Identifying work as a barrier to men's access to chronic illness (arthritis) self-management programs.

Why are men under-represented as users of arthritis self-management programs? What are the main barriers to service access? This paper explores the interaction between work, gender, and self-management of a chronic illness from a socio-constructive perspective. A qualitative study was conducted involving in-depth interviews with 17 men with arthritis. This paper discusses the role of work as one of the factors affecting men's access to arthritis self- management services. Work was found to be a significant conceptual, structural, and social barrier due to: its role in relation to men's concepts of health and fitness; practical difficulties in accessing services during business hours; and sociocultural influences resulting in prioritising of work commitments over health concerns. The structural, conceptual, and sociocultural work influences were more of a constraint for men in the middle stages of life when work and family obligations were greatest. Further research extending this understanding would inform the development of gender-sensitive delivery of self-management services.

Keywords: masculinity, work, gender, arthritis, qualitative research, self- management services

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There are well established gender differences in the utilization of primary health care services and in health management behaviours. For instance, women are more likely to use general health services than men (Australian Bureau of Statistics, 1996; Baum, 1998; Courtenay, 2000a), men and women access health services in different ways and for different reasons (Broom, 1991; Hegelson, 1995), and women can influence the health management behaviour of men more so than vice versa (Norcross, Ramirez, & Palinkas, 1996). These gender differences in the extent and patterns of primary health services use also occur in relation to chronic illness self-management services. For example, male participation rates in the Arthritis Victoria Telephone Information Service were reported as 23% (Gibbs & Reidpath, 2005). The rates were remarkably similar for the Cancer Helpline (22%) (Metcalfe, Akkermann, & Cohen, 1997), the Asthma Telephone Information Service (23%) (G. Irving, personal communication, 2002), the Epilepsy Foundation Telephone Information Service (26%) (E. Adamson, personal communication, 2002), the Arthritis Self-Help Courses (17%- 21%) (Goeppinger & Lorig, 1997; Lorig, Lubeck, Kraines, Seleznick, & Holman, 1985) and slightly higher for the Living with Cancer course (33%) (K. Todd, personal communication, 2001).

Self-management programs in the context of this study included all programs which complement medical services by assisting people to manage their condition on a day-to-day basis. Programs providing disease or symptom specific information, education, exercise or peer support, all represent a service designed to assist people to self-manage. Examples of such programs include arthritis water exercise classes, telephone information services, self-help groups and self-management courses. Chronic illness self-management courses usually involve a weekly 2 hour workshop over a period of approximately 6 weeks. They incorporate all of the elements of self-management, as well as meeting the criteria for true self-management education which includes:

   (a) content presentation focused on patients' perceived needs, (b)
   practice and feedback in new skills, including decision making and
   problem solving, (c) attention to emotional and role management in
   addition to medical management, (d) use of techniques to increase
   patients' confidence in their ability to manage their conditions,
   and (e) emphasis on the patients' active role in the
   physician/patient relationship. (Lorig, 1996, p. 680)

Chronic illness self-management programs may be offered as a disease-specific course, for example, the Arthritis Self-Help Course (Lorig & Fries, 1995). Alternatively, courses such as the Stanford Model (Lorig et al., 2006) of the Better Health Self-Management Course are offered to people with more than one chronic condition. Even disease-specific courses tend to have a generic component that is relevant to all chronic conditions, for example, dealing with issues such as fatigue, doctor-patient communication, fluctuations in health status, and emotional reactions to an uncertain future.

Our understanding of gender differences in patterns of health behaviour is enhanced by Connell's theories of masculinities (Connell, 1999) and relational theories of gender and health that explore the interplay between gender and social interactions/social structures and the subsequent impact on work and health opportunities and constraints (Courtenay, 2000b; Sabo, 2005; Schofield, Connell, Walker, Wood, & Butland, 2000). According to hegemonic constructions of masculinity, men are expected to not show pain, to be self-sufficient, and to not appear weak (Baum & Cooke, 1986; Nathanson, 1975; Verbrugge, 1985). This creates a tension between hegemonic masculinity and help-seeking behaviours that is heightened for men with a chronic illness because of the unpredictability and uncertainty of chronic illness (Cameron & Bernardes, 1998; Courtenay, 2000b; de Ridder, Depla, Severens, & Malsch, 1997; Gordon, 1995). Chronic illness can undermine the factors that have previously sustained a man's place in the gender order. In current society, work is a central means of establishing masculine identity (Hegelson, 1995; Rubin, 1983), so any impact of illness on work represents a threat to that identity (Watson, 2000). Further, men's perception of when it is appropriate to seek help is closely linked to their capacity to fulfil their work and social (e.g., family) commitments, such that as long as they are able to work, they tend to perceive themselves as having adequate health (Watson, 2000).

