Abstract

The subject of men’s help-seeking behaviour has been explored over a long period of time in general. Men are believed to be reluctant to seek professional help, putting themselves at an increased risk for developing serious medical or mental health problems. The COVID-19 pandemic brought this subject back to the centre particularly regarding the notion of vaccine hesitancy. At the time, being vaccinated was the only option that medical science suggested could protect against fatal infection. The paper aims to provide a summary of literature on men’s help-seeking behaviour to aid an understanding of this phenomenon, than to produce new conclusions. Using purposive sampling, this paper conducted a knowledge synthesis of selected literature about men’s help-seeking behaviour, couching this against the notion of masculinity, or how men imagine themselves as men. The selected literature was subjected to thematic analysis, and in the end the narrative literature review supported extant knowledge on men’s help-seeking behaviour, and produced seven main themes, namely gender role conflict, socio-economic status and income level, engagement and quality of previous help received, illness awareness and knowledge, power and the counterbalance of femininity, the notion of ‘traditional masculinity’, and men and their masculinity in the context of COVID-19. The paper concluded that how men imagine themselves as men, and as evincing behaviour that should be different from femininity, interfered with their ability to seek help. It posits that availability of resources does not guarantee that men will use them.

Introduction

Help-seeking is a critical part of our lives. It enables us to receive the treatment and support that we need when faced with medical conditions and adverse life events which may cause us distress. For purposes of this paper, it is important that there is a clear definition of what this concept means. This in turn will facilitate the exploration of how this behaviour is reflected by men, including in the context of efforts to respond to the COVID-19 pandemic. Help-seeking has been defined by Li et al. [1] “as any form of communication about a condition or adverse life event which is aimed at receiving support, advice, or assistance.” This, however, only defines help-seeking as a single act or only the initial communication about the problem, which leaves a large portion of the process of receiving help unexplained. A more comprehensive definition of this process is needed, and the section below explores the concept of help-seeking behaviour in some detail. Suffice it to state at this point that the definition of help seeking in terms of the focus of this paper will encompass the initial act of seeking intervention (including vaccination as a preventative measure), how patients become aware of their symptoms (where this applies), how patients respond to these symptoms, consultations with health care professionals or doctors, the treatment they receive and finally paying specific attention to the social norms and cultural practices involved.

It is also important noting that help-seeking does not reside solely within the medical field, but also exists in others spheres of human health including for example seeking psychological help. In the field of psychology individuals who seek professional treatment maybe be referred to as clients or as patients, depending on the psychologist and his or her theoretical orientation and work context [2]. In this paper, all individuals that seek assistance will be referred to as patients. This aligns with the multidisciplinary definition of the act that help-seeking should include in this paper.

Additionally, justifying why an exploration of help-seeking behaviours is necessary at this stage is important. As a start, examining statistics relating to mental and physical health provides part of the answer. A number of studies point out that men commit suicide at almost twice the rate of women [1,3-5]. Seidler et al. [6] suggests that although women are almost twice as depressed as men, the latter account for three quarters of completed suicides in western countries. In the context of COVID-19, men are at double the risk of both developing the severe form of the disease and mortality [7,8]. In addition men are half as likely as women to seek treatment or assistance from medical professionals [9,10], less likely to make use of preventative or screening practices, fail to secure a regular source of care, and seek medical interventions within a timely manner [11]. These patterns in behaviour clearly indicate a problem in the underlying help-seeking behaviours particularly in men. Writing about lessons that can be drawn from experiences with the COVID-19 pandemic, Spagnolo et al [8] states that ‘gender related factors affect adherence to treatment, access to health care, and health-seeking behaviour’. All these research findings accord with the widely accepted assertion that men are less likely to seek help for medical or mental health problems compared to women [12,13].

In the sections that follow the manner in which the concept of help seeking was explored and developed will be outlined. The discussion will focus on differences regarding how men and women relate to help-seeking behaviour. It will also look at the barriers and challenges that contribute to these differences. More specifically, this paper also attempts to explain what prevents men from making full utilization of available health promoting resources. The ensuing sections provide further engagement with the concept of help-seeking, given its centrality for this paper, and it also introduces and explains the concept of masculinity, which captures thoughts and opinions on how men do or should behave, including when it comes to help-seeking behaviour.

