Promoting Men’s Health Equity

Abstract

Men’s health equity is an area of men’s health research and practice that combines the literature on men’s health with that of health equity. More research is needed that describes how to intervene to promote men’s health equity. This introduction to the American Journal of Men’s Health special collection on promoting men’s health equity was created to feature research that describes aspects of promising interventions that (a) are population-specific approaches that consider the unique biopsychosocial factors that affect the health of socially defined populations of men; or (b) use a comparative approach to close or eliminate gaps between socially defined groups of men and women and among socially meaningful groups of men that are unnecessary, avoidable, considered unfair and unjust, and yet are modifiable. The dozen papers from across the globe included in the special collection are grouped in three areas: conceptual approaches and reviews; formative research; and evaluation findings. The papers represent a diverse array of populations under the umbrella of men’s health and a range of strategies to improve men’s health from tobacco cessation to microfinance. The collection features a range of alternative masculinities that emerge from original research by the contributors that are used in novel ways in the interventions. This editorial argues that more qualitative research is needed to evaluate the intended and unintended findings from interventions. This editorial also highlights the benefits that men’s health equity can gain from embracing dissemination and implementation science as a tool to systematically design, implement, refine, and sustain interventions.

The goal of men’s health research is not to document patterns of illness and disease, but to improve men’s health. In the United States and across the globe, the burden of men’s poor health is concentrated among men who are marginalized because of their race, ethnicity, gender identity, ability status, and other factors (Griffith et al., 2019a, 2019b, 2019c; Young, 2007). There is a need to move the health of men who live at the intersection of being male, adults, and of marginalized identities to become more of a central focus of men’s health research, policy, and practice (Baker, 2020; Griffith, 2020; Richardson et al., 2019). As men’s health equity has emerged from the margins of health equity and men’s health, it is critical to move beyond documenting the effects of masculinities and other factors that affect men’s health to focus on ways to improve the health of men who are marginalized. Griffith et al. (2019a, 2019b, 2019c) define men’s health equity as “. . .an area of research, practice, and policy that seeks to understand and address the needs of these men in ways that are sensitive to and congruent with the socially meaningful identities that have implications for health because their meaning is rooted in inequitable societal structures” (p. xxi).

The special collection of the American Journal of Men’s Health on promoting men’s health equity was created to provide examples of how to improve the health and well-being of socially marginalized groups of men through rigorous research. Men’s health equity can be pursued by building men’s health promotion interventions from the unique biopsychosocial factors that determine the health of these men, or by using a comparative approach that identifies the factors that disproportionately and negatively affect the health of marginalized men when they are compared with other groups of men or women, and then addressing these modifiable, avoidable, and unnecessary determinants of health (Griffith, 2020; Griffith et al., 2019a, 2019b, 2019c). The goal of this special collection is to feature articles that advance men’s health toward men’s health equity.

The Special Collection of Promoting Men’s Health Equity in the American Journal of Men’s Health

The papers in the special collection of the American Journal of Men’s Health on promoting men’s health equity were organized in three areas: conceptual approaches and reviews; formative research; and evaluation findings. In addition to several pieces that explore the health of men and the masculinities of African American and Latinx men, this special collection of a dozen papers includes contributions that critically discuss understudied populations such incarcerated men, Tanzanian men, American Indian and Alaska Native men, transgender men, and Aboriginal and Torres Strait Islander males.

