Men's mental health and interventions tailored to masculinity: a scoping review

Masculinity norms, characterized by specific behaviors, thoughts and emotions that are considered socially appropriate for both Eastern and Western men, have been perceived as obstacles to seeking professional help, especially in situations where men are mentally distressed. This scoping review aimed to gain insight into the different factors that affect men’s mental health and explore the different types of interventions tailored to masculinity conventions. Research published between January 2018 and June 2023 was examined using keywords to extract relevant studies from PubMed, CINAHL, SCOPUS and Web of Science, with discussion and cross-checking by both authors. Twelve studies consisting of six randomized-controlled trials, four qualitative studies and two mixed method studies were identified. A variety of interventions were identified in this review, including soccer-related physical activity-based interventions, online interventions, therapeutic counseling interventions that integrate interviews and cognitive-behavioral group therapy, and interventions using expert networks. The need for online interventions that consider traditional masculinity norms in encouraging help-seeking behavior, and the effectiveness of support groups in providing a safe space for men to discuss their mental health, are key findings. As a public health issue, men’s mental well-being is substantially significant, and tailored interventions are needed to support men’s mental health. Therefore, the implementation of effective interventions and the active role of policy makers in promoting mental health awareness for men is also required. Based on these findings, strategies to engage men in mental health services


Introduction
Men's mental health is a focus area for improving population health worldwide [1].Major depression is one of the most common mental illnesses, and can lead to suicide; however, only a third of those suffering from severe depression seek treatment from a mental health professional.Multiracial, Native American/Alaskan Native, Black/African and Latinx/Hispanic Americans have reported an increase in mental illnesses such as anxiety and depression in recent times [2].Post-COVID-19, interest in mental health has been growing, and the mental well-being of men is no exception [3].Even in non-pandemic situations, men search for and cope with help differently than women, and face unique difficulties.Specifically, men's social support networks, or how they seek or mobilize social support is not well known [4].In 2020, the World Health Organization investigated recent evidence published in English and Russian studies on the role of socially constructed masculine norms in the help-seeking behavior of men with mental health issues.According to the report, men are less likely to ask for help with mental health problems and far more likely to commit suicide than women [1].To understand this phenomenon, it is necessary to understand the meaning of masculinity for men and examine the theories behind it [5].
Masculinity is defined as a set of thoughts, feelings and actions that are generally considered suitable for men.Notably, it includes aspects that are considered inappropriate for men and "banned" as being opposing of masculinity [6].Masculinity refers to the expression of a dynamic and often contradictory gender.These behaviors exist in a hierarchy and range from the dominant ways of being male, such as being a "breadwinner" or "independent", to the marginalized expressions of masculinity, such as being "homosexual" and "indigenous" [7].Masculinity has been reported as one of the reasons why men are reluctant to report mental health problems or seek professional help [8,9].A recent study of 13,884 Australian men reported that compliance with masculine norms significantly increased men's risk of suicide attempts [10].This finding is supported by a systematic review of the role of masculinity in situations where depressed men engage in help-seeking behavior, which confirmed the problematic effect of compliance with traditional masculinity norms on how men experience depression and seek help [11].Generally, traditional masculinity norms prevent men from seeking help for psychological problems.Specifically, the social expectations surrounding masculinity play a role in shaping men's mental health experience and influencing their behavior, attitude and emotional expression [1].Increasing gender role-related conflicts, such as traditional masculinity related to mental health, increases men's selfstigma and consequently adversely impacts men's attitudes toward seeking mental health services [12].
Social role theory (SRT) is one of the leading theories on gender roles related to masculinity and proposes that the biological differences between men and women differentiate their required roles in society.SRT posits that men are larger, faster and have greater upper-body strength than women [13].Additionally, social identity theory suggests that the group to which people belong is a major source of individual selfesteem.Belonging to these groups provides a sense of social identity and belonging by categorization, social identification and social comparison [14].These traditional theories address a variety of factors, such as culture, family, education and media, that influence men's mental health, behavior and attitudes.In certain cultures, there may be societal expectations that men should find it difficult to express their emotions or avoid doing so.This may cause men to try to suppress their emotions or process them in other ways [13,14].In a mediation model, masculine norms were linked to self-stigma and attitudes toward counseling.Self-stigma and masculinity lead to negative beliefs, such as loss of status, autonomy and damage of identity [15].These theories explain why masculinity may have forced men to conceal their emotions in an attempt to demonstrate traditional masculine traits, particularly when faced with psychological problems such as depression or suicidal thoughts.This adherence to traditional masculinity limits men's health-seeking behavior, resulting in the suppression of emotional expression and the use of maladaptive coping strategies such as avoidance, thereby leading to depression and increased suicide rates [11,16].Therefore, it is important to develop interventions encouraging help-seeking behaviors in consideration of masculinity and self-stigma.
From this background, it is possible to understand the wide range of factors that affect men's health practices and engagement in health promotion [8].Tailored interventions that deal specifically with masculinity are needed to meet the specific needs and preferences of men to promote their mental well-being, and prevent or treat their mental health problems.These interventions enable the use of strategies that challenge the harmful aspects of masculinity, which can contribute to mental health problems, while recognizing and operating within the framework of traditional masculine norms and roles [17][18][19].To provide specific care appropriate for the male gender, a treatment approach is needed that adapts to and accommodates male and masculine diversity [20].Recently, male-specific psychoeducation programs have demonstrated effective reduction in negative affect, such as feelings of shame and depressive symptoms, while simultaneously increasing therapeutic adherence [17].A study using support groups as an intervention method reported that it was effective in enabling unique and tailored mental health support, providing a safe space to reconstruct traditional masculinity norms through the development of specific roles within the group [8].Further, a multimedia intervention called ManUp that includes documentaries and digital campaigns, has been developed and its effectiveness confirmed [21].Another study that evaluated the effectiveness of websites in promoting help-seeking and conversations about suicide, mental health and seeking help reported that media-based public health interventions could provide suicide prevention interventions and encourage help requests from men [22].However, it is unclear what these interventions are and how they relate to masculinity [21].
Therefore, the time is apt to review interventions that have been provided to address the unique vulnerability that possesses men seeking help in relation to the norms of masculinity and examine how these interventions work.This study employs a scoping review, a relatively new approach to evidence synthesis that aims to identify knowledge gaps, scope the literature, clarify concepts or investigate research behavior [23].A scoping review also provides a useful alternative to a literature review when a clearer explanation of a concept or theory is needed [24].
This study gathers insight into the various factors affecting men's mental health through the scoping review process, explores the different types of custom interventions applied, and evaluates the results and effects of these interventions.Our findings can inform the design of more practical and effective interventions to address future research directions regarding intervention, policy development and men's mental health issues.

