2.1.1. Influence of traditional masculinity norms

The evidence overwhelmingly showed that traditional masculinity norms stigmatize help-seeking for mental health problems and limit men's knowledge and capability concerning mental health; these norms vary and operate differently according to individual, interpersonal, community and societal contexts. Although stigma concerning mental health issues is increasingly being debated and challenged in many countries, it remains a powerful deterrent to help-seeking for men (74). In eastern European countries and the Russian Federation, most people have a strong bias against psychologists and psychiatrists, but not towards specialists or any system of detection (117).

Evidence from the Russian Federation described a culture of poor self-care and health literacy in men and a lack of effective training strategies in health care for men (118). The influence of traditional masculinity norms means that many men may experience greater stigma for mental illness (49,50). This is compounded by masculine stereotypes concerning self-reliance, which may deter men from seeking help (50,59,109,112). Norms such as toughness, anti-femininity, emotional control and rationality were seen to inhibit men from disclosing their mental health issues, especially within the wider culture of discomfort and prejudice around such issues (101).

Stigma around mental health may be internalized to produce self-stigma, whereby depressed men consider themselves as not measuring up to masculinity standards and, as a consequence, experience a sense of guilt and failure (85). Evidence from questionnaire-based studies showed that greater adherence to traditional masculinity norms was associated with higher levels of self-stigma (84,86). Evidence from the Russian Federation indicated a clear link between prevailing masculinity ideals and the reluctance/ambivalence of many men to seek help for mental health concerns: men make up only 20% of the client population and drop out of treatment prematurely (Case study 1) (109).

In the Russian Federation, cultural stigma is compounded by limited service provision for mental health problems: general practitioners are not trained to treat problems such as depression, while specialist outpatient services (dispanseri) work outside mainstream health-care services and are not equipped to treat large populations (119).

Some reports also identified a specific stigma around medication use for mental health issues: men seemed reluctant to admit to others (especially their male peers) that they were taking tablets (95,96). This was also influenced by masculinity norms such as self-reliance, emotional control, toughness, independence and action orientation. An observational study of reactions to and rankings of mental health labels and sources of support in 85 men in the United States noted that those who adhered to the norm of self-reliance responded more negatively to the prospect of taking medication (97). Evidence from the Russian Federation also revealed notable stigma around visiting mental health services and a preference for seeking advice from friends, if at all, who are ill-equipped to help (110).

2.1.2. Substance abuse and mental health issues

Several quantitative studies confirmed that women are more likely than men to report mental health problems (e.g. in Ireland (87)) and that men who conform more to traditional masculine norms are less likely to seek help (e.g. in the United Kingdom (103) and United States (86)). A questionnaire study of 1051 men and women in the United States found that high scores on toughness were linked to delayed help-seeking for both sexes, but especially for men (89). Evidence also showed that male-specific symptoms of depression-associated aggression, irritability, substance use, risky behaviour and physical complaints, which are not captured by the Diagnostic and Statistical Manual of Mental Disorders (120) or existing diagnostic tools (90), can make help-seeking less likely (91). Men in the Russian Federation are more likely to turn to alcohol consumption and drug use than to seek professional help (58). Further, drinking and poor self-care in Russian men have been linked to wider societal factors, including an overemphasis on state-sanctioned health care over individual lifestyle practices, and a smaller middle-class sector compared with western European and North American countries (where middle-class sectors are associated with healthier lifestyles) (121).

Substance abuse is a problem for some marginalized communities of men; for example, in gay, bisexual and transgender men (who disproportionately experience bullying, harassment and hate crimes), self-medication to manage minority stress often exacerbates mental ill health and increases risk of suicide (122). Different groups and subcultures have particular substance use preferences, for example steroid intake in younger men (123) and increased alcohol consumption in older men (124). Other groups vulnerable to substance abuse include homeless men, men in incarceration (106), indigenous men (e.g. native American Indians in the United States) and rural men (82).