The section that describes how researchers plan to conduct future interventions based on existing literature, frameworks, and theories begins with a piece by Sinclair and colleagues who describe the design and methods of a future randomized controlled trial of a diabetes prevention program for American Indian and Alaska Native men. Despite the disproportionately high rates of type 2 diabetes and related chronic diseases in this population, there are few culturally and contextually appropriate interventions for this group of men. Sinclair and colleagues highlight the importance of considering historical factors such as colonization, assimilation, and intergenerational trauma in the intervention while promoting strengths such as positive masculinities, purpose, cultural knowledge, and “making power” to reclaim traditions and cultural practices. In the second piece in this section, Watson and colleagues describe the process and framework for the SHARED Project: a citizen scientist intervention to increase lung cancer screening among African American men in Chicago, IL. Watson and colleagues highlight how training laypersons as citizen scientists may be an important strategy to increase the capacity of the community to engage in healthier behaviors (e.g., cancer screening) in ways that also build community trust in research. The third piece in this section is a scoping review conducted by Dhillon and colleagues to identify the barriers and facilitators of human papillomavirus screening uptake in transgender men (i.e., individuals assigned female at birth who currently identify as male but who may or may not have had genital reassignment surgery). Dhillon and colleagues demonstrate the need for health-care services to expand beyond a binary approach to gender identity and health, highlighting the critical role that the perceived trustworthiness of providers, providers’ ability to provide clear and accurate medical information, and the prevalence of health-care discrimination that transgender men face in transgender men’s decisions to undergo cervical cancer screening. Dhillon and colleagues find that these and other modifiable provider-level factors play a critical role in transgender men’s cancer screening practices. They also find that patients’ prior experience with cervical cancer screening; patients’ sense that they are retaining a sense of dignity and safety; and patients’ perceptions, knowledge, health practices, socioeconomic status, and health insurance all affect transgender men’s cervical cancer screening practices.

In the second section of the special collection on promoting men’s health equity that highlights formative research, Mhando and colleagues describe the findings from focus groups used to explore the perceived benefits of an intervention that integrates microfinance, health education, and peer health leadership to reduce violence and HIV risk among men in Tanzania. Mhando and colleagues find that providing three small loans, business and finance training, and training on leadership, gender-based violence, and sexual health increases men’s perceived agency or ability to increase income, reduce financial stress, and increase HIV testing among other benefits. They note that often these financial stressors affect men’s health because they threatened men’s ability to fulfill the financial provider role, which remains a key aspect of how men saw themselves and if they were respected as men by other men and women in Tanzania. Next, Smith and colleagues use thematic qualitative analytic methods to explore the findings from Yarning sessions (i.e., informal chats that are culturally responsive strategies to engage First Nations people globally) and Photovoice using Facebook to understand the health literacy abilities and needs of young Aboriginal and Torres Strait Islander males in the Northern Territory of Australia. Smith and colleagues find that alternative Indigenous masculinities—that embrace and simultaneously resist hegemonic masculine norms—and family, peer, and community supports are critical in fostering health literacy among these males. It is important for future culturally responsive and contextually appropriate interventions to expand existing family, peer, and community support structures and to incorporate the perspectives of young Aboriginal and Torres Strait Islander males. Williams, Wilson, and Bergeson use individual interviews to explore how Black men in a Northeastern city who had been incarcerated pursue and perform ideals of hegemonic masculinity by engaging in behaviors that may improve their economic circumstances but also increase their chances of returning to jail or prison. Williams and colleagues argue that Black men’s efforts to embody these “divergent masculinities” while seeking to fulfill roles as providers, fathers, and simply men need to be addressed directly in interventions to promote Black men’s health and well-being and decrease their recidivism. Richardson and colleagues use the phenomenological variant of ecological systems theory to analyze individual interview and focus group data from young Black men who were survivors of gun violence. Richardson and colleagues’ study identifies the ways that these young men described symptoms of traumatic stress and post-injury affective changes that are important to consider in future hospital-based violence intervention programs.