This paper focuses on findings relating to the interaction between work, gender, and self-management of a chronic illness from a socio-constructive perspective, arising from a qualitative study. It aims to increase understanding of why men are underrepresented as users of arthritis self-management programs. A greater understanding of the subtle interaction between gender and health behaviours (Cameron & Bernardes, 1998; Watson, 2000) is important in the consideration of gender-sensitive delivery of self-management services.

Method

This paper reports on a qualitative study conducted using a grounded theory (Glaser & Strauss, 1967; Strauss & Corbin, 1990) and a participatory research approach (Petras & Porpora, 1993). Semi-structured interviews were held with 17 men and 4 female partners.

Maximum variation sampling was conducted initially to allow identification of common patterns emerging from the variation between the male participants (Patton, 1990). Recruitment was restricted to men with arthritis and related conditions. Time since diagnosis ranged from four months to 25 years. The main sources of variation sought in the initial purposive sampling were health status, extent of participation in self-management programs, cultural diversity, and education levels. The health status of the men was self-rated as poor (3), fair (8) and good (6). Participation in self-management programs ranged from zero involvement to involvement in four different self- management programs. Twelve of the men identified as Anglo/Celtic, including one who also identified as a member of the Aboriginal community. The remaining 5 men identified as UK/European, Greek, Chilean, Italian, and Filipino/Asian. Two of the partners identified themselves as Anglo/Celtic, a third partner identified as Polynesian/New Zealander and the fourth as Italian.

Table 1 shows the range in education level of the participants.

Further theoretical sampling was conducted throughout the research process to explore emerging themes relating to age (see Table 2), employment status (see Table 3), and partners' role.

The majority of the interviewees were either retired (35%) for medical or age- related reasons, or were working full time (41%; see Table 3).

The men that were working were in a range of roles--health services, research, managerial, information technology, entertainment industry, motor mechanics, and farming.

The interviews were semi-structured to allow for greater flexibility and free flowing discourse. The interviews were guided by an interview protocol of possible questions designed to explore men's awareness of existing services, their level of use of self-management services to date, factors which have influenced their service use to date, and factors likely to influence their use of services in the future.

All but one of the interviews were tape-recorded with the permission of the interviewee and then fully transcribed. The one non-taped interview was conducted via email at the participant's request because of time constraints. The transcripts were entered into N-Vivo 1.1 qualitative software. This was used as a tool to assist with the organisation of the data during the data coding and analysis. The coded data was organised into conceptual categories, and relationships within and between categories were explored. This made it possible to identify patterns and emerging themes that formed the basis of a conceptual analysis of the data. Disconfirming evidence was explored further through additional sampling to develop an explanation for the discrepancies in the data, for example, the importance of work as a barrier did not come through as strongly in some older men. Further sampling across all age groups allowed for an understanding of the interplay with life stage to be developed. Consistencies and anomalies were then explored between the conceptual analysis and existing theories on gender and health. This made it possible to develop a theoretical understanding of issues affecting men's access to self-management services. Pseudonyms were assigned by the researcher to each participant to protect their anonymity. The results were circulated to participants and stakeholders at two stages in the concurrent data collection and analysis as part of the participatory research approach to establish the results' confirmability (Lincoln & Guba, 1985).

Findings

The focus of the interviews in this study was on men's awareness of the self- management services available to them, the extent to which they had accessed self- management services, and possible factors contributing to their decisions about whether or not to access services. The men generally perceived the doctors to be the main source of medical information and support. This is consistent with the findings of Pinnock and colleagues in their qualitative study of older men's concerns about their urological health (Pinnock, O'Brien, & Marshall, 1998). On the other hand, the men's perception that self-management services consisted solely of support groups involving sharing of experiences was a clear barrier. There was little awareness of the exercise, pain management, and educational options available (Gibbs, 2005). These were described by the researcher early in the interview to ensure a common understanding of services was discussed. The focus of this paper is on the emergence of work as a dominant theme in discussions about barriers to accessing services. This appeared to be due to its role in relation to men's concepts of health and fitness, prioritizing of work commitments over health concerns, and difficulties in accessing services outside of business hours.

