Men in the United States suffer more severe

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1 Traditional Masculinity and African American Men s Health-Related Attitudes and Behaviors American Journal of Men s Health Volume 3 Number 2 June The Author(s) Jay C. Wade, PhD This study investigates aspects of masculinity that may relate to African American men s health-related attitudes and behaviors. Two hundred and eight men completed measures of traditional masculinity ideology and healthrelated attitudes and behaviors. Results indicated that after accounting for participants age, education, income, and employment status, traditional masculinity norms of self-reliance and aggression were associated with behaviors conducive to personal wellness and certain health-related psychological tendencies. Restrictive emotionality was associated with anxiety about one s health and the belief that one s health status is outside of one s personal control. Implications of the findings for the health-related attitudes and behaviors of African American men are discussed. Keywords: traditional masculinity; health behaviors; African American men Men in the United States suffer more severe health-related conditions and have consistently higher death rates (Courtenay, 2000a). In general, African American men experience earlier onset of disease, more severe disease, higher rates of complications, and more limited access to medical care than European American men (Barnett et al., 2001). Among men, the life expectancy for African American men is 6.2 years less than for European American men (69.2 and 75.4 years, respectively; Hoyert, Kung, & Smith, 2005). Although differences in health-related beliefs and attitudes among men have rarely been investigated, it is known that minority race men, as well as majority race men, tend to have attitudes and behaviors that are detrimental to their health when compared with women (Courtenay, McCreary, & Merighi, 2002). The literature on men and masculinity indicates that men s masculinity ideology, that is, the normative prescriptions of masculinity, influence men s health behaviors (see Lee & Owens, 2002). Pleck, Sonenstein, and Ku (1993) defined masculinity ideology as beliefs about the importance of men adhering From Fordham University, Bronx, New York. Address correspondence to: Jay C. Wade, Psychology Department, Fordham University, Bronx, NY 10458; jwade@fordham.edu. to culturally defined standards of male behavior (p. 12). Much of the research on masculinity ideology has focused on what has been called traditional masculinity ideology. Masculinity, in these terms, not only restricts men from exhibiting signs of behavior or thought attributed to the female role but also entails a wide array of specific behaviors and self-perceptions that men closely adhere to. For example, traditional masculinity entails characteristics such as homophobia, competitiveness, physical and sexual violence, restricted emotionality, and restricted affectionate behavior between men (O Neil, 2002; O Neil, Helms, Gable, Laurence, & Wrightsman, 1986). A growing body of research indicates that men who endorse traditional beliefs about masculinity engage in fewer health-promoting behaviors and have greater health risks than men who endorse less traditional beliefs (e.g., Copenhaver & Eisler, 1996; Courtenay, 1998; Kristiansen, 1990; Mahalik, Lagan, & Morrison, 2006). There are a few research studies that have examined masculinity ideology and health-related attitudes and behaviors in African American men. Courtenay (1998) examined the influence of beliefs about manhood on the health risks of young men. When a variety of psychosocial factors were controlled for, beliefs about manhood emerged as the strongest predictor of a risk-taking behavioral style. Traditional 165

2 166 American Journal of Men s Health / Vol. 3, No. 2, June 2009 beliefs about masculinity predicted the greatest risk. Several factors were associated with traditional beliefs about masculinity: These factors included lower educational level, lower family income, and African American ethnicity. In their research on health care behavior and compliance, Rose, Kim, Dennison, and Hill (2000) identified that African American men were concerned about masculine pride or not wanting to appear weak or not macho, which influenced decisions about seeking help, both from professionals and from family and friends. Powell (2007) examined how traditional masculinity norms of self-reliance related to health behaviors of African American men. Although there was no relationship between self-reliance and preventive health dietary practices, self-reliance moderated the relationship between experiences of racial discrimination and physical health status. The findings indicated that endorsement of traditional masculinity ideology around self-reliance may buffer the impact of discrimination on African American men s health. Finally, in Wade s (2008) study of African American men, nontraditional masculinity was a predictor of health behaviors conducive to one s health. The literature suggests that men may attempt to prove their manhood through risk taking, which leads to adverse health outcomes (Sabo & Gordon, 1995). For men of color, who are marginalized and are not allowed mainstream ways to enact male gender roles, risk-taking behavior provides a way in which they can attempt to establish themselves as men (Courtenay, 2000b). Traditional masculinity ideology supports those health-related attitudes and behaviors that put men at risk for poor health. However, it is not clear what particular aspects of traditional masculinity may contribute to poor health outcomes in African American men. For example, what beliefs about manhood are predictors of a risk-taking behavioral style that can lead to adverse health outcomes? What other traditional attitudes about masculinity, other than self-reliance (Powell, 2007), might contribute to positive health outcomes? As such, the purpose of this study was to investigate the relationship between aspects of traditional masculinity ideology and the health-related attitudes and behaviors of African American men. Methods Participants Participants were 208 African American men residing in the New York City area, aged 18 to 71, with a mean age of 37 (standard deviation [SD] = 13.37). The demographic characteristics of the participants are provided in Table 1. Note that 70% of the participants were single, which is a larger percentage than the 2005 national average of 44% (BlackDemographics.com, 2006); 46% had no children, and the majority with children either had one child or two children. Almost all the participants were born in the United States (91%, n = 189), with the remaining few born in the Caribbean or Africa. As regards educational qualifications, 17% had 12 years or less of education, 43% had a GED or had graduated high school, 24% had some college education, and 14% had a college degree. A large percentage of the men were unemployed (44%). Half of the participants who reported an income indicated that it was below $9,999 (including men receiving government assistance); 48% were receiving Supplemental Security Income, Social Security Disability, public assistance, or unemployment insurance. Most had received a physical exam within the past year (71%) and had health insurance (76%), including Health Maintenance Organization, Medicare, and Medicaid health insurance. Measures To examine the relationship between traditional masculinity ideology and health-related attitudes and behaviors, the following measures were used: Male Role Norms Inventory (MRNI) to assess traditional masculinity ideology, Holistic Lifestyle Questionnaire (HLQ) to assess health-related behaviors associated with personal wellness, and Health Orientation Scale (HOS) to assess healthrelated psychological tendencies or attitudes. Male Role Norms Inventory. The MRNI (Levant et al., 1992) was used to assess traditional masculinity ideology. The MRNI Traditional Masculinity Scale is a 45-item scale that consists of seven subscales representing the dimensions of Avoidance of Femininity, Fear and Hatred of Homosexuals, Self- Reliance, Aggression, Achievement/Status, Attitudes Toward Sex, and Restrictive Emotionality. Participants respond to normative statements by indicating their agreement/disagreement on a seven-point Likerttype scale ranging from 1 = strongly disagree to 7 = strongly agree. Higher scores indicate more traditional masculinity ideology. In their review of research on masculinity ideologies using the MRNI, Levant and Richmond (2004) reported that the MRNI Traditional Masculinity Scale significantly

3 Masculinity and Men s Health / Wade 167 Table 1. Demographic characteristics of participants correlated with two other measures of masculinity ideology, the Gender Role Conflict Scale and Masculine Gender Role Stress Scale, providing support for convergent validity. Additionally, in several research studies, complex patterns of differences on n Percentage Marital status Single Married Divorced Separated Cohabiting Widowed Missing data Number of children None One Two Three Four Five Six Seven Eight Ten Missing data Education 12 years or less GED High school graduate Some college Associate s degree Bachelor s degree Master s degree Doctoral degree Missing data Employment Full-time Part-time Unemployed Retired Student Missing data Income Below $9, $10,000-$19, $20,000-$29, $30,000-$39, $40,000-$49, $50,000-$59, $60,000-$69, $70,000-$79, $80,000-$89, Missing data NOTES: N = 208. the MRNI subscales have been found relative to race/ethnicity, gender, geographic location in the United States, and nationality. The internal consistency reliabilities of the subscales in the current study were as follows: Avoidance of Femininity,.67; Fear and Hatred of Homosexuals,.53; Self- Reliance,.71; Aggression,.49; Achievement/Status,.67; Attitudes