The Sisyphean Task of Nursing: Muscular Roles and Masculine Responsibilities of Malayalee Male Nurses

*Cinoj George and Feyza Bhatti*

## **Abstract**

Hospitals all around the world are failing to keep up with demand due to an aging staff and a rising population. India has a severe shortage of nurses and the number of males entering the nursing profession has increased significantly over the last two decades, which shows that Indian men are eager to seek careers in nursing. Their experiences in the profession, however, has not received significant attention. This chapter aims at exploring the work experiences of male nurses in a profession in which workforce is predominantly female. A total of 45 participants from three major cities in Kerala were recruited for the study using a qualitative phenomenological approach. Semistructured face-to-face interviews were used to collect the data and thematic analysis were used. Four key themes were found. Male nurses had individual motivation to choose the profession, but over time, they have become discouraged and disillusioned with it. Male nurses were reticent to advocate nursing to other males because they saw no future in the profession. The study highlights the difficulties that male nurses encounter, and if these difficulties are not addressed, there may be a significant decline in the number of males choosing to pursue careers in nursing.

**Keywords:** male nurses, gender, recruitment and retention, qualitative study

## **1. Introduction**

The Covid-19 outbreak, which has ravaged the world over the past 2 years, has certainly put healthcare and caregiving in the limelight. The pandemic and its aftermath continue to transform healthcare delivery in the twenty-first century. How care is administered has never been more varied, including where, when, how, and to whom it is offered. Although the way care is delivered is changing and becoming more visible, it has not been able to successfully duplicate diversity in the caregiving profession [1]. Nursing has long been considered a female-dominated profession, and males have long been seen to be incapable of doing nursing duties as well as women [2].

Ninety percent of the world's nurses are women, and the pandemic has exposed the global nursing deficit that most nations are experiencing. This has reignited calls for more male nurses to join the profession to fulfill the growing demand [3]. Nursing is a profession in which the primary responsibility is to provide care to patients, and it is a human experience. It is not necessary to belong to a specific gender to provide care to another individual. Throughout history, men have made significant contributions to nursing, and they continue to do so in many nations, despite their small numbers. When male nurses chose nursing as a profession, they have the same good aims and motives as female nurses, yet they are unwanted and are often seen as not on par with female nurses [4–6].

Males have a long history in nursing in India; the first nursing school in the world, which opened in 250 BC, was exclusively for men. Before Florence Nightingale gave nursing a new meaning as a profession requiring female compassion and empathy, men nurses were highly active in providing care. According to a new study, Indian male nurses were highly active in the early twentieth century, particularly in the final two decades before independence [7]. A limited amount of male nurses were found in several regions, including Southeast Asia (21%), the Western Pacific (19%), Africa (35%), the Americas (14%), and the Eastern Mediterranean Region (21%) in the gender equality workforce study based on available multiple sources [8–15],

Men typically rule most occupations, yet there is a handful where female employees prevail [2]. One industry where women outnumber males in the workplace is nursing, where there is a very high level of gender segregation in comparison to many other industries. Nearly every country has male nurses, however, the proportions vary depending on which country they are in. In general, there are between 9 and 12% of male nurses in English-speaking nations such as the United Kingdom, USA, New Zealand, and Australia [16]; however, this figure substantially decreases to between 2 and 6% in Asian nations such as China and Korea [17–19]. Since the early 2000s, India has seen a steady increase in the proportion of male nurses, which now exceeds 20% [20]. Even though there are more male nurses in India, there isn't much research on them compared with other nations where men make up a smaller proportion of the nursing workforce.

Due to male nurses being a minority, a very unwelcoming door has opened up, exposing them to situations they weren't used to, such as encountering prejudice, preconceptions, and disparities from the three P's (peers, patients, and public) [1, 21]. According to one study, the necessity and significance of male nurses were generally disregarded and even accepted [22, 23]. Men's potential contributions to nursing were not emphasized; rather, the paucity of male nurses was only considered the inevitable result of prevailing societal mores and attitudes. The lack of assistance and study for male nurses merely exacerbates their situation; it has turned into a festering sore that won't cure. Male nurses' ability to provide the patients with the best care possible is hampered by the societal stigma associated with selecting a career that is unusual for males. Additionally, the stigmatization makes it challenging for male nurses to adjust to and perform as males in a job where women predominate [24, 25].

The stigmatization permeates every aspect of life, not just the job. The stigmatization starts in the classroom, where there are often more female students than male students. Male nursing professors struggle to teach as much as a male nursing student struggles to learn, and they both are equally stigmatized [22, 24, 26]. Degendering occurs as a result of the difficulties male nursing instructors and students experience to become more prominent nursing practitioners. To put it mildly, few people are aware of the difficulties male nurses experience and the coping mechanisms they use, particularly when degendering [27].

*The Sisyphean Task of Nursing: Muscular Roles and Masculine Responsibilities of Malayalee… DOI: http://dx.doi.org/10.5772/intechopen.106276*

Although data demonstrate otherwise, stereotypes that male nurses lack compassion will only harm the profession, promote division, and thwart attempts to achieve gender equality for all nursing personnel. They also make the worldwide nurse shortage, which is already at a breaking point, worse [28]. The lack of workplace diversity is another impact of the shortage of male nurses, which effectively denies patients of both sexes a caring environment that is holistic and loving. Due to the physical and emotional stress that preconceptions and stereotypes induce, men may continue to leave the nursing profession if prejudices are not eradicated [29].

The pandemic has amply demonstrated to the public what a health worker shortage may be like and the harm it might do. To achieve the very minimum required for caring for its population, India requires more than 2.4 million nurses. Despite the high need for nurses, an increasing number of Indian nurses are leaving the country in search of better prospects in the Middle East and Europe [30]. To analyze the contextual variables influencing the career trajectories of Malayalee male nurses and propose policy recommendations to attract and retain male nurses, this study will focus on their work experiences. Studying the work experiences of Malayalee male nurses in Kerala may also offer insightful information on how to attract and keep male nurses in other Indian states that have a similar nursing shortage. However, researching Malayalee male nurses can help us better understand how masculinities and gender play a role in the nursing profession across a range of social and cultural situations.

### **2. Background**

The study focuses particularly on the challenges faced by male nurses in Kerala, a state in southern India. Malayalee is the name given to the Malayalam-speaking population of Kerala. Kerala was chosen for the study because, compared with the other 28 states in India, it has consistently produced more nurses over a lengthy period. Due to the historical and cultural consequences, Kerala has been at the forefront in bringing progressive attitudes toward women. While much of India had a patriarchal family structure, Kerala had a matrilineal structure that allowed women to choose to work outside the house. Additionally, women from Kerala who opted to become nurses came from middle- and high-income families rather than low-income ones [30]. The rationale for this choice is that going into nursing gave women the chance to be more independent and to have greater job chances without having to compete with males in the workplace. The potential for migration to oil-rich Middle Eastern nations and several European nations was another factor in the decision to pursue nursing [31].

It was also in Kerala, UNA (United nurses association) was formed as a union to protest against the working conditions in private hospitals. There have been many protests and strikes since its formation all over India, and male nurses were at the forefront of the protests [32]. Since Kerala and Malayalee have been at the helm of it all, it was only a natural choice for the study.

### **3. The study**

#### **3.1 Design**

The most suitable approach for this investigation was thought to be a qualitative one. In general, qualitative research enables in-depth examination of the phenomena being studied while taking into account nuances and complexities [33]. The subject of this study, which elaborates on a phenomenological study, is the lived experiences of male nurses in Kerala and how becoming a nurse affects their masculinity. Face-toface, semistructured interviews took place at a location that was convenient for the participant of the study. Three significant metro cities in Kerala were chosen for the study (Kochi, Trivandrum, and Calicut).

#### **3.2 Participants**

For this study, a purposive snowball sampling method was adopted, and a total of 45 participants were recruited for the study. Twenty male nurses from five private hospitals spread across three major cities in Kerala were recruited for the study. Only nurses who were currently employed and had been working in hospitals consistently for more than 3 years were included in the research. Additionally, human resources managers of the five hospitals were interviewed too. To understand how female nurses evaluated their male colleagues, a female nurse from the same hospital was interviewed for every male nurse. Male nurses who were questioned often worked in intensive care units (ICUs), operating rooms (18%), and other hospital departments such as ambulatory care, surgical wards, and emergency rooms (12%).

#### **3.3 Data collection and analysis**

Between June and August of 2018, interviews were conducted. The male nurses' interviews included a range of subjects, such as their motivations for choosing the nursing field and their perceptions of the benefits and drawbacks of being a male nurse. The major topics of discussion during the interviews with human resources managers were how they viewed the advantages and drawbacks of female and male nurses, as well as their thoughts on the hiring and retention of male nurses. All of the interviews were captured on audio and then transcribed verbatim. Thematic analysis was used to code the transcripts in Atlas Ti.

