Health and Social Development, Faculty of (Okanagan)
Social Work, School of (Okanagan)
DSpace
UBCO
Pryzdial, Ian E.
Master of Social Work - MSW
University of British Columbia
Background: Men disproportionately experience the leading causes of death (e.g., heart disease, cancer), but are often hesitant to seek services for their health concerns. Additionally, suicide rates are higher for men, but they are less likely to be diagnosed with depression. Men’s under-reported illness and lower healthcare utilization is important in rural communities, where there are higher populations of older residents, less available local resources and less access to transportation to health services and that may further limit men’s intentions to seek help. This study aimed to gain an understanding of men’s perceptions and behaviours surrounding help-seeking. Research Design: Interpretive descriptive qualitative methods were used for the study. Data were collected via interviews with men living in two rural regions of the Southern Interior of British Columbia. Informal Community Conversations were also conducted in each region. Findings: Four themes on help-seeking were identified: environmental barriers (e.g., ruralness of communities, lack of health services); lack of health education or awareness; masculinity, with both positive and negative impacts; and informal support as a facilitator to help-seeking. Discussion: Men living in the rural communities of the Southern Interior face a range of external and internal barriers that limit their capacity to seek help when needed. Themes informed the thinking around a future framework of rural men’s help-seeking that highlighted the duality of these barriers. Additionally, findings were used to inform recommendations for changes in policy, practice, and education as well as future research specific to improving rural men’s well-being.
UNDERSTANDING HELP-SEEKING IN RURAL MEN OF THE SOUTHERNINTERIOR: A QUALITATIVE STUDYbyIan E. PryzdialB.A. (Psychology), University of British Columbia Okanagan, June 2017A THESIS SUBMITTED IN PARTIAL FULFILLMENT OFTHE REQUIREMENTS FOR THE DEGREE OFMASTER OF SOCIAL WORKinTHE COLLEGE OF GRADUATE STUDIES(Social Work)THE UNIVERSITY OF BRITISH COLUMBIA(Okanagan)October 2020© Ian E. Pryzdial, 2020iiThe following individuals certify that they have read, and recommend to the College of GraduateStudies for acceptance, a thesis/dissertation entitled:UNDERSTANDING HELP-SEEKING IN RURAL MEN OF THE SOUTHERN INTERIOR: AQUALITATIVE STUDYsubmitted by Ian E. Pryzdial in partial fulfillment of the requirements ofthe degree of Master of Social Work .Dr. Nelly Oelke, School of NursingSupervisorDr. Shelly Ben-David, School of Social WorkCo-SupervisorDr. Carolyn Szostak, Department of PsychologySupervisory Committee MemberDennis Jasper, School of NursingSupervisory Committee MemberDr. Joan Bottorff, School of NursingUniversity ExamineriiiAbstractBackground: Men disproportionately experience the leading causes of death (e.g., heart disease,cancer), but are often hesitant to seek services for their health concerns. Additionally, suiciderates are higher for men, but they are less likely to be diagnosed with depression. Men’s under-reported illness and lower healthcare utilization is important in rural communities, where thereare higher populations of older residents, less available local resources and less access totransportation to health services and that may further limit men’s intentions to seek help. Thisstudy aimed to gain an understanding of men’s perceptions and behaviours surrounding help-seeking.Research Design: Interpretive descriptive qualitative methods were used for the study. Datawere collected via interviews with men living in two rural regions of the Southern Interior ofBritish Columbia. Informal Community Conversations were also conducted in each region.Findings: Four themes on help-seeking were identified: environmental barriers (e.g., ruralness ofcommunities, lack of health services); lack of health education or awareness; masculinity, withboth positive and negative impacts; and informal support as a facilitator to help-seeking.Discussion: Men living in the rural communities of the Southern Interior face a range of externaland internal barriers that limit their capacity to seek help when needed. Themes informed thethinking around a future framework of rural men’s help-seeking that highlighted the duality ofthese barriers. Additionally, findings were used to inform recommendations for changes inpolicy, practice, and education as well as future research specific to improving rural men’s well-being.ivLay SummaryWhile men experience ill-health more frequently than women and under-report theirexperiences of mental illness, they tend to not seek help for their physical and mental healthconcerns. This is a particular problem in rural communities that have fewer resources and olderpopulations than urban areas. However, rural men’s beliefs and actions of help-seeking are notwell understood. This thesis sought to understand what rural men think about seeking help forhealth concerns and what barriers exist to doing so in the Southern Interior of British Columbia.Twenty-two rural men participated in the study; interviews were conducted with eight men and14 provided informal feedback about the research questions at rural community gatherings. Keythemes included: community barriers (rurality and lack of local services and providers), lack ofhealth education or awareness, masculinity (relying on themselves and fear of showingweakness), and the importance of informal support.vPrefaceThis thesis is original, unpublished work by graduate student Ian E. Pryzdial.Supervisors, Nelly Oelke and Shelly Ben-David, as well as supervisory committee members,Carolyn Szostak and Dennis Jasper, provided guidance for editing, formatting, and wording ofthis thesis. The graduate student led recruitment strategies, contacted potential participants,conducted interviews, and analyzed data. This study was granted approval by the University ofBritish Columbia Okanagan’s Behavioural Research Ethics Board [H18-01603].viTable of ContentsAbstract......................................................................................................................................... iiiLay Summary............................................................................................................................... ivPreface.............................................................................................................................................vTable of Contents ......................................................................................................................... viList of Tables ..................................................................................................................................xAcknowledgements ...................................................................................................................... xiDedication .................................................................................................................................... xiiChapter 1: Introduction & Definitions ........................................................................................1Men’s Health........................................................................................................................... 1Rural Communities ................................................................................................................. 3Rural Men’s Health................................................................................................................. 4Southern Interior of British Columbia .................................................................................... 4Summary and Rationale for Current Study............................................................................. 7Definitions............................................................................................................................... 8Health.................................................................................................................................. 8Mental Health ..................................................................................................................... 8Mental Illness...................................................................................................................... 9Health & Mental Health Concerns ................................................................................... 10Help-Seeking ..................................................................................................................... 10Rural ................................................................................................................................. 11Chapter 2: Literature Review ....................................................................................................12Health Service Utilization..................................................................................................... 12viiBarriers to Help-Seeking....................................................................................................... 15Tangible Barriers.............................................................................................................. 15Health Literacy ................................................................................................................. 17Masculine Norms .............................................................................................................. 19Summary ............................................................................................................................... 22Chapter 3: Methods .....................................................................................................................25Research Design.................................................................................................................... 26Methodology ..................................................................................................................... 26Study Population and Sampling ........................................................................................ 26Data Collection ................................................................................................................. 28Data Analysis .................................................................................................................... 29Ethical Considerations...................................................................................................... 31Storage of Data ................................................................................................................. 32Self as Researcher ................................................................................................................. 32Rigour ................................................................................................................................... 33Knowledge Translation and Outcomes ................................................................................. 35Chapter 4: Results........................................................................................................................37Participant Demographics ..................................................................................................... 37Environmental Barriers to Help-Seeking.............................................................................. 38Rurality of Communities ................................................................................................... 40Paucity of Local Service Providers................................................................................... 41Lack of Health Education or Awareness .............................................................................. 44Masculinity ........................................................................................................................... 45viiiSelf-Reliance ..................................................................................................................... 45Fear of Showing of Weakness ........................................................................................... 46Informal Support: A Facilitator of Help-Seeking ................................................................. 48Summary ............................................................................................................................... 50Chapter 5: Discussion ..................................................................................................................52Help-seeking for Rural Men in the Southern Interior ........................................................... 52Rural Health Services Versus Rurality: Environmental Barriers to Help-Seeking .......... 52How Rural Men Perceive Help-Seeking ........................................................................... 54Moving Towards a Future Framework of Rural Men’s Help-Seeking................................. 58Sociodemographic Factors ............................................................................................... 58Personal Factors............................................................................................................... 60External Factors ............................................................................................................... 61Help-Seeking ..................................................................................................................... 62Reflection on Engaging Men in Research ............................................................................ 63Strengths and Limitations ..................................................................................................... 65Recommendations................................................................................................................. 67Policy ................................................................................................................................ 67Practice ............................................................................................................................. 67Education .......................................................................................................................... 69Future Research ................................................................................................................ 70Next Steps ............................................................................................................................. 71Conclusion ............................................................................................................................ 72References .....................................................................................................................................74ixAppendices....................................................................................................................................89Appendix A........................................................................................................................... 89Appendix B ......................................................................................................................... 100Appendix C ......................................................................................................................... 101Appendix D......................................................................................................................... 103Appendix E ......................................................................................................................... 107Appendix F.......................................................................................................................... 111Appendix G......................................................................................................................... 113Appendix H......................................................................................................................... 114xList of TablesTable 1: Exemplar quotes from interviews and Community Conversations ................................ 39xiAcknowledgementsI would like to acknowledge a handful of individuals without whose strong support, this thesiswould have not been possible.First and foremost, my sincerest gratitude to my supervisors, Nelly Oelke and Shelly Ben-David.Your kindness and support during this process has been instrumental to my success. Thank youfor sharing your knowledge and experience with me. Both of you continued to spark my interestin research, even when I felt bogged down in writing and/or data analysis. Thank you for yourguidance, I am grateful to have worked with two such inspirational researchers.I would also like to thank my supervisory committee, Carolyn Szostak and Dennis Jasper. Yourfeedback throughout this project has been greatly appreciated. You both have helped improve thequality of this paper and simultaneously provided an extra source of support and validation.I feel incredibly grateful for my participants. Thank you all for entrusting me with yourperspectives and experiences. I learned far more than I could include in this thesis from you.Lastly, I want to thank my peers and family for supporting me in my academic pursuits.xiiDedicationI dedicate this thesis to my brother, the most resilient man I have ever known. His pursuit tobetter understand himself and the world around him is a constant source of pride for me.1Chapter 1: Introduction & DefinitionsFor rural-dwelling men, help-seeking for health and well-being concerns may pose adaunting and uncomfortable task. This thesis explores the factors that facilitate and act asbarriers to men seeking help in rural communities in the Southern Interior of British Columbia(SI). This chapter begins with an introduction of important issues surrounding men’s health andwell-being. This is followed by a brief discussion of rurality and its effects on men’s health.Contextual information on the setting of the study will then be provided, as well as socio-demographic information from these areas related to the health status, needs, and barriers toservices for residents. A rationale for the current study will be given, as well as researchquestions. Lastly, key terms will be defined.Men’s HealthAccording to the World Health Organization (2019a), globally, men have an average lifeexpectancy of 69.8 years, which is 4.4 years less than that of women. This disparity may suggestthat men experience more serious or frequent health difficulties than women. For example, menare, on average, more likely to die from road injury, interpersonal injury, and self-harm (Rosellaet al., 2016; WHO, 2019b). Additionally, men die more frequently from non-communicablediseases (NCD), including cancer and heart disease, than women (Griffith et al., 2019; Rosella etal., 2016;). This disparity may, in part, be the result of men also being more likely to engage inrisky health behaviour including: use of tobacco and alcohol, unhealthy diet, and lack of physicalactivity (Griffith et al., 2019). According to the WHO (2011), together, these behaviours lay thefoundation for NCDs by contributing to hyperglycemia, increased blood pressure, obesity, andhyperlipidemia. Poorer health outcomes among man have been suggested to reflect a biologicalpredisposition to illness and/or outcomes of socially constructed appropriate norms, values, roles,2and activities for men (WHO, 2019b). The latter is characterized when considering prevalence ofsuicide and mental illness in men.According to the Public Health Agency of Canada (PHAC) (2019), across the lifespan,men typically account for more deaths by suicide than women, while women attempt suicidethree times more frequently than men. Navaneelan (2017) reported that men take their lives byuse of firearms 17% more than women, perhaps suggesting that men have more access to (orreliance on) lethal means to take their own lives. The ratio of male-to-female deaths by suicidevaried across the lifespan, the lowest being between the ages of 10 and 19 with male youthaccounting for 58% of suicides (PHAC, 2019). Conversely, 80% of people who died by suicidein the 80+ age grouping were men. In Canada, men between the ages of 40 and 59 have thehighest suicide rates among adults (PHAC, 2019). In contrast to the higher rates of suicide, menhave been found to be less likely to be diagnosed with depression (a major factor contributing tosuicide) than women. This suggests that, in some cases, mental illness in men may be goingunrecognized or untreated (Canadian Institutes of Health Research [CIHR], 2014; Oliffe et al.,2012). The disparity between the higher rates of suicide and lower rate of mental illness has beenattributed to a variety of factors; such as a hesitancy on the part of men to seek mental healthservices or healthcare in general (Addis & Majalik, 2003; Spleen et al., 2014) and stereotypicalcharacteristics of masculinity being incompatible with admitting to having an illness (Oliffe &Phillips, 2008).Due to the issues of under-reported health concerns and healthcare avoidance, despiteincreased risk of illness and suicide for men, it is critical to gain a more comprehensiveunderstanding of men’s perceptions and behaviours surrounding help-seeking to inform best-practices for interventions and programs focused on men’s health and well-being. This is3particularly of importance in rural communities, where health concerns for men may beintensified, as access to services and supports may be more limited.Rural CommunitiesNational data of Canadian residents’ health status indicate a disparity between the overallhealth of urban versus rural-dwelling Canadians. Canadians living in rural regions typically havepoorer health than those living in larger urban centres (Commission on the Future of Health Carein Canada [CFHCC], 2002). In comparison to urban populations, residents of rural areas havehigher rates of disability, higher mortality rates, and demonstrate less healthy behaviours. Theunderlying causes of these disparities have been attributed to a number of sociopolitical factorsassociated with rural life. Rural populations typically have fewer resources and supports in theircommunities (such as healthcare and transportation), higher unemployment rates, lower averageincome, and lower education levels (DesMeules et al., 2012; Canadian Institute of HealthInformation [CIHI], 2006). As a consequence of these factors, higher rates of poverty have beenfound in rural communities, and residents often acutely feel the marginalizing effects of living ingeographically isolated areas (Hiebert et al., 2016). As well, rural communities typically have asmaller population of adults between the ages of 30 and 59 years old, instead having a far greaterproportion of adults aged 60 or older (British Columbia Ministry of Health [BCMH], 2015;DesMeules et al., 2012; CIHI, 2006). Older populations typically have greater physical andmental health needs and require access to a more diverse range of health services, such ashealthcare professionals (e.g., doctors, psychologists, counsellors), home support, and residentialcare (DesMeules et al., 2012). However, healthcare and social services in rural communities canbe lacking, meaning that travel to larger metropolitan areas is necessary to manage wellness(Halseth et al., 2015). This can make accessing appropriate healthcare a significant challenge for4older adults living in rural areas (Oelke et al., 2016; BCMH, 2015; Halseth et al. 2015; StandingSenate Committee on Agriculture and Forestry, 2006).Rural Men’s HealthGiven the determinants of poorer health in rural communities, men in geographicallyisolated rural communities are particularly at risk. Rural men's health is known to be poorer thanthat of women, with men having higher incidence of chronic disease, injuries, and motor vehicleaccidents (CIHI, 2006). Suicide rates for rural men are also higher than their urban counterpartsand men’s help-seeking behaviours were identified as