Methods
This scoping review explored available evidence related to men's mental health and tailored interventions related to masculinity published between January 2018 and June 2023.A scoping review is a useful tool in evidence synthesis approaches.It is conducted to distinguish between the types of evidence available in each field, examine how research related to a particular topic has been conducted, clarify key concepts and identify knowledge gaps.It is also helpful as a precursor to a systematic review [23].Therefore, the proposed scoping review was conducted in accordance with the Joanna Briggs Institute (JBI) methodology for scoping reviews [25].

Eligibility criteria
The eligibility criteria were related to the review's objective and questions.The specific question of the scoping review should be explained in the protocol and clearly linked to the objective of the review.We used JBI's population, concept and context (PCC) framework [25].The selection criteria for analysis were as follows: (a) population: only male adult participants, aged 18 or older; (b) concept: an intervention or program for men's mental health (e.g., randomized-controlled trial (RCT), pre-post, quasi-experimental and qualitative study to identify men's mental health coping strategies); and (c) context: a recent men's mental health intervention related to masculinity (research articles published in academic journals from January 2018 to June 2023).Using the PCC framework, our research question in this study was as follows: "How are the current status of men's mental health and tailored interventions to help them related to masculinity?".

Search strategy and information sources
A search strategy was drafted for one or more electronic databases, including planned limits, such that it could be repeated.All intended sources of information, such as electronic databases, contacts with study authors, or other gray literature sources were described [25].
We searched for studies dealing with men's mental health and interventions tailored to masculinity among research articles published in academic journals from January 2018 to June 2023.PubMed, CINAHL, SCOPUS and Web of Science were searched for published articles using the following keywords: (Men OR Masculinity OR Male OR Gender) AND (Helpseeking OR Engagement OR Service use) AND (Mental health OR Depression) AND (Culture).The following search terms were used: English language, full-text available, published between January 2018 to June 2023, and male participants.An additional manual search was performed on PubMed.
In total, 1916 articles were retrieved from the across databases.PubMed yielded 939 articles, CINAHL yielded 37 articles, Scopus yielded 638 articles, and Web of Science yielded 302 articles; of these, 214 duplicate articles were excluded.The two authors reviewed the titles and abstracts of the remaining 1702 articles.After excluding 1671 articles that did not meet the selection criteria, 31 articles remained.The full-text versions of these 31 articles were obtained and individually reviewed by the two authors, and the references of each study were also individually reviewed to determine the final sample of selected studies.Finally, 12 studies were included in the analysis.The detailed search process for data collection, selection and extraction was conducted following the PRISMA 2020 (Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020) flow diagram (Fig. 1).