The prevalence of substance abuse in marginalized male communities means that the men themselves, their friends and family, and even health professionals may not interpret this as a sign of mental health problems. This problem may be compounded by limited access to visible, culturally acceptable therapeutic services, leading to delays in help-seeking for these men: the increased risk of depression combined with a more negative attitude toward help-seeking has been described as double jeopardy (101,125). Such men may only decide to seek help following a crisis (e.g. a relationship breakdown) or after experiencing physical symptoms attributable to mental health issues (e.g. panic attacks (92)).

2.1.3. Stigma in male-dominated environments

In particular contexts, local gendered ideals and practices make it especially difficult for men to signal mental health issues. For example, a theoretical analysis suggested that military cultures discourage emotional disclosure through a combination of hypermasculine and working-class norms that promote stoicism, actions over words, denial of pain or weakness, and physical robustness (93). Russian analyses made similar findings concerning military veterans (126), and post-traumatic stress disorder exposure is now acknowledged to be linked to military combat (127) as well as to other traumas such as childhood sexual abuse and experiences of interpersonal violence. It is also increasingly recognized that historical and race-based mistreatment and victimization can have similar consequences for ethnic minority and indigenous men (128).

Men working in other traditionally male-dominated fields (e.g. the fire brigade (129)) may also encounter masculine norms that inhibit displays of vulnerability. Moreover, men may feel pressure to prioritize work commitments over family time and personal well-being, especially in male-dominated industries such as construction (130). Similarly, sporting cultures can inhibit emotional disclosure and help-seeking through promoting mental toughness, competitiveness, playing through pain, and controlled aggression. In a qualitative interview study of eight elite varsity football players in Canada (mean age, 22 years), participants' reluctance to disclose their mental health issues was linked to protecting their status, popularity and performance within the team, with those reporting such issues being viewed as weak, fearful of competition and compromising the team spirit and success (94).

Evidence also indicated that boys and men are particularly concerned that their male peers may react unfavourably to a disclosure of psychological distress (i.e. think less of them or judge them critically) (92,95). Thus, stigma around mental illness might be reinforced and policed by other men (or at least by the perception that other men would respond negatively), which discourages men from disclosing their psychological difficulties, at least in all-male group situations such as bars (92).

2.1.4. Stigmatizing environments for boys

Institutional contexts in which traditional masculinity norms operate to police male identities and practices include mixed-sex environments. For example, in school settings the dominant heteromasculine standards prescribe a restricted range of damaging (or toxic) behaviours, including homophobic and sexist behaviour (131). A recent European Union-funded study of young people in five European countries (Bulgaria, England (United Kingdom), Italy, Latvia and Slovenia) highlighted pervasive sexual bullying whereby boys perceived to deviate from heteromasculine standards were subjected to ridicule and sanctions (131), whereas girls were routinely sexually objectified and pressurized for sex (e.g. in Spain (131,132), the United Kingdom (133) and the United States (134)). Thus, being a victim of bullying is strongly linked to mental health problems, for example in young people who are lesbian, gay, bisexual, transgender or queer; however, young people who bully others are also at risk of mental illness, since violence against others tends to stem from personal experiences of aggression, social exclusion and disadvantage (80,135,136). Such evidence points to the potential of school- and youth centre-based interventions to promote tolerance, inclusivity and positive gender identities. The recent WHO strategy and report on men's health in the WHO European Region identified education on health, well-being and gender equality as a priority for boys and young men (3,5).

Within the family, parenting of boys may reproduce and reinforce restrictive masculinities. Several Russian reports considered gender role socialization for boys as key to understanding how their sociocultural environment influences the appropriation of men's attitudes towards help-seeking behaviours. Child-rearing practices and family traditions were found to influence boys, adolescents and men's attitudes and behaviours towards mental health help-seeking. For example, cultural stereotypes promoted by boys' parents propagated the myth of the “real man” (111). Approaches to analysing and revising this myth include counselling sessions informed by a narrative approach (111,137,138).

