Missing men – why health promotion leaves them behind and how to bring them on board: results of a rapid qualitative evidence synthesis

Abstract

Background

Men show a higher mortality than women, especially at a young age (between 15 and 39 years). They are more likely to engage in unhealthy behaviours and tend not to implement preventative efforts or to seek help. While (mental) health promotion programmes aim to foster healthy behaviours, men often do not feel addressed by them and are therefore reluctant to participate. This synthesis aims at drawing together barriers to and facilitators of male participation in (mental) health promotion programmes and identifying how to best address men in health communication and programme promotion.

Methods

This rapid qualitative evidence synthesis includes a sample of 21 studies. 18 are qualitative studies and 3 are mixed-methods studies with separately reported qualitative findings that captured the perspectives of males aged 12 to 79 years and of professionals working in men’s health on the barriers to and facilitators of participation in (mental) health promotion programmes and on preferred health communication.

Studies were purposefully selected to maximise variation across interview content, context, and participant characteristics (e.g., age, occupation). The selection was restricted to studies published between 2015 and 2025.

Results

Gender norms were one of the main barriers to participation in men’s (mental) health promotion programmes. Preferably such programmes should be integrated into settings attractive or familiar to men, such as sport clubs or handicraft workshops, or the workplace. Peers and peer support played a crucial role within men’s health promotion and were found to facilitate positive behavioural changes. When reaching out to men, clinical and stigmatising terminology should be avoided in favour of action-oriented language that emphasises control and practical solutions while keeping the messaging simple and focused on tangible benefits.

Conclusions

Health promotion programmes for men require embedding interventions within male-relevant contexts, such as sports, workplaces, and peer networks, that ease participation and reduce stigma. To reach and benefit men, communication strategies should use relatable, non-stigmatising language from credible messengers and should frame self-care as compatible with masculine identities.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-026-27454-6.

Background

In many European countries, gains in life expectancy slowed after 2011. This development is linked to reduced progress in lowering mortality from cardiovascular diseases and cancers, as well as slower improvements in risk factors such as high low-density lipoprotein (LDL) cholesterol and elevated blood pressure. At the same time, major risk factors for these non-communicable diseases, including high body mass index (BMI), poor diet, heavy alcohol use, and physical inactivity, remain widespread in Europe [1].

Globally the mortality ratio of men to women has increased. Especially between the ages of 15 and 39 years men are more likely to die than women. In 2021, the worldwide mortality rate in this age category was 65,9% higher for men compared to women. Causes amongst others are behavioural factors, occupational factors, homicide and suicide, which men are more affected by [2]. Men are two times more likely to die from suicide [3]. They also tend to underestimate health risks and engage more often in harmful behaviours such as smoking, heavy episodic drinking, and unhealthy eating [4, 5]. In addition, they underuse preventive healthcare services and often delay seeking treatment when ill—patterns strongly linked to traditional masculine norms [6–8], such as self-reliance, dominance and primacy of work [9]. These social expectations teach men to handle struggles alone, maintain the appearance of being in control at all times, and place work above their personal well-being [9]. Compared to women, men are less likely to attend routine health checks or to seek support for mental health problems [10–12]. Women, by contrast, more consistently adopt health-promoting and preventive behaviours [13].

Health promotion programmes are planned and structured interventions designed to enable individuals and communities to increase their control over and improve their health [3]. Health promotion is characterised by a positive orientation towards health, an asset-based perspective, participation, empowerment, and equity [14]. The Ottawa Charter articulated a broad vision of health promotion that extends beyond individual health behaviours to include healthy public policy, supportive environments, strengthened community action, the development of personal skills, and the reorientation of health services [3]. These programmes aim to prevent disease, promote healthier behaviours, and strengthen resources that support well-being by addressing both the individual and social determinants of health [3, 15]. They may take various forms, including community-based interventions such as smoking cessation groups, nutrition or cooking classes, and physical activity groups, as well as workplace initiatives focusing on stress reduction, back pain prevention, or corporate fitness. They may also encompass population-level campaigns, for example, alcohol harm reduction strategies, or health promotion activities in schools, such as healthy eating policies and physical activity programmes [16]. Health promotion initiatives can range from one-off campaigns to comprehensive community and workplace approaches [17, 18]. Yet, recruiting men into such programmes remains challenging, particularly among those from lower socioeconomic backgrounds [19–21].

Existing systematic reviews on the topic have synthesised the barriers to and facilitators of participation in health promotion programmes among men over 60 [22], or in men over 50, specifically addressing the effectiveness of Men’s Sheds, a community-based health promotion concept designed to reduce social isolation and increase well-being [23]. To the best of our knowledge no recent review has focused on men younger than 50 years.

This rapid qualitative evidence synthesis includes men across different age groups and therefore addresses an important gap by paying particular attention to younger and middle-aged men. It was guided by the following research questions: (1) What are the attitudes of different groups of men towards (mental) health promotion programmes, which factors—including perceived barriers and facilitators—influence their participation, and how can these barriers be addressed? (2) Which communication and outreach strategies most effectively motivate men’s participation and sustained engagement in health promotion?

In this qualitative evidence synthesis, we considered evidence on health promotion as a broad topic, including studies that focused on physical health promotion programmes, studies that comprised health promotion programmes that featured physical and mental health promotion, and studies, that focused on mental health promotion.

Methods

We conducted a rapid qualitative evidence synthesis, drawing on the guidelines of the Cochrane-Campbell Handbook [24]. In a rapid qualitative evidence synthesis, certain methodological steps are abbreviated to produce findings faster than in a traditional systematic review [25]. Because this evidence synthesis is part of a larger research project on this topic, resource and time constraints prevented us from conducting a full qualitative evidence synthesis. This rapid qualitative evidence synthesis aimed, in part, to inform the development of an interview guide for interviews with men on this topic. The review steps were defined in advance in an internal study protocol (available upon request by the first author). To make the evidence synthesis rapid, we applied the following methodological shortcuts: single screening of abstracts and full texts; data extraction by one person, sampling of studies for inclusion in the qualitative synthesis; omission of a formal quality appraisal of the included studies; and no assessment of the strength or certainty of evidence for individual findings. Reporting of the methodology and findings of the rapid qualitative evidence synthesis was guided by the ‘Enhancing transparency in reporting the synthesis of qualitative research (ENTREQ) Statement’, [26] which is reported in the Additional File, Table A1.