Help-seeking and masculinity

In addition to the description that is cited above, a Rickwood et al. [14] suggests that help-seeking can be divided into two different forms. The first form can be viewed as informal help-seeking which involves seeking help from social networks like family and friends [15]. The second is formal or professional help-seeking, which refers to any form of help-seeking from a recognised professional with-in their respective field of practice [16].

Hedge et al. [17] suggest that contrary to initial conceptions of help-seeking, the best results are obtained through a combination of informal and formal help. Hedge et al. [18] provide an example in which in the context of partner violence, a combination of informal and formal help-seeking is critical in reducing the associated mental health risks including anxiety and depression in women. This in turn allows for better conflict navigation and ensures self-protection from future violence.

Men hold similar practices to women in seeking informal help, engaging with friends and family [19] but this trend does not continue where formal help is concerned. One study found that men are less likely to seek help from medical doctors and informal services associated with medical conditions when compared to women, but are equally as likely to seek help from a psychological professional [20]. These findings were supported by Wendt and Shafer [21] who found that men were found to hold similar beliefs as women when it comes to mental health help-seeking, with some important exceptions. For instance, in the case of depression men held beliefs that professionals were inadequately experienced to help them deal with problems that are more emotional. COVID-19, and how men were inserted in discourses of prevention as resistant to taking vaccine against this fatal health threat, suggests both an urgent need to attend to and understand men’s help-seeking behaviour, and the complexity this phenomenon entails.

The notion of masculinity is key in thinking through men’s help seeking behaviour. As a concept it escapes a neat definition and varies across different cultural and social contexts. This has resulted in the formation of different theories in attempts to create a clear definition for it. Biological masculinity has been proposed as one of the explanations for attributes which can be seen as masculine. The core feature of this model is premised on the fact that the Y chromosome and hormones such as testosterone, are responsible for driving men to act in a specific way, such as being sexually adventurous and particularly prone to aggression [22]. This idea, however, is probably too simple as different authors have indicated that masculinity is not driven by biology but rather by social and cultural norms [23,24].

In 1985 Carrigan et al.[25] proposed a different explanation for the concept of masculinity. Their approach does not view masculinity as singular but rather as there being multiple masculinities. These different masculinities are not equal in nature and are arranged within a hierarchy. At the top of this hierarchy stands hegemonic masculinity, the idea that dominant men portray the stereotypical characteristics of being male and this is legitimised through society’s views of what a man should be [26]. This hegemonic masculinity can therefore be seen as the driving factor in the subservience of females and other marginalized groups of men. The concept of hegemonic masculinity has been challenged and reviewed many times within different fields of research but still remains a widely used concept today [27]. The concept of traditional masculinity proffers that male children are not born into the world with a predetermined masculine belief but rather construct these beliefs through the relationships they have with females and other males, and through what they are taught throughout their lives [28]. In this sense then, being a man and being a woman are perceived to be essentially different and having to be different. Kometsi (2004, p.12) emphasizes that behaviour that deviates from what is societally acceptable for both these genders is negatively sanctioned in an attempt ‘to call one back into line, coerce one into committing to the right performance’ or at the very worst, exclude or banish one from the masculine identity’. It may be appreciated then that if help-seeking behaviour is perceived to be a deviation from the expected masculine identity performance, it would put men in a serious predicament between wanting to be part of the masculine identity on the one hand, and engaging in activities that are health promoting or even life-saving on the other.

Research Methodology

The conundrum relating to the behaviour of consumers of professional services, particularly health-related services, is not a new issue. It has preoccupied the mental health and other professionals for some time, more so given the fact that poor cooperation between practitioners and patients affects the outcomes of treatment negatively and places a huge burden of wasted resources on society [29]. In more recent times, several African countries have had to destroy expired COVID-19 vaccines due to poor uptake by the citizens (Global Times, 26 December 2021). Reviewing literature on the concepts of adherence, compliance and concordance, Chakrabarti [29] points to the importance of prioritizing patients’ perceptions in providing care for patients. This paper focuses on men’s perceptions of help-seeking from the vantage point of how they self-imagine as men.

