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Background: In Pakistan, family planning has traditionally been perceived as primarily a women's concern, resulting in the exclusion of men from relevant initiatives. This situation is further exacerbated by cultural and social barriers that hinder men's access to family planning services. This study addresses a significant research gap by assessing the extent of family planning service provision for men in urban areas of Karachi. It delves into the exploration of men's involvement in family planning service delivery, identifies existing gaps in services catering to men, records men's perceptions of accessibility and acceptability of these services, and ultimately offers recommendations to enhance men's involvement and strengthen service provision to better meet their needs., Methods: We employed a qualitative exploratory research design using semi-structured interviews to investigate perceptions regarding family planning service provision to men. This approach involved 25 interviews, comprising eight key informant interviews with stakeholders, eight with service providers, and nine in-depth interviews with married men., Results: This study highlights the limited engagement of men in family planning programs, primarily due to entrenched sociocultural norms that confine female healthcare providers to serving women, hindering men's involvement. While national and provincial policies endorse men's participation, they lack defined roles for male providers. Behavioral and information-sharing barriers at the community level discourage male healthcare providers from collaborating with females. Family planning programs, except for NGO-led vasectomy projects, fail to adequately address men's needs. Despite policy recognition, implementation remains inadequate. Bridging the men's involvement gap necessitates more male providers and improved contraceptive stigma combat training. Further research is vital to explore effective methods for involving men in community and service delivery in family planning., Conclusion: There is a need to change the perception that contraception is solely the responsibility of women, as men's participation in family planning in Karachi is limited. Engaging men can yield positive health and non-health outcomes. Culturally sensitive services, developed with community input using a couple-centered approach, are crucial for equitable family planning. Further research is needed to explore men's inclusion strategies in service provision and utilization., (© 2024. The Author(s).)

The COVID-19 pandemic was a socionatural disaster that unprecedentedly disrupted the daily lives of individuals, families, and communities. Prior research indicates that Black American men living in rural contexts, particularly in Southern parts of the United States of America, were disproportionately affected by the psychological and economic effects of the pandemic. Despite these disparities, few studies have examined the pandemic's impact on rural Black American men's social networks. This study aimed to explore the effects of the COVID-19 pandemic on rural Black American men's interpersonal relationships. Informed by the principles of critical ethnography and guided by van Manen's hermeneutic phenomenology, seventeen men were interviewed using a semi-structured interview protocol. Interviews were transcribed and then analyzed using an iterative thematic reduction process consistent with van Manen's approach. Four themes were generated: Familial Reorganization, Adaptive Fatherhood, Rona Romance, and Essential Community. Participants recounted how the pandemic motivated them to improve their relationships with family members and children but contributed additional stress to their romantic relationships. Participants further recounted how their friendships were the least impacted as they were willing to make exceptions to their normal protective protocols to socialize with close friends. Participants also noted feeling disconnected from their wider community because they could not attend church even though their religious beliefs remained unchanged. Findings highlight the need for scholars, clinicians, and policymakers to consider men's relational health when developing and implementing pandemic recovery efforts, as it can significantly influence their ability to recuperate mentally and physically. Future research should be dedicated to (1) investigating the effects of the COVID-19 pandemic on fathers, as prior research has nearly exclusively focused on mothers' experiences and (2) delineating protective effects of rural Black American men's involvement in the Black Church from their individual spiritualities to gain a more comprehensive understanding of the influence of contextual crisis on their long-term health and wellbeing., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Curtis et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: In the United States, Latinos face a wide array of cultural and structural barriers to accessing and utilizing mental health care. Latino men specifically are at high risk of receiving inadequate mental health care, possibly due to additional obstacles they experience that are related to masculinity. Among men more generally, greater adherence to emotional control and self-reliance is associated with higher depression severity and less depression help-seeking. Men experience more stigma toward depression and help-seeking and are less likely to be diagnosed with depression than women. However, Latino men's barriers and facilitators to depression care remain largely unexplored. The objective of this study was to examine barriers and facilitators to depression care that are related to masculinity among English- and Spanish-speaking Latino men in a primary care setting., Methods: We used convenience and purposive sampling to recruit primary care patients who self-identified as Latino men, spoke English or Spanish, and screened positive for depressive symptoms on the Patient Health Questionnaire-2 or had a history of depression. Semi-structured interviews were conducted between December 2020 and August 2021. The interview guide examined views and experiences of depression, masculinity, and barriers and facilitators to engaging in depression care. Utilizing consensual qualitative research and thematic analysis informed by modified grounded theory, barriers and facilitators to depression care were identified., Results: We interviewed thirteen participants who varied in English proficiency, education, income, and country of origin. Barriers and facilitators were placed into three domains-Self-Recognition of Depression, Seeking Help for Depression, and Depression Diagnosis and Treatment. Participants described aspects of masculinity as barriers (emotional control and pressure to provide), facilitators (honesty, courage, collaboration, practicality, and responsibility), or both (self-reliance and autonomy)., Conclusions: Masculinity influences barriers and facilitators for depression care among Latino men at the levels of self-recognition, seeking help, and diagnosis and treatment. Clinicians may promote Latino men's engagement in depression care by understanding patients' values and framing depression care as affirming masculinity. Providing education to primary care physicians and other healthcare professionals on gender and depression and addressing structural barriers are essential to providing access to all who need depression care., (© 2024. The Author(s).)

There is limited research exploring men's experiences of infertility, and fewer previous studies have examined what information and support men desire after being diagnosed specifically with male-factor infertility. We conducted a mixed-methods study utilizing a combined sequential, concurrent design (online survey/semi-structured interviews). Survey outcomes ( N =12) were analyzed using quantitative data analysis, while qualitative survey data ( N = 5) was analyzed by reflexive thematic analysis. Heterosexual men (>18 years), fluent in English, diagnosed solely with male-factor infertility/sub-fertility, who required assisted reproductive treatment within Australia in the past 5 years were recruited online and through fertility clinics Australia-wide. Most men reported that their information and support needs were only somewhat, slightly or not at all met. Preferred information sources on male infertility were a dedicated online resource, app, or fertility doctor/specialist, while support was preferred from fertility specialists and partners. Three themes were identified from the qualitative analysis about men's experiences and support needs when diagnosed with male infertility (a) Ultimate threat to masculinity; (b) Holistic care, and (c) the power of words. The information-rich data collected provided valuable insights into men's experiences of male-factor infertility and important considerations to improve recruitment for future research. A diagnosis of male-factor infertility has the potential to be deeply impactful and difficult to navigate for men. Adequate and holistic information, recognition of emotional impacts, proactive offers of support and sensitive language are needed to improve men's experiences when undergoing assisted reproductive technology., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Minoritized communities are underreached by biomedical interventions, such as the COVID-19 vaccine. This mixed-methods study identified factors associated with vaccine likelihood (VL) and uptake (VU) among 187 Latino sexual minority men (LSMM) in South Florida. Regression models with LASSO variable selection and Classification and Regression Trees (CART) assessed determinants of VL and VU while open-ended questions were evaluated using thematic content analysis. VL (range 1-7; M = 6.00, SD = 1.84) and VU (63.6%) was high. LASSO modeling identified being insured, worrying about others, fear of transmitting COVID-19, and financial stress as the most influential factors for VL; working remotely from home was important for VU. Time (weeks) since addition of COVID-19 vaccination-related questions (December 2nd, 2020) was associated with both outcomes across both modeling techniques. Convergence between data suggests capitalizing on altruistic motivations and improving accessibility to vaccine campaigns are valuable assets to increase LSMM's vaccine confidence., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Previous studies have confirmed that both affect and emotion regulation strategies are closely associated with psychological capital (PsyCap) and resilience. These factors are assumed to buffer the effect of the COVID-19 pandemic on mental health, especially among males. However, these interactions have not been closely examined to date. To fill this gap, this paper explores the dimension-level relationships of these psychological constructs among Chinese males during the late stage of the COVID-19 pandemic and identified critical bridge dimensions using network analysis., Methods: A total of 1,490 Chinese males aged 21-51 years completed self-report scales assessing emotion regulation strategies, affect, PsyCap, and psychological resilience. Two regularized partial correlation networks, namely the affect and emotion regulation-PsyCap network and the affect and emotion regulation-psychological resilience network, were then constructed to examine links between the dimensions of these constructs. The bridge expected influence (BEI) index was also calculated for each node to identify important bridge nodes., Results: Positive affect, negative affect, cognitive reappraisal, and expressive suppression showed distinct and complex links to various dimensions of PsyCap or psychological resilience. In both networks, positive affect, cognitive reappraisal, and negative affect were identified as critical bridge nodes, with the first two having positive BEI values and the third having a negative value., Conclusion: The findings elucidate the specific role of the dimensions of emotion regulation or affect in relation to PsyCap and psychological resilience, which facilitates further understanding of the mechanisms underlying these interrelationships. These findings also provide implications for developing effective intervention strategies to increase PsyCap and psychological resilience., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Guo, Cui, Yang, Liu, Lu, Zhang and Zhu.)

