South Africa: Men Are Slower to Get Covid-19 Vaccines in South Africa - Lessons From HIV Research

Ongoing vaccinations at the Athlone Stadium vaccination site in Cape Town.
analysis

Men over the age of 35 in South Africa are not taking up the COVID-19 vaccination at the same rate as women. Only 40% of those who had been vaccinated by 13 August 2021 were men, according to a Health Department report.

This is an unusual pattern. In countries where vaccine uptake is recorded by sex, there is a slight trend towards men being more likely to get vaccinated than women.

So, why are South African men not getting vaccinated for COVID-19? There is currently no research on the specific question. Nevertheless it's possible to gain some insights by looking at research into men's attitudes to HIV testing and engaging with the health system.

There are, of course, significant differences between HIV testing and treatment and COVID-19. But research around HIV might point to some potential reasons why men may not be accessing COVID-19 vaccinations.

Research on men's access to HIV testing and treatment has shown men are less likely to test for HIV, and once they know they are HIV-positive, less likely to access treatment, and achieve viral suppression. A lot of qualitative and quantitative research has explored why this may be the case.

What emerges are that reasons for men's limited access, range from ideas about masculinity and health, ideas about the health system as a place for women, and ability to avoid the risk of infection.

Understanding why men may be less likely to get a COVID-19 vaccine is crucial for designing effective vaccination campaigns.

Vaccine hesitancy

Might one explanation be that there are higher levels of vaccine hesitancy among men? Reasons for not wanting to be vaccinated range from a lack of trust in vaccine safety to personal religious beliefs.

But there is no evidence that vaccine hesitancy is more common among men than among women in South Africa. A recent National Income Dynamics Survey showed that men and women were equally willing to get vaccinated.

And another recent survey showed that men slightly more willing to get vaccinated than women (among those not yet vaccinated).

So why the pattern when it comes to the COVID-19 vaccine?

Much of the research on why men may not seek HIV testing and treatment has focused on men's masculinity. Masculinity refers to the norms around "what it means to be a man" in a given time and space. These norms are shaped by economic, social and political forces, and they influence men's health behaviours, including vaccination.

Research has suggested that men feel testing and treatment for HIV is a threat to their masculinity. They think it will change how others will see them, as well as how they will see themselves. Men are also concerned about whether treatment will affect things which are important to them, including drinking alcohol, having sex, and fathering a child.

Other research has highlighted how men feel about ill health in general. It is a sign of vulnerability, and often masculinity means not showing vulnerability.

All these factors could be behind men's hesitancy to get the COVID-19 vaccine.

Another barrier to HIV-testing and treatment for men is that they see the South African health system as a space for women. They feel it does not accommodate the daily lives of men. Men have described clinics as spaces that are really for women to get contraception and healthcare for children.

Clinics, through limited opening hours, overworked staff and long queues, sometimes make it hard to access healthcare - especially for people who have to go to work.

It may be that men would like to get vaccinated, but are put off by not being familiar with health systems, and by long queues.

Another possible reason that men have been less likely to seek a COVID-19 vaccination is a lower sense of risk. Those in frontline jobs are overwhelmingly women and they may seek a vaccination because they know they are more likely to be exposed to infection. In South Africa only 9.1% of nurses are male, women dominate the teaching profession, and frontline workers such as cashiers are more likely to be women.

There is evidence that people who feel they cannot avoid getting COVID-19 are more vaccine supportive.

Next steps

Increasing the number of people vaccinated in South Africa is critical if the country is to achieve any form of normality. Many of the strategies to increase vaccination, including longer hours at vaccination centres, opening over weekends and locating centres near communities, are slowly happening.

But, if men are refusing vaccines because of their ideas about masculinity and health, then vaccine uptake campaigns need to emphasise how a vaccination protects an individual's health and their family's health. And that vaccinations only have short-term, minor side effects.

Lessons from HIV research also suggest that the COVID-19 vaccination drive should focus on more decentralising vaccine locations, reducing queues and creating supportive spaces.

Andrew Gibbs, Senior specialist scientist: Gender and Health Research Unit, Medical Research Council, South African Medical Research Council

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