Research Design

To the extent that health care users’ behaviour relating to the use of professional services has been of concern over a period of time, there is existing literature that can be used to shed some light on this conundrum, especially as it has occupied a central place again through the concept of ‘vaccine hesitancy’ with the arrival of the COVID-19 pandemic. Akojie et al. [30] are of the view that important findings from evidence-based studies are being underutilized. Mounting an argument for the usefulness of qualitative meta-analysis in reviewing these studies, they quote Sadelowski [31] to make the point that the usefulness and relevance of existing qualitative research can be enhanced. These authors proffer that meta-analysis makes possible the development of a body of knowledge on a specific phenomenon. To elucidate this point further, Ahn and Kang [32] emphasise that meta-analysis makes possible an arrival at a conclusion with more power and accuracy than what could have been attained by individual studies on their own.

Meta-analysis forms part of an approach to conducting research that falls along a continuum of rapid reviews. According to Douba (2022) review publications range from critical review, meta-analysis, scoping review and systematic review to cite some examples, with all of these having different levels of selection strictness and structure, and analysis rigour. Ganan, Ciliska and Thomas [33] provide a different characterization and labelling of knowledge synthesis methods illustrating these variations (rapid review, rapid response, rapid evidence assessment, technotes, succinct timely evaluated evidence review, systematic review, to name but some of them). The approach used for this review is the narrative literature review. According to Green et al. [34], narrative literature reviews provide an objective descriptive summary the current knowledge, more to enhance understanding than to produce new knowledge. These authors state that although critiquing each study included in the narrative literature review is possible, ‘this is not necessarily a property of overviews’ (p. 103) or narrative literature reviews. Narrative literature reviews are flexible, allow for analytic depth, and allow for a description of what is known on a particular topic through examining and critiquing existing literature [35]. Ganan et al. [33] also state that methods for speeding up rapid reviews varied, and included searching by years, databases, language, and sources beyond electronic searches. For the current paper, purposive sampling was used as an approach to including selected publications on which to conduct narrative literature review. Purposive criterion sampling is a non-probability sampling technique where researchers specifically select individuals (publications in this instance) with particular attributes relevant to the study question [36]. The sampling process details are described below.

Sampling

The process of selecting literature first began with the identification of an area of interest. The area of interest which was decided upon for this project was situated within the general studies of masculinity and related to how men reconciled help-seeking behaviour with their self-imaginations as men.

The sampled material was obtained through searching available databases on the University of Johannesburg library webpage. These databases included PsycArticles, Psychinfo, Sage online journals and Wiley online library. Key words and phrases used for the search included men’s help-seeking behaviours, barriers to men’s help seeking, help-seeking, barriers to mental health help-seeking, help seeking for medical health and differences between men and women’s help-seeking behaviours, COVID -19 and gender differences, vaccine hesitancy, men and COVID-19, and vaccine uptake. These articles were then limited to articles published between 2000 and 2022.

Of the available articles the inclusion of each was decided upon based on the title and abstract, and the extent to which the content was evaluated as focusing on men’s help-seeking behaviours. Articles that did not focus on this subject, as well as those that fell outside of the specified publication years were excluded. The result was a selection of fifteen articles (Appendix A) for review, after which each of the selected articles was read. The selected articles were each considered on an individual basis by extracting its core content and argument. After each article had been analysed, they were then compared against one another to identify recurrent themes.

As stated above, knowledge synthesis research methods influenced both the design of the study on which this paper is based, as well as its data gathering approach, while thematic content analysis became the main method of data analysis. The benefits of using thematic analysis include a flexible approach which can be tailored to a specific study, being fairly more accessible, and allowing for the analysis of multiple perspectives (quantitative and qualitative) [37]. All of these were essential for the current study in which a number of disparate pieces of literature are synthesized to arrive at a point with a stronger elucidatory power.

Themes extracted from a selective literature review

The discussion below focuses on a total of seven themes, that emerged more strongly from the selective and admittedly limited review which has been conducted. The themes do not represent an exhaustive list, and there are overlaps between them. Each theme is discussed to illustrate its impact on men’s help-seeking behaviour. In this analysis, specific consideration is made in regard to how the theme of traditional masculinity will be discussed given its incorrect use in research to refer to the concept of masculinity as a whole instead of being used to specifically describe the concept of traditional masculinity as articulated above in the introduction [26]. Potentially, this theme may have obscure connections to the other themes in this review and may exaggerate their effects and was therefore discussed second last, before the focus turned onto the more specific men’s help-seeking behaviour in the context of COVID-19. The other four themes are as follows: gender role conflict; socio economic status and income level; engagement and quality of help received; and illness-awareness and knowledge.

