• Tuberculosis
• Health systems

Globally and in Africa, tuberculosis (TB) affects more men than women, as masculine norms, behaviours, and practices can increase likelihood of exposure to TB while undermining engagement in TB care.1 The WHO Africa region remains particularly affected, accounting for nearly a quarter (23%) of the estimated 10.6 million people who developed TB and close to a third (31%) of the 1.6 million people who died from the disease in 2021,2 despite being home to only 15% of the world’s population.3 Twenty-five African countries are considered high burden countries for TB, HIV-associated TB, and drug-resistant TB.2 TB affects close to 6 million men globally and 1.3 million men in the WHO Africa region every year,2 undermining their physical health, mental well-being, and capacity to contribute to their families and communities.

Globally and in Africa, tuberculosis (TB) affects more men than women, as masculine norms, behaviours, and practices can increase likelihood of exposure to TB while undermining engagement in TB care.1 The WHO Africa region remains particularly affected, accounting for nearly a quarter (23%) of the estimated 10.6 million people who developed TB and close to a third (31%) of the 1.6 million people who died from the disease in 2021,2 despite being home to only 15% of the world’s population.3 Twenty-five African countries are considered high burden countries for TB, HIV-associated TB, and drug-resistant TB.2 TB affects close to 6 million men globally and 1.3 million men in the WHO Africa region every year,2 undermining their physical health, mental well-being, and capacity to contribute to their families and communities.

On this International Men’s Day 2023, celebrated on 19 November to draw attention to men’s health and well-being among others,4 we contribute to discussions on how to respond most effectively to men’s TB epidemiological and social scenarios.1 5 We reflect on what lessons can be drawn from the existing and growing body of knowledge that may be characterised as African-centred gender and masculinities theories, that can build towards person-centred, gender-responsive approaches to TB which address the underlying causes of socially constructed gendered barriers to health among men and facilitate their access to TB prevention and care.

Sex and gender differences in disease patterns result from biological differences and from socially constructed gender norms, roles, and relations that drive gendered differences in disease exposure, illness experience and meanings, health behaviours, and access to healthcare as well as gender-biased health systems, research, and institutions.6 Gender dynamics in the epidemiology of TB seem to fall outside common gender narratives, which are largely conflated to focus on women’s disadvantages. Yet the higher burden of TB among men is driven by a combination of biological, behavioural, social, and structural vulnerability to TB and systemic barriers to accessing healthcare1 that are grounded in gender norms, roles, and relations. These dynamics show how structures and systems underpinning gender inequality not only disadvantage girls and women but can also be harmful to boys, men, and people of non-binary gender identities.6 Yet despite clear disparities, gender-responsive care for TB remains elusive. TB programmes have relied heavily on standardised, biomedical approaches to disease control7 with limited consideration of the different needs of men, women, and people of non-binary gender identities.8

Masculinities are referred to as social practices or cultural representations associated with being a man in a given context and time, recognising the multiplicity of masculinities.9 Masculinities studies is an emerging field on the African continent, building on a longer tradition of gender studies and feminist movements.10 African theories on masculinities are concerned with notions of men as gendered beings and products of their social environments being shaped by the structural legacies of colonialism and imperialism on the one hand and indigenous African philosophies and ideologies on the other hand.9 11 Masculinities theories grounded in African contexts tend to emphasise the collegiality and interdependence of women and men challenging binary gender concepts that view men and women as conflicting opposites. Such notions resonate with African feminist theories which critique notions of polarised gender power relations based on supposed natural differences, claiming male superiority and female inferiority and instead recognise the greater variety of social roles and more complex power relations within African extended families and communities which have traditionally been determined by an interplay of lineage, gender, and seniority.12 Moreover, masculinity or what makes a man in an African community cannot be separated from, but intersects with, other social hierarchies likesuch as class, ethnicity, religion, sexuality, and seniority among others.13 Alongside the conceptualisation of masculinities as socially constructed, contestable, and changeable is the idea of acknowledging masculine vulnerability.14 Constant pressure to live up to masculine ideals, characterised by bodily strength, social control, and wealth among others, can lead men into side-lining their health, including when their circumstances and/or environment are unconducive.15

These theoretical underpinnings have practical implications for a gender-responsive approach to TB. First, understanding the health and healthcare-related barriers and disadvantages faced by men recognises that gender norms affecting women and gender norms affecting men are related rather than inherently conflicting. Second, viewing different genders as relational and/or complementary, rather than essential opposites, promotes a focus on both common and sex-specific challenges as well as the structural factors underpinning the TB epidemic. Third, considering structural and intersectional dimensions of masculinities allows opportunities to overcome monolithic generalisations of men as a group, and thus considering differences among men. Consequently, responses to TB in African contexts may not focus exclusively on people of any one gender. TB programmes need to consider the challenges faced by different groups of men, women, and people of non-binary gender identities and their needs in a given situation. The design and implementation of TB interventions must facilitate conditions that enhance, among people of all genders, the ability to thrive in positive dimensions in their roles, and in this way, also address the socially constructed gendered barriers to health.

Moreover, gender and social empowerment are collective processes. Strategies for engaging men in other fields16 are relevant to the TB response. For instance, the involvement of women and men in programmes to prevent violence against women has been shown to be key for facilitating and sustaining social norm change around gender.17 Family-focused HIV care models have been proven to increase uptake of HIV testing and anti-retroviral treatment among men and their involvement in care of the family.18 HIV programmes designed and led by and for communities and key populations have achieved beneficial prevention and treatment outcomes.19 Acknowledging the need for more theory-informed interventions,16 the emerging body of African-centred theories may help address some common limitations of male engagement strategies such as overemphasis on harmful masculinities20 and focus on individual agency or behaviour rather than structural issues,21 including in the design and strengthening of policies, programmes, and health systems.22

The global TB community is vocal and united on the importance of equitable, gender-responsive, rights-based, and stigma-free TB prevention and care.23 We argue that theoretical guidance on gender from Africa can facilitate inclusive pathways to health for people with TB across genders. Arguments presented here suggest gender-responsive care for TB should move beyond a focus on either men or women to recognise socially produced vulnerabilities of all genders so that TB responses address the needs of everyone in the community. We call on global and national TB programmes to be cognisant of the historic and cultural context of communities, offer differentiated care models accommodating the needs of populations affected by TB, and promote inclusive collaboration between men, women, and people of non-binary gender identities. These steps are essential to facilitate and sustain behavioural, social, and structural changes for an equitable and gender-responsive approach to end TB.