Participants
Twenty-four male students attended the focus groups (Fig. 1) and were compensated for their time with a £20 Amazon voucher. Participants’ demographic information is outlined in Table 1. The mean duration of the three focus groups was 72.47 min.
Table 1 Participants’ demographic information Five distinct themes were identified. These were: 1) protecting male vulnerability, 2) providing a masculine narrative of help-seeking, 3) differences over intervention format, 4) difficulty knowing when and how to seek help and 5) strategies to sensitively engage male students. These results and their underlying sub-themes are summarised in Fig. 2.
Theme 1: protecting male vulnerability
A prominent theme was that speaking about mental health was very difficult. The majority of participants were reluctant to confide in others and talk about their difficulties due to fears associated with opening up.
“why would you want to open a can of worms? there is no point to that… not immediately anyway” – Participant 5, Group 3.
“most people just don’t know, most people just, they’re so afraid of what they don’t know they just like don’t want to know [talking about mental health]” – Participant 5, Group 1.
To combat this, participants described environments that were safe and less threatening. They preferred settings that were more sensitive to male needs, enabling better management of the fear and vulnerability associated with opening up/seeking help. Many of the participants stressed the need for a safe space, trust and confidentiality.
“they have to trust you because men aren’t like women, we don’t open up very easily we don’t” – Participant 5, Group 1.
“people need more information about confidentiality because a lot of people are afraid that if they say anything about their mental health problems, other people will find out and they may have problems with that” – Participant 9, Group 2.
Others emphasised that talking about mental health with professionals can be a deterrent. Many had a preference for speaking to someone they knew such as a close friend or someone they have been briefly introduced to. Indeed, according to participants, this may help facilitate a trusting environment.
“for me, it would be better if I will be surrounded by people who at least I know for like 10-15 minutes rather than a complete stranger – [if you say] ‘let’s talk about depression, or let’s talk about anxiety’. [I’ll say] not really, I don’t want to talk about it, I don’t know you guys why should I open up” – Participant 1, Group 1.
Similarly, the importance of social support for psychological well-being and how this can encourage help-seeking was stressed.
“maybe like a time like hanging out with a friend, socialise, but at the same time like seeking help” – Participant 1, Group 1.
“I think in my case a big help of this phase is actually people around me. So, like when I first experienced the issue, I didn’t seek help personally, it was the people around me” – Participant 1, Group 3.
Furthermore, participants stated that a male-only space would also assist with protecting the vulnerability they experience when trying to seek help for mental health. Moreover, this could assist with validating difficulties male students may experience.
“there’s so much available for literally everything else. Men are like, they’re pushed to one side, you don’t need the help as much as women, young children, older people, disabled people, but men, we have nothing for ourselves” – Participant 5, Group 1.
“I think emphasising men’s mental health is insanely important” – Participant 1 Group 3.
“I think if there were women here, I think it would detract from people like actually being open” – Participant 4, Group 3.
These discourses emphasise the importance of providing a male only space or setting in which male students feel comfortable to disclose mental health concerns, whilst also providing an environment to facilitate further discussion around help-seeking. This may be enhanced by the assurance of trusting and confidential settings and facilitating social support with other male students.
Theme 2: provide a masculine narrative of help-seeking
Traditional masculine stereotypes of being strong, responsible, invulnerable and self-sufficient were identified as key barriers to seeking help. Male students preferred to do things by themselves as seeking help contradicted masculine ideals.
“responsibility that surrounds the male character is playing a huge role in this as well because if you are male and you have a lot of responsibility and then you know that, ‘okay I have a problem, now I have to seek help’, then you have to rely on someone else, then my responsibility is sort of, it could be that, I can’t do it anymore” – Participant 10, Group 1.
“you might also feel anxious about talking to people and then showing vulnerability, which is also a big part why guys just don’t talk about their emotions generally. They don’t want to show vulnerability” – Participant 2, Group 3.