Work as a Conceptual Barrier

It has been proposed that men interpret "fitness" as their ability to fulfill their social obligations in relation to work and family (Watson, 1993, 2000). Therefore, men tend to see themselves as fit as long as they are able to continue working. This makes it extremely difficult for health organizations to reach men at an early point in the pathway of their illness.

It became apparent through the interviews that the standard point for men to access self-management services was when they were no longer working, either because their condition had progressed to a point that they were physically unable to work, or because they had reached retirement age. The pattern of delaying access to self- management services until work was affected was consistently evident in the men's intentions as well as actual behaviours. Those men who had not accessed self-management services anticipated that they would only do so if they were unable to continue working.

During the interview, Eric (employed full time, age group 41-60) related how his condition was causing him considerable pain and fatigue and was affecting his working and home life, and yet he did not feel he was at a stage where he needed to access self-management services. He noted that, "I'm still not at that sort of stage where I still think I can probably manage myself.... It's funny you know, it would probably be if I got to the stage where I couldn't work."

Graham's (self-employed, age group 41-60) condition gave him regular pain and caused him to modify his farming practices and yet he, like Eric, did not feel he was at the stage where he needed to access self-management services. Graham predicted what would have to change before he was likely to access self management services. "If I can't get through the day.... Yeah, when I can't do it, I have to do something."

This tendency for men to identify inability to continue working as a parameter for help seeking supports Watson's contention that men perceive health and fitness in terms of their ability to fulfill work and social obligations. For men who were approaching retirement age, retirement rather than inability to continue working was the new parameter they set on accessing services. The wives interviewed also described retirement as the point at which their husbands were likely to act. This appeared to be because the barrier of work had disappeared and there was an acceptance that bodies require maintenance when they age (Watson, 1993, 2000). These findings are consistent with Pinnock and colleagues' (1998) findings in relation to men's access to doctors:

   Both men's and women's groups commented that, after retirement, men
   were much more willing to go to the doctor, confirming that time
   off work and having to support the family act as a barrier to
   accessing doctors. In the rural groups, this was complicated by the
   time it took to travel to the doctor. (p. 372)

This demonstrates that it becomes appropriate, acceptable, and achievable for men to seek help from health services after retirement.

Work as a Structural Barrier

One of the reasons these men repeatedly offered for not accessing services was lack of time because of work commitments. In fact work, and its demands on time and energy, was a significant structural barrier to accessing self management services.

Graham spoke repeatedly of time pressures throughout the interview, in particular the difficulty attending health services because of the demands of his work commitments on the farm. When told about the range of services offered by Arthritis Victoria he said, "Those sort of things are really out of the question for me though because I wouldn't have time to organise it properly." As noted in the Australian Draft National Men's Health Policy, "Often the realities of rural life are that it is either impractical to take time out for ill-health, or health and welfare services are just too far away" (Commonwealth Department of Human Services and Health, 1996, p. 32). This was certainly reflected in Graham's comments about the inconvenience of going to the doctor:

   ... [Y]ou know, it's half the day gone, by the time I stop what I'm
   doing and back here and get cleaned up. I can't just sort of go
   from the office and pop in there because I'm usually covered in
   grease and crap.... Anytime a doctor refers you to someone, you've
   got to go to Bairnsdale [closest town to his farm]. Well, that's a
   day gone virtually ... but then in the middle of summer I wouldn't
   go to Bairnsdale during the day anyway.... I won't go out anywhere
   I can't hear on the radio. I like to know what's going on out in
   the farm. I want to be involved in it not away from it. So I just
   don't go out.

The practical difficulties for a farmer in accessing health services involve traveling long distances, an unpredictable work environment, and the inconvenience of having to clean up and change before leaving. Lorig and colleagues (Lorig & Associates, 1996) suggest that it may be necessary to re-structure self-management services to minimise the number of visits for people in rural areas who have to travel long distances. However, Graham's difficulty with the travel distances is also linked to his reluctance to relinquish a sense of control over what is happening on the farm. This demonstrates the interplay between structural and social influences on Graham's behaviour.

