The interdependence of African American men's definitions of manhood and health

Abstract

In this paper we explore themes that cut across how 24-77 year old African American men define manhood and health. Utilizing a thematic approach, we analyzed data from nine focus groups (N=73). We found that manhood and health were relational constructs that are interrelated in men's minds and experiences. Manhood and health were defined by the characteristics men embody, the behaviors men engage in and the goals and values men had to positively influence their families and communities. Thus, manhood and health are interdependent constructs and their interrelationship should be considered in efforts to promote African American men's health.

Manhood is often thought of as an innate quality that is the natural result of being a biological male, but manhood is an identity that is constructed through intrapersonal and interpersonal relationships ^1,2. All men do not benefit equally from the social, economic and political benefits of being a man; many men are marginalized by race, ethnicity and class ³. Racism, segregation, economic discrimination and other structural forces in the US have limited the ways African American men can define themselves in relation to hegemonic masculine norms (e.g., fulfilling the role of economic provider, moving their families into desirable housing and neighborhood conditions, and accumulating wealth to pass on to their children and grandchildren) ^4-9. Hegemonic masculinity is the idealized cultural standard of masculinity that exists in a specific time, place and culture; it sets the ideal of how to be a man and sets the standard by which all men are judged ^10-12. Understanding the poor health status of males includes considering how gendered social determinants of health shape men's lives and experiences, particularly through economic and environmental factors ^3,13,14. In this paper, we explore how African American men define manhood and health, and we explore the implications of these definitions for health behavior and health outcomes.

What is Manhood?

Manhood is constantly precarious and can produce fears that others, particularly other men, will see them as weak, timid or frightened^15,16. Many men value their reputations and how other men perceive them in many areas of life ¹. Both men's notions of manhood and how men use behaviors to demonstrate that manhood vary over the course of men's lives in response to life experiences, aging and social context ¹⁷. The idea of proving one's manhood has been driven by social, cultural and structural changes in the context of family, political and work aspects of life, and the consequences of these changes have been both social and psychological ¹. Manhood is inherently racialized and class bound; it is inextricably linked to economic success and often defined by physical and sexual virility, the consumption and collection of consumer goods and leisure time activities ⁹. Because the fundamental meaning of masculinity and the salience of different aspects of masculinity change over the life course, it is critical to consider how notions of masculinity change over time and the importance of key health behaviors differ as men age^17,18. For instance, when men are younger they tend to demonstrate their physical strength, sexual prowess and risk tolerance, but as men age they tend to also want to demonstrate their ability to be a responsible father, provider, husband or partner ^4,5.

In addition to general differences in conceptualization of manhood as men age, there may also be important ethnic or cultural considerations too. African American men's views of themselves and their definitions of manhood differ from the conceptions of manhood that are often used by white men ^5,9,19,20. Whitehead's Big Man Little Man Complex argues that men attempt to achieve a level of respectability through economic success, educational attainment and social class status while simultaneously demonstrating prowess along the social and cultural dimensions of traditional masculinity: virility, sexual expertise, risk taking, physical strength, hardiness, etc. ²⁰. These factors highlight that masculinity may lead to stress and coping that results from: 1) trying to achieve success in areas of respectability, and 2) engagement in risky behaviors that may represent traditional aspects of masculinity (e.g., eating large portions, alcohol abuse, substance use, speeding while driving, risky types of physical activity, high numbers of sexual partners, inconsistent safe sex practices) ^21-23. Despite the contradictory and inconsistent demands of masculine ideologies and male gender norms, theories and measures have conceptualized male gender role strain as a stressor ²³. The strain men experience is rooted in how they think about gender-typed behavior, their degree of discomfort in particular gender-role situations and their concern about and actual violations of male gender role expectations or gendered behaviors that are associated with social and cultural roles ²⁴.

African American manhood has often been offered as an important contributor to the poor social, economic and health outcomes of African Americans in general, and the poor health profile of African American men in particular ^20,25-29. While African American manhood has been used to explain a variety of negative outcomes in African American men's lives, particularly health outcomes, frequently absent this literature has been that there are pro-social and positive aspects and demonstrations of manhood. Whether it is embodied in ways that promote or harm health, African American manhood – as an intrapersonal experience and a set of interpersonal behaviors – is shaped and contextualized by social determinants of health.

