The architecture of adherence: A gender–relational analysis of men's tuberculosis treatment journeys in Eastern Cape, South Africa

Background Men experience disproportionate delays in tuberculosis (TB) diagnosis and challenges in adherence to treatment in part due to gender norms and social perceptions that illness and help-seeking by men are forms of weakness and vulnerability. This study explored how men with TB navigate treatment adherence within a gender-relational context, with particular attention to how masculinity is negotiated through caregiving relationships. Methods A secondary qualitative analysis was conducted using de-identified, semi-structured interviews with 30 men who were undergoing or had recently completed TB treatment in Eastern Cape, South Africa. Guided by Courtenay's Theory of Gender and Health, a reflexive thematic analysis was conducted. Analysis proceeded through iterative phases of familiarization, codebook development, theory-informed categorization, thematic development and refinement, and conceptual synthesis. Results Four interrelated themes were identified: Managing Illness Visibility and Masculine Self-Presentation ; Negotiating Help-Seeking Through Trusted Relationships ; Relational Support for Sustaining Treatment Engagement ; and R esponsibility, Protection, and the Moral Logic of Adherence . Themes were organized into a theory-informed gender–relational process illustrating how masculinity may be negotiated in the context of illness, using TB as the empirical setting. Conclusion Men's TB treatment adherence may be best understood as a gender-relational process, embedded within a social and caregiving context. Recognizing relational conditions (i.e., women's caregiving contributions) that support men's engagement in care may inform more gender-responsive and relationally attuned approaches to supporting men when they are ill.