2.1.5. Marginalized and vulnerable groups

Help-seeking was found to be more challenging for men in specific disadvantaged groups. A meta-ethnography review of 51 qualitative studies highlighted intersections between gender, ethnicity and sexuality, and reported that help-seeking was lower in men in minority groups, including refugee and migrant, minority ethnic, indigenous, gay, bisexual and rural men (98). In general, difficulties in help-seeking were linked to cultural norms (e.g. family-based shame associated with mental illness), social exclusion and experiences of prejudice and discrimination (e.g. racism or homophobia). A qualitative interview study of 32 Canadian farmers reported that barriers to help-seeking included pride and ignorance about mental health and the available support (99). This was confirmed by survey data: quantitative data from 4825 men suggested that African-American and Mexican-American men are less likely to seek help and have less access to culturally competent health-care providers, and that men from lower lower-socioeconomic status backgrounds are also less likely to seek help (87,100,101).

A previous Health Evidence Network report described the barriers to accessing mental health care encountered by migrants in the WHO European Region (139). Evidence from the Russian Federation similarly showed that social exclusion of refugee and migrant men (who are mainly from central Asian countries (140)) helps to explain their lack of engagement with therapeutic services (141): they do not trust government and public organizations but instead regard their friends, relatives or partners within migration networks as valid sources of support and advice. Conversely, for some ethnic minority groups, migration may have a disruptive impact on their community values, traditions and well-being. For indigenous men of the Tomsk and Tyumen oblasts and Altai Region, Buryatia Republic, Chukotka Autonomous Region, Tuva Republic and Sakha Republic, the most significant causes of mental health imbalance were reported as separation from the family environment, loss of sociocultural traditions and the destabilizing influence of refugees and migrants. The most vulnerable group was men under 40 years of age who were living in a mixed family, not working in traditional types of employment and with social benefits as the main sources of income; men in this group were at risk of alcoholism and behavioural disorders (142). In addition, men returning from combat zones face multiple challenges in adjusting to their social environment, accessing employment opportunities and facing threats to their well-being. For example, in the former Yugoslav states that were undergoing post-socialist economic and societal transformations, former soldiers faced unemployment and were consequently unable to perform the traditional roles of breadwinner and protector, which were increasingly valued as nationalistic identities become more firmly established (143,144). Outside this context, a number of other nations are also currently witnessing discourses around men in crisis, anti-feminist rhetoric and precarious masculinity (145,146).

2.1.6. Poor health literacy

Constraints against help-seeking are also linked to limited mental health literacy: men may have a poor understanding of mental health; lack the vocabulary or confidence to articulate emotional distress; misinterpret or minimize psychological symptoms; and lack knowledge about the available sources of support (92,95,98,99,101–103). For example, an analysis of Canadian survey data featuring responses from 452 men found that over 40% felt that they were not well informed about mental illness (102). An interview study of Australian men reported a simplistic, distorted understanding of mental illness, featuring hallucinations, hearing voices and extreme behaviour (92). In a Swedish interview study of 13 young urban men, participants agreed that men are not socialized to understand, notice or articulate difficult emotions (95).

This lack of knowledge is clearly linked to traditional masculinity norms, particularly emotional control, strength, rationality and independence. Poor mental health literacy in men may be informed by familial, occupational, cultural and regional norms that discourage discourse about psychological issues, for example in male-dominated workplaces (e.g. construction sites (130)) and in working-class communities, where men may prioritize humour, breadwinning and protecting others (147). More broadly, the resources and cultural capital required to access information, advice and support on mental health issues may not be available to men in disadvantaged communities, while health services may not openly offer or promote culturally acceptable interventions.

2.2.1. Support from significant others

In general, men are more willing to disclose their emotional issues in communities where help-seeking is normative and appropriate support is readily available. Help-seeking by men may be facilitated by supportive environments in which emotional communication is normalized and validated (25,85). More specific evidence indicates that men can be persuaded to seek help by significant others (wives/partners, parents) and within trusted communities (groups/peers within the local neighbourhood; fellow members of social/sport clubs). Several papers cited the important role of female partners in encouraging men to disclose their psychological problems and prompting them to seek help. A questionnaire study of 136 rodeo cowboys in the United States reported a preference for talking things over with female partners over all other options (i.e. talking to an expert, joining an Internet forum or attending a relevant class/workshop) (91). An analysis of pre-existing data from the National Psychological Well-being and Distress Survey in Ireland found that male respondents currently in relationships with women were three times more likely to seek help compared with men living by themselves (87). A qualitative interview study of Australian men described the key involvement of wives and girlfriends in prompting help-seeking – with men noting that they might have done nothing without such support (92). This denotes a guarded vulnerability in which men only reveal their problems to select, trusted others so as to preserve their masculine identity (57). However, contradictory evidence was also found: an interview study of American men reported that respondents reacted more positively to the suggestion to seek professional treatment when made by a psychotherapist than by a medical doctor or romantic partner (97).

