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

Langa J.M. (1); Netshapapame T.S. (2); Goon D.T. (3)

Department of Public health, Faculty of Health Sciences, Health, University of Limpopo, Sovenga 0727, South Africa, mahlapsjonas@gmail.com

Department of Public health, Faculty of Health Sciences, University of Limpopo, Sovenga 0727, South Africa. tshifhiwa.netshapapame@ul.ac.za

Faculty of Health Sciences, University of Limpopo, Sovenga 0727, South Africa. daniel.goon@ul.ac.za

Langa Jonas 1✉ Emailmahlapsjonas@gmail.com Emailtshifhiwa.netshapapame@ul.ac.za Emaildaniel.goon@ul.ac.za

1 Department of Public health, Faculty of Health Sciences, Health University of Limpopo 0727 Sovenga South Africa

2 Department of Public health, Faculty of Health Sciences University of Limpopo 0727 Sovenga South Africa

3 Faculty of Health Sciences University of Limpopo 0727 Sovenga South

*Correspondence: Langa Jonas, mahlapsjonas@gmail.com

Abstract

Objective

Men in the city of Mbombela, face persistent barriers to healthcare access, driven by socio-cultural norms and systemic challenges. Community Health Workers (CHWs) are well-positioned to understand these barriers yet remain underrepresented in health system planning. This study aimed to explore CHWs’ perceptions of the obstacle’s adult men (18–60 years) encounter when seeking care and to identify feasible strategies to improve engagement within differentiated service delivery models.

Results

We conducted five focus group discussions with 63 CHWs using a semi-structured guide. Thematic analysis identified that men’s health-seeking behaviour is constrained by harmful masculinity norms, HIV-related stigma, financial hardship, and inflexible clinic hours. CHWs reported playing key roles in awareness-raising and linkage to care but noted limited resources and training to effectively engage men. Participants proposed practical solutions, including mobile clinics, workplace-based services, male peer support groups, and gender-sensitive counseling. Findings suggest that integrating CHWs into male-targeted, community-based care models, while addressing both structural and cultural barriers could enhance men’s access and retention in health services.

Key words:

CHWs

men’s health

healthcare access

qualitative research

FGDs

City of Mbombela

1. Introduction

South Africa’s healthcare setting, while strengthened by progressive policy commitments, continues to experience important gaps in adult men’s engagement with primary healthcare services, especially in rural and peri-urban contexts. Research consistently illustrates a distinct pattern of adult men frequently delay seeking care, and when they do engage the health system, it is often at an advanced stage of illness. This underutilization stem from social norms around masculinity, stigma associated with certain illnesses, economic pressures, and persistent distrust toward formal healthcare providers [1]. These factors intertwine to substitute reluctance, resulting in missed opportunities for preventive interventions and delayed treatment[2].

CHWs have emerged as essential facilitators of healthcare access in underserved settings, acting as frontline liaisons due to their community proximity and cultural competence. Their role is regarded as particularly effective in navigating the complex barriers faced by adult men, leveraging both trust and contextually relevant communication [3]. However, even with CHWs positioned positively within their communities, structural and attitudinal barriers still hinder adult men’s access and utilization of healthcare services. For example, men often report discomfort with healthcare settings perceived as female-oriented or unwelcoming, and many experiences logistical challenges, such as conflicting work schedules, transportation hurdles, and negative past interactions with health personnel[4]