The face-to-face, in-depth interviews concerned six phases: thematizing, designing, interviewing, transcribing, analyzing, and verifying. To prevent direct responses from individuals, the question was structured plainly. Malayalam was the language of choice for all participants during face-to-face interviews. Audio recordings of the interviews were made for later transcription. When no novel thought was presented and there was a recurrence of concepts among the individuals, data saturation occurred.

Two researchers conducted a thematic and inductive analysis. The thematic analysis seeks to isolate the most evocative information to derive codes, which are then shrunk and recognized as the most prevalent categories. As a result, groups of codes (categories) were combined into text, allowing themes to emerge that clarified the research participants' experiences as male nurses (self-perspective) or experiences of working with male nurses (female nurses/HR perspective).

Overall four themes emerged, including the reasons for men choosing nursing as a career and its challenges, male nurses as undesirables (cultural), male nurses' desire to change the status quo, and male nurses as undesirable employees due to protests.

The data analysis intended to capture and provide a comprehensive description of all interviews, to interpret the experiences of male nurses from a self-perspective, HR manager's perspective, and female nurses' perspective. Exploring these three perspectives helps the researcher to understand the struggles and coping strategies of male nurses and how they were bargaining for their masculinities in a female-dominated environment.

*The Sisyphean Task of Nursing: Muscular Roles and Masculine Responsibilities of Malayalee… DOI: http://dx.doi.org/10.5772/intechopen.106276*

#### **3.4 Ethical consideration**

Ethical approval was granted by the authors' institution's ethics committee. Additionally, participants were made aware of their ability to pause or end an interview as well as their 6-month withdrawal window from the study following the interview. A number was assigned to each audio recording and paper so that participants could not be specifically identified by name and participants were also made aware of this. As a result, all identities stated in the interviews have been changed, and the nurses who participated in the study have been given a pseudonym to use when reporting the results. Everyone who participated in the interview signed a permission form after receiving assurances about the confidentiality and anonymity of the information gathered.

#### **3.5 Credibility and qualitative rigor**

Credibility, confirmability, dependability, and transferability were used to evaluate the reliability of the qualitative study results [34]. Credibility was attained through continuous interaction with the study subjects and data and sustained interaction through repeated reviews of the interviews. Additionally, it was made guaranteed by including all of the study's objectives in the semistructured interview guide's design. To proofread and offer ideas, the researchers' coworkers received the initial draft.

Regarding confirmability, all procedures in the study including research phases and data collection methods were meticulously documented. Several research colleagues were also given access to the research procedure to verify its objectivity. By having the research's conclusions reflect those of the participants rather than the researchers, confirmability was attained. This was accomplished by verbatim transcribing the data and using verbatim quotes to support the findings.

Another external auditing was employed to compare and contrast the researcher's understanding and the external auditor's understanding of the issue to gauge dependability.

For the reader to have a favorable opinion of data transferability, the researcher attempted to completely describe the context in which the study was done by providing an accurate description of the participants, sampling procedure, and time and location of data collection in detail for the study to be replicated in the future.

## **4. Findings**

#### **4.1 Theme 1: the reasons for men choosing nursing as a career and its challenges**

According to the research, all male nurses chose the profession on their own. They were inherently motivated to pursue nursing as a career. In some instances, male nurses had to convince their families to let them pursue nursing. In Kerala, parents and close relatives have a strong say in what a family member must pursue academically. Nursing is not a career parent in Kerala want their children to pursue as it was considered feminene. Eighteen out of 20 male nurses cited the success of female nurses as a reason to become a nurse. The success of female nurses in this particular context was their ability to secure jobs in developed countries.

*I had to fight with my family when I told them I want to be a nurse. My parents could not believe that I want to be a nurse. They wanted me to join a business course, but I saw*  *no opportunity as the industry was saturated and there were no jobs. Most of my cousins had a business degree and had no success in securing a decent and satisfying job. (M 16)*

*I was the only person from my school to go into nursing school, and this was in 2005. At that time everybody wanted to be an engineer, but there were very few colleges at that time and I wasn't sure if I will get admission. I used to see a lot of advertisements about nurses wanted for Ireland. To me, it was better to do nursing and go to Ireland. Nursing was also far cheaper than an engineering degree or business degree. The tuition fee is less, but the return on investment is high. (M 9)*

*In my village, there are many nurses (female) and most of them work in the UK, USA, or Ireland and they are all financially stable. They have a successful career, they have a house in Kerala and one where they work. I don't know many professions where you could be this successful. (M 7)*

Some male nurses chose nursing as a second career. Eight male nurses possessed another qualification before they switched careers to nursing. According to them, it was only natural to do so as there were job opportunities in nursing in Kerala and abroad.

*I decided to become a nurse after finishing my course in biochemistry, in India, there is no scope for biochemistry and I was unable to find any jobs. I did some marketing jobs for Airtel and I decided to pursue nursing after that. (M 19)*

*I did nursing after I met my then-girlfriend and now wife. I was working in customer care and I was not happy with my job, she suggested I do nursing as it would be easier for us to migrate. (M 4).*

#### *4.1.1 Nursing as a tool to migrate*

Though all male nurses had given many reasons why they chose nursing, a common and recurring theme was their dream to find a job in Europe, Australia, and New Zealand or countries in the Middle East such as Oman, UAE, Qatar, Kuwait, and Saudi Arabia. The prospect of working as a male nurse in Kerala through the entirety of their career was not appealing to most. When probed further, 18 participants said they would try their best to find a job overseas, and if they can't they will stop working as a nurse in private hospitals as they found no future.

*I wanted to become a nurse as it has many opportunities abroad. Nursing is the easiest job to get abroad after software engineer. (M 5)*

*I chose nursing to migrate to Quebec, my sister is already working there and as a nurse, I get more points to migrate. (M 11)*

*I have no idea what to do. It is getting difficult to work as a nurse in Kerala as each day pass. I am trying very hard to find a job abroad. I am thinking of doing some courses in Canada as it is easier to get a PR there if I can't get a job as a nurse in the UK. (M 17)*

*I became a nurse with a dream to migrate to the UK. I am preparing for my language tests, if I get a good score I can apply for NHS jobs. This is my third attempt at IELTS* 

*The Sisyphean Task of Nursing: Muscular Roles and Masculine Responsibilities of Malayalee… DOI: http://dx.doi.org/10.5772/intechopen.106276*

*and if I don't pass this time I might give up the idea and look for some other jobs in India or abroad. (M 2)*

Male applicants 17 and 2 failed to get the necessary IELTS scores after several tries. Both of them were undergoing language instruction for the IELTS exam, which is fairly frequent among Kerala's nurses, both male and female. Male 17, who was preparing for his final try at the time of the interview, planned to give up nursing as a profession if he failed the test.

#### *4.1.2 Shelf life for male nurses*

Male nurses chose the career to grow and succeed and to succeed they have to compete with female nurses who dominate the industry and are often more preferred for jobs. In the stiff competition, they face they felt they had only two choices either to shape up or to ship out. Male nurses felt they had an expiry date on their career and if they failed to migrate within that period, which most nurses mentioned before they turn 35, they will not be preferred in any other hospital. Male nurses felt they had to look for jobs in other private industries if they can't migrate. Fourteen male participants mentioned quitting after 35 rather than continuing working in Kerala. Male participants believed they are a liability to the management.

*Male nurses have no future in nursing. After a certain age male nurses are not preferred in our industry, we have a lot of female nurses and the hospitals don't feel the need for having a male nurse. (M 4)*

*Men usually quit nursing after they are 35, now in our hospital men who were one of the first to become nurses are all leaving slowly as they don't see a future in this career. (M 13)*

*I believe a male nurse has 10 to 12 years in the industry before he can make it, if not they look for jobs elsewhere. It is funny that we have an expiration date on our careers. (M 3)*

*Who will hire a male nurse who is bald and 35 years old? When they have young female nurses do the same job. (M 14)*

#### *4.1.3 Challenges to finding a bride: no women wants to marry a man who is a nurse*

Male participants came from three religious backgrounds. Nine were Christians, seven were Hindus, and four were Muslims. Only two male nurses had wives who also were nurses. Fifteen participants were unmarried and three were married to women who had other jobs. Unmarried men shared their apprehension about getting married as they had heard the struggles their peers had gone through. Unmarried male nurses were waiting to get a job outside India before they marry; otherwise, they intended to pursue another career before they look for a prospective bride.