The practical difficulty of travel distance, unpredictability of work, and the need to change into clean clothes were also mentioned in the interview with Bruce (employed full-time, age group 26-40) as an issue when he had been working as a tradesman:

   I'm always moving so it could be Melton one day, the next day I'm
   in Ferntree Gully [two suburbs of Melbourne] ... [I] come home
   covered in cement stains.

This shows that tradesmen encounter similar structural barriers to those faced by rural workers.

Being self-employed and working for someone else were both mentioned as a barrier and an aid to taking time off. That is, those who were self-employed were likely to perceive it as being easier for people to take time off if they had sick leave, and those who were employed by others were likely to perceive it as easier to take time off if you work for yourself. Therefore, this aspect of work circumstances did not appear to differentiate access. Work circumstances varied, but placing work as a priority was consistently identified as a barrier, particularly when attendance at programs conflicted with work commitments.

Not surprisingly, evening courses were considered the most convenient by working men. However, the fatigue caused by constant pain and the effort of continuing with work commitments can make it difficult for men with arthritis to attend evening courses. There are mixed findings in the research about whether men would be more likely to attend services out of business hours. The experience of Baum and Cooke (1986) was that regardless of the time the service was held, men were less likely to attend than women, and of those men who did attend, it was usually those without work obligations.

Eric confirmed that fatigue was a significant barrier to him attending evening courses:

   The venue wouldn't worry me. The hardest part for me ... is time to
   do that. That's the hardest part. Sometimes I'm so tired when I go
   home from work because of the arthritis, all I do is go home to
   sleep.

So for Eric, it was not only the time spent at work that prevented him from accessing services. It was also the fact that work was consuming all of his energy so that the remaining time was spent resting.

Adam (retired, age group 41-60) confirmed the difficulty in going back out in the evening because of the fatigue that builds up after interrupted sleep and working all day in pain:

   Often you don't realise at the time you're pushing yourself because
   you're in denial I suppose in lots of respects. Because you're
   battling pain through the day, you don't realise just how tired the
   day's been. And then, particularly if you've got sore joints, your
   sleep tends to be disturbed when you roll over and all that sort of
   thing, so that all compounding too. You'd probably find excuses not
   to go because of the tiredness.... And you probably wouldn't even
   acknowledge to yourself you're too tired to go.

Clearly, for men with a chronic illness, evening courses are problematic. Daytime courses were the preferred option for retired men, but workplace courses were the only daytime option that working men were enthusiastic about, and only if it was suitable for their workplace. Weekends did not seem to be a viable option. The men tended to see the weekends as family or recreation time and were unlikely to consider attending a course, although some nominated Saturday morning as an option if necessary.

Work as a Socio-Cultural Barrier

It was clear that work acted as a structural barrier to access to arthritis self-management due to inflexible work circumstances and the economic necessity of work. However, its barrier to access also appeared to have a sociocultural influence, as evidenced through the prioritizing of work commitments over health concerns.

Peter (employed full-time, age group 26-40) discussed the things that deter him from attending self-management services:

   ... they're mostly geared for people who are disabled by their
   illness and so if you've got a full-time job and a life outside
   that job then there's no space for it.

Peter made it clear that he felt that services were designed for people who were not working and that his work commitments were a significant barrier to him accessing self-management services. It was also appears that he had assigned his work and other aspects of his life a higher priority than managing personal health. The reason for this became clear in the comment he made next, "I don't need it enough to make the space for it." This shows that he did not feel that he had reached the point where self-management services were warranted, yet he described throughout the interview how his condition was significantly limiting his working life, his home life, and his social life. This evidence of how social interactions, social structures, and organisations were constraining Peter's access to self-management options supports relational theories on gender (Sabo, 2005; Schofield et al., 2000). It also reflects the stoicism that is characteristic of hegemonic masculinity (Connell, 1999; Gibbs, 2005). Reluctance to adjust work programs to accommodate health-related activities is also consistent with the work of Saltonstall (1993) and Hegelson (1995) who noted that work tends to be given precedence by men, and health-related activities are perceived as being of secondary importance. Harry (unemployed, age group 41-60) explained that this perception by men that they do not have time to access self-management services really represents concerns about wasting time on something of little value. He described this idea when he noted, "... that's why blokes don't go to ongoing courses, they feel like they're being robbed of their time on something that's really not as important as work, sport, recreation."