Gender Role Conflict

Gender role conflict is defined by Wahto and Swift [38] as the consequences of engaging in acts that are found to contradict the stereotypical gender-role norms and these consequences may present in cognitive, emotional or behavioural forms. This definition is similar to that of Levant et al. [5] who state that gender role conflict occurs when adherence to social gender norms result in the restriction of behaviour or emotions. Gender role ideologies for men and women differ considerably, for example, women have been seen to be the primary care givers, care more about health in general, monitor others health and have a greater need for connectedness and self-disclosure. Male ideologies on the other hand may be associated more with aspects of risk taking, self-reliance and stoicism. In general men are seen to be responsible for the family’s economic needs [39]. The gender role conflict model suggests that some commonly used practices of therapy may contradict certain aspects of masculinity. This contradiction may leave men being less likely to seek, engage in, or even benefit from help [40].

Masculinity and femininity can be seen as gender role ideologies both of which play a role in the help-seeking behaviour of both genders. Nam et al. [41] state that individuals that possess a masculine gender role are significantly less likely to show an interest in seeking professional help when compared to individuals with a feminine gender role. Levant et al. [5] agree and state that individuals that endorse a traditional masculinity ideology in their everyday lives are less likely to seek help or express emotion even though they may believe that it would be beneficial.

Concurring with this view, Wenger [9] suggests that men may follow many different gender norms and may even challenge certain norms; however, they do this knowing that they will be evaluated on the appropriateness of their acts as men. This raises the notion of stigma, which may be related to both social aspects and aspects of oneself. Social stigma may result when society views men’s actions as inappropriate. This stigma does not only change the view of society but also the ideas of men themselves, meaning that not only do some men believe that seeking help would be seen as inappropriate by society, but such men may even view themselves as weaker (less traditionally masculine). Wasylkiw and Clairo [42] also make reference to what they refer to as ‘self-stigma’, asserting that help-seeking has been stigmatised as feminine. This conflicts with the self-imagination of men that have adopted masculinity as a gender norm. These authors add that men who have adopted a traditional masculine gender norm are more likely to self-stigmatise when it comes to situations which involve help-seeking. Finally, men who have held traditional masculinity norms will first have to overcome this self-stigmatisation as well as discomfort and negative beliefs before they may be able to benefit from professional help, particularly psychological help [40].

Socioeconomic Status and Income Level

Socioeconomic status and income level was also identified as playing a role in preventing men’s help-seeking. Socioeconomic status is defined as an intersection between an individual or group’s economic and social status with specific reference to income level, education and occupation [43]. Men are less likely to have health insurance, and health insurance status has been shown to have a significant impact on help-seeking. Individuals that are uninsured are less likely to go to the doctor when faced with a medical problem. This is due to the costs which may be incurred [4]. Magaard et al. [44] had similar findings suggesting that the availability of financial resources will impede or enable the use of health services at an individual level.

Lower economic status, as a result of lower income levels and unemployment, has been further linked to poor help-seeking behaviours by Möller-Leimkühler [45] and Keavey and Thompson [46]. These authors posit that men with a lower socioeconomic status are reluctant to visit a health care professional. When they do decide to approach a health professional it is through a general practitioner and not a specialist which may indicate that the treatment and care they receive may be of a lower quality. The impact of this phenomenon will be discussed later in this paper.

Within the Canadian population income and insurance levels have been linked to lower use of services, even under a government funded health insurance plan. In this case, beyond just the income level, other aspects of socioeconomic status play a significant role in help-seeking. For individuals that fall under a universal health care system, education level plays a more significant role in knowledge of illness and health help-seeking [47]. Farrimond [48] states that being a man that is able to take action in the face of health concerns may be a luxury only available to individuals that have got the time and resources to do so. Individuals from lower income levels are more easily disadvantaged in these instances. However, the idea of lower socioeconomic status being a predictor of poor help-seeking is not that simple. Parent et al. [12] state that income and poverty ratio which is a positive predictor of help-seeking in white men, had no relation to this behaviour in Mexican men and had a negative relationship with help-seeking within black men. This indicates that there is an important interaction between race, masculinity, and socioeconomic status impacting on help-seeking behaviour, rendering understandings of men’s help-seeking behaviour a much more complex phenomenon.

