Worsening of the overdose crisis in the USA has been linked to the continuing proliferation of non-pharmaceutical fentanyl (NPF). The recent wave of NPF spread in the USA has been fueled by an increased presence of counterfeit pills that contain NPF. This qualitative study aims to characterize the motivation and practices of counterfeit NPF pill initiation and use among individuals using illicit opioids in Arizona.Between October 2020 and May 2021, semi-structured interviews were conducted with 22 individuals meeting the following eligibility criteria: (1) 18 years or older; (2) residence in Arizona; and (3) use of illicit opioids in the past 30 days and/or opioid use disorder treatment in the past 12 months. Participants were recruited through referrals by a harm reduction organization, craigslist ads, and referrals by other participants. Interviews were conducted virtually via Zoom. Qualitative interviews were transcribed and analyzed thematically using NVivo.Out of 22 participants, 64% were male, and 45% were ethnic minorities. Age ranged between 25 and 51 years old. Participants noted significant recent increases in the availability of counterfeit NPF pills  that were most commonly used by smoking. The majority indicated first trying NPF pills in the past year, and the first use often occurred in situations of reduced access to heroin or pharmaceutical opioids. Participant decisions to switch over to more frequent NPF pill use or to maintain some levels of heroin use were shaped by local drug availability trends and personal experiences with NPF effects. They were also influenced by conflicting views of social acceptability of pharmaceutical-like drugs, perceived harms of NPF in terms of overdose risks and increased difficulty of quitting, and perceived benefits of switching to the non-injection route of opioid administration .Our findings highlight the need for the implementation of novel policy, treatment, and harm reduction approaches to address the growing unpredictability of drug supply and NPF pill-specific risks, attitudes, and behaviors. Provisional data from the US Centers for Disease Control and Prevention (CDC) indicate that there were over 100,000 drug overdose deaths in the USA during the 12 months ending in April 2021, almost a 30% increase compared to the year before . The conThe new wave of NPF spread is linked to the increased presence of counterfeit pills , 9. CounIncreases in counterfeit pill presence have been especially dramatic in Arizona. Located on important drug trafficking routes, Arizona is considered to be the “ground zero” of the evolving NPF epidemic . AccordiDespite the substantial uptick in the opioid overdose mortality in the Southwest, most prior studies on the NPF-related experiences among people who use illicit opioids (PWUO) were conducted in the eastern or midwestern states , 17–25. Individuals who use illicit opioids were recruited via social media posts, craigslist ads, referrals by a local harm reduction organization, and from other participants. To qualify, individuals had to meet the following criteria: (1) at least 18 years of age; (2) currently residing in Arizona; and (3) use of illicit opioids in the past 30 days and/or participation in substance use treatment for OUD in the past 12 months. Phone-based eligibility assessment was conducted first before scheduling an interview. Due to COVID-19 restrictions, all interviews were conducted using the Zoom platform. The study was approved by the Arizona State University Institutional Review Board.n = 2), were in long-term recovery from opioid use (n = 1), or did not reside in Arizona (n = 3). Out of a total number of 30 who were scheduled for an interview, seven did not keep their interview appointments. One respondent who passed phone-based eligibility and completed the interview was removed from the final sample because of inconsistencies that were identified in the interview responses. There was a final sample of 22 completed interviews between December 2020 and May 2021.A total of 36 individuals contacted the research team and participated in a phone-based eligibility assessment. Out of a total of 36 callers, 30 met eligibility requirements and were scheduled for a zoom-based meeting. Six individuals were not eligible because they did not use opioids  and eight were female (36%). In terms of ethnic/racial background, 12 were non-Hispanic White, seven were of Hispanic/Latinx ethnic background, one was of Native American, one African-American, and one of mixed white and Asian ethnic background. Age ranged from 25 to 51 years old, with a mean of 33.9 years. The majority of participants  resided in Maricopa County (Phoenix area), four individuals were from Pima County (Tucson), and others were from Mohave, Yuma, Pinal, and Yavapai Counties  reporting use of NPF pills. In terms of frequency of use, 14 individuals indicated that they used NPF more frequently than heroin, seven used heroin more frequently, and one person indicated only using non-prescribed pharmaceutical opioids. At the time of the interview, eight individuals were enrolled in opioid use disorder treatment .Nearly all participants described recent dramatic increases in the availability of non-pharmaceutical fentanyl (NPF) in the form of pressed pills mimicking 30 mg oxycodone, most commonly referred to as “blues,” “dirty oxys,” or fentanyl pills. Amy, a 31-year-old woman from Phoenix, who had a history of illicit pharmaceutical opioid use before transitioning to heroin at the age of 21 and then eventually to NPF pills at the age of 30, explained: “Well, they say it’s fentanyl, but they honestly look like Perc 30 s because…when I was doing Perc 30 s they looked exactly the same. And it says 30 on it.” Alex, a 43-year-old man who recently moved from Phoenix to his hometown in the northwestern part of Arizona to attend a methadone treatment center, also described the increased presence of NPF pills: “Okay, so, yeah, it was just an ingenious thing to make money that they did, making those counterfeit Perc 30 s. In Phoenix, they are absolutely everywhere.”There’s a mass amount [of “blues”]. The fact that when I first bought my first pills, it was $8. The way that it is now, it’s $5, shows you that the supply is flooding and outdoing the demand. They’re flooding the market so much that the pills are getting cheaper to buy.The increasing availability of NPF pills was associated with sharp declines in the prices of these pills. Ricky, a 42-year-old man from Phoenix, who started using NPF pills amid the COVID-19 pandemic and in the context of personal losses and turmoil in his life, explained the changes in prices between the summer 2020 and spring 2021:Similarly, Kai, a 31-year-old man from the Tucson area (Pima County), explained his experiences: “Cause before, in the beginning, it would be like $10 for one pill, but now I would never wanna pay that much for one pill. It’s more like $5 a pill or $6.”Increased street availability of NPF pills was often compared to the declining availability of heroin. Sofia, a 28-year-old woman from Tucson, noted, “It [heroin]’s been very difficult to find, and blues are everywhere. In the city I live in, they’re everywhere. That’s all anybody wants to do anymore is fentanyl.” Similarly, Jeff, a 40-year-old man from Phoenix who used illicit opioids to manage his pain issues, described his experiences: “Like my roommate, he's got to drive like eight miles to buy heroin when I could literally walk out in the apartment courtyard and find three or four people selling blues because the only reason I started doing it because it [blues] was cheaper and more accessible.”Most participants noted that unlike the easy availability of counterfeit pills, access to genuine pharmaceutical opioids has declined sharply. Johnny, a 31-year-old man from Phoenix who used “blues” daily, characterized genuine pain pill availability: “The real ones [pain pills] are extremely, extremely hard to get. You have to get those prescribed, and I think only car accident and cancer patients can get prescribed real Percocet, you know what I mean, especially 30 mg.”I've had heroin like that [mixed with NPF]. You can usually taste it. A lot of dealers will let you know, “Hey, this has been laced with fentanyl because it gives you a better high…” I stay away from that. I have one particular dealer that I use that I have had for quite some time now. He's pretty honest with me with what he knows is going into it, and I stay away from it for the most part.Several participants discussed the increasing presence of NPF in the local heroin supply. Powder-type heroin was viewed as being more prone to contamination with NPF. However, some individuals also noted the increasing presence of NPF in black tar heroin, which is the most common form of heroin available in the region. Lucas, a 26-year-old man from Mohave County described his experiences: “I mean, any time I get powdered heroin, then I know it’s fentanyl…. Even black tar heroin will have fentanyl in it, but it’s not as much. If it’s powdered heroin, then it’s pretty much just fentanyl.” Beth, a 40-year-old woman from Phoenix, also described prior experiences of obtaining heroin that was laced with fentanyl. She avoided it, though, by limiting her dealings to established and trusted sources:No, it's not [very available in Arizona]. It's really expensive. Most of my people that sell the pills don't also have access to the pure. But I've come across it quite several times and on it and then it is just kind of weird because some of the powder is white, some is pink, some is purple, and you're not really sure what you're getting. I guess, or why it's different colors. But it's great when you do find it. Some you can smoke it or shoot up and it's just really strong.A few participants mentioned sporadic availability of powder-type NPF in Arizona, although it was viewed as far less common than NPF in counterfeit pill form. Jasmine, a 26-year-old woman from Phoenix, described her experiences of obtaining powder-form fentanyl, referred to as “pure”:Antonio, a 25-year-old man from Yuma who had a prior history of selling NPF and other drugs, explained why local availability of NPF pills was greater than that of powder-form NPF, “Here […] for the most part the cartels are just pushing the pills. They don’t wanna sell the pure thing, or obviously, they’ll be killin’ the client base. For the most part, you only find pills out here…”.Nearly all individuals reported the first use of pressed NPF pills in the past year, and all of them had prior experiences of using other illicit opioids. A few individuals noted that they first tried NPF pills because of the social circumstances that facilitate their access to the drug and sparked their curiosity about its effects. Maria, a 47-year-old woman from Mohave County, transitioned to heroin use three years ago after many years of using prescribed and illicit pain pills. She indicated that she first smoked NPF pills just a few months prior to the interview: “Unfortunately, I had a family member that was, um, is probably still currently involved in the trade of it, and like that through them. Socially, you know, ‘Here, you want to try it?’”