This image of health activities "robbing" time that belongs to work, family, or recreation reflects the low priority being placed on health and the low value being placed on the self-management services.

Graham reported that his wife, Mary, had questioned his tendency to give precedence to his work:

   Mary says, "You're not really the biggest show in the world, of
   course you can get away," but when you're a one man band ... you've
   got to work in with other people too. It's not always that easy.

The tendency to give precedence to work over health was consistent for men from diverse cultural and employment groupings, although it appeared less prominent in both young and older men. When middle-aged and older men's work was affected by their condition, they saw it as a sign of ageing and were threatened by the prospect of impending retirement. When the younger men had to stop work because of their condition they saw it as a temporary interruption and, in the case of Phillip, a chance to embark on a new direction in his career. It is not clear whether this is because they are young enough to believe they are "immortal," have time to "start again," or whether it is due to less rigid notions of hegemonic masculinity in younger generations, reflecting a shift in dominant social constructions of masculinity over time (Connell, 1999). Older retired men were free of the constraints of work and were therefore free to access the services themselves. They were less likely to be influenced by the constraints of hegemonic masculinity because, according to Watson (Watson, 2000; Watson, 1993), men's concepts of health generally include an expectation that wear and tear will occur with ageing and will undermine the body's ability to maintain itself. This suggests that structural barriers, conceptual and sociocultural constraints have the greatest influence on health decisions during the middle stage of adulthood when work and family obligations are greatest.

Limitations

This study would have benefited from further sampling to test the theories that emerged and to search further for disconfirming evidence. However, the congruence between the findings and existing theories on gender and health supports their generalisability.

Without exploring issues affecting women's access to self-management programs, it is not possible to confirm that work as a barrier is a gender issue. It has been suggested that gender differences in employment options lead to a greater degree of inflexibility in the working lives of men. Waldron (1995) explored the impact of job flexibility on help-seeking behaviour by reviewing a range of relevant studies, including: a study by Marcus and Siegel (1982) who found evidence of only a modest contribution from employment status to gender differences in physician visits for chronic illnesses; studies that demonstrated there is no consistent difference between the help-seeking behaviour of employed women and of housewives (Cleary, Mechanic, & Greenly, 1982; Nathanson & Lorenz, 1982); and studies showing that women are just as likely as men to report inconvenience in arranging time for a physician (Verbrugge, 1982; Waldron, 1983). Waldron concluded that flexibility in employment and other role obligations are not the main source of gender differences in physician visits. In addition, as women represent approximately 75% of service users and sex differences in service use exist even after taking into account sex differences in prevalence rates (Gibbs & Reidpath, 2005), it appears that access issues are less problematic for women.

This paper focuses on the role of work as a barrier without fully exploring the interaction with the state of their health. A separate paper explores men's response to increasing severity of their condition, within the context of masculinity theories (Gibbs, 2005).

Conclusion

This paper explored the role of work as a barrier to men's access to arthritis self-management services. The findings suggested multi-level relational influences of work on men's access to arthritis self-management programs at different life stages. The influences acting in opposition to self-management service use were identified as conceptual, structural, and socio-cultural.

Work was integrally linked to men's concepts of health that equate fitness with an ability to fulfil social obligations in relation to work and family. This conceptual barrier meant that men did not feel it was necessary to seek help while they were still able to continue working. The economic necessity of work meant that men were often unable to access services at times and places that accommodated their work obligations. In this sense, work acted as a structural barrier to service access. In addition, the level of commitment given to work obligations over health issues was linked to hegemonic constructions of masculinity that promote stoicism and associate health care with feminism. If work and service times conflicted, precedence was given to work as the higher priority, reflecting relational theories of gender and acting essentially as a socio-cultural barrier to accessing self-management services. The structural, conceptual, and socio-cultural work influences were more of a constraint for men in the middle stages of life when work and family obligations were greatest.

