey (KDHS).\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eUrban and Rural\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"18.556701030927837%\"\u003e\n \u003cp\u003eGodia et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.278350515463918%\"\u003e\n \u003cp\u003e2013\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.402061855670103%\"\u003e\n \u003cp\u003eKenya\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.77319587628866%\"\u003e\n \u003cp\u003eMen and women\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e27-50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eQualitative \u0026ndash; FGDs, IDIs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eUrban and Rural\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"18.556701030927837%\"\u003e\n \u003cp\u003eMbonye et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.278350515463918%\"\u003e\n \u003cp\u003e2016\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.402061855670103%\"\u003e\n \u003cp\u003eUganda\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.77319587628866%\"\u003e\n \u003cp\u003eMen\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e18-35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eMixed: Quantitative - interim serosurvey; Qualitative - IDIs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eRural\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"18.556701030927837%\"\u003e\n \u003cp\u003eMuhamadi et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.278350515463918%\"\u003e\n \u003cp\u003e2013\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.402061855670103%\"\u003e\n \u003cp\u003eUganda\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.77319587628866%\"\u003e\n \u003cp\u003eMen and women\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e18 and above\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eQualitative - IDIs,\u003c/p\u003e\n \u003cp\u003eFGDs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eUrban\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"18.556701030927837%\"\u003e\n \u003cp\u003eSsekubugu et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.278350515463918%\"\u003e\n \u003cp\u003e2013\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.402061855670103%\"\u003e\n \u003cp\u003eUganda\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.77319587628866%\"\u003e\n \u003cp\u003eMen\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e15-49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eQuantitative - RCT Qualitative - FGDs\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eRural\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"18.556701030927837%\"\u003e\n \u003cp\u003eNalwadda et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.278350515463918%\"\u003e\n \u003cp\u003e2010\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.402061855670103%\"\u003e\n \u003cp\u003eUganda\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.77319587628866%\"\u003e\n \u003cp\u003eMen and women\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e15-25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eQualitative - FGDs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eUrban and Rural\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"18.556701030927837%\"\u003e\n \u003cp\u003eSiu et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.278350515463918%\"\u003e\n \u003cp\u003e2013\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.402061855670103%\"\u003e\n \u003cp\u003eUganda\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.77319587628866%\"\u003e\n \u003cp\u003eMen\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e27-51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eQualitative - IDIs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eRural\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"18.556701030927837%\"\u003e\n \u003cp\u003eSunnu et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.278350515463918%\"\u003e\n \u003cp\u003e2016\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.402061855670103%\"\u003e\n \u003cp\u003eGhana\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.77319587628866%\"\u003e\n \u003cp\u003eMen and women\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e15-65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eQuantitative - cross-sectional survey\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eUrban\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"18.556701030927837%\"\u003e\n \u003cp\u003eDako-Gyeke et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.278350515463918%\"\u003e\n \u003cp\u003e2014\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.402061855670103%\"\u003e\n \u003cp\u003eGhana\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.77319587628866%\"\u003e\n \u003cp\u003eMen\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e15-49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eQuantitative - cross-sectional survey\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eUrban and Rural\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"18.556701030927837%\"\u003e\n \u003cp\u003eLeblanc et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.278350515463918%\"\u003e\n \u003cp\u003e2015\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.402061855670103%\"\u003e\n \u003cp\u003eGhana\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.77319587628866%\"\u003e\n \u003cp\u003eMen\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e18 and above\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eMixed:\u003c/p\u003e\n \u003cp\u003eQuantitative \u0026ndash; self-administered structured questionnaire. Qualitative \u0026ndash; IDIs, FGDs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eUrban\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"18.556701030927837%\"\u003e\n \u003cp\u003eAddo et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.278350515463918%\"\u003e\n \u003cp\u003e2016\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.402061855670103%\"\u003e\n \u003cp\u003eGhana\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.77319587628866%\"\u003e\n \u003cp\u003eMen and women\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e15-25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eQuantitative - cross-sectional survey\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eUrban and Rural\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"18.556701030927837%\"\u003e\n \u003cp\u003eAdongo et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.278350515463918%\"\u003e\n \u003cp\u003e2014\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.402061855670103%\"\u003e\n \u003cp\u003eGhana\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.77319587628866%\"\u003e\n \u003cp\u003eMen and women\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e18 and above\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eQualitative \u0026ndash; IDIs, FGDs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eUrban and Rural\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"18.556701030927837%\"\u003e\n \u003cp\u003eChikutsa et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.278350515463918%\"\u003e\n \u003cp\u003e2015\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.402061855670103%\"\u003e\n \u003cp\u003eZimbabwe\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.77319587628866%\"\u003e\n \u003cp\u003eMen and women\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e18-49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eQualitative - FGDs, IDIs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eUrban\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"18.556701030927837%\"\u003e\n \u003cp\u003eHatzold et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.278350515463918%\"\u003e\n \u003cp\u003e2014\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.402061855670103%\"\u003e\n \u003cp\u003eZimbabwe\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.77319587628866%\"\u003e\n \u003cp\u003eMen\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e15-49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eMixed:\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eQuantitative - National, population-based survey, Qualitative - FGDs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eUrban and Rural\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"18.556701030927837%\"\u003e\n \u003cp\u003eMoyo et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.278350515463918%\"\u003e\n \u003cp\u003e2015\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.402061855670103%\"\u003e\n \u003cp\u003eZimbabwe\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.77319587628866%\"\u003e\n \u003cp\u003eMen\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e15-79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eQualitative - FGDs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eRural\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"18.556701030927837%\"\u003e\n \u003cp\u003eSkovdal et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.278350515463918%\"\u003e\n \u003cp\u003e2011\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.402061855670103%\"\u003e\n \u003cp\u003eZimbabwe\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.77319587628866%\"\u003e\n \u003cp\u003eMen and women\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e18 and above\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eQualitative - IDIs, FGDs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eRural\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"18.556701030927837%\"\u003e\n \u003cp\u003eThomas et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.278350515463918%\"\u003e\n \u003cp\u003e2015\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.402061855670103%\"\u003e\n \u003cp\u003eNigeria\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.77319587628866%\"\u003e\n \u003cp\u003eMen and women\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e18-30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eQuantitative - interview schedule - pre-tested questionnaire (scale)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eRural\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"18.556701030927837%\"\u003e\n \u003cp\u003eJones et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.278350515463918%\"\u003e\n \u003cp\u003e2017\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.402061855670103%\"\u003e\n \u003cp\u003eNigeria\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.77319587628866%\"\u003e\n \u003cp\u003eMen and women\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e18-24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eQualitative - IDIs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eRural\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"18.556701030927837%\"\u003e\n \u003cp\u003eHassan et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.278350515463918%\"\u003e\n \u003cp\u003e2015\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.402061855670103%\"\u003e\n \u003cp\u003eNigeria\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.77319587628866%\"\u003e\n \u003cp\u003eMen\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e25-60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eQuantitative - descriptive cross-sectional\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eUrban\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"18.556701030927837%\"\u003e\n \u003cp\u003eTamang et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.278350515463918%\"\u003e\n \u003cp\u003e2017\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.402061855670103%\"\u003e\n \u003cp\u003eNepal\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.77319587628866%\"\u003e\n \u003cp\u003eMen and women\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e15-24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eQuantitative - cross-sectional household survey\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eUrban\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"18.556701030927837%\"\u003e\n \u003cp\u003eGautam et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.278350515463918%\"\u003e\n \u003cp\u003e2018\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.402061855670103%\"\u003e\n \u003cp\u003eNepal\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.77319587628866%\"\u003e\n \u003cp\u003eMen and women\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e15-24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eQualitative - IDIs\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eRural\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"18.556701030927837%\"\u003e\n \u003cp\u003eRegmi et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.278350515463918%\"\u003e\n \u003cp\u003e2010\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.402061855670103%\"\u003e\n \u003cp\u003eNepal\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.77319587628866%\"\u003e\n \u003cp\u003eMen and women\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e18-22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eQualitative - IDIs and FGDs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eUrban and Rural\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"18.556701030927837%\"\u003e\n \u003cp\u003eGasasira et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.278350515463918%\"\u003e\n \u003cp\u003e2012\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.402061855670103%\"\u003e\n \u003cp\u003eRwanda\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.77319587628866%\"\u003e\n \u003cp\u003eMen\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e15-59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eQuantitative - cross sectional study\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eRural\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"18.556701030927837%\"\u003e\n \u003cp\u003eShattuck et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.278350515463918%\"\u003e\n \u003cp\u003e2014\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.402061855670103%\"\u003e\n \u003cp\u003eRwanda\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.77319587628866%\"\u003e\n \u003cp\u003eMen and women\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e24-45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eQuantitative - cross-sectional descriptive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eUrban and Rural\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"18.556701030927837%\"\u003e\n \u003cp\u003eAdams et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.278350515463918%\"\u003e\n \u003cp\u003e2015\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.402061855670103%\"\u003e\n \u003cp\u003eSwaziland\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.77319587628866%\"\u003e\n \u003cp\u003eMen\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e18-49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eQualitative \u0026ndash; FGDs, IDIs, participant observation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eUrban and Rural\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"18.556701030927837%\"\u003e\n \u003cp\u003eKelly et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.278350515463918%\"\u003e\n \u003cp\u003e2012\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.402061855670103%\"\u003e\n \u003cp\u003ePapua New Guinea\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.77319587628866%\"\u003e\n \u003cp\u003eMen\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e16 and above\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eQualitative \u0026ndash; FGDs, IDIs\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eUrban and Rural\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"18.556701030927837%\"\u003e\n \u003cp\u003ePlotkin et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.278350515463918%\"\u003e\n \u003cp\u003e2013\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.402061855670103%\"\u003e\n \u003cp\u003eTanzania\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.77319587628866%\"\u003e\n \u003cp\u003eMen and women\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e18-39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eQualitative - FGDs\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eUrban and Rural\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"18.556701030927837%\"\u003e\n \u003cp\u003ePrice et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.278350515463918%\"\u003e\n \u003cp\u003e2014\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.402061855670103%\"\u003e\n \u003cp\u003eZambia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.77319587628866%\"\u003e\n \u003cp\u003eMen\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e18 and above\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eQualitative - semi-structured interviews\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eUrban\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"18.556701030927837%\"\u003e\n \u003cp\u003eSabone et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.278350515463918%\"\u003e\n \u003cp\u003e2013\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.402061855670103%\"\u003e\n \u003cp\u003eBotswana \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.77319587628866%\"\u003e\n \u003cp\u003eMen\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e18 and above\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eMixed:\u003c/p\u003e\n \u003cp\u003eQuantitative - survey was cross-sectional, - \u0026nbsp;\u003c/p\u003e\n \u003cp\u003eQualitative \u0026ndash; IDIs, FGDs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eUrban and Rural\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"18.556701030927837%\"\u003e\n \u003cp\u003eSkolnik et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.278350515463918%\"\u003e\n \u003cp\u003e2014\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.402061855670103%\"\u003e\n \u003cp\u003eLesotho\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.77319587628866%\"\u003e\n \u003cp\u003eMen\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e18 and above\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eMixed:\u003c/p\u003e\n \u003cp\u003eQuantitative \u0026ndash; cross-sectional\u003c/p\u003e\n \u003cp\u003eQualitative - FGDs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eUrban and Rural\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"18.556701030927837%\"\u003e\n \u003cp\u003eYabeny et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.278350515463918%\"\u003e\n \u003cp\u003e2018\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.402061855670103%\"\u003e\n \u003cp\u003eMexico\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.77319587628866%\"\u003e\n \u003cp\u003eMen\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e20-39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eQualitative - IDIs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eUrban\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"18.556701030927837%\"\u003e\n \u003cp\u003eParcon et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.278350515463918%\"\u003e\n \u003cp\u003e2010\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.402061855670103%\"\u003e\n \u003cp\u003ePhilippines (Western Visayas)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.77319587628866%\"\u003e\n \u003cp\u003eMen\u003c/p\u003e\n \u003cp\u003e15-54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eQuantitative - National Health and Demographic Survey (NDHS)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eUrban and Rural\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"18.556701030927837%\"\u003e\n \u003cp\u003eMuntean et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.278350515463918%\"\u003e\n \u003cp\u003e2015\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.402061855670103%\"\u003e\n \u003cp\u003eEthiopia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.77319587628866%\"\u003e\n \u003cp\u003eMen and women\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e15-24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eQualitative - IDIs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eUrban and Rural\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"18.556701030927837%\"\u003e\n \u003cp\u003eOraby et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.278350515463918%\"\u003e\n \u003cp\u003e2013\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.402061855670103%\"\u003e\n \u003cp\u003eEgypt\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.77319587628866%\"\u003e\n \u003cp\u003eMen and women\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e15-24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eQualitative \u0026ndash; IDIs, FGDs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eUrban and Rural\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"18.556701030927837%\"\u003e\n \u003cp\u003eThongmixay et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.278350515463918%\"\u003e\n \u003cp\u003e2019\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.402061855670103%\"\u003e\n \u003cp\u003eLao\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.77319587628866%\"\u003e\n \u003cp\u003eMen and women\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e15-25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eQualitative - IDIs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eUrban and Rural\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"18.556701030927837%\"\u003e\n \u003cp\u003eZaw et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.278350515463918%\"\u003e\n \u003cp\u003e2012\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.402061855670103%\"\u003e\n \u003cp\u003eMyanmar\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.77319587628866%\"\u003e\n \u003cp\u003eMen and women\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e15-24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eQuantitative - cross-sectional study\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eUrban and Rural\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"18.556701030927837%\"\u003e\n \u003cp\u003eKhumalo-Sakutukwa et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"9.278350515463918%\"\u003e\n \u003cp\u003e2013\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.402061855670103%\"\u003e\n \u003cp\u003eZimbabwe, South Africa\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.77319587628866%\"\u003e\n \u003cp\u003eMen\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e18 and above\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eQualitative \u0026ndash; IDIs, FGDs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.49484536082474%\"\u003e\n \u003cp\u003eRural\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, Facilitators, and SRH issues\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellpadding=\"0\" cellspacing=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"15.306122448979592%\"\u003e\n \u003cp\u003e\u003cstrong\u003eAuthors\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.816326530612244%\"\u003e\n \u003cp\u003e\u003cstrong\u003eBarriers\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.510204081632654%\"\u003e\n \u003cp\u003e\u003cstrong\u003eFacilitators\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.367346938775512%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSRH issues\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"15.306122448979592%\"\u003e\n \u003cp\u003eHoffman et al.