Data extraction
Extraction of evidence was conducted to present the findings of the scoping review clearly and comprehensibly [25].Each author in this study extracted data using a data extraction sheet that presented conceptual categories such as authors, publication year, research country, study design, sample (population) and intervention or strategies [25].For data extracting, the two authors engaged in discussions and cross-checking.

Data analysis and presentation
Scoping reviews typically do not involve data synthesis but rather focus on descriptive analysis, often employing basic frequency analysis and percentages as the most common approach [25].In this study, data were analyzed both quantitatively and qualitatively.In the quantitative analysis, descriptive statistics used the characteristics of the 12 selected studies, including authors, publication year, research country, study design, sample (population), and intervention or strategies.For the qualitative analysis, the research findings were analyzed and categorized in accordance with the research questions (Table 1).

Characteristics of selected literature
Based on the scoping review, 12 studies were included.Their characteristics are presented in Table 1.First, in terms of the published year, there were five from 2023, three in 2022, one each from 2020 and 2019, and two from 2018.In terms of the origin countries of these studies, four were from the United States, two from Germany, and one each from Australia, the United Kingdom, Denmark, Kenya and South Africa.In terms of research design, RCTs and qualitative research were the most common, and there were two other mixed methods studies.Only adult male participants were considered, and their number ranged from at least 3 to 1193.

Tailored interventions related to masculinity and men's mental health
The identified interventions were highly diverse.First, one study provided physical activity as an intervention so that soccer could be played three times a week.The study tested the effectiveness of behavioral interventions using soccer training to reduce the risks associated with HIV and drug use.The experimental group attended soccer three times a week and its effectiveness were evaluated six months later [26].Two online interventions allowed visitors to navigate the website and alerted them to immediate risks.These studies evaluated the effectiveness of man therapy (MT), a randomly controlled online intervention experiment, in reducing suicidal thoughts and depression in working-age men [16,29].
Another study provided 14 weeks of cognitive behavior group therapy and used a discourse analysis approach to investigate how traditional masculinity features affect men participating in cognitive-behavioral group therapy [15].Two studies provided male-tailored psychoeducation for depression, which included information on the gender-specific etiology and role, comparing its outcomes with standard cognitive behavior therapy [27,30].
Another intervention study featured family-centered behavioral correction and developed a program called intervention, learn, engage, act and dedicate (LEAD) by including motivational interviews based on behavioral activation [31].A study on social media-based support interventions for young Black men examined 40 out of the 350 young Black men who had completed social media-based mental education programs for mental health promotion, gradual definition of masculinity, and sustainable social support [28].In addition, one study was on Dynamic Interpersonal Therapy (DIT) [32].DIT is a time-limited (16 sessions) psychodynamic model based on the editing of evidence-based short-term psychoanalysis or psychodynamic therapy for masculine depression.Here, the male depression scale was used, rather than a general depression instrument [32].Another study was of mental distress counseling intervention through interviews [8].
One study used documentaries and digital campaigns, and developed a multimedia intervention called "ManUp".Seventeen men of various ages and backgrounds were interviewed to determine if the multimedia materials aroused interest in the subject matter [21].Finally, one study used the "multiple hub and spoke" approach and employed 13 key men working in the field of male mental health both inside and outside the UK, to collected data mainly through interviews in the broader geographic and professional community context where they had a network.The study examined "what is effective" in promoting mental health for men [5].The summarized contents of the interventions featured in the analyzed studies are presented in Table 1.

Discussion
This scoping review investigated recent studies to explore various types of interventions to promote men's mental health tailored to masculinity norms.Overall, studies focusing on men's mental health promotion interventions are still limited [21]; however, the results drawn from existing literature are discussed below.

Overview of the identified interventions and effectiveness of tailored interventions
The interventions identified in the scoping review varied widely, as presented in the results section.This is similar to previous scoping reviews that highlighted the diversity of approaches used to address men's mental health [1,33].One intervention used physical activities such as soccer [26], four used online interventions [16,21,29,31], six corresponded to therapeutic counseling interventions including interview and cognitive behavior group treatment [8,15,27,[30][31][32], and one intervention used expert networks [5].Thus, the majority corresponded to online and therapeutic counseling interventions.These results are similar to those of a scoping review of studies published in English and Russian from 2009 to 2019 [1].The potential benefits and limitations of each intervention should be discussed to address the unique challenges and difficulties men face in seeking help and exploring masculine norms [5,8,11,15].As compliance with traditional masculine norms has a problematic impact on men seeking assistance for multiple mental problems [11], customizing and targeting clinical interventions can improve men's mental health [18][19][20].Interviews lasted between 45 min and 1.5 h.
Participants were asked about their life and background, their experience of mental distress and why they came to attend the group, their experiences of attending the support group and in what way it helped them to manage their distress.A "multiple hub and spoke" approach was used to assist data collection.The focus of data collection was on "what works" in mental health promotion for men.Data were analyzed using thematic analysis techniques.