.I live in Tucson now, but I actually ended up going back home—back to Scottsdale [city northeast of Phoenix] where I grew up—where my parents live. I went back for Christmas with my girlfriend at the time. We both did heroin. I got back to Scottsdale. We actually ran out of “black”—out of heroin—and we were trying to get more. I, actually, couldn’t find heroin. The people… that I’d known from growing up, didn’t have heroin. They had, actually, these pills. These fentanyl pills. They were actually the only thing I was able to get at that time. I ended up getting them. I wasn’t very happy about it. I didn’t really know about them. I knew about them, but in my opinion, I didn’t really care because I did heroin. I didn’t care to try anything else or try something different. Heroin worked for me. I didn’t really have a choice in the matter ‘cause I was gonna get sick. I actually ended up buying the fentanyl pills.More commonly, the first use of NPF pills occurred in the context of reduced access to heroin. In most situations, these initiation decisions were driven not by consumer preferences but by shifting market situations and circumstances. For example, Scott, a 30-year-old man, described his first use of NPF pills:All the pain management places that you go to, now they're so afraid because of the opiate epidemic that they don't want to put you on what you need to be on… […] I think after being out of the nursing home for a few months, and they cut my pain pills down again, and [it] just wasn't enough. And I couldn't function, I couldn't walk when you have two shattered legs. And I think somebody ended up giving me one of those fentanyl pain pills, and you know it helped… it was way better than what I was getting from my pain management.For a few individuals, the first use of NPF pills occurred through a pathway of reduced access to pharmaceutical opioids. Jeff, a 40-year-old man from Phoenix, explained how he was first introduced to NPF pills in the context of reduced access to legitimate pain pills that were prescribed to him after a serious work-related injury:Although nearly all individuals had tried NPF pills, participants noted distinct patterns and trajectories of switching over to NPF pills and/or maintaining some levels of heroin use. Some individuals transitioned to NPF use nearly immediately after trying them for the first time. For example, Scott explained, “Basically, from that moment on, is when I started seeking out the fentanyl pills and doing those on a daily. Then, basically, within a week I phased out heroin and was not shooting up anymore. I was just smoking these pills.”In contrast, others made a slower transition by initially supplementing and then eventually replacing heroin with NPF pills over the course of several weeks or months. Johnny, a 31-year-old man, who was smoking about 10 NPF pills per day, explained: “Gradually, I started picking a couple of them up along with some heroin here at a time, and then after a while, I just started to like the pills better.” Others have maintained a varying pattern of dual-use, relying on NPF pills intermittently when heroin was more difficult to find, while still using heroin when available. Some individuals had tried using NPF pills but attempted to avoid them altogether and maintained a more or less consistent pattern of heroin use. For instance, Beth, a 40-year-old woman, who used heroin daily to help her with chronic pain, noted: “The pills I won't even touch honestly unless I haven't been able to find the heroin or I'm somehow in some type of withdrawal state is the only time that I'll actually smoke one of those pills. It's really just to get better until I can find the heroin.”Participant decisions and processes of switching over to NPF pills or maintaining some levels of heroin use were shaped by a range of personal and contextual factors including availability trends, personal experiences with NPF effects, views about the social acceptability, as well as perceived benefits and risks of NPF versus heroin use.I didn’t really start using [NPF pills] until last year [2020] and just because it was cheaper. I know a lotta people that never would’ve touched it [NPF pills], touched it last year. That’s just because we were locked in and couldn’t go anywhere. The drugs got frozen pretty much south of the border, and the only thing coming in were [NPF] pills.For most participants, their personal experiences with the availability and prices of NPF pills relative to heroin  were among the most important factors that determined their transition trajectories and patterns of NPF pill use. For example, Antonio noted that the COVID-19 pandemic “shorted the market on a lotta drugs and opened up the way for fentanyl.” As a result, these changes pushed many into NPF pill use:Kai, a 31-year-old man from Pinal County who smoked NPF pills every day and heroin on about seven days in the past month, also noted that drug availability was one of the key factors in his transition to more frequent use of NPF pills: “Then the pills, they started just becoming more available. There was more of them than there was of the heroin, and they were cheaper.”In contrast, Alex, a 43-year-old man, explained that he did try using NPF pills on several occasions, but maintained more frequent heroin use before starting methadone treatment. One of the underlying reasons for his continued more frequent use of heroin: “I actually met somebody that would sell it [heroin] to me fairly reasonable, and I could afford to be a heroin addict in Phoenix. I was doing it for $20 a gram there in Phoenix.” Similarly, Lucas, a 26-year-old man from Mohave County, had tried smoking NPF pills but considered heroin his drug of choice and injected it daily in the past 30 days. He reflected on the potential for him to eventually switch over to NPF pill use: “If I can’t find heroin, then I definitely will switch to blues, you know what I mean? I’ll probably end up doing that.”For many individuals, subjective experiences of fentanyl high were often discussed as another key factor that influenced their decisions and preferences concerning more or less frequent NPF pill use. Scott, a 31-year-old man, explained that in addition to the shifting availability trends, greater potency of NPF pills was one of the key motivators for his rapid transition from heroin to NPF pills: “Me and my girlfriend at the time, we smoked them, and they worked amazing. They got me higher than heroin did.” Antonio, a 25-year-old man, shared similar experiences: “Fentanyl was just more powerful to me. It calmed me down faster, got me in a high zone a lot faster than heroin did.”The fentanyl is to me, I really didn't get a whole lot out of it personally. Then again, I didn't do a lot of it… It was once or twice in a probably a 4-5-day span and then that was it… I'm not continuing to use it at all, because I really didn't get a lot out of it.In contrast, Maria, a 47-year-old woman, smoked NPF pills on a few occasions but was not impressed with their euphoric properties. She preferred to inject heroin and continued to use it more frequently:Everyone is doing blues. It makes people nod out. It puts people asleep—look like they’re sleeping all the time… I don’t enjoy spending my entire day with my head sunk between my legs, nodded out. That’s what fentanyl does to everybody, at least that I see. I don’t enjoy that. I believe that heroin is better for me to do if I’m gonna do it because I don’t nod out on heroin.Some individuals disliked the effects of NPF pills even as they were gravitating toward more frequent use because of easier accessibility. In comparison with heroin, fentanyl was viewed as more overpowering and disruptive to their daily functioning and routines. Sofia, a 28-year-old woman, who preferred heroin and, to the extent possible, sought to use it more frequently than NPF pills, explained her hesitancy to make a complete switch from heroin to NPF pills:Well, because you only gotta do one-shot [of heroin] in the morning and you’re good all day. Fentanyl is one of them things. It’s like coke, man […] when you do smoke a fentanyl pill and you’re good for a little while, and then you gotta smoke another one. You’re good for a little while, and then the times get shorter and shorter...Similarly, Francisco, a 51-year-old man, used NPF pills more frequently than heroin because of easier access. However, he found fentanyl effects less attractive in comparison with heroin because of the shorter duration of action and the need to engage in more frequent use:Well, fentanyl was just a weird thing how that whole thing happened. I told you I was familiar with Perc 30. I took a lot of those pills from my pain management doctor. When the cartels decided they were gonna start making bootleg Perc 30s using fentanyl, I liked it initially.Some individuals felt that NPF pill resemblance to well-known pharmaceutical drugs contributed to the increased social acceptability and a sense of familiarity which made the transition easier and more likely. Alex, a 43-year-old man, described his initial reactions and experiences with increased NPF pill availability:Naturally, [since] the fentanyl is introduced as a Percocet, Percocet 30 milligram, of course people who already were keen with liking those kinda drugs took a keen interest to fake 30s… [They] were already comfortable with the idea of taking it ’cause it was familiar to them.Similarly, Antonio, a 31-year-old man, explained how he and his peers viewed the introduction of NPF pills to the illicit drug market:NPF pills in the form of pressed 30 mg oxycodone tablets were generally administered by smoking. Jaime, a 31-year-old man, explained his first experiences with NPF pills: “I remember, thinking it was weird that you put this pill on some tin foil and you smoke…. I didn't really care for the smell. I was still kind of all about heroin, but it did [work]…”.It was like my saving grace from a worse evil I guess you could say. Surprisingly, just one day… I put the needle and the heroin down, and I just started smoking [NPF pills]. I guess I could say it’s a matter of opinion, but I say it’s the lesser of the two evils when it comes to how you’re doing it as I think smoking is obviously a lot better than injecting.For individuals who had been using heroin by injection, switching to NPF pills also meant a transition from the injection route of opioid administration to smoking. As a result, some felt that their switch to NPF pills was “a saving grace” because smoking was viewed as a less stigmatized and overall safer and more convenient alternative to the injection route of opioid administration. Johnny described his transition to NPF pills:Lucas had been using black tar heroin more frequently than NPF pills, but considered that switching the route of administration was one of the attractive aspects regarding his potential future switch to NPF pills: “You know, actually, I’ve heard that a lot of people got off shootin’ heroin by doin’ blues. They stopped shootin’ heroin by doing that, so I don’t know. Maybe it’s something I’ll get into… It’d be nice to not have to shoot up heroin anymore…”.Others have also felt that the smoking route of NPF pill administration could help moderate their overdose risks, although in some situations these risk perceptions were difficult to reconcile with the observed NPF-related overdose experiences in the community. Scott reflected, “From my heroin addiction, people didn’t overdose when they smoked it. The only way to overdose was to do a huge shot of heroin. […] But now I’ve seen people overdose from smoking this fentanyl… I don’t really know how to weigh the risk.”Most of those pills are stronger than a regular pharmaceutical