Background: Cervical cancer represents a high burden of disease. Many women in low- and middle-income countries face opposition from their partners and families to undergo cervical cancer screening. Identifying the social, cultural, and psychological factors that underly the opposition to screening by male partners is an important step towards reducing barriers for men to support their wives' participation in cervical screening. This study explored the role of structural and psychological factors deriving from theoretical models as determinants of Indian men's opposition to their partners being screened for cervical cancer., Methods: A survey among 500 sexually active males was conducted between April 2020 and August 2020 to measure knowledge of cervical cancer and screening, awareness of screening possibilities, attitude towards screening, perceived barriers to screening, and health literacy. Regression analysis was performed to assess which of the potential factors contributed to the intention to support their wives' screening., Results: The majority of participants had very poor knowledge and awareness about cervical cancer and screening procedures, tended towards a negative attitude towards screening, and perceived several structural barriers. Attitude towards the screening procedure and routine participation in general screening significantly predicted their intention to support their wives' screening for cervical cancer. Education moderated the association between knowledge and awareness and the intention to support their wives' screening., Conclusion: As women often rely on their spouses' financial and emotional support of cervical screening, there is a need for men to be encouraged to support their wives' screening participation. Programs to encourage men to support their wives' cervical screening should focus on their attitude towards screening, educate about cervical cancer and screening procedures, and reduce perceived barriers., (© 2022. The Author(s).)

Background: In 2018, USAID published a report based on Demographic and Health Surveys data on the relationship between men's involvement and women and children's health outcomes. Using a flawed operationalization of "men's involvement," USAID's analysis implies that Senegalese men are not involved in women and children's health., Methods: The findings of this study come from 12 months of ethnographic research in Dakar, Senegal that examined the roles and responsibilities of expectant fathers. Research participants included 32 pregnant women and 27 expectant partners recruited from three maternity wards. Research methods included long-term, immersive participant observation and semi-structured interviews., Results: Pregnant women in Senegal are surrounded by a kin-based network of care providers called the entourage who share responsibilities for support. Expectant fathers, as members of the entourage, are expected to provide financial and emotional support, while other members of the entourage are expected to undertake the responsibilities which USAID have designated as "men's involvement." Men typically do not undertake additional forms of care and support because they are considered "women's business," meaning that women actively discourage men from doing those things, in order to preserve women's autonomy., Conclusion: This research demonstrates that expectant fathers are involved in antenatal care in ways that USAID does not track through DHS. Further, I argue that USAID's heterosexist, monogamous, and nuclear operationalization of "men's involvement" aligns with a long history of Eurocentrism in development discourse which may be potentially harmful and obstructive to improving maternal and child health when the problem that is targeted is not a problem at all. This study is yet another case that demonstrates an urgent need of public and global health engagement with local stakeholders and ethnographic researchers., (© 2022. The Author(s).)

Background: Men have traditionally not been fully involved in reproductive health care of their partners, and yet, they play a crucial role in family decision-making and therefore crucial key players in preventing poor pregnancy outcomes. This study aimed to assess prevalence and determinants of male participation in maternal health care and explore male partners' perspective of their involvement in antenatal care at an urban tertiary referral facility., Methods: A mixed-methods study was conducted from October 2018 to January 2019 at Muhimbili National Hospital. A cross-sectional survey of 428 nursing mothers and two focus group discussions of male partners (n = 7 and n = 11) of women attending antenatal clinic and nursing mothers in the post-natal ward were performed. Using SPSS Ver. 23 (IBM, Chicago, IL), frequency distribution tables summarized demographic data and categories of male partners' involvement in antenatal care. Focus group discussions included male partners of age from 24 to 55 years at their first to fifth experience of pregnancy and childbirth. Interviews were audio-recorded, and then transcribed and coded. Thematic analysis was applied., Results: The prevalence of male involvement in antenatal care was 69%. More than two-thirds of nursing mothers received physical, psychological and financial support from partners (76%) and attended four or more antenatal visits (85%). Five themes of male perspective of their involvement in antenatal care were generated, including: a) cultural norms and gender roles, b) ignorance of reproductive health service, c) factors outside their control, d) couple interaction and conflicts, and e) institutional obstacles., Conclusion: The prevalence of male partners' involvement in antenatal care was relatively high. Men's involvement in antenatal care depended on access to antenatal care education, standards of structure and process of antenatal service and how well their role was defined in the maternal health care system. Interactions and practice in society, employment sector and government health system should complement strategies to promote men's involvement in maternal health., Competing Interests: The authors have declared that no competing interests exist.

Background: Maternity waiting home (MWH) is a direct strategy to improve newborn and maternal survival. The utilization of MWH, however, remains very low in Ethiopia. Men involvement in maternal health programs is a key strategy to increase utilization of maternal health services, including MWH. This study defines men involvement in-terms of men's participation in deciding to admit their spouse to an MWH, accompanying their spouse to an MWH, providing financial support, availing food at an MWH, and taking care of the home or children. Thus, the current study aims to identify factors affecting men's involvement in MWH utilization., Methods: A community-based cross-sectional study was conducted from October 1st to December 30th, 2018. Four hundred three men were involved in the study. Data were analyzed by the statistical package for social science (SPSS) version 23. Independent predictors were identified by a multivariable logistic regression model. Adjusted odds ratios (AORs) with 95% confidence intervals (CIs) were reported., Results: Men's involvement in MWH was 55.6% (50.71, 60.45). Age (AOR = 0.86, 95% CI = 0.82-0.94), knowledge about MWH (AOR = 4.74, 95% CI = 2.65-8.49), decision-making power (AOR = 4.00, 95% CI = 1.38-11.57), and receiving counseling about MWH during spousal antenatal care visits (AOR = 9.15, 95% CI = 3.34-25.03) had statistically significant associations with men's involvement in MWH utilization., Conclusions: Nearly, half of the male partners were involved in MWH utilization. Men's age, MWH knowledge, decision-making power, and receiving counseling were factors affecting their involvement in MWH utilization. Interventions targeting to improve male involvement in MWH utilization should focus on building men's knowledge about MWH, increasing male involvement in ANC with an appropriate level of counseling about MWH, and changing patriarchal thinking in society with appropriate behavioral interventions such as community-based health education., Competing Interests: The authors have declared that no competing interests exist.

The stigma of men's mental illness has been described as having wide-reaching and profound consequences beyond the condition[s] itself. Stigma negatively impacts men's mental health help-seeking and the use of services amid impeding disclosures, diminishing social connection and amplifying economic hardship. Although men often face barriers to discussing their struggles with, and help-seeking for mental illness challenges, research focused on men's lived experiences of mental illness stigma is, at best, emergent. This scoping review explores men's mental illness related stigmas synthesizing and discussing the findings drawn from 21 published qualitative articles over the last 10 years. Four thematic findings were derived: (a) the weight of societal stigma, (b) stigma in male-dominated environments, (c) inequity driven stigmas, and (d) de-stigmatizing strategies. Despite evidence that stigma is a common experience for men experiencing diverse mental illness challenges, the field remains underdeveloped. Based on the scoping review findings, research gaps and opportunities for advancing the field are discussed.

Using an outcome expectancy framework, this research sought to understand sex differences in the underlying beliefs that influence harassment perception. One hundred and ninety-six participants (52% women) read a series of vignettes depicting common examples of digital male-on-female sexual harassment. They were asked to what extent they thought each scenario constituted sexual harassment, and how likely the perpetrator would experience positive and negative outcomes. Consistent with predictions, women were more likely to consider the behaviours as harassment than men were. Both sexes harassment perceptions had significant relationships with their outcome expectancies, but we also found evidence of a sex specific moderation; the link between men's negative outcome expectancies was moderated by their positive ones. The results suggest that perceptions of harassment may have sexually asymmetrical underpinnings. Measuring the interplay between positive and negative outcome expectancies in relation to sexual harassment perception is a novel approach, that may have implications for the development of anti-sexual harassment interventions. Implications for theory and future research directions are discussed., Competing Interests: The authors have declared that no competing interests exist.

Men are currently underrepresented in traditionally female care-oriented (communal) engagement such as taking parental leave, whereas they are overrepresented in traditionally male (agentic) engagement such as breadwinning or leadership. We examined to what extent different prototypical representations of men affect men's self-reported parental leave-taking intentions and more generally the future they can imagine for themselves with regard to work and care roles (i.e., their possible selves). We expected prototypes of men that combine the two basic stereotype dimensions of agency and communion to increase men's communal intentions. In two experiments (N1 = 132, N2 = 233), we presented male participants with contrived newspaper articles that described the ideal man of today with varying degrees of agency and communion (between-subjects design with four conditions; combined agentic and communal vs. agentic vs. communal vs. control condition). Results of Experiment 1 were in line with the main hypothesis that especially presenting a combination of agency and communion increases men's expectations for communal engagement: As compared to a control condition, men expected more to engage in caretaking in the future, reported higher parental leave-taking intentions, and tended to expect taking longer parental leave. Experiment 2 only partially replicated these findings, namely for parental leave-taking intentions. Both experiments additionally provided initial evidence for a contrast effect in that an exclusive focus on agency also increased men's self-reported parental leave-taking intentions compared to the control condition. Yet, exclusively emphasizing communion in prototypes of men did not affect men's communal intentions, which were high to begin with. We further did not find evidence for preregistered mechanisms. We discuss conditions and explanations for the emergence of these mixed effects as well as implications for the communication of gendered norms and barriers to men's communal engagement more broadly., Competing Interests: The authors have declared that no competing interests exist.