\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.816326530612244%\"\u003e\n \u003cp\u003eIntra and Post and procedure complications\u003c/p\u003e\n \u003cp\u003eLow-risk perception, Lack of social support\u003c/p\u003e\n \u003cp\u003eHigh costs\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eFear HIV test\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.510204081632654%\"\u003e\n \u003cp\u003eProtection against diseases (HIV, STIs, cancers) acquisition\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eHygiene\u003c/p\u003e\n \u003cp\u003eVirility\u003c/p\u003e\n \u003cp\u003eGood societal standing\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.367346938775512%\"\u003e\n \u003cp\u003eMMC\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"15.306122448979592%\"\u003e\n \u003cp\u003eHumphries et al.\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.816326530612244%\"\u003e\n \u003cp\u003ePost-procedure complications\u003c/p\u003e\n \u003cp\u003eLow-risk perception\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.510204081632654%\"\u003e\n \u003cp\u003eVirility\u003c/p\u003e\n \u003cp\u003eSocial support\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.367346938775512%\"\u003e\n \u003cp\u003eMMC\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"15.306122448979592%\"\u003e\n \u003cp\u003eLissouba et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.816326530612244%\"\u003e\n \u003cp\u003eIntra-procedure complications\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eNon-culture\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eHigh costs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.510204081632654%\"\u003e\n \u003cp\u003eSafety\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eSocial support\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.367346938775512%\"\u003e\n \u003cp\u003eMMC\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"15.306122448979592%\"\u003e\n \u003cp\u003eZissette et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.816326530612244%\"\u003e\n \u003cp\u003eThreat to masculinity (stigma around HIV)\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eFear of losing manhood\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.510204081632654%\"\u003e\n \u003cp\u003eSocial support\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eGood standing example\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.367346938775512%\"\u003e\n \u003cp\u003eHIV testing and management\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"15.306122448979592%\"\u003e\n \u003cp\u003eKhan et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.816326530612244%\"\u003e\n \u003cp\u003eLack of confidentiality\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eHigh costs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.510204081632654%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.367346938775512%\"\u003e\n \u003cp\u003eHIV counselling and testing (HCT)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"15.306122448979592%\"\u003e\n \u003cp\u003eMambanga et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.816326530612244%\"\u003e\n \u003cp\u003eFear HIV test (stigma around HIV)\u003c/p\u003e\n \u003cp\u003eCultural practices preference\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eLow-risk perception\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.510204081632654%\"\u003e\n \u003cp\u003eNone\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.367346938775512%\"\u003e\n \u003cp\u003eHIV counselling and testing (HCT)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"15.306122448979592%\"\u003e\n \u003cp\u003eMohlabane et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.816326530612244%\"\u003e\n \u003cp\u003eFear of HIV test (stigma around HIV)\u003c/p\u003e\n \u003cp\u003eStaff attitudes\u003c/p\u003e\n \u003cp\u003eLack of knowledge (testing sites, understanding HIV)\u003c/p\u003e\n \u003cp\u003eInconvenient opening hours Fear of death\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eIgnorance (lack of condom use)\u003c/p\u003e\n \u003cp\u003eLow-risk perception\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eHigh costs (traveling)\u003c/p\u003e\n \u003cp\u003eLack of social support\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.510204081632654%\"\u003e\n \u003cp\u003eKnowledge\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eIncentives for those who test for HIV\u003c/p\u003e\n \u003cp\u003eGood staff attitudes\u003c/p\u003e\n \u003cp\u003eRole modes\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.367346938775512%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"15.306122448979592%\"\u003e\n \u003cp\u003eStern et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.816326530612244%\"\u003e\n \u003cp\u003eCondom use\u0026ndash; Virility (sex interruption, incontrollable sexual urge)\u003c/p\u003e\n \u003cp\u003eLack of knowledge of HIV transmission\u003c/p\u003e\n \u003cp\u003eSubstance abuse \u0026nbsp;\u003c/p\u003e\n \u003cp\u003eLow-risk perception\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.510204081632654%\"\u003e\n \u003cp\u003eNone\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.367346938775512%\"\u003e\n \u003cp\u003eCondom use\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"15.306122448979592%\"\u003e\n \u003cp\u003eMorison et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.816326530612244%\"\u003e\n \u003cp\u003eLong waiting times\u003c/p\u003e\n \u003cp\u003eUnavailability of medicines and equipment\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eStaff attitudes\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eLak of privacy and confidentiality High costs (traveling)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.510204081632654%\"\u003e\n \u003cp\u003eNone\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.367346938775512%\"\u003e\n \u003cp\u003eHCT\u003c/p\u003e\n \u003cp\u003eFamily Planning\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eCondoms use\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eHIV and STI treatment and counselling\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"15.306122448979592%\"\u003e\n \u003cp\u003eMthembu et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.816326530612244%\"\u003e\n \u003cp\u003eStaff attitudes Long waiting times\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eHigh costs\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eAbsence of male health workers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.510204081632654%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.367346938775512%\"\u003e\n \u003cp\u003eHCT\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"15.306122448979592%\"\u003e\n \u003cp\u003eChikovore et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.816326530612244%\"\u003e\n \u003cp\u003eFear HIV test Low-risk perception\u0026nbsp;\u003c/p\u003e\n \u003cp\u003ePreference of traditional medicine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.510204081632654%\"\u003e\n \u003cp\u003eNone\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.367346938775512%\"\u003e\n \u003cp\u003eHCT and management\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"15.306122448979592%\"\u003e\n \u003cp\u003eEvens et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.816326530612244%\"\u003e\n \u003cp\u003eMyths (circumcised penis would tear a condom)\u003c/p\u003e\n \u003cp\u003eNonculture / Nonreligion\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eLack of trust in government witchcrafts beliefs\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eLow-risk perception\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eFear HIV test\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.510204081632654%\"\u003e\n \u003cp\u003eVirility\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.367346938775512%\"\u003e\n \u003cp\u003eMMC\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"15.306122448979592%\"\u003e\n \u003cp\u003eHerman-Roloff