Perc 30, and I liked that. I tended to stay more towards heroin. I did smoke my share of those pills. A lotta people die from 'em. That’s why it scared me.Several participants expressed their concerns about the increased overdose risks associated with NPF use, and these fears deterred some individuals from making a complete switch over to NPF pills. As Alex, who used heroin more frequently than NPF pills, explained:It’s very addictive. It’s a lot stronger than heroin so it’s a lot harder to get off of than heroin and that’s another thing that I’ve noticed. I’ve had a lot of people tell me that it’s almost impossible to get off of. That’s what I heard.Others were also concerned that NPF was more difficult to quit because of greater potency and more severe withdrawal symptomatology. Tahlia, a 26-year-old woman from Phoenix, discussed her concerns:This is one of the first studies to describe PWUO experiences with increased availability and use of counterfeit NPF pills in the USA. Similar to prior studies on the initiation of NPF in powder form and/or mixed with heroin , 29, couImportantly, our participants emphasized that counterfeit NPF pills in Arizona were generally used by a smoking route of administration, and for many, changes in the route of administration (from injecting heroin to smoking NPF pills) were viewed as a positive aspect of NPF transitions. No prior studies on heroin to NPF transitions conducted in the eastern part of the country have identified changes in the route of opioid administration that were described by our study participants. A recent study conducted in San Francisco, California,  was the Participant views and experiences with the transition to the non-injection route of drug administration have significant implications for the development of harm reduction services. Prior research has established that the injection route of drug use is linked to greater drug-related harms  than other routes of drug administration –35. MostWe acknowledge that these findings are based on the data derived from a small qualitative sample. Although we were able to recruit participants from distinct regions of the state Fig. , and difOur findings indicate the rapid proliferation of NPF in Arizona, primarily in counterfeit pill form, and are consistent with the law enforcement statistics  and overFrom a community and clinical practice standpoint, there is an urgent need to address the structural and attitudinal barriers for patient access to life-saving medications for opioid use disorder . Our intFrom a research standpoint, it is imperative to continue examining the confounding influence of the COVID-19 pandemic on individuals who are at risks resulting from NPF as the combined crisis could lead to increased health disparities over time  especial


Inadequate men’s engagement with health services may be influenced by unmet needs and demands of the local men’s community. This study aimed to explore men’s experiences with primary health services and their expectations of the characteristics of friendly primary health services, from the perspective of men in Kelantan, Malaysia. A qualitative study using in-depth interviews was conducted with 15 men from six primary health facilities in Kelantan, Malaysia, who were selected based on maximum variation sampling. The data were transcribed and analyzed using the thematic analysis method. The study found that experiences with the existing primary health services were categorized into four subthemes: provision of health services, health promotion delivery, attributes of healthcare providers, and the physical environment of the health facilities. Meanwhile, the expectations of the characteristics of friendly primary health services were categorized into four subthemes: meeting the needs of men in primary health services, approaching men through effective health promotion strategies, standards of a healthcare provider from the viewpoint of men, and a comfortable physical environment for men. Prior experiences hugely influenced men’s expectations of friendly primary health services. Men want these health service characteristics customized to meet their needs, allowing them to use health services with confidence and comfort. Thus, to strengthen primary health services for men, it is essential to comprehend their prior experiences with and expectations of the services. Men’s health is a field that promotes men’s physical, mental, and social well-being throughout their life cycle and addresses health problems related to men . The conGlobally, men have shorter lives than women, and, in 2016, the life expectancy of men at birth was 4.4 years lower than that of women . In KelaDespite the advancement of the population’s health overall, men’s health still lags, as evidenced by men’s shorter life expectancy and higher morbidity and mortality compared to women . FurtherMen are less likely to seek assistance with health issues , which tPrimary healthcare in Malaysia is provided through a two-tiered system: health clinics and community clinics. The services provided by health clinics have improved from outpatient, maternal, and child health services to the concept of a family doctor and personalized care, to build a patient–doctor relationship between each family and dedicated doctors, covering primary level curative as well as promotional, preventive, and rehabilitative components of primary healthcare services. Meanwhile, community clinics play a role in ongoing maternal and child healthcare and basic curative services . The infDifferences in the efficiency of health services provision are observed between clients or patients of different genders and may result from how the services are built and/or delivered . In addiA recent study conducted in Kelantan on treatment-seeking behavior among a group of men suggested that to improve men’s health, health service policymakers and providers need to accommodate men’s needs rather than directing men to adapt to the existing healthcare system . MoreoveThus, an exploratory study is needed to understand the expectations of friendly primary health services characteristics from local men’s perspectives. Accordingly, this study aimed to explore experiences with primary health services and expectations of the characteristics of friendly primary health services from the perspective of men in Kelantan, Malaysia. This study is expected to add to the current knowledge on how primary health services should be designed to provide services that are friendly to men.A qualitative study using in-depth interviews was conducted from April 2021 to April 2022 at six government-based primary health facilities in Kelantan, Malaysia. Qualitative research helps understand men’s thoughts and feelings , after half an hour, and sometimes more than an hour; I still have to wait to be called. If I go (early) in the morning, the process is still not finished in the afternoon. It frequently happens to me.”“When I go to a government health clinic, I go there in the morning, and yet in the afternoon [I am] still not finished. I do not know why; maybe too many patients.”Two of the participants also believed that the long waiting hours could be caused by the doctors performing detailed history-taking and clinical assessments. Therefore, they sometimes avoided the government health clinics and went to the pharmacy or private clinics to avoid the long waiting hours. Most of the participants did not experience a problem with the pharmacy unit; however, a few said they had to wait for a long time at the pharmacy because there were many patients there. Additionally, they discussed their unsatisfactory experiences with emergency services in the health clinics, including the slow service given to the patients.One participant, R5, a 60-year-old retiree from a private company, described inequality in the efficiency of the services offered in government and private clinics, noting that private primary health clinics managed their busy days better than government-based primary health clinics. Four of the participants also addressed the long waiting hours while at the registration unit. Non-systematic health card storage was believed to be one of the causes of long waiting hours, including R10, a laborer from Kuala Krai, Kelantan:“Out of the blue, my health card was lost [in the clinic card storage]. They will ask us back; when was the last time I came? For what [reason]? Then, the process of seeing doctors will be delayed due to [the] missing health card.”n = 14). However, two of them viewed men as more interested in and trusting of traditional medication or unqualified health practitioners compared to medical treatment, including for common chronic illnesses and sexual health problems. They also expressed that some men preferred to buy medications at a pharmacy instead of getting medical advice first. This could also be caused by a lack of information on health services, causing men to find alternatives, as stated by R5:Most participants did not question the clinical management of the healthcare providers, as they felt confident with their clinical knowledge and skills Regarding the quality of services provided, three participants mentioned that their expectations for adequate consultation time with the doctors might not be realized, especially during the busy hours with many patients, as the doctors tended to take brief histories. They felt disappointed with the short consultations despite the long waiting time. Further, they also reported inconsistent service quality in different primary health facilities and inadequate laboratory services compared to the hospital.Almost all of the participants had no problems with the medication supply, indicating that they were satisfied with the service and that the medications given were sufficient. However, one participant, R5, mentioned that he was given different types of medications for similar health complaints, which were not as effective as the medication given on the previous visit to primary health services. He was not given an explanation of why different medications were given, as illustrated in the following quote:“Since a few years ago, I [have] occasionally had back pain. I noticed that with similar health complaints, different clinics may provide different types of medications, and I was not informed why I have been given different medication that for me [are] not as effective as [the] previous medication.”Another participant, R9, a 70-year-old man from Kuala Krai, Kelantan, complained about the difficulty of continuing medications at a different clinic, since he was a frequent traveler. He was given medication for one month for his chronic illness, despite being prescribed for three months, and it needed to be retaken monthly. Since he usually travels to another district in Kelantan, he found it challenging to continue the follow-up medication despite having a valid prescription. He mentioned that the other clinic required that he be reinvestigated at the clinic in order to get the medication.Two codes formed the subtheme of health promotion delivery: awareness and acceptance of men. These codes are discussed below.The participants expressed that men might only seek treatment if they were experiencing a significant illness or sickness. They also agreed that men have poor health-seeking behavior, with some men prioritizing work over health, as indicated in the following quotes:“For me, only when I feel severely ill will I go. If had a normal fever, maybe tomorrow [I will go]. If not, [maybe the] day after tomorrow; if bad, I will go.”