*It is very hard to find a bride, the very first thing my dad told me when I chose nursing was that I will never get married. I think his prophecy is coming true. (M 19)*

*I am 32 years old and I have difficulty finding a bride. No woman wants to marry a man who is a nurse. (M 12)*

*In my community, there are very few male nurses, and no family would let me marry their daughter. Being a Muslim and a male nurse makes my life very difficult. Now I am looking for a female nurse to get married to, but even female nurses don't want to marry a male nurse. It is becoming embarrassing as I get rejected all the time. (M 8)*

*The curse in our job is that everybody makes fun of us, even female nurses make fun of us sometimes saying that we will never marry a male nurse. (M 6)*

As it is common practice in Kerala to have marriages arranged by the family, male nurses feel they are unwanted and incapable of finding a suitable bride. Love marriages are the exceptions and not the norm. Due to their poor pay and society's resistance to accepting males as nurses as it was against the traditional masculine role of men, male nurses are not regarded as desirable candidates for marriage. Three of the male participants said that because male nurses have a lower probability of becoming as successful as female nurses, even female nurses are not interested in marrying one. One of the female participants had something similar to say.

*I don't want to marry a male nurse, not because of his job but because of the problems I might face in the future. If I were to migrate as I intend to, my husband who is a male nurse has fewer chances of becoming a registered nurse, so he might end up working in a non-nursing profession or might become a carer in a care home. Both jobs don't pay well and that might create family problems due to the male ego. I have heard such stories. (F6)*

#### **4.2 Theme 2: male nurses as undesirable due to prevalent cultural beliefs**

Male nurses in Kerala have to fight the perceptions of the three P's (Peers, Patients, and the Public). Male nurses feel that the efforts they put in are often overlooked and though their numbers have swollen up in the ranks of nurses over the last two decades, they have been largely unsuccessful in changing the perception of people. According to male nurses, the public is used to seeing them in a hospital and is accustomed to them, but as nurses, they still don't feel very welcome and accepted. There still exist prejudices and other cultural barriers for male nurses to excel and succeed in their careers. The lack of appreciation therefore only exacerbates and intensifies their desire to either migrate or quit nursing.

#### *4.2.1 Patients' perspectives of male nurses*

Patients' responses differ from one patient to the next. While some patients don't like male nurses at all, others are quite accepting, interested, or both. According to 12 participants, dealing with young patients between the ages of 14 and 40 is the most difficult. Regardless of gender, people in this age bracket seem to choose female nurses. Four participants said there was no hard and fast rule and that age had no bearing. Rather, they thought it depended on the nurses' ability to make the patients understand that nurses were there to do their jobs and that gender had no bearing on the quality of care they provided.

*I think it is very difficult to get along with male patients, especially if they are young. You see they don't like being touched by another man. Young female patients are even worse. (M 8)*

*The Sisyphean Task of Nursing: Muscular Roles and Masculine Responsibilities of Malayalee… DOI: http://dx.doi.org/10.5772/intechopen.106276*

*Female patients especially if they are young are hard to deal with, in fact, more than the patients it is their relatives that are hard to please. It is funny because women are completely fine with male doctors, but are uncomfortable with male nurses. What is the difference? (M 16)*

*I struggled a bit in the beginning, now I just talk to them with authority and tell them it is my job and I have to do it. If you give them a chance they start complaining. (M 5)*

*I am very comfortable with old patients (male and female) because they don't care about gender, all they want and need is the care that we give. They are usually pleasant and loving. It is usually patients below 40 who give me all the trouble. (M 20)*

#### *4.2.2 The public perspective of male nurses*

The public perspective of male nurses was generally bad according to most male nurses. Most of the participants had done their nursing degree between 2005 and 2010 and at the time male nurses had only started entering the profession. It was very difficult for these pioneers as they had to bear the brunt of public disapproval. It was uncommon those days for men to be nurses, though the society's perception has begun to change, it hasn't changed a lot or not at least to the expectation of male nurses. Nursing for a man was even considered as a sign of being gay.

*After my school final exam, I told my friends that I wanted to become a nurse, they laughed at me and called me gay. It was hurtful. I felt disappointed. Now I am married, but those initial years were difficult for me. I had taken a loan from the bank to study, otherwise, I would have just quit. (M 16)*

*My best friend laughed and he had tears in his eyes from laughter. He simply could not resist laughing, he was shocked at my decision. (M 8)*

*I studied in a boy's school and I was the first to choose nursing as a career from my school. My teachers advised my parents not to send me to a nursing school. They said I was going to waste my career. This was in 2004 and there weren't many men joining nursing at that time. There was a wave of men entering the nursing profession in the years between 2003 and 2013. After the 2012 protests, career prospects have been damning. Now very few men choose to nurse. (M 1)*

From the study, it is clear that due to fewer career prospects and lack of acceptance, male nurses feel the number of men entering the profession will dwindle. There was always a strong barrier for men entering nursing, male nurses broke through the barrier but now are bogged down by the lack of acceptance and career prospects.

*We are a dying breed. What I mean by that is Malayalee male nurses are a dying breed. We might have men from other states of India becoming male nurses, but in Kerala, our growth is stymied by hospital management, government, and the public. Male nurses are by and large unwanted in Kerala. Some of them made it to developed countries, the others made it to the Middle- East and the rest moved to North Indian* 

*states as they have staff shortages for both male and female nurses. For the male nurses in Kerala, there is no future. (M 10)*

According to most male nurses, there is systemic and institutional discrimination against them in the hospitals in Kerala. So their only choice is to move to other cities in India or other countries should they choose to continue working as a male nurse.

#### *4.2.3 Peer perspective of male nurses*

Male nurses have had to battle prejudices from patients, the public, and also from peers. Nursing is a profession that was dominated by women until the early 2000s. They had no competition and there were hardly any male nurses in Kerala until then. With the arrival of male nurses in the profession female nurses started to create their own identity, which they believed was the crux of nursing. They saw in male nurses qualities that were new and sometimes unsuitable for the job.

*I believe as a woman even our attitude is suitable for this job. We are more compassionate than men are. Male nurses get angry easily and they retort to patients and relatives. They are not suitable for nursing in my opinion. They are good in some areas like in ICU. (F 6)*

*Women are kind-hearted and more service-oriented, male nurses, can't be as polite as female nurses are. They don't communicate much with the patient. They just do their duty and go home. Male nurses often lack empathy, which is a very important nursing quality. (F 17)*

*I believe women in general are more compassionate and caring than men are. I am not saying men are not good at it. It is in our blood we are natural when it comes to giving care. Most men have to make an effort. When you put in the effort it becomes tiring and they become harsh and lack empathy. (F 5)*

One of the female participants believed it is better to work under dominant men than under dominant women.

*When you have only female nurses, some nurses want to become very dominant and they pretend like they are men. I think it is better to work with real men than these female nurses who act like men. (F 16)*

Even in this case a male nurse is not seen as a male nurse, but under the lens of a dominant role that society has ascribed to men. Though all female nurses had good and bad things to say about male nurses. Female nurses in general saw male nurses as the "other." Female nurses had a "us" vs. "them" attitude. They believed men can be nurses, but at the same time were unwilling to accept them as competent as female nurses. There was only one participant who categorically mentioned a nurse is a nurse and gender plays no role in it.

*People don't understand that a nurse is a nurse both female and a male nurse is trained to save lives, there is no differentiation. All male nurses can deliver the same performance. It is just that their approach may be different. (F 13)*

*The Sisyphean Task of Nursing: Muscular Roles and Masculine Responsibilities of Malayalee… DOI: http://dx.doi.org/10.5772/intechopen.106276*

#### **4.3 Theme 3: male nurses' desire to change the status quo**

Male nurses have left an indelible mark in the history of nursing in Kerala in particular and India in general. The lack of public, peer, and patient acceptance along with the working conditions prompted men to challenge the order of the day. Male nurses were appalled at the work culture in private hospitals in Kerala. They demanded change and wanted it done as quickly as possible.

### *4.3.1 Defending nursing as men's work*

Occupational gender segregation has resulted in established norms in every society, though women have been breaking down barriers, and foraying into professions primarily held by men, the same cannot be held for their male counterparts. Men have continued to work in professions that by and large are dominated by men. According to male participants, this is primarily due to a lack of will and lack of awareness. For some male participants, justice hasn't been delivered for men as far as entering female-dominated professions is concerned. Male nurses believe that for women, there are campaigns, government programs, and quotas to welcome females into a men-dominated career, but it's completely lacking for men who wish to enter a female-dominated profession. Male nurses pointed out the lack of government initiative in attracting men into nursing, while there are social campaigns for transgenders. Male nurses in Kerala were no less important than anyone else and deserved equality.

*It is wrong for society to think that women are better at providing care, if women can do jobs that have been traditionally associated with men, why can't men do the same. In India, we need a lot of nurses, and not many people choose this profession. Why can't men fill that vacuum? (M 12)*

*A job is a job, it can be done by any gender even a transgender. You see in Kochi metro we have transgender and the government provided so much PR to get them accepted, they even provided security. I appreciate that and I believe people should stop identifying jobs with gender. (M 19)*

One of the participants believed a better nurse is a male nurse as he is stronger and is not too emotional. According to him being overwhelmed with emotion is detrimental to this profession and female nurses often get carried away.