Eligibility criteria

We included studies that captured the perspectives of males and all who identified as such aged 12 years and older, or of individuals working with men on relevant health promotion topics. Eligible studies comprised qualitative and mixed-methods studies, which separately reported qualitative findings, as well as qualitative evidence syntheses conducted in high- or middle-income countries. A detailed table listing all the inclusion and exclusion criteria is provided in the Additional File, Table A2.

Information sources and literature search

We conducted a targeted and focused literature search for this review, applying the ‘tailored approach’ proposed by Cooper et al. [27], an individualised strategy that combines different search methods. First, one team member (JD) searched for qualitative evidence syntheses on this topic in PubMed (https://pubmed.ncbi.nlm.nih.gov/). Several team members (NM, JD, UG) searched Google, Google Scholar, Bing, PubMed and the websites of country-specific public health institutes for qualitative evidence syntheses, qualitative studies, and grey literature on the topic in October 2024. Based on text analysis of literature identified, an experienced information specialist (IK) searched the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and PsycINFO databases for qualitative studies published between January 1, 2004 and December 18, 2024, using a combination of free-text terms and controlled vocabulary (e.g., Medical Subject Headings). (see detailed search strategies in the Additional File, Table A3 Details of CINAHL (Ebsco) search, search date: December 18th, 2024 and Table A4 Details of APA PsycInfo search, search date: December 18th, 2024) Additionally, two reviewers (NM, JD) shared the task of screening the reference list of a relevant systematic review [19].

Literature selection

We developed screening forms for abstracts and full texts based on the predefined eligibility criteria and piloted them with 50 abstracts and three full-text articles to identify missing elements and to ensure consistent understanding among the authors. The screening was conducted by three authors (NM, JD, KS). Thereby, each title and abstract was screened by two authors, who then consolidated whether or not to include a study. Thereafter, the included studies underwent a full text screening against the inclusion and exclusion criteria using Covidence [28]. For this screening step, a certain number of studies was assigned to each of the three authors (NM, JD, KS) who individually decided whether or not to include a study based on the full text (single screening). Any uncertainties in applying the criteria were discussed and resolved within the authors team.

We initially planned to synthesise all the included studies. However, due to the large number of eligible studies, we applied purposive sampling to select a subset for in-depth analysis [29]. To ensure thematic diversity and relevance to the aims of the evidence synthesis (i.e., to synthesise qualitative evidence on barriers to and facilitators of participation in [mental] health promotion programmes and to identify effective messaging strategies to engage men and encourage their involvement), we combined elements of maximum diversity and intensity sampling. We applied purposeful sampling and excluded studies that exclusively examined populations aged 65 years and older, primarily focused on older men, or did not clearly report the age groups interviewed [30, 31]. To enhance contextual diversity, we specifically sampled articles from non-English-speaking countries, as most identified studies originated from English-speaking contexts. We included school-based programmes, diverse settings, and community groups, while ensuring a balanced representation across other settings. Furthermore, we gave preference to studies published within the last 10 years.

Data extraction, data analysis, and synthesis

Four authors (NM, JD, KS, CKK) shared the task to extract the key study characteristics of all included studies into a pre-structured, standardised data extraction table. The extracted characteristics included: authors, year of publication, study design, study aim, setting, country, covered topics, age ranges and means, target population, method of data analysis, and a summary of findings. The extraction table provided an overview of the studies and served as the basis for the sampling process. Subsequently, the selected studies were uploaded as PDF files into MAXQDA 2024 [32] for thematic synthesis.

We conducted a rapid best-fit framework synthesis following the approach proposed by Shaw et al. 2021 [33], where the review questions and relevant categories from previous reviews [22, 34] served as an initial framework that is expanded and revised during the synthesis process. Five authors (NM, JD, UG, DH, CKK) applied line-by-line coding to participant data extracts and authors’ descriptions in the results sections (first-order concepts) and study authors’ interpretations (second-order concepts) across all eligible and sampled papers. We conducted this synthesis in two steps:

1. A coding framework was developed deductively based on the themes of the guiding review questions (for example: Barriers towards participation; Facilitators towards participation). Further categories and subcategories were added inductively during the coding process (as example for an inductively added category: Challenges of men regarding mental health). The coding framework was discussed in regular meetings among the team of reviewers to consolidate the codes and merge similar individual codes into one code and discuss boundaries between the codes.

2. In a second step, one author from the team (JD) developed descriptive themes from the individual codes, which were continuously discussed within the team to refine the themes, to consolidate boundaries between themes, or to establish new themes.

Results

Search results

After de-duplication of the search results, we screened 852 abstracts and titles and 113 full texts against our predefined eligibility criteria. 699 studies were excluded as they did not fulfill the inclusion criteria at the title/abstract level (see eligibility criteria in the Additional File, Table 2). After the screening, 78 reports were included. Of these, 21 articles were sampled and included for the qualitative synthesis (Fig. 1). Of the included studies, 57 studies were not sampled. These were studies that focused on older men or did not clearly report age groups, studies published before 2015, studies on specific prevention programmes or specific target groups (e.g., young fathers) and studies that were only marginally about health promotion but more on help seeking or perception of health in general. A list of the excluded studies is provided in the Additional file.

Fig. 1.

PRISMA Flowchart of the study identification and screening procedures

Characteristics of the included studies

A description of the included studies is available in Table 2. The majority of the included studies (n = 18) were conducted in English-speaking countries, namely Australia, the United Kingdom, the United States, Canada, and Ireland. The remaining three studies took place in Denmark, the Netherlands, and across Bosnia-Herzegovina, Croatia, and Serbia. Participants were recruited from various settings: the community (n = 8), the workplace (n = 5), sports clubs (n = 3), or from unspecified settings (n = 5).

Table 2.

