Background
The worldwide male population comprises almost four billion people. A significant portion succumbs to chronic and preventable conditions (Medici, 2021; United Nations, 2019). In Brazil, 48.88% of the population is male, totaling approximately 104 million. However, life expectancy at birth is 73.5 years (Instituto Brasileiro de Geografia e Estatística, 2021), and access to medium/high-complexity healthcare services is challenging.
Cisgender men, those who identify with the gender assigned to them at birth, which is socially associated with their biological sex (Hining & Toneli, 2023), have specific health issues and face challenges in accessing healthcare services and managing health conditions. This is evident in the data collected by public health policymakers, as exemplified by the National Policy for Comprehensive Men’s Health Care in Brazil, launched in 2009. This policy predominantly focused on cisgender men without considering transgender men.
This issue is particularly relevant in the field of nursing due to the urgent need to address men’s health, especially regarding prevalent unhealthy lifestyles, habits, and risk factors in this population, such as smoking and alcohol consumption, leading to the development or exacerbation of Non-Communicable Chronic Diseases (NCDs). Notable challenges for this group include higher mortality rates from external causes and underutilization of primary care services, exacerbating socioeconomic disparities and marginalization, factors contributing to increased vulnerability to violence (Pan American Health Organization, 2019).
In light of this, cisgender identity needs to be better understood so that nursing professionals can recognize that individuals born with male anatomy and identifying as men may shape attributes considered essential and unique to their gender constructions towards masculinities (Schall & Moses, 2023). This includes how they perceive self-care, health, coping with illness, exposure to risk-prone behaviors, and vulnerability. Additionally, it should be emphasized that the literature has pointed to the adherence to rigid and hegemonic models of masculinity by cisgender men, who require specialized and sensitive attention in the context of nursing care in healthcare services, including emergency units and hospitals (Silva et al., 2019).
The determinants of men’s health are striking: rigid models of masculinity directly influence men’s health behaviors (Hildt Ciupinska & Pawlowska Cyprysiak, 2020), particularly when they resist self-care practices. In this context, the Social Determinants of Health (SDH) – factors intertwined with living conditions that shape how individuals are born, develop, and age – under the influence of policies, economic systems, development agendas, social norms, and policies, as well as living and working conditions – including housing, sanitation, the work environment, and health/education services (Fiocruz, 2008; World Health Organization, 2019) – can be valuable and indispensable for analyzing and intervening in men’s health.
Therefore, it is crucial to comprehend the health-disease process among the male population, considering symbolic aspects, gender relations, race/ethnicity, age/generation, social class, and other social markers that define each individual’s uniqueness (Sousa et al., 2011). Consequently, the analysis of SDH can also enhance our understanding of men’s pursuit of ambulatory, pre-hospital, and intrahospital health services, facilitate a better interpretation of morbidity and mortality data, and guide the formulation of strategic actions within the healthcare system (Alves et al., 2017), addressing gaps in scientific knowledge on this matter (Ferreira et al., 2020). This approach aligns with the principles of Dahlgren and Whitehead, who expound on SDH across different levels of impact – proximal, intermediate, and distal (Dahlgren & Whitehead, 1991), thus justifying the execution of this study. Also, the scarcity of specific scientific publications on men’s health, especially in medium and high-complexity care scenarios, considering the interface with the theoretical framework of Social
Determinants of health still represent a critical gap in scientific knowledge that needs further exploration. In this context, nursing, as a central profession in healthcare delivery, plays a crucial role in analyzing, understanding, and addressing the unique health needs faced by the male population. Hence, this study is driven by the following question: How do social determinants/conditions shape the health status of adult cisgender men seeking medium/high-complexity care? The study’s objective was to analyze the health status of adult men in medium and high complexity based on social determinants and conditions. As essential healthcare team members, nursing professionals can significantly benefit from understanding these social nuances, thereby enhancing their ability to provide specialized, culturally sensitive, and effective care.
Methods
Study Design
A qualitative descriptive study with a deductive thematic analysis (Braun & Clarke, 2006) was employed. The research was conducted in two 24-hour emergency care units, one outpatient unit (a university outpatient service), a specialized municipal healthcare service, and a specialized hospital unit in the federal network in a capital city in northeastern Brazil. This study was guided by the Consolidated Criteria for Reporting Qualitative Research (COREQ) (Tong et al., 2007).