*People think nurses should be women, but I believe nurses should be men. The assumption of nursing as a caring profession is a lie perpetrated in the last century. It is a physically demanding job, and who better to do a physically demanding job than men. Are doctors compassionate? You need to do your job and all this hullabaloo with compassion and nursing is just propaganda. (M 9)*

#### *4.3.2 Occupational segregation: carrying the weight on their shoulders*

Male nurses believe that their role as a nurse has been relegated to departments where physical strength is in demand. Male nurses claim to have no responsibilities in departments where the primary responsibility is providing care. Most male nurses worked in departments such as the intensive care unit, emergency room, and operation theatre.

*If someone sees you free, you are immediately called to help female nurses move a patient. I understand it is nice to help our colleagues, but that doesn't mean I am seen as a person who is in the hospital to just help other staff carry things. (M 3)*

*Hospitals want only one man in these [OT, ICU, and ER] departments to do the job, the rest can be done by women. If you ask a female nurse she would want more male nurses in these departments. (M 19)*

*If I am in ICU, I am there to give CPR or carry patients. In my hospital, there are very few male nurses and we have one or two in almost all departments. We are hired to carry and do the heavy work. It is like male nurses are paid to assist female nurses in doing a job that needs strength. (M 11)*

One of the male participants mentioned that male nurses are only needed to use their strength and what would be the use of an old male nurse who may not be in a position to carry and move things around. He would neither be needed to provide care nor would he be needed to use the heavy lifting work.

*Nobody wants an old male nurse. If at all they want us it is only when we are young as we carry and push stretchers and wheelchairs. (M 14)*

#### *4.3.3 Nurses' burnout: a Sisyphean task*

All nurses complained about exhaustion and burnout at work. Some of the practices at hospitals that were unfathomable included long working hours without breaks and holidays. The problem of long work hours is due to staff shortage and the management is unwilling to address the issue. Male and female nurses were unhappy with the work culture, which included threats of not issuing experience letters/references, inadequate breaks, no leaves, non-nursing duties, and derisory salary.

*My workload is huge, there is tremendous pressure at work. From the time you start your duty to the time you finish you just have to work without any break. I have had situations where I was taking care of a patient and my colleague was feeding me because I have no time. Because if I were to take a break I have to take off the gloves and clean myself up. There is no time for such things.*

Most participants have had similar experiences often if not every day. The reason to have broken this way is again due to staff shortage. The nurse-to-patient ratio in an ICU was 1:6 and when someone needs to take a break of 10–15 min, washing up, and taking off gloves alone would consume 5 min. Most hospitals had their cafeteria either on the ground floor or on the top floor. Going and coming would take more time than the break itself. Nurses, therefore, were forced to manage their breaks in ingenious ways.

*Do you know how stressful the job is? We get so tired after work. We have no time for breaks even. In ICU we have deaths almost every night. In Cardiac ICU at least 1 death a night. We have to manage that. When we have night shifts it is even longer sometimes. The public is not aware of these things. I work for 12 to 13 hours every day*  *The Sisyphean Task of Nursing: Muscular Roles and Masculine Responsibilities of Malayalee… DOI: http://dx.doi.org/10.5772/intechopen.106276*

*for a salary of 15000 rupees. It is not an easy job as well, we have to carry the patient, take care of his health, give CPR and document everything. For such a hectic job we get paid so less. Do you have any job where people get paid less? We are professionals, not some slaves. I think nursing is equal to slavery. (M 4)*

Nurses in general had long working hours across all hospitals in Kerala. This was the norm, and nurses had to get accustomed to working in this routine. Since nursing is a physically challenging job, it gets very tiring for nurses, they spend 60–75% of their day in the hospital. The common perception among nurses was that they were expected to put in long hours of work because they were often young and unmarried. Most nurses opted to stay in hostels and other accommodations close to their hospital to avoid traveling home after work. Even if they stayed in the same region, a nurse would spend an average of 16 hours traveling to and from work. Both nurses were physically fatigued as well as emotionally, especially those who worked in operating rooms where they had to stand for lengthy periods each day without breaks.

*We have left, but we are not allowed to take them, usually, we get paid an extra month if we don't take leaves. It is because of staffing issues, we don't have enough staff at work. Generally, we don't take leaves, if we do someone has to work more or I have to compensate that day with double duty in that month. (F 10)*

*We don't give leaves, my nursing supervisor cancels my leave citing a lack of staff. So every time I apply for leave I get rejected citing the same reason. Curses of the nursing profession are nurses themselves some nurses don't join our protest. The reason why we suffer today is that our seniors never bothered to protest. (M 19)*

Nurses working long hours rarely got the opportunity to have a day off. More than half of the participants had at least once worked 30 days without a day off in their tenure at the hospital. Most nurses believed the current workplace culture was established by the management due to the complacent and lackadaisical attitude of nurses from the previous generation.

*It is a big problem, once you start working in a hospital you need to work for at least 2 years to get a proper experience letter. If you leave before two years they provide you just a letter which is not accepted anywhere. This is illegal but this is the practice. Some nurses work in small hospitals and pay the management to get experience letters. You need 2 years of experience to find a job abroad so they pay and get the experience. They will work for 1 year and maybe buy 2 years' experience. This happens in small hospitals. (F 9)*

*In Kerala, you have to work for 2 years to get an experience letter. The reason is, that nurses are always looking for jobs abroad and when they find one they leave. Hospital management wants to stop this. If they don't have the letter how can they prove their experience? (M 12).*

Hospital management uses coercive strategies to get the employees to comply with the work culture. The common practice in Indian hospitals is to issue a detailed experience letter after an employee quits an organization, but if an employee doesn't work for 2 years, the hospital issues a letter that just states that they worked in the hospital, it wouldn't give any details on what roles and responsibilities they had in the hospital. Such a letter is usually not accepted by employers. Using such covert strategies, hospitals ensure the continued commitment of nurses even though employees are unhappy with the hospital.

*Generally, we have to take care of the equipment, like carrying them, counting them and cleaning them. Cleaning equipment is not our job. There should be assistants to do this job in every department. Why should we clean the equipment? Imagine working for such long hours and you have to handle patients and clean equipment. (M 1)*

*We have a lot of non-nursing duties, we are made to clean the ventilator, cardiac table, and Ambu bags. Sometimes senior nurses ask junior nurses to do it. There is a lot of cleaning work that could be given to non-nursing staff. (M 7)*

*After our duty hours, or when the surgery is over we have to clean the OT we have 9 OTs and nurses have to clean them all. We are only 4 staff in our OT. All this work can be given to housekeeping. An OT after surgery is very messy, and cleaning that is not easy. We have to clean all the equipment and keep it ready for the following morning. I don't think it is our job to clean OTs. (M 17)*

Male nurses complained about performing non-nursing duties such as cleaning equipment, which should be done by medical assistants or housekeeping staff. To cut corners management of most hospitals substitutes nurses for these tasks, which makes their work hours longer and takes away their productive hours.

Another major concern was the salary, despite working long hours, with short breaks and fewer holidays while doing non-nursing duties, a nurse usually earns less than an unskilled laborer.

*We are not paid properly. We don't get paid for overtime. My salary is just 15000 rupees. A daily wage laborer gets 800 rupees in Kerala. It is funny he gets 5000 rupees more than I do. We spend money and time on education and get nothing in return. (M 1)*

When HR managers were asked about why nurses were paid so less, lesser than most professions that don't even require to have a university education. Managers defended it by saying they are the largest group of employees in a hospital, and they cannot afford to spend so much cash on them.

*We can't pay the salaries they demand as it is not feasible for any hospitals in Kerala, as you know we have an ongoing case in the court about revised pay, but if we pay 20000 rupees to each nurse that joins we cannot operate this hospital. We pay a new joiner around 9500 rupees and it doesn't make any sense to increase their salary by 100 percent. It will result in an operating cost of almost 70% of our income. Do you think any organization can function with just 30% of its earnings? (HR 1)*

#### *4.3.4 Male nurses as agents of change*

Due to the appalling working conditions in hospitals across Kerala and the exploitation nurses experience at the hands of hospital management, male nurses rose in protest against the management. Since early 2012, protests have sprung across Kerala *The Sisyphean Task of Nursing: Muscular Roles and Masculine Responsibilities of Malayalee… DOI: http://dx.doi.org/10.5772/intechopen.106276*

and across Indian cities where the bulk of the nursing workforce is Malayalee. Male nurses have been at the helm of these protests and have spearheaded such agitations by forming a nursing union called UNA.