“The problem is men, indeed. I know because I am a man. Only if we had it severe, at home or other places, collapsed, carried, then we will go.”n = 8). For example, participant R1, a 39-year-old man, mentioned that he thought many older men have erectile dysfunction but do not know how to get help and delay seeking treatment. In addition, the majority of the participants were unsure about the availability of the services, or they thought that no services were available, since no promotion was seen. This is illustrated by R15, an older Indian man from Kuala Krai, Kelantan:Most of them knew that the primary health facilities had done various health promotions at the community level via outreach programs, but they were unaware of the promoted men’s health program Most of them agreed that there was a lack or no promotion of men’s sexual health services, as illustrated by a few of the participants’ quotes:“So far, I have not experienced [promotion] health services like cervical cancer. For men, I do not think so, but I am not sure if I did not notice of that.”. What I saw, there is health promotion of female “It is not available, why? Because we, our culture, our people will not talk [about sexual health]… like a man with hemorrhoids , they will not show it unless there is no other way [due to severe bleeding or pain].”“At the clinic, I had not seen any [promotion on men’s health].”The participants also mentioned that men are less likely to follow or join health programs compared to women. Regarding the current health promotion activities, they said that men might not engage well with the program. Specifically, men might not join the health promotion activities unless they are targeted specifically at their social group, as indicated by the following quotes:“The program done was good enough, good enough, depends on [the] acceptance of men themselves.”“When the health program is done in a community hall, no one gathered there, maybe 3 to 4 persons go there. If [you] want to attract more, you can do it by collaborating with local small religious groups, for example.”Some current health promotion materials focus on the risky behavior of men, such as health education on the smoking ban, but men are usually not interested in the negative consequences of smoking cigarettes. R1 addressed this issue:“In general, negative health campaigns, such as on smoking habits, maybe he [smoker] will just take a quick glimpse at the advertisement and not read through because he already knows. It does not attract him, either to get treatment or to read the poster.”The subtheme attributes of healthcare providers emerged from three codes found in the study: attitudes and behaviors, communications, and favoring male providers.n = 8). However, some participants noted that sometimes the attitude of a healthcare provider toward certain patients was inappropriate (n = 6). For example, the participants noticed that healthcare providers called patients using a loud voice and appeared to be in a bad mood. One participant, R4, a 45-year-old man from Bachok, Kelantan, reported that he had seen a patient being called with a loud voice and thought it could make the patient feel sicker and was inappropriate for the relationship between healthcare providers and patients. The situation could also lead to an unpleasant perception on the part of other patients witnessing the situation. In addition, a less caring attitude by the healthcare providers when answering patient questions could cause patients to feel disappointed. The following quotes reflect the situation some experienced:Most of the participants were satisfied with the attitudes of the healthcare providers ((staff are) in a bad mood when calling“Sometimes  [patient to enter the room], ah, yes, I had experienced hearing a healthcare provider call a patient in [an] angry/stress tone, in Kelantanese described as ‘mechok’, for example, “Hey! Come here! Please hurry! Meaning with a little stress.”“I had experienced, in a place, they are like, do not care much, do not come [to give early treatment] although the patient had a wound and [was] bleeding.”The participants also mentioned that healthcare providers could sometimes be unfriendly to men, especially older adults. This view was expressed by four participants. For example, based on his previous experience, R2, a 59-year-old government pensioner who lived in the district of Kota Bharu, Kelantan, recalled that he saw a healthcare provider scolding an older man who walked slowly into the room. He thought the older man might have a hearing problem, causing him not to notice the healthcare provider’s call. The quotes from R2 are presented below:“Fierce, not friendly, because this man (patient), sometimes they are old people, they walk slow, have poor hearing. When he was called once, he does not hear it, right? The staff was angry and raised their voices, and I have noticed that.”“When the healthcare provider calls elderly men, the elderly might not hear well or sit far away, [so] the patient [does] not arrive as soon as possible and is scolded by the healthcare provider like this: ‘Where did you go? Don’t you hear me calling?’ (in a loud and rude tone).”However, not all of the participants were concerned with this issue, as they understood that the nature of work might place the healthcare providers in stressful conditions, so sometimes they might unintentionally use a loud voice with the patients, as illustrated in this quote from R8, a man from Kuala Krai, Kelantan:“When work involves (with) stress, we should already understand, understand (the situation). We just ignored it; sometimes they might get stressed… (they are) not angry, but their voice, high tone, haha.”The majority of the participants acknowledged that healthcare providers were friendly to the patients, but a few thought that such friendliness might depend on patients’ behavior toward them. For example, R14, a 56-year-old fisherman from Kota Bharu, Kelantan, stated that the healthcare providers’ behaviors and attitudes might depend on how patients behave; if patients talk nicely with them, they will be friendly. Moreover, the participants noted that friendliness could depend on the individual and sometimes varied in distinct clinics, as mentioned below:“[At the] counter, the initial part, we take a number, usually [looked like] egoist… not sure [how to explain], [looked] like they do not want to entertain, ah, as we just pay RM 1 [one Ringgit Malaysia] at the clinic.”“Ha! Less friendly, but at the children’s [health unit] a little different, more friendly, but in general [at the] health unit the services are lacking [in friendliness].”However, not all of the participants had a similar experience, such as R6. In addition, a few other participants mentioned that they were served well by the registration staff and other support staff. One participant, R3, mentioned that friendliness could vary by occasion or time, as he noticed the same healthcare provider showing a different attitude at different times. Some of the participants questioned the dedication of certain healthcare providers, reporting that they had experienced situations where healthcare providers refused to hear more about what they wanted to say due to the need to do other things. R10 added that sometimes he witnessed the doctor arrive late to the clinic, causing the consultation session to start late. According to R4, one possible reason for these problems was an unprofessional attitude on the part of the healthcare providers:“Maybe the healthcare provider had a problem [at home], then he brought it to the workplace. Then, other people [patients] become the victims.”In addition, the participants felt some healthcare providers were not dedicated to work and wasted time on other things , rather than doing the job quickly. This is illustrated by the following quotes from R5 and R6:“Sometimes they are chit-chatting with each other, [but] the patient’s document was not yet taken [to be sent to doctor’s room]. After [they] finish chit-chatting, they take the health card. If they take it early, [I] suppose the patient will be called earlier.”“There are many patients, but the healthcare providers chit-chat a lot, among them… chit-chatting, sometimes in the triage area, they are chit-chatting with each other while treating the patient.”Communication between healthcare providers and patients in the clinics happens as soon as patients enter the clinic for the registration process, consultation, investigation, medication supply, and other procedures. The participants described their experiences in communication-related matters, mainly related to how they occurred and the barriers to communication. Most of them were happy communicating with doctors and pharmacists, as illustrated by quotes from a few participants below:“The doctor’s [explanation] is ok, and the pharmacist’s explanation is also ok.”“So far, I understand what the doctor explained. So far, no problem.”One participant, R11, a 65-year-old pensioner from Kuala Krai, Kelantan, expressed his gratitude for the services the registration staff provided, as he believed they did their best to ensure smooth registration for all patients, and if a problem occurred, they would apologize and inform him of what happened. This showed good communication between the healthcare providers and clients (patients). However, another participant, R4, had an opposite experience of poor communication with the registration staff, as his number was not called after a few hours, although the next patient had already been called, and he was not informed why. This reflected a barrier in communication between healthcare providers and clients. R5 described the situation as follows:“There was a time I went early, but my name was not called. I was confused as a patient after me had already been called. I think I came first, after about two hours, then my name was called, and I was not informed why my turn was late.”Poor communication leads to patient having unpleasant views of the health service provided by the health facilities. Some of the participants experienced poor communication with healthcare providers, especially when asked about long waiting hours and being told to wait.Regarding the explanation of the clinical investigation, some indicated that they were not informed of the findings. One participant, R5, expressed disappointment that he was not informed of the results and raised the possibility of a gap between healthcare providers and patients, leading to poor communication. He perceived a barrier to communicating with the healthcare providers, as shown in his quotes below:“I do not know the findings of my urine sample. The same goes for blood [investigation finding].”“I hope healthcare providers will inform [about the results], but I am afraid to ask.”“Between we [patients] and them [healthcare providers][level]. We are just normal people; we have different thoughts. Their thought is different. When we communicate with them, we do not want to talk like we know more than them., there are many gaps, differences. We are not from their  [I] suppose they know more.”Almost all participants had no problem discussing general health issues with doctors of any gender, but they felt uncomfortable discussing sexual and reproductive health issues with female doctors. They felt embarrassed to talk about sexual health with a female doctor and might not give full details of the problem or even refuse to talk, as discussed in the following quotes:“Regarding getting treatment related to men’s problem or problem-related to male genitalia, itchiness, or other related symptoms, maybe [I] feel shy [to inform a] female doctor.”