Informants/Participants
The study included 45 adult men who self-identified as cisgender (identifying with the gender assigned to them at birth) and met the criteria for seeking and utilizing healthcare services while maintaining stable health conditions. Participants were approached in healthcare settings by a research team that had no prior relationship with the service or the participants. The researchers invited healthcare professionals to invite their users to achieve the desired number of participants.
Data Collection
The research team consisted of undergraduate, master’s, and doctoral nursing and health students supervised by PhD faculty members in the same field. This team was affiliated with a research group specializing in the field of masculinities and men’s health. They received training and possessed expertise in the research method and theme. They were also involved in teaching activities and did not have direct relationships with the participants. Participants were recruited as they sought care at the service and were interviewed in a private setting before or after their consultations.
Data were collected from July 2019 to February 2020. Individual in-depth interviews were conducted to ensure privacy and anonymity. A semi-structured instrument was used, which included closed questions about sociodemographic, work, and health characteristics and an open-ended and comprehensive question: “Tell me about your health situation?” An open-ended question allows participants to express their health experiences broadly and meaningfully without restrictions imposed by predefined response options. Furthermore, the open nature of the question promotes the collection of rich and detailed data, essential for a thorough understanding of participants’ experiences. To ensure the validity of the interview questions, a content-face validation process was carried out with ten subject matter experts, and a pre-test was conducted with five participants to assess the instrument’s applicability, effectiveness, and clarity.
Data Analysis
A deductive thematic analysis (Braun & Clarke, 2006) was employed for data analysis in this study, with a complete transcription of each interview (which lasted an average of 60 minutes), organized into separate files and processed using NVIVO12 software (owned by the research team). After forming the categories, the results were validated by a group of healthcare professionals with methodological experience and other men who did not participate in the research. This validation process enhanced the categories and the central phenomenon. Finally, data were interpreted based on the health determinants /conditions framework according to Dahlgren and Whitehead (1991), organized into distinct layers and levels of scope, divided into proximal, intermediate, and distal. At the base of the model are individuals with individual characteristics such as age, gender, and genetic factors. In subsequent layers are behavioral and lifestyle factors, social and community networks, living conditions, work, and access to health and education. Lastly, macro determinants are economic, environmental, and cultural aspects (Buss & Pellegrini Filho, 2007; Carrapato et al., 2017; Dahlgren & Whitehead, 1991).
Ethical Consideration
Ethical recommendations for conducting the study were followed in compliance with Brazilian legislation - Resolution 466/2012. The project received approval from the Research Ethics Committee (CEP) under approval number 3.313.5. Participants were assigned pseudonyms: “H” for man and a number (e.g., H01, H02, and so on). Free and Informed Consent was obtained from all study participants in writing.
Results
Participants’ Characteristics
The participants were in the age range of 30 to 39 years old. They self-identified as cisgender, heterosexual, of mixed race/ethnicity, in stable relationships, and with a completed high school education. They resided in urban areas, in peripheral neighborhoods with areas marked by armed conflicts and drug trafficking, living with spouses and children. They had access to piped water, electricity, and basic sanitation services. They used buses for transportation and found it easy to access the information they needed in their daily lives.
None of the participants had disabilities and were employed, although not formally, in positions related to commerce and services, working eight to 12 hours a day. Their daily commute to work took approximately 50 to 60 minutes, and they had no history of work-related accidents or absences. Their average monthly income was one minimum wage, and three dependents relied on this income. They did not receive government assistance and considered themselves responsible for providing for their households.
Participants described their physical, mental, and spiritual health as average, their healthcare practices as moderate, their physical vitality as good, and their self-esteem and mood as excellent. They denied having any psychological/psychiatric problems or undergoing any related treatment. They frequently consumed alcoholic beverages but denied smoking or using other drugs. They expressed faith in God but did not regularly engage in spiritual or religious activities.
They mentioned current health issues, primarily non-communicable chronic diseases diagnosed in emergency care units. They reported a family history of illness and frequent ailments, including headaches, gastric pain, musculoskeletal discomfort, and various symptoms related to changes in blood sugar, blood pressure, cardiovascular function, and urinary function. Some had been hospitalized for emergency clinical or surgical reasons. They exclusively relied on the Unified Health System (SUS) and had at least one prior medical, nursing, or dental consultation. They did not visit the Family Health Unit in their neighborhood or mention receiving visits from the Community Health Worker (CHW).