an important predictor of deaths by suicidein rural communities (CIHI, 2006). Many men avoid seeking professional help from counsellingor other mental health services and from more general healthcare professionals (Addis &Majalik, 2003), but particularly rural men (Spleen et al., 2014). This avoidance may be a productof men not acknowledging a mental health concern due to fear of stigma and masculine ideas ofendurance and self-reliance (Oliffe & Phillips, 2008). However, other researchers have foundthat when men do seek help for mental health concerns, they prefer talk therapy over seekingsupport from medical doctors and romantic partners (Berger et al., 2013). Rural men’s access toinformal supports for their health concerns may also be limited by poorer quality relationshipswith family members and loss of close friends and spouses in later life (Kosberg & Sun, 2010).Together, these factors leave rural men more isolated in terms of supports for their healthconcerns. Of particular concern to the current study, the determinants associated with poorerhealth have been found to exist in the SI (Halseth et al., 2015; Oelke, n.d.).Southern Interior of British ColumbiaThe rural regions of the SI targeted by the current study cover approximately 10,411square kilometers in British Columbia (BC), constituting 1.2% of the province’s total land(Statistics Canada, 2017a). Predominantly, the economy of the SI is centered around agriculture5(fruit and wine production) and tourism (Halseth et al., 2015). The scope of the study comprisedsix of the major rural communities in the SI, in addition to rural surrounding areas. Thepopulations of these communities range from approximately 240 to 5000 people (StatisticsCanada, 2017a). Approximately 50% of the population in these communities is 50 years of ageor older and the proportion of older to younger adults is expected to increase (Interior Health(IH), 2018; Provincial Health Services Authority, 2016). Poverty is a significant concern in theSI, as over 50% of the population’s annual income is less than $29,999 (Provincial HealthServices Authority, 2016). Additionally, 49% of the population have a high school education orless, compared to the provincial average of 45% (Statistics Canada, 2017a).In terms of prevalence of mental illness and mental health needs in these communities,the rates of anxiety and depression in adults have been documented to be higher compared to therest of British Columbia (IH, 2017). This trend is evidenced by 31% of adults in this regionhaving had at least two visits to a family physician or a visit to an emergency health centre fordepression during the past year, compared to 25% of the general population. Similarly, 36% ofSI residents have sought help for their concerns of mood and anxiety disorders, compared to theprovincial average of 31%. According to Interior Health (2018), the prevalence of other chronicillnesses, such as diabetes (13% vs. 9%), chronic obstructive pulmonary disease at age 45 ormore (11% vs. 7%), and heart failure (4% vs. 2%) are also higher in the SI than the rest of theprovince. Although the SI region statistically checks many of the boxes that suggest ruralcommunities have poorer overall health and well-being than do larger urban centres, residents ofthese communities certainly have areas of strength and resiliency. Interior Health (2018)indicates that 87% of residents report having regular access to a healthcare provider (as opposedto the provincial average of 83%), 68% self-report having very good or excellent mental health,6and only 34% of adults over the age of 18 report less than 150 minutes of physical activity perweek, which is the same rate as the province (IH, 2018).A number of studies have been conducted in the SI region aimed at assessing the mentalhealth needs of the area. Additionally, barriers to mental health and well-being have beeninvestigated. In a 2015-16 study, Oelke and colleagues 2016) held community focus groups withcommunity members and local mental health and social service providers to gain a betterunderstanding of the experiences of rural older adults with mental health concerns. Results forthe study identified six main themes of concern. Accessing services was difficult for communitymembers because it was neither clear what services were available locally, nor when or how theycould be accessed. Further, residents did not know how to access or be referred to services orspecialist care outside of their communities. Frustration with the limited capacity of mentalhealth services was also identified as a concern of locals and stakeholders. Residents felt theirlocal services were unable to meet the complex and critical needs of their communities. Longwaitlists for the few available healthcare professionals also significantly limited the capacity oflocal service use and was identified as a major concern. For this reason, many residents reportedthat they sought services in other communities; however, transportation to these larger urbancentres was difficult due to inconvenient bus schedules and hazardous road conditions in wintermonths.Poverty was reported to be a factor influencing mental health service utilization, and alsocontributed to the overall health of residents (Oelke et al., 2016; Oelke, n.d.). Some individualsreported that their socioeconomic status reduced their standard of living by forcing them intosub-standard housing, perpetuating food insecurity, and social isolation. Some reported socialisolation as also being the result of stigmatization of their mental health concerns, such that therewas a loss of social networks with family and friends. As well, stigma reduced the likelihood of7seeking mental health services from fear of being ostracized. This was due to residents feelingtheir communities afforded little privacy, which limited confidentiality in accessing services.When asked how the mental health of their communities could be improved, residents andstakeholders identified increased hours of mental health services, increased social connectedness,and access to life skills workshops as being paramount community needs (Oelke et al., 2016;Oelke, n.d.). However, as very few rural men participated in these focus groups, barriers to help-seeking specific to men living in the SI are still largely unknown.Summary and Rationale for Current StudyDespite evidence that living in rural communities contributes to poorer health outcomes,the health and well-being status and needs of these communities are poorly understood. Previousresearch conducted by Oelke and colleagues (n.d.) sought to explore the mental health servicesand support needs of rural communities in Regions A and B in the SI. However, the help-seekingbarriers of men in these regions are still unclear. Ignoring the perspectives of men risksperpetuating stereotypical gender norms that are barriers to help-seeking (CIHR, 2014). Beinguncomfortable admitting to experiencing health concerns and delaying help-seeking are thoughtto contribute to depression being under-diagnosed in men (CIHR, 2014; Oliffe et al., 2012).Assessment of hidden male depression and mental illness in rural communities is particularlyimportant within the context of under-reported mental illness due to the determinants of poorerhealth in rural areas, perhaps, exacerbating symptoms of poor mental health. This thesis willattempt to clarify the help-seeking behaviour and needs of men in the SI. To this end, key termsimportant for understanding the concepts explored in this document are defined following thissection. This thesis sought to describe the rural-specific barriers to seeking help for physical andmental health concerns for men living in rural communities and elucidate how these menperceive seeking help and their ability to do so in their community. To complete these objectives,8the research considered the questions: 1) What barriers to help-seeking do rural men experiencefor health concerns? and, 2) How is help-seeking for health concerns perceived among ruralmen?DefinitionsHealth“Health” is used to refer to “a state of complete physical, mental, and social well-beingand not merely the absence of disease or infirmity” (World Health Organization (WHO), 2006,p. 1). However, health is not universally experienced equitably. Inequalities exist as a function ofhow individuals experience and cope with a broad range of factors that affect health. Some of themajor recurring factors include income and socioeconomic status, social support and networks,education and literacy, employment, working conditions, social environment, physicalenvironment, personal health behaviours and coping skills, childhood development, genetics,available healthcare services, gender, and culture (WHO, 2019a). Individually, these couldcontribute to poorer health due to biopsychosocial disadvantage or sociopolitical persecution;however, there is a cumulative cyclical effect wherein factors negatively impacting an individualmay work to create further disadvantage in other areas, thereby influencing further factors, andso on.Mental Health“Mental health” refers to “a state of well-being in which the individual realizes his or herown capabilities, can cope with normal stresses of life, can work productively and fruitfully, andis able to make a contribution to his or her community” (WHO, 2001, p. 1). More specific to theCanadian context of this thesis, the Public Health Agency of Canada (PHAC) (2006) has definedmental health as “the capacity for each and all of us to feel, think, and act in ways that enhanceour ability to enjoy life and deal with the challenges we face. It is a positive sense of emotional9and spiritual well-being that respects the importance of culture, equity, social justice,interconnections and personal dignity” (p. 2). The PHAC’s definition functions to focus theconceptualization of mental health on positive subjective factors that work to help individualscontinue living despite stressful life circumstances. In relation to the latter portion of thedefinition, it is important to acknowledge the ways that individuals’ beliefs, values, culture,religion, experiences, etc. shape their subjective understanding of their own mental health andthe approaches they use to promote mental health. Further to this point, Ryff and Keyes (1996)identified additional dimensions of mental well-being that included: positive self-esteem,mastery of environment, quality relationships with family and friends, continued personalgrowth, purpose in life, and self-determination. Increased emphasis on these characteristicsworks to promote acknowledgement of areas of strength and resiliency in individuals who arefacing adverse life circumstances, such as mental illness.Mental IllnessThe fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5)states that no single definition can accurately capture all aspects of all mental illnesses(American Psychiatric Association [APA], 2013). A reductionist conceptualization of mentalillnesses stipulates that they are syndromes “characterized by clinically significant disturbance inan individual’s cognition, emotional regulation, or behaviour that reflects a dysfunction in thepsychological, biological, or developmental processes underlying mental functioning” (APA,2013, p. 20). In addition, mental illnesses are typically associated with distress and diminishedfunctioning in areas of daily life; such as, social relationships, education, and occupation. TheDSM-5 includes two stipulations to their definition of mental illnesses: 1) a socially or culturallyacceptable response to commonplace stressful events (such as loss of a friend or family member)cannot be considered a mental disorder, and 2) a behaviour that is socially unacceptable (such as10criminality or interpersonal conflict) is not indicative of a mental disorder unless the behaviour isthe result of disordered cognition (APA, 2013). More holistic conceptualizations of mentalillness support its onset as being rooted in the interaction of countless biopsychosocial-spiritualfactors (Berzoff, 2011). This is not to say that all people who are biologically or psychologicallypredisposed to having mental illness will develop one during their lifetime; as well, subjectiveinterpretation of stressful life events may or may not help to catalyze the onset of mental illness.Health & Mental Health ConcernsHealth concerns are a much broader range of biopsychosocial experiences that theindividual identifies as abnormal in relation to their typical homeostatic baseline. In a 2018paper, Rubin defined mental health concerns as occurring, “when a person seeking mental healthservices expresses. . . a concern about any of these topics: behaviour, emotion, mood, addictions,meaning of life, death and dying, managing chronic pain, work, relationships, education, eating,cognition, sleep, and challenging life situations” (p. 103). Expressed concern in these areas maybe construed as a risk factor for mental illness; however, a person may remain mentally healthywhilst experiencing a mental health concern or illness. Broadening Rubin’s (2018) definition torelate more generally to health and well-being, a health concern can be defined as biological,environmental, or social factors that result in an increase of risk for an individual to experiencepoorer health.Help-Seeking“Help-seeking” is used to refer to the act of reaching out to health service providers ormembers of one’s social network, including family and friends, for assistance and support inaddressing health concerns (Barney et al., 2006). The help a person seeks may be for eitherphysical or mental health concerns. Further, the help one receives may include treatment (such as11from a doctor or psychologist), health information and education, or simply support andrecommendations for further action (such as from family and friends).RuralThere are many different ways to operationally define what a “rural community” is. Forthe purpose of this paper, a community or town may be categorized as rural when it meets thecriteria of being located outside of the commuting zone of a larger urban centre with a populationof at least 10,000 (Statistics Canada, 2016; du Plessis et al., 2002). Further, to better focus oncommunities that face social issues exacerbated by being geographically isolated, this definitionwill include the additional criterion of having less than 30% of the population commuting to alarger urban area for the purpose of work. This encapsulates rural areas that have moderate (5%-29% population commuting for work [PCW]), weak (1%-5% PCW), or no (0% PCW) influencefrom metropolitan areas. du Plessis and colleagues (2002) assert that such considerations areimportant to show the effects of urban access for rural populations; the lack of which has beensuggested to exacerbate negative health outcomes in areas that struggle to provide necessaryinfrastructure for residents. Importantly for the current project, six rural communities in the SIhave been found to meet this classification (Statistics Canada, 2016). Three communities residedin a smaller geographic subdivision, herein referred to as Region A, while the other three residedin another subdivision of the SI, Region B.12Chapter 2: Literature ReviewThis chapter will provide a review of articles identified through literature searches of thedatabases CINAHL, Medline, PsycINFO, Social Service Abstracts, and Social Work Abstracts tobe relevant to rural men’s help-seeking, including for both psychical and mental health concerns.Inclusion criteria were peer-reviewed articles, English language, and date of publication between2009 and 2019. Exclusion criteria included books, protocols, and review articles. Articles thatdid not have a significant or specific focus on men’s health were also excluded. As well, articlesfocused on specific cultural, geographical, or socioeconomic contexts that were markedlydifferent from Regions A and B (such as rural villages in Africa) were excluded due tosociopolitical contexts differing significantly from the current study. Samples consisting solelyof participants under 19 years old were excluded for consistency with the recruitment strategy ofthe current study. Through these screening criteria, 25 articles were identified and reviewed.Articles ranged in setting, which included Australia (14 articles), the USA (6 articles), Canada (3articles), Chile (1 article), and Jamaica (1 article). Eleven articles utilized a qualitativemethodology, while ten were quantitative. Three articles used mixed-method design. Moredetailed information on the articles included can be found in Appendix A.The following sections of this chapter will include an examination of the current patternsidentified in rural men’s help-seeking. This will be followed by a discussion of factors thatlimited men’s intentions to seek help. These included both tangible barriers (such as not havingtransportation to a healthcare professional), educational barriers (such as low levels of healthliteracy), and personal barriers (mainly centered on masculine norms).Health Service UtilizationMen sought help for health concerns from a variety of resources, but not all potentialsupports were utilized equally, nor were all men equally likely to seek help compared to women.13General practitioners (GP) were found to be the primary contact for healthcare for some men(Misan et al., 2017). Among Misan and colleagues’ (2017) sample of 154 rural Australian Men’sShed participants (mean age 66 years), 95% identified their GP as the person who theycommonly sought medical advice from. Preventive health checks and physically limitingexperiences of pain were identified as the most common reasons for seeing a doctor (84.8% and82% respectively). Further, 79% of men reported discussing health concerns, including bloodpressure and cholesterol, with their doctor in the last 12 months (Misan et al., 2017). Whiledoctors were identified as the primary source of help for these men, it was important to consideralternative pathways to healthcare that men may follow, as well as the barriers they mayexperience due to the nature of their health concerns. These factors had the potential to influencetheir utilization of formal healthcare services.Following this premise, the majority of men in Misan and colleagues’ (2017) indicatedthat they relied on family members (72.8%) and partners (71%) as sources of health information,suggesting that their close friends and family may function as a significant source of adviceregarding health concerns, such as pain or severe symptoms of disease. Men underused particularservices due to perceptions of embarrassment or shame in regards to the symptoms they wereexperiencing. Misan and colleagues’ (2017) also identified that men were least likely to havevisited a doctor for mental health concerns (16%) and cancer of the bowel (21.7%) or prostate(35.9%). This was consistent with other research, which reported that rural men under-usemental health services and sexual health clinics when compared to their urban male and ruralfemale counterparts (Corboy et al., 2014; Labra et al., 2019; Staniford et al., 2009; Su et al.,2016). However, simply being rural was not found to consistently predict decreased help-seekingfor cancer symptoms in a qualitative study with 13 urban and rural Australian men (Fish et al.,2019). In this study, Fish and colleagues (2019) identified that difficulties in accessing healthcare14due to low availability of services and being overly optimistic regarding symptoms weresignificant barriers to rural men’s help-seeking. Corboy and colleagues (2014) identified ruralitydid limit over-the-phone psychological support following radical prostatectomy in ruralAustralian men, and suggested this may be related to men’s preferences for face-to-face services,mistrust of outsiders from urban centres providing the service, and men’s stoicism.Age was found to mediate rural men’s help-seeking needs in a number of studies;however, its effects were not always consistent. For example, findings highlighted the possibilitythat younger and older rural men may perceive different needs when accessing help. Labra andcolleagues (2019), identified that for Chilean rural men 55 years of age and older followingexposure to a major earthquake event, confidentiality, professionalism, and a welcoming staffwere the primary characteristics they considered when accessing social services and healthcare.On the other hand, men under the age of 55 viewed climates of trust, healthcare providers’reputation, weekend hours, and welcoming staff as most important for them to seek help (Labraet al., 2019). This suggested that for older men welcoming and courteous environments greatlyimpacted their intent and follow-through for help seeking, while for younger men, ease of accessand reputation or quality of service were most important for them to seek help (Labra et al.,2019). However, feelings of trust and privacy greatly affected decisions to seek help and stayconnected to healthcare services among older and younger men (Fischer et al., 2016). Feelings oftrust have also been found to facilitate informal help-seeking among Canadian farmers and havebeen reported to develop in the context of engaging in shared enjoyed social or physicalactivities (Roy et al., 2014). This could have included participating in local sports leagues orvisiting a local coffeehouse or bar with a group of peers. Age was also found to affect ruralmen’s likelihood of accessing health services. For example, in a sample of 447 rural Australianmen, Corboy and colleagues (2011) found that men who accessed mental health services were15significantly more likely to be younger than those who did not (M = 65.1 versus M = 73.05respectively). As well, among a sample of rural Chilean men, those 54 years old and youngerviewed seeking help more positively than did older men (Labra et al., 2019). In contrast, Oberoiand colleagues (2016) found that Australian rural men younger than 50 years of age were lesslikely to advise others to seek help from a GP for symptoms of lower bowel disease.Education and income were also found to moderate rural men’s help-seeking. Higherlevels of education and income have been found to be associated with being more open towardhelp-seeking (Labra et al., 2019; Oberoi et al., 2016). When seeking help, rural men with lesseducation (e.g., primary-level), tended to value climates of trust and good service reputation thehighest, while welcoming staff and weekend hours were also important (Labra et al., 2019). Onthe other hand, Labra and colleagues (2019) found that rural men with secondary-schooleducation or higher, valued confidentiality, professionalism, and welcoming staff the most whenseeking help for health concerns. Clearly, rural men’s help-seeking is influenced by a number offactors, including demographic characteristics and characteristics of the help itself. These factorsacted as both facilitators and barriers to help-seeking in certain cases; however, otherpsychosocial factors exist that function to impede or support rural men’s help-seeking.Barriers to Help-SeekingTangible BarriersBy virtue of living in rural and remote regions, rural-dwelling men may experiencebarriers to help-seeking that were unique to these areas. For example, among men in Connell andcolleagues’ (2019) sample of African-Americans living in rural communities along theMississippi Delta, poverty, high unemployment rates, and lack of medical insurance andhealthcare professionals were unanimously identified as barriers to seeking help. Rural men havealso been found to delay help-seeking due to being in the workforce and not being able to take16time off to access help, as there is no one else to cover working hours for them (Emery et al.,2013). Indeed, this incompatibility between help-seeking and rural men’s conflicting roles atwork and in the home were identified by other authors as a barrier (Emery et al., 2013; Fish etal., 2019).Other researchers found that in more ethnically diverse communities, language barriersexisted between clients and practitioners (when and if they were available), such that interpreterswere necessary (Radermacher & Feldman, 2015). Family members were often asked to fulfil thisroll