Characteristics of the included studies

Author, year	Study aim	Study design	Country	Setting	Methods of data collection	Number of interviewees	Age (of interview/focus group participants)	Methods of Data Analysis
Ahmadu 2021 [35]	To explore where men living with mental health challenges feel well*	Qualitative study	Canada	No specific setting	Semi-structured interviews	24 men	Mean NR; age range 20–79	Coding framework coding lineby-line, using a constant comparison approach
Bell 2023 [36]	To explore men’s perceived barriers to and facilitators of uptake and engagement with interventions designed to improve their physical and mental health and well-being*	Qualitative study	UK	Community	Focus groups	25 men	Mean NR; age range 28–65	Thematic analysis
Bunn 2016 [37]	To explore men’s experience of the Football Fans in Training (FFIT) programme, focusing on how masculinity, social interaction, and group dynamics influence lifestyle changes	Qualitative study	UK (Scotland)	Sports clubs	Focus groups, programme observations, field notes	63 men	Mean NR; age range 35–65	Thematic analysis
Carnahan 2018 [38]	To understand rural men’s perceptions about physical activity, engagement, and the influence of masculinity and social norms	Qualitative study	USA	Community	Focus groups	57 men	Mean 55.0 (SD 17.8); age range 18 +	Thematic analysis using inductive content analysis methods
Crane 2022 [39]	To explore the views of men working in blue-collar occupations on their experiences with weight loss, their preferences for weight loss programmes, and the messaging related to these programmes	Qualitative study	USA	Workplace	Interviews (online, telephone, face-toface)	20 men	Mean 43 (SD 13); age range 23–69	Conventional content analysis approach
Dahl 2023 [40]	To explore Arabicspeaking male immigrants’ perceptions of preventive initiatives, particularly for cardiovascular diseases (CVD), and to understand how to address inequalities in engagement	Qualitative study	Denmark	Community	Telephone interviews	10 men	Mean NR; age range 60–66	Inductive content analysis
Drummond 2022 [41]	To explore young males’ mental health and well-being needs within masculinised sporting cultures and to provide insights into creating safe spaces that promote positive masculinities and mental health*	Mixedmethods study	Australia	Sports clubs	Semi-structured interviews	10 (athletes, athletes’ parents)	Mean 39.20 (SD 16.90); age range 18–58	Descriptive statistics (quantitative); thematic analysis (qualitative)
Hanna 2020 [42]	To explore how masculinities operate within the construction industry, both inhibiting and promoting health and well-being, and how generational differences affect health behaviours*	Qualitative study	UK	Workplace	Semi-structured interviews	21 (20 men, 1 woman—site managers, health and safety officers, and construction workers)	Mean NR; age range between early 20 s and early 60 s	Thematic analysis
Lefkowich 2017 [43]	1) To investigate what strategies or mechanisms contribute to meaningful programme/service development for men 2) To provide insight into the ways in which a genderspecific focus contributes to meaningful and effective practices in men’s health	Qualitative study	Ireland	Community	Semi-structured qualitative interviews	9 session facilitators	NA (interview partners were session facilitators)	Grounded theory approach
Lefkowich 2018 [44]	To investigate men’s experiences as members of Men’s Sheds and the relationship between their involvement in the Shed and their well-being	Qualitative study	Ireland	Community	Semi-structured interviews, focus groups, observations	27 men	Mean NR; age range from early 20 s to mid-70 s, with the majority being middleaged or older	Grounded theory and key strategies as articulated by Corbin and Strauss (1990) and Auerbach and Silverstein (2003) iteratively using open and comparative coding techniques
Lems 2019 [45]	To understand perceptions of health and health‐promotion strategies among adolescent boys from disadvantaged neighbourhoods to identify opportunities for health promotion that are better tailored to their needs	Qualitative study	Netherlands	Community	Semi-structured interviews, participant observations, and cocreation sessions	15 adolescent boys	Mean 14.1 (SD NR); age range 12–18	Ethnographic content analysis
Matthews 2021 [46]	To explore barriers to and enablers of men’s use of Employee Assistance Programmes’ mental health services and differences between blue- and whitecollar workers in Australia*	Qualitative study	Australia	Workplace	Focus groups, interviews	44 men	Mean 37.37 (SD 10.94); age range 22–60	Thematic analysis
McGeechan 2017 [47]	To explore ‘Shedders’’ perceptions of their shed	Qualitative study	UK	Community	Focus groups	32 men	Mean NR; age range 18–69	Thematic analysis
Namy 2015 [48]	To explore the perspectives of participants in the Young Men Initiative (YMI), an innovative programme that aimed to promote healthier masculinities among boys attending vocational high schools in several Balkan countries through educational workshops, residential retreats, and a social marketing campaign	Qualitative study	Bosnia and Herzegovina, Croatia, Kosovo, and Serbia	No specific setting	In-depth interviews, focus group discussions	48 boys and programme facilitators	Mean NR; age range 14–16	Framework Method (Ritchie and Lewis 2003), frequently used in thematic analysis of qualitative data in public health research (Gale et al. 2013)
Oliffe 2017[49]	To describe ruralbased working men’s views about health to distil acceptable workplace approaches to promoting men’s healthy lifestyles	Qualitative study	Canada	Workplace	Focus group interviews	21 men	Mean 46 (SD 11,5); age range 23–73	Thematic analysis
Robertson 2018 [50]	To present the findings from a multi-phase study looking at ‘what works’ in mental health promotion for men*	Qualitative study	Primarily UK	No specific setting	Interviews	13 key stakeholders	NA (interview partners were key players in the mental health field)	Thematic analysis techniques
Seaton 2019 [51]	To explore the gendered views of men and workplace representatives about workplace mental health promotion in male-dominated industries*	Qualitative study	Canada	Workplace	Group consultations (with men) and individual interviews (with the workplace representatives)	30 (23 working men, 7 workplace representatives from maledominated industries)	Working men: mean 46.1 (13.8); age range 23–71 Representatives: mean 38.3 (8.0); age range 27–48	Thematic analysis
Sharp 2018 [52]	To explore men’s perspectives of their participation in a gender-sensitised intervention targeting healthy eating, active living, and social connections	Qualitative study	Canada	Sports club	Semi-structured telephone interviews	23 men	Mean 53 (SD 9.9); age range NR	Inductive thematic analysis(Braun &Clarke, 2006)
Sharp 2022 [53]	To explore men’s perceptions of mental health and preferences for mental health promotion*	Qualitative study	Australia	No specific setting	Focus groups	43 men and 16 stakeholders	Mean 50.65 (13.75); age range NR	Inductive thematic analysis
Sharp 2023 [54]	To report the feasibility and acceptability of Buddy Up, a peerbased suicide prevention campaign for men*	Mixedmethods study	Canada	Community	Individual interviews	19 men	Mean 47.89 (SD 14.7); age range 24–70	Thematic analysis (Braun & Clarke, 2006)
Sharp 2024 [55]	To explore men’s preferences for language and communication in mental health promotion and provide recommendations for current and future programmes*	Mixedmethods study	Australia	No specific setting	Focus groups, individual interviews	64 men	Mean 51.92 (SD: 12.05); age range 18 + (focus group), 35–64 (interviews)	Interpretive description, constant comparative analysis, data triangulation