The third and final section of the promoting men’s health equity special collection includes five papers that describe evaluations of interventions conducted in various settings. Valera, Acuna, and Vento describe the feasibility, appropriateness, and preliminary efficacy of a smoking cessation intervention for incarcerated men and transgender females. In this 6-week program, Valera et al. found that a combination of group therapy and nicotine replacement patches proved promising and is potentially scalable to other correctional facilities, particularly if inmates are screened for tobacco dependence during initial processing and classification. Rhodes and colleagues evaluate the implementation of a well-established HIV and STI prevention intervention (HoMBReS) for Spanish-speaking, predominantly heterosexual Latinx men in three community-based organizations. Using the scale up and spread implementation framework and a combination of archival and interview data, Rhodes and colleagues find this dissemination promising and find that it is critical to recognize that implementation in a new organizational and community context is a process that takes time and community input at every stage of the research process. Torres and colleagues describe the mixed methods evaluation of a pilot randomized controlled trial of a brief intervention to reduce unhealthy alcohol use among Latino immigrant men. While the findings are promising and the participants were satisfied with the content, setting, and mode of intervention delivery, Torres and colleagues indicate that the Latino men in the study noted that they would have preferred to have more contact with the promoters and clearer and more directive feedback to help reduce unhealthy alcohol use. Watkins and colleagues use a mixed methods approach to describe the findings from a social media-based psychoeducational program to improve the mental health of young Black men enrolled in universities. In the Young Black Men, Masculinities, and Mental Health (YBMen) project, Watkins and colleagues find that the intervention was effective in reducing depressive symptoms over the 5-week intervention. Postintervention interviews highlight the critical changes that also occurred in mental health, manhood, and social support of YBMen participants. Bowleg and colleagues use the analysis of structured interviews of poor, urban heterosexual Black men to argue for and illustrate the importance of expanding evaluation criteria for health interventions to include unanticipated outcomes. MEN Count was an intervention designed to promote HIV/STI prevention, gender equity, and healthy relationships by providing case management to promote housing stability and employment. Bowleg and colleagues find that it was critical to capture the importance of one key project staff, and their concordance with participants by race, gender, and relatable life experiences to address the social-structural contexts and realities of participants to develop future multilevel interventions to pursue health equity.

Discussion

The promoting men’s health equity special collection provides examples of promising research in pursuit of men’s health equity (Griffith et al., 2019a, 2019b, 2019c). Because masculinities and other social determinants of health are shaped by the organizational, institutional, community, and other contexts in which they operate, the articles in this special collection specifically illustrate how masculinities and context affect the intervention strategy selected to improve men’s health. Racism, homophobia, and other oppressive structures are omnipresent contextual structures that limit men’s health and well-being (Ford et al., 2019a). Men who are marginalized or subordinated often reject hegemonic ideals that become part of organizational and institutional cultures (Griffith, Childs, et al., 2007; Griffith, Mason, et al., 2007; Griffith, Mason, Yonas, et al., 2007; Griffith et al., 2010) in part because these masculinities often promote a discourse that primarily blames men for their poor health and well-being and may present a deficit view of men in relation to their health behaviors and health practices (Robertson et al., 2016). Rather, men who are marginalized or subordinated do not allow themselves to be reduced to the experience of racism or marginalization, and they redefine their ideals, goals, and aspirations in the context of what they have the capacity to be and do (Coles, 2008; Griffith & Cornish, 2018). This special collection highlights some of the critical ways that men’s health research is capturing novel masculinities, and how researchers are applying these alternative masculinities in interventions to achieve men’s health equity.

Intersectionality is an approach that appears in many of the papers across the special collection. For almost a decade, scholars have borrowed the concept and approach of intersectionality from critical race theory (Crenshaw, 1995) and applied it to men’s health (Bowleg et al., 2013; Ferlatte, Salway, Hankivsky, et al., 2017; Ferlatte, Salway, Trussler, et al., 2017; Griffith, 2012; Griffith et al., 2011; Wong et al., 2017). While initially an intersectional approach was pioneered to better understand the experience of people who were marginalized because of their race and gender (Bowleg, 2008), men’s health researchers have adapted this approach to consider how the social and economic advantages of being male intersects with socially identifiable markers of disadvantage and marginalization (Baker, 2020; Bowleg, 2013, 2017a; Griffith, 2012, 2016, 2020; Griffith et al., 2011). In spite of the ways that gender ideals, gender norms, and masculinities have changed over time, heteronormative gender roles continue to provide important prescriptive (i.e., expected or desired) and proscriptive (i.e., forbidden or undesired) standards that are central to understanding how cisgender men negotiate their gender status (Vandello et al., 2019). Heteronormative gender roles continue to represent characteristics, ideals, and standards for many men. The ideals and standards that shape men’s efforts to adhere or refer to these heteronormative standards are set not only by men, but by communities of practice that include women (Creighton & Oliffe, 2010) and people who are of nonbinary genders.