“If possible, male [healthcare provider] for male [patients], female [healthcare provider] for female [patients], so if men want to seek treatment, he will not feel little shy.”In addition, the participants reported good experiences with the physical condition of the primary health facilities, when their needs and expectations were met. As a result, a few codes emerged and were grouped under the health facility physical environment subtheme, which include cheerfulness, comfortability of the waiting area, the consultation room, and visitor-friendly amenities.Most of the participants accepted the general cheerfulness of the clinics and were not too concerned about this matter, as illustrated by R6 and R7:“I think cheerfulness of the clinic is acceptable for men.”“For me, it is ok. As far as I look at this clinic, it seems cheerful.”However, R5 had a different perspective, indicating that the environment of the current health clinic was not cheerful enough. He said that the clinic felt like being in a mortuary and was not colorful, which could improve the atmosphere.Four of the participants expressed that they were uncomfortable in waiting areas with limited seats. Among those who were satisfied, they described the character of a comfortable waiting room as being large enough, having a functioning television, being located near toilets, having adequate chairs, and featuring exciting reading materials. In addition, they added that a functioning television and exciting reading materials helped to reduce their boredom while waiting.With the advancement of technology, most adult patients have phones, but according to the participants, they could not fully utilize their phones while waiting, if the phone coverage was not good and there was no free Wi-Fi for patients. In addition, a few of them raised concerns about the comfort of a mixed waiting area for both men and women, and sometimes the presence of children playing could cause an uncomfortable situation for men, as described by R4 and R5:“Uncomfortable! Because it [waiting area] is mixed for men and women. The majority who sit are women. Men [who have a seat] can be counted [small number]. Rarely [found]. The majority [of men] wait outside the clinic. We felt very uncomfortable.”“Uncomfortable because… number one [reason] when, we, men, only two males [are] in the clinic, others are women, chit-chatting among them. We felt stressed. [Also], a child making noise/crying, we felt like, just get out and back home. It happened to me. After I had registered, I turned back.”An insufficient number of chairs in the waiting room usually caused men to stand while waiting outside the clinic, as priority was given to women, children, and the elderly to use the chairs, making men feel discriminated against based on the social norm.n = 8) felt unsatisfied with the condition of the consultation room, as they were uncomfortable with the small and shared room, while the rest were satisfied with the current condition. One participant, R7, a 39-year-old man from Kota Bharu, Kelantan, mentioned that he had a satisfying experience in the consultation room/area when it was large and was not shared with another patient. However, most of the other participants expressed dissatisfaction, mainly due to a lack of privacy, when they shared the room with other patients during a consultation. Some did not accept sharing a consultation room for any health issue, but others tolerated sharing a room when dealing with non-sexual health issues.More than half of the participants A few mentioned that small consultation rooms made them uncomfortable, including R5:“The area [consultation room] is narrow. Sometimes another patient sits next to me. It is too near [between patients in a consultation room], and when we enter the room, I feel like [I am] in a tight situation.”He also added that he had experienced disappointment when he did not feel welcome to have a good conversation with the doctor, since there was signage at the consultation door warning patients not to take a long time in the consultation room to prevent others from waiting too long. He described the situation as follows:“I do not want to ask or talk much because it stated outside [at the door] that the clinic is in a hurry because more people are waiting. On the outside [of the door], there is a picture/signage warning [us] not to take a long time [in the consultation room].”n = 10). Sometimes, they had to park in the wrong parking space because there was no parking area near the clinic. Certain patients might require a parking area near the clinic due to an inability to walk or the severity of their illness. The geography of parking areas that were not on the same level as the clinic could also be problematic for certain patients:Most of the participants were not satisfied with the shortage of parking spaces and needed to find parking far from the clinics Two of the participants also worried about being cited by local authorities if they parked in the wrong place. Sometimes, they canceled their plan to get treatment at the health clinic because there was no parking available. However, for those who rode a motorcycle, parking spaces might not be an issue.They had different experiences with the toilets in the clinics. Some of the participants had a poor experience with an inadequate number of toilets and had to share with another gender. For example, R3 shared that he needed to use the same toilet as female patients for urine collection, and he felt very uncomfortable with the situation. Other participants also had an unsatisfactory experience using the clinic’s toilet because it did not function well, was poorly maintained, or was smelly. However, most of the participants indicated that the toilets in the clinics seemed to be in satisfactory condition, adequate in numbers, not smelly, and clean.Four subthemes were related to the expectations of characteristics of friendly primary health services from a men’s perspective: (1) meeting men’s needs in primary health services; (2) approaching men through effective health promotion strategies; (3) standards of a healthcare provider from a men’s viewpoint; and (4) a comfortable physical environment for men.The participants described several characteristics they expected of friendly primary health services to meet their needs. These characteristics were coded and grouped under this subtheme. The codes include efficiency, clear motto, monitoring, appropriate waiting time, an extension of the time for services, general health services for men, emergency services, and men’s sexual health services.Men demanded that primary health clinics have systematic administrative management, with fast and proper patient health card distribution to the doctor’s room and modern technology to increase management efficiency. Modern technology is necessary today, as described by R2, who noted that even coffee shops have adapted technology to reducing waiting time and streamline procedures for preparing food and drink and sending it to the clients. Therefore, he suggested that primary health clinics should adapt similar technology to quicken their administrative processes. Moreover, the health services should be continuous and not interrupted due to a lack of staff, especially consultations with doctors.Some participants highlighted that priority should be given to older or very ill patients, as they need simpler and faster services:“They need to categorize patients, (old) people with diabetes (for example). These people need to go early, to enter (the consultation room) early. [The have] no need to wait among other normal people; normal people they are not very ill.”In addition, they also expected primary health services to improve based on demand, as people are now using them more for non-life-threatening conditions rather than going to the hospital. Some suggested that health clinics could provide a server or waitress in the waiting room to assist patients who require help. They believed that such providers could assist patients, give directions, and help the elderly in the clinic. However, not all of the participants agreed with this idea. One participant, R12, a 57-year-old government servant from Kuala Krai, Kelantan, expressed his disagreement with the need to add more staff as servers or waitresses:“In my opinion, the clinics already have many ‘waitress’. All [healthcare providers] are waitresses [that can assist patients].”Some participants mentioned the importance of the primary health clinics having a clear motto or objectives, including services related to men’s health. In addition, they wanted the clinic’s motto or objectives to be published, so they knew what health conditions are covered by the services, especially those they could benefit from. R15 offered his view on this:“The most important thing, what is the clinic for? For what? For all? Or for certain diseases only; that is important.”Regarding improvement and evaluation of the health services, two participants suggested that a monitoring body should be present to communicate and receive feedback on the services provided. They should also provide clients feedback forms. They also suggested an accreditation standard for the health clinics to ensure efficiency and consistency in all clinics. Some suggested that the clinic should conduct regular morning briefings to boost staff morale and confidence, so they would be more enthusiastic about serving the community.When visiting a primary health clinic, the participants were concerned about the amount of time they had to wait. Mostly, they wanted shorter waiting times, as they could not bear long waits and become bored easily. For some, a long waiting time is inappropriate for a sick person to endure. However, they felt a long waiting time is tolerable if they feel satisfied with the quality of the treatment received. Moreover, they were disappointed with what they thought was inadequate treatment despite waiting hours for a consultation. They felt that if the clinic could provide information on the estimated amount of time they would have to wait before receiving a consultation, it might be an added value. They could then estimate when it would be their turn and do other things while they waited, as noted by R2:“Usually, the doctor has their estimation [on the time allotted for a consultation], about 10 min per patient, and if I go to the [registration] counter, they should [be] able to give [the] estimated time before my turn, for example, at 3:40 p.m., I should have met the doctor.”Extended service hours or times, which might include services in the late evening or on the weekend, could benefit men who might not be able to come during office hours due to job commitments, as mentioned by three of the participants. In addition, one participant, R14, observed that people could get sick anytime, even on the weekend. Thus, he suggested the clinic should also be operated during the weekend.n = 5). However, they mentioned that there was no regular checkup for men of any group except for those with chronic illnesses. They also mentioned that prevention programs for men were lacking:The