What does health mean to men?

How men conceptualize manhood is an important determinant of men's health-related decisions, and they are the strongest predictor of men's health behaviors ^17,30. Health behaviors are used in daily interactions to help men negotiate social power and social status but these same health practices can either undermine or promote health ³¹. Health is often considered a low priority for men until poor health impairs some aspect of their lives (e.g., sexual relationships, job) or roles (e.g., provider, father, spouse) that is considered a higher priority because it is associated with notions of manhood ^4,32,33.

Strong and consistent evidence suggests that health behaviors play a key role in the etiology of most of the leading causes of death among men ^{18,21,31,34-37}. Men's lower life expectancy seems to result from gender differences in health behavior and other health outcomes such as infectious diseases (e.g., most often HIV/AIDS), cardiovascular disease, suicide, motor vehicle accidents and liver disease (most often secondary to alcohol dependence) ¹⁸. The ways that men think about and internalize notions of masculinity, masculine social norms and gendered stressors and strains are often implicated in explanations of men's unhealthy behaviors (e.g., reckless driving, interpersonal violence, alcohol and drug abuse, risky sexual behavior, high-risk sports and leisure activities) ^31,38-42. Substance use and other health behaviors are often tools that men use to cope with the stressors that these ideals, norms and goals create in their lives ⁶. These behaviors often are culturally sanctioned ways of distinguishing among males and between males and females, and may help explain the association between men's risky and unhealthy behaviors ^17,31. Because of the differences in health behaviors between men and women, men's health research fails to consider the wider social and economic determinants of men's health or men's health behavior ⁴³.

While some men may define health based on diagnoses of illnesses or biological and physiological processes, Robertson (2006) found that men's definitions of health may be influenced by their perceptions of what it means to be a man. In his qualitative work, Robertson (2006) found that men related their perceptions of health to their general lifestyle and well-being (e.g., drinking and eating in moderation), engagement in healthy behavior (e.g., regular physical activity, adequate sleep) and ability to fulfill socially important roles (e.g., provider, partner, father). Additionally, Ravenell and colleagues (2006) found that African American men may define health broadly and in relation to other aspects of their lives that have little to do directly with their own individual health. African American men have conceptualized being “healthy” as being able to fulfill social roles, such as holding a job, providing for family, protecting and teaching their children, and belonging to a social network ⁴⁴. Prioritizing success in fulfilling key social roles at the expense of one's health is consistent with various theories that link gender and health ^{6,7,33,41,45,46}.

Complicating our understanding of the intersection of manhood and health, existing scholarship has found mixed results when investigating the relationship between health and manhood. Some studies found positive effects of manhood on health while others reported more negative implications ⁴⁷. For instance, Levant and colleagues found that masculine risk-taking and self-reliance were negatively related to health behavior measures but that emotional control, primacy of work, and winning were positively related ^47,48. This complexity is echoed in the work of Gordon and colleagues who found that toughness was related to both more exercise and increased junk food consumption ⁴⁹.

How men define health in relation to their conceptualizations of manhood is an important, yet frequently absent, aspect of the ways that scholars often explain men's health practices and outcomes ⁴⁶. Whereas previous research has explored separately how African American men define manhood and how diverse groups of men define health, in this paper, we explore how African American men's definitions of health and conceptualizations of manhood may be related to one another. The research questions guiding this study are: (a) what is the relationship between characterizations of manhood and health for African American men? And (b) how do social determinants of health shape men's intrapersonal experiences of manhood and their interpersonal performances of manhood?