Societal attitudes around masculinity further compound these barriers. In many communities, norms that compare health seeking mainly for preventative or non-acute care with weakness, discourage men from proactively engaging with health services [5]. Stigma surrounding illnesses like HIV, tuberculosis, and mental health disorders intensifies this hesitancy, especially where CHWs report that disclosure or open discussion is culturally troubled [6]. Moreover, in some focus group findings from similar contexts, men expressed scepticism about the confidentiality of community-based health workers, fearing breaches of privacy in tight-knit rural areas [7].Despite these obstacles, CHWs have made notable steps in building trust and enhancing men’s participation through tailored interventions. Successful strategies include door-to-door outreach, peer-led educational campaigns, and the integration of health services into male-dominated community spaces, such as sports leagues or workplaces [1]. These approaches help reshape health-seeking behaviors and gradually wear away gendered stereotypes about care utilisation. CHWs also highlight the value of involving male community leaders and role models in their advocacy efforts, finding that these collaborations increase men’s receptivity to health messaging[8]. Persistent systemic barriers, however, highlight the need for broader, multi-sectoral changes. Limited transportation options in rural areas impose physical barriers to service access, while inflexible clinic hours often clash with work commitments, making healthcare less accessible to working-aged men[9]. Additional challenges include a shortage of male CHWs, whose presence could normalize engagement and address gender-specific concerns more effectively [10]. As such, the perspectives of CHWs point toward a double approach on addressing deeply rooted socio-cultural norms while implementing pragmatic structural changes. Recommendations include expanding community-based service delivery, increasing flexibility in health system scheduling, investing in male-targeted health promotion, and sustaining ongoing community dialogues to challenge stigma and gender norms[4]. Ultimately, a participatory and context-sensitive strategy that builds on CHWs’ local knowledge stands as the most promising way to improve adult men’s healthcare access and utilization in the City of Mbombela’s rural and peri-urban in Mpumalanga Province, aiming to inform strategies that enhance service delivery and engagement[3].

2. Methods

Study Design and Setting

This exploratory qualitative study was conducted to capture the perspectives and lived experiences of CHWs regarding men’s access to healthcare services in the City of Mbombela. The study aimed to explore the depth and complexity of barriers affecting men’s health-seeking behaviors and service utilization. A qualitative descriptive approach was employed to provide a contextual understanding of the structural and social factors influencing these behaviors. CHWs were encouraged to share their experiences in their own words, offering rich, nuanced insights into the challenges they encounter in their outreach work. This design enable deeper engagement with participants through attentive observation and listening, ensuring accurate documentation of their perceptions, practices, and counselling experiences. Data were collected through semi-structured focus group discussions (FGDs), and thematic analysis was used to identify key themes and subthemes from the transcripts.

Study Population

The study population comprised CHWs who met the inclusion criteria and were actively providing community-based outreach services for more than a year at healthcare facilities within the City of Mbombela, South Africa.

Sampling Strategy and Sample Size

Purposive sampling was used to recruit CHWs who were available and met the study criteria. This non-probability sampling method was chosen to ensure that participants had relevant experience and awareness aligned with the study objectives. Data saturation was defined as the point at which no new information or themes emerged was reached after five FGDs, each involving 10–12 participants, resulting in a total sample size of 63 CHWs.

Data Collection Procedures

Data collection was conducted on pre-arranged days at selected healthcare facilities. The researcher arrived early to prepare a comfortable and private setting conducive to open dialogue. Rapport was established through informal conversation before the interviews began. The researcher introduced herself, explained the purpose and procedures of the study, and obtained informed consent from participants. Semi-structured interview guides were used to explore both observable and non-observable variables, including CHWs’ knowledge, perceptions, and experiences related to men’s healthcare access and utilization. While the guides provided structure, flexibility was maintained to allow for deeper exploration of emerging themes. Probing questions were used to clarify and expand on responses. Each FGD was conducted in a quiet room within the health facility to ensure privacy. Discussions were facilitated in Siswati and English, depending on participants’ preferences.

Non-verbal cues such as facial expressions, gestures, and tone of voice were noted, and field notes were taken to document group dynamics and contextual factors.

The researcher facilitated the sessions, encouraging participants to speak freely and share their experiences beyond the scope of the interview guide.

Data Analysis

Data were collected, transcribed verbatim, and analyzed using inductive thematic approach, to understand patterns and themes. An independent coder was engaged for professional guidance and validation of codes and themes. Data analysis followed Braun and Clarke's six-step framework, to ensure a logical process. The data was manually coded with relevant features using ATLAS.ti version 23.0.0. software. Codes were studied to ascertain patterns and themes addressing the research question. Themes were refined, defined, and named to capture the data's substance. Findings were written up, combining rich examples to support themes. A complete audit trace was continued, documenting analytical decisions, data collection, and methodological choices, improving dependability.