Engagement and quality of previous help received

Men’s current poor engagement with help-seeking behaviour may be a contributing factor to poor help-seeking behaviours in the future. Several studies have found that men do not engage in preventative health care practices, do not visit a physician and psychologist as often as women do, and fail to secure a regular health care practitioner [5,9,11,46]. This possibly demonstrates that women may be more aware of what avenues are available when the need to seek help arises. Given that men may be less knowledgeable of these avenues they may be more reluctant to seek help as they do not know what is available for the symptoms that they are experiencing, resulting in men seeking help much later than women.

Together with this late engagement with care facilities, men may also be reluctant to seek help due to past experiences. They tend to hold beliefs and expectations when they do engage in help-seeking behaviour, and these expectations may result in men having bad experiences and not making full utilization of the help or treatment they receive [5]. Seidler et al. [6] found that men would seek help as long as the help was accessible, appropriate for their situation and engaging. However, if men perceived the help that they are receiving as unengaging or as not meeting their expectations, chances that they will attempt to reengage at a later time or through a different service is low. This may not be the fault of the professional or practitioner as men may be reluctant to ask questions and fully comply during consultation, leading to poorer experiences and in turn reducing the chance of future help-seeking [4].

As a way to illustrate the a foregoing, men’s experience of persistent erectile dysfunction implicate late engagement, expectations and the quality of help that men receive. Erectile dysfunction is prevalent within the general population affecting around 20% of men in all age groups. This disorder can cause significant distress yet remains underreported and undertreated, with 70-80% of patients showing hesitance to get treatment, even though treatment options are readily available. The reasons for this have been given as embarrassment, thoughts that the physician will not take the problem seriously, fears of developing an addiction (relating to the medication provided), and the wish for anonymity throughout treatment [49-51]. Erectile dysfunction is also associated with both physiological and psychological factors, with available treatment options including psychological therapy, lifestyle changes, herbal or vitamin supplements and other medications (phosphodiesterase type- 5 inhibitors) [52,53]. The high level of prevalence but low levels of treatment, with such a large range of available treatments, shows that the barriers to help-seeking behaviour are a significant problem.

Henninger et al. [54] state that for men to be able to begin treatment they first have to have knowledge of where they can receive treatment and what treatment options are available to them. When one considers the “late engagement” as discussed above, this knowledge may be lacking. Secondly these authors show that between 70 – 90% of men are reluctant to seek treatment due to beliefs and expectations associated with their self-imaginations as masculine. Some of the expectations which are held by men are that there is no medical treatment, they may not be prepared to attempt any form of pharmacological treatment and finally the idea that the medical professional will not take their problem seriously. In an earlier study by Berner et al. [49] it was found that in the case of erectile dysfunction, men themselves did not perceive their condition as medically significant and as a result would not feel the need to seek help. Similar problems are shown by Seidler et al. [40] where one in four men have been shown to drop out of psychological treatment due to the fact that it did not meet their previous expectations.

Illness awareness and knowledge

Timely identification and interpretations of symptoms is important in the early stages of help-seeking in both the medical and psychological fields. It is for this reason that it is important to understand the way men perceive and interpret their symptoms and illnesses. Symptom perception is the conscious interpretation of a physiological problem or imbalance [55]. If help-seeking can be viewed as a process, as indicated in the definitions above, the consultation of a professional regarding one’s concerns can be seen as the last stage in the process. The first stage of help-seeking can be thought of as the identification of a problem or a concern, leaving men at a disadvantage before they even begin [4,45]. Inaccurate symptom identification and normalization of symptoms is one of the major drivers of delayed help-seeking [9]. Powell et al. [11] states that men engage in a “watch and wait” strategy, which entails them, having identified a problem but normalizing that symptom in-terms of their age, race or gender. Levant et al. [5] concurs with this, indicating that men do not seek help for problems which they identify as minor, rather waiting for the problem to either disappear on its own or worsen. In the event that the problem becomes more severe, men will then begin to consider seeking help. This is a detrimental practice, as it can result in what was once a manageable disease or situation, developing into something much more severe due to the delay. To provide another example regarding health problems that men experience, prostate cancer is shown to be responsible for 10% of all male cancer related deaths [56]. A delay in treatment may lead to the metastases of the prostate cancer, with the most common sight of metastasis being bone and lymph nodes. This results in a once more easily treated cancer developing into a more serious life-threatening cancer [46,57].