Methods

Study Design

As a complement to the Men 4 Health study that focused on determinants of African American men's eating practices, physical activity and stress ⁵⁰, we developed the current exploratory focus group protocol to examine how African American men described and experienced more basic issues such as health, manhood and chronic illness. The focus group protocol was semi-structured to allow for guided open discussion and mutually beneficial interactions among the participants and between participants and the facilitator. We began each focus group with instructions, a general overview of the study aims, and a questionnaire gathering basic demographic data. The discussions proceeded from general to more specific questions and we probed extensively for greater detail and clarity. Focus group questions and topic discussions included: “How would you define health?”; “Tell us about what it means to be a man”; and “What does being healthy mean to you?” The focus groups were digitally recorded and transcribed for analysis. As an incentive, participants were given a meal and either a $20 gift card or an electric grill valued at $20.The University of Michigan Institutional Review Board reviewed the study purpose, design, protocols and materials. Focus groups were utilized to gain insight into participants’ conceptualizations of health and manhood and allowed for dynamic interaction between participants that fostered increased exploration of the relationship between the two (Carey, 1994; Kitzinger, 1996).

Setting

The data for this study were collected in Detroit, MI in the summer of 2011. Detroit's population is 82.7% African American (U.S. Census Bureau, 2010), and the city ranks low on most socioeconomic indicators (U.S. Department of Labor, 2011). African American men in Detroit experience higher rates of mortality from diseases associated with physical inactivity than women and men of other ethnic groups living in the same city, and also when compared with state and national averages (Michigan Department of Community Health, 2008).

Detroit has experienced a double-digit decline in population in recent decades ⁵¹, and the city is perhaps the most vivid example of the transformation of the US economy over the last three to four decades. Detroit has seen the collapse of the auto industry, the foreclosure crisis, had the highest unemployment rate of any urban center in the nation ^52,53. Detroit symbolizes the harmful effects of deindustrialization and has come to epitomize the plight of urban economies in the post-industrial landscape, yet the city has many positive aspects. For example, Detroit is beginning to experience reinvestment in the built environment and resources deliberately being committed to revive this once great city. In sum, Detroit is an important site for the study of masculinity and health in the context of an urban setting because the economic and social challenges that shape the lives and health of Detroiters are so intimately intertwined.

Recruitment

Participants were recruited by snowball sampling via word-of-mouth, fliers, presentations at appropriate venues, and social network connections of outreach staff and the partner organizations of a university-based research center on men's health. Outreach staff also recruited men from local faith-based organizations, health clinics, hospitals, community-based organizations and the Detroit Department of Health and Wellness Promotion. The outreach staff was composed of African American men who live in the cities of interest; they have experience and reputations of being activity involved in addressing men's health in their communities. The outreach staff strategically attended events and contacted organizations, groups, and informal social networks serving the population of interest to raise awareness about the study and recruit a diverse sample of men that met our eligibility criteria to participate in the study.

Participants

Seven focus groups, with a total of 73 African American male participants, were conducted by experienced African American male facilitators. The age range of participants was 24-77 years old (average age of 51 years old). To be eligible to participate in a focus group, each participant had to self-report that he was a man, self-identify as African American or Black, self-report being 18 or older, and self-report that he was a resident of Detroit, MI. Forty-three percent (43%) of all participants were employed, but 38% reported having an income below the federal poverty line.

Data Analysis

^37,53-57The focus group interviews were audio-taped, transcribed verbatim, and entered into the qualitative data software package, ATLAS.ti, 5.6 (Scientific Software Development). A thematic analytic approach was used to identify, analyze and report themes and classifications that relate to the data; this type of analysis is considered appropriate when researchers are seeking to discover, organize and describe interpretations of the data ⁵⁴. ⁵⁹The systematic data organization and analysis process we used was similar to the methods used by Griffith, Allen, and colleagues ^38,55-59.