2. Results

The study findings report that a total of 63 CHWs participated in five FGDs. Thematic analysis was conducted using ATLAS.ti software, version 23.0.0, allowing for the identification of key themes, categories, and subcategories. Results are presented in both tabular format Table 1 on sociodemographic characteristics and Table 2 through direct quotations to enhance credibility and give voice to participants.

3.1. The sociodemographic characteristics

Table 1

Descriptive characteristics of CHWs
Variables	Category	Frequency	Percentages
Age	18–24 years	0	0.00
	25–49 years	34	53.97
	> 50 years	29	46.03
Gender	Female	62	98.41
	Male	1	1.59
Marital Status	Never Married	40	63.49
	Married	23	36.51
Education	Below Matric	38	60.32
	Matric	23	36.51
	Above Matric	2	3.17
Religion	Christian	62	98.41
	Islam	1	1.59

3.2 Key Findings

The CHWs provided insights into the challenges adult men face in accessing healthcare services. They highlighted systemic barriers such as long waiting times, lack of privacy, and limited clinic hours, as well as cultural and societal factors including stigma, masculinity norms, and reliance on traditional healing practices. CHWs emphasized their role in addressing these barriers through awareness, support, and tailored counselling. Strategies proposed included community-based support groups, mobile unit clinics, and direct service delivery to improve accessibility and reduce stigma. Thematic analysis revealed four overarching themes: CHWs’ awareness and support, cultural influences, systemic barriers, and proposed strategies for improvement on summarized in the Table 2.

Table 2

Summary of theme, subthemes, and categories
Theme	Subthemes	Categories
CHWs’ Awareness, Support, and Counselling	• Non-disclosure and reluctance to seek help. • Limited health knowledge	• Fear of judgment • Fear of HIV testing • Embarrassment
Cultural Influences	• Masculinity and stigma • Preference for traditional healing	• Social norms • Traditional remedies
Systemic Barriers	• Long waiting times • Financial constraints • Inconvenient clinic hours	• Slow clinic processes • Transport costs • Fear of being seen
Proposed Strategies	• Enhancing access • Supportive programs • Service delivery improvements	• CHW trust-building • Medication delivery by CHWs • Male-led support groups
,
Theme 1: CHWs’ Awareness, Support, and Counselling
CHWs highlighted that men often avoid healthcare services due to non-disclosure and reluctance to seek help, primarily driven by fear of judgment and embarrassment. Limited health knowledge further compounds this issue, as men lack adequate understanding of HIV prevention and treatment. Participants supported this:
Quotations
“Many men openly admit that they feel deeply embarrassed about visiting clinics because they believe others will judge them harshly. They worry that even the nurses or other patients will assume they are sick or HIV-positive, which makes them avoid healthcare altogether.” – Female CHW, 51
“Men often tell us that the idea of HIV testing terrifies them. They fear what a positive result would mean for their reputation, their relationships, and their sense of masculinity. This fear is so strong that they would rather stay away from clinics completely than face the possibility of knowing their status.” – Female CHW, 30

These quotes illustrate how stigma and fear act as psychological barriers, preventing men from accessing essential health services.

Theme 2: Cultural Influences

Cultural norms around masculinity and stigma significantly influence men’s health-seeking behavior. Many men perceive seeking healthcare as a sign of weakness, and some prefer traditional remedies over clinical treatment, masculinity and stigma. Participants supported this:

“In our communities, many men strongly believe in traditional medicine and see it as a safer, more private option compared to clinics. They say that going to a clinic makes them look weak or dependent, while using herbs or consulting a traditional healer feels more aligned with cultural expectations of strength and resilience.” – Female CHW, 28

This reflects deeply rooted cultural beliefs that hinder engagement with formal healthcare systems.