participants expect good services and practices from healthcare providers. Expertise in the primary health clinic, including a counselor and medical specialists, could attract men to the clinic. In addition, the population’s rapid growth has increased the demand for the country’s health services. The participants indicated that they expect a high standard quality for all primary health facilities and the ability to perform advanced laboratory investigations to reduce dependence on the hospital. They believed that men differed from women, as once men were unsatisfied with the services, they would not return to that clinic. Some also expected health service providers to provide a regular health program or checkup for men, similar to well-established health programs for women “Support for those without illness to come to the clinic to have health assessment [or screening]… now, if possible, young men also need to go to [the] clinic.”Regarding services provided by pharmacy units, three participants emphasized the importance of high-quality medications. For example, R15 mentioned that he noticed particular medications given by private clinics were more effective in reducing pain. Moreover, the supply of follow-up medications for chronic diseases should not be problematic for travelers when they have a valid medication prescription slip. R9 strongly emphasized this point:“Just continue the medication! So there is no need to do things [repeating the lab investigation]; some might like it, but others might not, with the procedures.”Three participants expressed their thoughts about the provision of emergency services in a primary health setting. They said that the availability of emergency services at primary health clinics gives men confidence that the clinic can provide the necessary health services, especially during emergencies. One participant, R14, indicated that particular pain or health conditions might be inappropriate for hospital emergency unit visits but should be treated at the clinic level. Emergency services at the clinic level should be provided promptly to patients with a medical emergency or who were involved in an accident:“Need for strict action and [to] be fast. Sometimes an individual come[s] due to skidding from a motorcycle. He comes to the clinic first. If [he] cannot be treated at [the] clinic level, the clinic should send [him] to [the] hospital… before that, [he] needs to be treated first, because he is in pain.”According to the participants, the provision of 24 h emergency service in primary health facilities is essential for men, as they tend to use the services more, so providing such care in primary health facilities could increase men’s engagement with the clinic. In addition, an ambulance should also be made available in every primary health clinic so patients can be sent to the hospital when necessary.n = 11). This could be done weekly or monthly, according to the number of patients and the clinic’s capability. However, some suggested such care should be available along with general health services. Meanwhile, two participants suggested that men’s sexual health clinics or services should be rebranded with a different name to reduce the stigma for those who receive treatment. The failure to provide men’s health services or men’s clinical services could lead to adverse health behaviors, as indicated by R5:Most participants mentioned that men’s health services, including male sexual health services, are vital for providing male-friendly primary health services. The main staff who manage the men’s sexual health clinic should be men, to reduce male patients’ embarrassment. The majority agreed that the clinic should be operated at certain times only or on an appointment basis, as that would ensure privacy, since not all men need the services “When [there is] no place to discuss, whom do men meet? ‘Consultant’, the unqualified ‘consultant’ who sells [unregistered health] products.”The participants described various ways and methods for healthcare providers to improve health promotions and education for men. The participants’ views were coded and grouped under the following subthemes: content, location, styles, approaches, Internet and social media, local men’s community, and acknowledgment.Nine participants recommended that healthcare providers spread more information about men’s health services or male-friendly health services to attract men and give them confidence in the health services. Health promotion and education could emphasize common diseases among men or men’s reproduction and sexual health problems and the available treatments at primary health facilities. In addition, knowing that the services are available would improve men’s engagement with local clinics, as mentioned by R1:“I think that health provider[s] should make an announcement on diseases related to men and when and where they can get treatment so that they get the treatment and not only stay at home.”Further, two participants added that promoting an active lifestyle may also help men manage their health conditions. Therefore, a variety of health promotion content is expected to improve men’s health literacy.The participants viewed a variety of locations as appropriate for health promotion, including clinics, social media, and mass media. In addition, health promotion activities could be done in gathering areas frequented by men, including religious places, coffee shops, or restaurants. A few participants discussed how such gathering areas favored by men could be used in health promotion:“Can make at [the] local community mosque… some doctors like to do community activities, so can give a talk at the mosque.”“Men like to hang out at the coffee shop, and many men are there, so [they] can do [promotion] there casually.”Posting health flyers in coffee shops or restaurants may also reach the men who like chit-chatting there. According to some of the participants, the community hall is a good option as a location to educate men on men’s sexual health issues because it provides more privacy for men. On the other hand, open spaces, such as shopping complexes, are inappropriate for health education involving sexual health topics because they expose men to stigma, as mentioned by R9:“Supermarket, boring, because many people walk there. Men will walk and take a quick look… sometimes he will smile only, not stopping, [thinking that] whatever men [are] at the place must have that problem.”Most of the participants expected polite, soft persuasion and the use of more positive words or approaches to promote health for men. For example, R1 talked about negative health campaigns, such as those related to smoking, arguing that men might not even read the health promotion materials, since they already knew about the negativity, and so it would not catch their attention. Another participant, R15, stated that men’s health promotion must be done using soft language or style:“Need to be soft, like say, [focus on] what [is] important for men… we need to treat men like that, tell them like that. Do not say in two to three months you could die.”Men must be encouraged and supported to change for better health and informed that health services are available to them. However, some of the participants thought that men needed a more direct form of health promotion to get their attention. For example, R6 indicated that threatening words might encourage men to get medical checkups at the clinic:“Show threatening words a little bit, then they will come. They will feel afraid and want to go to the clinic for a check-up.”At the clinic, participants expected the clinic manager to take the opportunity to promote health in the facility using various approaches, including giving short talks on health in the waiting area that could fill the client’s waiting time with a worthwhile message. In addition, discussion on health topics with the patients and accompanying relatives could improve patient engagement, thus promoting trust. R11 discussed this matter:“[It is] better to have a healthcare provider there, better a nurse… One staff, to give a talk, estimated about 20 min, 15 min.”“When many patients are waiting in the waiting area, [give a] talk, and [be] open for any question.”Pamphlets could also be used in the clinics to educate men. Furthermore, the televisions that most clinics have in waiting rooms should be used to provide health education, as discussed in R6’s statement below:“In the clinic, we have [a] television, right? So make [health] programs [or videos] to be shown on the clinic’s television.”Five participants expressed their opinions on using the Internet and social media to promote health among men. They mentioned that healthcare providers in the clinics should utilize the Internet and social media to engage with the local community. This could be done by regularly updating their activities and programs and providing a contact number for any queries. R3, who was working as a technician for a private company, discussed this issue:“The first thing is that [they] need to update the community, as nowadays people are more on the internet and use more social media, so the clinic should update the community. It needs to have its own social media account, so that it is easier for people to refer and see [the available programs and activities] and if they have any inquiries [they can reach the healthcare providers].”n = 9). Men from different social groups or with different demographic characteristics might have different interests in community activities. Local clinic managers need to acknowledge this and plan community health activities accordingly. For example, men in Kelantan might be interested in Dikir Barat , sports such as football, cycling, and badminton, or karaoke. R14 discussed the added value of offering Dikir Barat as one of the side activities in a health program:Many participants believed that educating men’s communities requires healthcare providers to participate in community activities Clinic managers can plan to include these activities in their programs or join a venture community program by giving talks and offering health exhibitions. Moreover, health promotion activities could be done by collaborating with religious groups, as some men might engage well with religious programs or activities. One participant, R11, suggested that healthcare providers could engage with the local community where they live, by assisting the community in establishing and conducting health screenings among their community.Two participants thought that promoting health among men must involve men as active participants. Men could be involved by giving them the responsibility to take care of their community. Quotes from two participants emphasized that giving men responsibility would make them feel more welcomed and appreciated:“They [healthcare providers] can attract regular patients to become the promoter of the clinic to attract men to go to clinic.”