Societal stereotypes depict girls as less interested than boys in computer science and engineering. We demonstrate the existence of these stereotypes among children and adolescents from first to 12th grade and their potential negative consequences for girls' subsequent participation in these fields. Studies 1 and 2 ( n = 2,277; one preregistered) reveal that children as young as age six (first grade) and adolescents across multiple racial/ethnic and gender intersections (Black, Latinx, Asian, and White girls and boys) endorse stereotypes that girls are less interested than boys in computer science and engineering. The more that individual girls endorse gender-interest stereotypes favoring boys in computer science and engineering, the lower their own interest and sense of belonging in these fields. These gender-interest stereotypes are endorsed even more strongly than gender stereotypes about computer science and engineering abilities. Studies 3 and 4 ( n = 172; both preregistered) experimentally demonstrate that 8- to 9-y-old girls are significantly less interested in an activity marked with a gender stereotype ("girls are less interested in this activity than boys") compared to an activity with no such stereotype ("girls and boys are equally interested in this activity"). Taken together, both ecologically valid real-world studies (Studies 1 and 2) and controlled preregistered laboratory experiments (Studies 3 and 4) reveal that stereotypes that girls are less interested than boys in computer science and engineering emerge early and may contribute to gender disparities., Competing Interests: The authors declare no competing interest., (Copyright © 2021 the Author(s). Published by PNAS.)

The aim of this study was to assess the relationships among motivational profiles, their responsibility levels, the school social climate and resilience, and the differences according to gender and age of students from different secondary schools in Spain. A sample of 768 students (mean age of 13.84 years), 314 boys (46.1%) and 354 girls (53.9%) was used. The measurements taken concerned: personal and social responsibility, basic psychological need satisfaction, motivation, resilience and school social climate. Bivariate correlation, cluster and multivariate analyses were carried out. The cluster analysis was made using the Motivation toward Education Scale with its different variables (intrinsic, identified, introjected, external motivation and amotivation), revealing four profiles: low quality (1, low values in all motivational variables except in amotivation), low quantity (2, low values), high quantity (3, high values), and high quality (4, high values except in amotivation). The contrast in comparisons shows differences in resilience, personal and social responsibility, teacher climate and school climate (p < .001). The group with the highest values in resilience, basic psychological needs, responsibility and school social climate was that with a high quality profile. There were statistical differences in all variables with respect to the low quantity and low quality groups (p < .001), while the high quantity group showed statistical differences only in personal and social responsibility (p < .001). The low quality group had the lowest values among all the variables, with statistical differences with respect to all groups (p < .001). On the other hand, there were more boys than girls associated with high quantity, without differences in their age. In conclusion, high quality motivation profiles (those with high or low amotivation values and high values in autonomous and controlling motivation), also have a higher satisfaction of basic psychological needs. Moreover, these students are more resilient, show more responsibility and enhance the school/teaching social climate, while low quality and /or quantity motivation, influence negatively on these variables., Competing Interests: The authors have declared that no competing interests exist.

Background: Corporal punishment (CP) is still a common practice in schools globally. Although illegal, studies in South Africa report its continued use, but only a few have explored factors associated with school CP. Moreover, extant studies have not shown the interrelationships between explanatory factors. This study aimed to determine the prevalence and factors associated with learners' experiences, and to examine pathways to the learners' experiences of CP at school., Method: 3743 grade 8 learners (2118 girls and 1625 boys) from 24 selected public schools in Tshwane, South Africa, enrolled in a cluster randomised controlled trial evaluating a multi-component school-based intervention to prevent intimate partner violence, and completed self-administered questionnaires. We carried out descriptive analysis, simple linear and structural equation modelling to examine factors and pathways to the learners' experience of CP at school., Results: About 52% of learners had experienced CP at school in the last 6 months. It was higher among boys compared to girls. Experience of CP at school amongst learners was associated with learner behavior, home environment, and school environment. Learners from households with low-socio economic status (SES) had an increased risk of CP experience at school. Amongst boys, low family SES status was associated with a negative home environment and had a direct negative impact on a learner's mental health, directly associated with misbehavior., Conclusion: CP in public schools in South Africa continues despite legislation prohibiting its use. While addressing learner behaviour is critical, evidence-based interventions addressing home and school environment are needed to change the culture among teachers of using corporal punishment to discipline adolescents and inculcate one that promotes positive discipline., Competing Interests: The authors are not aware of any competing interests.

White upper middle-class Americans at the turn of the twentieth century were entrenched in a battle with a newly discovered, or invented, mental illness called neurasthenia. This essay examines the ways in which the medical discourse of neurasthenia reflected late nineteenth- and early twentieth-century white Anglo-Saxon men's belief in, as well as anxiety over, American values bolstered by their idea of cultural, racial, and sexual superiority and consolidated through a conjunction of medicine and politics. The idea of neurasthenia as white American men's malady functioned as a mark both of whites' racial superiority to the "new" immigrants and African Americans as well as of women's intellectual inferiority to the opposite sex of their own race. Imposing a subtle distortion on the etiology and diagnosis of neurasthenia and associating it with specific groups of people, the "American disease" constituted the era's representative pathological symptoms which addressed Anglo-Saxon American men's anxieties about overcivilized effeminacy and racial and national decadence which was originated as a response to the racial and sexual heterogeneity. This essay also argues that neurasthenia was an imagined disease which addressed late nineteenth-century American men's spatial anxiety about the decline of the American pastoral ideal caused by the closure of the frontier. Given that the treatment for neurasthenic men was an escape to the frontier in the West in which they could rejuvenate withered American masculinity, their uneasiness about barbarous, unhygienic, and prolific immigrants and unruly white women, in fact, was tied to their spatial anxiety which symptomatically signifies the crisis of American masculinity. Channeled through the medical knowledge of neurology, it made American men's racial, sexual, and spatial anxieties function to act out their racist, misogynist, nativist, and imperialist impulses which legitimized exclusionary political techniques toward the racial and sexual others such as the U.S. imperial expansion in the 1890s and 1900s and a eugenic-influenced immigration policy from the 1900s through the1920s. In this sense, the decline of neurasthenia around 1920 should not be attributed solely to the continued efforts to professionalize American medicine accompanied by recent discoveries of chemical factors such as hormones and vitamins and the rise of psychiatry and psychology which offered physicians with a more specific theory of health built on clinical laboratory science. Like its rise, the decision to move away from the neurasthenic diagnosis was rather a cultural phenomenon, which reflected the American ascendancy to global power in the early twentieth century, particularly after the First World War. Sustaining a political order rested on racial and sexual hierarchies both within and outside the American continent, American men felt that they were no longer liable to specific, time-tested anxiety and somatic symptoms of neurasthenia, which was more an ideological and cultural construct than a clinical entity that dramatizes the racial, sexual, and imperial politics of the-turn-of-the-twentieth-century America.

Aims: The present study aimed to investigate whether the psychological impact of the COVID-19 crisis varied with regards to young Swiss men's pre-crisis level of education and socioeconomic status and to changes in their work situation due to it., Methods: A cohort of 2345 young Swiss men (from 21 out of 26 Swiss cantons; mean age = 29) completed survey-based assessments shortly before (April 2019 to February 2020) and early on during the COVID-19 crisis (May to June 2020). Outcomes measured were psychological outcomes before and during the COVID-19 crisis (depression, perceived stress and sleep quality), and the fear, isolation and psychological trauma induced by it. We investigated associations between these outcomes and their predictors: pre-crisis socioeconomic status (relative financial status, difficulty paying bills, level of education), changes in work situation during the crisis (job loss, partial unemployment, working from home, change in workload) and working in contact with potentially infected people, both inside and outside the healthcare sector. For outcomes measured before and during the crisis, the analyses were adjusted for their pre-crisis levels., Results: About 21% of participants changed their employment status (job loss, partial unemployment or lost money if self-employed) and more than 40% worked predominantly from home during the COVID-19 crisis. Participants with a lower relative socioeconomic status already before the crisis experienced a higher psychological impact due to the COVID-19 crisis, compared to participants with an average socioeconomic status (major depression (b = 0.12 [0.03, 0.22]), perceived stress (b = 0.15 [0.05, 0.25]), psychological trauma (b = 0.15 [0.04, 0.26]), fear (b = 0.20 [0.10, 0.30]) and isolation (b = 0.19 [0.08, 0.29])). A higher impact was also felt by participants who lost their job due to the COVID-19 crisis, the partially unemployed, those with an increased workload or those who worked mainly from home (e.g. depression b = 0.25 [0.16, 0.34] for those working 90%+ at home, compared to those not working at home)., Conclusions: Even in a country like Switzerland, with relatively high social security benefits and universal healthcare, the COVID-19 crisis had a considerable psychological impact, especially among those with a lower socioeconomic status and those who experienced deteriorations in their work situation due to the COVID-19 crisis. Supporting these populations during the crisis may help to prevent an amplification of inequalities in mental health and social status. Such support could help to lower the overall impact of the crisis on the mental well-being of Switzerland's population., Competing Interests: The authors have declared that no competing interests exist.