because third-party interpreters were often unavailable in rural communities. However,sometimes neither a third-party, nor a family member interpreter may be appropriate or desirablefor rural men (Radermacher & Feldman, 2015). Lack of confidentiality was particularly an issuefor men experiencing depression living in small Canadian rural communities where privacy waslimited due to the close proximity of other residents (Creighton et al., 2017). In these cases, ruralmen may feel they were unable to seek-help without other residents noticing and gossipspreading quickly. Conversely, other researchers identified the tight-knit nature of ruralAustralian communities as a barrier to help-seeking because rural men feel sufficiently supportedby their social networks (Corboy et al., 2011). While rural men may have felt content seekingsupport from trusted informal networks, they may have had no interest in seeking help as somemen did not trust formal resources. For example, some studies identified that, rural men who hadnegative experiences or interactions with local agencies were less likely to seek help from them,believing them to be ineffective, non-responsive to their needs, and uncaring (Emery et al., 2013;Fischer et al., 2016; Isaacs et al., 2013). As well, rural men who believed available services wereunaffordable will not seek help (Radermacher & Feldman, 2015); however, in some samples ofrural men, this barrier was only identified by a minority (Corboy et al., 2011).17Across many studies, issues of transportation were frequently cited as a significant barrierto rural men seeking help (Bennett at al., 2011; Bourne et al., 2010; Connell et al., 2019; Corboyet al., 2011; Emery et al., 2013). As rural communities often did not have local healthprofessionals or centres, rural men were commonly forced to travel long distances to obtain help;however, not all rural residents endorsed that transportation was a concern (Bourne et al., 2010;Corboy et al., 2011). Among Corboy and colleagues’ (2011) sample of Australian men, travelwas not perceived as an issue by those who felt adequate services were available in their regionor via the telephone. Many rural men, especially older men, reported not having access toadequate transport (personal or public) and often had to ask and/or pay neighbours or familymembers to drive them to appointments (Bennett et al., 2011; Connell et al., 2019; Corboy et al.,2011). Collectively, these systemic and geographically-related factors presented significanttangible barriers to rural men’s help-seeking.Health LiteracyAmong their sample of rural Australian men and service providers, Radermacher andFeldman (2015) identified that rural men, particularly older men, often did not seek medical helpuntil they experienced severe symptoms. Similarly, in another rural Australian sample, Su andcolleagues (2016) found that rural men only used formal healthcare services as a last resort andtypically tolerated uncomfortable and irritating symptoms. Other research supported this delay inhelp-seeking due to perceptions of non-critical symptoms, such as symptoms that were perceivedto be milder and more intermittent (Emery et al., 2013; Fish et al., 2019). Instead, rural menmore readily sought help when they experienced drastic changes in the severity of theirsymptoms (Emery et al., 2013; Fish et al., 2019). This suggested that men minimized distressingsymptoms until they drastically worsened (Emery et al., 2013). In relation to this, Emery andcolleagues (2013) suggested that among their sample of rural Australian men, men’s over-18optimism about their health contributed to their evaluation their symptoms as benign, whichfunctioned to delay help-seeking as men attempted to self-manage these symptoms. The highprevalence of self-doubt regarding the seriousness of symptoms and optimism of theeffectiveness of self-management, suggested rural men may have lower levels of health literacy.In a study of 1020 rural Jamaican men, Bourne and colleagues (2010) found that only44.5% were health literate versus 56.9% of 980 urban residents. While this suggested that mostmen, urban and rural, had limited awareness and/or understanding about health, rural men wereeven less health literate than urban men. This paucity of health knowledge among rural men wasalso observed in Australian samples, and concerned a range of health topics, including cancers,sexually transmitted infections (STI), and mental illness (Fish et al., 2019; Isaacs et al., 2013;Misan et al., 2017; Radermacher & Feldman, 2015; Su et al., 2016). Rural men’s limitedknowledge around mental health was also highlighted in a study of Canadian men’s experiencesof depression in a rural town in British Columbia (Coen et al., 2013). Coen and colleagues(2013) identified that among their participants, depression was thought to be caused by aninability to overcome affronts to manly virtues. This belief perpetuated stigma surroundingmental health, as well as a culture in which men’s help-seeking was discouraged (Coen et al.,2013).Level of education was found to affect men’s knowledge of health-related topics.Understandably, men who were less educated were more likely to be health illiterate and,consequently, less likely to seek help (Radermacher & Feldman, 2015; Su et al., 2016).However, Fish and colleagues (2019) suggested that rural men’s health illiteracy may bemediated by conformity to masculine norms that perpetuated feelings of invulnerability to healthconcerns. To counteract feelings of vulnerability, rural men may have taken a naively optimisticapproach to their health concerns. Researchers identified an “I’ll be alright” or “it will go away”19attitude among rural men towards their health concerns, which often prompted them to wait-outtheir symptoms instead of seeking help (Fish et al., 2019; Radermacher & Feldman, 2015).Men’s perceptions of shamefulness or weakness in experiencing health concerns wereexceptionally problematic because such beliefs represented the outcomes of socially constructednorms that dissuaded rural men from help-seeking until a critical health incident occurred.Masculine NormsWhile other barriers to rural men’s help-seeking could be partially attributed tosituational factors, such as simply having lived in rural communities or having not been educatedin health matters, some inherent aspects of being men functioned as significant barriers to help-seeking. Manhood and machismo in rural men have been found to be a product of genderedsocialization and included a range of domains of masculine ideals or norms that lead men toperceiving seeking help as un-masculine and therefore undesirable (Fish et al., 2019; Getrich etal., 2012; Herbst et al., 2014). Across studies, the particular masculine norms varied, butcollectively painted a detailed picture of what a “good” rural man looked like. For example, Fishand colleagues (2019) identified aspects of rural masculinity including being successful andpowerful, stoic or emotionally in control, and self-reliant, all potentially contributing to delayedhelp-seeking. The Australian men were also found to prefer appearing strong or tough, to believethat they were invulnerable to illness, and value of privacy (Fish et al., 2019). Similarly, Herbstand colleagues (2014) identified that among rural men involved in rodeo and ropingcompetitions in the US, emotional control, power over women, and self-reliance had significantnegative correlations with help-seeking behaviours (including talking with peers, familymembers, or a spouse and reaching out to a doctor or mental health worker). Additionally,heterosexual self-preservation was identified by a number of researchers as a masculine idealthat greatly affected rural men’s help-seeking by making certain medical screenings taboo, which20reinforced the unacceptability of talking about health problems, and ostracized rural men whomay have been questioning their sexuality (Creighton et al., 2017; Emery et al., 2013; Getrich etal., 2012; Herbst et al., 2014). While rural men could be characterized broadly as embodyingmental and physical endurance, Coen and colleagues (2013) identified a plurality of ruralmasculinities in their study of rural Canadian men. Despite this, experiences of illness,particularly mental illness, were still viewed as problematic in their capacity to impact men’sability to uphold masculine ideals (Coen et al., 2013). Further, Roy and colleagues (2014)identified more fluid masculine practices becoming acceptable among Canadian farmers as oldermen retired from farm life and younger men took over. Among the traditional masculine normsidentified above, several were highlighted across numerous studies as particularly conducive topoor help-seeking behaviours, including: toughness versus weakness, stoicism, and self-reliance(Fish et al., 2019; Getrich et al., 2012; Herbst et al., 2014).To rural men, being perceived by others as weak was unacceptable. This belief wasidentified in Connell and colleagues’ (2019) sample of rural African-American men as a productof gendered socialization, which taught young men that going to a doctor was a feminineactivity; instead, men were expected to be tough enough to manage their own problems. Thissentiment was supported by the majority (81.9%) of Labra and colleagues’ (2019) SouthAmerican sample, who felt that seeking help made them feel weak, as well as in other American(Fischer et al., 2016). In particular, a number of studies reported that men felt a great deal ofvulnerability and weakness when they sought help for mental health concerns (Coen et al., 2013;Creighton et al., 2017; Fischer et al., 2016; Perceval et al., 2018). In Creighton and colleagues’(2017) study of Canadian rural men, this perception led to men being self-reliant in managingtheir mental health concerns rather than seeking help from others. Rural men’s tendency for self-21reliance in the face of mental health concerns was identified by their family members as acontributor to men’s suicide (Creighton et al., 2017).Self-reliance was reported by many researchers to be a critical barrier to help-seeking forphysical and mental health concerns in rural men (Bennett et al., 2011; Corboy et al., 2011;Fennell et al., 2018; Fennell et al., 2017; Fischer et al., 2016; Labra et al., 2019; Staniford et al.,2009; Perceval et al., 2018). Labra and colleagues (2019) found that self-reliance was pervasiveamong their sample of rural men. Approximately 91% supported finding solutions by themselvesin the event of medical difficulties. This belief was more prevalent among older men in thesample, as 100% of men over the age of 55 (n=45) indicated that they would attempt to solveproblems on their own, while 94.7% indicated that they felt their pride would suffer if theysought help and that they would not disclose their problems to others (Labra et al., 2019). Self-reliance not only functioned as an ideal of rural masculine identities, it also in itself functioned asa pathway to alternative, gendered forms of help-seeking. These could have been risky healthbehaviours, such as self-medicating through drugs and alcohol, or engaging in distractingbehaviours, such as intense involvement in sports or alternative medicines (Creighton et al.,2017; Isaacs et al., 2013; Misan et al., 2017). However, Roy and colleagues (2014) identifiedamong their sample of Canadian farmers that some men re-interpreted their independence(associated with self-reliance) as a strategy for legitimate formal help-seeking as an appropriatechoice for men. In these cases, help-seeking was facilitated by men perceiving their own well-being as more important than conforming to masculine norms. Further, participants in Roy andcolleagues’ (2014) study viewed other farmers who had sought help and publicly disclosed theirexperiences favourably, hoping that such practices and transparency would help to normalizemen’s help-seeking.22Stoicism, defined as endurance of hardship or pain without complaint (Fischer et al.,2016), was also identified as a barrier to rural men’s help-seeking and its effects were found tobe more acute within rural communities (Corboy et al., 2014). Stoicism often was thought torelate to control of emotional expressions of one’s distress (Corboy et al., 2011; Fish et al., 2019;Fennell et al., 2018). For example, Fennell and colleagues (2017) found that Australian menwere significantly more likely to identify stoicism as a barrier to seeking help from healthcareprofessionals for mental health than physical concerns and endorsed personal barriers, such asclaiming to not like getting emotional about things. Similarly, preference for not showingdistress to others was reported to be a barrier for men seeking help for mental health concerns(Fennell et al., 2018). Among Creighton and colleagues’ (2017) Canadian study focusing onsurviving family members of rural men who had died by suicide, masculine norms of toughnessand stoicism were indicated to be prevalent in their community’s trades-oriented economy. Oneparticipant recounted her son being shamed at his workplace by his boss when liquid metal fellon him and severely burned him. She stated that the boss had laughed and told her son to “suck itup” when he was in significant pain (Creighton et al., 2017). This finding indicates that stoicismcan also be associated with expressions of physical distress. Additionally, this story alsosuggested that rural men may perceive a great deal of stigma for acting contrary to traditionalmasculine norms. This both reinforced conformity to gender norms and acted as a barrier to help-seeking (Coen et al., 2013; Corboy et al., 2011; Fischer et al., 2016; Getrich et al., 2012; Isaacs etal., 2013; Perceval et al., 2018; Su et al., 2016).SummaryThis literature review provided an overview of the current evidence surrounding thecomplexities of the help-seeking beliefs and behaviours of rural-dwelling men. Althoughresearchers identified high rates of common health and mental health concerns (Bennett et al.,232011; Misan et al., 2017; Radermacher & Feldman, 2015; Staniford et al., 2009) among thispopulation, often only a minority of men sought help for these issues (Bourne et al., 2010;Corboy et al., 2014; Labra et al., 2019; Misan et al., 2017; Staniford et al., 2009; Su et al., 2016).Of critical importance, researchers additionally identified that rural man were particularlydisinclined to seek-help for mental health concerns (Misan et al., 2017; Radermacher &Feldman, 2015). Gendered socialization and traditional masculine norms were found to play acritical role in men delaying help-seeking. Specifically, norms of stoicism, self-reliance, andtoughness presented barriers to help-seeking because rural men wished to avoid perceived publicshame and stigma for appearing weak by showing their vulnerability or distress and reaching outto others for help (Fish et al., 2019; Herbst et al., 2014; Labra et al., 2019). Other researchersreported older, less educated, and lower-earning rural men were even less likely to seek help(Corboy et al., 2011; Labra et al., 2019; Oberoi et al., 2016). Rural men were also identified ashaving lower health literacy and understanding about health and illness generally than average(Fish et al., 2019; Isaacs et al., 2013; Misan et al., 2017; Radermacher & Feldman, 2015; Su etal., 2016). Additionally, aspects of rural life were found to inherently limit access to healthcare(Connell et al., 2019; Corboy et al., 2011; Creighton et al., 2017; Emery et al., 2013).To date, a paucity of studies have assessed the effects of the dynamic between ruralityand masculinity on rural-dwelling men’s help-seeking beliefs and behaviours, with very fewstudies conducted in North America. Additionally, only three articles relevant to the currentproject with Canadian samples were identified in the literature search (Coen et al., 2013;Creighton et al., 2017; Roy et al., 2014), suggesting that the perspectives and behaviours ofCanadian rural men were vastly under-represented in the literature. Furthermore, the focus of thesamples lacked diversity. In particular, no literature was found for Canadian Indigenous men.24The current study will add to this developing body of knowledge and will attempt to elucidatethe barriers to help-seeking rural-dwelling men in the SI of British Columbia experience.25Chapter 3: MethodsTo address the gap in the literature surrounding Canadian rural men’s help-seeking, thecurrent thesis was part of a larger project conducted in partnership between the University ofBritish Columbia Okanagan campus (UBCO) and the Okanagan Men’s Shed Association(OKMSA). The OKMSA is based on a larger movement that originated in Australia and thatfocuses upon providing men an opportunity to find new hobbies, socialize with other men, avoidisolation and work together on projects with their peers (AMSA, 2017). It strives to enhance thewell-being of all men by building self-esteem and social connections through participation andsharing in meaningful tasks and interests with other men. The goals of the over-arching projectincluded: 1) evaluating the effectiveness of the Mobile Men’s Shed in rural communities; 2)building public awareness and interest in development of local Men’s Shed activities; and 3)gaining an understanding of health needs of men in rural communities in the SI. This thesisaddressed the third goal, and asked two questions: 1) What barriers to help-seeking do rural menexperience for health concerns? and, 2) How is help-seeking for health concerns perceivedamong rural men? These questions helped to describe the rural-specific barriers to seeking helpfor physical and mental health concerns for men living in rural communities and elucidated howthese men perceived seeking help and their ability to do so in their community.The researcher described the shared experiences of men and interpreted these experiencesin relation to intersections between sociocultural, spatial, and environmental factors that thesemen may have encountered on a daily basis. The intention of this effort was to provide localstakeholders and healthcare service providers information that would assist in the developmentof initiatives and specialized services to promote awareness of barriers and facilitators to men’shelp-seeking for health concerns and tailor local services and supports to better meet the needs ofmen.26Research DesignMethodologyAn interpretive description (ID) approach was utilized to answer the questions of thisresearch study. First developed by Thorne and colleagues (1997), ID is a methodologicalapproach focused on generating understandings for clinical practice. Being rooted in constructiveand naturalistic philosophy, ID is based on the assumption that reality is complex and subjective,constructed socially and experientially in local contexts as described by Guba and Lincoln(1994) and Lincoln and Guba (1985). For this reason, individual experiences were not reducedby deductive theorizing, they were studied holistically by grounded interpretation of datacollected through interaction between the researcher and the researched (Lincoln & Guba, 1985).Following these ontological and epistemological positions, the purpose of ID was to generatecoherent narratives that captured thematic patterns and commonalities within subjectiveexperiences that at the same time accounted for variation in the experience of phenomena(Thorne et al., 2004). This design was operationalized by conducting face-to-face individualinterviews with men, as well as informal Community Conversations at local community events.Together, these data collection approaches allowed the researcher to gather a broad range of richperspectives that were integrated into a regional narrative.Study Population and SamplingThe study population consisted of men over the age of 19 living in the communities ofRegions A and B, geographic subdivisions of the Southern Interior of BC. Given that we wereprimarily interested in health and well-being, participants did not represent a specific group or aspecific health condition (e.g., they did not necessarily have a health or mental health concern).To gain maximum variation of perspectives, men of all sociocultural demographics living in27rural communities within Regions A and B were invited to participate. Additionally, participantswere required to be fluent in written and spoken English at approximately a Grade 8 or 9 level.Based on ID’s emphasis on the use of multiple sources of data to provide maximumvariation of perspectives on the phenomena of interest to researchers, multiple recruitmentstrategies were utilized to encourage participation from local men, including convenience andpurposive sampling (Hunt, 2009). The primary modality was convenience sampling, a method ofatheoretical, non-probabilistic recruitment based on obtaining participants from convenient oreasy-to-reach locations or events (Paik & Shahani-Denning, 2017). Participant recruitmentoccurred via three methods. The first strategy was linked closely with the larger OkanaganMen’s Shed Association (OKMSA) outreach initiative, wherein an item in the community surveywas included inquiring as to whether the participant would be interested in sharing theirexperiences in an interview about Men’s Sheds, and men’s health and well-being needs. Thesecond involved community organizations and contacts being forwarded information about theinterviews, including the researcher’s contact information. They were asked to distribute thisinformation to local eligible men. The third method involved “Community Conversations” atlocations or events in the target communities that were led by local organizations. At theseevents, the researcher engaged with men in attendance and collected data directly at that time. Aswell, when appropriate, the researcher recruited men in attendance to participate in a subsequentinterview if they wished to share further information.In addition, the researcher also used purposive sampling (recruitment based on priortheoretical knowledge of phenomena) when necessary to engage with further participants for theinterviews and/or when specific themes needed to be further developed by participants who wereidentified to have knowledge of these topics (Elliot et al., 2016; Hunt, 2009). A snowball methodwas used wherein participants were asked to refer other men in their community to the study.28The researcher hoped to enlist at least 10 participants for the interview phase of the study,reflecting prior evidence of theoretical saturation, the point at which no new themes are evidentfrom additional data collection (Guest et al., 2006). Guest and colleagues (2006) suggested thattheoretical saturation begins at approximately six in-depth interviews and is evident with 12interviews. While other studies using interpretive description methodology utilized similarrationale for recruitment of similar sized samples (Murphy et al., 2016), Thorne (2016)contended that reliance on saturation may be problematic. This was due to an assumptioninherent in theoretical saturation that the researcher had gathered adequate data to understand allthere was to know about the experiences of the sample (Thorne, 2016). In relation to the currentproject, the researcher acknowledged that due to the variation and complexity of individualexperience, not all perspectives would be represented in the selected sample. However, whilesmall, the proposed sample size was thought to be large enough to achieve a meaningfulunderstanding of men’s health and well-being needs in the SI (Thorne et al., 2004).Data CollectionData were collected between April to October, 2019. The researcher conducted twoCommunity Conversations, one in Region A and another in Region B. In both cases, withpermission from the organizer, the researchers set up a small display table and posted fourquestions (Appendix A) on flip charts for men and their families to consider and share theirperspectives on. Information on men's health and wellbeing was gathered using written responseson the flip charts, post-it-notes, or in a confidential notebook. A consent form (Appendix B) wasavailable at the display table for potential participants to read and decide if they wished to sharetheir perspectives.Individuals self-selecting