“We cannot call them directly to come without giving them responsibility. They will feel satisfied when given responsibility; they will feel satisfied.”In terms of their view on the characteristics of healthcare providers, the participants mentioned several key points they expect. The standards regarding healthcare providers’ characteristics are categorized under the following codes: dedication, admirable attitudes, good knowledge, professional work practice, preference for male healthcare providers, and older and experienced healthcare providers.Many participants said that being dedicated to serving patients is vital for gaining patients’ trust. The participants had various views on how healthcare providers could show dedication while working. These include being a good listener to patients’ complaints, talking nicely with patients, prioritizing patient care, being ready to serve, and showing care to the patients. In addition, being a good listener is crucial for health providers, especially doctors, as it greatly impacts their relationships with the patients. One participant, R15, emphasized that doctors are responsible for allocating time to listen to patients’ health complaints:“It is your responsibility [the doctor]. You become a doctor, we find you…. A person who wants to be a doctor, he must treat the patients well because the government pays your wages and takes care of you, so you need to take care of patients. People come, and you need to take care [of them], [you] need to discuss [communicate] well.”Most of the participants believed that being friendly would strengthen relationships with the patients. A healthcare provider who always has a smile on their face, greets patients, and is approachable could attract men to the clinic, and men themselves would spread the information about the friendliness of the healthcare providers in the community, thereby improving public trust.According to the participants, if inappropriate services are given to men, especially adult males or elderly males, men will refuse to return, leading to poor health-seeking behaviors among men. In addition, a poor working attitude, such as chit-chatting with other healthcare providers while serving or treating a patient, can negatively influence the view of the services by men and should be avoided.Five participants highlighted the need for healthcare providers to have good health knowledge to treat patients. Regarding men’s health, the men requested that healthcare providers have exposure to and be able to detect and offer early treatment for men’s health issues, including sexual health issues. This is not only true for doctors but also for other healthcare providers involved with men’s health.“I think maybe staff also need to have exposure to problems related to men so that they can be able to help to give the best treatment for the disease.”“Necessary, necessary, meaning that from any aspect if we [patients] ask, he or she [is] able to answer. Although not a doctor, he or she is a nurse [and] needs to have knowledge.”The participants evaluated good healthcare providers by observing their practice. Some stated that they wanted healthcare providers, especially doctors, to be thorough in their clinical assessments and treatment, asking the right questions before making a diagnosis. They also emphasized the importance of empathy and proper treatment by healthcare providers. R15 discussed this matter:“They need to take care, as [with] their relative, ah! Do not treat the patient like it is not their concern. Do not be like that; do not let the health problem [remain] not treated, and they should take care like your relative, like your parents, siblings.”Further, they also expected the healthcare providers to answer any queries appropriately. For example, they should not simply ask the patient to wait when they are asked about the reason for the long waiting period, as mentioned by R4. In addition, healthcare providers must have good communication skills and communicate using appropriate language and words that are understood by the community. R5 expressed concern about poor communication between healthcare providers and clients and recommended improvement:“Between we [patients] and them [healthcare providers], have many gaps, differences… our thinking and theirs are not same. [We] feel afraid to communicate with them… suppose they [should] try to understand patients’ concerns and give a proper explanation.”The participants expressed strong preferences for male healthcare providers when discussing sexual health issues, as men might be shy to talk with female doctors about such issues. A team of male staff should handle men’s sexual health services if circumstances permitted. The support staff does not necessarily have to be all male. Most participants did not expect to be treated by male doctors for general health issues , as mentioned in R1’s statement below:“I think, if common diseases like cough, runny nose, there is no problem if [men see a] female doctor. But if, for example, to get treatment for men’s problem or problem-related to genitalia, itchiness, or other [complaint], may feel shy to discuss [the problem] with a female doctor.”From another point of view, men might be attracted to visit the clinic due to the presence of female healthcare providers due to their gentle approach, as mentioned by R15:“To attract men… the clinic that has more female healthcare providers, men must go there, not due to sensual, it is different, it is like the mind, mind becomes calm when men go there. The way female healthcare providers treat men, he will tell other men to go to the clinics due to [the] gentle services of the female healthcare providers.”The participants prefer to deal with aged healthcare providers, as they appear to have more experience and maintain patients’ confidentiality better than younger healthcare providers.“[Men’s clinics] need to handled by veteran staff, senior, that can keep secret, at the registration counter.”However, most of the participants did not consider this a must, as long as the healthcare providers could treat them well and maintain integrity.Due to budget constraints, some of the participants are aware that providing all the measures to ensure clients’ convenience is not easy. R11 highlighted this issue but emphasized that it would be helpful for patients’ satisfaction if the government could do so. In addition, the availability of primary health facilities near one’s residence is a factor influencing attendance. The participants’ expectations of comfortable physical environments are coded as followed: cheerfulness, placement of health support services, comfortable waiting area, men-only waiting area, privacy-protected and comfortable consultation room, specific men’s sexual health services setting, and visitor-friendly amenities.n = 9). They had different views, as some wanted colorful environments, so the clinic looked more “alive”, while others did not expect the clinic to be colorful, as it had little influence on men’s view of the services. The quotes below reflect the participants’ views on this matter:Some of the participants discussed the cheerfulness of clinics “I think cheerfulness of the clinic is acceptable for men.”“For me, it is ok. As far as I look at this clinic, it seems cheerful.”The placement of units in the clinic also needs to be correct to ensure that patients are not burdened or encounter difficulties. For example, R2 mentioned that a physiotherapy unit should not be located on the upper level, as patients with back pain may find it difficult to go there.Participants expected clinic management to provide comfortable and adequate chairs for every client in the waiting area and to separate them by unit. In addition, they were concerned about the division of the waiting area, as clients from different units were using the same waiting rooms, which caused congestion. One participant suggested that clinic management could provide massage chairs in the clinic, but others did not view this as an essential aspect. Others indicated clinics could provide coffee-shop-like chairs and tables to make patients more comfortable. Different types of chairs might also be considered, as not all patients can sit on a regular clinic chair due to health problems.However, different chair types are not crucial to some participants, who reported that they were satisfied with the current chairs. Moreover, while waiting, men can get hungry, and the participants suggested that the clinic could provide free cold water and coffee or sell soft drinks and light food for snacking. This could help men cope with the long waiting times before receiving services.“Clinics should have drinking water point or place for long waiting, [to] drink water.”“[I] want to sit, drink something, chit-chat while waiting.”n = 5). If the circumstances permit, such a waiting area would make men feel more comfortable. R2 noted that men like to be among men and to talk to each other about current issues. Men sometimes get irritated with mixed waiting areas, as mentioned by R5:Some participants suggested that the clinic manager should provide a men-only waiting area However, not all of the participants requested a men-only waiting area. They felt the current conditions were acceptable, and the separation of seats based on gender could be problematic to people who come with their families. The clinic manager should ensure that the waiting area offers health promotion materials compatible with men, including posters and pamphlets about diseases and graphic information about men’s health problems and treatment. In addition, other reading materials that are not health-related should be available. Other suggestions by men included toilets near the waiting area, free Wi-Fi or stable phone coverage, a functioning and operating television, and the use of a loudspeaker to announce each patient’s turn.From the participant’s perspective, the most crucial characteristic of a consultation room is maintaining privacy. Men expect that they will not have to share a room with another patient during their consultation, especially when they want to talk about sexual health issues. Sharing a consultation area makes men uncomfortable, and they do not have privacy to talk about their problems, especially regarding sexual health. R13, a 41-year-old Chinese man living in Kuala Krai, Kelantan, spoke about this issue:“Sometimes shared with other doctors, so how does it feel to share? Truly uncomfortable because we do not know the other person, so like me, a lot of privacy problems… afraid to share.”In a limited setting where sharing is unavoidable, two doctors should not share one table or face each other, and they should use a curtain to create a barrier to ensure privacy. Men are also concerned about the friendliness of the room for disabled people to enter and easily receive services. The size of the room also needs to be large enough.n = 13). The setting should be a specific room to ensure the patient’s privacy. Patients might feel embarrassed if other patients can hear their conversation with the doctor.According to most of the participants, men’s sexual health services need to be available in every primary health facility, to encourage men to discuss their sexual health issues Regarding other areas in the clinic, the participants stated that the toilet should not be shared between genders and should be functioning and clean. In addition, a children’s playground area would be more convenient for men who come with their families, allowing their children to be entertained while they receive treatment.Furthermore, they demanded that clinics provide more parking spaces, since, currently, most people use cars to go to the clinic. Inappropriate parking on the sidewalk could result in them being cited by local authorities. In addition, a lack of parking might cause men to cancel the clinic trip altogether. The participants suggested that clinic management could request