Introduction: Though there are several interventions evaluated over the past 25 years, significant knowledge gaps continue to exist regarding the effective prevention of sexual violence. This study explored the socio-economic and context-specific distinctive characteristics of husbands and wives on sexual autonomy and unwanted sexual experiences of currently married women in India., Methodology: We have utilized the recent round of National Family Health Survey (NFHS-4, 2015-16) data for this exploration. The NFHS-4 survey had adopted a stratified two-stage sample design to reach out to the survey households. A total of 63,696 couples are included in the analysis comprising of women of 15-49 years age and men of 15-54 years age. Multivariate techniques have been applied to understand the adjusted effects of socio-economic and demographic variables on control over their sexuality and sexual violence., Results: Uneducated women married to uneducated men experienced more sexual violence and had less control over their sexuality than the other categories. The adjusted multivariate logistic model shows that educated husbands were significantly more likely to exercise control over their educated wives' sexuality (AOR = 0.88; CI:0.78-0.99). Women having older husbands were significantly less likely to be having no-control over own sexuality (AOR = 0.89; CI:0.83-0.95) and experienced sexual violence (AOR = 0.81; CI:0.70-0.95). Women having comparatively more-educated husbands were significantly less likely to experience sexual violence (AOR = 0.62; CI:0.47-0.81). Muslim women were significantly more likely to have no control overown sexuality. SC/ST women were significantly more likely to experience sexual violence (28%)., Conclusions: This study highlights the factors associated with control over one's sexuality and preponderance to sexual violence: age, education, spouse working status, wealth status, husband's alcohol consumption, women autonomy, decision-making, and freedom for mobility. This study suggests that empowering women with education, creating awareness regarding reproductive health, and addressing their socio-economic needs to help them achieve autonomy and derive decision-making power., Competing Interests: The authors have declared that no competing interests exist.

Background: Breast cancer (BC) is a public health problem that affects many populations worldwide. Women's health care behavior, including seeking mammography screening, might be affected by men, especially in conservative Arab societies. Few studies have investigated men's behavior toward mammography for female relatives. The main aims of this study were (i) to evaluate men's knowledge about mammography screening and (ii) to assess men's behavior toward women regarding mammogram screening and the factors influencing their behavior., Methods: A cross-sectional study was conducted among male residents of the five main geographic areas of Saudi Arabia. Data were obtained with a self-administered questionnaire. In addition to sociodemographic data, the questionnaire assessed respondents' general knowledge about mammograms, their behavior toward female family members who use mammography, and their perceptions about awareness campaigns., Results: A total of 9691 male respondents were included in the study. The majority (79%) recommended mammography to their female family members. Multiple factors were significantly associated with men recommending mammograms, including age (p <0.01), education (p <0.01), employment status (p <0.01), and region (p <0.01). Only 33.8% of the participants had a high knowledge score about mammography. Approximately 45% of respondents reported that BC awareness campaigns were weak, while 48% were not aware of BC screening programs., Conclusions: Despite their positive behavior in recommending mammograms to female relatives, men exhibited a notable lack of knowledge about mammography. Establishing national programs and educational campaigns for men to explain the benefits of screening and access to free mammography are essential., .

Background: Male involvement in maternal healthcare has been widely recognized as essential for positive health outcomes for expectant mothers and their unborn babies. However, few studies have explored men's experiences of maternal health services. The purpose of this paper is to explore men's involvement in antenatal care in urban Ghana and to discuss how men navigate their roles in a space that has been constructed as feminine. The study draws upon theories of space, place, and gender., Methods: A qualitative exploratory study using semistructured interviews, focus group discussion, and observation was conducted in Accra, Ghana. Expectant fathers and health workers were interviewed, and observation was conducted at a selected public hospital in Accra., Results: The findings suggest that the few men who attend antenatal care with their expecting partners become involved to a limited extent in the clinic's activities. Beyond a few who take an active role, most men stay on the outskirts of the hospital grounds and rarely participate in consultations with their partner and midwife. Men still view their presence as necessary to acquire knowledge and as sources of emotional, financial, and physical support for their partners. On the health workers' side, the study found no clear agenda for engaging men at the clinic, and nurses/midwives felt there was a lack of staff who could engage more directly with the men., Conclusion: The study indicates that most expecting fathers feel too shy and uncomfortable to locate themselves in the female space that makes up antenatal care/maternity wards. Health workers do not feel they have the necessary resources to involve men fruitfully. Thus, men do not engage in the activity as hoped but rather remain on the outskirts of the maternity clinic. However, if men continue to negotiate their involvement at the clinic and become more assertive in their roles, the maternity clinic as a female space could, with time, be transformed into a space in which both expecting mothers and fathers can actively participate and be engaged to the benefit of all.

This article examines men's involvement in an institutional gender equity award scheme and how their self-concept as allies develops over time. It draws specifically on a subset of qualitative data from the four men participating in a study involving in-depth interviews with university staff involved in the self-assessment team of one Australian institution's Science in Australia Gender Equality (SAGE) Athena SWAN pilot. Data related to the men's experiences is the article's focus. Key themes from the data include: 1) men's motivations for engagement; 2) men's self-understandings as 'champions for change' 3) the barriers/risks associated with male championship; and 4) men's evolving perceptions and critiques of the male champions model. Findings show that men demonstrated personal growth and increased awareness through their participation in the pilot. Yet, their frustration with how equity and diversity was managed in their organisational context highlights pitfalls in the concept of a male 'champion'. This article provides timely guidance for institutions seeking to engage allies in gender equity initiatives., Competing Interests: The authors have declared that no competing interests exist.

HIV care provides an opportunity to integrate comprehensive sexual and reproductive healthcare, including sexually transmitted infection (STI) management. We describe STI prevalence and correlates among men living with HIV (MLWH) accessing safer conception care to conceive a child with an HIV-uninfected partner while minimizing HIV transmission risks. This study reflects an ongoing safer conception program embedded within a regional referral hospital HIV clinic in southwestern Uganda. We enrolled MLWH, planning for pregnancy with an HIV-uninfected partner and accessing safer conception care. Participants completed interviewer-administered questionnaires detailing socio-demographics, gender dynamics, and sexual history. Participants also completed STI laboratory screening for syphilis (immunochromatographic testing confirmed by rapid plasma reagin), and chlamydia, gonorrhea, trichomoniasis, and HIV-RNA via GeneXpert nucleic acid amplification testing. Bivariable associations of STI covariates were assessed using Fisher's exact test. Among the 50 men who completed STI screening, median age was 33 (IQR 31-37) years, 13/50 (26%) had ≥2 sexual partners in the prior three months, and 46/50 (92%) had HIV-RNA <400 copies/mL. Overall, 11/50 (22%) had STIs: 16% active syphilis, 6% chlamydia. All participants initiated STI treatment. STI prevalence was associated with the use of threats/intimidation to coerce partners into sex (27% vs 3%; p = 0.03), although absolute numbers were small. We describe a 22% curable STI prevalence among a priority population at higher risk for transmission to partners and neonates. STI screening and treatment as a part of comprehensive sexual and reproductive healthcare should be integrated into HIV care to maximize the health of men, women, and children., Competing Interests: The authors have declared that no competing interests exist.

First-person narratives of suicidal behavior may provide novel insights into how individuals with lived experience of suicide understand and narrate their behavior. Our aim was to explore the narratives of young men hospitalized following nonfatal suicidal behavior (NFSB), in order to understand how young suicidal men construct and understand their actions. Data were collected via narrative interviews with 14 men (aged 18-34 years) admitted to hospital following an act of NFSB in Cape Town, South Africa. Narrative analysis was used to analyze the data. Two dominant narratives emerged in which participants drew on tropes of the "great escape" and "heroic resistance," performing elements of hegemonic masculinity in the way they narrated their experiences. Participants position themselves as rational heroic agents and present their suicidal behavior as goal-directed action to solve problems, assert control, and enact resistance. This dominant narrative is incongruent with the mainstream biomedical account of suicide as a symptom of psychopathology. The young men also articulated two counter-narratives, in which they deny responsibility for their actions and position themselves as defeated, overpowered, wary, and unheroic. The findings lend support to the idea that there is not only one narrative of young men's suicide, and that competing and contradictory narratives can be found even within a dominant hyper-masculine account of suicidal behavior. Gender-sensitive suicide prevention strategies should not assume that all men share a common understanding of suicide. Suicide can be enacted as both a performance of masculinity and as a resistance to hegemonic gender roles.

Men's e-health promotion programs can offer end-user anonymity and autonomy that provide avenues for supporting positive health behavior change. The twofold purpose of the current study was to use a benchmark cohort as a reference group to: (1) describe associations between men's usage levels of the e-health program Don't Change Much (DCM) and their recent and intended health behavior changes, and (2) report an exploratory analysis of the moderating effects of demographic variables on the associations between DCM users and their recent and intended health behavior changes. Based on self-report, DCM users were classified into limited ( n = 613, 34.7%), low ( n = 826, 46.8%), and high ( n = 327, 18.5%) exposure groups. Compared with the benchmark cohort, DCM high-exposure respondents had significantly increased odds for eight of the nine recent behavior changes, with the largest effect size observed for "Made an effort to sit less and walk more" (odds ratio [OR] 2.996, 95% CI [2.347, 3.826]). Eight of the nine intended health behavior changes in the DCM high-exposure group had significantly increased odds compared to the benchmark cohort, with "Reduce stress level" (OR 3.428, 95% CI [2.643, 4.447]) having the largest effect size. Significantly greater total numbers of recent ( F (12, 2850) = 29.32; p = .001; R 2 = .086) and intended health behavior changes ( F (12, 2850) = 34.59; p = .001; R 2 = 0.100) were observed among high exposure respondents while adjusting for demographics. Younger age, being employed, and household income <$120,000 had an enhancing moderator effect on DCM users' number of intended behavior changes.