*Male nurses are expected to take on the wrong and unjust practices in hospitals. Female nurses provide us all the support but they want us to lead from the front. Female nurses tend to be more submissive to hospital management and that is what the management wants. (M 12)*

*What they are doing [Protests] is right but this is Kerala and I don't have faith in any hospital management. Even charitable hospitals run by religious institutions be it any religion all exploit nurses. So I think what male nurses are doing is right. In another 15 years, I think there won't be any male nurses in Kerala. (F 3)*

*Nowadays men entering the nursing profession is gradually decreasing. 10 years back we had a lot of men considering nursing but now numbers are low and after all the media reports more and more men are not choosing the nursing profession. Our fight for justice has affected men in their careers. (F 4)*

Male nurses have taken it upon themselves to protest against the existing workplace conditions and bring dignity and honor to the nursing profession. For 70 years, nurses endured such work practices, and it is only after men entered the nursing profession that such unity of strength was put on display*.* Female nurses are happy about the protests, but they also feel that Malayalee male nurses paid a hefty price for it. Most female participants believe that had the male nurses not protested society would not have known what nurses were going through in the private hospitals in Kerala. Though the protests started in Kerala, they eventually spread all over India.

#### **4.4 Theme 4: male nurses as undesirable employees: why invite trouble?**

Since the protests began in 2012, male nurses are generally not hired. Male nurses have been viewed as trouble makers. Hospital management believes that without male nurses it would be easy to control the female nurses at hospitals. Though there is no official declaration banning male nurses from being hired, their hiring in hospitals is generally discouraged by human resources managers.

*Male nurses are expected to take on the wrong and unjust practices in hospitals. Female nurses provide us all the support but they want us to lead from the front. Female nurses tend to be more submissive to hospital management and that is what the management wants. (M 19)*

*The management wants to keep the number of male nurses to a minimum. Hospitals see us as a threat. They think we are here to protest. All we want is a good salary and good working hours. (M 11)*

*Being a male nurse is a crime in Kerala, there is huge discrimination. The only good thing that happened because of us joining the workforce is that we made the whole country learn about our condition. After male nurses joined we fought against the injustice. (M 17)*

*Men nurses are not seen as nurses and it is a bad thing. If there were no male nurses most female nurses would carry on with their idealistic doggedness and nothing would change. (M 20)*

HR managers interviewed for this study were unanimous in seeing male nurses as a threat. They, therefore, plan to keep the number of male nurses to the bare minimum. HR managers fear male nurses can stir things up and make it difficult for the hospital to function. According to them, a female nurse rarely questions the management wherein a male nurse does it authoritatively and encourages others to do so.

*Men joined nursing only to migrate, In Kerala, we did not have male nurses before 2000 it is only in the last 10 or 15 years due to high opportunities abroad they have joined. Most nurses who have joined protests are people who can't migrate. It is their frustration that led to most strikes. (HR 1)*

*Male nurses are trouble makers, we used to hire them until 2014, but now we don't hire them anymore. It is the management's decision. We are a small hospital and we can't afford strikes. (HR 2)*

*I don't think male nurses are bad at work. Most hospitals in Kerala were hiring male nurses, now things have changed. To be honest, though women participate in strikes more than men do. It is male nurses who instigate everything. After the strikes began, male nurses started questioning doctors too. Doctors decided to have female nurses. As a hospital we need to listen to doctors, patients come to the hospital because doctors are good, not because nurses are good. (HR 3)*

*We have plenty of female nurses in Kerala and even the patients prefer female nurses, so why should we hire male nurses. Why invite trouble? (HR 4)*

*Male nurses are ungrateful to the management, we had no need to hire them, and even then we hired them and gave them jobs. Now they are creating problems all over the state. Is this how they pay us back? This is India, not UK. Since they can't go to the UK they are trying to create the UK here. We don't have the budget to be like UK. (HR 5)*

According to HR managers, male nurses are trying to create a space for themselves in Kerala by asking for better working conditions. The hospitals fear that if the number of male nurses increases, naturally they will demand more as years pass by. Earlier hospitals were satisfied with having a workforce that was more or less a floating crowd. Most nurses worked for 2 years, gained experience, and moved on to other countries. This gave the hospitals a young and cheap supply of nursing workforce. When male nurses failed to migrate, they started asking for better working conditions as they wanted to pursue the career in which they had invested their time and money. Female nurses see the arrival of male nurses in the profession as a blessing, because of which many work practices that were thought to be acceptable are no more acceptable and the plight of nurses has been brought to the public's attention, thereby forcing the government to direct hospital managements into overhauling the existing system.

*The Sisyphean Task of Nursing: Muscular Roles and Masculine Responsibilities of Malayalee… DOI: http://dx.doi.org/10.5772/intechopen.106276*

### **5. Discussion**

In the study, it was vividly established that all male nurses had individual and personal motivation in choosing nursing as a career. Male nurses see nursing as a career as good as any other. They have had to fight their way into this profession due to a lack of acceptance and awareness among the public in Kerala. Consistent with the finding of Uhlimann and Cohen [35], when men generally pursue professions that are dominated by women, like nursing, they usually see it as a new opportunity or unexplored territory where they can make startling gains such as getting career promotions faster than women and also to get hired easily than their female counterparts. Even if this thought is not intentional, it is subconsciously present.

Although Malayalee male nurses had similar noble reasons as their female colleagues, it was the opportunity to migrate that acted as the pull factor. The challenges faced by male nurses are different from what women face in a male-dominated profession. For a woman professional her sexuality is not questioned when she chooses to pursue a career in a male-dominated profession, whereas for a male nurse his sexuality is questioned and nursing for men was considered as a threat to traditional masculine roles [2, 3, 36, 37].

Numerous studies have explored male nurses' experiences within the Western context, but only a few such studies have been conducted in India to understand the lived experience of male nurses and their challenges. Malayalee male nurses working in private hospitals across Kerala feel like their career choice has been a mistake due to the unexpected turn of events. Malayalee male nurses braved the storm of ridicule and embarrassment that they had to face at the onset of their career only to realize that they were not seen as equal to a female nurse.

There were cases of male nurses abandoning a career to choose nursing as it offered better prospects. Some of the nurses possessed another qualification before they went to nursing school. Nursing therefore for some was not the first career choice. Most male nurses entered this profession at the peak of international recruitment when more and more female nurses got job opportunities in Europe. Female nurses from Kerala were always finding work in the Middle East, but it was the newfound opportunity in Europe and the other developed world that attracted male nurses into this profession.

Since the primary reason to choose nursing as a profession was to migrate, they found stiff competition from female nurses. Female nurses were generally preferred over male nurses in most countries, and this was an impediment male nurses could not overcome.

Working conditions in private hospitals in Kerala could be deemed disastrous and detrimental to the health and well-being of an individual. Long working hours, coupled with few short breaks resulted in emotional and physical exhaustion. Male nurses who had dreamt to move abroad in search of a better life had to come to grapple with the reality of having to work in private hospitals in Kerala for longer than they had imagined.

Male nurses were given work that included heavy-lifting and cleaning, which they believed was not part of their job roles and responsibilities, but they were matching with what was expected from a man. All of this was done for a salary that was meager and negligible. Female nurses had coped with such working conditions before, and they didn't protest as most knew they had a higher probability of finding a job outside of India, but for male nurses, the chances were slim to none. Male nurses thus rose in

protest against the management of private hospitals across Kerala asking for a better wage in particular and better working hours in general.

The power of collective bargaining and unionizing helped male nurses to get the attention of the public and government to the plight of nurses in the hospitals of Kerala. Such efforts resulted in male nurses being declared as trouble makers, thereby jeopardizing their career opportunities in Kerala too.

Malayalee male nurses are caught in a rut now, with their careers at stake. Most male nurses interviewed were apprehensive about leaving the job as they would find it difficult to find another job in the nursing profession. Most male nurses have come to terms that their future in nursing is at stake. Male nurses are generally preferred to work in departments where they are expected to use their physical strength, but now male nurses believe as they age, they will be unwanted as they will be physically weaker than now.

The dream of going abroad is fading and so are the job prospects in Kerala due to their efforts in organizing protests against inhuman working conditions. The fate of the Malayalee male nurse is sealed. Male nurses use their physical strength until they are deemed unfit, or they use their masculine traits of organizing and rebelling against the injustice perpetrated against them. In the process, male nurses have lost more than what they have gained. Their presence in nursing benefitted female nurses the most, who until then had inured to the appalling work environment. Male nurses became the catalyst that expedited the process of breaking the shackles of wage slavery, which was enforced on nurses by private hospitals. The efforts of male nurses in galvanizing the entire nursing workforce to act in unison though a success came with a steep cost. They have come to the stark realization of the existence of a shelf life for their career, which is far shorter than expected. A Malayalee male nurse has become a tragedy resembling Sisyphus who was cursed to roll a boulder up a mountain only to see it roll back down. Malayalee male nurses have been laboring hard but to no avail. Nursing to them has become a Sisyphean task.