RCT: Randomized-Controlled Trials; *Protocol development (trial results cannot be found).
Therefore, it is necessary to confirm the effectiveness of the interventions applied to improve the mental health outcomes of men.Results of the study that applied soccer to the experimental group thrice a week, reported after six months that it was not effective in addressing various risk behaviors in young people, suggesting that early adulthood may be too late to change established risk-behavior [26].Therefore, it is evident that the age of the participants must be considered when employing interventions such as sports that involve physical activities, though this needs to be confirmed through further research.However, the results of studies applying various online interventions were helpful in improving men's mental health [16,21,29,31].An online intervention designed for men, MT, reduced suicide risk, stigma and depression [16], while encouraging men to seek professional help [29].Another online intervention called "The Young Black Men, Masculinities and Mental Health" (YBMen, Young Black Men) project provided a multimedia intervention with online social support to reduce depression [31].To prevent men's suicide, a multimedia intervention, "ManUp", was incorporated into an online program to revise and improve website images and messages using feedback from male participants [21].These online interventions used platforms such as Facebook or Twitter to deliver and advertise [16,21,29,31].However, careful design of online programs may be necessary, and some of the reviewed studies presented high deviations among men [34]; results on the effectiveness of online programs are also complex [33].The results of the six studies corresponding to therapeutic counseling interventions, including interviews and cognitive behavior group therapy, are as follows.A study that applied group cognitive behavior therapy found that practicing expressing emotions in group therapy could help break the stigma of masculinity-related mental health, even though men did not expect such practice to help them [15].Thus, it is necessary to provide men with opportunities to express and share their thoughts or feelings in small groups.The studies on maletailored psychoeducation for depression provide information on the gender-specific etiology and role to the participants and compared outcomes with standard cognitive behavior therapy.An intervention called learn, engage, act and dedicate (LEAD) applied motivational interventions to nine fathers who reported problem drinking, based on behavioral activation and was found to be highly accepted and helpful [31].DIT is an effective counseling intervention for veterans form a military culture and hegemonic masculinity.Gender norms can be changed through training, and interpersonal therapy can relieve rigid gender norms [32].Another study of men's experience with mental health support groups identified the social benefits that support groups may have in men who have limited social networks or are experiencing isolation [8].A support group is an organized group where people come together to share their health issues.The results of this study highlight how men in the group valued the shared understanding of experience and the mutual respect presented by the group environment.Thus, the effectiveness of peer support groups is presented, and corroborates previous findings that support from important people and online peer groups are effective [1].
Additionally, using an expert network, a multi-level project involving interviews, gray literature and survey, could be effective in identifying strategies to instill effective coping mechanisms in men for suicide prevention [5].These findings show that men can reduce the negative aspects of masculinity by expanding their limited social network through support groups, sharing their experiences and understanding each other.

