The Urgency of Access to Men-Centered Mental Healthcare Services to Address Men’s Sensitive Issues in the Communities of South Africa

Abstract

South Africa yet again faces an upsurge of a national crisis. Approximately 13,774 deaths were reported in 2019 as a result of suicide. In total, 10,861 of the deaths were men. It has been said men usually take time to seek healthcare services. Most regard their problems to be solved over a few bottles of alcohol. Most of the suicides are linked to mental health issues. This poses an inquiry on the current services offered to address men’s mental health issues. Therefore, this shows the significant urgency to access modified men-centered mental health services to address men’s sensitive issues in the communities of South Africa (SA). However, this chapter seeks to review the prevalence of suicides, health-seeking behavior among men, and factors to poor utilization of mental health services in men. In addition, it discusses the proposed strategies to improve access to men-centered mental healthcare services.

1. Introduction

Mental health is the state of which one is aware of self, able cope with normal stress situations, and work productively. However, some studies define mental health as a state of which there is absence of mental illness [1, 2]. South Africa yet faces an upsurge of national crisis of men’s death in relation to mental health problems. Approximately 13,774 deaths were reported in 2019 because of mental-health-related problems. In total, 10,861 of the deaths were men. It has been said men usually take time to seek mental healthcare services. Most men regard problems to be solved over few bottles of alcohol. Studies showed that men have been found to seek psychological help at a lower rate compared to women [3, 4].

Men are more at risk of dying of suicide than women in South Africa. When compared with 10 years ago, more men are found to be depressed and are being admitted to psychiatric hospitals due to burnout and depression [5]. The Depression and Anxiety Group affirmed that men do not seek help until later when it is more serious, and although depression is ranked high on the list of chronic diseases, most men are not on treatment. The risk factors for mental health illness in men in South Africa are alcohol, substance use, unsafe sexual practice, diet, lack of physical exercises, violence, and other stressful life events [5].

Based on the recent statistics on suicide rates, it seems as if men’s mental health is being neglected. It is against this background for the urgency of access of men-centered mental healthcare services to address men’s sensitive issues in the communities of South Africa. Therefore, it requires redirection of resources to achieve a 100% sustainable mental health for all through access to men-oriented mental healthcare services to address sensitive issues among men.

2. Prevalence of suicides associated with mental health issues among men

Mental health is of significance to the well-being of individuals. However, individuals go through events in life that cause stress altering the mental health, consequently, resulting into suicides. Suicide is a major health problem worldwide contributing to 1.4% of the mortalities. The majority of the suicides are associated with mental health problems [6]. Over the years, gradual increase in acknowledgement of the role mental health in individual lives has been noted. Despite this progress and the transformed health system, men die every day as a result of mental health issues. Suicide is one of the leading causes. Furthermore, nearly 40% of countries have greater than 15 suicide deaths per 100,000 men [3, 7], with Lesotho, Guyana, Eswatini, South Korea, and Russia being the highest. Over 3000 Australians died of suicide every year. Some studies affirmed that majority of the suicides are linked mental illness such as depression, psychosis, and substance use [3].

Suicide is the twelfth leading cause of death in the United States, approximately 45,979 Americans died in 2020 as a result of suicide, and 1.2 million suicide attempts were reported. Correspondingly majority of the suicides were men accounting for 69.68%. Furthermore, in 2020, mortalities of men who died of suicide were 3.88 times than women [8]. The suicide rates have been gradually increasing over the years [9]. Similarly, in Shanghai, China, a rise in deaths due to suicide was noted, and most of the deaths were men with a rate of 6.38 per 100,000. Moreover, 22.54% of the suicide deaths were due to depression [10]. However, there are other factors associated with suicides; this includes sociodemographic, physical, lifestyle, stressful life events, and mental health factors (Figure 1) [11].

Figure 1.

Shows the rates of suicide in the United States over the years [9].

South Korea is the fourth highest country with higher suicides at a suicide rate of 28.6 per 100,000 [3]. Majority of the suicides were men with a suicide rate of 35.5 per 100,000 deaths being the third highest suicide rate globally. It was revealed that some of the suicides were due to social factors, religious activities, and higher social isolation [3, 12]. However, the state of health reported that the reasons for committing suicides among Koreans were mental illness, which accounted for the 28% of the men, and financial problems as well as physical illness [13]. Therefore, this shows the significant urgent need of mental health services for men (Figure 2).

Figure 2.

Shows number of suicide deaths in South Korea by gender per 100,000 [14].