for interviews were contacted by the researcher (MSW student)to follow-up on their interest, and sent a consent form (Appendix C) if they were interested in29participating. A date and time was then scheduled to meet for a one-hour interview. Participantsreviewed and signed consent forms and sent them electronically to the researcher or werecollected on the day of the interview. Interviews were completed in a private location agreedupon by the researcher and each individual participant; typically, the participant’s home. Prior tobeginning the interview, each participant was asked to complete a demographic surveycomprised of items relating to age, place of residence, socio-economic status, and quality of life(Appendix D). The researcher audio-recorded the conversation, provided consent was given bythe participant, and used an interview guide (Appendix E). Questions in the interview guidecovered topics including the men’s experiences and observations of health and mental well-beingin their community and whether they or others had experienced barriers to seeking help. Inaddition, the researcher took field notes. Men participating in the interviews received a $25coffee gift card to a local coffee house, but did not receive other direct benefits in terms of well-being from participation. All participants were informed of their right to access the final reportand/or a summary of findings.Data AnalysisAudio files were transcribed verbatim by a professional transcriptionist and the data werethen analyzed by the student researcher using qualitative software NVivoTM. The subsequent dataanalysis was conducted using a thematic analytic framework, which functioned to produce anarrative that characterized “experiences of individual participants by general insights from thewhole of the data” (Bradley et al., 2007, p. 1761). The three steps of this process are described inthe following sections.Step one: Immersion. The researcher began the analysis by reading and re-reading thetranscripts to become familiarized with them, while noting initial impressions and ideas withoutlosing the context of the data (Bradley et al., 2007; Braun & Clark, 2006).30Step two: Coding. The initial coding phase involved the first interview being codedindependently by the researcher using the coding structure outlined below and then met with thePrimary Investigator (Dr. Nelly Oelke) to review. The researcher and Dr. Oelke then reachedconsensus on the coding process and emerging codes. The remainder of coding was thenconducted by the researcher, who met regularly with Dr. Oelke and Co-Supervisor, Dr. ShellyBen-David, for feedback and guidance. A grounded inductive approach to developing a codingstructure was utilized in which the transcripts were reviewed systematically line by line,assigning codes as concepts began to emerge (Bradley et al., 2007). The researcher made note ofspecific lines or sections of transcript that reflected the emergent concepts and refined codes tobetter fit the emerging concepts as more data were analyzed. Constant comparison was used toensure codes were properly assigned; that is, sections of text were compared to others that hadpreviously been assigned the same code to determine whether they highlighted the same concept(Bradley et al., 2007; Glaser & Strauss, 1967). According to Glaser and Strauss (1967), thecoding structure could be considered complete when theoretical saturation is reached.Step three: Generation of Themes. Bradley and colleagues (2007) defined themes aspropositions that were created from the interrelationships between clusters of codes and sub-codes that joined concepts together. Codes were grouped together into potential themes andchecked to ascertain if they were appropriate in relation to codes, as well as in the context of thewhole data set (Braun & Clarke, 2006). Themes and the emerging narrative were refined asdefinitions and labels for each theme were further developed until theoretical saturation wasreached. Themes and concepts were then synthesized into a coherent narrative detailing theexperiences of local men in the SI.31Ethical ConsiderationsThis project was approved by the UBC Okanagan Behavioural Research Ethics Board(H18-01603). While some of the questions touched on sensitive topics, participants had the rightto not answer if they felt uncomfortable. If a participant became distressed during the course ofan interview, the researcher asked if the participant wished to stop the interview. If so, it wasstopped immediately and the researcher took steps to ensure the participant’s safety and provideda list of organizations that they could contact for support. The researcher assessed whether theparticipant would like to phone a friend or family member for help and whetherrecommendations for accessing mental health services could be made. If the risk to theparticipant was serious, the researcher would call 911. A similar protocol was implemented if aparticipant disclosed suicidal ideation during an interview. In this case, the researcher wouldinform the participant of their duty to protect the participant from harm under the CanadianAssociation of Social Workers’ Code of Ethics (2005) and would attempt to assess the level ofrisk. Assessment questions were adapted from the Carleton University Suicidal ThoughtsProtocol for use in Research Settings (2018) (Appendix F) and included whether the thoughts ofsuicide were current and how long they had been present for, whether the person had a well-developed plan and if they had the means of executing it, and whether they felt they hadresources to rely on. If, based on the response to this assessment, risk was deemed to be low, theresearcher would offer recommendations to access mental health services and ask whether theparticipant wished to continue the interview. If risk was deemed high, the researcher would call911. Aside from this, there were no foreseen risks beyond those experienced in the day-to-daylives of participants. None of the interviews required implementation of these protectivemeasures.32Storage of DataAll participants were assigned a pseudonym (a name or number) that was used on alltranscripts, data files, and documentation relating to the study to ensure confidentiality. Anydocumentation that might have associated participants’ identity with the given pseudonyms (e.g.,consent forms) was kept separately in a locked file cabinet in Dr. Oelke’s office. During the timeof the study, the researcher stored all physical data (e.g., field notes) in a locked filing cabinet ina research office located at UBCO. Similarly, electronic data (e.g., transcripts and data files)were stored on an encrypted UBCO network. Password-protected and encrypted computers wereutilized when working with data and then stored in a locked file cabinet. Additionally, the UBCOencrypted network was used to transfer audio files and typed transcriptions with the externaltranscriptionist, who was required to sign a confidentiality agreement (Appendix G) beforeworking with the files. Data will be stored for up to five years following publication, after whichtime physical data will be shredded and electronic files deleted under the supervision of the Dr.Oelke or a designated affiliate of Dr. Oelke.Self as ResearcherThe researcher was a 26-year-old urban-dwelling, heterosexual, cisgender, Caucasianmale with no particular religious affiliation, or identification with monologic masculinity. Hewas deeply passionate about mental health and well-being, particularly in vulnerable and at-riskpopulations, including youth and older adults. A proponent of evidence-based practice and healthservice utilization, he had previously worked as a Student Mental Health Clinician at a mentalhealth clinic on the UBCO campus. There, he was part of a team of clinicians who assessed,planned, and delivered treatment for youth with mental health concerns and their families.Having completed an extensive literature review concerning the topic of rural men’s help-seeking, the researcher had a robust knowledge of prevalent theory and interpretation concerning33phenomena that the participants may have been experiencing. This knowledge may have biasedthe researcher to guide participants into particular lines of inquiry that functioned to confirm hispre-established beliefs about the experiences of men living in a rural community. The personaltraits and experiences of the researcher may have similarly biased him to shy away from certaintopics of dialogue and pursue others. To address these potential biases, the researcherimplemented a methodology that is atheoretical and positions academic inquiry in a position ofreduced power as interpretations must be grounded in what is learned from participants’perspectives. As well, the use of an interview guide ensured that dialogues consistently touchedupon similar over-arching themes while allowing for variation in individual experiences.RigourTo establish rigour and validity for the current project, debriefing was used to gainfeedback from impartial readers concerning potential errors, faulty assumptions, vagueness, orbiases that may be present in the data or analysis (Spall, 1998; Lincoln & Guba, 1985). Thisprocess was critical for assisting the researcher to reflect critically on the way their socialposition, values, and knowledge influenced decision making, interpretation, and behaviourduring the scope of the research project. Debriefing was utilized to gain feedback and insightsfrom multiple perspectives; such as supervisors and committee members. Reviewing theemerging results of data analysis with supervisors and committee members assisted in formingmore coherent codes and themes. This feedback was provided in addition to the meetings withDrs. Oelke and Ben-David concerning data analysis described above.In addition, the current study employed a number of strategies to address issues oftrustworthiness of the knowledge generated from the analytic framework described above. Thesespecifically addressed four domains of trustworthiness (credibility, transferability, dependability,and confirmability) identified by Lincoln and Guba (1985). A study’s credibility related to34whether the study explores what is intended by the researchers (Shenton, 2004). Shenton (2004)detailed a number of strategies to establish credibility that have been discussed or conductedabove, including: 1) utilizing well established research methodology; 2) establishing protocol toensure honest participation; 3) holding debriefing sessions with a supervisor; 4) seeking scrutinyfrom peers and academics; 5) producing robust description of the phenomena of interest; and 6)conducting a literature review to investigate previous findings relating to the research question.All of these were implemented during the course of the study.While it is difficult to establish transferability (the ability of findings to be applied toother contexts) in qualitative research, as findings are specific to particular populations, contexts,and sample sizes (Shenton, 2004), Lincoln and Guba (1985) suggested that if researchersproduced reports rich in description of the context and/or population being studied, the readerwould be able to make inferences about other contexts that the results could be generalized to.This strategy was reflected in the researcher’s implementation of ID methodology, whichproduced detailed narratives of commonalities within subjective experiences of phenomena(Thorne et al., 2004).Dependability related to the extent to which a study can be replicated by other researchers(Shenton, 2004); however, this did not necessarily entail replication of findings due to theirspecificity of context and population. To establish particular research methodologies asdependable for replication in other contexts, Shenton (2004) suggested providing reports thatincluded a thorough description of research design and implementation, and critically evaluatedthe effectiveness of the process utilized. This strategy was implemented in the study by detailingthe coding process and including appendices of information relevant for developing the finalcode structure used.35Lastly, confirmability was similar to the concept of objectivity in that it demanded stepsbe taken to confirm that the results were generated from the experiences and perspectives ofparticipants, as opposed to the values, beliefs, or preferences of the researcher (Shenton, 2004).Reflective commentary was a method for promoting confirmability in which the researcherdiscussed the values and beliefs that led to particular decisions being made in the researchprocess. Additionally, it involved acknowledging the perceived validity and limitations of thesechoices (Shenton, 2004). Such reflections on the rationale behind decisions made during thecourse of the research process were included in the final description of the research designdescribed above. Another method of establishing confirmability was to seek feedback from avariety of sources. This included holding debriefing meetings with supervisors and otheracademics, which were completed as part of the study.Knowledge Translation and OutcomesStrategies of knowledge translation (KT) occurred throughout the research process.According to the CIHR (2012), KT needed to involve a process wherein research findings areproduced, exchanged, disseminated, and applied through collaborative interactions betweenknowledge users and researchers. The overall goal of KT was to promote beneficial, evidence-based change to the Canadian healthcare system and thereby improve the health of all Canadians(CIHR, 2012). Integrated KT occurred largely through collaboration with knowledge usersduring critical phases of the research processes. The OKMSA largely functioned as knowledgeusers, defined as individuals who were likely to utilize research findings in their decision makingaround public health programs, policies, or practices (CIHR, 2012). This communityorganization offered critical assistance in the early recruitment strategies of the current study, aswell as the early planning stages of Mobile Men’s Shed Study overall. Additionally, otherknowledge users who held careers in healthcare or local government within the target36communities were engaged with during recruitment to facilitate broader dissemination ofinformation about the study. In both cases, exchanging of perspectives and insights on how bestto address men’s health and well-being helped to inform the results of the current study such thatthey are more relevant and better tailored for uptake by providers of services for men in ruralcommunities (CIHR, 2012).37Chapter 4: ResultsThis chapter presents the results of this qualitative study surrounding rural men’s help-seeking beliefs and behaviours. Although the majority of participants reported being connectedwith a general practitioner or family doctor (GP) (n = 7) and/or other health professionals, theydescribed personal or observed barriers to help-seeking that were unique to the rural context inwhich they resided. Through data analysis, four overall themes were identified: three themesrelated to barriers were identified including environmental barriers to help-seeking, lack ofhealth education or awareness, and masculinity. An additional theme, informal support, wasidentified as a facilitator to help-seeking. In the following sections, these themes will beexplained. The chapter begins with the demographic characteristics of the participants in thestudy. Then, the barriers that men experience in help-seeking -- from environmental barriers tomore socially-constructed, personal barriers -- are described. This will be followed by anexplanation of how men seek support from one-another. Quotes supporting themes will beprovided in-text from both interview and Community Conversation participants.gParticipant DemographicsIn total, eight participants completed individual interviews, while a further 14 providedtheir perspectives informally at Community Conversations. Six interview participants resided inRegion B, while the remaining two were from Region A. Community Conversation participantsincluded six men from Region A and eight from Region B. No demographic information wasgathered at Community Conversations, so the remainder of the demographic information appliedto interview participants only. Men were between the ages of 59 to 77, with a mean age of 67.3(SD = 6.5). All participants identified as Caucasian/White. The majority of participants had livedin their communities between 2 – 7 years (M = 3.8 years). However, the shortest time spent inthe region was three months, while one participant had spent over 70 years living in his38community. The majority of men (n = 7) had romantic partners, identifying as either married,common-law, or partnered. While all participants had completed high school, the majority (n=6)had some post-secondary education or had a college or technical diploma. Many participants (n =6) identified as being retired, while two were receiving disability benefits. Most participants’yearly household incomes were greater than $25,000 (n = 6). Most participants reported that theywere “fairly healthy” (n = 5), suggesting that participants may have had some health difficulties,but did not perceive these as severely impacting their well-being. Other participants rated theirhealth as “not very healthy” (n = 3); two men identified that they had serious health problems.Most participants had chronic health conditions (n = 6), including heart disease (n = 6) and/ormental illness, such as depression or anxiety (n = 3). The majority of participants felt they werefairly well socially connected (n = 5). Meanwhile, three men identified they were at leastsomewhat socially isolated.Environmental Barriers to Help-SeekingThe sociopolitical and geographic context of the SI of BC emerged as a key barrier tohelp-seeking. Two subthemes were identified: the inherent rurality of the communities (andassociated issues of transportation), and the paucity of local health service providers(encompassing lack of GP’s and other service providers and long wait times) (see Table 1 foradditional quotes).39Table 1: Exemplar quotes from interviews and Community ConversationsCode QuotesEnvironmental Barriers toHelp-SeekingRurality of Communities There is quite a difference between the Lower Mainland and[the Southern Interior]; medical services [here] are closed mostdays. Town is close by, but people can be very clicky; everyoneknows what everyone else is doing, no privacy orconfidentiality. (Community Conversation – Region B)Paucity of Local ServiceProvidersLack of GP’s andOther ServiceProvidersThere’s just not enough doctors to go around. (InterviewParticipant 6)[Doctors] want the big houses. . . they want access to the betterschools for their children. (Interview Participant 5)Wait Times I understand that they’re inundated. . . I feel that part of thereason is because that it takes too long to get into see aphysician. . . that’s if you're on their list. (Interview Participant4)It took a few months to, you know, get to the actual meetingwith the counselor (Interview Participant 2)Lack of Health Educationor AwarenessThey have an issue and they don’t know if it’s serious or notand they think, “Well, I'll either do one of two things. . . I'll goto the hospital on my own. . . or I won’t go and I’ll just see howit goes”, and then, things deteriorate. (Interview Participant 3)MasculinitySelf-Reliance Self medication [is an important topic that needs to beaddressed in men’s health]. (Community Conversation – RegionA)There’s that superman macho kind of suit of armour. . . that getshanded down from generation to generation. So, we kind ofinherit our father’s suit of armour, even if it doesn’t fit. . .That’s where much of that conditioning is. . . big boys don’tcry. (Interview Participant 4)40Code QuotesFear of ShowingWeaknessTo talk about your mental health is even . . . it shows thatyou’re more vulnerable and, you know, you’re even weaker ifyou express these concerns. (Interview Participant 7)I was exposed to a cross-section of different attitudes anddifferent types of people and that one common thread seems tobe don’t show too much weakness, you know, especially insome of the tougher occupations and situations, so I think thathas a lot to do with. . . guys hanging back [from seeking help].(Interview Participant 6)Informal Support Some of them are a little reserved at first but once they get toknow you, they relax. . . They join right in and it doesn’t takelong. . . they’re more forthcoming about things… (InterviewParticipant 6)Somebody’s keeping an eye out on you, keeping an eye out tomake sure you’re okay. (Interview Participant 1)Rurality of Communities“I hate. . . I have to drive. . . half an hour. . . for a GP for just a regular checkup.”Interview participants from both regions (n = 5) indicated that rural geography presenteda barrier to their ability to seek help, particularly emergency help. For example, one participantfrom Region B stated that there was no health facility in his community, which created “a barrierof distance for physical issues” (Interview Participant 1). He added that if someone had a serioushealth episode, such as a heart attack, they would have to wait for an out-of-town ambulance toarrive in his community and then drive back to the nearest health centre. He estimated that itwould take one hour to reach emergency care. Further, two of the interview participantsdescribed having to drive for up to 40 minutes to see their GPs. Another participant identifiedthat having to travel long distances to access help “as being something that would dissuadepeople from wanting to seek the help” (Interview Participant 4).41Transportation. Issues concerning the distance to health professionals includedtransportation. Several men from both regions and several participants of both CommunityConversations identified that not being able to drive would negatively impact help-seeking. Forexample, participants reported that “transportation issues between small towns and larger citiesfor healthcare” were a barrier to men taking care of themselves (Community Conversation –Region A). Although alternative forms of transportation were identified by three interviewparticipants from Region B, such as a bus that traveled between communities in Regions A andB, a participant of the Region B Community Conversation indicated that the bus had a limitedschedule. An interview participant agreed, describing how the bus was not necessarilyconvenient for men trying to attend out-of-town appointments or medical procedures. Thissentiment was echoed by another participant who added, “You can’t structure appointmentsaround [the bus] because it’s only there for a couple of hours. If your appointment [runs] late,then you have to stay there” (Interview Participant 5). While a couple of interview participantspointed to reaching out to friends or family to assist in transportation, they acknowledged itcould place a burden on social networks and their help was not always available. Additionally,one of these participants pointed out that “if you’re [socially] isolated, you’re even morehooped” for accessing out-of-town services (Interview Participant 7).Paucity of Local Service Providers“There’s just not enough doctors to go around”Lack of GP’s and Other Service Providers. Almost all interview participants (n = 7)acknowledged that one of the most critical “healthcare challenges. . . [was] that GPs are less andless” and there are “more and more people without a GP” in their communities (InterviewParticipant 3). In some communities, there was only a single clinic where the doctor workedpart-time, which meant that participants’ access to their family doctors was limited. Otherwise,42they would “see whichever doctor [was working]”, which impacted the continuity of care(Interview Participant 3). Further, one man indicated that, in his community, only one doctorworked there. Participants expressed a range of opinions on the availability of other healthservice providers in the communities. Among communities in Region B, three interviewparticipants mentioned that some healthcare providers, such as paramedics and a counselor,traveled to their communities from