et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.816326530612244%\"\u003e\n \u003cp\u003eFear of losing a job\u003c/p\u003e\n \u003cp\u003eNoncultural, nonreligious\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eIntra and Post procedure complications\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eLack of knowledge\u003c/p\u003e\n \u003cp\u003eVulnerability to ignorance\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eDistance to health facilities\u003c/p\u003e\n \u003cp\u003eFemale service providers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.510204081632654%\"\u003e\n \u003cp\u003eHygiene\u003c/p\u003e\n \u003cp\u003eSocial acceptance\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eVirility\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eProtection against diseases\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eConvenience (easier to use condom)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.367346938775512%\"\u003e\n \u003cp\u003eMMC\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"15.306122448979592%\"\u003e\n \u003cp\u003eMacintyre et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.816326530612244%\"\u003e\n \u003cp\u003eNonculture, nonreligion\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eLow-risk perception \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.510204081632654%\"\u003e\n \u003cp\u003eHygiene\u003c/p\u003e\n \u003cp\u003eProtection against diseases Social support\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.367346938775512%\"\u003e\n \u003cp\u003eMMC\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"15.306122448979592%\"\u003e\n \u003cp\u003eWithers et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.816326530612244%\"\u003e\n \u003cp\u003eLack of knowledge or awareness\u003c/p\u003e\n \u003cp\u003eReligious prohibition\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eUnvirility\u003c/p\u003e\n \u003cp\u003eHindrance to community development\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.510204081632654%\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.367346938775512%\"\u003e\n \u003cp\u003eFamily planning\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"15.306122448979592%\"\u003e\n \u003cp\u003eGodia et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.816326530612244%\"\u003e\n \u003cp\u003eLimited knowledge and competency of HSP\u003c/p\u003e\n \u003cp\u003eStaff attitudes\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eLack of medicines and equipment\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eLack of confidentiality and privacy\u003c/p\u003e\n \u003cp\u003eLong waiting times\u003c/p\u003e\n \u003cp\u003eHigh costs.\u003c/p\u003e\n \u003cp\u003eInconvenient hours\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.510204081632654%\"\u003e\n \u003cp\u003eNone\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.367346938775512%\"\u003e\n \u003cp\u003eFamily Planning \u0026nbsp;\u003c/p\u003e\n \u003cp\u003eSTI/HIV services,\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eCondom use\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"15.306122448979592%\"\u003e\n \u003cp\u003eMbonye et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.816326530612244%\"\u003e\n \u003cp\u003ePost-procedure compilations\u003c/p\u003e\n \u003cp\u003eFear HIV test\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.510204081632654%\"\u003e\n \u003cp\u003eProtection against diseases\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eHygiene\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.367346938775512%\"\u003e\n \u003cp\u003eMMC\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"15.306122448979592%\"\u003e\n \u003cp\u003eMuhamadi et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.816326530612244%\"\u003e\n \u003cp\u003eNone\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.510204081632654%\"\u003e\n \u003cp\u003eProtection against diseases\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eHygiene\u003c/p\u003e\n \u003cp\u003eSocial support \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eVirility\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.367346938775512%\"\u003e\n \u003cp\u003eMMC\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"15.306122448979592%\"\u003e\n \u003cp\u003eSsekubugu et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.816326530612244%\"\u003e\n \u003cp\u003ePost-procedure compilations\u003c/p\u003e\n \u003cp\u003eFear HIV test\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eMyths (infertility)\u0026nbsp;\u003c/p\u003e\n \u003cp\u003ePartial protection against diseases\u003c/p\u003e\n \u003cp\u003eLong waiting times\u003c/p\u003e\n \u003cp\u003eFear of losing a job\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.510204081632654%\"\u003e\n \u003cp\u003eProtection against diseases\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eHygiene\u003c/p\u003e\n \u003cp\u003eSocial support \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eIncentives.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.367346938775512%\"\u003e\n \u003cp\u003eMMC\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"15.306122448979592%\"\u003e\n \u003cp\u003eNalwadda et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.816326530612244%\"\u003e\n \u003cp\u003eMyths (infertility, porous and infectious condoms) Virility\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eLow-risk perception\u003c/p\u003e\n \u003cp\u003eIncontrollable sexual urge \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eStaff attitudes \u0026nbsp;\u003c/p\u003e\n \u003cp\u003eLack of privacy and confidentiality,\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eLack medicines and equipment\u003c/p\u003e\n \u003cp\u003eHigh costs\u003c/p\u003e\n \u003cp\u003eLong distance to health facilities\u003c/p\u003e\n \u003cp\u003eInconvenient opening hours,\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eLong waiting times\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.510204081632654%\"\u003e\n \u003cp\u003eNone\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.367346938775512%\"\u003e\n \u003cp\u003eFamily Planning \u0026nbsp;\u003c/p\u003e\n \u003cp\u003eSTI/HIV services,\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eCondom use\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"15.306122448979592%\"\u003e\n \u003cp\u003eSiu et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.816326530612244%\"\u003e\n \u003cp\u003eThreat to masculinity\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eFear HIV test \u0026nbsp;\u003c/p\u003e\n \u003cp\u003eLong waiting times\u003c/p\u003e\n \u003cp\u003eLack of confidentiality and privacy\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.510204081632654%\"\u003e\n \u003cp\u003eNone\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.367346938775512%\"\u003e\n \u003cp\u003eHIV services\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"15.306122448979592%\"\u003e\n \u003cp\u003eSunnu et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.816326530612244%\"\u003e\n \u003cp\u003eLack social support\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eNonreligious, noncultural\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eStaff attitudes Distance to health facilities\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.510204081632654%\"\u003e\n \u003cp\u003e\u0026nbsp;None\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.367346938775512%\"\u003e\n \u003cp\u003eFamily planning\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"15.306122448979592%\"\u003e\n \u003cp\u003eDako-Gyeke et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.816326530612244%\"\u003e\n \u003cp\u003eFear HIV test\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.510204081632654%\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.367346938775512%\"\u003e\n \u003cp\u003eHCT\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"15.306122448979592%\"\u003e\n \u003cp\u003eLeblanc et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.816326530612244%\"\u003e\n \u003cp\u003eCultural beliefs (non-condom use)\u003c/p\u003e\n \u003cp\u003eEmbarrassment\u003c/p\u003e\n \u003cp\u003eDesire for children\u003c/p\u003e\n \u003cp\u003eFear of HIV test (stigma)\u003c/p\u003e\n \u003cp\u003eHigh costs\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eLack of confidentiality\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.510204081632654%\"\u003e\n \u003cp\u003eNone\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.367346938775512%\"\u003e\n \u003cp\u003eHIV services\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eCondom use\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"15.306122448979592%\"\u003e\n \u003cp\u003eYeboah et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.816326530612244%\"\u003e\n \u003cp\u003eEmbarrassment\u003c/p\u003e\n \u003cp\u003eHigh costs\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eFemale health\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eStaff attitudes\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eReligious doctrines\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.510204081632654%\"\u003e\n \u003cp\u003eNone\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.367346938775512%\"\u003e\n \u003cp\u003eFamily planning\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eSTI services\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"15.306122448979592%\"\u003e\n \u003cp\u003eAdongo et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.816326530612244%\"\u003e\n \u003cp\u003eLack of social support\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eUnvirility\u003c/p\u003e\n \u003cp\u003eVulnerability to ignorance\u003c/p\u003e\n \u003cp\u003eIntra and Post procedure complications\u003c/p\u003e\n \u003cp\u003eLack of knowledge\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eReligious doctrines\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.510204081632654%\"\u003e\n \u003cp\u003eNone\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.367346938775512%\"\u003e\n \u003cp\u003eVasectomy\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eCondom use\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"15.306122448979592%\"\u003e\n \u003cp\u003eChikutsa et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.816326530612244%\"\u003e\n \u003cp\u003eMyths (circumcised penis would tear a condom, foreskin may be used in satanic rituals.)\u003c/p\u003e\n \u003cp\u003eNonculture, nonreligion \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eLack of trust in government\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eLow-risk perception\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eFear HIV test \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.510204081632654%\"\u003e\n \u003cp\u003eVirility\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eProtection against diseases\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.367346938775512%\"\u003e\n \u003cp\u003eMMC\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"15.306122448979592%\"\u003e\n \u003cp\u003eHatzold et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.816326530612244%\"\u003e\n \u003cp\u003eIntra procedure complications\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eLow-risk perception\u003c/p\u003e\n \u003cp\u003eLack of social support,\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eHigh costs\u003c/p\u003e\n \u003cp\u003eFear of an HIV test\u003c/p\u003e\n \u003cp\u003eMyths (infertility)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.510204081632654%\"\u003e\n \u003cp\u003eProtection against diseases\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eHygiene, \u0026nbsp;\u003c/p\u003e\n \u003cp\u003eVirility\u003c/p\u003e\n \u003cp\u003eSet good example\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.367346938775512%\"\u003e\n \u003cp\u003eMMC\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"15.306122448979592%\"\u003e\n \u003cp\u003eMoyo et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.816326530612244%\"\u003e\n \u003cp\u003eLack of knowledge\u003c/p\u003e\n \u003cp\u003eFear of HIV testing\u003c/p\u003e\n \u003cp\u003eMyths (foreskin to be used in witchcraft)\u003c/p\u003e\n \u003cp\u003eLack of trust in government\u003c/p\u003e\n \u003cp\u003eThreat to masculinity\u003c/p\u003e\n \u003cp\u003eFemale health care provider\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eUnvirility\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.510204081632654%\"\u003e\n \u003cp\u003eNone\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.367346938775512%\"\u003e\n \u003cp\u003eMMC\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"15.306122448979592%\"\u003e\n \u003cp\u003eSkovdal et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.816326530612244%\"\u003e\n \u003cp\u003eFear of HIV test\u003c/p\u003e\n \u003cp\u003eStigma\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eEmbarrassment\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eThreat to masculinity\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eLow-risk perception\u003c/p\u003e\n \u003cp\u003eLack of knowledge\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.510204081632654%\"\u003e\n \u003cp\u003eSocial support\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eRole models\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.367346938775512%\"\u003e\n \u003cp\u003eHIV services\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"15.306122448979592%\"\u003e\n \u003cp\u003eThomas et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.816326530612244%\"\u003e\n \u003cp\u003eFear of HIV test\u003c/p\u003e\n \u003cp\u003eStigma\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eNonculture\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.510204081632654%\"\u003e\n \u003cp\u003eNone\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.367346938775512%\"\u003e\n \u003cp\u003eHIV services\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"15.306122448979592%\"\u003e\n \u003cp\u003eJones et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.816326530612244%\"\u003e\n \u003cp\u003eStigma\u003c/p\u003e\n \u003cp\u003eInaccessibility\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eLack of knowledge \u0026nbsp;\u003c/p\u003e\n \u003cp\u003eInaccessibility\u003c/p\u003e\n \u003cp\u003eLow-risk perception\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.510204081632654%\"\u003e\n \u003cp\u003eNone\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.367346938775512%\"\u003e\n \u003cp\u003eHIV services\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"15.306122448979592%\"\u003e\n \u003cp\u003eHassan et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.816326530612244%\"\u003e\n \u003cp\u003eLow-risk perception\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eLack of time\u003c/p\u003e\n \u003cp\u003eIntra procedure complications\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eFear of PC test outcome\u003c/p\u003e\n \u003cp\u003eLack of knowledge\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.510204081632654%\"\u003e\n \u003cp\u003eNone\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.367346938775512%\"\u003e\n \u003cp\u003eProstate Cancer screening\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"15.306122448979592%\"\u003e\n \u003cp\u003eTamang et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.816326530612244%\"\u003e\n \u003cp\u003eEmbarrassment\u0026nbsp;\u003c/p\u003e\n \u003cp\u003ePoor health services Lack of knowledge\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eInaccessibility\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.510204081632654%\"\u003e\n \u003cp\u003eNone\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.367346938775512%\"\u003e\n \u003cp\u003eCondom use\u003c/p\u003e\n \u003cp\u003eFamily planning\u0026nbsp;\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\" width=\"15.306122448979592%\"\u003e\n \u003cp\u003eGautam et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.816326530612244%\"\u003e\n \u003cp\u003eEmbarrassment \u0026nbsp;\u003c/p\u003e\n \u003cp\u003eLack of knowledge\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eStaff attitudes \u0026nbsp;\u003c/p\u003e\n \u003cp\u003eLack of privacy and confidentiality\u003c/p\u003e\n \u003cp\u003eLack of medicines and equipment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.510204081632654%\"\u003e\n \u003cp\u003eNone\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.367346938775512%\"\u003e\n \u003cp\u003eAll\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"15.306122448979592%\"\u003e\n \u003cp\u003eRegmi et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.816326530612244%\"\u003e\n \u003cp\u003eEmbarrassment\u0026nbsp;\u003c/p\u003e\n \u003cp\u003ePoor health services\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eLack of knowledge\u003c/p\u003e\n \u003cp\u003eSubstance abuse\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eInaccessibility\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eHigh costs\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.510204081632654%\"\u003e\n \u003cp\u003eNone\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.367346938775512%\"\u003e\n \u003cp\u003eCondom use\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\" width=\"15.306122448979592%\"\u003e\n \u003cp\u003eGasasira et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.816326530612244%\"\u003e\n \u003cp\u003eLow-risk\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eIntra procedure complications\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.510204081632654%\"\u003e\n \u003cp\u003eProtection against diseases\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eHygiene\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.367346938775512%\"\u003e\n \u003cp\u003eMMC\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"15.306122448979592%\"\u003e\n \u003cp\u003eShattuck et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.816326530612244%\"\u003e\n \u003cp\u003eNone\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.510204081632654%\"\u003e\n \u003cp\u003eFinancial relief (limit family size)\u003c/p\u003e\n \u003cp\u003eComplications of other family plaining methods\u003c/p\u003e\n \u003cp\u003ePermanent method\u003c/p\u003e\n \u003cp\u003eLow-risk of complications\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.367346938775512%\"\u003e\n \u003cp\u003eVasectomy services\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"15.306122448979592%\"\u003e\n \u003cp\u003eAdams et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.816326530612244%\"\u003e\n \u003cp\u003eThreat to masculinity\u003c/p\u003e\n \u003cp\u003eVirility\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eIntra and post procedure complications\u0026nbsp;\u003c/p\u003e\n \u003cp\u003ePartially protective against diseases\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eLack of trust in government\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eNoncultural, nonreligious\u003c/p\u003e\n \u003cp\u003eLack of knowledge\u003c/p\u003e\n \u003cp\u003eMyths (foreskins used for witchcraft)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.510204081632654%\"\u003e\n \u003cp\u003eVirility\u003c/p\u003e\n \u003cp\u003eProtection against diseases\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eConvenience (wearing condoms)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.367346938775512%\"\u003e\n \u003cp\u003eMMC\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"15.306122448979592%\"\u003e\n \u003cp\u003eKelly et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.816326530612244%\"\u003e\n \u003cp\u003eVulnerable to ignorance\u003c/p\u003e\n \u003cp\u003eNoncultural, nonreligious\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.510204081632654%\"\u003e\n \u003cp\u003eProtection against diseases\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eHygiene\u003c/p\u003e\n \u003cp\u003eCulturally appropriate\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eVirility\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.367346938775512%\"\u003e\n \u003cp\u003eMMC\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"15.306122448979592%\"\u003e\n \u003cp\u003ePlotkin et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.816326530612244%\"\u003e\n \u003cp\u003ePost procedure complications\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eFear of losing job \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.510204081632654%\"\u003e\n \u003cp\u003eProtection against diseases\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eHygiene\u003c/p\u003e\n \u003cp\u003eSocial support\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eVirility\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.367346938775512%\"\u003e\n \u003cp\u003eMMC\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"15.306122448979592%\"\u003e\n \u003cp\u003ePrice et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.816326530612244%\"\u003e\n \u003cp\u003eIntra and post procedure complications\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eLack of time\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.510204081632654%\"\u003e\n \u003cp\u003eSocial support\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eHygiene\u003c/p\u003e\n \u003cp\u003eProtection against diseases\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.367346938775512%\"\u003e\n \u003cp\u003eMMC\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"15.306122448979592%\"\u003e\n \u003cp\u003eSabone et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.816326530612244%\"\u003e\n \u003cp\u003eLack of medicines and equipment\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eLong waiting times\u003c/p\u003e\n \u003cp\u003ePoor transport to health facilities \u0026nbsp;\u003c/p\u003e\n \u003cp\u003ePost procedure complications\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.510204081632654%\"\u003e\n \u003cp\u003eAdvertisement\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eSocial support\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eRight staff attitudes\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.367346938775512%\"\u003e\n \u003cp\u003eMMC\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"15.306122448979592%\"\u003e\n \u003cp\u003eSkolnik et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.816326530612244%\"\u003e\n \u003cp\u003eIntra procedure complications\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eFear of HIV test\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eHigh costs\u003c/p\u003e\n \u003cp\u003eFemale health workers\u003c/p\u003e\n \u003cp\u003eLong waiting times\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.510204081632654%\"\u003e\n \u003cp\u003eProtection against diseases\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eHygiene\u003c/p\u003e\n \u003cp\u003eSocial support\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eVirility\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.367346938775512%\"\u003e\n \u003cp\u003eMMC\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"15.306122448979592%\"\u003e\n \u003cp\u003eYabeny et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.816326530612244%\"\u003e\n \u003cp\u003eLow-risk perception\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.510204081632654%\"\u003e\n \u003cp\u003eFear of illness\u003c/p\u003e\n \u003cp\u003eMistrust in relationship\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.367346938775512%\"\u003e\n \u003cp\u003eCondom use\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"15.306122448979592%\"\u003e\n \u003cp\u003eParcon et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.816326530612244%\"\u003e\n \u003cp\u003eLack of knowledge\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eMyths (loss of libido)\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eUnvirility decreased\u003c/p\u003e\n \u003cp\u003esexual activity, loss of vitality,\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eInconvenience\u003c/p\u003e\n \u003cp\u003eEmbarrassment \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.510204081632654%\"\u003e\n \u003cp\u003eProtection against diseases\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.367346938775512%\"\u003e\n \u003cp\u003eVasectomy \u0026nbsp;\u003c/p\u003e\n \u003cp\u003eCondom use\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"15.306122448979592%\"\u003e\n \u003cp\u003eMuntean et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.816326530612244%\"\u003e\n \u003cp\u003eHigh costs\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eLong distance to the health facility\u003c/p\u003e\n \u003cp\u003eStaff attitudes\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eInconvenient location of facilities\u003c/p\u003e\n \u003cp\u003eInconvenient hours\u003c/p\u003e\n \u003cp\u003eLack of privacy and confidentiality\u003c/p\u003e\n \u003cp\u003eEmbarrassment\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eLack of knowledge\u003c/p\u003e\n \u003cp\u003eNoncultural \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.510204081632654%\"\u003e\n \u003cp\u003eNone\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.367346938775512%\"\u003e\n \u003cp\u003eAll\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"15.306122448979592%\"\u003e\n \u003cp\u003eOraby et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.816326530612244%\"\u003e\n \u003cp\u003eInaccessibility\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eAbsence of male health workers\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.510204081632654%\"\u003e\n \u003cp\u003eNone\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.367346938775512%\"\u003e\n \u003cp\u003eAll\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"15.306122448979592%\"\u003e\n \u003cp\u003eThongmixay et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.816326530612244%\"\u003e\n \u003cp\u003eLack of medicines and equipment\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eLow-risk perception\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eLack of knowledge\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eLack of privacy and confidentiality\u003c/p\u003e\n \u003cp\u003eSubstance abuse\u003c/p\u003e\n \u003cp\u003eNoncultural, nonreligious \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003cp\u003eEmbarrassment\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eHigh costs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.510204081632654%\"\u003e\n \u003cp\u003eProtection against diseases\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eSocial acceptance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.367346938775512%\"\u003e\n \u003cp\u003eCondom use\u003c/p\u003e\n \u003cp\u003eFamily planning\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"15.306122448979592%\"\u003e\n \u003cp\u003eZaw et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.816326530612244%\"\u003e\n \u003cp\u003eHigh costs\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eLack of confidentiality\u003c/p\u003e\n \u003cp\u003eLack of transport\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eStaff attitudes\u003c/p\u003e\n \u003cp\u003eFear of HIV test\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eEmbarrassment\u003c/p\u003e\n \u003cp\u003eLack of knowledge\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.510204081632654%\"\u003e\n \u003cp\u003eNone\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.367346938775512%\"\u003e\n \u003cp\u003eFamily planning\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eHIV services\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eCondom use\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"15.306122448979592%\"\u003e\n \u003cp\u003eKhumalo-Sakutukwa et al.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.816326530612244%\"\u003e\n \u003cp\u003eNoncultural\u003c/p\u003e\n \u003cp\u003eIntra and post procedure complications\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.510204081632654%\"\u003e\n \u003cp\u003eNone\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.367346938775512%\"\u003e\n \u003cp\u003eMMC\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"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"University of KwaZulu-Natal","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Men, Sexual and Reproductive Health services, factors influencing SRH service utilization, factors facilitating the SRH service utilization, factors inhibiting SRH service utilization","lastPublishedDoi":"10.21203/rs.3.rs-1418093/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-1418093/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eLow-Middle-Income countries (LMIC) present with a high aversion to the utilization of Sexual and Reproductive Health (SRH) services by men. Nevertheless, in both Low-Middle-Income and High-Income countries, low SRH utilization is mainly related to men's poor Health Seeking Behaviour (HSB). Identifying SRH inhibitors and facilitators remains an essential approach to improve SRH utilization and avert higher mortality and earlier morbidity associated with poor HSB among men. This literature review identifies factors contributing to men's decisions not to utilize SRH services, particularly to inform a conceptual model illustrating men's SRH utilization in LMIC.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eIn this narrative review, we searched articles published between 2004 and 2021 from international databases, including Google Scholar, Science Direct, EBSCOhost, Scopus, PubMed, Medline, and reference lists of retrieved published articles.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA total of 2219 articles were retrieved, from which 51 articles met the inclusion criteria. We reveal lack of access and availability of SRH services, poor health-seeking behavior among men and, SRH facilities often not being seen as \"male-friendly\u0026rdquo; spaces and not providing men's services under one roof as the underlying factors contributing to the poor uptake of SRH services by men. Further influences to decline in SRH utilization by men included lack of focus on adult men's sexual and reproductive health; the lack of inclusion of men in a meaningful way; and the insufficient evidence about large-scale and implementable approaches to address men\u0026rsquo;s SRH needs. Our reviews reveal that dealing with negative or inhibiting factors to manage low utilization of SRH services had improved men's SRH utilization where this was carried out. We conclude by proposing a framework to illustrate men's engagement with SRH services.\u003c/p\u003e","manuscriptTitle":"Factors influencing men’s decisions whether or not to utilize sexual and reproductive health services in Low-Middle-Income countries: A narrative review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2022-03-07 23:12:23","doi":"10.21203/rs.3.rs-1418093/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"af602ebb-ca94-45b5-a6b3-3c2604047c82","owner":[],"postedDate":"March 7th, 2022","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":10832334,"name":"Epidemiology"}],"tags":[],"updatedAt":"2022-03-07T23:12:23+00:00","versionOfRecord":[],"versionCreatedAt":"2022-03-07 23:12:23","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-1418093","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-1418093","identity":"rs-1418093","version":["v1"]},"buildId":"GqpaHPwrfC8PjnIFayRh5","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}