Toward Sex,.73; and Restrictive Emotionality,.68. Traditional masculinity total scale reliability was.92. Holistic Lifestyle Questionnaire. The HLQ (National Wellness Institute, 1992) was used to assess healthrelated behaviors. The measure consists of 100 questions measuring 10 dimensions of personal wellness. Each dimension forms a subscale that consists of 10 items. Items are scored on a five-point scale, where 1 = almost never and 5 = almost always, with higher scores reflecting higher levels of personal wellness. Validity of the instrument has been examined in a sample of wellness professionals (Jones & Frazier, 1994), high school students (Owen, 1997), and graduate students (Owen, 1999). In support of construct validity, HLQ scores positively correlated with scores on a measure of self-esteem (Jones & Frazier, 1994). The internal consistency reliabilities of the subscales (10 dimensions) in the current study were as follows: Physical Fitness and Nutrition,.75; Medical Self-Care,.75; Safety,.82; Environmental Wellness,.72; Sexuality and Emotional Awareness,.86; Social Awareness,.85; Emotional Management,.87; Intellectual Wellness,.88; Occupational Wellness,.91; and Spirituality and Values,.85. Total scale reliability was.96. Health Orientation Scale. The HOS (Snell & Johnson, 2002) was used to assess health-related psychological tendencies. The self-report measure consists of 50 items measuring 10 separate dimensions: Personal Health Consciousness, Health Image Concern, Health Anxiety, Health-Esteem/Confidence, Motivation to Avoid Unhealthiness, Motivation for Healthiness, Internal Health Control, External Health Control, Health Expectations, and Health Status. Each dimension forms a subscale that consists of five items. Items are scored on a five-point scale where 1 = not at all characteristic of me and 5 = very characteristic of me, with higher scores reflecting higher levels of the above-mentioned domains. In their development of the measure, Snell and Johnson (2002) conducted a validity study. Correlations computed between HOS subscale scores and a measure

4 168 American Journal of Men s Health / Vol. 3, No. 2, June 2009 of health-seeking behaviors provided support for the validity of the scales. The internal consistency reliabilities of the subscales in the current study were as follows: Personal Health Consciousness,.68; Health Image Concern,.79; Health Anxiety,.71; Health-Esteem/ Confidence,.77; Motivation to Avoid Unhealthiness,.72; Motivation for Healthiness,.79; Internal Health Control,.75; External Health Control,.28; Health Expectations,.59; and Health Status,.69. Total scale reliability was.85. Personal Data Questionnaire. The Personal Data Questionnaire was developed to gather demographic information on participants age, education, employment status, income, marital status, number of children, country of origin, and how long they were living in the United States. Additionally, certain health information was gathered: time elapsed since the last physical exam, current medical or health conditions, and whether the participant had any health insurance. Procedures All the procedures for conducting the research study were first approved by an institutional review board. Participants were recruited using an advertisement in local newspapers and with flyers at the two sites where the research was conducted: a community church and community YMCA. Flyers were distributed in the community by hand on the street, and by leaving flyers at two community hospitals and a community recreation center. A telephone number was provided for the participant to contact the research team for information about the study: purpose of study, amount of time needed to complete the study, location and times for research participation, and remuneration. Participants would hear a taped message in which callers could hear the information and if interested leave a message providing contact information. Participants were then contacted and arrangements were made to schedule the participant for participation at one of the sites. Participants completed the questionnaires in groups of 10 to 30 during a 3-month period. Informed consent for the materials was obtained by providing a written form to participants as well as a verbal explanation by the researcher. After collecting the consent forms, the researcher provided the participant with a copy of the informed consent and the questionnaire packet with the measures. After completing the questionnaire, participants received a debriefing statement. Results Scale means, ranges, and SDs for the measures are provided in Table 2. Test of the hypothesis involved analyzing correlations between the variables and then conducting a regression analysis. First, the distributions were inspected and skewness statistic assessed for all measurement variables. The skewness value used as a cutoff was ±1. There were no out-of-range values. Second, the correlations