Men and sexual and reproductive healthcare in the Nordic countries: a scoping review

Context Men generally seek healthcare less often than women and, other than traditional gender norms, less is known about the explanation. The aim was to identify knowledge gaps and factors influencing men regarding sexual and reproductive healthcare (SRHC) in the Nordic countries. Methods We searched PubMed and SveMed+ for peer-reviewed articles published between January 2010 and May 2020. The analyses identified factors influencing men’s experiences of and access to SRHC. Results The majority of the 68 articles included focused on pregnancy, birth, infertility and sexually transmitted infections including HIV. During pregnancy and childbirth, men were treated as accompanying partners rather than individuals with their own needs. The knowledge and attitudes of healthcare providers were crucial for their ability to provide SRHC and for the experiences of men. Organisational obstacles, such as women-centred SRHC and no assigned healthcare profession for men’s sexual and reproductive health issues, hindered men’s access to SRHC. Lastly, the literature rarely discussed the impact of health policies on men’s access to SRHC. Conclusions The literature lacked the perspectives of specific groups of men such as migrants, men who have sex with men and transmen, as well as the experiences of men in SRHC related to sexual function, contraceptive use and gender-based violence. These knowledge gaps, taken together with the lack of a clear entry point for men into SRHC, indicate the necessity of an improved health and medical education of healthcare providers, as well as of health system interventions.

The paper finds up to 68 studies worthy of inclusion. 61/68 address men's experiences and so this review is well set up to synthesize these studies and make a very positive contribution.
However, the authors set the aim as 'to identify knowledge gaps and factors influencing men regarding SRHC in the Nordic countries' Hence the results move away from examining men's experiences to also examining the predictors of men's use.
While the results on predictors of/socio-demographic factors associated with men's use of HIV testing is interesting -it is not clear that the body of the research allows reliable conclusions on this. The body of work is most clearly set up to report men's experiences.
Similarly when talking about predictors of prostate cancer care, the authors use the word 'studies' but report only one study: 'Studies showed no associations between age and the overall satisfaction with cancer care, while a higher level of education was associated with lower overall satisfaction with prostate cancer care.65 Furthermore, the literature indicated that manual workers were less likely to receive a bone scan and radical prostatectomy, and they had higher overall and cancer-specific mortalities as compared to non-manual employees.66' The four-part framework from Kilbounre et al is useful to report the experiences and the factors influencing experiences. So in summary overall, I would like to suggest to authors that they consider limitations of their conclusions relating to sociodemographic predictors -and the strength of their review in synthesizing literature on men's experiences in Nordic countries in relation to SRHC.
A second more minor recommendation is to reconsider the examples of sex differences given in the introduction. Women also underreport sexual dysfunction. It is also not universally the case that women test more often for STIs than men. The authors do not make the claim that it is universally the case but the examples imply when that context is not given. Could the case be made for the importance of looking at men's sexual and reproductive health alongside that of women -and especially perhaps that men's reproductive needs are neglected?

Introduction
Page 4, Lines 15-16. This is an interesting point. However, there is a lot of international literature focused on MSM's SRHC use/experiences accessing SRHC and their use/experiences often vary greatly from cisgender men's. For greater clarity, it would be beneficial to provide a brief explanation/example of MSM's SRHC's more frequent use.
Page 4, line 27. 'This mirrors the lack of response of the health system to men's needs . . .' This is a bit unclear as to what 'this mirrors' is in reference to. Would recommend rephrasing for greater clarity -While MSM are mentioned early into the introduction section, they are only mentioned once, making the article appear to predominantly focus on cisgender, heterosexual men. If, this is in fact the focus, this should be explicitly stated in the introduction. Without this statement, the reader will expect to see discussion about MSM and their SRHC experiences in Nordic countries.

Methods
1) The paper's title points to the use of a scoping review to locate selected articles. However, not all parts of the scoping review's methodological framework were noted (e.g. research question), no explanation as to why only 2 databases used and why only peerreviewed empirical studies were assessed and a grey literature search avoided. This section would benefit from briefly responding to the abovementioned items. Further, scoping reviews have the option of a consultation exercise where one can go to stakeholders to seek additional feedback about the review findings. If space permits, it would be good to state if this did or did not happen.
2) It is also unclear if the eligibility criteria included all articles irrespective of the language it was written in. For greater clarity, it should be written here and not just in the results section.

Data extraction and synthesis
Page 5, line 28. There appears to be a grammatical error '. . . and the result parts . . .' would recommend revising.
-It would also be beneficial to explain why the WHO's framework was used here vs another.