Objective: To analyze the meanings attributed to fatherhood by first-time fathers., Participants and Method: Qualitative research of Hermeneutic-Dialectic design. Data collection was carried out through in-depth interviews with fathers and mothers (10 of each) of children older than 12 months. The analysis of the data was carried out through the participants' discourse analysis and their articu lation with the historical-social context and the theoretical references of the research., Results: The meaning and social participation of men when they became a first-time father were grouped in five categories: meaning of the fatherhood experience; meaning of fatherhood from a gender perspective; meaning of the experience in the father-child relationship; meaning of the parenting experience in the couple relationship; and exercising fatherhood and its relationship with the health system. Con clusions: It is necessary to implement strategies to include the father in the upbringing and care of the children, favoring his participation, and thus, the growth and comprehensive development of the child conceived in the different types of families.

The relationship of problematic cannabis consumption with perceived risk, socioenvironmental and sociodemographic factors among youth in Spain is not well known. The aims of this study are: 1) to describe the patterns of cannabis consumption (problematic and non-problematic) in Spanish youth, and 2) to explore whether problematic cannabis consumption is related to perceived risk, environmental factors and individual sociodemographic characteristics. A cross-sectional design based on data from the 2015/16 Spanish Household Survey on Alcohol and Drugs (EDADES) was performed. Individuals between 15 and 35 years old having used cannabis during the last year with a complete Cannabis Abuse Screening Test (CAST) were included (N = 1,674). Problematic consumption (CAST &gt;= 7) was considered as dependent variable. Perceived risk, environmental factors (availability of the substance and exposure to consumption situations) and sociodemographic factors were taken as independent variables. Descriptive analyses of consumption patterns were performed and univariable and multivariable Poisson regression models were done. All analyses were stratified by gender. Problematic cannabis consumption was more frequent among men (38.9 %) than among women (23.2 %). While among men, problematic use was related to environmental factors and educational level, among women it was associated with perceived risk and unemployment. Problematic cannabis consumption among Spanish youth is associated with different types of gender-related factors. Due to its representativeness at the population level and the validity of the measures, these results might have important implications on the development of prevention strategies targeted at problematic cannabis consumption.

Background: Increasing men's involvement in their pregnant partners' wellness has been reported as one of the ways to improve access to and utilization of maternal health services, including birth preparedness and complication readiness. Men can play meaningful roles in the support systems that pregnant women need to achieve better maternal health outcomes. In Rwanda, the roles that men take vary, resulting in diverse expectations and responsibilities to support the health of women during this critical time. In this study, we aimed to examine the views, perspectives, and experiences of women on men's involvement in maternal health and how this impacts access and utilization of maternal health services., Methods: We conducted 21 interviews with pregnant and recently-pregnant women to gain an understanding of their views on men's involvement in facilitating their partners' health during pregnancy. Interviews were conducted across five Rwandan districts in both rural and urban settings of the country. Data analysis was guided by a thematic analysis approach. This started with independent transcript review by the investigators, after which a meeting was held to discuss emergent themes and to identify potential codes. A coding scheme was created and transcripts were coded in NVIVO™ software according to conceptual and practical topics that formed an understanding of men's involvement in maternal care., Results: Three key themes emerged during the analytic process that categorize the specific roles that men play in maternal health: 1) facilitating access to maternal health services, which involves assisting women with getting and or attending appointments jointly with men; 2) supporting women's decisions, wherein men can support the decisions women make with regard to their maternal healthcare in a number of ways; and 3) evaluating information, including gathering information from multiple sources, especially from community health workers, to assist women with making informed decisions., Conclusion: Rwandan men take on three types of roles in supporting women's maternal health, and their responsibilities are experienced differently by women. Interventions involving men are encouraged to increase their understanding of the implications of their involvement in maternal health without compromising women's autonomy in decision-making and to promote positive maternal health outcomes.

Sexual violence against women and girls is a major public health problem globally and in South Africa. Although young men have been identified as an important risk group for prevention interventions, scant attention have been given to this age cohort in low and middle-income countries. There is strong evidence that perpetration starts early and increasing attention is being drawn to Higher Education Institutions (HEIs) as settings for prevention interventions. The main objective of this study was to adapt the One Man Can Intervention for use with male university students in residences and develop materials for implementation. This paper presents the qualitative findings of the adaptation process of the One Man Can Intervention with 15 young male student leaders at a HEI in South Africa. The same participants who started in the study, participated throughout. Only five of the 15 participants were located and participated in the interviews six months post intervention. The results show the emergence of a six-hour session adapted intervention that addresses key drivers of violence against women and girls (VAWG). Critical engagement and dialogue on sexual violence is shown to shift key norms on gender equality, on being a man and reflection on their role in preventing sexual violence. This paper contributes to the field where much learning, refining and improvement of prevention interventions for VAWG are ongoing., Competing Interests: The authors have declared that no competing interests exist.

Background: Historically, men's experiences of grief following pregnancy loss and neonatal death have been under-explored in comparison to women. However, investigating men's perspectives is important, given potential gendered differences concerning grief styles, help-seeking and service access. Few studies have comprehensively examined the various individual, interpersonal, community and system/policy-level factors which may contribute to the intensity of grief in bereaved parents, particularly for men., Methods: Men (N = 228) aged at least 18 years whose partner had experienced an ectopic pregnancy, miscarriage, stillbirth, termination of pregnancy for foetal anomaly, or neonatal death within the last 20 years responded to an online survey exploring their experiences of grief. Multiple linear regression analyses were used to examine the factors associated with men's grief intensity and style., Results: Men experienced significant grief across all loss types, with the average score sitting above the minimum cut-off considered to be a high degree of grief. Men's total grief scores were associated with loss history, marital satisfaction, availability of social support, acknowledgement of their grief from family/friends, time spent bonding with the baby during pregnancy, and feeling as though their role of 'supporter' conflicted with their ability to process grief. Factors contributing to grief also differed depending on grief style. Intuitive (emotion-focused) grief was associated with support received from healthcare professionals. Instrumental (activity-focused) grief was associated with time and quality of attachment to the baby during pregnancy, availability of social support, acknowledgement of men's grief from their female partner, supporter role interfering with their grief, and tendencies toward self-reliance., Conclusions: Following pregnancy loss and neonatal death, men can experience high levels of grief, requiring acknowledgement and validation from all healthcare professionals, family/friends, community networks and workplaces. Addressing male-specific needs, such as balancing a desire to both support and be supported, requires tailored information and support. Strategies to support men should consider grief styles and draw upon father-inclusive practice recommendations. Further research is required to explore the underlying causal mechanisms of associations found.

Background: There is significant evidence of the prevalence and factors associated with domestic violence in high and low-income country settings. However, men's views on domestic violence are still understudied and have never been reported in Nepali society., Objective: The aim of the study was to explore Nepali men's perceptions regarding domestic violence in their communities., Method: The authors undertook a qualitative study using focus group discussions., Results: Sixty-six married men, considered they were responsible for upholding family discipline and physically demonstrating their masculinity, and they suggested that violence was a mean for achieving this. Men's frustration when unable to fulfil their family's expectations or material needs, and cultural attitudes that precluded interference in other families' lives, were perceived as factors contributing to domestic violence. The men held the opinion that women also perpetrated domestic violence. Some men were reluctant to accept domestic violence as a norm in Nepali families and were aware of recent changes in societal expectations regarding gender roles., Conclusion: Overall, the Nepali men who participated in the study held different and sometimes opposing views on domestic violence, ranging from violence justified as a necessity for family discipline, uneasy acceptance that violence was commonplace in families, to definite opposition to the use of domestic violence. The study's findings provide information for identifying points of intervention for violence-prevention efforts and strategies to alter the social and cultural norms that lead to acceptance of domestic violence.

Introduction: No prospective studies have examined the prevalence, antecedents or concurrent characteristics associated with self-harm in non-treatment-seeking primary school-aged children., Methods: In this cohort study from Melbourne, Australia we assessed 1239 children annually from age 8-9 years (wave 1) to 11-12 years (wave 4) on a range of health, social, educational and family measures. Past-year self-harm was assessed at wave 4. We estimated the prevalence of self-harm and used multivariable logistic regression to examine associations with concurrent and antecedent factors., Results: 28 participants (3% of the 1059 with self-harm data; 18 girls [3%], 10 boys [2%]) reported self-harm at age 11-12 years. Antecedent (waves 1-3) predictors of self-harm were: persistent symptoms of depression (sex-age-socioeconomic status adjusted odds ratio [aOR]: 7.8; 95% confidence intervals [CI] 2.6 to 24) or anxiety (aOR: 5.1; 95%CI 2.1 to 12), frequent bullying victimisation (aOR: 24.6; 95%CI 3.8 to 158), and recent alcohol consumption (aOR: 2.9; 95%CI 1.2 to 7.1). Concurrent (wave 4) associations with self-harm were: having few friends (aOR: 8.7; 95%CI 3.2 to 24), poor emotional control (aOR: 4.2; 95%CI 1.9 to 9.6), antisocial behaviour (theft-aOR: 3.1; 95%CI 1.2 to 7.9; carrying a weapon-aOR: 6.9; 95%CI 3.1 to 15), and being in mid-puberty (aOR: 6.5; 95%CI 1.5 to 28) or late/post-puberty (aOR: 14.4; 95%CI 2.9 to 70)., Conclusions: The focus of intervention efforts aimed at preventing and reducing adolescent self-harm should extend to primary school-aged children, with a focus on mental health and peer relationships during the pubertal transition., Competing Interests: The authors have declared that no competing interests exist.