Suicidal behavior is a major public health concern global and in Africa. Studies in Africa revealed that suicide rates in Africa are three times higher in men than women [15, 16]. In South Africa, the suicide rates are approximately five times in men than women. As of 2012, suicides rates ranged from 11.5 per 100,000 to as high as 23.5 per 100,000 in 2019, rendering South Africa being number tenth of the countries with highest suicide rates [3, 17]. An exploratory study on how group of young South African men think and talk about suicide revealed that they perceived suicide as goal-directed behavior that provides a means of recuperating control, asserting power, communicating and rendering oneself being noticeable [18].

3. Major mental health conditions associated with suicide in men

A number of studies have specified that there is silent crisis in men’s health, which is mental health. Over the years, the number of suicides linked to mental health conditions has been gradually increasing. Most studies affirmed that the most common mental health conditions among men subsequently resulting in suicide were depression, anxiety disorders, and substance abuse [6, 19]. Here below only depression is discussed as it is the major ignored one among men.

3.1 Depression

Over the years, depression has been positioned as a mental health disorder dominant in women. However, changes have been observed over the years where more males are affected by depression; it been said some of the causes include financial problems, family problems, and overwhelming family responsibilities [20, 21]. Depression is regarded as an illness in which it affects the cognitive behavior of individuals. It affects how one thinks, feels, and acts [21]. Approximately 6 million men are affected by depression in the United States. Most of the men suffering from depression often remain undiagnosed or untreated, consequently resulting into suicide. Men’s mental health has persisted undertheorized. One of the reasons includes social norms and masculinity such as statements like “Boys don’t cry and men don’t shed a tear.” [22, 23, 24]. Furthermore, various masculinities identities and roles are implicated by men’s depression; for instance, men’s depression can be of result of divorce whereby the men are disrupted of from provider and protector roles. Moreover, also unemployment can exacerbate or trigger depression [25]. However, signs and symptoms of depression do not differ between males and females. Most depressed individuals exhibit different signs and symptoms, this includes [26]:

• Depressed mood all day, sometimes every day, i.e., feeling of sadness, empty, or hopelessness.

• Diminished interest or pleasure to all activities.

• Weight loss not related to diet

• Insomnia or hypersomnia almost everyday

• Fatigue or loss of energy nearly everyday

• Feelings of worthlessness nearly everyday

• Diminished ability to think, concentrate, or indecisiveness

• Recurrent thoughts of death

4. Factors contributing to poor access to mental healthcare in men

4.1 Role of culture

The role of culture in mental health is not well understood in spite of the fact that the cultural conception of the self has a powerful influence on the manner in which the disorder is expressed and understood. The majority of men’s understanding of mental disorder is informed by an indigenous cultural perspective. Men make sense of their illness from both cultural perspective and social context in which they found themselves. Some men’s understanding of mental disorder is in terms of issues such as witchcraft [27].

4.2 Socialization into traditional masculine gender roles

Men are thought to be deterred from engaging in mental health services due to socialization into traditional masculine gender roles. The social and cultural expectations make men think of themselves as risk-takers, thus leading to the probability of engaging more in risky behaviors that could lead to injury and death. Environmental pressures have been proposed to be one of the major causes of men’s premature death and have predisposed them to engage in unhealthy behaviors (e.g., risky sexual behavior, alcohol use and abuse, high-risk sports, reckless driving) detrimental to their mental health. The chances that men will seek mental health when they feel discomfort are reduced because of their socialization experiences.

Men are often socialized through role-playing in such a way that they undermine help-seeking behavior, and if at all they intend to seek help, the individual is faced with cognitive dissonance, which is a consequence of contradictory beliefs of what they believe they are and what action they intend to take. Traits associated with traditional masculinity include stereotypes of stoicism, invulnerability, and self-reliance, which are frequently discussed as they do not fit comfortably with psychological help-seeking. For instance, negative emotions are perceived as a sign of weakness, discouraging men from reaching out to friends. This negatively impacts men’s overall help-seeking behaviors and their choice of treatment type. Failure to adhere to these masculine stereotypes can result in the internalization of discriminative views held by the wider public. These self-stigmatizing beliefs further discourage men from seeking help [28, 29].

4.3 The problem of stigma – Social rejection and labelling

Stigma is described as a painful and distressing experience and a significant barrier to the inclusion of persons living with mental disorders in community activities, healthcare service, workplaces, and accessing education [27].

4.4 Differences in coping strategies

Men cope with mental health difficulties differently compared to women, demonstrating an increased tendency to self-medicate with alcohol and drugs to alleviate emotional distress.

4.5 Poor mental health

Literacy is reported to be associated with lower use of mental health services. Men are regarded as having poorer mental health literacy compared to women as they are worse at identifying mental health disorders [27].

4.6 Lack of appropriate diagnostic instruments and clinician biases

Men express symptoms of depression that do not always conform to the Diagnostic and Statistical Manual of Mental Disorders [30]. For example, they may express more externalizing behaviors such as alcohol consumption, irritability, and aggressive behaviors while underreporting other symptoms. These factors may mask men’s difficulties, leading to inaccurate diagnoses and inappropriate treatment.