Theme 3: Systemic Barriers

Structural challenges such as long waiting times, inconvenient clinic hours, and financial constraints were repeatedly mentioned by CHWs as major deterrents such as slow clinic processes, fear of being seen and judged and fear of being seen, judged and transport costs: Participants supported this:

Quotations

“Men complain that clinic visits take too long—sometimes they wait for hours just to be seen. For someone who works or has responsibilities, this feels like wasted time. After one bad experience, they often decide not to return because they feel the system doesn’t respect their time.” – Female CHW, 49

“Men often tell us they avoid clinics because they don’t want anyone in the community to see them there. They fear gossip and judgment, especially in small villages where everyone knows each other. Just being seen at a clinic can lead to rumours about HIV or other illnesses.” – Female CHW, 14

“For men living far from clinics, the cost of transport is a big barrier. Some say they would rather spend that money on food or family needs than on a trip to the clinic. When combined with long waiting times, the whole process feels expensive and inconvenient.” – Female CHW, 38

These systemic issues create practical obstacles that discourage men from consistent healthcare engagement.

Theme 4: Proposed Strategies

CHWs suggested practical interventions to improve men’s access to healthcare, including trust-building, medication delivery by CHWs, and male-led support. Participants supported this:

Quotations

“When I approach men, I make sure to introduce myself properly and explain why I’m there. This simple step helps break the ice and shows that I’m not there to judge them but to support them. Once they understand my role, they open up more easily.” – Female CHW, 20

“Many men tell us they feel more comfortable getting their medication from us rather than going to the clinic. It saves them time and avoids the embarrassment of being seen at a health facility. They trust us because we come to them discreetly and respect their privacy.” – Female CHW, 34

“I believe that support groups led by men themselves can make a big difference. When men see other men talking openly about health issues, it reduces stigma and creates a safe space for sharing. It helps them realize they’re not alone and encourages them to seek care.” – Female CHW, 40

3. Discussion

Our finding demonstrated that CHWs strongly highlighted systemic obstacles such as long waiting times, inadequate privacy, and inflexible clinic hours as central barriers for men. These findings align with multiple studies from various African contexts, where health system inefficiencies and structural constraints have been shown to particularly hinder men’s engagement with healthcare [9]. Men are also affected by economic pressures and logistical burdens, with transport costs and loss of work time acting as powerful deterrents to attending clinics [5]. This is especially true in rural and peri-urban settings, where facilities may be distant and public transport options limited.

Concerns over privacy and confidentiality also emerged, as men reported reluctance to be seen attending clinics for fear of community judgment or breaches of confidentiality. Such findings are consistent with broader literature, where confidentiality concerns are a recognized barrier to healthcare utilization among men, fuelling doubts and avoidance behaviors[7, 11].CHWs repeatedly referenced deeply entrenched masculinity norms that discourage men from acknowledging vulnerability, seeking preventive care, or disclosing health problems. In sub-Saharan Africa, health-seeking is often constructed as a feminine activity, and men may perceive clinic attendance as incompatible with ideals of strength and patience[5, 12]. The literature consistently demonstrates that masculine identity preservation contributes to late presentation and underutilization of healthcare among men [13].

Stigma especially relating to HIV, tuberculosis, and sexual health was frequently cited as a critical barrier. Men’s discretion to engage with clinics often comes from fear of being labelled, both within their peer groups and at the broader community level[14, 15]. Furthermore, CHWs noted the appeal of traditional healing practices among men, whom they observed to prefer traditional remedies over biomedical interventions in some cases[16].Despite these challenges, CHWs play a vital role as mediator, using personal introduction and clear communication to gain men’s trust and facilitate care. Their proximity and insider status within communities allow them to tailor services and provide culturally sensitive counselling, which literature identifies as essential for overcoming gendered barriers and increasing men’s healthcare engagement[3]. However, the feminization of the CHW workforce may limit their impact with male clients, underlining a need for more gender-balanced staffing and specialized training in male-targeted outreach[10].

Strategies proposed by CHWs including community mobile unit clinics, direct home medication delivery, and peer-led support group that reflect evidence-based recommendations in the literature. Community-based interventions, particularly those leveraging trusted male peers or integrating care into male-dominated communal spaces, have proven successful in shifting norms and addressing access barriers among men[8, 17]. Peer-led and male-support groups, highlighted in both qualitative research and intervention trials, build community around health while eroding stigma and boosting uptake of testing and treatment [17, 18].