Participants denied a history of communicable diseases, long-term health treatments, or possessing a vaccination card. Their vaccination status was irregular. They underwent diagnostic tests annually and used continuous medications for blood pressure control and herbal supplements like teas and multivitamins. They did not engage in integrative and complementary health practices or attend public spaces for health-related activities.
They considered their diet average, consuming meals at popular eateries at least three times a day and including a regular intake of processed foods. They did not follow dietary restrictions and perceived themselves as overweight. They drank more than seven cups of water daily and rated their body image and appearance as average. They reported engaging in regular physical activity, such as walking and weightlifting, three to four times a week and maintained personal hygiene and grooming practices. They rated their sexual and reproductive health as excellent, had an active sex life, and considered their libido, desire, and sexual repertoire as excellent. They denied urological problems related to the penis, urinary tract, testicles, prostate, ejaculation, or infertility. None of them had ever consulted with a urologist. Those with children mentioned not accompanying their partners during prenatal care, childbirth, or postpartum care but enjoyed paternity leave.
They assessed their emotional relationship with family, romantic partners, and friends as good and their relationship with coworkers as average. They described their social interactions as good. However, they did not participate in community groups, social/volunteer activities, artistic endeavors, or therapeutic health groups. They denied experiences such as traffic accidents, homelessness, imprisonment, prostitution, or being victims/perpetrators of violence. They stated they had never participated in men’s health initiatives and were unfamiliar with the National Policy for Comprehensive Men’s Healthcare (PNAISH).
Thematic Findings
The data revealed the influence of social determinants/conditions on men’s health in medium/high-complexity healthcare settings. These determinants/conditions were categorized according to different layers and levels of scope, from the closest layer of individual determinants to the distal level, where macro-determinants are situated. Social determinants/conditions were categorized as follows: 1) Proximal: biological factors, preventive behavior, lifestyle/social life, and aging processes. 2) Intermediate: work conditions, access/use of healthcare services/medications, psychosocial factors. 3) The macro-determinants identified were income distribution, power and resources, health inequalities and inequities, morbidity, cultural factors, political decisions, and environmental and structural factors. Thus, empirical findings were organized into thematic categories and subcategories.
Category 1: Proximal Social Determinants/Conditions in Health
Subcategory 1.1: Biological Factors
The biological determinants originated from men’s experiences, revealing the presence of pre-existing health issues that had consequences in their adult lives, subsequently impacting their health status. Therefore, adverse health outcomes were associated with biological factors perceived as hereditary or congenital, often influenced by social markers such as race/ethnicity. These factors have interfered with the functionality of organs and systems, induced physical changes, resulted in disabilities, and increased dependence and impairment in socio-emotional interactions. Consequently, men sought more complex therapeutic interventions that necessitated hospitalization.
Medium complexity:
“[…] I already have a family history of illnesses; many relatives have diabetes and face various health problems caused by the disease. It involves a frequent routine that has been accumulating for many years, visiting hospitals and other healthcare facilities and having to spend money on medications, health insurance, and medical treatments. I wouldn’t want it to be the same for me, as similar health problems have already started to emerge.” (H02)
“[…] my family has a history of severe illnesses with a poor prognosis, progressing to advanced terminal stages.” (H10)
“[…] the issue of race is significant in my health situation, as the Black population, including my family, is significantly affected by sickle cell diseases, diabetes, hypertension, and heart diseases.” (H25)
High complexity:
“[…] I’ve had a lifelong history of living with a postural alteration since childhood due to having a supinated foot. I was born this way, and it continued through puberty, adolescence, and adulthood, compromising my health and requiring constant medical attention, as well as guidance on how to maintain good health.” […]. “I experienced health issues during adolescence that were related to my prematurity. The development of physical changes, such as heart dysfunction, has led to frequent hospitalizations and specialized medical treatment, as well as restrictions on daily activities, a lack of leisure, and the need for adaptations to live well and maintain good health.” (H28)
Subcategory 1.2: Preventive Behavior
As an existing social determinant/condition in men’s health related to medium and high-complexity health situations, preventive behavior emerged from the data, indicating male vulnerabilities, with a focus on cardiovascular and metabolic diseases, sexually transmitted infections, and violence.
