Adapting health systems to men’s realities: An intersectional exploration of men’s barriers to TB care in Nigeria’s peri-urban communities

Although men bear the brunt of TB morbidity and mortality globally and in Nigeria, understanding of men’s barriers to TB care is limited, including in peri-urban settlements where the risk of TB exposure is high. This research explored how masculinities combine with layers of disadvantage among men in peri-urban communities to limit their access to TB services. We conducted 20 in-depth interviews among 12 men and 8 women with presumptive or confirmed TB, 3 focus group discussions among 24 men in their workplaces, and interviews with 12 key informants exploring experiences of TB symptoms and care seeking. Audio recordings were transcribed and analysed using a reflexive thematic approach. Findings suggest many men in peri-urban settlements could not afford to show TB symptoms due to strict masculine gender expectations and norms (Theme 1), while official TB information was not tailored to reach them (Theme 2). When developing symptoms presumptive of TB, men negotiated the least disruptive way to wellbeing (Theme 3). After TB diagnosis, female healthcare workers used strategies such as baiting and negotiating to engage and retain men in care (Theme 4). In conclusion, health systems need to address the compounded barriers facing different groups of men in high-burden peri-urban settlements in Nigeria highlighted by this study and leverage existing community resources to create scalable adaptations to care that make services more responsive to their realities. • Men bear the burden of TB, late TB diagnosis and missed care globally and in Nigeria • Gendered social, economic pressure in peri-urban areas make men suppress TB symptoms • TB information fails to reach men and community resources remain untapped • Men use informal health providers to minimize life and economic disruptions • Female healthcare workers adapt services to engage and retain men in TB care