out of town. Meanwhile, one participant at each CommunityConversation reported that “things [were] good” (Region B) in terms of having adequate accessto necessary services and supports” and that “no services [were] missing in the community.Many [were] available through a local social service agency and there [was] a local [AlcoholicsAnonymous] and Alzheimer’s supports” (Region A). These views contrasted greatly with theoverall lack of healthcare professionals and services described more consistently acrossinterview and Community Conversation participants in both regions. As well, several otherparticipants of the Community Conversation held in a Region B community explained thathomecare, senior’s care services and facilities were lacking, while “social workers and similarsupports” and “specialized medical care, such as for cancer” were limited in a Region Acommunity. While contrasting opinions reflected individuals’ differing perception of healthservice, differences in population size, sociopolitical context, and corresponding allotment ofmedical services between communities may have also contributed to differing opinions of healthservice availability.The paucity of services was attributed to limited funding by two interview participants.This sentiment was echoed by several participants of the Region A Community Conversation,where “issues of space and funding [created] gaps in services in the community for men” wereidentified. In contrast, several interview participants (n = 3) recognized the possibility that ruralcommunities might not be an attractive option for service providers. One participant43hypothesized that physicians often preferred to live in areas with busier health centres. Anotheragreed, saying, “It’s hard to get doctors who want to move into rural areas and stay there. Theywant the big urban cities because it has all the facilities that they want and need” (InterviewParticipant 5). He added that the better amenities and opportunities available in largercommunities were more attractive to physicians and their families. Still another said “some ofthe new doctors, they go to bigger practices” in the Central Okanagan or Lower Mainland“because they want to become specialized” (Interview Participant 7). Further, he added that inhis community the number of available local doctors had greatly diminished due to severalretiring over the last five years.Long Wait Times. Across Community Conversations in both regions, several men inattendance highlighted long wait times to see doctors as barriers to men being able to take care ofthemselves. This was echoed by three-quarters of the men that were interviewed (n = 6), whoidentified that long wait times to see healthcare professionals was a significant barrier to theirown and their peers’ ability to seek help. One participant commented on how it was difficult toconnect with GPs in his community and how “once you [got] your foot in the door, [you] still[had] to wait two weeks for an appointment, on average” (Interview Participant 4). However, ifnot connected to a GP locally, “good luck to you, it might be six months or a year before youfind one” (Interview Participant 4). This sentiment was shared in the experience of another man,who was told before he moved to his community that to be connected with a GP, he had tosubmit an application to be added to the practice’s patient roster at least one year in advance. InRegion B, one man stated that all local GP’s patient rosters were full. He was forced to travel toa larger urban centre in Region A to connect with a GP. This was detrimental to his and othermen’s ability to seek help. His frustration was echoed by another man, who explained that “a lotof people wait a long time to get a family doctor” (Interview Participant 6).44Lack of Health Education or Awareness“I thought I was feeling, you know, pretty much fine but. . . ”An “I don’t need it” (Region A) attitude towards healthcare was identified as a barrier tomen taking care of themselves by a couple of Community Conversation participants. This wasechoed by half of the interview participants, who pointed to a more general lack of knowledge oreducation around health and healthcare (see Table 1 for additional quotes). For example, aparticipant who was a retired healthcare provider described how when men “have a [health] issueand they don’t know if it’s serious or not and they think, ‘Well, I’ll either do one of two things. .. I’ll go to the hospital on my own or I’ll go to the clinic on my own or I won’t go and I’ll justsee how it goes’, and then, things deteriorate” (Interview Participant 3). He also emphasized thatthe older generation was more likely to endure and self-medicate for their health concerns.Conversely, younger men were thought to be less likely to soldier through concerning symptomsas they were more educated about health conditions and how best to access healthcare when itwas needed. Due to age-related influences on health literacy, he felt that younger people mightbe better equipped to survive in a rural community long-term. Another interview participantrecounted a past health crisis in which he had to make critical decisions about seeking help whenhe had a heart attack, “as a guy. . . do I call [911] now or am I okay or what? And then, finally Italked to somebody else and she said, ‘Oh no, phone the ambulance right now’” (Participant 5).He described that he was waiting to go to a local health centre, because he had attributed thesymptoms to over-exposure to heat and forest fire smoke.While an overall lack of health literacy was most commonly highlighted, a differentperspective was that it was denial that caused men to not recognize a health concern despiteproblematic physical or psychological symptoms. Similarly, in regard to choosing whether or notto seek help, a participant described how “fear of the unknown can cause people to choose a45nonchoice, in other words to sort of pretend that it isn’t happening, the old ostrich head in thesand type of thing” (Interview Participant 5). Similarly, several interview participants believedmen resisted seeing a GP when necessary and were less health-conscious than women. This wasthought to occur because men’s pride kept them from admitting to having a health concernand/or believing it was not manly to seek help.When asked about mental health, most interview participants (n = 7) generally had someknowledge about more common mental illnesses, such as depression. However, one participantstated that he did not “know anything about it really” (Interview Participant 8). When askedabout his observations of mental health concerns of other men in his community, he stated thathe was unable to answer. Rural men’s low mental health literacy was additionally highlighted byseveral participants of Community Conversations, who suggested “mental health [is an importanttopic that needs to be addressed in men’s health]. This included building men’s awareness andwarning signs of depression.” This discrepancy may have suggested that while rural men wereaware of mental illness, they were most often not familiar with the etiology and commonsymptoms of common mental illnesses, or men’s unique experiences of depression.Masculinity“I don’t know the name of a doctor; I look after myself”By virtue of being men, most interview participants (n = 7) indicated that they perceivedhealth in a particular way that acted as a barrier to help-seeking that was unique to men. Inparticular, self-reliance and fear of showing weakness were thought to reinforce theunacceptability of help-seeking (see Table 1 for additional quotes).Self-RelianceRural men’s tough, individualistic natures were described as facilitating their rurallifestyles, but also as a detriment to help-seeking. To one participant, “self-reliance” (Interview46Participant 1), was thought to be a characteristic required to survive in rural communities and hedescribed rural men tended to be self-reliant for house repairs and automotive work, due to thelimited availability of skilled trades-people in the region. Conversely, three quarters of interviewparticipants (n = 6) and several attendees of both Community Conversations described ruralmen’s self-reliance in efforts to self-manage symptoms and persevere despite continuing healthconcerns. For example, a participant described that when faced with a health concern, menwould “put up with it and self-treat it” and/or “just ignore it” (Interview Participant 3). This lattersentiment was exemplified by a participant, who shared that men take care of themselves byfeigning normalcy. Expanding on this, another described how he “[preferred] to avoid talkingabout health issues because [he felt] that by. . . expanding on them, [he was] simply adding moreenergy to the problem rather than the solution” (Interview Participant 4). Men’s ability topersevere through health challenges was additionally identified by one interview participant as aprotective attribute that was passed down from father to son. This macho demeanour was definedby interview participants as a “suck it up buttercup, lace up my boot, I can walk on it, sort ofJohn Wayne attitude” (Participant 7). A tough attitude was thought to be a barrier to help-seeking, as men would adopt a “big boys don’t cry” (Participant 4) attitude towards theirexperiences of health concerns, which prompted them to either try to ignore them, or deal withthem on their own. For example, an interview participant described how some men heavily usedalcohol and tobacco to cope with health problems and find some enjoyment in life. Substance usemay have also been a strategy to “[hide] their emotions” and cope with mental health concerns(Interview Participant 5).Fear of Showing of WeaknessMost interview participants (n = 7) described how men did not like asking for help andhad an inherent discomfort in talking about their health concerns. They explained that in their47social circles, men did not talk “about their health, unless it was really very obvious. . . butnothing before that” (Interview Participant 7). For example, a participant remembered workingwith a man who had had a serious heart condition that he kept hidden until he had a health crisiswhile working. He went on to describe how men minimized their health concerns despite severesymptoms. In his experience, men would “just bite the bullet and shuffle on” (InterviewParticipant 7). Men were described as not being ones to complain about their issues orlimitations. Rather, they tended to “just live with it and joke about it and make the best ofsituations” (Interview Participant 6). Instead of asking for support, men preferred not to reach outfor help to avoid being perceived as weak or vulnerable. Explaining this tendency, one interviewparticipant described that “down through human history, if anybody showed a sign of weakness,he did not last very long, as a rule” (Participant 6). He elaborated on this point, explaining that inmore physically difficult occupations, men had to be tough and not show weakness, whichnegatively impacted their inclinations to seek help. These sentiments were echoed by several ofthe Region A Community Conversation participants, who thought “fear of accepting help due toit being viewed as a sign of weakness” was a significant barrier to men seeking help.While men were viewed as not being in touch with their health, this was particularly thecase in regards to their mental health and emotions. More than half of the interview participants(n = 5) observed that men in their communities and social circles were even less comfortabletalking about mental wellbeing than physical health concerns. For example, one participantdescribed his own discomfort:To be honest with you, it kind of scares me to think about interacting with people. . . todo with mental health. It seems. . . kind of scary. . . it’s not something I really would wantto share with a bunch of people. (Interview Participant 2)48Another participant said that, “no one tells you about their deep dark secrets, we don’t go there”(Interview Participant 6). Similarly, other participants reported that mental health was “not talkedabout” by men (Interview Participant 1) and they particularly “don’t talk about depression”(Interview Participant 7). Admitting to having concerns in these areas was perceived as a taboobehaviour to men, as it was viewed as showing weakness and vulnerability. Among men, oneinterview participant described that expressing sadness in relation to a lost loved one wasacceptable, but no further elaboration on symptoms of depression should be given. Althoughsome interview participants reported that they were able to identify signs of mental distress intheir peers, others acknowledged that this could be difficult as symptoms were concealed.Despite men being able to hide their distress, taking the initiative to ask about mental healthconcerns was still considered to be a taboo behaviour by an interview participant who suggestedone “can’t go up to somebody and say, ‘It looks like you’re having issues’” (Participant 3). Hefelt that conversations about mental illness were reserved for very close, trusted peers.Informal Support: A Facilitator of Help-Seeking“We’re a band of brothers and we do help each other out and care a lot.”Although half of the interview participants (n = 4) recognized that men would shy awayfrom directly discussing their health problems, they also identified that men sometimes relied onone another for support (see Table 1 for additional quotes). This tendency was supported byseveral participants of both Community Conversations. For several interview participants (n = 3),mutual feelings of trust between male peers was key to initiating conversations about health andwell-being. One of the interview participants described that men could sometimes take a while tobuild trust, as they often tended to be fairly private initially, but they gradually became moreopen about their health and life circumstances as they developed familiarity with their peers. Toanother participant, this process was important because they felt that “healing. . . comes about49when that sense of comradery and trust is established because there’s somebody there whoknows what you’ve been through and what you’re going through” (Interview Participant 4). Thissentiment was shared by five participants of the Region A Community Conversation and threeRegion B Community Conversation participants, who explained that “trusting relationships”were “built [between men] through engaging in shared activities together” (CommunityConversation - Region A), “which [led] to comradery and talk” of health concerns (CommunityConversation – Region B).Indeed, “communication and camaraderie” (Community Conversation – Region A)between men were identified as ways that could help rural men take care of themselves. Criticalfor these strategies was men getting together and enjoying common interests or activities. Forexample, most interview participants residing in Region B (n =5) reported having had regular,weekly contact with other male peers, often getting together at local coffee houses. Whilecouples were often in attendance together, “a lot of single men” were reported to “come forcoffee in the morning for socializing” (Interview Participant 1). During these get-togethers, menwould generally gather together, separate from the women. While women were reported todiscuss topics including health and family, men’s conversations were typically more focused onmechanics, other trades work, or politics. Similarly, some interview and CommunityConversation participants also reported getting together outside of the coffee house to engage inmutually shared interests and activities, including, golf, fly-fishing, machinery or mechanics, andwoodwork. Particularly in relation to work in the trades, woodworking, and mechanics,participants identified that men often got together to work on projects collectively and thiscollaboration often involved exchanging assistance on projects. Some Community Conversationparticipants identified that an aspect of rural life for men was to “barter and negotiate with each50other when you need something” (Community Conversation – Region B). This social dynamic ofgiving and receiving help was thought to contribute to the development of trusting relationships.By virtue of this trust and comradery, a couple of interview participants described thatlocal men typically looked out for one-another’s well-being. For example, “if somebody [didnot] show up for coffee for two or three days who normally does, usually there [would be] aknock on the door of that person” (Participant 1). Another agreed, that if a local man wasstruggling, he would be comforted by knowing it was likely that his peers would come and checkon him. Alternatively, men sometimes sought or provided help or support for one another.Participants identified that “without being formal about it, [men] do sort of self-help each other”(Interview Participant 6). While in some cases, men poked fun at each other and used humour asa way of supporting each other, if there was a significant health concern, it would be discussedseriously, though informally. One interview participant explained how when providing help tomale peers, “don’t try and tell them how to live or anything like that” (Participant 6). When hewas concerned about a peer, he would discuss the issue with them and provide examples fromhis own life of going through similar circumstances while trying carefully to not give advice.Through trusting relationships and informal help-seeking, local social networks of rural menprovided a strong sense of community among local men.SummaryAlthough participants identified having access to health service providers, they describeda variety of barriers to seeking help, by virtue of living in rural communities. Rurality and lack ofavailable transportation were significant barriers for men accessing help both locally and out-of-town. As well, many men identified that their communities critically lacked healthcare staff,particularly doctors and specialized care. This resulted in long wait times to see local healthcareproviders and/or travel to other communities for primary or specialist care. In addition to the51limited availability of providers, men’s help-seeking was also thought to be adversely impactedby a general lack of awareness of health issues. While some participants described how menwould ignore concerning symptoms, hoping that they would go away, others recounted timeswhen they had mis-interpreted symptoms and consequently delayed help-seeking for serioushealth issues. Although some attributed this to poor health education by earlier generations,others considered it being in denial about one’s health problems. This was viewed as beingdriven by fear of the unknown and not wanting to appear weak by admitting to needing help. Aswell, rural men’s preference for self-reliance, relying on their own fortitude and self-management strategies to overcome distress or illness, was thought to delay help-seeking. Thisperceived inherent toughness made seeking help for a health concern, particularly a mentalhealth concern, a taboo among male peers. However, men also heavily relied on informal supportnetworks to navigate experiences of health concerns. If social networks were available, trustbetween local men was identified as a key component of rural men taking care of themselves.Trusting relationships were thought to be built by developing a sense of comradery with malepeers by engaging in shared activities. With this trust and familiarity, they felt they could discusstheir health concerns with one another and shared experiences and careful advice, therebyinformally supporting each other in times of distress.This study highlighted that in British Columbia’s SI, rural men faced several barriers tohelp-seeking. Most participants identified that seeking help for a health concern was stigmatizingfor men. However, men felt that their concerns could be validated by seeking the informalguidance of their trusted male peers. The following chapter will explore how these findingsaligned with or were dissimilar to the extant literature surrounding rural men’s help-seeking sothat recommendations could be made to improve service delivery for rural men.52Chapter 5: DiscussionThis thesis sought to gain a better understanding of the perceptions and behaviourssurrounding help-seeking of men living in the targeted rural communities in the Southern Interiorof British Columbia (SI). The key objectives of the study were to identify: 1) what barriers tohelp-seeking rural men experience for health concerns? and, 2) how help-seeking for healthconcerns is perceived among rural men? The data for this study were part of a larger studycentered on men’s health and well-being in the Southern Interior.This chapter begins with an examination of the relationships between the themesdescribed in the previous chapter, as well as how these relate to the research questions andobjectives. Additionally, the results will be compared with the existing literature on rural men’shelp-seeking. Thinking around moving towards a future framework for rural men’s healthservice utilization will then be discussed. Next, the researcher will offer a reflection on theprocess of conducting research on men’s health and well-being. The strengths and limitations ofthis study will then be discussed. The implications of the findings are then discussed broadly andrecommendations are made to improve health policy and practice. Suggestions for futureresearch are also included. Next, end-of-grant knowledge translation strategies are presented.Lastly, concluding statements are made.Help-seeking for Rural Men in the Southern InteriorThis section addresses the research questions by considering how they relate to thefindings of the study. The inter-relationships between themes will be explored, thus elucidating anarrative of experiences and perspectives of rural men surrounding help-seeking in the SI.Rural Health Services Versus Rurality: Environmental Barriers to Help-SeekingSome men in the current study experience difficulty in accessing services and recognizeothers’ struggles in doing the same in their communities. During both the interviews and53Community Conversations with men, being situated in a rural community where there are gapsin health services, particularly more specialized services, was a common concern. The low levelof availability of health service providers in rural communities is consistent in previousliterature, which identified professional shortages in North American and Australian ruralcontexts (McGrail et al., 2017). Although participants consistently identify barriers to help-seeking in their communities, most participants are connected with a GP or have some access toother health services. In accord with Oliffe and Moodie (2019), this discrepancy is notsurprising. They suggest that men not going to the doctor is a myth, highlighting thatapproximately 60% of men who die by suicide access professional help within the year of theirdeath. Instead, they argue that men’s continued engagement with health services involves findinghealth professionals who deliver services in a way that is more consistent with men’sperspectives and attitudes towards health. This may involve engaging men as active participantsin their own care planning and education on safe and effective self-management, which couldimprove the lack of knowledge and awareness of health among rural identified in the currentstudy (Oliffe & Moodie, 2019). The men in the current study may have continued engagementwith their healthcare provider because these providers approach services in such a way that madeuptake of health information and treatment more accessible or comfortable for the men. Thisaligns with previous research that suggests that rural men who are satisfied with their care will bemore likely to remain engaged with that provider (Emery et al., 2013; Fischer et al., 2016; Isaacset al., 2013). Conversely, River (2018) found that some men avoid seeking help due to fear ofencountering services that are clinician-centered and not tailored for men. However, in thecurrent study, participants have little choice in