Dividuality, masculine respectability and reputation: exploring the link between men's uptake of HIV treatment and their masculinity in rural eastern Uganda

This thesis discusses the link between men’s HIV treatment seeking behaviour and their masculinity. It is based generally on ethnographic research conducted in Busia district, rural eastern Uganda, and specifically on 26 interviews conducted between 2009 and 2010 with different categories of men: treated for HIV, tested but dropped out of treatment, not tested but suspect HIV infection, and those with other health problems unrelated to HIV. The study explored how masculinity is constructed and discussed among the men from the Iteso ethnic group, how those notions of masculinity influence men’s uptake of HIV treatment, and how HIV diagnosis and/or its treatment, in turn, affects men’s perception of their masculinity. Thematic framework analysis identified recurrent themes and variations across the data. The thesis argues that there are, essentially, two forms of masculinity in rural Uganda, one based on reputation, the other on respectability, and that these emerge in different contexts, and have different effects on men’s behaviours regarding HIV testing and treatment. Respectable masculinities are endorsed largely by the wider society, while reputational masculinities are endorsed predominantly by the men themselves, although some ideals are shared by both. Theoretically, this categorisation is consistent with the distinction between the value systems of respectability and reputation as described by PJ Wilson (1969). Men’s dividuality (Helle-Valle 2004), allowed them to, unproblematically, adopt the different and sometimes contradictory, forms of masculinity, in different social circumstances and phases of life. Individual men can engage in a variety of HIV treatment seeking behaviours that typically correspond with different masculine ideologies and dividualities; some discouraging treatment seeking for HIV, others encouraging it. On the one hand, acknowledging illness is incompatible with men’s notion of strength. Being diagnosed with HIV threatens respectability and ability to work and earn an income, hence treatment is delayed, while couple testing threatens men’s freedom to engage in extramarital sex. On the other hand, HIV treatment may be undertaken and adhered to, in order to regain and maintain health, so as to fulfill family and societal expectations, notably that of provider and being a role model. Through the core themes of ‘dented’ and ‘resuscitated’ masculinities, this study suggests that HIV diagnosis negatively affected masculinity while treatment led to more positive ways to express masculinity

Maternal experiences of caring for an infant with neurological impairment after neonatal encephalopathy in Uganda: a qualitative study.

PURPOSE: The study investigated maternal experiences of caring for a child affected by neurological impairment after neonatal encephalopathy (NE) ("birth asphyxia") in Uganda. METHODS: Between September 2011 and October 2012 small group and one-on-one in-depths interviews were conducted with mothers recruited to the ABAaNA study examining outcomes from NE in Mulago hospital, Kampala. Data were analysed thematically with the aid of Nvivo 8 software. FINDINGS: Mothers reported caring for an infant with impairment was often complicated by substantial social, emotional and financial difficulties and stigma. High levels of emotional distress, feelings of social isolation and fearfulness about the future were described. Maternal health-seeking ability was exacerbated by high transport costs, lack of paternal support and poor availability of rehabilitation and counselling services. Meeting and sharing experiences with similarly affected mothers was associated with more positive maternal caring experiences. CONCLUSION: Mothering a child with neurological impairment after NE is emotionally, physically and financially challenging but this may be partly mitigated by good social support and opportunities to share caring experiences with similarly affected mothers. A facilitated, participatory, community-based approach to rehabilitation training may have important impacts on maximising participation and improving the quality of life of affected mothers and infants. Implications for Rehabilitation Caring for an infant with neurological impairment after NE in Uganda has substantial emotional, social and financial impacts on families and is associated with high levels of emotional stress, feelings of isolation and stigma amongst mothers. Improved social support and the opportunity to share experiences with other similarly affected mothers are associated with a more positive maternal caring experience. High transport costs, lack of paternal support and poor availability of counselling and support services were barriers to maternal healthcare seeking. Studies examining the feasibility, acceptability and impact of early intervention programmes are warranted to maximise participation and improve the quality of life for affected mothers and their infants

Intersectionality of HIV stigma and masculinity in eastern Uganda:implications for involving men in HIV programmes

Background Stigma is a determinant of social and health inequalities. In addition, some notions of masculinity can disadvantage men in terms of health outcomes. However, few studies have explored the extent to which these two axes of social inequality intersect to influence men's health outcomes. This paper investigates the intersection of HIV stigma and masculinity, and its perceived impact on men's participation in and utilisation of HIV services in Uganda. Methods Interviews and focus group discussions were conducted in Mbale and Jinja districts of Uganda between June and October 2010. Participants were men and women living with HIV (n = 40), their family members (n = 10) and health providers (n = 15). Inductive analysis was used to identify mechanisms through which stigma and masculinity were linked. Results Our findings showed that HIV stigma and masculinity did not exist as isolated variables, but as intersecting phenomena that influenced men's participation in HIV services. Specifically, HIV stigma threatened masculine notions of respectability, independence and emotional control, while it amplified men's risk-taking. As a result, the intersection of masculinity and HIV stigma prevented some men from i) seeking health care and accepting a 'sick role'; ii) fulfilling their economic family responsibilities; iii) safeguarding their reputation and respectability; iv) disclosing their HIV status; and v) participating in peer support groups. Participation in some peer support activities was considered a female trait and it also exacerbated HIV stigma as it implicitly singled out those with HIV. In contrast, inclusion of income-generating activities in peer support groups encouraged men's involvement as it enabled them to provide for their families, cushioned them from HIV stigma, and in the process, provided them with an opportunity to redeem their reputation and respectability. Conclusion To improve men's involvement in HIV services, the intersection between HIV stigma and masculinity should be considered. In particular, better integration of and linkage between gender transformative interventions that support men to reconstruct their male identities and reject signifiers of masculinity that prevent their access to HIV services, and stigma-reduction interventions that target social and structural drivers of stigma is required within HIV programmes