Selected transcripts were reviewed in order to inductively identify recurring concepts that emerged from the transcripts and topics. Members of the research team first read the transcribed data for participant responses that dealt with similar topics. Members of the research team used highlighting and margin notes to: a) summarize themes within each document, using a combination of in vivo restatements of the data and direct quotes; and b) document potential questions, connections, underlying themes, and possible implications of the text for further analysis. Each transcript was ‘chunked’ into segments of text that represented distinct quotes that conveyed their original meaning apart from the complete transcripts. Each data chunk included all codes assigned to that segment of text, the unique identifier of the speaker, the date of the focus group, the overall question the individual was responding to, and any other stimuli (prompts, comments of other participants) that appeared to influence the content of the statement⁶⁰. This process yielded a codebook that was used by coders to organize the meaning units gleaned from the text that were organized into codes: key concepts and domains. An inter-coder reliability measure was calculated by comparing the percent agreement between the original and recoded transcripts and achieved 75% agreement on the initial codes created for these data ⁶¹. The research team created a “gold standard” set of agreed upon codes given the text of the initial focus groups. The two coders of these focus groups each had to accurately apply the correct code, or not code, each segment of text 75% of the time to be allowed to move forward with coding the remainder of the focus groups.

^61,62,63During the iterative process of collectively reviewing the summarized coded data, compelling themes related to men's notions regarding gender and how they defined health emerged. For the purpose of this paper, we examined two codes from our codebook—gender and definitions of health. Gender was coded any time participants mentioned “gender, masculinity, differentiating between men and women, stereotypes, assumptions related to gender, generalizations based on gender. Also social norms and expectations (both those men hold internally and those they identify others—family, society, community) for men or women because of gender.” The majority of the text segments coded gender were in response to the question, “What does it mean to be a man?” Definitions of health was coded in any instance where a participant mentioned “a definition of what healthy means and doesn't mean.” The majority of the text segments coded definitions of health were in response to the questions, “How would you define health?” and “What does being healthy mean to you?”

The coding of each construct led to preliminary themes within each code. The first two authors independently identified themes within and across the codes and came to consensus. These authors used an inductive approach to create themes that best represented key concepts discussed by participants to associate an analysis of a theme to the larger content ^54,62. These authors also documented the frequency of focus groups and men who discussed each topic to ensure broad representation. They then developed an outline of the prominent themes within the data and organized the text segments into a comprehensive document according to this outline. The cross-cutting themes that were used to organize the results emerged from the separate analysis of the gender and definition of health codes. The authors used a comparison analysis to ensure consistent interpretation of the statements, and then documented potential questions, underlying themes, and possible implications of the data for further analysis ⁶³. Upon examining these preliminary themes, the authors decided to try and answer the empirical question of the possible relationship between these concepts.

⁶¹Results

The goal of this study was to examine commonalities across how African American men define manhood and health. We identified three themes that cut across men's definitions of these constructs: who you are; what you do; and how you seek to affect others. Using illustrative quotes, we will discuss each topic in turn.

Who you are: how embodying certain characteristics defines manhood and health

These African American men described how independence was central to how they defined health, which also appears to be shaped by how they define manhood. For example, one man defined being healthy this way: “Being healthy to me is continuing to be able to be independent, being supportive, and being able to accomplish the things that I put out.” He suggests that demonstrating these characteristics that are consistent with hegemonic notions of masculinity are important to him and they also define health. In addition, consistent with other characteristics that define manhood, participants went further and stated that manhood may be defined by self-discipline while health might be defined as enacting one's full potential. For example, a participant noted, “Another concern with that would be learning how to be disciplined, self-disciplined. Learning how to control your emotion and learn how to control your energy of emotions because many of us on too many occasions, particularly in this area now, have a tendency not to really think before you act.” This idea of self-control and being unflappable in the face of adversity also are important aspects of manhood. Further, one participant said, “Healthy mean[s] to me being all you can be. You know, like, healthy means that you can choose to have out of life. You can choose, like, if you want to.” Having control over one's circumstances was central to the way participants defined health and lived their lives. Participants in this study repeatedly stressed that demonstrating independence, self-reliance and agency were important to manhood and health.

What you do: how behavior defines manhood and health

These African American men discussed the critical interplay between the explicit choices men make to engage in certain behaviors that may shape their lives and health across the life course. As one participant said, “Your health is determined by the life you lead. You know, if you tend to see more men that's 60; that has a stable job; or maybe in the church then you may see they may be living a life of crime... Your life expectancy or the longevity of your life is determined by the life that you lead from the ground up.” Another participant concurred, “...if you live a certain life, your diet is a certain way. If you live a certain life, it causes, it takes away more stress.” These men seemed to suggest that the non-health related life choices that men make have important implications for their health (e.g., you are more likely to see men who are healthy having stable jobs and going to church than men who are living a life of crime).