Abbreviations: IQR Interquartile range, NA Not applicable, NR Not reported, SD Standard deviation, UK United Kingdom, USA United States of America

^*Mental health (promotion) included in this study

In 14 of the sampled studies, the interviewees were only males, ranging from 12 to 79 years of age. Two studies included both, males and stakeholders in the field of (mental) health programming, such as men’s (mental) health experts and programme facilitators. Two studies included only such stakeholders. Moreover, two studies included men and managers or workplace representatives. In one study young males (between 15 and 24 years old) and their parents were interviewed. The 21 sampled studies involved between 9 and 64 interview or focus group participants. An overview of the interviewed person groups, as well as the number of included studies featuring each group and the total number of interviewed persons is provided in Table 1.

Table 1.

Interviewed person groups

Interviewed person group	Number of included studies	Total number of persons interviewed
Only men/male adolescents	14	444
Males and stakeholders	2	107
Stakeholders	2	22
Men and managers/workplace representatives	2	51
Men/male adolescents and their parents	1	10

The following results are structured according to the review questions and comprise barriers to as well as facilitators of participation in health promotion programmes and suggestions regarding reaching out to men.

As the interviewees differed in the included studies, we indicated who a statement stems from in the following results section. If only men were interviewed, we included age range, where reported and mean age, where reported, in brackets throughout the findings, wherever only one study is mentioned at a time. When statements are made referring to more than one study at a time, as the majority of the studies included participants with a wide age range (see Table 2), we decided to not report age to maintain readability and because it is highly likely that a broad age range is covered.

In some studies, findings were reported narratively without indicating how many participants contributed to specific themes. Therefore, it was not possible to calculate the proportion of participants contributing to specific topics. Thus, we had refrained from an exact quantification and primarily described the topics that emerged in our analysis.

Throughout the results and the discussion, we use the term (mental) health to indicate that a finding referred to both, mental health promotion and health promotion. If a finding referred to mental health promotion only, we reference it as mental health promotion. If a finding referred to health promotion but did not specifically include mental health aspects, it is referred to as health promotion.

Barriers to participation in health promotion programmes

Although men acknowledge the importance of physical activity for maintaining health [38], recognise the value of mental health [36], and are aware that disease prevention is both more effective and cost-efficient than treatment [40], multiple barriers to their participation in health promotion programmes persist.

Sociocultural and gender norms as a main barrier to participation in health promotion programmes

(Mental) health promotion programme facilitators considered deep-rooted sociocultural gender norms in western societies to be one of the main barriers to men’s participation in health promotion programmes [43]. A young man (between 14 and 16 years old, mean age: not reported) from a Balkan country interviewed by Namy et al. [48] described: ‘To become a man here in our country, we smoke cigarettes and drink alcohol (…)’. This quote demonstrates that the perception of ‘being a man’ is linked to engaging in unhealthy behaviours. Boys (between 12 and 18 years old, mean age: 14.1 years) interviewed by Lems et al. [45] stated the importance of health, but at the same time displayed unhealthy habits such as drinking energy drinks on a daily basis. Lefkowich et al. [43] found that health promotion programme facilitators struggled to have men put behaviour or lifestyle changes into practice because these changes contradicted the perception of their masculinity. Sharp et al. [53] found that although men (age range: not reported, mean age 50.65 years) were aware of existing preventive mental health support services, they faced considerable barriers and stigmas associated with accessing these services. Thereby, men feared being perceived as weak or unmanly if they talked about mental health [53]. Moreover, men perceived their mental health as their own responsibility and preferred suppressing their emotions rather than talking about them because they thought that talking was not a solution to a problem [46] but rather promoted a focus on the problem [53].

Men (age range between early 20s and early 60s, mean age: not reported) working in a male-dominated industry, such as construction work, emphasised the importance of saving face and preserving one’s social credibility within their peer group, including showing no weakness and not appearing soft [42]. The pressure of being perceived as a strong man and handling difficulties single-handedly is described as omnipresent:

‘You’re not manly if you have [a] mental illness—you’re not strong. It’s about being strong, and that looks, that’s weak. You know what I mean? You’re weak if you’re mental, if you have mental issues. We’re the hunters, we’re the gathers [sic!], you know? There’s a lot riding on our shoulders to be this strong man. And everything else is a sign of weakness, right? It’s like a sick animal. The wolves go after the sick one. It’s just like at work. Your coworkers, the wolves, are gonna be going after that lame deer’ [51].

Interviewed male employees considered that talking about problems or seeking help would jeopardise these perceived gender norms [42, 51].

Moreover, white-collar workers, working in an accounting firm, some of them in management positions (between 22 and 66 years old, mean age 37.37 years) questioned their participation in mental health promotion programmes, as they felt that their participation could impede their masculinity, lead to being stigmatised, or even jeopardise their career. They articulated genuine concerns about job loss or career damage when disclosing mental health struggles [46]. Stakeholders who had frontline experience working with men caution that men could damage their career if they open up too much to others at work [53]. Despite employer rhetoric about mental health support, the reality is often dismissive:

‘“Here’s a number, call the helpline”, like they are kind of saying, “We didn’t mean it”. I guess what I mean is that there is some place to bring some more of yourself and your emotions to the workplace but not too much. Curated’ [53].