These points emphasise that seeking help reduces one’s ability to fulfil masculine ideals, particularly of responsibility and invulnerability. Furthermore, because men are often regarded as privileged in society they are not supposed to be disadvantaged. This in turn, makes it more difficult to open up about not feeling well or experiencing adversity.
“the term patriarchy because it just infers that, that it’s impossible, or at least very difficult for men to have it bad, or to be disadvantaged in some way” – Participant 4, Group 3.
Furthermore, the participants suggested that help-seeking appeared to be evaluated as an overall net loss. In this instance, seeking help would result in a loss to one’s masculine identity without necessarily any immediate benefit.
“men especially, it’s [i.e. mental health] is always going to rank in the lower things you know, you’re never going to go, even like with regular health. I’m like ‘oh I think it’s broken but I’m not going to seek help immediately’” – Participant 5, Group 3.
“you have to make like a big commitment [to therapy], and this commitment is like a short-term loss, it’s a short-term loss” – Participant 1, Group 3.
Concerns about responsibility, vulnerability and patriarchy infers that male students may benefit from a narrative that highlights how help-seeking can be masculine, will not be detrimental to their masculinity and engaging would be an overall net-gain. This was evidenced by some participants stating that help-seeking does not have to be weak and can be a sign of strength whilst working towards better health and personal growth.
“if you tend to run away from your problems then you’re weak in this sense, not in the eyes of others, but towards yourself” – Participant 5, Group 2.
“people who attend then feel empowered because they’re doing something strong not weak. I’m here looking after myself and that’s empowering. It makes people who attend feel good and so I think that’s a really really good idea” – Participant 7, Group 2.
One way to encourage help-seeking was to normalise the behaviour by emphasising that it was common. In addition, utilising male role models to talk about their own mental health experiences and help-seeking stories would inspire hope and reduce the perceived negatives associated with help-seeking.
“I think just give them some materials or some something to the public that gives the feeling that seeking mental health [help] is not very special or a serious thing, just a normal thing, that it’s fine. So, when you just get a mental health problem you will feel easy to seek help” – Participant 3, Group 3.
“if they see another gentleman, high profession, high functioning individual, and they’re talking about XYZ, they might think ‘you know what, he’s done it, why not myself?’. If you could do a personal narrative that’ll be amazing” – Participant 5, Group 1.
Overall, this theme highlights that help-seeking was perceived as a net loss to one’s masculine identity and male-students could feel disqualified from seeking support due to male-privilege. Indeed, framing help-seeking to fit masculine norms, as a normal act of self-care was suggested to improve male-students engagement with mental health interventions.
Theme 3: differences over intervention format
Theme 3 highlighted a lack of consensus regarding the format of appropriate interventions for male students. These views were polarised, with participants disagreeing over the formality and duration of the intervention. Much of the discourse emphasised the need for a fun and informal structure to help promote engagement.
“approach this from a different angle because we always do workshops, we always do lectures, we always do something which is like really formal rather than informal” – Participant 1, Group 1.
“something that’s fun, even if you are okay, something that you just come to anyway because it’s enjoyable, I definitely think that will be better” – Participant 7, Group 2.
Equally, many participants felt the opposite and stated that they would prefer a formal and serious structure. This disagreement was centred around these participants perceiving mental health as serious and they were concerned that an informal group would not be structured enough to facilitate openness.
“some people may be more open to sharing things if it’s in a more private setting. It may not be best to do it with a group of friends or anything like that” – Participant 4, Group 1.
“you don’t want to alienate people by making it seem so light-hearted, because it’s not. Because other issues are absolutely serious” – Participant 5, Group 1.
The second disagreement was in response to the duration of the intervention. There was a preference, among half the participants, for something brief that lasted 1–2 h and was spread across one or two sessions.
“an hour is fine, no-one has more than that to give away really” – Participant 6, Group 1.