As opposed to focusing exclusively on comparisons to hegemonic ideals of masculinity, these African American men also tended to define manhood by the fulfillment of social roles and family and community responsibilities. As one participant summed up how he defined being a man, “To be a man is to handle one's responsibilities, to take care of one's family, to support one's neighborhood and community.” One participant added, “[Being a man is] wanting to take our responsibilities, support his family, pay child support, he works, 40 hours a day.” Similarly, health was defined in terms of men's behaviors and abilities. As one participant stated: “[Health is] to be able to perform 8 to 10 hours of labor, daily and then having excess energy for another 3 or 4 hours to enjoy life with your family.” Thus, manhood and health was not defined by abstract gender ideals but through engaging in behaviors that enrich the lives of families and communities. These definitions of manhood highlight how men are not choosing reputational or respectable aspects of masculinity ²⁰ but they often seek to achieve success in both, contradictory, areas simultaneously.

Further, men discussed the direct relationship between being a man and caring for one's health. As one participant stated, “I think one of the things that it takes to be a man is being man enough to go and take care of yourself, being the physical, checking yourself out, going to the doctor, doing the things that the doctor suggests that you need to do, and pass that information onto your children or your grandchildren.” While manhood was defined in part through behavior, so was health. Continuing with this theme of behavior, African American men in Detroit often linked definitions of health to consciously making choices to engage in healthy behavior. As one participant stated,

“I think about not having ailments, but at the same time, I think it has to do more with you being very conscious of what are you doing to your body? What are you eating? Be aware of what you're eating. You know, what other activities do you do, whether it's like smoking or drinking, be aware of what those effects are gonna have on your body, which is one thing I think a lot of us don't really think about... If we were very conscious of what we do to our bodies... that's what I mean by being healthy.”

He recognizes the importance taking care of himself and he emphasizes the need to be conscious of how unhealthy behavior can harm health. Another participant operationalized what is meant by “healthy behavior,” saying, “Being healthy means taking walks every morning, drinking lots of water, breathing fresh air, resting a lot, getting a lot of rest and resting your body. Just being healthy! Eatin’ vegetables, eatin’ fruits, just takin’ walks and relaxin’.”

Another related element discussed by some participants was the need to take the initiative to learn more about health and wellness, and subsequently change one's behaviors. For example, one participant reflects on his personal health experiences and shares what actions he believes made him healthier:

“...how my health has gotten better over the years is reading more about nutrition, getting involved in nutrition, learning about nutrition, living a productive, healthy lifestyle; being proactive: you know, getting in the gym, working out, exercising, walking. A lot of those things is, has a lot to do with me, you know, learning about being more healthier is educating myself on it.”

Yet another participant discusses the need to engage in healthy behavior but also focused on the need to taking personal responsibility for his health. He said, “...being healthy is to follow the simple suggestions, take my medications, because you know I'm sick, and abide by the rules and regulations that I know are conducive to my recovery.” Thus, in addition to manhood and health being defined by efforts to embody key intrapersonal characteristics and men's work, social and health behaviors, the final theme these African American men from Detroit discussed was how manhood and health were defined by men's efforts to affect the lives and well-being of others.

How you seek to affect others – relational definitions of manhood and health

Many participants stated that working and fulfilling social responsibilities, being self-reliant and having individual agency were all aspects of being a man and being healthy. While the behavior that one uses to demonstrate his priorities is important, participants’ highlight the goal or aspiration itself. One key aspect of manhood and health that was tied together in these men's narratives was that they conceptualized both manhood and health via the legacy and impact they might have on their family and community. The men discussed their role in the community and how their actions not only affect themselves but the community around them. As one participant stated: “So many of us are destroying ourselves. And you can't say that by destroying yourself, ‘I’m not hurting nobody, but me.’... And a man's man will kind of stand for those things that he believe in. I mean, in spite of the risk involved - because the risk is greater if we destroy ourselves and there's nobody left.” In addition, another man said, “To be a man, period, is to have the ability to either be on board, destroy our own communities by our actions. We have a certain power that we yield [wield] that we have a responsibility for.” Thus, the responsibilities men felt they had did not only revolve around their own ability to be successful in their chosen careers or economic exploits but to also have a positive influence on the African American community at large.