Medium complexity:
“[…] I live with the fear of having a heart attack because my father had heart disease and died from it. It was frightening. As a result, I have taken control of my health, avoiding fatty foods and excessive salt. Because I had similar symptoms, I sought care at the Emergency Care Unit (UPA).” (H19)
“[…] as a heterosexual man with a single partner, I don’t have many concerns about sexual diseases. […] I undergo prostate exams to prevent cancer, which poses a high risk to men as it is a silent disease that progresses rapidly.” (H08)
High complexity:
“[…] I have been paying more attention to my body undergoing preventive monitoring with a cardiologist. I also have regular eye checks because my mother has glaucoma and heart disease. My mother’s illness has led me to establish a routine for taking care of my vision, making me more observant of my eyes and heart.” (H09)
“[…] I have rigorous follow-ups with an endocrinologist due to diabetes decompensation.” (H37)
“[…] I had health complications due to uncontrollable illnesses that were not preventable by me […] due to the lack of routine preventive care, I ended up in emergency situations.” (H12)
“[…] I developed a mitral valve disorder, which required hospitalization. After accessing healthcare professionals, I am trying to engage in physical activity and resume daily activities.” (H39)
Subcategory 1.3: Lifestyle Habits
The lifestyle habits that conditioned/determined men’s health situations revealed efforts to improve behavioral patterns related to diet, hygiene, and sleep control, engaging in physical activities, and managing continuous medication use.
Medium complexity:
“[…] I struggle to follow dietary plans. I try to avoid consuming foods composed of processed carbohydrates, processed foods, and fried foods, but the lack of time prevents me from eating better.” (H03)
“[…] I have been trying to consume natural foods and prepare more alternative meals, avoiding the need to eat fast food outside, and I pay attention to controlling the consumption of red and fatty meat.” (H04)
“[…] I have been favoring the consumption of lean white meats, such as fish, and reducing daily meat intake, substituting it with other foods.” (H05)
High complexity:
Improvement of dietary, hygiene, and sleep patterns:
“[…] I have been adopting a healthy lifestyle to prevent health problems, researching self-care, what I can and cannot do, what will benefit or harm me, and what will be advantageous or not to undertake. I try to sleep more to avoid insomnia and manage oral hygiene.” (H31)
Medium complexity:
“[…] I have been encouraging my wife to go for walks together and practice weightlifting or Pilates to stay active and maintain a physical activity routine.” (H06)
“[…] I have been investing in understanding the medications I take for controlling Type 2 diabetes and blood pressure, and this has helped me improve my health, with positive outcomes in weight reduction.” (H32)
Subcategory 1.4: Aging Processes
Due to aging processes, situations such as the pursuit of quality of life, changes in life processes, observation, and control of health status have become more common among the male population. Furthermore, experiencing the impacts on life and health caused by aging has contributed to health promotion and disease prevention, motivating men to pay more attention to self-care:
Medium complexity:
“[…] I made a choice to age with a good quality of life so that it could change the course of my life and have a positive impact on my health.” (H20)
“[…] I have been trying to address health problems, observing myself better, and preventing issues that accumulate over time as a way to improve health and allow me to live longer.” (H39)
High complexity:
“In order to avoid being bedridden as I get older, I have tried to prevent infection, and I believe that’s the right thing to do because nobody likes to get sick.” (H22)
“As the years went by, I felt the difference in my health quality, which deteriorated due to weight gain, smoking, alcohol consumption, insomnia, lack of physical activity, physical and mental fatigue, bone and vision problems. However, I have been trying to reverse this situation, paying more attention to health, being discharged from the hospital, and curing my health problems.” (H43)
Category 2: Intermediate Social Determinants/Conditions of Health
Subcategory 2.1: Working Conditions
The social determinants/conditions related to work in the health of these men revolved around experiencing poor working conditions characterized by heavy workloads and high intensity, leading to physical and mental health issues, resulting in illness, surgeries, and the need for rehabilitation:
Medium complexity:
“[…] Work has subjected me to a lot of pressure. The company I work for imposes many demands and requirements, which distresses me and prevents me from taking better care of my health, resulting in illness. Hence, the need to come to the emergency room.” (H38)