revealed that there was a large amount of missing data (e.g., complete cases analyzed ranged from 120 to 134). To detect whether or not the data were missing completely at random, Little s MCAR (i.e., missing completely at random) test was used. The chi-square statistic was not significant, indicating that the data were missing completely at random (i.e., no identifiable pattern existed to the missing data) and that, therefore, the estimated parameters are not biased by the absence of data. Therefore, missing values were imputed using the series mean for each subscale. Finally, the demographic variables were examined for their relation to the MRNI, HLQ, and HOS. Age, education level, income, and employment status (i.e., being employed) significantly positively correlated with the HLQ. Age, education, and income significantly negatively correlated with the MRNI, and income positively correlated with the HOS. As a result, partial correlations were computed controlling for the relative demographic variables. Correlations between the MRNI and HLQ scales included all four demographic variables as control variables. Correlations between the MRNI and HOS scales included all but employment as a control variable. Correlation Analyses First, correlations between the MRNI total scale, HLQ subscales, and HOS subscales were examined, and there were no significant correlations. To explore the particular aspects of traditional masculinity that may relate to men s health behaviors and health orientations, the relationships between the seven MRNI subscales and the HLQ and HOS subscales were examined while controlling for the demographic variables. For the 70 correlations for each health scale analysis, the alpha level test of significance was adjusted to.001. Of the seven MRNI subscales, Self-Reliance and Aggression significantly correlated with HLQ and HOS subscales (see Table 3), and Restrictive Emotionality significantly correlated

5 Masculinity and Men s Health / Wade 169 Table 2. Scale Means (M), Ranges, and Standard Deviations (SD) Scale Scale M SD Range Holistic Lifestyle Questionnaire Health Orientation Scale Male Role Norms Inventory NOTES: N = 208. with two HOS subscales. For the HLQ, Self-Reliance and Aggression positively correlated with Social Awareness, Emotional Awareness and Sexuality, Emotional Management, and Intellectual Wellness. Self-reliance also positively correlated with Safety and Occupational Wellness, and Aggression also positively correlated with Spirituality and Values. For the HOS, Self-Reliance positively correlated with Personal Health Consciousness, Motivation to Avoid Unhealthiness, Motivation for Healthiness, and Internal Health Control. Aggression also positively correlated with Internal Health Control. Restrictive Emotionality significantly positively correlated with Health Anxiety and External Health Control. The low internal consistency reliability of the Aggression subscale (.49) indicates that the scale may not be capturing the traditional masculinity norm of aggression in this sample. Therefore, each item was correlated with each subscale of the HLQ and HOS to examine how the specific norm related to health behaviors and health orientations. The scale comprises five items, so for each analysis, an adjusted alpha level of.005 was used to test for significance (.05/10 health subscales). The norm, Men should get up to investigate if there is a strange noise in the house at night, significantly positively correlated with the HLQ (r(184) =.35, p <.001) and 7 of the 10 HLQ subscales. This item also significantly positively correlated with the HOS subscales of Motivation to Avoid Unhealthiness (r(185) =.19, p <.005), Health- Esteem/Confidence (r(185) =.19, p <.005), and Internal Health Control (r(185) =.23, p <.001). The norm, Boys should be encouraged to find a means of demonstrating physical prowess, significantly positively correlated with Motivation for Healthiness (r(185) =.20, p <.005). The norm, A man who has no taste for adventure is not very appealing, significantly positively correlated with Health Anxiety (r(185) =.20, p <.005). Finally, the norm, When the going gets tough, men should get tough, significantly Table 3. MRNI Self-Reliance and Aggression Subscale Correlations: Holistic Lifestyle Questionnaire and Health Orientation Scale Subscales positively correlated with Personal Health Consciousness (r(185) =.20, p <.005) and Motivation to Avoid Unhealthiness (r(185) =.21, p <.005). Regression Analysis Self- Restrictive Reliance Aggression Emotionality Holistic Lifestyle Questionnaire Physical Fitness and Nutrition Medical Self-Care Safety.27* Environmental Wellness Sexuality/Emotional Awareness.32*.26*.01 Social Awareness.25*.24*.06 Emotional Management.34*.27*.05 Intellectual Wellness.26*.24*.04 Occupational Wellness.30* Spirituality and Values.16.23*.01 Health Orientation Scale Personal Health Consciousness.30* Health Image Concern Health Anxiety * Health-Esteem/Confidence Motivation to Avoid.29* Unhealthiness Motivation for Healthiness.31* Internal Health Control.38*.23*.01 External Health Control * Health Expectations Health Status NOTES: N = 184 for the Holistic Lifestyle Questionnaire; N = 185 for the Health Orientation Scale. MRNI = Male Role Norms Inventory. *p <.001. A hierarchical multiple regression was conducted to examine the contribution of the seven MRNI masculinity factors to personal wellness (total HLQ score) while accounting for age, education, employment, and income (see Table 4). In the first step of the equation, the demographic variables accounted for 14.9% of the variance in HLQ scores (F(4, 185) = 8.09, p <.001). At the second step, the masculinity factors accounted for an additional 10% of the variance (F(11, 178) = 5.36, p <.001), and the change in F was significant: F Change (7, 178) = 3.38, p <.005. The full model accounted for 24.9% of the variance, with education level, income, self-reliance, and aggression being significant positive predictors.

6 170 American Journal of Men s Health / Vol. 3, No. 2, June 2009 Table 4. Hierarchical Regression Results Predicting Holistic Lifestyle Questionnaire Total Scores Variable B β F Step *** Income *** Age Employment Education * Step *** Income ** Age Employment Education * Self-reliance * Aggression * Avoidance Homophobia Achievement Sex attitudes Emotionality NOTES: N = 189, R² =.149 for Step 1; ΔR² =.100 for Step 2 (ps <.005). *p <.05. **p <.005. ***p <.001. Discussion The purpose of this study was to investigate the relationship between aspects of traditional masculinity ideology and the health-related attitudes and behaviors of African American men. The findings indicate that in this sample of African American men, certain aspects of traditional masculinity were related to their health attitudes and behaviors. Specifically, after accounting for participants age, education level, income, and employment status, traditional attitudes about self-reliance and aggression were associated with personal wellness. Self-reliance also related to particular health orientations: being aware of and thinking about one s health, being motivated to avoid poor health and to keep in excellent health, and the belief that one can exert an influence on one s health whether positive or negative. Traditional masculinity norms about controlling the expression of emotion were associated with particular health orientations as well: anxiety about one s health and the belief that one s health status is determined by experiences and influences outside of one s personal control. In the research literature, self-reliance has most often been associated with not seeking help for psychological problems (e.g., Mansfield, Addis, & Courtenay, 2005; Ortega & Alegria, 2002). In studies using the Conformity to Masculine Norms Inventory, one study of Kenyan and U.S. men revealed that conformity to self-reliance norms was not associated with health-related behaviors (Mahalik et al., 2006), whereas in a study of Australian men, self-reliance norms related to behaviors that put one s health at risk (Mahalik, Levi-Minzi, & Walker, 2007). However, the current findings are mostly consistent with Powell s (2007) study of African American men, where self-reliance moderated the relationship between racial discrimination experiences and health status. These contradictory findings suggest that there may be cultural factors associated with how self-reliance norms are perceived in different racial/ethnic groups. For example, the concept of self-reliance has been used as a means for improving health care with Cherokee men (Lowe, 2002). According to Lowe (2002), the adult male Cherokee perceives and demonstrates self-reliance through being responsible, disciplined, and confident. Perhaps the African American men in this study perceive self-reliance in a similar fashion, which would be a basis for taking care of one s health. Traditional masculinity norms related to aggression were also related to behaviors conducive to one s health. However, the reliability of the scale measuring aggression was low; so the particular norms on the scale were examined for their relationship to health behaviors and orientations. The norm that Men should get up to investigate if there is a strange noise in the house at night related to personal wellness and certain health orientations (i.e., Motivation to Avoid Unhealthiness, Health- Esteem/Confidence, and Internal Health Control). This norm suggests that men should be brave, daring, and fearless. Such qualities would possibly relate to caring for one s health. In a related qualitative study using this sample of African American men (Wade, 2007), a frequent reason that men stated that they did not go to the doctor was because of fear fear of finding out that there is something wrong with one s health. From this perspective, it would take courage to check on the status of your health with a physician and risk finding out that you need medical intervention. The norm that Boys should be encouraged to find a means of demonstrating physical prowess related to Motivation for Healthiness. This norm suggests that being physically fit and demonstrating fitness is desirable. It follows that a man who subscribes to such a norm would also value being healthy. The norm that