Because men are not a monolith who are equally privileged by patriarchy (Pease, 2009), strategies to improve men’s health must be developed with the heterogeneity of people who fit under the umbrella of men’s health in mind (Baker, 2020; Griffith et al., 2011; Treadwell & Ro, 2003). An intersectional approach has been used to systematically consider the heterogeneity among men in ways that consider the meaning and consequences of socially defined constructs (e.g., race, ethnicity, gender) for understanding the social and health effects of key aspects of identity and context (Bowleg, 2017a; Griffith, 2012). Socially defined characteristics jointly and simultaneously structure health practices and health outcomes (Warner & Brown, 2011). Using an intersectional lens to study men’s health helps researchers to contextualize and recognize the ways that race, class, sexual orientation, disability, and other structures and axes of inequity constitute intersecting systems of oppression when conceptualizing the gendered and nongendered determinants of men’s health (Griffith, 2018). Stressors and strains that affect health that result from the unequal distribution of opportunities, resources, life chances, power, privilege, and prestige are best understood by using an intersectional approach (Watkins & Griffith, 2013).

The Special Collection of Promoting Men’s Health Equity in a Scientific Context

Sinclair and colleagues, Watson and colleagues, and Dhillon and colleagues offer examples of how to design novel intervention strategies that are culturally and contextually appropriate to reduce chronic disease risk. Each of these strategies explicitly consider how the historical legacy of racism or discrimination (Ford et al., 2019b)—in its unique population-specific forms—is important to address to overcome a legacy of distrust and mistrust that may adversely affect participation in research (Griffith, Bergner, et al., 2020; Jaiswal & Halkitis, 2019). These three conceptual pieces (including the scoping review) also explicitly use a range of strategies that facilitate trustworthiness or efforts to move the responsibility of issues related to trust from research participants or health-care patients to the researchers and providers using processes that engender trust in research and clinical practice (Crawley, 2001; Griffith, Jaeger, et al., 2020; Jaiswal, 2019). Finally, Sinclair and colleagues, Williams and colleagues, and Dhillon and colleagues explicitly incorporate notions of positive masculinities or positive attributes (e.g., dignity) that provided an important foundation of assets and strengths rather than treating gendered notions in men’s health as only having toxic or negative forms. The piece by Dhillon and colleagues in particular highlights a point previously made by Vandello et al. (2019). Each group of scholars note that discrimination is particularly harmful because it constitutes a threat to dignity that is central to the foundations of how some men define themselves.

In the second section of this special collection, the four formative research papers each use qualitative methods to refine their understanding of gendered and nongendered social determinants of health that intersect and become obstacles to health and well-being. Qualitative approaches are often employed to document and contextualize how psychosocial factors across levels of the social ecological framework affect health (Krieger, 2008; McLeroy et al., 1988). Qualitative approaches can highlight the subjective meaning of health behaviors, health practices, and psychosocial determinants of health that are key to developing novel concepts, theoretical approaches, and strategies to achieve health equity (Griffith, Shelton, et al., 2017; Shelton et al., 2017). Heeding the caution of Bowleg (2017b), however, it is critical to remember that qualitative methods or strategies of inquiry are not intrinsically more progressive than quantitative methods. Qualitative methods are only as illuminating as the epistemological stance of researchers and their adherence to rigorous scientific principles that will determine if the research approach yields the insights to inform strategies to improve men’s health in pursuit of men’s health equity. What is also noteworthy about the papers by Mhando and colleagues, Smith and colleagues, Williams and colleagues, and Richardson and colleagues (and others in this special collection) is that they highlight how men who are marginalized or subordinated because of their socially defined characteristics do not let that subordination define their identities or their daily lives (Coles, 2008; Griffith & Cornish, 2018). This is consistent with research that has found that it is critical to identify how masculinities operate at the micro or individual level while research continues to clarify how structural factors like hegemonic masculinity shape psychosocial factors that affect men’s health (Griffith & Cornish, 2018). Alternative masculinities is consistent with research that describes how marginalized men take aspects of hegemonic masculine ideals that they value to create new aspirational ideals (Smith et al., 2020). It is critical for men’s health equity research to recognize and build from alternative masculinities rather than the circus mirror of hegemonic masculinity that distorts the ideals and aspirations of men. As the pieces by Smith et al. and Williams et al. in this special collection suggest, alternative masculinities that reflect the aspirations, identities, and experiences of marginalized men are the foundational pillars that interventions to pursue men’s health equity can be built.