Illness awareness and knowledge can be tied to the themes of socioeconomic status. More specifically, poor education has been identified as an important factor related to insight into symptoms and attitudes towards treatment [47]. Late engagement in care practices such as preventative screenings and tests, are often the result of men simply not being as familiar with the symptoms.

Power and the counterbalance of femininity

It is important to acknowledge that masculinity cannot exist on its own, as it makes up one side of a coin with the flip side of the same coin being femininity. Masculinity has a socially determined set of characteristics. For instance, being masculine is associated with being inexpressive with emotions, aggressive, ambitious, analytical, independent and dominating. Femininity on the other hand has its own set of characteristics and a feminine person is perceived as being emotional, expressive, gentle, sensitive, understanding and submissive. In the context of help-seeking behaviour, it is important that we identify different characteristics as being perceived as part of masculinity or femininity because men may avoid certain situations due to the feminine connotations. In terms of these societal perceptions, the performance of one identity, is associated with the non-performance of the other.

Farrimond [48] states that being a good patient requires individuals to relinquish control and place their faith in the hands of the health care practitioners. Using the lens of differentiating between men and women’s behaviour as described above, this relinquishing of control can be seen as a feminine characteristic and therefore can be part of the reason men struggle to follow through with help-seeking. This idea is also raised by Galdas et al. [39] who also state that men are reluctant to release control of their situations and allow health practitioners to take control. This often results in men being “bad patients”. In the context of this paper, being a bad patient might include either not returning for follow-up sessions or not initiating the help seeking behaviour in the first place. Wahto and Swift [38] emphasize that seeking psychological help particularly can be perceived as a feminine trait, as tarnishing the masculine identity, or is associated with being weak. The negative perception of help-seeking behaviour does not relate only to possibly being seen by others as transgressing the masculine script, but it can also be internalised, affecting the way men feel about themselves. By rejecting health concerns and engaging in health risk behaviours, men cement themselves as the stronger sex within the social and self-stigma contexts [48].

It is important to distinguish to what extent men identify with certain masculinity norms, as this can then be a predicting factor in how they will respond to situations which challenge these norms, such as seeking help. Powell et al. [11] underscore this idea in asserting that identification with masculinity norms produce the most significant barriers to health help-seeking when they are foremost in men’s lives.

On the notion of ‘traditional masculinity’

Beyond the general notion of masculinity as being the opposite of femininity, there is also what is referred to as ‘traditional masculinity’. This concept recurs throughout the literature that was consulted, suggesting a need to pay some close attention to it. Like the general notion of masculinity that is discussed above, traditional masculinity is a socially constructed ideal and refers to the idea that men should be dominant, independent, aggressive and stoic [58]. Traditional masculinity is thought to further encompass four other areas which include rejection of femininity (in a man), the want to be powerful, self- sufficiency and aggression/dominance [42]. Importantly, we should point out that traditional masculinity is not constant and can have some variations linked to cultural and racial groups as well as differences within societies, socioeconomic status and sexual orientations. Even after accounting for these variations, the notion of ‘traditional masculinity’ in various contexts is still valorized as the norm for men, particularly those from Western cultures [11].

To explain why traditional masculinity produces such a powerful response in the form of help-seeking avoidance, Powel et al. [11] makes reference to reactance theory. Reactance theory attempts to understand why conformity to traditional masculinity norms in conjunction with other aspects of identity affects men’s help-seeking behavior. The core aspect of this theory is that individuals are less likely to seek help if they are confronted with life events which reduce their sense of control. Individuals who have a low sense of control feel helpless and attribute their lives to external factors such as luck or chance. On the other hand individuals who have a high sense of control attribute aspects of their lives to internal characteristics which foster the belief that they are responsible for their own life outcomes [59]. A diminished sense of control ties in with the notion that men are seen to be “bad patients” as they struggle to relinquish that sense of control even in the face of health challenges as stated above [39].