4.7 Clinicians may suffer from their own biases with the expectation that men should fulfill particular masculine stereotypes

For example, when men do not conform to these traditional masculine stereotypes by expressing themselves emotionally or by taking responsibility for their health, they may be regarded as deviant and/or feminine. These biases influence the quality and type of care provided and leave men less likely to receive a diagnosis despite presenting with similar or identical symptoms to women [29].

5. Adverse coping strategies used by men to deal with mental health-sensitive issues

5.1 Substance abuse

Substance use and mental health issues have substantial impact on individuals, families, communities, and societies [31]. Substance abuse is often linked to a number of triggering factors and to deal with such factors, men often resort to substance use; some other scholars concurred that the common causes of substance abuse among men include the following:

1. Masculinity and self-medication

   Men are taught from early that men should take risks and do not display any signs of weakness. As a result of such gender-related expectations, men involve themselves in dangerous activities to prove their masculinity. This includes the use of drugs and substances. Furthermore, masculinity impacts the heath-seeking behavior of men for treatment of mental healthcare services as it may be regarded as a sign of being a coward and will put stain in their expectant masculinity [32, 33]. Masculine norms internalize help-seeking behavior [34]. Therefore, as a result, they self-medicate with drugs and substances. Most individuals with substance abuse exhibit signs and symptoms such as mood changes, anger, and sadness [26].

2. Pressure from life circumstances

   Stressful life events play a major role in substance abuse among men. A study conducted among American African men revealed that unintentional drug use and substance abuse inflicted mental illness. Social issues such as struggling to succeed at work and lack of support family members, and financial struggles were a trigger to substance use and abuse [35].

3. Grief and loss of a loved one

   Complicated grief is prolonged bereavement-specific disorder with substantial psychological and physical consequences. Individuals deal with complicated grief differently. More complicated grief represents a greater risk of substance misuse and abuse [36]. Substance abuse has become a coping method to avoid dealing painful experiences such as grief and significant loss among men. Loss of a loved one is tied to emotions strains and poses suicidal ideation among individuals [37].

4. Trauma and negative childhood experiences

   Substance abuse and posttraumatic stress disorders are comorbid. Due to exposure of the traumatic events, individuals self-medicate with drugs and alcohol to deal with anxiety, subsequently leading to substance abuse [38].

5.2 Domestic violence as a coping mechanism

Domestic violence has been gradually increasing worldwide; it is associated with the gender role inequalities such as abusing women as an exertion of power and assuming the traditional masculine role [39, 40]. However, despite the gender role inequalities as an expression of masculinities, domestic violence could be a result of substance abuse by perpetrators and could also be associated as a mechanism to deal with internal conflicts and mental health problems among men. The World Health Organization affirmed that as a result of societal expectations and traditional masculinities discouraging men from seeking help, instead they lash out and abuse their families as a coping mechanism to deal with the mental health problems. Although there is limited literature pertinent to domestic violence as a coping mechanism, majority of studies focus on the impact of abuse on the mental health of both men and women. Therefore, this requires further studies looking more into association of domestic abuse by men and their mental health status during the abuse toward their families.

5.3 Informal support

Dealing with mental health-sensitive issues among men is a difficult issue due to poor health-seeking behavior. Men often seek informal support from non-health professionals, and this includes family and friends; sometimes, they do not seek any support at all. They rather deal with such issues alone [40].

6. Cultural norms as a major barrier to seeking mental health services

Men are more disinclined to seek help with regard to health problems than women; this has mostly been associated with traditional ideas of masculinity [34]. Men are burdened by what is expected of them, and the masculinity roles are expected to assume in their lives. As a result, many young men are soldiering on nonetheless and swallow their own feelings, and this comes to a point the men reach a stage to take own life. While men are trying to accomplish the societal respects as a consequence of higher expectations from them, their stress levels increase and their mental health mostly remains unchecked (Figure 3) [28].

Figure 3.

Masculinity norms of what men are expected to be [41].

6.1 Theories of masculinity and its effects on men’s mental health

Masculinity includes cultural and social norms, behaviors, and practices. The concept of toxic masculinity aims at underlining how certain socially constructed definition of masculinity can be detrimental to a society, men, and women [42]. The numerous reasons behind toxic masculinity include biological and social dimensions. The social dimensions include the family and friend’s environment, educational system, workplace, and religion [43]. Examples of toxic masculinity include overtly aggression of a man to a female to show power and dominance and also never showing emotions as they are viewed as feminine trait because it shows weakness. Toxic masculinity affects and harms the one’s mental health [44]. This may be one of the reasons why men commit suicide. A study conducted on social media, behavior, toxic masculinity, and depression revealed that toxic masculinity is associated with depression [45].