which health service provider they could see, dueto overarching professional shortages in the SI.54To participants, it is rurality that is thought to be an unattractive option for healthprofessionals. This belief was supported by McGrail and colleagues (2017), who found thatmedical professionals gravitate towards better educated and affluent communities with larger,older populations and local hospitals. Due to these shortages, participants’ navigation of ruralhealthcare often involves having to endure long wait-times to see a doctor or planning nearly ayear in advance to potentially connect with one of the few health clinics in Regions A and B. Forthese reasons, many rural men in the SI are forced to seek healthcare outside of their community,as no other option was available. This practice is also reported by other researchers (Bourne etal., 2010; Corboy et al., 2011). While in some cases, men in smaller rural communities are ableto travel to nearby communities with a health centre, others have to drive up to 40 minutes toconnect with their physician in a larger urban centre. While most participants are able totransport themselves to medical centres throughout the SI, they mentioned that this is not alwayspossible for all rural men. One’s inability to drive themselves or find transportation was asignificant barrier to help-seeking, which is consistent with the literature (Bennett at al., 2011;Bourne et al., 2010; Connell et al., 2019; Corboy et al., 2011; Emery et al., 2013). Affordabilityof services was not identified as a barrier to help-seeking in the current study, which contrastswith some previous studies (Radermacher & Feldman, 2015), but is consistent with others(Corboy et al., 2011). This discrepancy may be due to the majority of participants being retiredand/or generally not requiring health services not covered by Canadian universal healthcare.How Rural Men Perceive Help-SeekingAlthough rural men in the current study generally perceive help-seeking positively, theysimultaneously identify a level of discomfort engaging in such behaviour with theircontemporaries. Largely, this is associated with men generally not feeling comfortable talkingabout their experiences of health concerns or asking for help, which is consistent with previous55research (Fish et al., 2019; Getrich et al., 2012; Herbstet al., 2014). Due to this discomfort, menreport not always being well-educated about health, resulting in them not knowing when they areexperiencing a health concern or what action to take in response to distressing symptoms. Ruralmen’s low health literacy is supported by other researchers who have observed that men delayseeking help due to incorrectly appraising the seriousness of health concerns (Bourne et al.,2010; Emery et al., 2013; Fish et al., 2019). Appraisal of health concerns is further influenced bytraditional gender norms, which presents some men with the difficult task of overcoming self-stigma, discomfort, and negative beliefs related to help-seeking (Coen et al. 2013; Creighton etal., 2017). As well, participants describe how mental illness was difficult to identify in others orstate they do not know what mental illness is, such as depression. This suggests an overall lackof awareness of common signs and symptoms of mental illness, which is also consistent withprevious research (Isaacs, Maybery, & Gruis, 2013; Misan et al., 2017; Radermacher &Feldman, 2015). Rural men’s low mental health literacy may be due to participants and/orclinicians being unaware of the gender differences in externalizing symptoms of depression.According to Oliffe and colleagues (2019), for men, these can include substance misuse, risktaking, self-isolating, and poor impulse control (often involving irritability or anger). Further,these unique symptoms are typically not captured in common screening tools, perhapsperpetuating men’s underreported experiences of mental illness as these symptoms may beattributed to normative masculine behaviours (Oliffe et al., 2019).Consistent with findings by Connel and colleagues (2019), participants report men’sdiscomfort with health to be socially constructed, a product of intergenerational learning of whatit is to be a “man”. While previous research states that masculine norms including toughness,stoicism, and self-reliance have the most significant impact on help-seeking in rural men (Fish etal., 2019; Herbst et al., 2014), the current study highlights that fear of being perceived as weak56(toughness) and the importance of being self-reliant delays help-seeking among men in the SI. Incontrast with previous research, the current study did not identify instances of rural menlegitimizing their help-seeking by reframing it as a courageous act or a pathway to maintainmasculine roles of the breadwinner or protector (Oliffe et al., 2012; Roy et al., 2014). Toparticipants of the current sample, self-reliance is an inherent part of rural life because men oftenrely on their own technical knowledge and skills to compensate for the lack of amenitiesavailable in their communities. Self-reliance is also described as a barrier to help-seeking in thatlocal men attempt to persevere through troubling symptoms and delay seeking help. However,men’s self-reliance is more limited following the onset of severe symptoms or a critical healthepisode. Once their personal fortitude is compromised, men may engage in various strategies toaddress their symptoms. . In these instances, River (2018) suggests that men engage in dynamicpatterns of help-seeking behaviours that encapsulate active avoidance and seeking of engagingwith professional help, as well as engagement facilitated by unsolicited contact with a healthprofessional. Further, men’s willingness to engage with service providers was significantlyimpacted by the service provider’s approach to delivering services, particularly for mental health.Services that focused on individual psychopathology were largely rejected by River’s (2018)participants, as they felt this approach to services did not align with their unique understandingof their health and presenting problems. This suggests that while men are willing to seek help inmany cases, their engagement with health services may be influenced by the expectancy thatthey are misunderstood by the healthcare system.While rural men are described as self-reliant and do not necessarily reach out for formalsupports due to personal or environmental factors, they often connect with their informal supportnetworks. Through these interactions, men are able to address their health concerns in a way thatis more comfortable to them, and that might lead to recommendations to seek formal care. Many57participants endorse the importance of informal help-seeking, which is consistent with extantliterature, which supports the importance of promoting men’s social connectedness as apreventive measure in mitigating the effects of both physical and mental illness (Ogrodniczuk etal., 2016). Further, connection with informal support networks may promote more healthybehaviours among men. For example, among Canadian Indigenous men, Levesque andcolleagues (2019) found that greater Indigenous social capital and family ties was associatedwith less weekly heavy episodic drinking of alcohol. The informal support men provide eachother is flexible in nature, reportedly looking different in a range of contexts. For example, thesimplest support is keeping an eye on one another. While not necessarily “support”, men discussa high level of awareness of missing members of their peer groups during daily or weeklygatherings at local coffee houses. Someone missing for more than one day would be noticed byothers, who would then perform an informal wellness-check. The literature supports the benefitsof this kind of community-driven behaviour. Additionally, Harley and colleagues (2020) foundsignificant reductions in men’s self-reported levels of stress following participating in once ortwice-monthly men’s peer support groups. These groups include group discussions of topicsrelating to men’s wellness, as well as outings to sports events (Harley et al., 2020). Participantsin the current study endorse engaging in male-centric activities, including mechanics andwoodworking, collectively as a modality of forming social networks in their communities. Toparticipants, the sense of comradery and trusting relationships built through engaging inactivities together is key to initiating conversations about health with peers.Previous research also supports the importance of trusting relationships between men forimproving well-being. Robinson and colleagues (2015), for example, found engagement in anactivity-based facilitated peer support program for men focusing on resilience-building iseffective in encouraging trusting relationships among participants. They suggest that these58relationships bolstered men’s short-term resilience by mutual encouragement of positive healthbehaviours and knowledge sharing. Further, long-term resilience is enhanced by supporting peersin accessing formal health services (Robinson et al., 2015). While one participant in the currentstudy reports having a peer recommend he seek professional help for a health concern, othersreport having provided male peers their experience and knowledge when dealing with healthconcerns. Together, these findings suggest that social networks function as an effectivemechanism for rural men to support help-seeking by drawing on their strengths and prosocialbehaviour, wherein peers’ awareness of a man experiencing health concerns may thereafter leadto more poignant forms of informal support or support in accessing formal care. However, Oliffeand colleagues (2010) report that some men utilize social isolation as a pathway for relief frommental or physical pain. For this reason, community-based initiatives to support men’s socialconnections are also an important consideration for improving rural men’s overall well-being.Given the complex social milieu men must navigate to receive help for health concerns, it iscritical that researchers develop a framework of men’s help-seeking to better informdevelopment of policy and clinical practice strategies for men’s health and well-being.Moving Towards a Future Framework of Rural Men’s Help-SeekingDue to rural men’s unique sociopolitical circumstances affecting their use of healthservices, the creation of a rural male-centric framework for help-seeking will be essential fortailoring interventions for men’s unique needs and perspectives of health. To this end, thefollowing section considers the current study’s findings through the lens of several extant modelsand frameworks of well-being and health service use.Sociodemographic FactorsMany participants point to social and demographic factors of their lives that impact theirability to seek help. In terms of social factors, the impact of traditional masculine social norms59on help-seeking is a significant finding in the current study. Some participants explain that theseare passed down intergenerationally, particularly norms of self-reliance and toughness (fear ofappearing weak). Due to traditional masculine norms being more salient in the lives of rural men,as well as being socially constructed and reproduced, the researcher believes they are moreappropriately placed as a social factor for men’s help-seeking. The social determinants of health(including age, SES, education, ethnicity, etc.) should also be considered as critical aspects ofmen’s lives.Important for future research surrounding men, masculinity should be considered withinsocial determinants of health. This is in response to Evans and colleagues’ (2011) Health, Illness,Men, and Masculinities (HIMM) framework, which describes masculinity as a determinant ofhealth that intersects with other determinants throughout the lifecourse, resulting in varioushealth disparities as men age. This adaptation highlights the subjectivity of the experience andexpression of masculinity, as well as the existence of multiple masculinities between and withinindividuals (Evans et al., 2011). Additionally, the existence and quality of one’s social networksis also important to consider as a social factor. This is because several participants highlight thatrural men are often well-connected socially and rely on their social networks for support, whichis similar to the Network-Episode Model-III-R (NEM) (Pescosolido, 2011). The NEMconceptualizes health and help-seeking among adults as social processes that are shaped by theinteraction one has with their social networks (Pescosolido, 2011). Through this lens, one’srelationships with service providers, family members, and peers may impact their propensity toseek help. Many participants also identify social factors on the community-level that influencetheir ability to seek help, such as rurality and lack of service providers. This is consistent withRiver’s (2018) assertion that men are more likely to access services that frame health concernsand treatment in a way that is more congruent with men’s unique perspectives of health and60illness. Meanwhile, McKenzie and colleagues (2018) suggest men engage in diverse strategies ofacquiring and utilizing their social networks for social support, challenging the stereotype of menbeing uninterested or uncomfortable in engaging with one-another regarding health concerns.Personal FactorsThe current study also identified personal factors that influence help-seeking. Participantsidentified masculine norms including self-reliance and fear of showing weakness. Inconsideration of the HIMM framework (Evans et al., 2011), these factors should be considered tobe dynamic, changing in nature and importance for men throughout the life course.In relation to self-reliance, participants describe rural men as perceiving themselves astough, self-reliant individuals. For these men, help-seeking for health concerns may not becongruent with who they believe they are as men. The impact of self-concept is further supportedby Wenger (2011), who asserts that men deny accepting bodily dysfunction due to it challengingtheir male power and strength. However, self-concept may additionally function as a factor thatpredisposes men to particular orientation to engaging with services. For example, for some men,diagnosis of cancer produces a process of identity re-evaluation (Wenger, 2013). According toWenger (2013), men may resist cancer-related changes to their sense of self and engage withservices in such a way that knowledge of the disease is increased, as well as their sense ofstrength and endurance. Wenger (2013) suggests that this behaviour allows men to maintain theirpre-cancer understanding of themselves and position themselves as the physically capable expertof their illness. Men may also re-negotiate their self-concept in the face of illness, therebyacknowledging change and connecting with the feelings of vulnerability related to it (Wenger,2013).In the current study, several participants explain that some men in their communitiesendorse beliefs of not needing health services because men expect to be perceived as weak for61seeking help. However, Wegner (2011) suggests that men are more likely to seek help from theirsocial networks when the benefit of reaching out outweighs the cost. This is consistent in thecurrent study, wherein participants believed their peers would be receptive to discussions ofhealth if feelings of mutual trust were present. Participants of the current study additionallyidentify that they and/or their peers associate a level of shame and stigmatization with seekinghelp, creating a barrier for this behaviour. However, due to participants identifying a higher levelof discomfort seeking help for mental health concerns amongst their peers, the nature of healthconcerns men seek help for may exacerbate the effect of individual factors on seeking help.External FactorsDue to the majority of participants identifying several barriers to help-seeking for ruralmen, future research should consider external factors that moderate rural men’s help-seeking. Inthe current study, several participants identify that men lack knowledge and understanding ofhealth and illness, which influences their propensity to seek help. This is particularly the case formental health, where participants report a low level of knowledge amongst their peers. As well,considering knowledge aligns with Wenger’s (2011) assertion that for men’s help-seeking tooccur, individuals must recognize symptoms as problematic and believe an intervention isneeded. This is supported by several participants who describe a lack of understanding about thesymptomology of physical and mental illness, as well as being unsure if particular concerningsymptoms warrant emergency care. However, these evaluations are a product of subjective waysin which men apply meaning to their symptoms. For this reason, “knowledge” can be broadenedto encompass how rural men’s knowledge, socialization, and experience affects their perceptionof their situation, presentation, and need (Wegner, 2011). Participants of the current study alsodescribe a variety of environmental barriers that are unique to their rural communities. These62include the rural nature of their communities, lack of transportation, and the lack of healthcentres and professionals.Help-SeekingParticipants of the current study identified informal help-seeking in addition to the use ofhealth services (“formal help-seeking”). The former represents an important aspect of men’shealthcare when social networks are available and characterized by trusting relationships. This isconsistent with Wenger (2011), who asserts that help-seeking is a performance of masculinitythat is constructed with others, encompassing health professionals and lay people (partners andpeers). Men’s help-seeking may take on several appearances. Wegner (2011) asserts that thestigma and social norms surrounding men’s help-seeking influences the dynamic way in whichmen engage in the help-seeking process. Due to men’s increased discomfort with mental health,the specific avenue men take in seeking help may be affected by the nature of their healthconcerns. Additionally, some participants and previous research (Oliffe & Moodie, 2019)identify that men sometimes informally share knowledge and experiences surrounding healthwith one another, such as in Men’s Sheds (AMSA, 2017). Through this informal support, mencan also make recommendations to formal health services. Although, this relationship was notrobust in the current study, it is supported in extant literature. Wegner (2011) asserts that men’shelp-seeking is a dynamic process, wherein delaying formal (or even direct informal) help-seeking should not lead to evaluations of men being “inactive” in terms of their help-seekingbehaviours. Instead, men also engage in various coping or self-care strategies that satisfy theirneeds throughout their experience of health concerns, despite the pressures experienced bystigma and traditional masculine norms (Wenger, 2011).63Reflection on Engaging Men in ResearchDuring the course of this study, planned recruitment methodology was continuallyevaluated and adapted to address issues that presented themselves. Originally, recruitment wasplanned to center around the larger Okanagan Men’s Shed Association (OKMSA) mobile shedoutreach initiative that the current study was a part of. It was hoped that through attendingsummer-time community events in the SI, a community survey, which included an invitation formen to participate in an interview, could be broadly disseminated. The research team (includingUBCO staff and OKMSA members) planned to attend nine events, three each in Regions A andB for maximum coverage of the target population. Unfortunately, only three events in the SIwere completed, one in Region A and two in Region B. In attending these events, the researchernoted that while local men quickly took interest in the booth due to the presence of table sawsand similar equipment, once the conversation turned towards research on men’s health, it wasmore difficult to keep passers-by engaged. Overall, only a few men at the events agreed to fillout the survey. The researcher suspected that this may have been due to the local men beinguncomfortable with discussing health in a public venue with strangers, particularly those fromout of town. Additionally, the woodworking equipment and activities available at the booth mayhave distracted from the purpose of the research team’s presence: to distribute surveys andrecruit for the study. Both of these factors made recruitment through the originally plannedmethod incredibly difficult, as men would happily engage with the research team, but not inregards to the research project. Of those men who did fill out a survey, all opted out ofconducting an interview.As the initial method of recruitment was largely unsuccessful, the researcher elected tobroadly advertise the study throughout Regions A and B utilizing posters, which included a briefdescription of the study and the researcher’s contact information. Although, advertisement via64posters was more effective than recruiting through the OKMSA-related outreach initiative (4 ofthe 8 participants in the final sample of interview participants responded to the posters, while theother 4 were recruited through Community Conversations), the response rate was low.Additionally, several community organizations were sent information about the study and askedto share with eligible men; however, the researcher received no referrals. Due to the researcherliving over an hour outside of the SI, he was forced to rely heavily on potential participantshaving access to (and understanding how to operate) a computer, as consent forms were sentelectronically. While most participants were able to email back and forth with the researcherafter the initial follow-up telephone conversation, in some cases, technological malfunctionsoccurred, such as a participant being unable to open the consent form file. The online and over-the-phone component of the recruitment process may have been a barrier to some rural menparticipating in the study. For example, some potential participants were lost to follow-up afterbeing sent the consent form, while others withdrew their interest in participating after expressingconcern to the researcher about meeting the criteria for an interview (such as having attended aMobile Shed event). Although the researcher assured these men that they were eligible toparticipate, they declined further participation. These issues suggested to the researcher that itwould, perhaps, be more effective to recruit men face-to-face, as technological issues would beavoided and clarification of questions and concerns could be more easily given. This rationalepartly inspired the inclusion of Community Conversations into the research design.Overall, the experience of engaging men for research purposes was both frustrating butenlightening. The difficulty in engaging men during the initial and secondary phases ofrecruitment may be indicative of men’s overall discomfort in talking about their health. Low andslow response rates to the advertisement posters supported this assumption; however, it mayhave also been the result of men not typically stopping to read poster advertisements when they65were out in the community. Further, men may be less likely to phone or email responses toadvertisements for research participants. This may be related to men feeling more comfortablediscussing topics of health and well-being with trusted friends and family, as described in theinterviews. Due to men potentially being less inclined to phone a researcher who they have nofamiliarity with, it will be critical in future research, for researchers to be present in the ruralcommunities which they recruit from. By attending local events or community gatherings, localscan gain a level of familiarity and rapport with the researchers, which would potentially makethem feel more comfortable in agreeing to engage in the research. Such endeavours must,however, be succinct and clear in their purpose. While the outreach initiative recruitment didwell in engaging men, it failed to foster interest in rural men to participate in