### **6. Conclusion**

Overall, we found that, after entering the nursing profession, Malayalee male nurses had worse career prospects and promotion chances compared with their female counterparts. Though male and female nurses had similar working conditions, their career prospects were vastly different. The extraordinarily low participation percentages of males in nursing are directly correlated with popular stereotypes and biases against men who work in fields where women predominate. The high turnover rate among male nurses is further explained by their significantly lower professional prestige when compared with other masculine professions.

#### **6.1 Implications for nursing management**

India has a better proportion of men in nursing in comparison with many other developed countries. Though India has a higher number of male nurses, the current working conditions and job prospects will dissuade many prospective male nurses from joining the nursing workforce. India, like many developing countries, faces an acute shortage of nurses, which if not addressed will only exacerbate over the years. The need to bridge the gap in nursing demand is pertinent and must be done to ensure access to healthcare for millions of people who at the moment have no access to healthcare whatsoever.

## *The Sisyphean Task of Nursing: Muscular Roles and Masculine Responsibilities of Malayalee… DOI: http://dx.doi.org/10.5772/intechopen.106276*

It is important to devise strategies to attract, recruit, and retain more male nurses. This can be achieved by running government campaigns to create awareness among the younger population to choose nursing as a career. Measures must also be made to ensure proper working hours and a government-mandated salary, which can raise the social status of nurses.

## **6.2 Strengths and limitations**

One of the study's shortcomings is that it only included nurses who worked in Kerala's cities; those in rural regions were left out. It is advised that further studies be carried out utilizing a mixed-method approach because the usage of a single technique and design is another constraint. The fact that this study is one of the few to explore the motivation and experiences of male nurses in India was one of its strengths.

## **Author details**

Cinoj George\* and Feyza Bhatti Girne American University, North Cyprus, Cyprus

\*Address all correspondence to: cinojgeorge@gau.edu.tr

© 2022 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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## **Chapter 5**

## Impacts of Masculinity on Men's Health in Maseru, Lesotho

*Nkeka Peter Tseole*

## **Abstract**

Masculinity is a health determinant for men and a risk factor for non-communicable diseases. This chapter explores how dominant masculinity influences lifestyle risk factors for non-communicable diseases focusing on adult men. The study conducted eight exploratory focus group discussions with adult men from Maseru, Lesotho. The participants were recruited using purposive sampling. Thematic analysis processes were followed to analyse data. The participants' rationales and behaviours indicated dependence on women for healthy living even though men claimed taking responsibility as one of the key descriptions for a man. Smoking was perceived as one of the practices used to prove masculinity. Participants were informed about the unfavourable impacts of smoking. Stress, leisure time and peer pressure were reported as contributing factors to harmful alcohol consumption among participants. Many participants understood the benefits from healthy diets, however, they depended on females for healthy meals. Nearly all the men were aware of the health benefits of physical activities. Participants were aware of the undesirable effects of physical inactivity. Participants reported various challenges to effective physical activities and classified some activities as suitable for middle-class individuals. Health education focused on men is critical in order to alleviate the negative impacts of masculinity on men's health.

**Keywords:** lifestyle risk factors, noncommunicable diseases, masculinity, adult men

## **1. Introduction**

Masculinity is a multifaceted concept which is socially and culturally constructed [1]. Masculinity is a significant socio-cultural determinant of health and health-related behaviours [2]. Masculinity traits are largely created and shaped by life experiences in different settings resulting in sets of behaviours in which men, in particular, are socialised to practice [3]. In many countries, men often lead health defeating behaviours owing to their subscription to toxic masculinity. The two predominant approaches used in the study of masculinity are the trait and the normative approaches to masculinity. The trait perspective is essentially rooted in the differences between male and female genders [4]. Based on normative viewpoint to masculinity, the concept of masculinity is socially constructed and does not necessarily depend on the differences perceived between men and women [4]. Masculinity qualities appear similar across the globe. They include independence, invulnerability, sexual promiscuity, competitiveness,

bravery, leadership and control, and physical strength. In most societies, men are socialised as those with high tolerance to pain, are self-reliant, and the sole decisionmakers, and fundamentally avoid any feminine behaviours [5, 6].

In addition to power dynamics between genders on dominance and subordination, masculinity may also be described in relation to power relations between different sides of masculinity. Scholars in the field acknowledge hegemonic masculinity, complicit masculinity, marginalised masculinity, and subordinate masculinity as the main facets [2, 7]. Hegemonic masculinity is the dominant type and is characterised by strength, heterosexuality, superiority, being white, suppression of emotions as well as feelings [2]. Complicit masculinity is the passive expression of masculinity which lacks most characteristics observed in hegemonic masculinity. Men in this category do not challenge gender systems, they somehow benefit from being males [2, 7]. Marginalised masculinity refers to the subculture of hegemonic masculinity. Even though men in this group do not have some qualities of hegemonic masculinity like race, individuals in this category demonstrate the same traits as the hegemonic masculinity, for instance, physical strength, suppressing emotions and ferociousness [2, 7]. Subordinate masculinity displays the opposite characteristics from those of hegemonic masculinity. Men in this category demonstrate feminine behaviours comprising physical weakness, and they easily show their emotions [2].

Negative masculinity traits encourage health defeating behaviours [8, 9]. Individuals who subscribe to masculinity are most likely to embrace hazardous behaviours that discourage a healthy lifestyle and long life [8, 10]. Irrespective of their awareness of the negative consequences of unhealthy living, masculine men resist healthy living practices and often engage in risky behaviours generally associated with manliness [11, 12]. The reckless behaviour practised by masculine men shows how dedicated men identifying with dominant masculinity are to proving their masculinity. Different media platforms similarly contribute in different ways to the construction of masculinity. Images depicting hegemonic masculinity showcasing undesired behaviours, for example, reliance on fast-food, excessive alcohol consumption and excess consumption of red meat as cool and attractive influence the construction of hegemonic masculinity [13]. This chapter explores the role played by masculinity in the prevalence of lifestyle risk factors for non-communicable sicknesses.

This chapter draws from a qualitative study that was conducted in Maseru, Lesotho. Data was collected using eight exploratory focus group discussions (FGDs). The FGDs were made up of adult men aged 18 years and older. The FGDs were arranged with different groups of men who devoted their time, efforts and experiences to inform this study. Each group of men was invited to a central place for that specific group. These places included worship buildings, schools and sports facilities. The researcher transported most participants to and from these central places. However, some participants voluntarily transported themselves to and from the places where the FGDs were facilitated. The researcher had planned to recruit more men for FGDs, however, from the sixth group, it was evident that the researchers were not going to get any new information. A total of eight FGDs were held. On average, 60 adult men took part in eight FGDs on risk factors for non-communicable diseases (NCDs). A relaxed atmosphere during the FGDs encouraged open discussion among participants as well as between participants and the facilitator. The FGDs covered questions related to risk factors for NCDs—harmful consumption of alcohol, smoking, unhealthy diet and physical inactivity. Data were collected from November 2016 to February 2017. Verbatim narratives were used in this chapter in order to substantiate participants' arguments.

#### *Impacts of Masculinity on Men's Health in Maseru, Lesotho DOI: http://dx.doi.org/10.5772/intechopen.104888*

Participants were recruited through purposive sampling where the existing men's social groups such as recreational and sports clubs, business cooperatives and religious groups were targeted. The other strategy was to identify '*popular men*' comprising local school principals and local business owners from different communities. These men were instrumental in that they assisted in recruiting adult men who showed interest to participate in the study from their communities.

During data analysis processes, thematic analysis was used. This approach was useful in that it assisted the researcher to explore the study participants' opinions, knowledge and experiences from the qualitative data collected. Six steps practised in thematic analysis were followed, that is, the familiarisation with the data and notes, coding, generation of themes, revision of the generated themes, defining and naming of themes and lastly the writing up of the analysis report emanating from the data.

The names used in the report are not the real names of participants in order to protect their identity. The main study was conducted through the University of KwaZulu-Natal, Durban, South Africa. The ethical clearance was attained from the University of KwaZulu-Natal's ethics committee (reference number: HSS/0697/015D). The study participants, that is, adult men, were members of society and were not representatives of any organisation during the interviews. Data collection process did not require any approval from any organisation; however, participants were given consent letters which invited them to participate in the study. The consent letter further provided details on what the study was about and highlighted that participation was voluntary and that participants were allowed to pull out from the study at any time they felt uncomfortable. The potential participants who were comfortable participating in the study signed the consent letters and returned them back to the researcher.