Background: Although fertility is a couple-based outcome, fertility studies typically include far fewer males than females. We know little about which factors facilitate or inhibit male participation in fertility research. In this study we aimed to explore factors that influence male participation in fertility research among North American couples trying to conceive., Methods: We conducted a qualitative research study of male participation in Pregnancy Study Online (PRESTO), a prospective preconception cohort of couples actively trying to conceive in Canada and the United States. Between January-August 2019, we carried out 14 online one-on-one in-depth interviews and one online focus group of males and females with varying levels of participation. The in-depth interviews included females who enrolled in PRESTO but declined to invite their male partners to participate (n = 4), males who enrolled in PRESTO (n = 6), and males who declined to participate in PRESTO (n = 4). The focus group included 10 males who enrolled in PRESTO. We analyzed the transcriptions using inductive content analysis., Results: Male and female participants perceived that fertility is a women's health issue and is a difficult topic for men to discuss. Men expressed fears of infertility tied to masculinity. However, men were motivated to participate in fertility research to support their partners, provide data that could help others, and to learn more about their own reproductive health., Conclusions: Male participation in fertility studies will improve our understanding of male factors contributing to fertility and reproductive health issues. Results indicate a need for more education and health communication on male fertility to normalize male participation in fertility and reproductive health research. Men are much less likely than women to participate in research on fertility and pregnancy. However, it is important for men to participate in fertility research so that we gain a better understanding of male factors that impact fertility and pregnancy outcomes. In this qualitative study, we interviewed men and women from Canada and the United States who were trying to become pregnant to understand why men choose to participate in fertility research, why men choose not to participate in fertility research, and why women choose not to invite their male partners to participate in fertility research. We found that both men and women believe fertility is a woman's health issue. Men find it difficult to talk about pregnancy and fertility and have fears of infertility tied to masculinity. However, men are motivated to participate in fertility research to support their partners, to help others, and to learn more about their own reproductive health.

Emerging evidence suggests that menstruation-related teasing is a common experience among adolescent girls with ramifications on their school participation, yet empirical evidence on the prevalence and determinants of period teasing in schools remain scarce. Menstrual hygiene research and policies almost exclusively focus on girls and women, leading to a dearth of knowledge of male attitudes. We conducted the first quantitative survey of period teasing in schools in sub-Saharan Africa, focusing on 432 male and 524 female students in four co-educational secondary schools in northern Tanzania. Period teasing is prevalent; 13% of girls have experienced period teasing, and more than 80% fear being teased, especially by male classmates. Girls' fears are associated with insufficient menstrual hygiene management resources and practices. Girls cope by reducing school attendance, participation, and concentration in the classroom during periods. Boys engage in period teasing because they perceive periods as embarrassing, especially visible markers of periods (odor or stains). Social norms, such as peer behavior and home restrictions on menstruating women, are associated with more teasing. Boys believe it is strongly inappropriate for girls to reveal period status or to discuss periods with males, including male teachers. In contrast, boys are well informed about basic biological facts of menstruation (scoring 60% on a knowledge quiz, not statistically different from the girls) and have received information from school curricula and health workers. Lack of suitable menstrual hygiene practices and restrictive social norms is correlated with period teasing, which hinders gender equality in educational opportunities. Providing narrowly bio-medical focused education about menstruation may not be enough to reduce period teasing in contexts with period stigma., Competing Interests: The authors have declared that no competing interests exist.

Growing interest in gender-sensitive assessment of depression in men has seen the development of male-specific screening tools. These measures are yet to be subject to longitudinal latent modelling, which limits evidence about the ability of these tools to detect change, especially relative to established screening scales. In this study, three waves of data were collected from 234 men (38.35 years, SD = 14.09) including 3- and 6-month follow-up. Analyses focused on baseline differences and symptom trajectories for the Patient Health Questionnaire (PHQ; prototypic symptoms) and the Male Depression Risk Scale (MDRS; male-type symptoms). At baseline, men not accessing treatment reported higher MDRS scores relative to treatment-engaged men. There was no group difference for the PHQ. Internal consistency (α, ω) coefficients indicated comparable reliability for both measures across the three waves. Multidomain latent growth modelling, including current treatment engagement as a covariate, reported good model fit (CFI = 0.964, TLI = 0.986, RMSEA = 0.081, SRMR = 0.033) with differential findings for the PHQ and MDRS. Consistent with the baseline between-group analysis, current treatment effects were observed for the MDRS, but not the PHQ. Trajectory modelling for the MDRS indicated that greater severity resulted in slower improvement by 6 months. In contrast, there was no difference in the PHQ rate of change between baseline and 6 months. Findings support the psychometric utility of the MDRS as a male-specific symptom domain measure sensitive to both longitudinal change and potential treatment effects for symptomatic men, in ways not discernible by the PHQ. The MDRS may be a useful adjunctive screening tool for assessing men's depression.

Objective: The aim of this study was to use a structured questionnaire in a large cohort of Duchenne Muscular Dystrophy (DMD) patients to assess caregivers and patients views on respiratory function and to establish if their responses were related to the patients' age or level of functional impairment., Methods: Questionnaires were administered to caregivers in 205 DMD patients of age between 3 and 36 years (115 ambulant, 90 non-ambulant), and to 64 DMD patients (3 ambulant, 61 non-ambulant) older than 18 years, subdivided into groups according to age, FVC, ambulatory and ventilatory status., Results: Some differences were found in relation to FVC % values ( p = 0.014), ambulatory ( p = 0.043) and ventilatory status ( p = 0.014). Nearly half of the caregivers expected deterioration over the next years, with the perspective of deterioration more often reported by caregivers of non-ambulant ( p = 0.018) and ventilated patients ( p = 0.004). Caregivers appeared to be aware of the relevance of respiratory function on quality of life (84%) showing willingness to enter possible clinical trials if these were aiming to stabilize the progression of respiratory function with a very high number of positive responses across the spectrum of age, FVC, ambulatory and ventilatory status. The boys older than 18 years showed similar results., Conclusions: Our study showed that the concern for respiratory function increases with age and with the reduction of FVC or the need for ventilation, but the need for intervention was acknowledged across the whole spectrum of age and functional status., (©2020 Gaetano Conte Academy - Mediterranean Society of Myology, Naples, Italy.)

Background: Sexual violence-any sexual act committed against a person without freely given consent-disproportionately affects women. Women's first experiences of sexual violence often occur in adolescence. In Asia and the Pacific, 14% of sexually experienced adolescent girls report forced sexual debut. Early prevention with men that integrates a bystander framework is one way to address attitudes and behavior while reducing potential resistance to participation., Methods: This paper describes a study protocol to adapt RealConsent for use in Vietnam and to test the impact of the adapted program-GlobalConsent-on cognitive/attitudinal/affective mediators, and in turn, on sexual violence perpetration and prosocial bystander behavior. RealConsent is a six-session, web-based educational entertainment program designed to prevent sexual violence perpetration and to enhance prosocial bystander behavior in young men. The program has reduced the incidence of sexual violence among men attending an urban, public university in the Southeastern United States. We used formative qualitative research and the Centers for Disease Control and Prevention's Map of the Adaptation Process to adapt RealConsent. We conducted semi-structured interviews with college men (n = 12) and women (n = 9) to understand the social context of sexual violence. We conducted focus group discussions with university men and stakeholders (n = 14) to elicit feedback on the original program. From these data, we created scripts in storyboard format of the adapted program. We worked closely with a small group of university men to elicit feedback on the storyboards and to refine them for acceptability and production. We are testing the final program-GlobalConsent-in a randomized controlled trial in heterosexual or bisexual freshmen men 18-24 years attending two universities in Hanoi. We are testing the impact of GlobalConsent (n = 400 planned), relative to a health-education attention control condition we developed (n = 400 planned), on cognitive/attitudinal/affective mediators, prosocial bystander behavior, and sexual violence perpetration., Discussion: This project is the first to test the impact of an adapted, theoretically grounded, web-based educational entertainment program to prevent sexual violence perpetration and to promote prosocial bystander behavior among young men in a middle-income country. If effective, GlobalConsent will have exceptional potential to prevent men's sexual violence against women globally., Trial Registration: U.S. National Library of Medicine Clinicaltrials.gov NCT04147455 on November 1, 2019 (Version 1). Retrospectively registered. Protocol amendments will be submitted to clinicaltrials.gov .

