Towards a deeper understanding of male involvement in the prevention of mother to child transmission of HIV in the Bogodogo District of the Central Region of Burkina Faso

Introduction Men can play crucial roles at each stage of HIV mother-to-child-transmission (MTCT) prevention. Low male involvement in preventative MTCT (PMTCT) in Burkina Faso is partially associated with increased MTCT rates in the country. Male involvement is at the intersection of individual experiences, social locations, organizational and systemic forces. It is crucial that PMTCT interventions are co-designed with all stakeholders, using approaches which account for such interconnected elements. This study, aims to provide a deeper understanding of male involvement using an intersectionality framework. Methods We used an intersectional theoretical approach as it positions male involvement at the intersection of social location, systemic forces, individual experiences, and dynamics within couples. We applied an interpretative qualitative description design. The study was performed at St-Camille’s hospital in Ouagadougou, Burkina Faso. Our sample was theoretical to contrast for individual experiences and socioeconomic characteristics. Eligible women were identified via chart review and invited to participate with their male partners. We conducted individual semi-structured interviews with 12 couples. We performed a semantic thematic analysis using QDA Miner to identify themes and patterns among subjective perspectives, while accounting for variations between individuals. Results We interviewed 12 couples; 6 were serodiscordant. All women were HIV-positive. Participant ages ranged from 23 to 48 years. We found male involvement to be multidimensional and multifaceted, covering a large spectrum (from rejection to true partnership) and diverse involvement. Male involvement was limited by competing priorities, contradictory expectations, organizational opportunities and societal beliefs. We found interactions with caregivers impacted male involvement. Conclusion This study contributed to enhancing our understanding of male involvement in PMTCT of HIV as a dynamic result of the interconnected individual, organizational and systemic experiences. Increasing male involvement will require implementation of coordinated interventions. Such interventions must strive to simultaneously integrate individual, organizational and systemic actions together. This study was informed by intersectional theory as it positions male involvement at the intersection of social location, systemic forces and individual experiences, as well as highlights power dynamics within couples [14, 15]. Additionally, it focuses on the interdependence of social location and its impacts on experiences rather than applying an additive approach. We applied interpretive description [16] which examines a “clinical phenomenon with the goal of identifying themes and patterns among subjective perspectives, while accounting for variations between individuals” [17]. The initial study phases were oriented toward identifying the forms of male involvement whether financial and/or psychological, professional, partial or total. As patterns within the data became more apparent, we adopted an intersectional approach, which allowed us to examine the interconnections of men’s and women’s personal experiences, and the structural elements that shape their involvement. The research team included two senior researchers (SH and AB2): the first, a specialist in health services research and impact assessment in Burkina Faso and the second, a public health specialist; two research associates (AB1 et LS): both with sociology backgrounds and a mid-career researcher (MJD) with extensive experience in qualitative health service research who was primarily involved in the data analysis. The team acknowledged multiple identities of each researcher and adopted self-reflective stances for occasional review of each researcher’s shift in attitude towards male involvement throughout the research process [18]. The study was performed at St-Camille’s hospital in Ouagadougou (henceforth referred to as the Hospital). It is a Christian hospital founded in 1967 by the Camilian’s religious community and located within the Central Health Regional Center. This not-for-profit care center also offers hospitalizations and performs complementary paraclinical examinations. It covers 9 wards (maternity, maternal and child care, laboratory, pharmacy, pediatrics, new pediatrics, neonatology, general medicine and specialized medicine, which includes 20 specialties). The maternity ward is one of the biggest within the Hospital with between 3500 and 4000 deliveries per year, 105 beds, and 4 private air-conditioned first-class rooms equipped with a television, fridge and hot running water. The sole selection of this health facility is justified by the exploratory nature of this study as well as the excellent organization of the follow-up of people living with HIV, which facilitates research (accessible archives for example). As usual with interpretative description, our sample was theoretical. Thus, St-Camille’s hospital care providers contributed to the selection of participants, in order to contrast for individual experiences and socioeconomic characteristics. To be eligible to participate in the study, women must have i) a confirmed HIV–positive status; ii) informed her partner about her status; iii) given birth to a child at least six weeks before the study; iv) invited her partner to participate in the study. Eligible women were identified with the PMTCT care provider via chart review. A research assistant explained the study objective to the provider and assisted with chart reviews. The Hospital chart contains detailed information about the woman’s HIV status, her partner’s status and whether or not the status has been communicated to their partner. Eligible women were invited to participate in the study at the beginning of their consultation with the care provider. Those who agreed met with the research associate after the consultation, received an in-depth explanation about the project and confirmed their willingness to participate. They were then asked to provide their consent in writing and to inform their partner about the project. Before the interview, the research associate checked the partner’s agreement to also participate and confirmed an appointment with the woman. A total of 33 individuals were approached. This 33 ceiling is explained by the exploratory nature of this study but also the desire to limit the workload of health workers who helped with the recruitment of patients. We recruited 12 couples (12 women and 12 men). Nine individuals (3 men and 6 women) refused to participate: four women because they were either separated or threatened to be abandoned by the partners, and refused to inform their partners about the study. Two women consented to participate but were unreachable by phone. One research assistant, AB1, conducted individual (one-on-one) semi-structured interviews with all of the participants between November 15th, 2017 and March 16th, 2018, using two different tailored interview grids (one for women and one for men) developed within the research team. This duration of data collection did not impact data quality or participants’ access to the health services, because of the long tradition of involvement of this health facility in research. Thus, the health facility managers ensured the usual care is not disturbed in the facility. AB1 conducted 12 interviews in French and 12 in Mooré. The interviews took place according to participant preferences which were in a quiet room close to the clinic area (n = 14), at the participant’s home (n = 6), at their work location (n = 2) or at a restaurant (n = 2). The interviews were audio recorded and lasted an average of 59 minutes. Promptly following each interview, field notes regarding participant reactions throughout the interview were documented in the form of written notes. Mooré interviews were simultaneously transcribed and translated into French, and French interviews were transcribed verbatim. AB1 and LS reviewed Mooré interviews recordings while verifying the verbatim transcriptions for accuracy. All interviews were anonymized and then analyzed using QDA Miner. We performed a semantic thematic analysis [19]. Two researchers (AB1, LS) developed a common codebook and independently did line-by-line transcript coding. We identified dominant categories inside the corpus as patterns became more apparent and established them as themes. Initial themes were discussed with MJD, SH and AB2, revised and reformulated as needed [19]. The analysis ended by establishing and checking relationships between the individual beliefs of the participants, the organizational structure, the systemic elements and the type of involvement, as required by an intersectional approach. The team met regularly for the purposes of analysis. Finally, we examined the male involvement trend over time, thus providing a temporal perspective of the involvement. This study was approved by the Burkina Faso Health Service Research Review Board (N° 2017-12-177) and an authorization from the Minister of Health. Written informed consent was completed in person by all participants prior to commencing interviews. The study also received ethical approval from the CHU de Québec Institutional Review Board (Projet 2017–3197 / Renouvellement F9–26065). “Additional information regarding the ethical, cultural, and scientific considerations specific to inclusivity in global research is included in the Supporting Information (S1 Checklist).