outside land from the local authority for use as a parking area for clients and ensure that the parking area is not abused by someone parking there for days.n = 13), in line with the sociodemographic characteristics of the residents of Kelantan. In addition, most of the participants were middle aged or older (n = 14). The main reason for this is that more older adults were available in the clinics during data collection and were more cooperative in terms of sharing their experiences and expectations related to the study topic.In this study, most of our participants were Malays , but they felt that there was room for improvement in terms of providing friendly services. They noted that there is still a lack of efficiency in management and a lack of services provided, specifically for men. Long waiting times also caused the participants to feel uneasy, as they admitted having low patience for waiting. A similar finding was reported in an earlier study on male civil servants in Kelantan, in which one of the reasons for poor treatment seeking by men was a lack of patience. Thus, the men preferred to buy medications at the pharmacy [The majority of participants were generally satisfied with the primary health services they received (pharmacy . A systepharmacy . This fin = 7) compared to maternal and child health, which they viewed as well established. As men’s health is a relatively neglected subject compared to women’s health, men have been left behind in terms of health screenings and programs [The participants noted that men’s health promotion activities are lacking, which could cause men to have poor health literacy and to exhibit poor health-seeking behaviors. They were also not well aware of men’s health services . A crowded waiting room with limited seats causes an unpleasant feeling as they wait for their turn for services. Shared and small spaces for consultations also make patients feel uncomfortable. A literature review by Jazla Fadda on the impact of the physical environment on quality of care found that health facilities with a privacy-protected environment, adequate space, and some visitor-friendly amenities were expected to improve patient satisfaction [Most participants focused on their experiences in the waiting and consultation rooms when asked about their experiences with the physical conditions of the primary health facilities (sfaction . This con = 14). A previous study conducted in South West Ethiopia showed a substantial correlation between patient satisfaction with waiting and consultation times, the types of investigations conducted, and securing the prescribed medications [Regarding the participants’ expectations, we found that most of the participants related their experiences with their views and expectations on how the services should be provided , and they suggested an accreditation system to ensure high-quality health services. This finding is consistent with C. Reeve et al., who found that the evaluation of health service performance is essential in health services planning to improve service performance and community health outcomes [n = 3). A qualitative study on men’s health needs found that employed men report having time constraints in caring for their health, and they have difficulty accessing primary care services due to limited hours of operation [Some of the participants addressed the inconsistency in effectiveness between clinics . Such a setting is expected to include male doctors. In line with our findings, an earlier qualitative study exploring factors influencing health screening behavior in young men also found that Muslim men usually preferred doctors of the same gender, because they felt more at ease and found it easier to develop mutual understanding, especially when discussing sexual health issues or having a genital or rectal examination [The majority of the participants agreed that health clinics should provide men’s sexual health services in specific men’s clinic settings (mination .n = 5). Thus, having experts in the clinic could improve men’s confidence and trust in the services. Furthermore, our study found that the vital characteristics of health providers from a men’s perspective include working professionally, showing empathy to patients, and being comfortable communicating, which is consistent with the findings of a previous study on men’s expectations of physicians in relation to sexual health concerns [A previous study found that men’s perceptions of healthcare providers were influenced by masculinity, as men may not trust healthcare providers to be able to give good treatment, and some men felt they knew better than the providers . In our concerns .Urology Times listed three vital design elements, suggested by urologists and internists, when setting up a men’s health center: (1) an entrance, reception, and waiting area that is separated from other units in the clinic; (2) a masculine decor, which makes men feel at ease; and (3) plenty of sports, men’s magazines, televisions, and, if possible, free Wi-Fi [According to the participants, a friendly physical environment is characterized by comfortability, confidentiality, and convenience. An article published in 2014 in ee Wi-Fi . In addiOur study was an exploratory study involving three districts in Kelantan. The participants were selected based on maximum variation sampling to ensure a variety of socioeconomic backgrounds. This allowed various voices from different groups of men in Kelantan to emerge, sharing their experiences and expectations of the characteristics of friendly primary health services. Thus, the results offer a more precise account of what would make primary health services friendlier for men. In addition, the in-depth interviews allowed men to express their thoughts without bias from other participants, which resulted in rich data. All participants were patients or relatives of patients who come to the clinic for general primary health services.Several limitations of the study should be mentioned. The COVID-19 pandemic limited the selection of participants, as some health services were unavailable during this time. Thus, this study did not directly include patients with recent experiences of using the men’s sexual health services provided by the primary health facilities. Although the combination of in-depth interviews and focus group discussions can be expected to improve the understanding of the phenomenon of interest , no focuFuture research is needed to establish men’s expectations of primary health services in a more extensive research population, to help local health authorities provide better health services for men. In addition, more research is needed on the provision of male-friendly primary health services, to encourage more men to use health services.As a new qualitative researcher, the primary researcher might have values and perspectives that influenced the study’s implementation, including the data analysis and interpretation. He has been a medical doctor for almost nine years and has attended extra courses on qualitative research at a university and elsewhere. He was aware that his academic background might play a part in the conduct and analysis of this study. As an adult man living in Kelantan, his background, beliefs, and experiences could affect any aspect of the research. Therefore, in conducting this study, he received guidance from experts in qualitative research, including the other research team members involved in qualitative studies and men’s health studies, to reduce the potential effect of researcher bias and to recognize and address any ethical issues. In addition, living in Kelantan might have helped him to communicate in the local dialect, which provided a comfortable medium for the participants to talk and discuss the issues. Although he is Malay, the researcher has experience dealing with patients with various backgrounds, including Chinese and Indian patients, and has been exposed to their cultures and world views.The development of the conceptual framework of this study involved a thorough literature review to provide a logical and convincing argument for the research. The qualitative study’s sampling design was purposive sampling to ensure the inclusion of appropriate participants in the study. The data collection and analysis were performed concurrently, with the results of the ongoing analysis informing the data collection until data saturation was achieved. A matrix of participants’ characteristics was created to ensure a diverse sample, to control the balance of the participants, and to ensure informed consent before the interviews started. The confidentiality and privacy of the participants were protected to the highest degree possible.Member checking was done to ensure the credibility and confirmability of the study, which involved providing the interview transcripts to the participants . This waInvestigator triangulation was also applied in this study. The first and second authors reviewed all audio recordings and performed individual data analyses to identify patterns or themes related to the aims of the study. The findings of codes, subthemes, and themes were compared and discussed with all the research team members. Improvements were made, based on a series of discussions, until a consensus was reached. Validity was established once all the researchers reached the same conclusion. Investigator triangulation entails the involvement of two or more researchers in the same study to obtain multiple observations and conclusions  and is eEngaging men with primary health services requires healthcare providers and managers to not only cater to men’s health needs but also consider their expectations regarding how the services should be provided. Thus, it is vital to understand the experiences of men using existing primary health services and their expectations of the characteristics of friendly primary health services, to design services that are friendlier to men. Our study found that men’s experiences with the existing primary health services could be described in four subthemes: provision of health services, health promotion delivery, attributes of healthcare providers, and the physical environment of the health facilities. Meanwhile, men’s expectations of the characteristics of friendly primary health services were elaborated in four subthemes: meeting the men’s needs in primary health services, approaching men through effective health promotion strategies, standards of a healthcare provider from a men’s viewpoint, and a comfortable physical environment for men.


In the published article, there was an error in the Funding statement. Missing grant supporting this manuscript. The correct Funding statement appears below.Funding“Thanks to Immunology department  and Institute of Biotechnology and Biomedicine (IBB-UAB) for their help during the writing of this article. This work has been partially supported by grants from the Instituto de Salud Carlos III, Spanish Ministry of Health , Fondo Europeo de Desarrollo Regional (FEDER) “una manera de hacer Europa”, “La Caixa” Foundation (CP042702/LCF/PR/GN18/50310007), and Secretaria d’Universitats i Recerca del Departament d’Empresa i Coneixement, Generalitat de Catalunya, project 2020PANDE00079.”The authors apologize for this error and state that this does not change the scientific conclusions of the article in any way. The original article has been updated.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.