The meaning of fatherhood to men in relationships with female sex workers in Kampala, Uganda: The struggle to model the traditional parameters of fatherhood and masculinity.

Many women who engage in sex work in sub-Saharan Africa become pregnant, often unintentionally. There is limited attention paid to the experiences of fathers of children born to women engaged in sex work. We examine the meaning of fatherhood to these men, the significance of children, and how they navigate the economic and cultural challenges of fatherhood in this context. Analysis is based on ethnographic data from 13 men who identified as intimate long-term partners of female sex workers (FSW) in Kampala City, Uganda. Our findings illustrate how men who have children with FSW struggled to model the traditional parameters of fatherhood and masculinity. We found that men who had children with FSW faced hurdles fitting within the social construction of ideal fatherhood. Accepting fatherhood often started with doubts over the pregnancy because of the multiple partnerships of women. Men who only saw themselves as clients struggled to adjust to being fathers because of their perceptions of the social implications of fathering a child with a FSW. Integration of mothers who were also sex workers into the man's extended family was a challenge because of the fear of negative reactions from family members. However, when men accepted their roles as fathers, they started seeing value in their children. Due to poverty, most of the men fell short of the societal measures of masculinity, but children transformed their social status before their society and family. The provider role often used to define good fathering was a challenge for men. However, the financial support from FSW partners softened the burden and facilitated the creation of a family environment constructed to the perceived standards of the broader society. Our findings provide insights into the state of parenting among FSW and their partners which can guide interventions that are tailored to their unique circumstances

Conflicted masculinities: understanding dilemmas and (re)configurations of masculinity among men in long-term relationships with female sex workers, in Kampala, Uganda.

This ethnographic study explores the experience of men in long-term relationships with sex workers and their construction of masculine identities in Kampala, Uganda. Data were collected in 2019 and comprise in-depth interviews with 13 male partners and two group discussions of women with long-term male partners. Thematic analysis used an intersectional lens to frame reconfigurations of gender and masculinity in the context of relationships with sex workers. All men had been clients of sex workers before progressing to become long-term partners. We discuss the complex ways in which men participated in value systems of respectability and reputation to (re)configure gender relations that made sense of their long-term relationships with sex workers. Men viewed their relationships with women through the normative lens of traditional masculine roles associated with monopoly over a partner's sexuality, provider and father. However, poverty, HIV, the failure to have exclusive sexual rights over a partner, and the shame associated with sex work intersected and disrupted masculinities. Despite this, men found meaning in these relationships through the woman's commitment to the relationship, her financial support, her help in accessing HIV services, and the children from the relationship, thereby attaining respectability and avoiding a crisis of masculinity

Men’s Involvement in a Parenting Programme to Reduce Child Maltreatment and Gender-Based Violence: Formative Evaluation in Uganda

AbstractParenting programmes involving fathers can reduce child maltreatment and gender-based violence. However, most parenting programmes find it difficult to recruit fathers. We piloted a 21 session parenting intervention, ‘Parenting for Respectability’, with fathers and mothers near Kampala, Uganda. Sixty-one fathers and 83 mothers were recruited initially and 52 fathers and 76 mothers retained to the end. We interviewed with 24 fathers and 16 mothers. Data were analysed thematically. Success in involving fathers was probably due to (a) the first 10 sessions being father-only, allowing them to share experiences before participating in mixed-sex sessions; (b) exploiting men’s pre-existing motivation to improve their children’s behaviour, thereby enhancing family respectability; and (c) the interactive, participatory delivery. Mixed sessions enabled couples to clarify conflicting perspectives regarding spousal relationships and gendered norms. However, men experienced social pressure to conform to conventional masculinity, suggesting the need to instil intervention values at community level. </jats:p

The impact of the parenting for respectability programme on violent parenting and intimate partner relationships in Uganda: a pre-post study