“[…] My job is very physically demanding, and I frequently experience muscle and back pain, which has led me to the Emergency Care Unit (UPA) many times.” (H41)
High complexity:
“[…] My working conditions are really bad. I spend many hours working throughout the day and night. The workload is enormous, which worries me due to the impact on my health, which is often affected by sleep disturbances. This has made me ill and required constant physiotherapy sessions.” (H30)
Subcategory 2.2: Access and Use of Healthcare Services and Medications
Access to and use of healthcare services and medications emerged as a consequence of illness, especially those related to chronic diseases. The data also point to difficulties in accessing continuous medication, with access to services driven by the need to prevent and control diseases and health issues:
Medium complexity:
“[…] My routine visits to healthcare services have focused on medical consultations with the general practitioner, cardiologist, and urologist, related to the need to prevent the onset of diseases.” (H11)
“[…] I sought healthcare due to persistent pain that could only be alleviated through analysis by a healthcare professional. However, access to a doctor is very difficult and further worsens my health since I remain without proper treatment when I need it the most.” (H26)
High complexity:“[…] Despite many countries dealing with an epidemic of diseases like hepatitis B, which is transmissible, I face many problems accessing medications. Consequently, my health deteriorated, and I had to be hospitalized.” (H23)
Subcategory 2.3: Psychosocial Factors
Psychosocial factors emerged as significant in the male experience, involving a set of socioeconomic, political, and social contingencies that promote suffering in men, leading to illness. This suffering is marked by constant social tensions that manifest as somatic symptoms. These factors were also related to the functioning of healthcare services, with care delivery by healthcare teams perceived as lacking in humanity:
Medium complexity:
“[…] There’s a lot of accumulated stress due to work demands, pressures, financial difficulties, and all of this makes me anxious, with a racing heart, necessitating a visit to the emergency room.” (H16)
High complexity:
“[…] My health has been affected by the ‘hysteria’ that society is experiencing in the pursuit of perfect health, a perfect body, and perfect social conditions. This has led to widespread anxiety among people.” (H10)
“I have been trying to take care of my emotional and psychological well-being, but it’s been difficult because I live in a space that doesn’t provide me with less stressful leisure and recreation moments. Moreover, there’s no time to travel and avoid disruptions to mental health.” (H21)
“[…] I have depression, which is a result of the social phobia I developed. Society imposes difficulties for men seeking psychological support, and all of this prevented me from seeking help for a long time to address the issue.” (H24)
“Additionally, I have been trying to practice harm reduction concerning drug use. I often discuss my drug use during consultations with the nursing team, doctors, and dentists, as I know they can have effects on HIV treatment, like cocaine, which I have stopped using because it’s incompatible with antiretroviral medication.” (H29)
Category 3: Macro-Social Determinants/Conditions of Health
Subcategory 3.1: Income Distribution, Power, Resources, Health Inequalities, and Inequities
Another determinant that became evident was the distribution of income, power, and access to resources in the daily lives of men. Issues such as difficulties in accessing health communication resources for the adoption of self-care practices, economic and financial problems affecting the maintenance of health treatments and therapies, the challenges of coping with diseases and health conditions, and socioeconomic inequalities were raised. These socioeconomic inequalities led to unemployment, hunger, financial deprivation, difficulties accessing healthcare services, and adhering to care practices.
Medium complexity:
“[…] When I have a health problem like an illness, I try to educate myself and learn about it. I search for information and access content about self-care on the internet, for example: what I can and cannot do, what will benefit me, and what will harm me.” (H14)
“I have tried to internalize the need to get a check-up every year to detect any health issues since I have a family risk factor. However, I don’t have health insurance, and I have faced a lot of difficulty in getting an appointment for preventive care.” (H15)
High complexity:
“[…] I face many financial difficulties, including maintaining the treatment for my health problem and providing for my family, as I am hospitalized and unemployed. If I can’t work, my entire family suffers. It’s very hard, and it makes me sad and worried.” (H44)
Subcategory 3.2: Morbidity
The data pointed to morbidity as a determinant, considering the emergence of diseases and health conditions that required men to visit healthcare services regularly.