## **2. Who is a man?**

In their description of a man, participants used age, sex, marital status, being a father, and taking responsibility with varying emphasis as the key contributing factors to who a man was perceived as. Being born male and aged 18 years and older, a male person was defined as a man by most participants. Alex, a participant in one of the FGDs put it this way:

*A man is a male individual who is eighteen years old and can take responsibility, married or not married. As long as he is old enough to be trusted to take responsibility in the family he is a man.*

Heterosexuality was an important determinant for one to be referred to as a man. This stereotype led to hegemonic masculinity subscribers disregarding homosexuality irrespective of other characteristics and behaviours related to manliness. Homosexual males were mostly disqualified as men by most study participants. In addition to homophobic views perceived, some of the FGD participants emphasised that some heterosexual males were ignorant:

*Being born male does not necessarily mean that we are all men. There are [male] people who are eighteen years old and above and responsible in their families but whose [social] behavior and the way they live does not say they are men. I have an example; gay men were born males but the way they conduct their lives does not* 

*reflect the way a man should live. They are 'women', they take women's role even in sexual intercourse. Even their general behavior in public is similar to that of women.*

Being married was another determining factor in the definition of a man. Most participants in the FGDs strongly associated manhood with marriage. In most societies, bachelor men are alleged irresponsible and socially deviant. This perception led boys to be taught from a young age by their mothers and shown by their fathers how to become men [14]. Jacob explained this as follows:

*A man is a married male person. When he is married, he is now having the responsibility of caring for other people, his wife and children which he did not have before getting married. If you do not get married and start having children, you are still a boy.*

In addition to marriage, men who had biological children had a sense of pride and bearing children had resulted in acknowledgement and acceptance of these men in their families. One of the newly married men confirmed:

*Just like me, before I got married, in my family, the elders treated me like one of the boys in the family regardless of my age especially for serious family matters. My opinions in any family matters were not taken serious until now. Now I am married and my wife is pregnant. My voice is heard in the family, my elders have started treating me like one of the family men and even listening to me. So, for me, until a male person is married, in my opinion and experience he will always be a boy.*

*One cannot become a father without bearing a child, at the same time; he cannot become a man unless he gets married. If he is not married, he can only be referred to as a man as praise if he has done some good works associated with men. So, in this case, his good actions can lead to referring to him as a man, but it will be temporary. (Tigger, FGD#3)*

Among the older men, graduating from traditional initiation school was one of the determining factors for males to qualify as men. Physical and emotional capabilities similarly dictated the definition of a man. Men who had the ability to protect and provide for their households were defined as men:

*I can say a man is somebody who can work and provide for his family, one who can be able to protect the family and somebody who has control and works and protects the family. He can do tough/heavy jobs. He can work in the garden, prune trees. The other thought that comes to mind goes together with a Sesotho saying which says 'a man is a sheep, he does not cry'. He does not display emotions. (Thabo, FGD #7)*

*A man is a male person who has gone for our Sesotho traditional initiation school (lebollo). When he gets back to the society, he is now referred to as a real man because we have now taught him how to be a man while he was in the mountain. He can even get married now. (Thabo, FGD #7)*

The last part of the previous quotation highlights extreme hegemonic masculinity which usually led to men living risky lifestyles is highlighted in the quote

above. Men are socialised as strong even against illnesses resulting in these men shying away from consultation with health professionals. One of the participants alluded:

*There is also this statement: 'Be a man', drive like a man, man up, etc. for you to be a man you should drive at a certain speed, at high speed basically, for you to be a man you should drink so many quarts [of beer] a day. The risky kind of behaviours one engages in, the man you are. The feminine part of a man who takes a good care of himself, respecting his family and wife is seen as not being man enough. A man is a sheep, he does not cry. Even if you go through hardship, do not cry, do not let people know. A man can be sick, but cannot go to the hospital or clinic because that would be a sign of weakness. A man is expected to be resilient and able to stand the pain in any forms of it. A man should mask his emotions and emotional experiences he goes through and should always come out as strong. (Tsebo, FGD#2)*

Young men were acknowledged as men post their graduation from the traditional initiation school. After the initiation process, the older generation in society trusted these initiates and perceived them as ready to take responsibility including getting married. The traditions taught at initiation school were thought to have shaped, equipped young men and capacitated them to become accountable members of society. Some males, particularly those who were born and grown in urban areas did not subscribe to traditional initiation schools and its teachings. These men did not believe that young men's behaviours could only be transformed through traditional initiation experience:

*Those people are not turning into men just because they have gone to the mountain. They are just full of theory of what a man should be like. They are still boys until they get married like everybody else. Some of them practice the worst behavior when they come back to the society. (Tumelo, FGD #6)*

## **3. Masculinity and smoking**

Participants in the study knew about the harmful health effects of smoking. Nevertheless, they still reported a high prevalence of cigarette smoking, specifically among the working class and students at institutions of higher learning. Hand-rolled tobacco smoking was a common habit among older men, particularly the unemployed and men with lower formal education while smoking marijuana was common among younger men. Most current smokers during the study reported that the habit of smoking was developed during teenage-hood when they wanted to prove their masculinity owing to peer pressure and too much leisure time:

*I was in secondary school when I started smoking and it was out of peer pressure and also wanting to be regarded as cool and as a man. To tell you the truth, I was already convinced that smoking was not right from what we were taught at school. (Mike, FGD #4)*

*I do not really keep track of how many times I smoke a day but now I think I have decreased my smoking to roughly four times a day. One of the reasons why I have decreased the number of times I smoke is because I am now busy most of the time.* 

*Before I came here (college campus) I had nothing to do for almost the whole day so I smoked a lot. Since I came here, I have really decreased my smoking because of being busy throughout the day with my schoolwork. (John, FGD #2)*

#### Once initiated, smoking is addictive:

*I have always thought smoking helps me release stress, but honestly speaking, if I go for two or three days without smoking, I feel good. I usually get back to it because of the strong cravings I get, but health wise it is not good to smoke. I tried stopping to smoke, in fact at one point I stopped for six months. I cannot really tell what happened, but today I am back to smoking. I think there is something about smoking; it is not easy to stop smoking once you start. (Pule, FGD #2)*

Subscribers to dominant masculinity avoided any feminine behaviour. One man who was a current smoker alleged:

*I cannot smell like a woman, smoking gives me that smell, different from a woman. There should be a difference between a man and a woman. We cannot smell the same. (Andre, FGD #5)*

A follow-up from a different participant in the same FGD however indicated that the reasoning by the participant above was flawed. There were women who smoked, and the trend was reported growing during the study:

*Can I say something about women and smoking? Eish! We are seeing this habit of smoking growing even among our women here. This was not a norm, but it is becoming popular especially here. So, it's not only men who are smoking my brother. (Morena, FGD#5)*

## **4. Harmful alcohol consumption**

Detrimental periodic heavy drinking was the most prevalent among men in this study. This binge drinking often took place on weekends and at social events. Beer, especially the locally brewed '*Maluti*' was the popular beverage among men. Very few men consumed traditional beer. Similar to smoking, the men who consumed traditional beer were mostly older unemployed men with lower formal education. Participants said social drinking was therapeutic as they got to share life experiences with other male counterparts during these drinking gatherings:

*I always hangout with my boys. Mostly on weekends. We drink and talk about life; I mean everything from our hurts and joys maybe from the family or girlfriends. It is funny that when we are sober it is difficult to talk about some stuff. I for one cannot openly talk about family issues to my friends when I am sober, but when I am tipsy anything goes. I do not know why this happens so for me that is one of the reasons why I drink, I become free. (Luke, FGD #3)*

Some men in England believe excessive drinking of alcohol makes one to appear masculine [15]. This stereotype contributes to the high and reckless consumption of alcohol by men in comparison to their female counterparts [10, 16]. The

#### *Impacts of Masculinity on Men's Health in Maseru, Lesotho DOI: http://dx.doi.org/10.5772/intechopen.104888*

masculine standards of being a '*playboy*', endearing and taking risks are determinants alluded to in literature for heavy consumption of alcohol and high risks of alcohol-related challenges [17]. Subscribers to hegemonic masculinity hide their feelings or emotions when they are abstemious. The avoidance of emotions, the belief that excessive alcohol consumption prevents boredom and that stress caused by female partners caused men to excessively consume alcohol were illustrated as follows:

*Men usually cannot stand pain. Not physical pain as such, this emotional pain. For example, a man who has a wife who is always shouting at him would rather be in a bar and get home drunk and care free. Unfortunately, some women do not realise that they are the source of their husbands' bad drinking habits. (Thato, FGD #8)*

*For some the reason is family problems faced. They are running away from a nagging wife. They would rather arrive home drunk because they are not respected in their houses anyway. They are treated like children. For some, bars are the only place where they get to socialise with friends and avoid boredom. (Thabang, FGD #2)*

*I think we are created different from women. Men get stressed when they are just idling, that is when the thought of at least going to the bar comes. Even if there is money in the house that the wife has hidden for some serious housekeeping, a bored man would steal some of that money and go for alcoholic drinks. (Tumelo, FGD #4)*

One of the participants differentiated men from women, as seen from other men, he attributed this difference to masculine identities especially the competitive nature of masculine men:

*Yeah, there is a huge difference. Men drink more alcohol containing beverages than women. Men like showing off what they can do. Somebody mentioned the issue of competition; that is one of the reasons. Men enjoy competition almost in everything they do. (Lerata, FGD #6)*

Different from smoking, participants did not instantly link harmful consumption of alcohol to negative health effects, instead they related excessive alcohol consumption to social issues experienced in society. They pointed out unwanted behaviours that usually lead to more violence and fights between friends and family members, avoidable road accidents and deaths.