As may be deduced from this, both the general notion of masculinity, as well as traditional masculinity, contain aspects that overlap and run through the other three themes identified above. In the case of gender role theory masculinity is directly implicated as it represents a gender norm which men are socialized into and adopt both implicitly and explicitly. Men who conform to a traditional masculine ideology are less likely to seek help which may be linked to the values that the concept of ‘traditional masculinity’ is connected to (including self reliance, stoicism and emotional restriction amongst others). In the case of the quality of help that men receive and the stage at which they begin to seek help, masculinity may be linked as an underlying cause as seeking help and scrutinizing one’s body are seen as feminine practices and therefore may be avoided by certain men. This avoidance helps to reduce the challenges that men might experience in their performance of the masculine identity. By avoiding help seeking behaviour, men attempt to guarantee that nothing will pose a threat to how they self-imagine as being masculine [9].

Men and their masculinities in the context of COVID-19

Once the COVID-19 vaccine became available for the broader population in South Africa, there were media reports that men were not taking up the vaccine in numbers as high as women did. Borrowing from research findings relating to HIV testing and treatment uptake, Gibbs (2021) explored what explanations might exist in this regard. He stated that it was particularly in the age-group of men that were above 35 where the phenomenon of vaccine hesitancy had been observed. South African men evincing levels of vaccine hesitancy that were higher than women was inconsistent with the trend in research on vaccine hesitancy. Gibbs (2021) references findings from HIV testing and treatment suggesting that men’s lack of help seeking behaviour in this context related to ideas about masculinity and health, believing that the health services provisioning places are women’s places, and beliefs that they (men) could avoid the risk of infection. In this regard, Gibbs (2021) points out that men associate seeking testing and treatment with being vulnerable, and vulnerability is incompatible with certain performances of hegemonic masculinity. It is possible that these reasons might be implicated in this cohort of men being COVID-19 vaccine hesitant.

As stated in the introduction, COVID-19 related fatality rates are higher in men than in women [8], and this points to the urgency with which men’s help-seeking behaviour should be understood and integrated in efforts to promote vaccine uptake. In other studies, focusing on gender differences relating to responses to COVID-19, explanations of vaccine hesitancy go beyond just gender differences. For instance, Galasso et al [60] explores men and women’s responses based on perceptions of the seriousness of COVID-19, attitudes towards restraining measures, and compliance with rules. In this case still, women were found to perceive COVID-19 as being more serious than their male counterparts, agreed more with restraining measures, and complied more with rules.

Echoing Galasso et al. [60], Cooper et al. [61] focus on the South African context in regard to vaccine hesitancy, and conclude that what would promote vaccine uptake includes trust-building measures focusing on government transparency, opportunity for citizens to participate in COVID-19 response initiatives, and a sense of justice. Nonetheless, some of the studies that they review to arrive at this conclusion highlight the following findings in regard to COVID-19 vaccine hesitancy: men are more skeptical than women, and there are higher levels of distrust amongst men than amongst women. Cooper et al. [61] also point out that only one of the seven South African studies that they reviewed suggested that women are more hesitant to take up the COVID-19 vaccine. Despite these, and with the examples of the findings that are cited above in mind, it is clear that there are certain responses towards vaccine uptake that align with gender identities. Vaccine uptake in the context of COVID-19 is viewed as being part of help-seeking behaviour, and men seem to evince lower levels of this desirable behaviour in fighting the spread and severity of COVID-19 infections, at least in South Africa during the early stages of rolling out the vaccine.

Galasso et al. [60] also make an interesting observation in positing that countries that are led by women (Germany: Angela Merkel, New Zealand: Jacinda Ardern) have responded more effectively to the pandemic of COVID-19, whereas those that are led by men who have projected strong masculinity attitudes (United States: Donald Trump, and Brazil: Jair Bolsonaro) have tended to dismiss crucial precautions forming part of preventing the spread of COVID-19. This too, adds to the suggestion that in the context of fighting the COVID-19 pandemic, masculinities have been implicated in problematic ways, not only in South Africa.