Background There is a growing need for interventions that reduce both violence against children and intimate partner violence in low- and middle-income countries. However, few parenting interventions deliberately address this link. We tested the feasibility of a 16-session group-based parenting programme, Parenting for Respectability, in semi-rural Ugandan communities. Methods This was a pre-post study with parents and their children (N = 484 parents; 212 children). Results Pre-post comparisons found large effects for parent-reported reduced harsh parenting (Cohen’s f2 = 0.41 overall; f2 = 0.47 (among session attendees); with an overall reduction of 26% for harsh parenting. Session attendees reported higher reductions than non-attendees (p = 0.014), and male caregivers reported higher reductions than female caregivers (p<0.001). Children also reported reduced harsh parenting by attending fathers (f2 = 0.64 overall; f2 = 0.60) and attending mothers (f2 = 0.56 overall; f2 = 0.51); with reduction in harsh parenting ranging between 27% to 29% in the various categories. Overall, spousal violence reduced by 27% (f2 = 0.19 overall; f2 = 0.26 (among session attendees). Both parents and children reported reduced dysfunctional parent relationships; parents: f2 = 0.19 overall; f2 = 0.26 (among session attendees); and children: f2 = 0.35 overall; f2 = 0.32 (for attending parents); with reductions ranging between 22% to 28%. Parents who attended more than 50% of the program reported greater effects on reduced dysfunctional relationships than those who attended less than half of the program (B = -0.74, p = 0.013). All secondary outcomes were improved with f2 ranging between 0.08 and 0.39; and improvements ranging between 6% and 28%. Conclusion Results suggest the importance of more rigorous testing to determine program effectiveness

How Mothers in Poverty Explain Their Use of Corporal Punishment: A Qualitative Study in Kampala, Uganda

Corporal punishment in the early years is associated with antisocial behaviour and violence, but little is known about its social and cultural context in low-income countries. This paper analyses how 12 deprived women in Kampala, Uganda, perceived corporal punishment, drawing on repeated semi-structured interviews. All thought it was sometimes necessary, for three main reasons. First, it was an important strategy to ensure good behaviour and maintain their and their child’s, respectability, crucial to self-respect given severe poverty. Second, it was a means of establishing household routines and managing scarce resources. Third, it was a way to protect children from health risks. However, all mothers thought corporal punishment could be excessive, and most said it can be counter-productive, making children ‘stubborn’. There appeared to be considerable variation in their degree of harsh parenting and emotional support. These findings could inform culturally appropriate interventions to reduce violence against children

Community perceptions of paediatric severe anaemia in Uganda

BACKGROUND: Severe anaemia remains a major cause of morbidity and mortality among children in sub-Saharan Africa. There is limited research on the beliefs and knowledge for paediatric severe anaemia in the region. The effect of these local beliefs and knowledge on the healthcare seeking of paediatric severe anaemia remains unknown. OBJECTIVE: To describe community perceptions of paediatric severe anaemia in Uganda. METHODS: Sixteen in-depth interviews of caregivers of children treated for severe anaemia and six focus group discussions of community members were conducted in three regions of Uganda between October and November 2017. RESULTS: There was no common local name used to describe paediatric severe anaemia, but the disease was understood in context as 'having no blood'. Severe anaemia was identified to be a serious disease and the majority felt blood transfusion was the ideal treatment, but concomitant use of traditional and home remedies was also widespread. Participants articulated signs of severe pediatric anemia, such as palmar, conjunctival, and tongue pallor. Other signs described included jaundice, splenomegaly, difficulty in breathing and poor appetite. Poor feeding, malaria, splenomegaly and evil spirits were perceived to be the common causes of severe anaemia. Other causes included: human immunodeficiency virus (HIV), haemoglobinuria, fever, witchcraft, mosquito bites, and sickle cell. Splenomegaly and jaundice were perceived to be both signs and causes of severe anaemia. Severe anaemia was interpreted to be caused by evil spirits if it was either recurrent, led to sudden death, or manifested with cold extremities. CONCLUSION: The community in Uganda perceived paediatric severe anaemia as a serious disease. Their understanding of the signs and perceived causes of severe anaemia to a large extent aligned with known clinical signs and biological causes. Belief in evil spirits persists and may be one obstacle to seeking timely medical care for paediatric severe anaemia

Caregivers and community perceptions of blood transfusion for children with severe anaemia in Uganda

Objective To describe local perceptions of blood transfusion for children with severe anaemia in Uganda. Background Blood transfusion is a common emergency treatment for children with severe anaemia and saves millions of lives of African children. However, the perceptions of transfusion recipients have not been well studied. A better understanding of the perceived risk may improve transfusion care. Methods A qualitative study based on 16 in‐depth interviews of caregivers of transfused children, and six focus group discussions with community members was conducted in three regions of Uganda between October and November 2017. Results Caregivers of children and community members held blood transfusion in high regard and valued it as life‐saving. However, there were widespread perceived transfusion risks, including: Human immunodeficiency virus (HIV) transmission, too rapid blood infusion and blood incompatibility. Other concerns were: fatality, changes in behaviour, donor blood being ‘too strong’ and use of animal blood. In contrast, recent transfusion, older age, knowledge of HIV screening of blood for transfusion, faith in God and having a critically ill child were associated with less fear about transfusion. Respondents also emphasised challenges to transfusion services access including distance to hospitals, scarcity of blood and health workers' attitudes. Conclusion Perceptions of the community and caregivers of transfused children in Uganda about blood transfusion were complex: transfusion is considered life‐saving but there were strong perceived transfusion risks of HIV transmission and blood incompatibility. Addressing community perceptions and facilitating access to blood transfusion represent important strategies to improve paediatric transfusion care