Furthermore, local norms can influence men’s health-related behaviour. Carnahan et al. [38] studied the physical activity in rural US men (starting at 18 years old, mean age 55.0 years) and found that men adjusted their physical activities to local norms: in areas where it was stigmatised when men engaged in physical exercise, they were less physically active. For example, men reported that it was not very common for men in their living area to be physically active but that it was more common for females to exercise. Thus, if men physically exercised in public, other men might make fun of them. Conversely, in subcultures that promoted physical activity among men, activity levels were higher. For instance, in a rural area, where it was common for older men to hike on trails, men were found to be more active, engaging in trail hiking [38].

Inappropriate programme setups

Lack of anonymity and trust in formal organisations

The way programmes are set up can create barriers to participation. In small, rural areas where people know one another personally, attending mental health promotion programmes can stand in contrast to the desire to attend services anonymously, as men (between 20 and 79 years old, mean age: not reported) preferred for others not to know that they feel unwell [35]. Negative attitudes towards participation in (mental) health promotion programmes were also found to be rooted in distrust and suspicion towards formal organisations [40, 46, 48, 50]. According to men’s mental health experts, men, particularly those from marginalised communities, had a preference for confidential and anonymous access [50]. The desire for anonymity of Arabic-speaking male immigrants living in Denmark (between 60 and 66 years old, mean age: not reported) was caused by doubts about data protection and fear that sensitive information might be shared, for example, with local authorities [40]. Moreover, in a workplace-related service talking about mental problems was not perceived as appropriate by participants as help-seeking could be a sign of weakness and unreliability and, thus, negatively affect the perception of the man being a reliable employee, or even hamper relationships among coworkers [42, 53].

A study conducted in the Balkan states exploring the perspectives of adolescents who participated in an initiative aiming at promoting healthier masculinities found that the participating boys were uncertain about the political agenda of the organisation facilitating the programme. Their first impression was that the programme was related to a gay pride parade, so they assumed it aimed at promoting homosexuality. It was particularly difficult for programme facilitators to change this first impression [48].

Settings or programme facilitators not appealing to men

Stakeholders reported that the settings, content, or type of programme facilitators of health promotion programmes can constitute a barrier to male participation. For example, according to experts in men’s mental health, men are less likely to attend if programmes are offered in community facilities predominantly used by women or in locations unfamiliar to them [50].

Lems et al. [45] interviewed adolescent boys from disadvantaged neighbourhoods. The interviewees emphasised that a school-based programme on healthy eating did not cater to their needs. Moreover, the facilitators, whom the interviewed boys described as ‘skinny females’, did not encourage them to participate; they would rather prefer a local role model as a facilitator. In the context of a weight loss programme, men (between 35 and 65 years old, mean age: not reported) explained that a very competitive setting could decrease their interest in participating. They preferred a setup where men sharing the same problem came together and worked on the same goal rather than a setup where they felt like they were competing against already very fit men [37].

Content or focus of the programme is not clear enough

Men may be reluctant to attend (mental) health promotion programmes if the aim or topic is not communicated clearly: Matthews et al. [46], who explored men’s (between 22 and 66 years old, mean age: 37.37 years) use of a workplace-based mental health support programme, found that employees did not participate due to a lack of clear information about the programme, including the topics covered and whether it could be used to address ‘everyday problems’. Moreover, not receiving a personal recommendation for the programme, not knowing who else has participated and how successful the programme was made the men hesitant to attend.

Socioeconomic and language barriers

Some studies reported a lack of equitable access to health promotion: Representatives and facilitators of an Irish health and wellbeing programme for men reported that health promotion programmes were often middle-class oriented, which made men from other socioeconomic backgrounds hesitant to attend [43]. Furthermore, men with an immigrant background stated that language barriers hindered them in attending health promotion programmes [40].

Lack of motivation and necessity

For some men [36, 38], an intrinsic lack of motivation or perceived necessity seemed to be the main barrier to participation in health promotion programmes. Either they simply did not enjoy physical activity and therefore could not find the motivation to be physically active [36], or men stated that, generally speaking, men were not expected to look as good and be as slender as women are expected to, so they did not feel the necessity to go the gym, for example [38]. Furthermore, some men (starting at 18 years old, mean age 55.0 years) claimed that they were already active enough within their jobs and there was no need to engage in additional physical activity [38].

Facilitators of participation

Despite existing barriers, men and programme facilitators described several factors that can encourage men’s participation in (mental) health promotion. These include the relevance of the content, supportive settings, and the role of peers and role models. The following list and description of these factors do not follow a hierarchical order.

Content-related factors

When asked about the topics and themes which men wanted to be addressed in health promotion programmes, they expressed interest in physical activity, exercise, alcohol management, and sleep improvement; diet was rarely identified as a target for intervention [36], whereas sports was particularly valued as a tool for self-learning and personal development [41]. Regarding mental health promotion, men did not mention content-related factors in the sampled studies.

Settings fostering men’s participation

Blending into day-to-day life

The sampled studies have shown, that choosing or providing settings that are attractive to men is a key factor in men’s (mental) health promotion [43, 51, 54]. Men found it important that programmes are easy to access, for example, being close to home [36, 44]. Moreover, this evidence synthesis showed that health promotion programmes should accommodate men’s existing lifestyles, responsibilities, and preferences rather than expecting them to completely restructure their lives around health goals. Programmes should be integrated into men’s existing routines and schedules rather than being added as an extra burden [39, 45]. Men (between 23 and 69 year old, mean age: 43 years) did not want to ‘clock in for work’ when focusing on health—they needed approaches that did not compete with work and family time [39]. For example, in Robertson et al.’s study [50], key players in the mental health field suggested that offering a mental health promotion programme for African American men at barbershops could be a good setting, as barbershops play an important cultural role in their lives and they therefore gather there anyways.