Conclusion and recommendations

The purpose of this narrative review was to provide an understanding of men’s help-seeking behaviour for both mental and medical health issues. The objective was to shed light on the barriers to help seeking behaviour in men. It produced seven discussion points or themes exploring barriers for men against help-seeking behaviour. The specific areas included gender role conflict, socioeconomic status and income level, engagement and quality of help received, illness awareness and knowledge, power and the counter-balance of femininity, traditional masculinity, and help-seeking behaviour in the context of the COVID-19 pandemic. These barriers have been discussed individually to ensure an adequate exploration of each of them, and also to enhance clarity of factors that are involved. However, and as alluded to earlier in this review, it is more of an interaction between the themes under-which these barriers are discussed that impacts on men’s help-seeking.

There exists adequate literature both on the broad subject of men’s help-seeking behaviour, as well as on the more specific subject of the gendered responses to the COVID-19 vaccine uptake. Vaccine hesitancy is understood in this context as being linked to help seeking behaviour, to the extent that being vaccinated represented the most effective way to responding to the COVID-19 pandemic [62]. The availability of the literature covered allowed for modelling the writing of this paper as a rapid knowledge synthesis, leading to the identification of a few significant themes which were then used to illuminate men’s help-seeking behaviour.

Amongst the limitations of this paper is that the analysis and the findings are not based on primary research data. However, this paper utilized the rapid knowledge synthesis design, enabling the compilation of a purposive sample of papers that address men’s help-seeking behaviour in general, including in the context of the COVID-19 pandemic specifically. Narrative literature review, a form of rapid knowledge synthesis, involves an analysis and interpretation of existent findings to provide an objective summary of extant knowledge and thereby promote understanding. A narrative literature review by its nature does not purport to produce new knowledge. Considering the continuum of knowledge synthesis approaches that include meta-analysis and systematic literature review, these would be chosen when the objective is to synthesize knowledge so as to produce new conclusions. Narrative literature reviews are unsystematic as contrasted to systematic reviews, and the ideals of new knowledge production fall outside of their purview. For this paper, narrative was also attractive to the extent that it elides the dangers of capitalizing on chance while engaging this broad and complex question of men’s help-seeking behaviour [63].

Further, to the extent that we have called this a convenient or purposive sample of literature, there is a risk of bias in the selection of the literature sources. To address this, we used phrases and words that did not suggest the direction to which the findings of a given study would point. In particular, in the choice of articles relating to responses to COVID-19 vaccine, there exists divergent views on whether it is men or women who evince the higher level of vaccine hesitancy. In addition to men’s higher levels of vaccine hesitancy in South Africa being an inconsistent phenomenon to the rest of other studies done elsewhere, there is, nonetheless, data that suggests that gendered responses to the COVID-19 vaccine are worth understanding better to ensure nuance in encouraging people to respond to this much needed medical intervention accordingly.

There are more recent studies that suggest that men’s help-seeking behaviour is a more complex phenomenon than might have been covered in this paper. For instance, the concept of self-compassion has emerged as significant in understanding men’s help seeking behaviour Wasylkiw and Clairo (2016) suggesting that it predicts more positive attitudes toward help-seeking. However, Komlenac et al. [64] recommend a need for more research on the relationship between self-compassion and help-seeking behaviour in men, because their study concluded that self-compassion was not always a buffer promoting more help-seeking behaviour in men. Additionally, and in the context of the COVID-19 pandemic, Cooper et al. has suggested that there are instances where women may be more vaccine-hesitant than men, also pointing out that vaccine hesitancy has grown substantially over the years due to perceptions of vaccine unsafety, even regarding pandemics other than COVID-19. This notwithstanding, and more importantly for the current paper, these and other studies still uphold the understanding that ‘men have consistently been seen to have a greater reluctance to consult health professionals for health problems’ [13], making this overview an important contribution still.

Further, more pointed research is required to better understand how the diverse South African society relates to the concept of help seeking behaviour. As the experience with the COVID-19 pandemic suggests, there are ways in which South Africa, and other countries as well, could have been better prepared in responding to a pandemic of this nature. One of the ways in which to prepare is building on and integrating existent knowledge on men and their help-seeking behaviour in general. The COVID-19 pandemic has brought to bold relief that the availability of resources does not guarantee uptake, notwithstanding the detrimental impact of poor uptake. A much more nuanced understanding of social groups, as well as the ideologies affecting their behaviour is crucial in ensuring that available help gets used effectively.

Competing Interests:

The authors declare that they have no competing interests.

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