“I can maybe come once but not more often, so there should be a tactic to reach people in one workshop” – Participant 2, Group 3.
Conversely, others felt that multiple sessions that were repeated more frequently were a better format. This was due to a perception of mental health as a more enduring problem, thus requiring repetition of information and longer-term support to encourage help-seeking.
“I know, even getting information, even getting information one session is not enough, you need repetition to get mental health across” – Participant 1, Group 3.
“I think one off things don’t actually work that much” - Participant 5, Group 2.
Theme three captures the lack of consensus over the formality and duration of an intervention. This presents some difficulties when designing future mental health initiatives, but none-the-less demonstrates that these are salient factors, which may contribute to engaging male students with mental health support and other well-being practices.
Theme 4: difficulty knowing when and how to seek help
Theme 4 provides an overview of how male students conceptualised mental health and determined appropriate action. Many students acknowledged their limited understanding of common mental health conditions, such as anxiety and depression, and how they present in men. Participants felt common mental health conditions and how they present should be addressed more openly to facilitate greater help-seeking. This should be explained in lay terms, as opposed to using medical terms, such as those from Diagnostic and Statistics Manual of Mental Disorders [42] and the International Classification of Diseases [43].
“ask someone what depression means to you, and he’ll be like ‘err just someone who’s really sad’. Which is not necessarily clear, what we mean by it is that there’s biological changes, so they don’t understand it’s a lack of understanding and awareness”- Participant 5, Group 1.
“I think not necessarily describing it as a kind of symptomatic profile, it’s often the DSM approach. So, maybe having something a bit more holistic and a bit more solvent” – Participant 3, Group 2.
Alongside difficulties with understanding mental health symptoms, two other notable areas were mentioned. Firstly, teaching students how to identify symptoms that are severe enough to warrant professional psychological support was highlighted. Many of the participants articulated difficulty in assessing their perceived need for mental health support.
“the difficult part was thinking, convincing myself I need help. And that was it, it’s just getting over that first barrier and thankfully I did get over it. But the issue is that for me personally, that’s the biggest barrier for myself - realising I need help” – Participant 5, Group 1.
“we’re all at university, there’s a lot of other pressures going on, there’s a certain amount, everyone just expects you to be stressed, and there’s just certain expectations that you should be feeling that way. So, it’s difficult to then think to yourself okay, there’s a certain amount of this I should be feeling, but I’m now feeling too much” – Participant 6, Group 1.
Other suggestions included: mental health interventions should explain when symptom awareness translates into seeking help, provide a checklist so students can cross-reference their symptoms, or include group discussions around mental health to facilitate self-reflection and greater awareness of symptoms.
“I’d have very generic statements, ‘I am not enjoying what I used to enjoy’, ‘I feel like I’m tired all the time’, blaa blaa blaa. If you’re to say these out loud to certain individuals and ‘how many of these can you relate to?’, at this point it might trigger something to check themselves by” – Participant 5, Group 1.
“anyone who talks about their [mental health] issues and so forth publicly, the people in the audience will start to relate and then that will start triggering stuff and people will start talking about it, guaranteed every time” – Participant 5, Group 1.
Secondly, participants suggested information about psychological treatment, namely the process, duration and general service structure would be helpful. Many participants acknowledged that they were unsure about which services were available, how to engage with them, and what kind of support they would receive if they did.
“I think it’s a big thing about knowledge you need to know where to actually go, for instance I would normally, if I were to have mental health problems, I would normally think about the Student Union, just go maybe look at the Student Union but at the moment I have no idea where to look” – Participant 2, Group 3.
“we don’t actually talk about the process itself [i.e. therapy], how long does it take, what it looks like, when we should expect the first effect, why it’s not straight away, people don’t know this” – Participant 1, Group 1.
The final point emerging from this theme highlighted logistical and structural barriers to seeking help. This included long waiting lists, lack of available support and slow administration surrounding university and professional mental health services.