Relatedly, several participants mentioned having a long life or longevity as an important goal of manhood and health. For instance, one respondent stated: “It means I’ll be around for my kids and, hopefully, they kids. You know, I want to be around, I want to be around as long as I can.” Another participant added: “... [Being healthy] hopefully ensures longevity to be able to provide for those who you care for and love for.” Another participant stated how important health is for transitioning into different phases in life: “Being healthy is just like watching yourself go to the next phase of life. You have to go into all this metamorphosis and change and stuff like that. When you are in good health, it makes you feel good about yourself.” Finally, another participant said: “Being healthy is seeing another day.” Many participants that mentioned longevity as a definition of health also stated that living a long life was particularly important because they wanted to be around to support, be a part of and provide for their family as long as possible.

Discussion

While previous research has explored the ways that men define health and conceptualize manhood separately, in this study we sought to explore how urban African American men's characterization of these constructs may be similar. For these African American men, both manhood and health were rooted in relational constructs and interrelated with one another, yet some behaviors that men used to operationalize these constructs were not relational. The three broad themes that we identified were that both manhood and health were defined by: (1) having key characteristics in common; (2) engaging in certain behaviors; and (3) how men seek to affect others. While previous qualitative studies have identified factors that link manhood and health in the UK ^41,46, defined African American manhood in the US ^5,64,65, explored the relationship between masculine norms and African American men's wellness behaviors, and identified how African American men define health ⁴⁴, this is one of the first studies to explore themes that connect how men define manhood and health.

The current study extends Robertson's work on the “don’t care, should care dichotomy” and the recognition that men tend to define health through what their bodies can do ^41,46 by highlighting how social determinants of health shape the intrapersonal characteristics African American men seek to embody. Both hegemonic masculinity and African American men's perceived commitment to family and the African American community shaped their definitions of manhood and health, and the behaviors and goals they set. While Ravenell's qualitative work highlighted African American men's relational definition of health ⁴⁴, it did not capture how African American men define themselves as men. Conversely, Hammond and Mattis’ research on African American men's notions of manhood characterized how men think about what it means to be a man ⁵, but did not explore how African American men think about health. While some work has been done to link masculinity with mental health and help-seeking ^66-72, most of these prior studies have included younger, White men in college, limiting our understanding of these constructs and the generalizability of their findings ⁷³. Few studies have incorporated developmentally-appropriate notions of manhood or examined masculinity in relation to physical health behaviors ⁶.

Men's notions of masculinity are often used to explain their high rates of risky and unhealthy behavior ^17,31,74, but we found that men's notions of manhood seemed to share many commonalities with more prosocial and healthy behavior. While masculinity is a generic construct that is thought to be equally relevant to men across the lifecourse, our sample of African American men were seeking to define manhood through characteristics, behaviors and ideals that are more consistent with being a responsible, middle-aged adult ^6,17,38,55. One of the major limitations of the ways that masculinity has been measured in men of color, and perhaps why there have been so few studies that have shown any relationship between masculinity and health for men of color, is because the measures of masculinity are not capturing ideas about manhood that are consistent with the roles, responsibilities and goals of middle-aged and older men ^4,6,75,76. A previous systematic review of studies of men of color that included measures of health and masculinity found no studies that included a sample with a mean age of 40 or older ⁶. Additional research should seek to understand how manhood and masculinity impacts health behaviors among younger men and follow them over time to provide insight to how these two constructs manifest over the life course.