Objective: The study aimed to explore the experience of male members of a rapidly grown community of Bangladeshi immigrants while accessing primary healthcare (PHC) services in Canada., Design: A qualitative research was conducted among a sample of Bangladeshi immigrant men through a community-based participatory research approach. Focus group discussions were conducted to collect the qualitative data where thematic analysis was applied., Setting: The focus group discussions were held in various community centres such as individual meeting rooms at public libraries, community halls and so on arranged in collaboration with community organisations while ensuring complete privacy., Participant: Thirty-eight adults, Bangladeshi immigrant men, living in Calgary were selected for this study and participated in six different focus groups. The sample represents mostly married, educated, Muslim, Bangla speaking, aged over 25 years, full-time or self-employed and living in an urban centre in Canada >5 years., Result: The focus groups have highlighted long wait time as an important barrier. Long wait at the emergency room, difficulties to get access to general physicians when feeling sick, slow referral process and long wait at the clinic even after making an appointment impact their daily chores, work and access to care. Language is another important barrier that impedes effective communication between physicians and immigrant patients, thus the quality of care. Unfamiliarity with the healthcare system and lack of resources were also voiced that hinder access to healthcare for immigrant Bangladeshi men in Canada. However, no gender-specific barriers unique to men have been identified in this study., Conclusion: The barriers to accessing PHC services for Bangladeshi immigrant men are similar to that of other visible minority immigrants. It is important to recognise the extent of barriers across various immigrant groups to effectively shape public policy and improve access to PHC., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Men aged 85 years and over have the highest rate of suicide of any age or gender group in Australia. However, little is known about their trajectory toward suicide. The objective of this study was to understand the role of masculine norms and other life factors in the suicidality of older men. Thirty-three men aged 80 years or more took part in a semistructured focus group or interview, and/or completed a survey. Participants were asked about the issues facing older men, well-being and aging, physical health challenges, social support, mental health and help-seeking, and suicide and suicide prevention. Five themes emerged: "finding out we're not invincible," "active and tough," "strong silent types," "decision makers," and "right to die." Participants spoke about masculine norms that had influenced their lives as providers and decision makers, and now influenced how they coped with aging and their journey toward death. For some participants, suicide was seen to be a rational alternative to dependence in their final years. Suicide prevention should adopt a gendered approach and be cognizant of the influence of gender roles and masculinity in older men's lives. Further research and prevention efforts should be mindful of the impact of masculine norms of self-reliance and control on an older man's decision to end his life. Suicide prevention efforts should work to reduce stigma around the challenges of aging, maximize opportunities for control, facilitate social connection, and improve residential aged care.

Introduction: Male involvement in maternal and child health is a practice wherein fathers and male community members actively participate in caring for women and supporting their family to access better health services. There is positive association between male involvement and better maternal and child health outcomes. However, the practice is not always practiced optimally, especially in low- and middle-income countries, where women may not have access to economic resources and decision-making power., Aim: This study investigates how key stakeholders within the health system in Uganda engage with the 'male involvement' agenda and implement related policies. We also analyzed men's perceptions of male involvement initiatives, and how these are influenced by different political, economic, and organizational factors., Methodology: This is a qualitative study utilizing data from 17 in-depth interviews and two focus group discussions conducted in Kasese and Kampala, Uganda. Study participants included men involved in a maternal health project, their wives, and individuals and organizations working to improve male involvement; all purposively selected., Result: Through thematic analysis, four major themes were identified: 'gaps between policy and practice', 'resources and skills', 'inadequate participation by key actors', and 'types of dissemination'. These themes represent the barriers to effective implementation of male involvement policies. Most health workers interviewed have not been adequately trained to provide male-friendly services or to mobilize men. Interventions are highly dependent on external aid and support, which in turn renders them unsustainable. Furthermore, community and religious leaders, and men themselves, are often left out of the design and management of male involvement interventions. Finally, communication and feedback mechanisms were found to be inadequate., Conclusion: To enable sustainable behavior change, we suggest a 'bottom-up' approach to male involvement that emphasizes solutions developed by or in tandem with community members, specifically, fathers and community leaders who are privy to the social norms, structures, and challenges of the community.

Objectives: To explore how sociocultural factors may support or impede the adoption of community-based distribution of injectable contraceptives in Nigeria., Design: A qualitative study based on inductive thematic analysis was conducted through in-depth interviews and focus group discussions., Setting: Most participants lived in Gombe State, North-East Nigeria. Other participants were from Ibadan (South-West) and Abuja (Federal Capital Territory)., Participants: Through seven key informant interviews, 15 in-depth interviews and 10 focus group discussions, 102 participants were involved in the study., Methods: This study conducted in 2016 was part of a larger study on scale-up of community-based distribution of injectable contraceptives. Qualitative data were collected from traditional and religious leaders, health workers and community members. The data were audio recorded, transcribed and analysed using a thematic framework method., Results: Sociocultural challenges to scale-up included patriarchy and men's fear of losing control over their spouses, traditional and religious beliefs about fertility, and myths about contraceptives and family planning. As a result of deep-rooted beliefs that children are 'divine blessings' and that procreation should not be regulated, participants described a subtle resistance to uptake of injectable contraceptives. Since Gombe is largely a patriarchal society, male involvement emerged as important to the success of meaningful innovation uptake. Community leaders largely described their participation in the scale-up process as active, although they also identified the scope for further involvement and recognition., Conclusion: Scale-up is more than setting up health sector implementing structures, training health workers and getting innovation supplies, but also requires preparedness which includes paying attention to complex contextual issues. Policy implementers should also see scale-up as a learning process and be willing to move at the speed of the community., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY. Published by BMJ.)

Background: The sexual behaviour of adolescents is of importance due to the engagement in risky sexual activity at a too early age, which may be associated with the adverse outcomes. The study aims to understand the transitions in adolescent boys and young men's high-risk sexual behaviour in India using two rounds of Indian demographic health survey, NFHS-3 (2005-06) and NFHS-4 (2015-16)., Methods: A total of 25,538 in NFHS-3 (2005-06) and 35,112 in NFHS-4 (2015-16) men were considered for the analysis. Men have been divided into two age groups as 15-19 years (adolescent) and 20-24 (young men) for comparison purposes. Descriptive and multivariate statistics have been used., Results: Overall, high-risk sexual behaviour has increased among adolescent boys (64 to 70%) and young men (18 to 27%) from 2005-06 to 2015-16. The trend of live-in relationship has increased among adolescent boys of rural areas (0.6 to 6.0%) as well as in urban areas (3.1 to 10.9%) over the last 10 years. Adolescent boys having 10th and above years of schooling (AOR = 1.98; p < 0.01), residing in urban areas (AOR = 2.23; p < 0.01), and belonging to the affluent class of households (AOR = 1.41; p < 0.05) were more likely to engage in high-risk sexual activity than the young men in India. The odds of high-risk sexual behaviour was higher among alcohol-using adolescent boys (AOR = 1.82; p < 0.01) and young men (AOR = 2.38; p < 0.01) in 2015-16., Conclusions: The study concludes that early sexual debut, lower prevalence of condom use at first sexual experience, tendency of live-in-relationship, and alcohol consumption indicate the hazardous interconnection between such behaviours among adolescent boys over the last decade which placed them at higher-risky sexual behaviour as compared to young men. Adolescent' sexual behaviours have both short-term and long-term consequences, and interventions that focus on multiple domains of risk may be the most effective in helping to promote broad reproductive health among young adults.

Introduction: Men who have sex with men (MSM) and transgender women (TW) in Colombia are highly affected by HIV. To improve understanding of the role of HIV risk behaviors in HIV acquisition, we used the syndemic framework, a useful concept to inform prevention efforts., Objective: To examine the effect of four psychosocial conditions, namely, forced sex, history of childhood sexual abuse, frequent alcohol use, and illicit drug use on unprotected sex and the synergistic effects ("syndemic" effects) of these conditions on HIV risk behavior., Materials and Methods: We enrolled a total of 812 males (54.7% men who have sex with men, MSM; 7.3% transgender women, and 38% non-MSM). The participants were recruited from neighborhoods of low socioeconomic status through free HIV-counseling and -testing campaigns. We performed Poisson regression analysis to test the associations and interactions between the four psychosocial conditions and unprotected sex with regular, occasional, and transactional partners. To test the "syndemic" model, we assessed additive and multiplicative interactions., Results: The prevalence of any psychosocial condition was 94.9% in transgender women, 60.1% in MSM, and 72.2% in non-MSM. A higher likelihood of transactional sex was associated in MSM (prevalence ratio (PR)=7.41, p<0.001) and non-MSM (PR=2.18, p< 0.001) with three or all four conditions compared to those with one condition. Additive interactions were present for all combinations of psychosocial problems on transactional sex n MSM. No cumulative effect or additive interaction was observed in transgender women., Conclusions: Our study highlights the need for bundled mental health programs addressing childhood sexual abuse, illicit drug use, and frequent alcohol use with other HIV prevention programs.

Background: The underestimation of depression among men may result from atypical depression symptoms and male help-seeking behaviour. However, higher suicide rates among men than among women indicate a need for gender-specific services for men with depression. In order to develop gender-specific services, it is essential to examine professionals' attitudes towards men's depressive symptoms and treatment needs as well as barriers to and facilitators of treatment. This study examined gender-specific treatment needs in male patients and treatment approaches to male patients from a professional perspective., Methods: Semi-structured face-to-face interviews were conducted with 33 mental health professionals (MHPs) from five German psychiatric institutions. The study assessed the characteristics and attributes of male patients with depression risk factors for the development of depression among men, their condition at the beginning of treatment, male patients' depressive symptoms, the needs and expectations of male patients, the importance of social networks in a mental health context, and MHPs' treatment aims and treatment methods. Transcripts were analysed using qualitative content analysis., Results: The professionals' reference group of male patients were men who were characterised in accordance with traditional masculinity. Attributes reported as in line with this type of men were late initiations of inpatient treatment after crisis, suicidal ideation or attempted suicide, and high expectations towards treatment duration, success rate in recovery and therapeutic sessions. In contrast, male patients who deviate from these patterns were partially described with reference to female stereotypes. Professionals referred to psychosocial models in their explanations of the causes of depression and provided sociological explanations for the development of masculine ideals among men. The consequences of these for treatment were discussed against the background of normative expectations regarding the male gender. From the professionals' point of view, psychoeducation and the acceptance of depression (as a widespread mental illness) were the most important goals in mental health treatment., Conclusions: In order to improve mental health among men, gender-specific services should be offered. Awareness of the role of gender and its implications on mental health treatment should be an integral part of MHPs' education and their daily implementation of mental health treatment practices.