“when they’ve [i.e. a friend] looked for help the NHS has something like a 6-month waiting list, 6 months to see help. It’s a joke, it’s a joke” – Participant 5, Group 1.
“because of this high turnaround time I reckon that a lot of people might have the same feelings during exam time, during essay time, so a lot of people might want to talk to people and then it’s just going to get so convoluted everybody wants to talk and then I reckon services in this case might not be able to help people out” – Participant 2, Group 3.
This theme summarises the help-seeking barriers identified by participants: difficulty identifying/understanding mental health symptoms, problems identifying whether support is actually needed, lack of clarity surrounding available services, how to engage with services, what support they would receive, long waiting lists and other structural barriers to treatment.
Theme 5: strategies to sensitively engage male students
The most widely recommended method suggested during the focus groups to promote mental health in male students was paradoxically not to place emphasis on mental health or well-being. Indeed, this may overlap with a more informal approach advocated by some participants. Here, ‘mental health support’ was not perceived as beneficial and would result in a greater loss of time and resources if one were to attend. Having a title that does not reference mental health avoids this problem and was seen as less alienating, allowing for wider outreach to those who may not identify as having a mental health difficulty or who have symptoms that are not typically associated with mental health - such as problematic drinking, aggression and somatic symptoms.
“well-being sort of seems to ‘ah it feels like I’m going to another session and I’m going to get lectured’ and it’s just a word I’ve heard a lot, it’s an empty wishy-washy word [i.e. well-being]” – Participant 7, Group 2.
“you know if you’re struggling with depression and what not as a man, let’s be real are you going to go to this workshop talking about men’s mental health? Probably not” – Participant 1, Group 2.
Similarly, providing an incentive or clear short-term benefit would help tip this cost-benefit analysis more favourably.
“So, I feel like if you have a side benefit to going to a workshop like that, that might be really cool” – Participant 5, Group 3.
“Something similar to this with some snacks, like with some food or something kind of… an incentive to come” – Participant 6, Group 1.
Other recommendations included promoting interventions through student networks or clubs, pre-existing bodies within the university and face-to-face advertising, as opposed to university wide e-mails and posters, as it was considered more engaging resulting in potentially higher levels of attendance.
“Getting societies involved, now I’m thinking about it, is a really really good idea ‘ cause you catch so many people like that, you catch the people at events, you catch a lot of different groups of people by getting societies involved” – Participant 5, Group 3.
“Yeah well, human contact, like ‘hey dude it’s actually quite cool come along’ and then you are much more inclined to go instead of seeing a poster” – Participant 5, Group 3.
Finally, participants felt delivering mental health initiatives at the beginning of an academic year during orientation or ‘freshers’ week could elicit higher engagement. During this period, students have more time available to engage with extra-curricular activities and are more motivated to participate.
“for freshers you just say ‘okay, now I have time’ you want to do stuff, you feel like you’ve got an obligation to actually do stuff, maybe like 3 weeks afterwards you’re like I don’t care anymore but at the start you want to do something, you want to be informed, and maybe that’s the best place to get to people so when they’re still motivated” – Participant 2, Group 3.
In addition to this, delivering mental health initiatives during ‘critical’ or ‘darker’ months was also considered to be a good idea. Participants thought running interventions around exams and before the Christmas/winter break would be more appealing and relevant to male students.
“then there should be like in these ‘dark months’ before exams” – Participant 4, Group 3.
“you introduce sessions maybe before Christmas and then before exams” – Participant 4, Group 3.
This theme captures key strategies which might help attract male students to attend mental health initiatives, and more specifically seek help. Labelling the intervention as something other than mental health, providing a short-term incentive, advertising via pre-existing bodies and delivering initiatives during orientation and before exams were the most widely discussed strategies.
Overall, these five themes provide insight into how male students might think and how to better engage male students with mental health initiatives, possibly resulting in more effective and positive changes to psychological help-seeking.