Results
This section provides a good overview of the selected studies. As Nordic countries have had increases in their immigrant populations in recent years, with these populations often experiencing healthcare delivery and access in ways that often differ from those born in these countries, it would be beneficial to briefly discuss if any of the selected papers specifically focus on these populations.

Theoretical framework for Analysis
-it's unclear why Kilbourne's framework was used and adapted here. Would benefit from briefly discussing its use and why.
Page 7, line 16. 'The literature described on how factors . . .". Would recommend rephrasing section for greater clarity Page 7, lines 30-34. Would recommend not using 'Additionally' to start to subsequent sentence. Would recommend modifying this for greater readability.

Prevention and Control of HIV and other STIs
Page 8, line 30-31. It's unclear as to what 'it' refers to at the end of this sentence. Would recommend explicitly stating what 'it' is for greater clarity.
-It's unclear what age group is being referred to here when the term 'school boys' is being used. Would recommend being explicit by what age group is being referred to here.
-was there any variations in the literature for MSM vs heterosexual, cisgender men? If yes it would greatly enrich this section if this were briefly stated.

BOX 1. The sociodemographic factors of users in relation to HIV testing and treatment
-it's unclear how knowledge and risk perception are considered sociodemographic factors in this context as they're not sociological or demographic characteristics of a group/(s). If this box remains, would recommend rephrasing this as key characteristics of users in relation to HIV testing and treatment to avoid any confusions.

BOX 2. The characteristics of satisfying information and communication-men's views
Page 11. Lines 11-12. It's unclear what 'exaggerations', 'exaggerated information' means, would recommend rephrasing/explaining for greater clarity.

Discussion
-This section provides a robust critique of the current state of SRHC literature focused on men. While it is appreciated that the authors critique the lack of particular groups discussed in the literature (e.g., national minorities, MSM, transgender men) it would greatly enhance this section if a sentence or so was added to explain why this literature gap is significant as well as the seeming focus of the literature on men's reproductive-fertility vs infertility compared to other aspects of sexual health (e.g., satisfying sex life, the choice to reproduce).

Strengths and limitations of the study
Page 16, lines 22-23. See point 1 in methods section feedback. Page 16, line 29. It's stated that a relevant ecological lens was used but it was not clearly stated/implied in earlier sections of this article. If it was, it needs to be more explicit for the reader/named for greater clarity.

Conclusion
-Conclusion provides a good summary of the review and potential future next steps. Would also recommend further emphasizing the need for additional research that moves beyond a cis-gender, heteronormative view of SRHC in Nordic countries.

Reviewer: 1 Ms. Maria Lohan, Queens University of Belfast
This is an original rigorous and significant scoping review which will be a very valuable addition to the literature.
My main recommendation to the authors would be to consider a tension the in the aim of the paper as follows and subsequently some of the framing of the results: The paper makes the case that 'men's experiences of SRHC' are not adequately Thank you for accepting to review our paper. Your time and efforts are much appreciated.
We agree with you that our scoping review is best suited to answer the question about men's experiences in SRHC more than identifying the factors influencing men's use of SRHC which is also reflected by our search terms. reviewed in the literature.
The paper finds up to 68 studies worthy of inclusion. 61/68 address men's experiences and so this review is well set up to synthesize these studies and make a very positive contribution.
However, the authors set the aim as 'to identify knowledge gaps and factors influencing men regarding SRHC in the Nordic countries' Hence the results move away from examining men's experiences to also examining the predictors of men's use.
While the results on predictors of/sociodemographic factors associated with men's use of HIV testing is interesting -it is not clear that the body of the research allows reliable conclusions on this. The body of work is most clearly set up to report men's experiences.
Similarly when talking about predictors of prostate cancer care, the authors use the word 'studies' but report only one study: 'Studies showed no associations between age and the overall satisfaction with cancer care, while a higher level of education was associated with lower overall satisfaction with prostate cancer care.65 Furthermore, the literature indicated that manual workers were less likely to receive a bone scan and radical prostatectomy, and they had higher overall and cancer-specific mortalities as compared to non-manual employees.66' The four-part framework from Kilbounre et al is useful to report the experiences and the factors influencing experiences.
So in summary overall, I would like to suggest to authors that they consider limitations of their conclusions relating to sociodemographic predictors -and the strength of their review in synthesizing literature on men's experiences in Nordic countries in relation to SRHC.
Access to healthcare is however a multi-stage process that includes perceiving the need to seek healthcare, seeking and visiting healthcare, and the outcome of healthcare. We think that each step of this process influence men experiences in healthcare. Therefore, we chose to also synthesize the literature we found in relation to the utilization of healthcare and the outcome of healthcare even though -as you noted-no conclusion is made from this body of literature, As a response to your valuable comment and to make the readers more aware about this issue, we have now addressed this in the strengths and limitation of the study: "However, the design of our study and our search terms are best suited to draw conclusions about men's experiences of SRHC rather than the determinants of SRHC utilization even though we reported both in this study."(Lines 487 to 489) A second more minor recommendation is to reconsider the examples of sex differences given in the introduction. Women also underreport sexual dysfunction. It is also not universally the case that women test more often for STIs than men. The authors do not make the claim that it is Thanks for pointing this out. Indeed, the examples given might implicitly indicate that women have no SRH problems, therefore adding the following clarification was necessary.
"Addressing men's sexual and reproductive health (SRH) needs alongside that of women's is universally the case but the examples imply when that context is not given. Could the case be made for the importance of looking at men's sexual and reproductive health alongside that of womenand especially perhaps that men's reproductive needs are neglected? essential, however men´s SRH is neglected." (Lines 58,59) Reviewer: 2 Dr. Nakia Lee-Foon, University of Toronto This paper provides an overview of an important aspect of men's SRHC that is often overlooked in the literature. It highlights significant service delivery gaps and points to areas where men's SRHC can be improved. Kindly see attached for my feedback, which I hope, will further enhance this important scoping review.
We would like to appreciate your time and efforts spent on this review. We have tried to respond to your important comments as follows:

Abstract
Page 2, Line 31-it is unclear as to what 'no assigned profession' is referring to. Would recommend revising and providing an explicit example of a profession that is being referred to here.
Thanks for pointing this out. A clarification has been added as follows: "no assigned healthcare profession for men's SRH issues" (Lines 35,36) Page 2, line 37-It is unclear what exactly the 'identified knowledge gap' is. Would recommend stating this for greater clarity.
Thanks for this comment. We have now added which knowledge gap is identified as follows: It would also be interesting to also note that this study does not find many in depth, articles on differences in men's experiences based on their gender identity (cisgender and transgender men), immigration status as other, international studies indicate variations in experiences based on these We agree with you that the study does not find many in-depth studies about the experiences of various men's groups.
We consider this, however, as a limitation of the literature rather than a limitation of our study. We tried to be inclusive to all men's experiences and and other social locations.
did not restrict our search term to cis-men. Therefore we chose not to mention this limitation here but in the discussion. We also included a statement in the strengths and limitations section as follows: "Due to the restricted time of the project and the limited funding we included only peer-reviewed literature in two databases, we did not register a review protocol prior to the study and no stakeholder consultation was conducted after performing this scoping review."(Lines 492 to 495) 2) It is also unclear if the eligibility criteria included all articles irrespective of the language it was written in. For greater clarity, it should be This have now been added to the method section: written here and not just in the results section. "A structured search of the literature was conducted using two databases, PubMed and SveMed+ (a Scandinavian database) without restriction of language."(Lines 99, 100)

Data extraction and synthesis
Page 5, line 28. There appears to be a grammatical error '. . . and the result parts . . .' would recommend revising.
Thanks for pointing this error out. This have now been corrected.
-It would also be beneficial to explain why the WHO's framework was used here vs another.
A clarification has been added to the text as follows: "This framework was used because it demonstrates the interlinked nature between sexual health and reproductive health, yet clearly distinguish topics for intervention and research in both sexual health and reproductive health"(Line 140 to 142)

Results
This section provides a good overview of the selected studies. As Nordic countries have had increases in their immigrant populations in recent years, with these populations often experiencing healthcare delivery and access in ways that often differ from those born in these countries, it would be beneficial to briefly discuss if any of the selected papers specifically focus on these populations.
We found only two papers that focus on foreignborn MSM and their experiences with HIV testing. The lack of focus on this group is mentioned in the discussion as follows: " have now been changed.

Conclusion
-Conclusion provides a good summary of the review and potential future next steps. Would also recommend further emphasizing the need for additional research that moves beyond a cis gender, heteronormative view of SRHC in Nordic countries.
Thanks for this recommendation. We have now added this to the conclusion as follows: "Further research should examine the influence of policies and the healthcare organization on men's access and experiences in SRHC and explore the identified knowledge gaps of men's experiences in SRHC related to specific groups of men such as migrants, MSM and transmen and to specific SRH subject areas such as sexual