Medium complexity:
“[…] I have high levels of anxiety, and this issue has caused me discomfort and illness. Because of this, I have tried to reduce stress and impulsiveness, eliminate excess tasks, and engage in activities like reading and meditation.” (H07)
“I am HIV-positive, and when I need to visit an emergency unit, I inform them of my diagnosis because I notice that I am attended to more quickly by healthcare professionals, such as nurses.” (H17)
High complexity:
“[…] I have experienced situations of hospitalization, medical evaluations, and diagnostic tests due to significant weight gain that escalated to obesity and brought about blood, gastric, renal, and cholesterol level issues.” (H01)
“The reason for my hospitalization is problems with uncontrolled hypertension and diabetes that led to complications. I have to follow strict control to keep my hemoglobin A1c levels stable. Because of this, I have to check my blood pressure and glucose levels daily.” (H33)
Subcategory 3.3: Cultural Factors
Regarding cultural factors, significant contexts of a lack of caregiving references during childhood growth and development emerged. There was also paternal invisibility in promoting and teaching healthcare. Furthermore, models of masculinity and femininity related to behaviors, attitudes, and caregiving practices were replicated. These factors highlighted a disparity in how women and men approach self-care. Consequently, there were deficiencies in adopting a healthcare culture from other family members and their social networks, resulting in the replication of behaviors that were less engaged and responsible for health:
Medium complexity:
“[…] I didn’t receive any encouragement or access to healthcare information from my mother or father. I lacked paternal role models for caregiving. What I experienced until adulthood was a pattern of falling ill, with illnesses only being discovered when they were already in advanced stages. As a result, I developed a similar mindset about my health.” (H10)
“Women are encouraged to undergo preventive exams, such as cervical exams, but men don’t receive the same encouragement. I spent my childhood and adolescence without understanding the importance of healthcare, and I only became aware of it as an adult, after turning 40, when I had my first medical appointment, not even knowing which specialist to see.” (H11)
High complexity:
“[…] I never had a clear notion of health, which stemmed from our family culture. I was never committed to treatments or obedient to what needed to be done, often only paying attention to the first sign of discomfort in my body.” (H12)
Subcategory 3.4: Political Decisions
Political decisions in the country and territory where men live have significantly impacted men’s health. The fragility or absence of public policies has negatively affected maintaining health. This is evident in the lack of knowledge about the implementation of the National Policy for Comprehensive Men’s Health Care. Similar situations were observed regarding political decisions that influence men’s healthcare practices within institutional healthcare spaces. These decisions are often viewed as controlling, dictating rules, and pathologizing:
Medium complexity:
“[…] not everything that happens or manifests in my body should be pathologized. Sometimes, it’s about the energy being off, me not being in a good place, and I need to calm down. However, this is not always understood because there’s a hypochondriacal social belief that dictates that everything must be medicalized, and if something hurts, you need to see a doctor.” (H13)
“We don’t have active public healthcare policies for men. The men’s health policy is unknown, and there are no concrete actions which directly and indirectly affect my health.” (H36)
High complexity:
“[…] it has been very difficult to maintain good health because rules are being imposed, suggesting that you can’t eat anything anymore, as everything is bad for your health: eggs, red meat, lettuce. How am I supposed to survive like this?” (H14)
“Due to my chronic illness and having gone through many healthcare services, I can see how challenging it is to access healthcare rights in this country. The government officials who should advocate for those in need are the ones denying these rights, causing medication shortages and making it difficult to access benefits. All of these factors interfere with my health because I know that when I leave the hospital, I’ll have to face many difficulties in caring for my health.” (H45)
Subcategory 3.5: Environmental and Structural Factors
Environmental and structural factors were present in the healthcare experiences of men who required medium and high-complexity care. These factors converged across different levels, indicating the occurrence of social determinants/conditions of health. These men reported difficulties in accessing healthcare services, encountering attitudinal barriers from healthcare professionals, and facing infrastructure problems. These issues reduced and limited service delivery capacity within the network where these men sought care. Additionally, they experienced discomfort during their stay in spaces such as hospitals:
Medium complexity:
“[…] I don’t perceive interconnectedness between the various sectors of healthcare services. Professionals don’t communicate, and this has a negative impact on my health situation. Assistance becomes deficient and doesn’t fully meet my needs.” (H30)
“Everything affects my health because reaching the service involves many difficulties, from leaving home to travel to the UPA, which is far from my neighborhood, enduring crowded and noisy public transportation of poor quality, to dealing with an outdoor queue and slow service. All of this made me more stressed, anxious, and worried, exacerbating my symptoms, such as pain.” (H40)
High complexity:
“[…] the healthcare service provided by my health plan is deficient. Professionals show no interest or attention. The service is very fast, in a ‘fast-food’ style. They don’t look at my face, and conversation is almost nonexistent. How can they understand my health situation?” (H34)
“The hospital environment seems to focus only on illness, not health. Professionals end up addressing the disease rather than my health. Most of the time, they lack humanity, creating an unpleasant environment that constantly reminds me of illness and death.” (H34)
Discussion
Based on the structuring of categories and subcategories that composed the phenomenon of men’s health situations in medium and high complexity, influenced by health determinants/conditions, the explanatory model of how social conditioning and the determination of the health of these men behaved. In a broader sense, cisgender men experienced impacts on their lifestyle and health habits, making them less healthy. These impacts were influenced by various factors related to their work environment, income, purchasing power, assets, and resources, with influences tied to aging. Additionally, they were affected by contexts that contributed to various inequalities, making them persistent, thus resulting in the presence of social health inequities.