Gender-sensitive and men-only settings

Moreover, representatives from a health promotion programme for men highlighted that offering health promotion programmes in gender-sensitive settings that are acceptable for men facilitated male participation [43].

Looking at settings from a gender-sensitive perspective, men felt more comfortable attending programmes that were embedded in typical male settings, for example, in a sporting activity, such as ice hockey [52], or in craftwork [44, 47]. Men participating in a health promotion programme that promoted healthy eating, social connectedness, and active living in the context of ice hockey reported that the integration of the intervention within the ice hockey theme resonated with them and sustained their engagement. Through ice hockey, they (age range: not reported, mean age: 53 years) felt connected to their current ice hockey fandom as well as to their childhood when they dreamt about becoming an ice hockey athlete [52].

Especially for mental health promotion programmes, male-friendly settings were found to be essential to reduce stigma and facilitate participation (age range: not reported, mean age 50.65 years) [53]. One example are ‘Men’s Sheds’, community- and volunteer-run spaces for men focused on woodwork and craftmanship. Men who regularly visited such sheds and were interviewed for Sharp et al.’s (2022) study emphasised the promoting factors of the male environment and that the atmosphere of being together as men and doing work made it easier to also discuss mental health.

Multiple sampled studies revealed that men or programme facilitators stated that it was crucial to have a focus on men within health promotion programmes or to have a men-only setting [37, 43, 44, 47, 52]. This would allow them (between their early 20s and mid-70s with the majority being middle-aged or older, mean age: not reported) to talk more openly [44], and they (between 18 and 79 years old, mean age: not reported) would not have to hold back in their tone of conversation (‘men-talk’) [47].

Safe spaces

Health promotion programmes need to be perceived as a ‘safe space’ for men [37, 50, 52]. This entails mutual trust [48], a comfortable environment [41], and being able to open up [43]. As seeking out for mental health support can be especially stigmatising for men, feeling safe is particularly important in mental health support. Men (between 22 and 66 years old, mean age: 37.37 years) described that, in case of problems, they would first turn to their ‘circle of trust’, including spouses, friends, or family members, rather than to public services [46].

Furthermore, the white- and blue-collar workers interviewed in Matthews et al. [46] regarding an employee assistance programme reported that, to use the programme, they needed to trust the facilitators, which required a prior connection. As a blue-collar employee described: ‘It’s just a manly thing, they don’t automatically trust anybody’ [46]. The necessity of approachable health promotion programme facilitators was also outlined in the findings of Lefkowich et al. [43].

Peer support and role models

Peer support and camaraderie

Men articulated that connecting with peers who shared similar experiences—in contrast to interaction with professionals—promoted sharing thoughts, health challenges, and struggles more casually [37, 44]. Moreover, a programme facilitator explained that peer support may circumvent traditional masculine resistance to help-seeking by repositioning programme participation as an opportunity to provide support to peers, thereby making engagement more acceptable while simultaneously facilitating personal health behaviour change through indirect pathways [53].

A positive group dynamic was often described within sport settings [37, 41]. The team spirit occurring naturally within sport teams helped men bond with others [50] and provided an environment where men were able to naturally talk to one another [53]. Camaraderie within the sporting club was reported in several studies as an important element for (mental) health promotion [41, 43, 48, 51, 53]. Health promotion programme facilitators suggested that programmes should intentionally counteract competitive masculine expectations by emphasising teamwork, group encouragement, and collaborative work. This could allow men to question gender stereotypes and develop nurturing roles [43, 49].

The sampled studies demonstrated that both giving and receiving support was found to be important for men: men (between their early 20s and mid-70s with the majority being middle-aged or older, mean age: not reported) experienced pride and purpose in helping others [44]. Men highlighted the importance of having mental health promotion anchored in a peer social group because it provided a sense of meaning and connection, that is, it allowed them to support others, which helped with their mental struggles at the same time [53, 54]. A male programme facilitator explained how the perspective of providing help to peers makes men more likely to participate in a programme and further look out for themselves:

‘In getting help, I am helping others. Maybe men aren’t as good at getting help as they should be, but blokes really like giving help, offering help, being useful. So you train people to look after their mates rather than train them to look out for themselves, but in the process they learn how to look out for themselves’ [53].

Role model approach

Bell et al. [36] found that having strong and encouraging role models within health promotion programmes can facilitate men’s (between 28 and 65 years old, mean age: not reported) participation. In particular, Sharp et al. [53] demonstrated that such role models are especially important when initiating conversations about men’s (age range: not reported, mean age 50.65 years) mental health. Coaches, local champions, invited professional athletes, or older participants within intergenerational programmes or in a workplace setting can function as role models [37, 41, 43, 45, 46]. In sporting contexts, coaches provided mentorship and supported the development of a cohesive team [41]. Lems et al. [45] (participants were between 12 and 18 years old, mean age: 14.1 years) found that for health promotion, local role models can work ‘just as well or better than celebrities’, suggesting that authenticity and relatability may be more important than fame [45]. Drummond et al. [41] explored young men’s mental health within sporting cultures through interviews with young men and their parents. One of the parents stated that the sporting club functions as a second family to their child. Thereby, older participants served as role models for younger men, creating supportive networks across age groups.

Role models were found to also play a role in the workplace. Men (between 23 and 73 years old, mean age: 46 years) reported that observing weight loss in colleagues eating healthily served as a strong motivator, while senior management support can shift organisational norms around healthy food options [49].

Reaching out to men

Messaging approach

Messaging approaches are a major factor in reaching out to men, as even a well-designed programme is likely to fail without carefully planned communication [39, 40, 43, 46, 48–52].

Engaging men through in-person opportunities and offering tailored approaches can help encourage their participation in health promotion programmes [43]. Men favoured personalised invitation strategies, for example, in collaboration with general practitioners, as they are trusted [40].

Using male-friendly language, avoiding negatively conceived phrases and terms when advertising health promotion programmes or when presenting health information was considered essential: for example, men (working men: between 23 and 71 years old, mean age: 46.1 years; workplace representatives: between 27 and 48 years old, mean age: 38.3 years) perceived terms such as emotional well-being or mental well-being as synonymous with mental illness, leading to negative connotations [51].