7. Strategies to improve access to men-centered mental healthcare services

7.1 Teamwork

One of the key aspects of this approach is the recognition that professionals should work as a team and that high-quality healthcare involves improving relationships between staff and between patients and their families [46].

7.2 An intervention aiming to reduce self-stigma associated with mental health problems

Reducing stigma associated with healthcare, ill-health, and health-seeking behaviors by addressing internalized stigma with men. Reducing healthcare worker stigma associated with healthcare, ill-health, and health-seeking behaviors by providing sensitization training for healthcare workers [5]. A male-sensitive brochure to address help-seeking in depressed men, an intervention aiming to reduce self-stigma associated with mental health problems [29].

7.3 Key processes that improved help-seeking attitudes, intentions, or behaviors for men

The use of role models to convey information, psychoeducational material to improve mental health knowledge, assistance with recognizing and managing symptoms, active problem-solving tasks, motivating behavior change, signposting services, and finally, content that built on positive male traits were important processes that improved help-seeking attitudes, intentions, or behaviors for men.

7.4 Public awareness campaigns and interventions designed to improve men’s psychological help-seeking

These include campaign focusing on educating the public about depression in men. This awareness can be motivated through advertisements and campaigns such as the Real men Real Depression campaign with emphasis on targeting at-risk subgroups first and then the general community [28].

7.5 Psychological referral

When men seek help from mental health experts, men-centered therapy that emphasizes enhancing the client’s capacity for accepting their circumstances is of important. A concise structured therapeutic plan that is clear and straightforward will be more effective and encourage client trust in both the therapist and the course of treatment [28].

7.6 Bias reduction

Every step of the therapy process should take the client’s uniqueness and culture into account. In other words, prejudice reduction should be prioritized at all client contact levels. The client’s belief that men cannot experience mental health issues could be a barrier to treatment acceptance and compromise the therapy’s efficacy. Thus, taking into account this cultural idea will aid in neutralizing any potential therapeutic bias. According to the client’s needs, it is suggested that the therapist take into account the numerous types of biases, including therapist, cultural, and individual [28].

7.7 Demand

A range of social and behavior change communication (SBCC) interventions are needed, including mass media communication, community outreach, and peer education. Such SBCC approaches need to provide clear, factual, and unbiased information, to increase men’s knowledge and self-efficacy; promote communication among men, among peers, and within families; and encourage men to seek care and use services [5].

8. Policy considerations to men’s mental health

8.1 Platform for men’s mental health

Although there are mental health services available in South Africa, attention should be mostly directed toward creating more platforms to address sensitive issues affecting men, consequently leading to suicide. The extensive platforms should be of nonjudgmental and focused on self-determination as well as building the mental well-being of men. Studies revealed that men die of depression and substance abuse disorders; and these are mostly liked due to financial stress, pressure from society and family as well as cultural and social norms. Furthermore, to curve suicide mortalities globally, it is recommended that men’s mental health should be given more attention and more research should be done in exploring strategies and procedures to address men’s sensitive issues with the aim to reduce mortalities due to suicide among men. Therefore, health practitioners should be trained to have an effective role in asking men about their sensitive mental health issues to determine the root of the mental health problems [40]. Online support forums should be made available where men can vent their stories, experiences, and receive support [2]. In addition to addressing men’s mental health issues, peer-led men-only groups may improve the self-esteem and confidence of men in disclosing weaknesses [34].

8.2 Mental health before cultural norms

Despite our pride toward our culture and religions, some of the cultural norms put an extensive pressure in men, leading them to most likely resort into depression and substance abuse, subsequently leading to suicide attempts. Traditional masculinities and cultural expectations for men’s behaviors discourage men to recognize and seek mental healthcare services; consequently, these mental health problems remain hidden or manifest in disastrous ways such as domestic violence, substance abuse, and sometimes suicide [2]. Therefore, it is recommended that human lives should be a priority before our cultural norms. Putting the mental health needs of men before our cultural norms is most likely to save the lives of men worldwide. Moreover, healthcare professionals should be trained on the impact of masculine norms on the mental health [34].

9. Conclusion

Changes should be made on the existing social and cultural norms as they suppress the mental health being of men. To reduce the statistics of suicides mortalities due to mental distress, interventions should be implemented from early childhood stages to address gender variations. Despite the masculine advantages, men should not be raised different from women. This could reduce the implications of societal expectations and cultural norms in the mental being of men. Programs addressing the mental well-being of men should be vigorously implemented and inform men that there is no shame in seeking mental healthcare services and there is no shame in crying. This could possibly reduce completed suicides and suicide ideation among men as well as substance abuse and domestic violence.