Addressing masculinity and gender norms
We then examined how the identified interventions affect masculinity and gender norms.Here, we would like to discuss the harmful aspects of traditional masculinity that these interventions challenge and their positive impact on male mental health within the framework of masculine norms.Theories have been proposed on traditional masculine norms to specify how they affect men's depression and suicidal thoughts, and lead men to try to hide their emotions to prove their masculinity [13,15,16].A multiple-expert network study to identify strategies for suicide prevention suggests preparing safe spaces in which men feel comfortable, providing male-centered language and activities that allow men to feel valued and engaged, establishing appropriate partnerships and understanding gender and masculinity.In addition, the intervention needs to be direct and purposeful [11].
Online interventions conducted in a gender-responsive manner to help reconstruct healthy definitions of masculinity suggest that online screening can play a role in reducing suicidal thoughts and depression among men, with potential benefits associated with mental health, social support and treatment motivation [16].The interventions in these studies were as follows.All participants received standard treatment online, including immediate feedback on their personal screening outcomes on the website and recommendations of suicide and mental health resources.After receiving personalized results, participants were guided to browse related websites in a new web browser related to engaging men in psychotherapy, including the use of male-oriented language and metaphors.The main strategies to engage men involved hope, resilience and humor.MT provided male-oriented marketing, free online use, a more visual design, information tailored for men and anonymity [16,29].The YBMen project considered masculinity norms, culture and gender in their intervention for young Black men [32].ManUp, a multimedia campaign website to prevent male suicide and correct masculine identity issues, revised the documentary synopsis with strong direct language and statistics, and used simplified humorous platform banners that considered multicultural diversity and varied sensitivity levels in men [21].
Although online interventions have been shown to be effective in this review, it should be considered that some men at risk of suicide may not prefer online support, at least as much as women do [35].Men traditionally view asking for help as non-masculine; however, further intervention studies are required to identify the impact of web-based methods on men's search for help [29].The study that developed and applied LEAD [8] in relation to customized treatment for men suggested the following: It is about taking an open and evaluative approach toward men, using male counselors with common traits, dealing directly with masculinity norms in treatment, and building strong treatment alliances.It is noteworthy that dealing directly with masculinity in treatment was effective [31].Relationship therapy can also help some men reframe their identities in relation to their rigid gender norms [32].Another intervention that examined the effectiveness of support groups by forming a peer group comprising men who had experienced similar psychological distress such as depression, anxiety, loneliness and isolation, allowed participants to develop new roles and regain their masculine identity [8].Although group therapy provides strategies to counter the stigma associated with mental health problems, therapists should consider that patients with strong masculine norms may have difficulty expressing their feelings in group therapy [15].Masculine identities shared through support groups allow for expression of emotional vulnerabilities that may still be unacceptable.In addition, being with other men with shared experiences in the support group context facilitates the reconstruction of masculinity in a healthy way [8].In other words, interventions using support groups can help rebuild masculinity in a healthy way through shared experiences.However, it is most important to give men an opportunity to express their emotions even in group interventions.

Policy implications and practical applications
Recognizing men's mental health as a key public health issue is essential, and customized interventions are needed to support men's welfare.Policymakers should actively implement and support effective interventions to this end, and promote mental health awareness among men.
As this is a scoping review, there may be limitations to the data comparison and the analysis results are not as comprehensively presented as a review that presents research conducted through different methods, samples and analyses.Therefore, it is necessary to discuss what the reviewed studies have in common, how these interventions can reduce the negative aspects of masculinity in seeking help and encourage men's helpseeking behavior.Studies identified in this review commonly found that the influence of masculinity according to SRT limits health-seeking behavior [13], suppresses emotional exposure, and leads to maladaptive coping strategies such as avoidance.
Based on this review, strategies should be considered to engage men in mental health services, strengthen social support networks, and challenge harmful male norms within the medical discipline and the community at large.In addition, it may be useful to design an intervention that respects diversity by considering the differing characteristics of men and women [33].However, men are not a homogeneous group and a single approach may not be effective for all men [34].Future studies must employ innovative approaches such as technology-based or community-based programs.
The results of this scoping review are also linked to the role of masculinity in the psychological help-seeking process.However, future studies require experimental and intervention studies on participants of various cultures and ages to strengthen existing knowledge.Follow up studies on what form of intervention or program can help improve men's men-tal health while minimizing the negative aspects of masculinity will be required.
This review has certain limitations.We chose to examine studies from the last five years, as several interventions related to male norms were developed in this period.However, we likely missed out on several older studies that may have provided invaluable information; thus, it is necessary to expand the publication period and include them as a subject of review.In addition, our inclusion of only literature in English and the small sample size of some of the reviewed studies may have skewed our findings.

Conclusions
The goal of this scoping review was to gain insight into the factors affecting men's mental health and explore the different types of interventions tailored to masculinity norms.The review confirmed the importance of online interventions, the impact of traditional masculinity norms on help-seeking behavior, and that value of support groups in providing a safe space for men to discuss their mental health.
Our findings contribute to the understanding of men's mental health and the development of effective tailored interventions, confirming the need to address the harmful aspects of masculinity within the framework of traditional male norms.Moreover, practical interventions are needed to enhance men's understanding of mental health and improve the effectiveness of customized interventions.Continuous efforts to promote men's mental well-being and support their unique needs are necessary, and thus this scoping review can be of value.

AVA ILABILITY OF DATA AND MATERIALS
The data presented in this study are available on reasonable request from the corresponding author.

A UTHOR CONTRIBUTIONS
SK and SY-contributed to the design of this study, conducted searches, screened studies, evaluated the quality of the paper, drafted the manuscript.All authors read and approved the final manuscript.

ACK NOWLEDGMENT
We thank the researchers who are working to improve men's mental health.

F UNDING
This research received no external funding.