For younger men, mothers may be key figures in prompting help-seeking and may even physically escort them to the health centre: in the case of one young Swedish man, his mother called the service provider and took him there (95). Fathers were notably absent from these scenarios; however, as new generations of men transition to more-involved models of fatherhood, boys and young men might feel equally at ease disclosing their mental health problems to fathers as to mothers. Engaging fathers in this form of emotional labour would require supportive government policies concerning parental leave, free childcare, flexible working patterns and gender equality more generally (5).

2.2.2. Online support

Growing evidence indicates that many men are engaging with online resources to find out more about mental health issues, including advice on mitigating their problems. A small Swedish study highlighted the use of the Internet by six male interviewees aged in their 20s in a self-management approach to seek information and advice and, where suitable, incorporate this into their lifestyle practices, in alignment with traditional masculinity norms around self-reliance, autonomy and rationality (104). Other men may actually disclose their issues online and seek help anonymously, for example within relevant forums where they can elicit peer support without the risk of losing face or having their masculinity questioned (92,105). In an interview study, a group of Australian men reported that finding out about peers with similar problems online proved helpful by reminding them they are not alone (92). An analysis of online forum interactions involving British men experiencing depression found that the men were concerned to present themselves as having gone to great lengths to manage their problems themselves before seeking help, highlighting the continued influence of traditional masculinity norms such as self-reliance (105).

A clear benefit of anonymous support is that men feel able to maintain control over their situation (85). Nowadays, many such forums and websites hosted in different countries focus on diverse mental health issues and distinct groups of men: some provide support to men experiencing depression and suicidality (e.g. Campaign Against Living Miserably (CALM): Case study 2) while others focus on other problems. For example, men with eating disorders must cope with its dominant cultural and media representations as a women's illness (150). An online community in the United Kingdom dedicated to supporting men with experience of eating disorders offers help and support and features testimonies from men telling their stories (151). Other online sites focus on supporting men struggling with a range of medical issues that affect their well-being, including different forms of cancer (152), infertility (153) and obesity (154). Such websites seem to attract a lot of traffic and engagement, but as yet evidence of impact is sparse.

2.2 3. Role models

Other evidence indicates that men can be encouraged to seek help for their mental health issues through endorsement of help-seeking by familiar role models, including members of their community or respected male public figures. However, to be effective, the role models must be perceived as credible through having accrued sufficient masculinity capital (so-called man points), that is, men perceived to embody valued masculine attributes (149). For example, an interview study of 21 college men experiencing depression reported the potential value of other (masculine) men expressing psychological difficulties and promoting help-seeking (96). A man who is perceived to be traditionally masculine (e.g. in terms of his physical stature) and is prepared to display vulnerability and promote help-seeking for emotional problems may be able to influence other men to do so. Other role models may be respected because of their work achievements. For example, an interview study of 32 farmers reported the positive reception of a news story featuring a successful farmer disclosing his mental health difficulties, with interviewees expressing sympathy and support (99).

Clearly, different role models will resonate with different groups of men with shared identity, occupation or leisure interests. The world of sport increasingly provides role models for many men. For example, Australian interviewees made positive references to displays of vulnerability by various high-profile sportsmen (92). Similarly, a Canadian study of varsity footballers highlighted the importance of masculinity capital (i.e. being able to command respect from one's peers) when sportsmen talk about their emotional problems (94). The evidence suggests that men who command respect from other men, whether through success in valued masculine domains (e.g. work or sport) or simple masculine embodiment, can play a key role in reaching men and encouraging help-seeking for psychological problems. Importantly, more diverse role models are needed for disadvantaged and minority men. Currently, elite sport does not provide many role models for gay, bisexual and transgender men. For example, despite recent initiatives to tackle homophobia, no top-level soccer player is currently out in the United Kingdom, and prejudice against sexual minority men continues within elite and amateur sport internationally (155).