Background: Male involvement in maternal health has been linked to positive health outcomes for women and children, as they control household resources and make significant decisions, which influence maternal health. Despite of the important role they have in maternal health care, their actual involvement remains low. The objective of this study was to explore community perspectives on potential barriers to men's involvement in maternity care in central Tanzania., Methods: Qualitative research methods were used in data collection. We conducted 32 focus group discussions (16 FGDs with men and 16 FGDs with women) and 34 in-depth interviews with community leaders, village health workers and health care providers. Interview guides were used to guide the focus group discussions and in-depth interviews. The interviews and discussions were audio recorded, transcribed and translated into English and imported into QSR NVivo 9 software for thematic analysis. Three themes emerged from the data; men's maternity care involvement indicators, benefits of men's involvement in maternity health care services and barriers to men's involvement in maternity health care services., Results: Both men and women participants acknowledged the importance of men's involvement in maternity health care services, even though few men actually got involved. Identified benefits of men's involvement in maternity health care services include: Learning any risk factors directly from the health care providers and getting prepared in addressing them; and reinforcing adherence to instruction received from the health care provider as family protectors and guardians. Barriers to men's involvement in maternity health care services are systemic; starting from the family, health care and culture-specific gender norms for maternity related behaviour as well as healthcare facilities structural constrains inhibiting implementation of couple-friendly maternity health care services., Conclusions: Men's involvement in maternity care is influenced by culture-specific maternity-related gender norms. This situation is compounded by the conditions of deprivation that deny women access to resources with which they could find alternative support during pregnancy. Moreover, structures meant for maternal health care services lack privacy, thus inhibiting male partners' presence in the delivery room. Intervention to increase men's involvement in maternity care should address individual and systemic barriers to men's involvement., Competing Interests: The authors have declared that no competing interest exist.

Background: Globally only 79% of adults living with HIV (human immunodeficiency virus) know their status and men in sub-Saharan Africa are considered a particularly hard-to-reach population for HIV testing. Home-based HIV couple testing during the antenatal period is a safe and effective method that has been used to test male partners of pregnant women. The goal of this qualitative study was to identify elements that made couple testing successful and describe important characteristics of this home-based intervention from couples' perspectives., Methods: Couples who received scheduled home-based couple testing during pregnancy in Kisumu, Kenya, were purposively sampled based on HIV status from January to May 2015. An interviewer administered all of the in-depth interviews and two coders were directly involved in the data analysis and reconciled codes several times in the process., Results: Twenty-one couples were enrolled: 9 concordant HIV-negative couples, 8 HIV discordant couples, 3 HIV concordant HIV-positive couples, and 1 whose concordance status was unknown. Median age at the time of home-based couple testing was 24 and 28 years for women and men, respectively. Median relationship duration was 3 years and couples had a median of two pregnancies. The major themes that emerged were that home-based couple testing 1) removed the female burden of requesting couple testing, 2) overcame logistical barriers associated with clinic-based testing, 3) encouraged participants to overcome their fear of testing and disclosure, 4) provided privacy in the home, and 5) provided quality time with the health advisors. Importantly, some women appreciated individual testing at the clinic before couple testing and some couples preferred skilled, anonymous health advisors delivering the intervention rather than known community health workers., Conclusions: The results of this qualitative study suggest that home-based couple testing during pregnancy overcame many of the barriers that limit men's access to and uptake of clinic-based testing. It encouraged participants to overcome their fear of testing and disclosure through a setting that afforded privacy and quality time with skilled health advisors. These qualitative results may help design effective partner and couple HIV testing programs in the antenatal setting and alongside or within other assisted partner notification services., Trial Registration: Clinicaltrials.gov registry: NCT01784783. Registered prospectively on June 15, 2012.

Background: Along with sexual partners of other high-risk groups, men who purchase sex (MWPS) represented 18% of new HIV diagnoses worldwide in 2018. They are therefore an important population for HIV prevention globally. Despite very low HIV testing coverage among MWPS in many countries, the role of HIV self-testing to increase testing coverage has not been explored. We, therefore, conducted a pilot intervention study to evaluate the uptake and acceptability of assisted and unassisted HIV self-testing among MWPS in Indonesia., Methods: MWPS attending seven brothels in Bali between December 2017 and January 2018 were recruited by lay health providers to participate in a brief health survey, and then invited to have a HIV self-test (assisted or unassisted) with an OraQuick® ADVANCE Rapid HIV-1/2 Antibody Test and complete a post-test acceptability survey., Results: A total of 292 men completed the health survey (response rate: 70%) and 188 (64.6%) accepted HIV self-testing. Of these men, 13.3% had ever tested for HIV and 58.9% reported condom use at their last sexual encounter with a brothel-based female sex worker. Nearly all men (98.9%) who accepted a HIV self-test preferred assisted HIV self-testing - of whom 83.9% preferred to be fully assisted and 16.1% opted to be partially assisted and read their results privately. Of the men who accepted the test and showed the result to the lay health providers, 4 (2.1%) received reactive results. Linkage following HIV self-test is a concern, as none of the four men with a reactive result attended HIV testing at the recommended referral HIV testing clinic over a two-month follow-up period., Conclusions: This study is the first to investigate the acceptance of HIV self-testing when offered to MWPS in brothels by lay health providers. The high uptake of HIV self-testing suggests that this testing model is acceptable and could increase the very low HIV testing coverage among MWPS. The strong preference for fully assisted HIV self-testing highlights the importance of involving lay health providers in future testing programs. When scaling up HIV self-testing programmatically, strategies to improve linkage-to-care should be considered and evaluated.

Background: In order to reduce women's exposure to violence and develop culturally appropriate interventions, it is important to gain an understanding of how men who use violence rationalize it. The present study sought to explore the perspectives of men who had used violence on their female partners, specifically their views on intimate partner violence (IPV), gender norms, manhood, their gender attitudes and to understand how these may drive male perpetrated IPV against women in the Central Region of Ghana., Methods: This was a qualitative study involving purposively sampled adult men who had participated in a household-based survey in selected districts in the Central Region of Ghana and who had self-reported perpetration of IPV in the past 12 months. In-depth interviews were conducted with 17 men., Results: Data revealed how a range of social, cultural, and religious factors ̶ stemming from patriarchy ̶ combined to inform the construction of a traditional masculinity. These factors included the notion that decision-making in the home is a man's prerogative, there should be rigid and distinct gender roles, men's perceptions of owning female partners and having the right to have sex with them whenever they desire, and the notion that wife beating is legitimate discipline. Findings suggest that it was through performing, or aspiring to achieve, this form of masculinity that men used varying forms of violence against their female partners. Moreover, data show that the men's use of violence was a tactic for controlling women and emphasizing their authority and power over them., Conclusions: Developers of interventions to prevent IPV need to recognize that there is a coherent configuration of aspirations, social norms and behaviours that is drawn on by some men to justify their use of IPV. Understanding the perspectives of men who have perpetrated IPV against women and their motivations for perpetration is essential for interventions to prevent IPV. This is discussed as drawing authority from 'tradition' and so engaging traditional and religious leaders, as well as men and women throughout the community, in activities to challenge this is likely to be particularly fruitful.

Background: Afghanistan has high maternal and infant mortality which is in part driven by high fertility and low modern contraceptive use. Using modern contraceptive methods can reduce maternal and infant mortality, however there are several barriers to modern contraceptive use in Afghanistan. Married men have the potential to hinder or facilitate their wives' contraceptive use. Internally displaced persons (IDP), a growing population in Afghanistan, are rarely included in reproductive health research. We explored whether married men's, including IDPs', gender-related attitudes and other factors were associated with reported modern contraceptive use to inform programming to meet reproductive health needs of married couples., Methods: Cross-sectional study using data from 885 married men determined to have contraceptive need in seven Afghan provinces. We explored associations between sociodemographic factors, IDP status, wives' involvement in household decision-making and men's attitudes towards intimate partner violence (IPV) with reported modern contraceptive use using logistic regression analysis., Results: Most men (78%) had ≥2 children, 60% reported any formal education, and 30% reported being IDPs. Only 38% of married men and 24% of IDPs with contraceptive need reported using modern contraception with their wives. Most (80% overall, 63% of IDPs) reported their wives' involvement in some/all household decisions, while 47% overall and 57% of IDPs reported IPV was justified in one or more listed circumstances. In bivariate analysis, men responding that IPV was not justified in any listed circumstance were more likely and IDPs less likely to report modern contraceptive use. In multivariable analysis, involvement by wives in household decision-making (AOR 2.57; 95% CI: 1.51, 4.37), owning a radio and/or television (AOR 1.69; 95% CI: 1.10, 2.59), having more children, age, and province of interview were independently associated with reported modern contraceptive use, while IDP status was not., Conclusions: Our findings reflect positive associations between wives' participation in household decisions and mass media exposure (television/radio ownership) with reported modern contraceptive use. Reproductive health initiatives engaging men to promote communication within couples and through mass media channels may further increase modern contraceptive use and advance Afghanistan's family planning goals. As fewer IDPs owned a radio/television, additional outreach methods should be tested for this group.