Further research is required to investigate if these findings are consistent for different illness groups and to explore men's experience of self-management programs once they have been accessed. Quantitative studies of these issues would allow determination of a causal relationship between work and service access which would inform the need for the development of gender-sensitive delivery of self-management services. The increased understanding provided by this study and its alignment with existing theories on gender and health suggest that it may be useful to evaluate the efficacy of promoting self-management services as a means of maintaining working capacity.

The generosity of the men and their partners in sharing their life experiences is greatly appreciated. The support and guidance provided by Dr. Maria Pallotta-Chiarolli, as supervisor of this doctoral study, and Dr. Daniel Reidpath, as co-supervisor, is gratefully acknowledged.

References

Australian Bureau of Statistics. (1996). 1995 National Health Survey, First Results Australia (No. Cat. No. 4392.0). Canberra: ABS.

Baum, F. (1998). The new public health: An Australian perspective. Melbourne: Oxford University Press.

Baum, F., & Cooke, R. (1986). Community health services for men in the southern area of Adelaide: Rationale, development and evaluation (Research). Morphett Vale: Southern Community Health Services Research Unit (Part of S.A. Health Commission).

Broom, D. (1991). Damned if we do: Contradictions in women's health care. NSW: Allen & Unwin.

Cameron, E., & Bernardes, J. (1998). Gender and disadvantage in health: Men's health for a change. Sociology of Health and Illness, 20, 673-693.

Cleary, P. D., Mechanic, D., & Greenly, J. R. (1982). Sex differences in medical care utilization: An empirical investigation. Journal of Health and Social Behavior, 23, 106-119.

Commonwealth Department of Human Services and Health. (I 996). Draft national men's health policy. Canberra, Australia. Primary Health Care Group.

Connell, R. W. (1999). Men's health: A research agenda and background report. Canberra: Commonwealth Department of Health and Aged Care.

Courtenay, W. H. (2000a). Behavioural factors associated with disease: injury and death among men: Evidence and implications for prevention. The Journal of Men's Studies, 9(1), 81-142.

Courtenay, W. H. (2000b). Constructions of masculinity and their influence on men's well-being: A theory of gender and health. Social Science and Medicine, 50(10), 1385-1401.

de Ridder, D., Depla, M., Severens, P., & Malsch, M. (1997). Beliefs on coping with illness: A consumer's perspective. Social Science and Medicine, 44(5), 553-559.

Gibbs, L. (2005). Applications of masculinity theories in a chronic illness context. International Journal of Men's Health, 4(3), 287-300.

Gibbs, L., & Reidpath, D. (2005). What about the men? Gender differences in utilisation of chronic illness self management services. Australian Journal of Primary Health, 11(1), pp. 63-71.

Glaser, B. G., & Strauss, A. L. (1967). The discovery of grounded theory: Strategies for qualitative research. New York: Aldine De Gruyter.

Goeppinger, J., & Lorig, K. (1997). Interventions to reduce the impact of chronic disease: Community-based arthritis patient education. Annual review of nursing research (Vol. 15, pp. 101-122).

Gordon, D. F. (1995). Testicular cancer and masculinity. In D. Sabo & D. F. Gordon (Eds.), Men's health and illness. Gender, power, and the body (Vol. 8, pp. 246-265). Thousand Oaks, CA: Sage.

Hegelson, V. S. (1995). Masculinity, men's roles, and coronary heart disease. In D. Sabo & D. F. Gordon (Eds.), Men 'S health and illness. Gender, power, and the body (Vol. 8, pp. 68-104). Thousand Oaks, CA: Sage.

Lincoln, Y. S., & Guba, E. G. (1985). Naturalistic inquiry. Beverly Hills, CA: Sage.

Lorig, K. R. (1996). Self-management of chronic illness: A model for tertiary prevention (Perspectives on chronic illness: Treating patients and delivering care). American Behavioural Scientist, 39, 676-678.

Lorig, K., & Associates. (1996). Patient education. A practical approach (2nd ed.). Thousand Oaks, CA: Sage.

Lorig, K., & Fries, J. (1995). The arthritis helpbook. A tested self-management program for coping with arthritis and fibromyalgia. Reading, MA: Addison-Wesley.

Lorig, K., Holman, H., Sobel, D., Laurent, D., Gonzalez, V., & Minor, M. (2006). Living a healthy life with chronic conditions (3rd ed.). Boulder, CO: Bull Publishing Company.