2.3.1. Interventions for hard-to-reach groups

Efforts have recently been made to develop community-based initiatives targeting hard-to-reach men in different regions. For example, older men living alone following marital breakdown or bereavement (or even through choice) may be at risk of declining mental health and social isolation and, therefore, in need of special consideration for interventions. One success story is the Men's Sheds movement (Case study 3), which focuses on older, isolated men at risk of mental illness, often in economically deprived and/or geographically remote neighbourhoods (156). Here, community venues are used as spaces for men to congregate and work together on projects, while building social connections and improving well-being in the process. Community-based initiatives also include crisis centres for men in the Russian Federation (Case study 4). Other community-based initiatives may use sport to attract men: even when an initiative focuses on physical health, there is evidence of mental health gains (160). Interventions are generally tailored to particular groups. For example, programmes for military veterans, a predominantly male population, work well when fellow veterans are involved in the design and management and when insider language, customs and humour are accommodated (161). Emerging initiatives focused on diverse minority communities are tackling cultural issues pertaining to health and well-being. In the United Kingdom, a number of recent newspaper articles, funded projects and community programmes have focused on Muslim men, mixed race men and Afro-Caribbean men (Case study 5).

2.3.2. Interventions for boys and young men

A WHO priority for men's health and well-being in the European Region relates to early interventions for boys and young men around mental health, gender equality and positive masculinities (5). Despite a growing literature on boyhood studies and young masculinities, there has as yet been little focus on mental health. There is, therefore, potential to develop interventions involving young people (e.g. in school and youth centre settings) and to include well-being as a cornerstone of personal, social and health education. In the United Kingdom and elsewhere, various local and regional initiatives focus on specific issues, including body image, bullying and equality, to promote the mental health of young people; indeed, some schools now provide sessions on mindfulness, yoga and the natural environment to encourage healthy minds (e.g. PSHE Association (164)). For some boys and young men, education and well-being may be compromised by online activities, including gaming, social media and consumption of pornography (165) – all of which need to be addressed within schools and youth centres. Some programmes also explicitly tackle gender identity, relations and equality. For example, the Good Lad Initiative in the United Kingdom is a nongovernmental organization that conducts workshops with male pupils designed to debate and question restrictive (i.e. toxic) masculinities and promote more positive, inclusive and caring masculinities (166). In addition, some bullying prevention programmes incorporate gender as a key focus; for example, in an European Union-funded project on young people and sexual bullying (131), the research team developed a series of exercises with young people that encouraged critical thinking and behaviour change concerning homophobic and sexist practices (167). WHO has also stressed the importance of gender, sex and relationship education and of equipping young people with the skills to make positive choices (168).

Interesting anti-bullying methods are used in Kazakhstan, which has no special anti-bullying rules in schools. Cases of bullying are considered by the Council of Fathers at the request of a teacher or pupil-victim to ensure that the bully is stopped and punished (169). Local government leaders are also involved in such issues. The Russian Federation also has a number of local and regional anti-bullying programmes and initiatives. As part of a federal programme of mental health services, a national Federal Resource Centre (to be completed by 2025) is planned for teachers and psychologists working in the education system. The Centre will organize a programme to prevent bullying, aggressive and suicidal behaviour for children in schools (170).

Young people who do well educationally are more likely to enjoy better health and well-being (171,172). However, boys and young men are known to perform worse at school than their female counterparts (173), are more likely to leave education early and less likely to engage in further training or gain employment (i.e. to be NEET (young people not in education, employment or training)) (174). This is more likely to be the case for young men and women from marginalized groups (e.g. Roma), with disabilities and from ethnic minorities (175), who may experience institutional bias, microaggression and a lack of cultural recognition within the school environment (82). Consequently, these young men are at risk of coming into contact with the criminal justice system, experiencing violence and substance abuse, and suffering poor mental health (135).