7 Masculinity and Men s Health / Wade 171 When the going gets tough, men should get tough related to Personal Health Consciousness and Motivation to Avoid Unhealthiness. Being tough suggests a physical hardiness (as well as emotional), which would relate to being concerned about and caring for one s body and physical health. Finally, the norm that A man who has no taste for adventure is not very appealing related to Anxiety About One s Health. This norm associates masculinity, or being a man, with risk taking. Men who believe in taking risks may be more anxious about the status of their health because of the behaviors that put their health at risk. Traditional masculinity norms about controlling the expression of emotion were associated with anxiety about one s health and the belief that one s health status is determined by experiences and influences outside of one s personal control. The construct of restrictive emotionality has been investigated using several scales, most commonly the Restrictive Emotionality Scale of the Gender Role Conflict Scale (O Neil et al., 1986). In research using the Restrictive Emotionality Scale, restrictive emotionality has related to trait anxiety (Cournoyer & Mahalik, 1995; Young, Pituch, & Rochlen, 2006) and externally oriented thinking that is characteristic of alexithymia (Young et al., 2006). It may be that health anxiety is subsumed under the more general trait anxiety, and external health control is subsumed under the more general externally oriented thinking that is associated with restrictive emotionality. There are several limitations to this research that deserve mentioning. Although the results show relationships between the variables, it is important to note that the findings of this study do not mean that there is any causality between the factors for which there were significant correlations. Furthermore, many of the correlations were small, leaving a lot of the variance unaccounted for. The findings are limited in terms of their generalizability to other African American men. For this study to have greater significance, a larger sample size with a diverse sample is needed. Future research could examine whether the relationships found among the variables are replicable in other populations, for example, African American college students and men from other socioeconomic statuses and geographic regions of the United States. Future studies should also attempt to discover what other psychosocial factors contribute to African American men s health-related attitudes and behaviors. It would be enlightening to further investigate how sociodemographic variables (e.g., age, education level, income, employment status, marital status, children) have an effect on men s health behaviors. Implications of the findings in this study concern the assessment of health risk behaviors as they relate to masculinity ideology. Masculinity attitudes about self-reliance may be ones that should be encouraged as a means for promoting caring for one s health. Aggression norms could be reconstructed and applied to caring for one s health. Societal and community interventions could involve the development of programs and public announcements that are race and gender specific and associate manhood and masculinity with care for one s health. Such initiatives and programs have begun for African American men, for example, the National Cancer Institute s national campaign that encourages African American men to eat nine servings of fruits and vegetables a day to help prevent cancer and other health problems. Similar to the National Institute of Mental Health s Real Men Real Depression promotion where traditional norms of courage are applied to help seeking ( It takes courage to ask for help ), health promotion targeting African American men could incorporate traditional norms of self-reliance and associate masculinity norms of physical fitness, prowess, and toughness with caring for one s health. As such, addressing men s masculinity ideology is a potential way by which gender disparities in health among African Americans can be addressed. References Barnett, E., Casper, M. L., Halverson, J. A., Elmes, G. A., Brahan, V. E., Majeed, Z. A., et al. (2001). Men and heart disease: An atlas of racial and ethnic disparities in mortality. West Virginia University, Morgantown, WV: Office for Social Environment and Health Research. BlackDemographics.com. (2006). Blueprint of Black America. Retrieved March 15, 2008, Copenhaver, M. M., & Eisler, R. M. (1996). 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