Lorig, K., Lubeck, D., Kraines, R., Seleznick, M., & Holman, H. (1985). Outcomes of self-help education for patients with arthritis. Arthritis and Rheumatism, 28(6), Appendix 2.

Marcus, A. C., & Siegel, J. M. (1982). Sex differences in the use of physician services: A preliminary test of the fixed role hypothesis. Journal of Health and Social Behavior, 23, 186-197.

Metcalfe, R., Akkermann, D., & Cohen, P. (1997, 29-31 October). Promoting men's health through the cancer helpline: Current advances. Paper presented at the Second National Men's Health Conference, Fremantle, Western Australia.

Nathanson, C. A. (1975). Illness and the feminine role: A theoretical review. Social Science and Medicine, 9, 57-62.

Nathanson, C. A., & Lorenz, G. (1982). Women and health: The social dimensions of biomedical data. In J. Z. Giele (Ed.), Women in the middle years--Current knowledge and directions for research and policy (pp. 37-87). New York: Wiley.

Norcross, W. A., Ramirez, C., & Palinkas, L. A. (1996). The influence of women on the health care-seeking behavior of men. The Journal of Family Practice, 43(5), 475-480.

Patton, M. Q. (1990). Qualitative evaluation and research methods. Newbury Park, CA: Sage.

Petras, E. M., & Porpora, D. V. (1993). Participatory research: Three models and an analysis. American Sociologist, 24, 107-126.

Pinnock, C., O'Brien, B., & Marshall, V. (1998). Older men's concerns about their urological health: A qualitative study. Australian and New Zealand Journal of Public Health, 22(3), 368-373.

Rubin, L. B. (1983). Intimate strangers. New York: Harper & Row.

Sabo, D. (2005). The study of masculinities and men's health. In M. S. Kimmel, J. Hearn, & R. W. Connell (Eds.), Handbook of studies on men and masculinities (pp. 326-352). Thousand Oaks, CA: Sage.

Saltonstall, R. (1993). Healthy bodies, social bodies: Men's and women's concepts and practices of health in everyday life. Social Science and Medicine, 36(1), 7-14.

Schofield, T., Connell, R. A., Walker, L., Wood, J. F., & Butland, D. L. (2000). Understanding men's health and illness: A gender relations approach to policy, research and practice. Journal of American College Health, 48(6), 247-256.

Strauss, A., & Corbin, J. (1990). Basics of qualitative research: Grounded theory procedures and techniques. London: Sage.

Verbrugge, L. M. (1982). Sex differences in legal drug use. Journal of Social Issues, 38, 59-76.

Verbrugge, L. M. (1985). Gender and health: An update on hypotheses and evidence. Journal of Health and Social Behavior, 26, 156-182.

Waldron, I. (1983). Sex differences in illness incidence, prognosis and mortality. Social Science and Medicine, 17, 1107-1123.

Waldron, I. (1995). Contributions of changing gender differences in behaviour and social roles to changing gender differences in mortality. In D. Sabo & D. F. Gordon (Eds.), Men's health and illness. Gender, power, and the body (Vol. 8, pp. 22-45). Thousand Oaks: Sage.

Watson, J. (1993). Male body image and health beliefs: A qualitative study and implications for health promotion practice. Health Education Journal, 52(4), 246-252.

Watson, J. (2000). Male bodies: Health, culture and identity. Buckingham, UK: Open University Press.

LISA GIBBS

Deakin University 

Correspondence concerning this article should be sent to Lisa Gibbs, School of Health and Social Development, Deakin University, 221 Burwood Highway, Burwood 3125, Victoria, Australia. Electronic mail: [e-mail]

Table 1
Education Level of Participants

Education   Primary   Secondary   Passed    Tertiary diploma
             only                 Year 12       / trade

Men            1          5          1             7
Partners       0          0          1             2

Education   University   Unknown

Men             3           3
Partners        1           0

Table 2
Age Group of Participants

Age group   18-25   26-40   41-60   61-75   over 75

Men           2       3       7       3        2
Partners      0       1       3       0        0

Table 3
Employment Status of Participants

                                                    Part time/
Work situation   Retired   Unemployed   Student   casual/domestic

Men                 6          1           1             2
Partners            1          0           0             2

Work situation   Full time

Men                  7
Partners             1