2.3.3. Interventions for fathers

Fatherhood provides another opportunity for intervention. Increasing evidence shows that more-involved fathers enjoy better mental health, and that these benefits are transferred to their partners and children (176). In addition, boys with caring fathers are more likely to become caring fathers themselves (72). Obviously, cultural norms and expectations influence the degree of paternal involvement (108,111), but other institutional and societal factors are also important, including workplace policies on parental leave and flexible working, the availability of free childcare, and wider gender equality and family policies (176). The Russian Federation has been experiencing a trend towards more-involved fathers that is associated with a transformation in masculinity norms (177).

The modern phenomenon of the more-involved father has also been noted in refugee and migrant communities and can be linked to cultural integration (e.g. in Polish migrants (178)). Labour migration in the European Union has been linked to the reaffirmation of traditional masculinity ideals in both host and recipient cultures (179). Interestingly, some religions (e.g. the Russian Orthodox Church) have been intensively rejuvenated through promoting traditional values within which a model of responsible masculinity and fatherhood is promoted as “conservative norm protagonism” (180).

2.3.4. Interventions for marginalized groups

Confidential services are also needed for men in desperation who have not had the good fortune to benefit from peer, familial, institutional or community assistance. Such groups of marginalized men include ex-offenders struggling to adapt to life outside prison, homeless men, male victims of violence and abuse, and men addicted to alcohol or other substances (75,109). In Russian-speaking countries, where mental illness and men's disclosure of emotional problems is stigmatized, crisis centres established to help men in extreme difficulty offer advice to practitioners working with men based on evidence from the Russian Federation and beyond (75,109).

2.4.1. Gender-sensitive language in mental health promotion

A study of 1397 men with depression who had not sought help for their condition found that a male-sensitive brochure was more effective than previous brochures in changing their attitudes towards seeking counselling (84). Informed by theory and research on masculinity and mental health, the brochure featured nonmedical, pragmatic language; an emphasis on problem-solving; and testimonials with images of stereotypical men. This research highlights the importance of language in engaging men by replacing medicalized or psychological terminology (which men may consider effeminate) with less pathologizing and more familiar, acceptable language (e.g. stressed, burnt out or overwhelmed) (98,104). Through careful attention to language within mental health promotion materials, men's limited mental health literacy might be addressed in an appropriate, comfortable and safe way. The language and presentation should be tailored to specific groups of men. For example, staff/interpreters who speak the relevant language and promotion materials in different languages are essential to engage refugee and migrant men in mental health services. The customs, traditions and values of particular ethnic communities should also be acknowledged, for example their religious/spiritual beliefs, traditional familial roles and responsibilities, and main challenges and resources (see Case study 5). For younger men in general, social media has been suggested as a fruitful avenue for mental health promotion. There have been some general initiatives in this area but there is a need for specific interventions that work for specific groups, such as young gay men, young Asian men or young disabled men, and for subgroups such as young gay Asian men.

2.4.2. Gender-specific symptoms can mask mental health issues

Several papers highlighted that men with mental health conditions may experience non-traditional symptoms that are not routinely recognized in diagnosis. For example, symptoms such as aggression, irritability, substance use, risk-taking and somatic complaints might reduce help-seeking in men with depression (91). To address this problem, efforts have been made to construct diagnostic tools to more efficiently identify (male) depression (114,182).

2.4.3. Redesigning traditional masculinity ideals in mental health interventions

Successful initiatives can reframe traditional concepts of masculinity by presenting help-seeking as a masculine norm rather than a feminine stereotype. For example, the brochure study (section 2.4.1) reframed help-seeking so that, instead of being associated with fragility, femininity or failure, it was more constructively presented as the more responsible, rational, brave and independent option – thereby maintaining traditional masculinity ideals (84). Reframing has also been reported in men who have engaged with services. For example, in an interview study of depressed men in Canada, some participants reformulated help-seeking as an active, rational, decisive move (57).