The social determinants of health model observed among cisgender men revealed the early onset of chronic diseases, with a historical pattern of diseases in the family, including disabilities, intertwined with psychosocial vulnerabilities that led to mental health issues. These mental health challenges were consistently exacerbated by socioeconomic precariousness, affected employability, poor working conditions, and work overload.
Significant difficulties in accessing healthcare services, barriers to treatment adherence, and challenges in interacting and connecting with healthcare professionals were identified. These difficulties were influenced by weaknesses in public policies and poor governmental management. Consequently, cisgender men had their health care compromised due to an unfavorable sociocultural environment for adopting healthy lifestyle habits. For example, the absence of paternal role models in promoting self-care and recognizing health needs led to difficulties in changing determinants and social conditioning factors affecting their health.
In this way, the underlying premise of our investigation has proven to be true. The alignment between the identified factors and the Social Determinants of Health (SDH) becomes evident as we delve into the narratives extracted from individual in-depth interviews, capturing a holistic spectrum of factors. These include economic stability, educational context, social and community context, access to healthcare services, and the intricate interplay of living conditions.
Our analysis revealed significant similarities between the identified determinants and the traditional categories of SDH. For instance, the narratives emphasize the profound impact of economic stability on health outcomes, echoing the broader domain of SDH. Similarly, social and community contexts emerge as influential factors in the identified determinants and the SDH framework. This study contributes to expanding existing knowledge about men’s health by uncovering these convergences and divergences. It provides a differentiated understanding of how these determinants manifest within the complex Brazilian healthcare system.
Our study demonstrated how the action of health determinants/conditioners influences men’s health through medium and high-complexity care services, intertwined with biological factors, preventive behavior, lifestyle and social life, aging processes, work conditions, access and use of health services and medications; psychosocial; income distribution, power, and resources; health inequalities and iniquities; morbidity; cultural; political decisions; and environmental and structural factors.
In line with the literature, a large number of health determinants/conditioners categories emerged from the study that are inseparable from the health-disease process in the male population in medium and high complexity care, and they require apprehension from the perspective of gender, generation, and genetic aspects (Carrapato et al., 2017). Regarding the gender category, our findings are useful in highlighting cisgender identity as a component of the human experience and individual identity. However, it is essential to understand this concept in a broader sense, identifying problematic factors that may accompany the social construction of cisgender masculinity. For example, this can include excessive power, a sense of subordination, normative regulations that naturalize certain behaviors, and misconceptions and stereotypical views of what it means to “be a man.” These factors can have a negative impact on the health condition, situation, and quality of life of the male population.
Analyzing the health situation of men implies considering the cultural and behavioral factors that directly impact the male population’s use of health services (Das et al., 2018). Thus, a study conducted in a slum in Calcutta, India, revealed that men primarily seek health services based on models with greater technological support, quick resolution, and ease of access. This behavior is strongly influenced by gender issues and reflects the preference for health services offering greater complexity, technological resources, and better resolution, such as emergency and outpatient services, at the expense of preventive actions (Reis de Sousa et al., 2019).
In this sense, a previous study (Arruda & Marcon, 2016) observed that the health situation of the male population in medium complexity care is often guided by signs and symptoms that indicate a more serious condition. This is often caused by delays in seeking preventive services and a tolerance for the appearance of early premonitory symptoms of health risks. Furthermore, men’s use of health services is mostly motivated by ongoing illness and emergencies with aggravated symptoms, resulting in a health situation that requires specialized attention, hospitalization, and consequent curative care (Leone et al., 2017).