A focus group participant in Sharp et al. [55] stated:

‘Mental health is kryptonite. Anything with mental health in it would be like “fuck that, that’s not my people.”’

Another focus group participant in Sharp et al. [55] said:

‘If we are looking to improve men’s mental well-being, put aside the clinical stuff, the addiction, the anxiety, depression, all that stuff. Do we even have to call it out? Do we have to actually say this is about “mental health” or is it about using other terms like connection and getting healthy… If you’re struggling at work, you’re talking about performance. If you do it in families, you’re probably talking about better connections or less friction.’

Similarly, programme facilitators [50] and men [55] suggested avoiding stigmatising language or wording with a stronger female connotation, such as emotions and feelings. A participant in Sharp et al. [55] explained:

‘Self-care is a terrible word for men because it’s so associated with women, personal time, and meditation.’

Furthermore, Seaton et al. [51] found that men (working men: between 23 and 71 years old, mean age: 46.1 years; workplace representatives: between 27 and 48 years old, mean age: 38.3 years) preferred language that directs at managing difficulties and highlights having control over a situation, for example, ‘controlling stress’ or ‘beating stress’. Using wording that addresses health in a more indirect way could also be beneficial [43, 50].

When advertising health promotion programmes or presenting health information, men were found to prefer descriptions that comprised necessary and relevant information about the programme and procedures. They valued examples illustrating when help-seeking or programme participation was warranted, as well as clear information on the benefits of participation, for instance, through statistics, visualisations, or figures [39, 40, 45, 46, 49].

Moreover, men preferred that invitations and informational materials use simple, clear, concise, and easy to understand language [39, 45, 49]. Using less formal or even conversational language or storytelling was also found to be preferred by men [43]. Younger men (between 12 and 18 years old, mean age: 14.1 years) especially considered health information that is presented in a fun and humorous way advantageous and more engaging [45]. Bringing in positive, empowering messages in relation to men, for example, ‘Be a Man! Change the Rules!’ can be catchy and shape the perception of the participants (between 14 and 16 years old, mean age: not reported), showing that changes are possible [48].

More suggestive language was preferred over direct commands or directives. Thus, instead of saying ‘do this or don’t do this’, ‘try this or try to avoid this’ was more appreciated among men (age range: not reported, mean age: 53 years) [52]. Men valued practical approaches such as ‘don't quit drinking beer altogether’ that felt realistic and sustainable [52]. Rather than prescribing wholesale lifestyle changes, programmes should encourage men to make small, incremental modifications they can apply to their personal circumstances.

Discussion

This rapid qualitative evidence synthesis assembles both the recent literature on younger and middle-aged men’s attitudes towards (mental) health promotion programmes and factors influencing their participation as well as the communication and outreach strategies that most effectively motivate their participation. Men generally recognise the value of physical and mental health and the benefits of prevention, yet they face persistent barriers to engage in (mental) health promoting activities. The strongest impediments are sociocultural and gender norms—stigma around help-seeking, fear of appearing weak, and concerns about career repercussions—which promote self-reliance across community and workplace settings.

A key underlying barrier is the persistent perception of traditional masculinity norms. The studies sampled for our synthesis have revealed that seeking help or engaging in healthy behaviours was often described as ‘not manly’. Such gender norms have been evident in both community-based and workplace settings. This aligns with earlier reviews: Gavarkovs et al. [56] found that programmes focused on topics such as nutrition or physical activity were perceived as female-oriented, discouraging men’s participation. Similarly, Howell et al. [22] reported that men over 60 were reluctant to engage in fall prevention programmes, viewing them as feminine, and that preventive activities were more broadly perceived as unmanly.

While conflicts with masculine ideals have been reported in general health promotion, this qualitative evidence synthesis shows that they were particularly pronounced in mental health promotion. The recurring tension between appearing ‘manly’ and seeking help or adopting healthy behaviours must be addressed, as men are disproportionately affected by preventable non-communicable diseases [57]. Masculinity, as a social construct, shapes men’s perceptions of health and illness and influences their behaviours. Multiple masculinities reflect social diversity shaped by age, race, ethnicity, culture, class, and sexuality [58]; hence, men’s (mental) health promotion needs vary across different groups.

Our synthesis identified a broader range of factors influencing men’s participation in health promotion programmes than that of Howell et al. [22], who focused primarily on older men, whereas our included studies spanned males aged 12 to 79 years. While Howell et al. [22] highlighted masculine norms, discomfort with female facilitators or participants, and mismatched programme interests as key barriers, our synthesis both corroborates and extends these findings. Facilitator gender and men-only formats remained important considerations, but overly competitive dynamics within male-only groups also emerged as a notable barrier; however, clarity of content, credible facilitators, and accessible, stigma-reducing settings were identified as stronger facilitating factors than male-only settings.

Moreover, this evidence synthesis highlights that (mental) health should be presented as an integrated, everyday concern rather than as the explicit focus of a programme. This aligns with the broader concept of health promotion, which emphasises a positive orientation towards health, an asset-based perspective grounded in participation and empowerment [14] and the understanding that health promotion extends beyond individual health behaviours to include supportive environments and strengthened community action [3].

The wording used in (mental) health promotion programmes is also important. Terms that may carry negative or feminine connotations, such as mental well-being or feelings, should be used cautiously in outreach communication to men. To appeal to men, programmes and their promotion should align with men’s daily lives and interests, using language and formats that resonate with them.

Given that (mental) health promotion is a stigmatised topic for many men, anonymity and trust are valued highly. This became particularly apparent in small communities or workplaces, where men might feel uncomfortable with friends or co-workers to know that they are seeking (mental) health support.

Our rapid qualitative evidence synthesis shows that several studies have highlighted men’s reservations about formal organisations, suggesting that personalised invitations from trusted individuals can help to overcome these reservations.