the study.Conversely, the Community Conversations were very successful in engaging communitymembers (both men and women) in discussing issues surrounding men’s health and well-being.Through these conversations, additional interview participants were recruited (n = 4),presumably due in part to the men having spoken with the researcher in person and developed asense of familiarity with him and interest in the study.Strengths and LimitationsThe primary strength of this thesis is that the unique perspectives surrounding health andhelp-seeking of rural men in the SI were captured. This includes both the formal and informalavenues men utilize to address their health concerns, as well as how rural-life and masculinitywork to shape how men view their well-being and interferes with help-seeking efforts. The studyutilized a range of recruitment strategies and adapted them to better engage with men in the SI,whose perspectives had been absent from previous research conducted in the region (Oelke et al,2016; Oelke, n.d.). In keeping with the tradition of Interpretive Description (ID), a range ofperspectives on men’s health and help-seeking have been gathered through data collection from66formal (interviews) and informal (Community Conversations) means (Hunt, 2009). As well, ahigh degree of rigour is sought throughout the study. The credibility of the study is strengthenedby establishing detailed protocols for both data collection and analysis, as well as conductingregular weekly debriefing sessions with supervisors to discuss the research process and criticallyevaluate emerging findings. The transferability of the study is enhanced though a rich narrativeof participants’ common experiences that is generated from the data. This is accomplishedthrough utilization of the interpretive description methodological framework (Thorne et al.,2004). Further, the thoughts around a future framework of rural men’s help-seeking facilitatesthe study’s transferability.Although the current study is firmly rooted in empirically validated methodologicalframeworks, some limitations exist. Firstly, the target sample size of the study is small and fairlyhomogenous in terms of ethnicity, age, and socioeconomic status, which may limit the richnessof the presented narrative rural men’s help-seeking in the SI. Specifically, the study lacks ethnic,sexual, and gender diversity, which may impact its applicability to groups of men that arehistorically marginalized and racialized. Additionally, theoretical saturation has been found to beattainable in studies with methodologies and sample sizes similar to the one here (Guest et al.,2006). A second limitation is that participants may have exhibited social desirability bias and,consequently, over/under-report nuances of their experiences. While controlling for this isdifficult, due to the socially interactive nature of interviews, establishing the aim of the study aslearning from the participant and positioning them as the expert of their own experience mayhave reduced social desirability bias. Social desirability bias is addressed by discussing theimportance of honesty, building rapport and creating a safe environment, and letting participantsknow that it is acceptable to withdraw from the study if they do not feel comfortable sharingtheir perspectives honestly.67RecommendationsThis chapter considers the relationships among the key results of this qualitative study.The following recommendations are rooted in the findings generated from the rich experiencesof local men in the SI. Critical, system-wide changes are necessary to help reduce the burden ofmen’s poor health in Canada, which is estimated at $36.9 billion per year (Canadian Men’sHealth Foundation, 2016). For this reason, changes in policy, practice, and education, and futureresearch are required.PolicyOverwhelmingly, all participants felt that the SI needs more healthcare providers.Participants often are unable to access formal help within their own communities and in somecases have to travel long distances to connect with their GP. To fill this gap, communitystakeholders and policy makers need to broaden the availability of primary care in ruralcommunities. This could include extending the hours of rural health clinics to include eveningsand weekends (Kirby & Yabroff, 2020). Alternatively, policymakers could considerimplementing virtual care for rural communities in the SI. This is consistent with the literaturethat supports the effectiveness of telehealth in providing rural and remote regions of Canada agreater range of services, including specialist services, than would be feasible locally (Liddy etal., 2017). Further, due to participants suggesting that their towns are not attractive to potentialproviders contributing to a paucity of services, decision makers in healthcare and local policymakers should develop incentives for professionals to practice in rural communities, includinghousing supplements or reductions in accreditation, business, or tax costs (Yong et al., 2018).PracticeAs men’s views of health and help-seeking are unique, service providers need to workdifferently with men in such a way that it meets their needs and addresses their concerns. To this68end, men’s informal help-seeking networks may be a target for intervention. For men, informalhelp-seeking provides necessary support, but also potential health information and guidancenavigating the healthcare system. For this reason, local community organizations or healthauthorities could implement male peer support groups and/or peer support workers, which aresupported in the literature (Harley et al., 2020; Ogrodniczuk et al., 2016; Robinson et al., 2015).Overall, the goal of such services would be to provide men caring, knowledgeable support.However, these could also work to foster enhanced sense of trust and community among localmen. Further, peer support workers and support group moderators would function to connectmen with others in the community, facilitating connection by “doing”, as is supported by Men’sSheds (AMSA, 2017). Similarly, programs such as the DUDES Club (Gross et al., 2016), whichprovides a safe space for men to socialize, be vulnerable, and improve peer support and healthliteracy skills, have been beneficial for the biopsychosocial-spiritual well-being of participants.Additionally, due to men’s unique experiences and perspective surrounding health, formalservices must adapt their approach to working with men to enhance their well-being. Forexample, the APA (2018) suggests that psychologists need to promote gender sensitivity in theirprovision of services to men. This would initially involve mental health clinicians understandingmasculinities as existing on a spectrum that is constructed through the influence of socioculturaland contextual norms. This would help to broaden clinicians’ perspectives of typical malebehaviour within the therapy room and reduce the impact of stereotyping men as being emotionilliterate. Additionally, due to gender differences in the expression of depression, mental healthclinicians must adapt assessment and screening tools to more effectively capture male-centricpresentations of mental illness (such as irritability or substance use). Further, the APA (2018)highlights that mental health clinicians tend to focus on perceived behavioural deficits, ratherthan mobilizing healthful aspects of masculinity as areas of strength in men’s lives.69EducationSimilarly to recommendations for health professionals to position masculinities as pointof strength among men, endeavors for men’s education programs should utilize strength-basedapproaches to work with men and create environments where masculine norms can be reframedto promote men’s well-being. To this end, any initiative aimed at men’s health and well-beingmust be co-created by men so it is tailored specifically to reflect their perspectives andunderstandings of their health and make recommendations that are feasible and attractive formen. In such programing, Oliffe and colleagues (2019) suggest that providers not assume healthinequalities to uniformly impact men, particularly men belonging to minority groups. Providersmust thoroughly investigate the needs of the intended audience of educational programming andevaluate the resources necessary to customize programming to meet these needs (Oliffe et al.,2019). As discussed earlier, the Men’s Shed (AMSA, 2017) is an example of such a program thathas been found to improve men’s overall well-being through expanding social connectedness(Taylor et al., 2017). While Men’s Sheds generally center around trades work, such aswoodworking, other effective men’s programs have centered around physical activity such as theHAT TRICK program for men’s healthy living and social connectedness (Sharp et al., 2018)Through such programming, local education sessions could be provided to men that exploresigns and symptoms of common health concerns. This is of particular importance due toparticipants in the current identifying low health literacy as a barrier to help-seeking, which issupported by extant literature (Bourne et al., 2010; Emery et al., 2013; Fish et al., 2019). For thisreason, men’s health education programs should include efforts to expand men’s health literacy.However, Oliffe and colleagues (2019) critique the tendency of program providers to evaluateimprovement in health literacy in terms of acquisition of medical knowledge, which is viewed asinsufficient. Instead, they suggest men’s health practices are rooted in men’s understandings of70health and are critical for contextualizing men’s help-seeking behaviours (Oliffe et al., 2019).Such a shift in conceptualization of “health literacy” would allow men’s performances of healthbehaviours to be considered in range of contexts, including the intersections of socialdeterminants of health and masculinities that produce them. Further, it would allow programdevelopers to consider gender-differences in externalizing symptoms, particularly mental health,and create interventions specifically for men in relation to these.In all cases of men’s education or health literacy programming, the most beneficialresults would produced when conducted in a semi-informal manner, in spaces that are men-friendly and that men frequent, using analogies and examples with which men could relate(Oliffe et al., 2019). The same strategy could be implemented for mental health informationsessions for men. Based on the data gathered in the current study, rural men’s perspectives ofmental health are still not well understood. Therefore, education sessions for mental healthshould direct a significant degree of effort on normalization, as mental health is largely a tabootopic among men. Oliffe and colleagues (2009) offer a unique approach to normalization ofprostate cancer in the context of support groups: humour, which was thought to reduce men’sanxieties surrounding their cancer, as well as being amongst strangers. Further, inserting humourbefore addressing traditionally taboo topics among men (including erectile dysfunction, urinaryincontinence and death) allowed program providers to assess audience interest and indirectlyreceive permission to engage in the related discussion (Oliffe et al., 2009).Future ResearchDue to the small sample size of the current study and complexity of the male perspective,further research is required to continue building rich understandings of men’s help-seeking. Aswell, future research may explore men’s experiences engaging with healthcare services to betterunderstand how to create safe, gender-sensitive approaches to providing services for men. To71this end, data from significantly more diverse samples of rural men (e.g., ethnically diverse,different age groups) needs to be gathered. In addition, exploration is needed to refine andvalidate the initial framework of rural men’s help-seeking. However, in the researcher’sexperience, men are difficult to connect with in a research setting. For this reason, researchersmust develop innovative strategies for broad recruitment of men. Perhaps the most effectivemethod of doing so would be to meet men where they gather. Similar to the CommunityConversations conducted in the current study, recruitment for subsequent studies must occurwithin the communities themselves. In particular, future researchers must focus on findingcommunity events or local clubs that have a high or predominantly male attendance. Forexample, many men may gravitate towards local sporting or hobby clubs with a male-centricfocus, such as hunting or fishing. Extant literature also supports garnering male involvement inresearch through use of male researchers or research assistants and engaging with spouses(Gavarkovs, et al., 2016). Researchers may also seek to incentivize participation through food orattendance of professional athletes (particularly a local one) at recruitment events. In the lattercase, researchers could also work with these individuals to act as champions of the communityand reach out to men for participation in men’s health studies. Additionally, Friedman andcolleagues (2015) suggest that financial incentives and incentives that benefit one’s family werestrong motivators to participate in research among rural residents. Overall, future researchersmust get creative in their approaches to engaging men in health-related research and tailormethodologies to be more accessible to men.Next StepsFollowing completion of the project, end-of-grant KT strategies will be implemented todisseminate information and findings produced to a wide audience, but also, critically, to thecommunities in which the knowledge was produced. As the CIHR (2012) identifies publications72and presentations as the predominant modes of communicating produced knowledge toresearchers and academics, the researcher will seek to publish the results of the current project inrelevant research journals. Additionally, the researcher will seek to attend local communityevents and/or organizations in Regions A and B, and to make presentations to interestedstakeholders, community members, and knowledge users. Information sheets describing thecurrent study, its rationale, and its results will be created by using lay language and disseminatedto local community organizations to make the knowledge more accessible to individuals outsideacademia (CIHR, 2012). Together, these KT strategies will ensure that the knowledge createdthrough the research process is highly relevant to the experiences and perspectives of the targetpopulation, as well as accessible to them and to key individuals who might be able to integratethe findings in the planning and development of services for men (CIHR, 2012).ConclusionThis thesis sought to better understand the barriers to help-seeking that rural-life presentsto men and how they perceive seeking help for health concerns. To this end, the researcherconducted a qualitative study in two regions of the Southern Interior of British Columbia.Utilizing a broad range of recruitment strategies, eight participants completed interviews, whilean additional eleven provided informal feedback through Community Conversations. Fourimportant themes were identified: environmental barriers (rurality of communities and paucity oflocal service providers), lack of health education or awareness, masculinity (self-reliance, fear ofshowing weakness), and informal support. From these themes and the experiences of rural men,a model of rural men’s help-seeking was developed.The knowledge generated in this study may be helpful to produce promising practices forengaging men in health services and providing care for men in Regions A and B. However, itmay additionally assist in reduction of men’s perception of stigma surrounding health,73particularly mental health. As well, the findings may serve to better inform men of how toprovide informal help to one another. By providing space for reframing masculine norms tosupport men’s health and safe and respectful community-based opportunities for improvingmen’s health literacy, men’s wellbeing has the potential to be significantly improved. 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Constitution of the world health organization.http://www.who.int/governance/eb/who_constitution_en.pdfWorld Health Organization. (2019a). Health impact assessment: The determinants of health.https://www.who.int/hia/evidence/doh/en/World Health Organization. (2019b). World health statistics overview 2019: Monitoring healthfor the SDGs: Sustainable development goals.https://apps.who.int/iris/bitstream/handle/10665/311696/WHO-DAD-2019.1-eng.pdf?ua=1Yong, J., Scott, A., Gravelle, H., Sivey, P., & McGrail, M. (2018). Do rural incentives paymentsaffect entries and exits of general practitioners? Social Science & Medicine, 214, 197-205. https://doi.org/10.1016/j.socscimed.2018.08.01489AppendicesAppendix AAuthor/YearSetting/CountrySample Method Main ThemesSize DescriptionBennett etal. (2011)USA 617(54%rural)Veterans ofNationalGuard andReserve.Sample was92%Caucasian.89.5% ofruralparticipantswere men.40.7%participantswere 40+years oldand 27.5%werebetween 30-39.Quantitative(survey) No differences in numberof barriers for rural versusnon-rural participants. Greater barriers oftransportation for accessingmental healthcare for ruralveterans. Greater negative viewstoward mental health help-seeking among rural men. Rural participants were lessconcerned about stigma inworkplace.Bourne etal. (2010)Jamaica 2000men(51.0%rural)57.5% wereover the ageof 64.Quantitative(survey) 48.2% of participants hadhealth literacy difficulties.56.9% of urban and 44.5%of rural men were healthliterate. Rural men engaged inhealth-seeking more oftenthan urban men, but moreurban men had visited adoctor recently. Rural men were faced withnavigating a shortage ofhealthcare sites, forcingthem to travel.90Author/YearSetting/CountrySample Method Main ThemesSize DescriptionCoen et al.(2013)Canada 9English-speakingheterosexualcouplesThe couplesranged inage from 26– 44 yearsold. (Formen, M =36.8; forpartners M= 34). Eightof the ninemenidentified asAnglo-Canadian.Qualitative(semi-structuredinterviews) Experiencing depressionnegatively impacted men’sability to maintainmasculine roles. A lack of understanding ofdepression was identified. Participants incorporatedhealthful monologic traitsinto dialogic masculinities.These were co-created andmaintained with theirpartners.Connell etal. (2019)USA 64 (24men)African -Americancommunityhealthadvisors,communitymembers,and healthcareproviders.68% werebetween 45-64 yearsold.Qualitative(focus groups) Structural barriersincluded: poverty,unemployment rates, lackof health insurance, lack ofmedical specialists, andtransportation. Gender socialization was abarrier for men seekinghelp, which was viewed asweakness.91Author/YearSetting/CountrySample Method Main ThemesSize DescriptionCorboy etal. (2011)Australia 82 Mendiagnosedwith cancer.The meanage of theparticipantswas 69.78years (SD =10.18).Mixed method(survey andinterviewswith nineparticipantsand three withhealthprofessionals) Men who used apsychosocial supportservice were significantlyyounger than those menwho did not. While survey findingsuggested high level ofawareness of services,interviews suggested lackof awareness. Stigma was identified thatrelated to notions ofmasculinity and masculinebehaviour.o Many interviewparticipantsendorsed traditionalviews about men’shelp-seeking. Family members andfriends were significantsources of support. Majority of interviewparticipants and surveyrespondents did not identifytransportation as a majorconcern.Corboy etal. (2014)Australia 447 Participantswere aged42–77 years(M= 63.03,SD= 6.82).64%; livedin majorcities, 23%lived ininnerregionalareas, 10%lived inouterregionalareas.Quantitative(survey) Geographic remotenesswas found to negativelyaffect intentions to use atelephone-based supportservice, but did not predicthigher self-efficacy. Distance from metropolitanareas predicted increasedstoicism. A negative relationshipbetween stoicism andsubjective norms was alsoidentified.92Author/YearSetting/CountrySample Method Main ThemesSize DescriptionCreighton etal. (2017)Canada 13women& 2menParticipantswerebetween 23and 71years-oldand had losta male tosuicide 1 to3 yearsprior.Qualitative(individualinterviews andphotovoicemethodology) Most participants describedstigma in mental illness. Participants thought theirloved ones experiencedsocial pressure to fit in to aheterosexual model. Professional help wasdifficult to accessconfidentially, causing mento self-medicate throughalternative medicine,sports, or substance use.Emery et al.(2013)Australia 66 (28men)Mean agewas60.5 yearsMixedmethods(survey andinterviews) Participants were less likelyto seek help if symptomswere intermittent,perceived as mild, orincreased gradually. Optimism contributed todelays in help-seekingbehaviour and wasassociated with stoicism asa response to healthconcerns. Perceptions of anineffective rural health caresysteminfluenced decisions toengage in help-seeking.Fennell etal. (2017)Australia 201(33.8%male)Mean age61.7 years-old (SD =15.4),ranged from18 to 94.Quantitative(telephonesurvey) Men were significantlymore likely to endorsepersonal barriers to help-seeking. Men scored significantlyhigher on self-reliance –related items Men scored higher on "Idon’t know how to talkabout something like this",highlighting the importanceof education targetinghaving conversations abouthealth.93Author/YearSetting/CountrySample Method Main ThemesSize DescriptionFennell etal. (2018)Australia 409(40.8%men)Mean age62.6 (SD =14.1).Quantitative(survey) Men endorsed higherperceived barriers for themental health scenario thanthe physical healthscenario. Men strongly endorsed‘need for control and self-reliance’ and ‘minimisingthe problem, resignationand normalisation’ for thephysical health scenario.Fischer etal. (2016)USA 25 (19men)Themajority ofveteranparticipantswere male,white, andranged inage from 28to 68 years.Qualitative(survey) Barriers to help-seekingand continued engagementincluded: self-reliance,stoicism, stigma, and lackof trust in the VAhealthcare system. Perceived need for care andsupport from family andfriends were identified toencourage treatment-seeking.o Perceptions ofeffective treatmentand building trustwith providersencouragedcontinuedengagement.94Author/YearSetting/CountrySample Method Main ThemesSize DescriptionFish et al.(2019)Australia 13 menand 8femalepartnersParticipantsranged inage from 54–79 years(M = 68years).Sevenresided in arural area.Qualitative(interviews) Most participants reporteddelaying seeking help. Nodifferences between urbanand rural participants wereidentified. Participants had limitedknowledge of commoncancer symptoms, asidefrom skin cancer.o Participants whoperceivedsymptoms to bemild or intermittentwere more likely todelay help-seeking. Appearing strong, stoicism,self-reliance,invulnerability to disease,preference for privacy andbeing successful andpowerful were masculinenorms identified asimpacting help-seeking. Half of symptomaticparticipants initially soughtinformal support from theirpartner. Rural men more frequentlyreported over-optimismregarding symptoms, whichlead to delaying seekingsupport. Access issues were morefrequent among ruralparticipants.95Author/YearSetting/CountrySample Method Main ThemesSize DescriptionGetrich etal. (2012)USA 66(50%male)8 providers(75% non-HispanicWhite), 6clinic staff(female,83%Hispanic),and 52patientsQualitative(interviews/focus groups) Mexican participants sawmachismo as a part ofeveryday life, whileHispanos described it as ahistorical phenomenon. Colonoscopies wereidentified as potentiallyactivating machismo due tothe anus being considered ataboo area among Mexicanparticipants. Mexican men expressedconcern that a colonoscopywould affect theirreputation amongst theirpeers.Hammer etal. (2013)USA 4748men18 to 79years old(M = 32.9;SD = 12.2years)72.7%identified asEuropeanAmerican(10% AsianAmerican;7.3% LatinoAmerican;and 4.7%AfricanAmerican).16.5% ofparticipantlived inrural areas.Quantitative(survey) Rural men endorsed greatermasculine norms thanurban men. Rural men endorsed greaterself-stigma than moreurban men. Rural men reported fewerfavorable attitudes moreurban men. Rural men had a strongerassociation betweenconformity to masculinenorms and self-stigma thanurban men.96Author/YearSetting/CountrySample Method Main ThemesSize DescriptionHerbst et al.