Background Gender is a social determinant of health. Gender power dynamics can impact women’s and children’s health outcomes. The Demographic and Health Survey (2015) showed that 68% of women participated in decisions about their own healthcare in Malawi, but there is a lack of information on the socio-determinants and gender attitudes associated with primary health decision-making. This study aims to examine these factors during the male clinic days (health education activities) in four healthcare facilities in Southern Malawi.

Methods We included men who participated in the male clinic days between August and November 2022. The main outcome of interest was the extent of women’s participation in their own healthcare. We designed a questionnaire that included the Gender-equitable Men Scale (GEM), which measures attitudes toward gender equality on a scale of 0 to 1. In addition, we collected socio-demographic, relationship, and family-related variables. Univariable and multivariable analyses revealed the association between the main and the other variables.

Results 422 men were included in this study. The average GEM score was 0.53 (0.37–0.67; 95% CI: 0.004). Among the participants, 64.2% (271/422) reported that their female partners did not have the final say in healthcare decisions. When female partners assumed primary decision-making roles (35.8%, 151/422), men reported higher levels of gender-equitable attitudes compared to cases where men were the primary decision-makers (0.57 vs 0.47, p=0.004). Factors such as higher education level, location, formal employment, and male village chiefs emerged as the main socio-determinants associated with women’s decision-making role in health.

Conclusion This study emphasizes the significance of socio-economic factors and gender-equitable attitudes in healthcare decision-making. This suggests the need for targeted interventions involving both men and women in discussions about healthcare decisions.