Another barrier is inequitable access to (mental) health promotion programmes, for example, due to cultural and language barriers, or when offers are targeting a specific socioeconomic class. Therefore, promotional approaches should also be tailored to different cultural and socioeconomic groups to ensure equitable access, for instance, by advertising (mental) health promotion programmes in culturally relevant sites, such as Barber shops for African American men in the United States.

Moreover, a barrier occurs when programmes are perceived as too feminine, or as primarily addressing females. Therefore, the social context and setting of programmes are crucial. Embedding (mental) health promotion within familiar, male-oriented environments, such as sports clubs or handicraft workshops can facilitate male participation.

This finding aligns with Bottorff et al. [59], who identified sports-based interventions as effective avenues for engaging men in health promotion. Likewise, a recent realist review by Timm [60] found that using sports clubs for interventions was particularly effective among middle-aged men. Their review identified key facilitators such as leveraging the identity of sports clubs, addressing masculinity-related barriers, improving accessibility, and building trust. These results are consistent with the present synthesis, which emphasises the value of settings that foster camaraderie, peer support, and credible role models demonstrating healthy behaviour, rather than a competitive focus. Our findings further emphasise the importance of peer support and role models in facilitating men’s engagement in (mental) health promotion. This aligns with the findings of Vickery [61], who described the varied ways in which men seek help when experiencing mental health difficulties and highlights the significant influence of familial and friendship networks on help-seeking behaviour.

Thus, (mental) health promotion programmes that are set up well, can foster positive masculine behaviours through peer support and role modelling, shift gender norms, and promote healthier lifestyles.

Strengths and limitations

This qualitative evidence synthesis has several strengths: It synthesises recent qualitative literature and details insights and perspectives from men across a broad age range and stakeholders working with men on (mental) health promotion and prevention programmes. We considered literature addressing the attitudes, opinions, and facilitating and hindering factors related to health and its promotion over the past 20 years. To capture the broadest possible range of findings, we included a wide variety of qualitative studies. In doing so, we deliberately selected studies that differed as much as possible in terms of interview content, settings, countries, and participant characteristics (e.g., age, occupation).

Our study has some methodological limitations. We limited our inclusion criteria to publications in English and German, the languages spoken fluently by the review team, in line with recommendations from rapid review guidance [62]. This may have led to the exclusion of relevant studies published in other languages. Furthermore, we followed a rapid approach with a focus on recent literature. Although we cannot rule out that relevant studies or findings were overlooked, the primary goal of a qualitative evidence synthesis is conceptual diversity rather than comprehensiveness. For this reason, we are confident that the most central and insightful studies on the topic were included in our analysis. Additionally, we did not assess the methodological quality of the included qualitative studies due to time constraints. Therefore, we cannot assess the strengths of the evidence. However, as our synthesis was intended to provide insights into the themes rather than the strict strengths of evidence ratings, we feel that our results are nevertheless valuable.

The literature search was targeted but thematically broad, focusing on health promotion in general. Although studies addressing mental health promotion were included, no separate search strategy was conducted for this topic. Studies comprising mental health promotion were therefore included only if they were identified through the general health promotion search. Other specific areas, such as digital health promotion, were not explicitly searched for and are therefore less represented in the identified studies.

We included studies with men of different ages in the sample but did not concentrate on men older than 65 years because evidence syntheses with this focus already exist [22, 23]. While the middle-aged group of men is well-represented, only two sampled studies explicitly focused on adolescents and young adults. Therefore, the generalisability of the results to adolescents and young adults may be limited.

The majority of the synthesised studies (18 out of 21) originated from English-speaking countries and covered a variety of settings, including communities, workplaces, sports clubs, and rural regions. However, the available data did not allow for systematic comparisons across these settings. While the workplace setting could be analysed in more detail, other contexts lacked a sufficient evidence base in the literature for comparison. Another limitation is that none of the studies included participants who identify as men but are not cisgender. This may also have influenced the findings and limits the generalisability of the results.

Conclusions and implications for research and practice

This qualitative evidence synthesis provides in-depth insights into the barriers to and facilitators of younger and middle-aged men to participate in (mental) health promotion programmes and into how men prefer to be approached and addressed. Rather than positioning men within feminised or clinical environments, effective interventions embed themselves within male communities and social networks, normalising participation and reducing stigma. Such approaches enable men to support one another in making lifestyle changes while maintaining a sense of masculine identity, thereby creating environments where vulnerability and help-seeking are accepted rather than perceived as weakness.

To achieve this, potential users of (mental) health promotion programmes should be involved at all stages of the intervention design, implementation, and evaluation to ensure that the initiatives are responsive to diverse masculinities and more effectively engage participants in sustained behaviour change [63]. This participatory approach is particularly important for reaching disadvantaged men, where community and workplace settings offer promising access points [64].

The findings also highlight the need for gender-sensitive and context-specific approaches in both research and practice. Future research should further explore how varied expressions of masculinity influence engagement across different life stages and social groups, drawing on participatory and intersectional methods to capture this complexity. In practice, programmes should move beyond deficit-oriented framings and instead integrate health promotion into every day, male-relevant contexts, such as sports, workplaces, or peer networks, where trust, anonymity, and social support can be cultivated. Communication strategies should use relatable, non-stigmatising language and rely on credible messengers and personalised outreach. Ultimately, interventions that normalise help-seeking and frame self-care as compatible with masculine identities are likely to reach and benefit more men.

Authors’ contributions

UG conceived the study idea and led the project planning and conduct. JD, NM, and UG developed the study protocol. IK conducted the electronic database searches, and NM, JD, and UG performed the supplementary searches. NM, JD, UG, and KS screened abstracts and full texts. NM, KS, CKK, and JD extracted the data, and UG checked the extracted data. UG and NM conducted the sampling of studies included in the synthesis. JD, NM, CKK, DH, and UG conducted the qualitative synthesis. CKK prepared the figure (the PRISMA Flowchart) and the table (Characteristics of the included studies). NM, DH, CKK and UG drafted the manuscript. All authors critically revised the manuscript for important intellectual content and approved the final version for publication.

Funding

The study was funded by the Lower Austrian Health and Social Fund.

Data availability

The data that support the findings of this study are available from the first author upon reasonable request.

Declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.