Therefore, it is necessary to analyze disparities in male health, evidenced by prevalence, mortality, a high number of diseases, and other adverse health consequences in this segment of the population. This is also the case for American men when stratified by race, ethnicity, and socioeconomic status, who are also influenced by social determinants of health, such as poverty and unemployment (Silva et al., 2014). Additionally, a study in Poland (Hildt Ciupinska & Pawlowska Cyprysiak, 2020) on men’s health behavior revealed that positive factors were associated with good economic conditions, high self-assessment of health care, positive concepts about life, as well as a strong association with work. In this regard, men’s concern for work is prominent in the construct of masculinity, especially in low-income groups, confirming the socially assigned role of men as family breadwinners. This factor can be exacerbated when a man is unemployed (Ribeiro et al., 2015).
However, the poor health behavior among the male population, exacerbated by the perception of invincibility, is a determining factor in health. This is attributed to lifestyle and cultural habits that often predict comorbidities. For example, a study conducted in Canada (Punjani et al., 2018) on detrimental health behaviors among men revealed an excessive use of tobacco and alcohol, inadequate sleep patterns, insufficient physical activity, and unhealthy dietary choices. These factors were associated with a heightened risk of heart disease, high blood pressure, and type 2 diabetes.
Despite the health determinants/conditioners that influence men’s health status, promoting the utilization of medium and high-complexity healthcare services, it is crucial to underscore the significance of healthcare professionals catering to the male population. Comprehending these factors enables the development of appropriate intervention strategies across various levels of care to reshape the health landscape for this demographic.
Social determinants/conditioners, such as lifestyle, have the potential for transformation through information-driven actions. Consequently, nursing and healthcare professionals play pivotal roles in delivering care to the male population and comprehending masculinity as a determining factor in men’s health. Nursing is integrated into all tiers of healthcare, with a focus on both preventive measures and health promotion, as well as the provision of more intricate care. Moreover, it assumes strategic management roles in diverse healthcare settings. Additionally, cultural and behavioral determinants/conditioners, such as lifestyle choices, social interactions, working conditions, and access to and utilization of healthcare services, deserve attention due to their distinct relevance in men’s health. These issues require political interventions to ensure men’s access to healthcare (Gomes et al., 2020). Based on these findings, we emphasize the need to affirm gender identity, whether for cisgender men, transgender individuals, or non-binary people.
Implications for Nursing Practice
The knowledge gained from this study on the determinants of men’s health and their impact on access to and outcomes of healthcare carries significant implications for nursing practice. Nursing professionals should conduct comprehensive assessments that go beyond visible physical health indicators. It is important to consider broader social, cultural, and behavioral determinants influencing men’s health, such as healthcare needs, lifestyle choices, social support, and economic status.
Furthermore, the development of gender-sensitive care is necessary, which involves recognizing and addressing the unique healthcare needs of men. Understanding how norms and expectations related to masculinity can directly or indirectly affect men’s healthcare-seeking behaviors is crucial in this process, as well as adapting care to meet their needs and demands. Nurses should actively engage with men in discussions about tobacco and alcohol consumption, physical activity, sleep patterns, and dietary choices, providing guidance for positive changes and promoting health.
In this way, this study provides valuable insights to nursing professionals who, in general, play a fundamental role in addressing the complex interplay of determinants that influence men’s health. By recognizing and addressing these determinants in their practice, nurses can help reduce health disparities, promote healthier lifestyles, and improve the overall well-being of male patients.
Limitations
The study’s limitation lies in the reliance on a singular model of social determination and the decision to approach men based on medium and high-complexity services. It is worth noting that within the territories where they reside, labor, and exist, other facets of social determination may arise, which are not included in this study.
Conclusion
Various determining factors influenced the male health situation within medium and high-complexity care. These include structural aspects related to healthcare services, cultural elements reinforcing the social reproduction of hegemonic gender norms and expressions of masculinity, lifestyle, social support, income, and the assurance of public policies that fully realize the right to health. Nevertheless, acknowledging the social determination of the health-disease process among men exposes numerous social health inequities that contribute to and exacerbate unfavorable outcomes for men. They grapple with societal expectations and have less engaged self-care behaviors. Therefore, it becomes imperative to comprehend these determinants in the health situation analysis process, particularly in planning healthcare actions and services. This ensures that interventions are aligned with genuine needs while promoting autonomy engagement and encouraging the participation of these individuals. Thus, promoting and constructing knowledge and practices capable of effectively transforming the social determination framework of male illness are paramount.