## **5. Masculinity and healthy food consumption**

Participants considered cooking as a women's obligation. This finding concurs with previous studies that reported cooking as a feminine task [18]. The belief that cooking is women's responsibility has resulted in unhealthy eating behaviours in men [14], particularly in the absence of females who are expected to prepare food for men. Men who endorse traditional masculine identities are therefore at higher risk than women of developing chronic NCDs related to poor diet. Most men in Maseru, Lesotho relied on women for food preparation mainly because food preparation was considered a feminine task. Similarly, other men from different surroundings who do not cook [19], some men in Maseru said they did not cook at all in their households:

*I do not know much about food stuff and preparation. The truth is that I am not interested. As long as my stomach is full I am okay. (Molisa, FGD #4)*

Masculinity was associated with less attention on food and what to eat. For men having especially dominant masculine characteristics, cooking their own meals is often optional [20]. Finnish men from different working groups define food purchasing and preparation as feminine [20]. Femininity is also used to label food and beverages in most communities. For instance, consuming red meat and alcoholic beverages is an indicator of masculinity in different cultures, whereas eating salads, fruits, and desserts is considered feminine [20]. The femininization of food preparation and cooking is a stereotype that has led to men's poor eating habits which are health defeating and exposing men to multiple NCDs. Men who were married but were not living with their spouses reported that they only ate healthy meals when their wives visited them. Single men who were not living with their partners but lived with their family members and depended on their female relatives for healthy meal preparation. Men who were single, and not living with their family members and not with their partners failed constantly to cook healthy meals for themselves. Buying fast food was a common alternative for this group of men.

*I am not staying with my wife here, so I always go for meals that are easy to get at work and even at home except if my wife is around. If I cook, it's always eggs or grilled chicken from the oven and prepare some papa and eat without vegetables. The only time when I eat healthy food is when my wife is around. On my own, I always go for fast food. Proper cooking is a mission. (Liketso, FGD #6)*

*It is my wife who always prepares food for my family. I usually prepare my own meals when there is a need, [that is], when my wife is not around. (Paul, FGD #8)*

Cooking was considered a woman's obligation even though there was an acknowledgement of unfairness to cooking deemed a women's responsibility, especially in cases where both partners were working:

*The fact that women are also working these days, they are doing men a huge favour, they should be staying at home nurturing babies and making sure that there is cooked food for the kids, men and the family at large while men are out at work. Strange enough when we get back home, both from work, I sit down and expect her to give me some food and even start complaining that she is too slow to prepare me some food. (Liketso, FGD #3)*

With regards to the unemployed men, there was inclination to sharing responsibilities such as cooking and other household chores previously perceived women's responsibility:

*It is not only women who should cook in the house. We should assist and share whatever house chore we have. Even doing laundry is one of the activities that I personally help with. I really do not mind. (Thulo, FGD #5)*

Being intentional about healthy diet consumption was criticised by some participants as feminine. However, there were men who aspired to develop courage and commitment to healthy eating in the future:

*I have lately realized that some men, like women, are too careful on the food they eat. They are so picky. It is a very small number of them that I have seen. I think that is a good thing to practice. I am not one of those men but hopefully I will be one day. For now, for me, being so selective on food to eat is too much admin. Maybe as time goes I will be able to change. For now, I eat whatever I lay my hands on. As long as I am full and the food is nice, I am a happy man. (Mohau, FGD #7)*

Participants were asked to provide possible and effective strategies that can be used to encourage men to practice healthy dietary habits. The majority of the men alluded to nutritional education and awareness specifically targeting men. Some men thought that there was a general need to empower men to challenge health by defeating cultural beliefs and practices.

## **6. Masculinity and physical inactivity**

Physical strength and competitiveness are among other features previously deemed important to masculinity. Men usually participate in rigorous physical activities to realise these two qualities. Individuals aspiring and subscribing to masculine energy usually participate in rigorous physical activities. Research reports physical activity as more prevalent, especially among men than it is among women [10]. High competition is one of the traits associated with masculinity and participation in competitive physical activity exposes masculine subscribers to a platform for competition with others with similar characteristics.

Majority of the men were aware of the susceptibility to various health challenges and undesirable health effects related to physical inactivity. However, due to a lack of knowledge and awareness for some men, physical activities, especially recreational physical activities were associated with sophisticated community members and sportsmen. This lack of understanding and awareness restricted physical activities to leisure physical activities. Unemployed men and non-office workers were some of the groups that perceived physical activity as a middle-class practice. The blue-collar employees were of the view that their daily jobs were already physical activities, but they did not know of the health benefits attained from physical activities carried out at work:

*It [physical activity] is mostly done by the middle-class people who are usually using cars as their mode of transport most of the time so they try and do jogging as a physical activity to keep healthy. From there it would be those people who are actively participating in sports who go jogging to get their bodies ready for games. I am a construction worker, when I get home; all I need is to rest for the next day. My job takes all my energy away. (Mosebi, FGD #6)*

Some participants engaged in domestic activities which they correctly perceived as physical activities:

*I am a farmer, I am always busy in my garden and I also feed my chickens and pigs and clean their shelters on daily basis. In doing so, I believe I am engaging in physical activities that keep me healthy and active. What do you think? (Tanki, FGD #6)*

However, consistency in physical activities was lacking:

*There are days when I do not enjoy this thing [farming]. If it was not work I would not be doing it. (Lebo, FGD #4)*

Some men in the study reported that they did not participate in any form of physical activities owing to their too busy daily schedules:

*To be honest with you, for me there is no sport or games that I play. I do not have the time. The only time I get to do a physical activity is when am at church. The type of music we do there makes us run around and jump up and down. I would therefore say that is the only chance I have for a physical activity in a week. (Tlotli, FGD #5)*

Consistent physical activities are associated with healthy body weight. When asked about the societal meaning attached to men's body mass in Lesotho's context, most responses alluded to associations between wealth and being obese, especially with the older generations. However, the men reported a shift in perspective where the current generation seems aware that obesity is unhealthy and does not indicate wealth. Some men indicated that they were aware of the health challenges linked to obesity. One participant alluded to the fact that many illnesses that are caused by obesity are avoided. Study participants also shared that obesity constrains physical activities citing particularly men's sexual performance:

*I work with women in the farm. When they see a fat man, they always comment that they doubt that fat [man] is doing well in his sexual life because of the weight he is carrying. So, when women see fat men, they get too curious about their sexual performance in bed. You cannot even satisfy your woman in bed if you are fat my man. These women talk chief. I do not think this relate to sexual life alone. I mean, being fat must be heavy; I am sure any physical work is a challenge for a fat man. So again, I would say for me when I see a fat man, the first thing that comes to mind is laziness. (Jerry, FGD #3)*

*I do not know, but personally I think a man should be physically fit. That helps him to be admired and respected by other men as well as women. (Theo, FGD #1)*

Hegemonic masculinity is protective as seen in the quotation above showcasing that men's sexual prowess was valued by masculinity subscribers.

## **7. Conclusion**

Masculinity is one of the major determining factors contributing to the risky lifestyle of masculine men. The preventable exposure to NCDs increases particularly in men due to increased risky behaviours masculine men practice. This chapter explored the role of masculinity in the prevalence of lifestyle risk factors for NCDs. Participant's lifestyle and attitude did not match the men's awareness and knowledge about the harmful health effects caused by lifestyle risk factors. Not all characteristics of masculinity have negative effects on health, however, identifying with masculinity can be problematic. It contributes to the initiation of smoking, excessive alcohol consumption, and lack of motivation to maintain healthy food consumption. Masculinity can be protective thereby resulting in motivation to maintain a healthy body weight. Key features to the definition of a man included having the knowledge, and the ability *Impacts of Masculinity on Men's Health in Maseru, Lesotho DOI: http://dx.doi.org/10.5772/intechopen.104888*

to take responsibility for others, however, it was startling that men generally relinquished responsibility for their health to their female counterparts, for example, their wives and female partners. Men can be considered high-risk members of society. They need to commit and adopt lifestyle changes that lessen the negative effects related to lifestyle risk factors for NCDs.

## **Author details**

Nkeka Peter Tseole School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa

\*Address all correspondence to: nkekathabiso@gmail.com

© 2022 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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## **Chapter 6**