Because where men fall along the lifecourse appears to be central to how they define health and manhood, our findings are consistent with a role strain framework ⁴ and previous qualitative research on middle-aged and older African American men's definitions of manhood and health as separate constructs^{5,38,44,55-57,59,77,78}. This theoretical framework describes the psychological strain African American men experience in trying to achieve success across the life course. Bowman's conceptualization of role strain highlights how different goals, roles and responsibilities become more or less salient in different phases of men's lives, social and economic conditions, and in relationship to different behaviors. This theory has been used to describe how African American men's efforts to achieve success in professional, family and community roles can be barriers to healthy behavior ³⁸. What is especially unique about this framework is that it highlights how notions of manhood and perhaps definitions of health, are shaped by social determinants of health.

Particularly during middle-age, African American men's perceived success in fulfilling the roles of provider, husband, father, employee, and community member are fundamental aspects of their identities and a major focus of this phase of life ^4,5. Despite the cultural shifts that have allowed for more flexibility in defining some men by their fulfillment of certain roles and responsibilities, the family provider role continues to be a salient aspect of African American men's identity ^4,79. These notions can be extended to help explain men's efforts to try to overcome some of the social, economic and time barriers that adversely affect their ability to engage in regular physical activity ³⁸, but may not affect other health-related behaviors such as smoking, eating or going to the doctor through the same time and stress pathways. Future studies should explore how social determinants of African American men's health affect manhood and health, since the social and economic determinants that limit African American men's ability to fulfill social and cultural expectations of manhood remain stressors that adversely affect men's physical and mental health ^71,72,80.

In addition to the role strain framework, the findings of the current study also map onto Whitehead's Big Man Little Man Complex framework. Whitehead highlights how African American men's efforts to embody key characteristics that define manhood and health are intimately intertwined with notions of respectability. Manhood's historical ties to economic success, material wealth and social class status ^9,81 have remained consistent across generations. While these aspects of manhood are essential to men's efforts to measure up to other men and be positive role models for their families and communities ¹, being highly regarded by other men still means demonstrating self-reliance, independence, virility, sexual prowess, physical strength and hardiness ²⁰, characteristics that can lead men to engage in behaviors that reify manhood but put their health and well-being at risk. The findings from the current study highlight that these African American men define manhood and health in relation to both respectability and reputations constructs.

Limitations

The results of this study provide insights into common themes related to both manhood and health in the minds and lives of African American men. The primary goal of this study was to explore how African American men define manhood and health. However, our findings may not be generalizable to other groups of men who may be different races, ages or live in other geographical locations. Our findings are not broadly generalizable, but, instead, describe the ways that these urban, African American men describe key constructs that are key foundations of health interventions and men's health research. Our study was limited by the fact that we did not collect data on men's individual socioeconomic status nor did we track speakers in the focus groups so we could not conduct analyses of responses by age or phase of life. Because the sample came from an urban, low income area, it is possible that our findings may be most congruent with men who are from similar settings.

Qualitative research methods and data analysis techniques often elicit concerns about the validity and reliability of the data. Our data analysis strategy involved a systematic process of coding scheme development, refinement, and quote attribution. Some perspectives were lost in the data coding, analysis, and reporting processes, as themes that were not articulated by at least a few focus group participants were not included in the paper. We also elected not to present our findings in a more ethnographic fashion that incorporated the context of the quotes ⁸². While our procedures captured the strongest and most prevalent themes, they may have eliminated unique perspectives voiced by a minority of respondents. In particular, our study design did not capture the perspectives of men who did not connect the concepts of manhood and health. Despite these limitations, there are many benefits of this methodological approach. The thick descriptions elicited via qualitative methods tap into many different voices and perspectives in participants’ own words. This study design enabled the recognition of patterns, as well as subjective interpretations and perceptions of causality ^60,83.

Conclusion

The ways in which African American men define manhood and health share some important core characteristics. Social determinants of health also seem to be social determinants of manhood. How African American men perceive that they embody notions of manhood and health seem to be intertwined, though previous research has treated them as separate constructs. The interrelationship of manhood and health suggests that future intervention and clinical research should seek to connect the two, and not treat these as separate issues. Highlighting how being healthier can also help men to achieve the family, community, economic and professional goals they have is a promising strategy to be explored in future research.