(2014)USA. 136 Majority(96%)identified asCaucasian/EuropeanAmerican.Mean agewas 44.24years (SD =13.74).Quantitative(survey) Participants most stronglyendorsed masculine normsof Heterosexual Self-Preservation, Winning,Violence, Risk-taking, andEmotional Control. Respondents were resistantto seeking interpersonalhelp for depression. Higher conformity tomasculine norms wasassociated with being lesslikely to talk to familymembers about healthconcerns and more likely tohave a few drinks to cope. Men endorsing emotionalcontrol, power over womenand self-reliance werethought to have mostdifficulty in seeking help.Isaacs et al.(2013)Australia 17 (15men)AustralianAboriginalpeople aged25 – 65.Qualitative(interviews) Difficulty in recognizingmental health concerns wasmore prevalent among menwho lived alone or infamilies with people whohad similar concerns. Barriers to disclosing one’sproblems related topreserving one’s role in thecommunity, peer pressure,stigma and negativeexperiences withgovernment organizations. Reluctance to contactservices was related tobarriers feeling shame orfearing of hospitals/mentalhealth services. Alternate coping strategiesincluded use of alcohol.97Author/YearSetting/CountrySample Method Main ThemesSize DescriptionLabra et al.(2019)Chile 45 55.6% (n =26) wereaged 54 andyounger and44.4% (n =19) were 55and older.Mixed method(survey andinterview) 64.4% (n = 29) ofparticipants demonstratedpositive attitudes towardsseeking help. Participants aged 55 andolder expressedreservations about seekinghelp in difficult situations. Men under 54 respondedmore positively to seekinghelp from a physical health(78.9%) or mental healthprofessionals (73.7%).McPhedran& De Leo(2013)Australia 3203menwhohaddied bysuicide44.3% werefrom rurallocations.Rural menwho died bysuicidewere onaverageolder thanurban men(M = 44.5years vs. M= 42.8years).Quantitative(suicide data) Rural men were less likelyto be connected withmental health services 3months prior to death, butwere not less likely tocommunicate suicidalintent.o 40% of rural menhad contact with amental healthprofessional andstill died by suicide.Misan et al.(2017)Australia 154 RuralMen’s Shedmemberswithaverage age66 years(SD = 13.4years).Quantitative(survey) Chronic health conditionswere prevalent among thesample, as well as beingoverweight or obese, butmany participants ratedtheir health as “good”. Most participants hadcontact with a doctor in thelast year for preventativehealth checks, but secondmost common was pain andloss of daily functioning. Participants agreed thatthey preferred learning bydoing, as was offered inMen’s Sheds.98Author/YearSetting/CountrySample Method Main ThemesSize DescriptionOberoi et al.(2016)Australia 408 Sample wasaged 18 andolder(76.2%between 30– 59 yearsold).Quantitative(survey) Health beliefs werestrongly associated withwhether participantsrecommended help-seeking. Regional and remoteparticipants were less likelyto refer than urbanparticipants. Many participantsdisagreed with expertsabout symptoms of lowerbowel cancer that requiredhelp-seeking.Perceval etal. (2018)Australia 63 (30males)Mostparticipantswere agedbetween 35and 65years.Qualitative(focus groups) Increased socialengagement was identifiedas a protective factoragainst suicide thatincreased well-being. Help-seeking wasnegatively impacted bycommunity attitudes andstigma.Radermacher &Feldman(2015)Australia Serviceproviders: 12(7 men,5women)Oldermen:26The oldermen werefromvariousethnicbackgrounds (Turkish,Albanian,Italian andMacedonian).Participantshad anaverage ageof 67(rangingfrom 39 to85 years).Qualitative(focus groups) Changes in the agricultureindustry and family valuesresulted in negative healthoutcomes that participantsfelt they were not equippedto cope with. Service providerscharacterized older ethnicminority men asproblematic, but the menthemselves demonstratedan understanding andawareness of healthyliving.99Author/YearSetting/CountrySample Method Main ThemesSize DescriptionRoy et al.(2014)Canada 32 Malefarmersaged 27 –63.Qualitative(interviews) Diverse masculinities wererevealed which counterstereotypes of farmers nottalking about health. Contradictions wereidentified betweentraditional norms andpositive regard for menwho had the courage toseek help.Staniford etal. (2009)Australia 16 (12men)Participantswerefarmers andranged inage from 30to 82 years(M = 49.72& SD =13.9)Qualitative(interviews) Coping mechanisms forstress included socialsupport.o When not available,stress was not aswell managed andmental healthprofessionals werenot accessed. Negative attitudes towardshelp-seeking and self-image contributed toresistance to seek help. Improvements to existingmental health services wereidentified as a need.Su et al.(2016)Australia 1057(49.6male)Sample wasbetween 15– 29 yearsold. Of1057residents,678 (42.8%men) hadvisitedsexualhealthclinic.Mixed-methods(clinic dataaudit, focusgroups withIndigenousyoung men andinterviewswith ruralclinicians. Low health literacy anddiscomfort were identifiedas barriers to seek helpfrom the clinic. Indigenous men feltservices did not feelappropriate for them. Men’s reluctantance toattend the clinic wasassociated with avoidingfeeling shame. Understanding the risks ofSTI’s was associated withendorsement of masculinenorms100Appendix BMobile Men’s Shed StudyQuestions to Guide Community Conversation1. What can you tell us about how you and other men care for yourselves in thiscommunity?2. What are some of the things that help men to be able to care for themselves? What aresome of the barriers?3. What are service and support gaps missing here in your community to address health andwellbeing of men?4. What are some important topics that need to be addressed for men’s health and wellbeingin your community? How could these be addressed?101Appendix CMen’s Health and Wellbeing StudyCommunity Conversations Today we are holding a Community Conversation as part of the Men’s Health andWellbeing study led by Dr. Nelly Oelke (Principal Investigator, University of BritishColumbia, Okanagan) and Ian Pryzdial (Graduate Student, University of BritishColumbia, Okanagan). The study is funded by the by the Social Sciences and HumanitiesResearch Council of Canada (SSHRC). The goal of this research is to better understand the health and wellbeing of men in ruralcommunities in the SI and what they do to take care of themselves. The discussion will take approximately 5-10 minutes of your time. You can share yourfeedback on men’s health and wellbeing through adding comments directly to a flip chartpaper or poster board, writing your comments on a yellow sticky note, writing commentsin a book, or telling the researchers directly about your feedback. Discussions maybeone-on-one, or several men may participate at the same time individually providingfeedback or as a group. Others will know that you have participated and will have heard your opinions, thougheveryone will be asked to keep the discussion confidential. If you do not feel comfortablesharing your feedback openly you can write your feedback privately in a book. If youwould rather, there is also the opportunity to discuss your feedback in a private phoneinterview with Ian Pryzdial, the graduate student. Your name will not be attached to your responses; only group data will be presented.Research data will be stored in a locked cabinet at UBCO in a designated research area.Research results will be included in presentations and publications to let communitymembers, community leaders, healthcare providers in the SI, the [name of organization](a partner on this research) and other researchers. Results will also be reported in I.Pryzdial’s masters thesis available online. There is no direct benefit to participating, but information will be used to providerecommendations for better supports and services for men in these communities. If you have any concerns about your rights as a research participant and/or yourexperiences while participating in this study, you may contact the Research ParticipantComplaint Line in the UBC Office of Research Services at 1-877-822-8598 or the UBCOkanagan Research Services Office at 250-807-8832. You can also contact them by102email: RSIL@ors.ubc.ca. Please reference the study number (H18-01603) whencontacting the Complaint Line so the staff can better assist you. Your participation in this study is entirely voluntary. By participating in the discussionand providing feedback it will be assumed that consent has been given.103Appendix DMobile Men’s Shed StudyConsent Form (Interviews with Men)Principal Investigator:Nelly Oelke, Assistant Professor, School of Nursing, University of British Columbia, Okanagan(UBCO)Telephone: 250-807-9880E-mail: nelly.oelke@ubc.ca.Co-Investigators:Carolyn Szostak, Associate Professor, Department of Psychology, UBCOTelephone: 250-807-8736E-mail: carolyn.szostak@ubc.ca.Dennis Jasper, Lecturer, School of Nursing, UBCOTelephone: 250 807-8615Email; dennis.jasper@ubc.caIan Pryzdial, Masters of Social Work Student, UBCO. Ian will be completing this study as partof his thesis work.Telephone: 250-807-9948Email: ian.pryzdial@alumni.ubc.caOther study team members:Art Post, President, Okanagan Men’s Shed AssociationTelephone: 250 717-1575Email: okmshed@gmail.comFunding: This research is funded by the Social Sciences and Humanities Research Council ofCanada (SSHRC).Why are we doing this study?For some men, maintaining health and social networks can be a difficult task. We are doing thisstudy to better understand men’s health and wellbeing. As little is known about how men in ruralcommunities of British Columbia take care of themselves, we are collecting information on thehealth and wellbeing needs of men in the SI. The information collected will help us to betterunderstand the challenges men face in this area and assist us to develop better services for menwho live in rural communities.This study is being conducted in conjunction with the Mobile Men’s Shed project. Men’s Shedsprovide a place for men to gather and participate in various activities (e.g., woodworking) andengaging in meaningful community projects while building connections with other men. We areworking with the[name of organization] on this important work.Who can take part in this study? Men 19 years of age or older104 Live in one of the six SI communities or surrounding areaWhile English doesn’t have to be your first language, you must be able to speak and read Englishat around a Grade 8-9 level. Unfortunately, if you are not able to provide informed consent youwill not be able to take part in our study.What does participation involve?You indicated you would be interested in participating in an interview by replying to aninvitation located in your community or by completing a survey at the Mobile Men’s Shed. IanPryzdial, the Master of Social Work student will do the interview with you. The interview willtake place in a location suitable to you that will provide sufficient privacy (e.g., your home,community organization office) and will take 1-1.5 hours. You can also do the interview over thephone if that is more convenient. Ian will ask you a series of questions aboutyour experiences with health and well-being, your observations of the same in other men in yourcommunity, barriers to seeking support, and supports/services that you believe would be of valuein your community. With your permission, your interview will be audio-recorded. As well, noteswill be taken. No information that could identify you will be included in the transcripts or thenotes. We would like to share your transcript of your interview and the common themes acrossthe interviews to get your feedback. We will do this with three of the interview participants in thestudy.We will also ask you to complete a short survey about yourself. Questions will ask you aboutyour age, where you live, and some questions about activities you are involved in.It is important to know that participation in this study is completely voluntary. You may changeyour mind at any time. If you decide that you no longer want to take part in the study, pleasecontact Nelly Oelke (250-807-9880 or nelly.oelke@ubc.ca) or Ian Pryzdial (250-807-9948 orian.pryzdial@alumni.ubc.ca). If you decide to withdraw before we have started to analyze thedata, all information that you have provided to us will be destroyed. However, if you withdrawonce analysis has begun, we will make sure that we do not include any quotes from yourinterview in any presentation or publication.What are the risks associated with participating in this study?We do not think that this interview will cause any risks that you would not normally experienceevery day. Some of the questions may make you feel uncomfortable. You can choose not toanswer any of the questions that are you asked.What are the benefits of participating in this study?There is no guarantee that you will directly benefit from participating in this study. However,your comments will be helpful to gain a better understanding of men’s health and well-beingconcerns in the SI. You will be given a copy of the summary report of this study.Will you be paid for participating?You will receive a $25 coffee gift card for participating in an interview.How will your privacy be maintained?All information that you provide us will be kept confidential. You will be assigned a uniqueresearch ID number to protect your confidentiality. This number will be used to identify your105information (e.g., interview transcript, consent form). This will help us to track your data whilekeeping your identity private. Only the researchers directly associated with this study will beable to access these files. Audio-recordings of the discussions will be transcribed by aprofessional transcriptionist who will sign a confidentiality form. All files will be transferred viaa secure UBC platform between the researchers and transcriptionist.Signed consent and release forms will be stored in a locked filing cabinet in Nelly Oelke’s UBCOffice. Paper copies of other documents (e.g., field notes) will be stored in a locked filingcabinet in Nelly Oelke’s research space at UBCO. Electronic data files (e.g., transcripts) will bestored on the Masters Student password-protected laptop during the study. All electronic fileswill be backed up on a part of the secure UBC network that only the researchers will have accessto. Once the study is completed, all files will only be stored on the UBCO secure network. Wewill keep all research files for at least 5 years after publication of the findings, when they will bedeleted or shredded.Some quotes from the interviews will be included in presentations and publications. You will notbe identified in these quotes. These presentations and articles will be used to let communitymembers, community leaders, healthcare providers in the SI [name of organization]’s Board toknow what we learned from this study. We also plan on presenting the findings at professionalmeetings and in journals. Finally, the results of this study will be published as part of IanPryzdial’s thesis, which will be available on the internet.Will the data be used for other purposes?This study may be extended to other communities. If this happens, data from this study may becompared with the other sets of data.Who can you contact if you have any questions about the study?If participants have any questions or concerns about this project and what you are being asked todo, please contact Nelly Oelke at 250-807-9880 or by e-mail at: nelly.oelke@ubc.ca.Who can you contact if you have complaints or concerns about this study?If you have any concerns about your rights as a research participant and/or your experienceswhile participating in this study, you may contact the Research Participant Complaint Line in theUBC Office of Research Services at 1-877-822-8598 or the UBC Okanagan Research ServicesOffice at 250-807-8832. Participants can also contact the research office by email:RSIL@ors.ubc.ca. Please reference the study number H18-01603 when calling so that theComplaint Line staff can better assist you.Would you like to participate in this study?Your decision to take part in this study is completely up to you. You may refuse to participatewithout any negative consequences. In addition, you can decide to stop participating at any timeduring the study.Your signature below indicates that you have been given a copy of this consent form for yourown records.Your signature indicates that you consent to participate in this study.Participant Signature Date106Printed Name of ParticipantI consent to my interview being audio-recorded:  Yes  NoI agree to be contacted to review my transcript and the overall themes from the study. We willcourier or send the information via registered mail for privacy.  Yes  NoAddress:If you would like a copy of the summary and/or final report please include your email address. Asummary will also be available by contacting the researchers or the Okanagan Men’s ShedAssociation. Contact information is included on the front of the form.Email107Appendix EMobile Men’s Shed StudyDemographic Survey1. Age:2. Sex: MaleFemaleOtherPrefer not to say3. Where do you live: [name of town] (or surrounding area)[name of town] (or surrounding area)[name of town] (or surrounding area)[name of town] (or surrounding area)[name of town] (or surrounding area)[name of town] (or surrounding area)Other:4. How long have you lived in the community above?5. If you recently moved (within the last 5 years), for what reasons did you move?6. Marital statusSingleMarriedCommon-lawSeparated/divorcedWidowed1087. Ethnicity: Please indicate all that apply:White (i.e., Caucasian)AboriginalChineseSouth Asian (e.g., East Indian, Pakistani, Sri Lankan, etc.)BlackFilipinoLatin AmericanSoutheast Asian (e.g., Vietnamese, Cambodian, Malaysian, Laotian, etc.)ArabWest Asian (e.g., Iranian, Afghan, etc.)KoreanJapaneseOther, please specify:8. Educational statusLess than high schoolHigh schoolSome post-secondaryCollege/technical diplomaUniversity degreePostgraduate education9. Are you:retiredemployed (full-time)employed (part-time)unemployedon some type of disability10. What is your total or combined household income per year (estimate)?Less than 25,000 80,000-99,99925,000-39,999 More than 99,99940,000-59,99960,000-79,99911. Which of the following statements best describes your physical health?I am extremely healthyI am pretty healthy; just some minor “aches & pains”I am fairly healthy though I am not as healthy as I wasI am not very healthy but I don’t have any serious health problemsI am not very healthy because I have some serious health problems10912. Do you have any of the following health conditions?High blood pressureDiabetesAsthmaArthritisProblems sleeping at nightDepression/anxietyHeart diseaseOther:13. To what extent do you find that you have a sense of purpose in your everyday life?0 1 2 3 4Not at all A little Somewhat Quite a bit Extremely14. To what extent do you find that you are socially isolated?0 1 2 3 4Not at all A little Somewhat Quite a bit Extremely15. How fulfilling is your life these days?0 1 2 3 4Not at all A little Somewhat Quite a bit Extremely16. What would help to improve your quality of life?17. If you are retired, how has your retirement been? Is it what you expected or is it different?Please explain:18. Please indicate which of the following activities you do and how often you do them.Activity: Never Rarely Monthly(more orless)Weekly(more or less)DailyVolunteer workPlay cards or othergamesPlay golf or othersportsRead books, etc.Gardening110Woodworking,mechanical work, etc.Other, please specify:__________________If you volunteer, what kind of things do you do?19. Did you attend the Mobile Men’s Shed at an event? Yes NoIf yes, where was the event(s):I would like to receive more information about the Men’s Shed program.111Appendix FMobile Men’s Shed StudyInterview GuideAsk questions about Mobile Men’s Shed if applicable (recruited through Mobile Men’sShed visits)1. Can you describe your experience inattending the mobile men’s shed in[insert location]? # of times attended Length of time spent at the Shed Types of activities involved with? Interactions with others in thecommunity and the Shed What prompted them to attend Accessibility2. What did you like most about the mobilemen’s shed? What did you like least?What suggestions would you have forimproving the mobile men’s shed?3. Can you tell us about the effectiveness ofthe mobile men’s shed for you and othermen in your community?Questions to be asked of all interview participants4. Can you tell us about your health andmental well-being concerns and/or thoseof the men in the community? Physical health concerns Social well-being concerns (e.g., socialisolation, fulfillment, quality of life, etc.) Mental well-being including depression,anxiety, substance use, and suicide Which are most significant?5. What are the barriers experienced byyourself and other men in seeking helpfor these concerns?6. What is the potential value of the havinga men’s shed for men in your communitywith regular activities? Men’s Sheds areorganizations that provide an opportunityfor men to meet in a “shed-type” locationto work on woodworking, mechanical,and other practical skills together. Itprovides a safe location for socializationand discussion of men’s concerns.1127. What other types of services and supportswould you like to see for men in yourcommunity?8. What additional comments do you haveabout what we talked about today?113Appendix GMobile Men’s Shed StudySuicide Risk Assessment1. Are thoughts of suicide present?  How long have they been present for? Do they feel hopeless? Has a previous attempt been made?2. Does the person have a current plan?  How well developed is the plan? Do they have the means to execute theplan (e.g., painkillers or firearms readilyavailable)?3. When does the person intent to carryout the plan?4. What are their resources??  Are they alone? Do they have supports (formal andinformal)?5. Have they talked to anyone about thesethoughts? Are they seeing a therapist currently?Adapted from: Carleton University. (2018). Suicidal Thoughts Protocol for use in ResearchSettings. Retrieved from https://carleton.ca/researchethics/policies-and-resources/suicidal-thoughts-protocol-for-use-in-research-settings/114Appendix HConfidentiality AgreementMobile Men’s Shed StudyAny information gathered during the course of the above research project is privilegedinformation, whether these concern interviews, focus groups, or surveys. The same applies to allrecords or documents associated with individuals participating in this research project asparticipants.I, ________________________________________, (PLEASE PRINT), affirm that I willmaintain the anonymity and confidentiality of all individuals participating in the study as well asother information gleaned from the practice setting.I also affirm that I will uphold personally, and in cooperation with my research colleagues, thefollowing: No record will be reproduced in any manner, in full or in part, having potential personalidentification capabilities either directly or indirectly; No record will be reviewed in any way, including casual reading, by anyone without expressauthorization of the one of the co-PIs; No personally identifying information, direct or indirect, will at any time be disclosed toanyone; No records, or reproductions of records, will be removed at any time from the premisesnormally used by researchers and staff, without the specific approval of one of the co-PIs; If copies are made (e.g., transcript by transcriptionist) it will be removed from all non-research computers as soon as the files have been successfully and confidentially transferred.Signature: _________________________ Witness: __________________Name, Printed: __________________________Date: _____________________________
Thesis/Dissertation
eng
Social Work
Vancouver : University of British Columbia Library
Attribution-NonCommercial-NoDerivatives 4.0 International
Graduate
Understanding help-seeking in rural men of the Southern Interior : a qualitative study
Text