Mental health services can try to engage men by deploying traditional masculinity ideals. For example, men may respond more positively when services involve strength-based action rather than “just talking” (which men may associate with femininity and passivity) (101). One study reported a marked preference in men for cognitive behavioural therapy, with an emphasis on action (57); an interviewee in another study viewed therapy as a means of regaining autonomy (85). Therefore, although engagement with services may be construed as potentially emasculating, the process can be reconstructed in traditionally masculine terms (e.g. action-focused) and/or as a route to regaining valued masculine attributes (e.g. independence). More generally, men may need to negotiate the transition from self-management to engagement with health-care services (95). Conversely, linking common mental health problems with factors beyond the individual's control, whether biological (genetics, neurochemistry), experiential (trauma, isolation) or societal (availability of services, social exclusion), may reassure some men and encourage their engagement (84), although resistance to medication may persist (95). A model emphasizing masculinity-related virtues may be more effective in engaging men who respond to factors influencing traditional masculinities. Consequently, a therapeutic approach featuring collaboration, pragmatic focus and goal-setting may well work for some men – ultimately, men will seek help if it is accessible, appropriate and engaging (101). Interventions should also be informed by the target community of men; for example, what works for traumatized military veterans may not work so well for young men with body image issues.

2.5.1. Challenging traditional concepts of masculinity

High conformity to masculine norms is known to correlate with reduced help-seeking (97). It, therefore, follows that men who do not identify strongly with traditional masculinity are more likely to seek help. The analysis showed that some groups of men are more likely to question, rework or reject conventional notions of masculinity, including those from more socially privileged groups, who have greater resources and (masculinity) capital (87), and those who have experience or knowledge of mental health issues, either personally or within their family or social network (38,96).

In one study, a middle-class interviewee predicted that disclosure of his mental health issues would be received differently by his “white-collar” versus “blue-collar” peers, and that he would receive more understanding and sympathy from the former (85). In an interview study of depressed college men, one participant acknowledged that his openness to emotional expression was not normative but was borne from family experience (96). In another interview study, some men said they were open to talking things through with a health professional and appreciated being listened to and cared for, which represents a traditionally more feminine position (57). In an interview study, young urban Swedish men with depression described their experience of coping with mental illness as occurring alongside a process of redefining masculine identity to accommodate emotional well-being, including being entitled to feel vulnerable (95). Russian analyses also reported that men's experiences of mental illness may prompt a reconsideration of masculine stereotypes (38) and a more positive attitude towards help-seeking (11).

2.5.2. Changing depictions of masculinity in popular culture

Popular culture has an important role in propagating particular masculinities in different geographical regions. Although every region features a complex array of gendered signifiers, some interesting patterns and developments were noted. Evidence from the Russian Federation showed that popular male icons include stars of western European and North American action movies, who exhibit hegemonic masculinity through behaviours such as explicitly reserved brutality, courage, risk-taking, resilience, active sexuality and an individual code of honour (e.g. Jason Statham). Importantly, physical health, elegance and commitment to exclusively male friendship form part of his masculinity norm package. In contrast, the Russian national film industry more actively promotes the paternalist image of male brotherhood (i.e. commitment to male power, rationality, risk-taking and solidarity for the sake of a just cause) (183,184). At the same time, contemporary models of masculinity that include the values of taking part in sport, physical health care, involved fatherhood, pro-family values and traditional collective male hobbies (fishing and hunting) are also popular.

In some countries such as the United States, a widespread cultural debate about changing masculinities is taking place in the wake of high-profile social media campaigns such as #metoo. Although this has led to a backlash from various men's rights organizations and the populist media, the movement towards more positive, progressive masculinities is evident (185). More mature, nuanced depictions of masculinities are also becoming more evident in popular culture, including in best-selling books (e.g. How Not to be a Boy (186)) and documentaries (e.g. All Man: Grayson Perry on Masculinity (187)). Interestingly, some manufacturers of male grooming products are retreating from macho advertising towards depicting more inclusive forms of masculinity (Case study 6). In the Russian Federation, morning prime time on the national television channels, Channel 1 Russia and VGTRK (All-Russia State Television and Radio Broadcasting Company), is given to the health literacy and health promotion programmes (e.g. Health, It's Great to Live!, and About the Most Important Things), which regularly cover the questions and issues related to masculinity and aspects of men's health and well-being. Contemporary Russian films have also addressed the theme of masculinity crisis, with reference to either ethnicity (Solbon Lygdenov's 2013 film, Bulag – the Sacred Spring, about the rural Buryat community (190)) or men in a class struggle (Yurii Bykov's 2018 film, The Factory (191)).