Strengths and limitations

The study offers valuable awareness into CHWs perspectives on the barriers and challenges men encounter when seeking healthcare services. A key strength lies in its qualitative design, which enables an in-depth understanding of the underlying factors influencing men’s health-seeking behaviors. Furthermore, the research is context-specific, reflecting the realities of a particular local municipality, which makes the findings highly relevant for designing interventions tailored to the community’s needs.

However, the study also presents notable limitations. The small sample size may not adequately represent the broader population of CHWs in the City of Mbombela, limiting the generalizability of the findings to other settings. Cultural, social, and economic characteristics unique to the study area further restrict the applicability of results to different populations. Additionally, reliance on self-reported data introduces potential biases, including social desirability effects. The use of a single data collection method, focus group discussion may also limit the comprehensiveness of the findings, as incorporating multiple methods could provide a more holistic understanding of the topic.

4. Conclusion

It is evident that the multifaceted nature of barriers to healthcare access among adult men, encompassing cultural beliefs, systemic inefficiencies, and social stigma. CHWs identified practical strategies such as mobile clinics, direct medication delivery, and male-led support groups as promising interventions. Empowering CHWs through training and resources can enhance their capacity to engage men effectively. Future interventions should prioritize integrating CHWs into broader health system planning to ensure sustainable and inclusive healthcare access for all.

Abbreviations:

CHWs Community Health Workers.

FGDs Focus Group Discussions

SAMRC South African Medical Research Council

Acknowledgement

The Mpumalanga Health Department and Research Unit, University of Limpopo. The participants for participating in the study; the Mpumalanga Department of Health for granting permission to conduct the study in selected health facilities in the City of Mbombela; and the research assistants for their assistance in data collection.

Author Contribution

JML contributed to conceptualization, methodology, data curation, and writing of the original draft. TSN was responsible for formal analysis, writing review and editing, and supervision. DTG contributed to investigation, validation, and writing review, editing and Co-supervision. All authors confirm that all stages of the research and manuscript preparation were conducted collaboratively and that they fully support the results.

Funding:

The work reported herein was made possible through funding by the South African Medical Research Council through its Division of Research Capacity Development. The content hereof is the sole responsibility of the authors and does not necessarily represent the official views of the SAMRC.

Data Availability

The datasets used and analysed during the current study available from the corresponding author upon reasonable request.

Declarations

Conflicts of Interest:

The authors declare no conflicts of interest.

Institutional Review Board Statement: The study was conducted in accordance with the Declaration of Helsinki and Ethical approval was obtained from University of Limpopo Ethics Committee with the code (TREC/110/2024:PG) on 20 May 2024.

Informed Consent

Statement: Informed consent was obtained from all the participants involved in the study.

Electronic Supplementary Material

Below is the link to the electronic supplementary material

Supplementary Material 1

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Tables for Manuscript Submission – Community Health Workers ‘s perspectives on healthcare accessibility and utilisation by adult men in the City of Mbombela, Mpumalanga Province, South Africa.

Table 1. Descriptive characteristics of CHWs

Variables	Category	Frequency	Percentages
Age	18–24 years	0	0.00
	25–49 years	34	53.97
	> 50 years	29	46.03
Gender	Female	62	98.41
	Male	1	1.59
Marital Status	Never Married	40	63.49
	Married	23	36.51
Education	Below Matric	38	60.32
	Matric	23	36.51
	Above Matric	2	3.17
Religion	Christian	62	98.41
	Islam	1	1.59

Table 2: Summary of theme, subthemes, and categories

Theme	Subthemes	Categories
CHWs’ Awareness, Support, and Counselling	• Non-disclosure and reluctance to seek help. • Limited health knowledge	• Fear of judgment • Fear of HIV testing • Embarrassment
Cultural Influences	• Masculinity and stigma • Preference for traditional healing	• Social norms • Traditional remedies
Systemic Barriers	• Long waiting times • Financial constraints • Inconvenient clinic hours	• Slow clinic processes • Transport costs • Fear of being seen
Proposed Strategies	• Enhancing access • Supportive programs • Service delivery improvements	• CHW trust-building • Medication delivery by CHWs • Male-led support groups

Yes