The third section of this special collection on promoting men’s health equity features five articles that describe evaluations of interventions to improve men’s health. Moving beyond the narrow confines of impact or outcome evaluation, these articles seem to be building on the growing research in dissemination and implementation science (Koh et al., 2018). Dissemination and implementation science is critical for the advancement of men’s health equity as it systematically considers not only preliminary efficacy or even fully powered trial effectiveness; this scholarly area seeks to determine what aspects of interventions with some level of proven efficacy and effectiveness should be disseminated and implemented in new settings and contexts (Koh et al., 2018). By considering the congruence between the intervention, stakeholders, population, and contextual resources, dissemination and implementation science offers steps for identifying the functions and mechanisms that underlie why key intervention components are expected to work, based on theory and concepts (Koh et al., 2018).

In this aspect of the special collection on promoting men’s health equity, Valera et al. highlight the importance of considering the institutional context of correctional facilitates and how that intersects with the identities and experiences of incarcerated men and transgender females. The unique stressors, strains, and coping strategies that these populations brought with them into the correctional facilities that Valera and colleagues identify represent an important example of the context assessment and intervention selection that is part of dissemination and implementation research (Koh et al., 2018). Rhodes and colleagues describe the evaluation of the dissemination and adaptation of HoMBReS to three new organizational and community settings. This mixed methods evaluation (and that of Torres and colleagues, Watkins and colleagues, and Bowleg and colleagues) highlights a way to capture the heterogeneity among real-world settings in which well-established interventions may be implemented to successfully marry fidelity to the core components of the intervention with the culture and context of the setting (Koh et al., 2018). Torres and colleagues describe what they learned in implementing a brief alcohol use intervention among Latino immigrant men that illustrated the importance of focusing not just on what content was delivered but the dose and mode of delivery. While researchers may have hypotheses that suggest these factors, Torres and colleagues build on a long tradition of partnering with and learning from the community in their efforts to refine strategies to improve men’s health and well-being (Miller & Shinn, 2005).

Watkins and colleagues use a mixed methods approach to evaluate a virtual mental health intervention for young Black men. Mixed methods research combines qualitative and quantitative research approaches to help capture the breadth and depth of understanding and corroboration that would not be possible with each method alone (Watkins & Gioia, 2015). Not only are Watkins and colleagues able to document the impact of the intervention on depressive symptoms but they are also able to capture critical changes in key conceptually driven mechanisms that affect the mental health and well-being of participants and the size and sustainability of the effectiveness of the intervention. Bowleg and colleagues use qualitative methods to not only capture the ways that the intervention affected participants, but they also highlight the critical role that evaluation plays in capturing not only hypothesized but unintended but nonetheless critical benefits of the intervention. These benefits of the intervention are particularly critical in the context of men’s health equity as they represent the ways that interventions may mitigate structural roots of health inequities (Blankenship et al., 2000; Geronimus, 2000).

Conclusion

The special collection of the American Journal of Men’s Health on promoting men’s health equity features and celebrates the global importance of men’s health and the complex array of factors that are men’s health equity. The diversity of men, settings, masculinities, determinants of health, intersectional components, research methods, evaluation strategies, and other factors illustrates why this area of men’s health is so important, and this special collection celebrates an array of scholars who are leading this work across the globe. Given the work this special collection includes, it certainly seems that there is great potential and promise to achieve men’s health equity.