Table 1: Open in new tab Annotated...

Table 1:

Annotated bibliography—men’s health literacy

Author/year	Methods	Findings	Sex and gender
Reviews
Davey et al. (Davey et al., 2015) The correlates of chronic disease-related health literacy and its components among men: a systematic review BMC Public Health, 15, 589	Methods: Systematic review (2003–13) of observational and experimental studies related to men’s health literacy, heart disease and type 2 diabetes Sample: N=9 international studies; USA, Asia, Portugal; none Canadian Article retrieval difficult b/c authors claimed as recently as 2009 the term health literacy was not used by some authors and the conceptual framework has no consensus	Majority of studies focussed on one aspect of HL: knowledge. Twenty correlates with HL were identified and rated as high, moderate or low. Only one, education, was assessed to show any strength of evidence Factors identified as important associates of HL were education, age, insurance status, income, marital status, overweight/obesity and access to primary care services. Increasing age was associated with lower HL	Authors pointed to the shortage of studies into men’s health literacy. Little attention paid to HL as a mechanism of prevention to reduce disease among men. Only 9 of 55 candidate studies focussed exclusively on men or stratified their results by sex Focussed on how an understanding of correlates of men’s health literacy is needed to develop gender strategies for health promotion to improve chronic disease burden among men
Geller et al. (Geller et al., 2006) Crafting a melanoma campaign to reach middle-aged and older men Journal of Cutaneous Medicine and Surgery, 10, 259–268	Method: Descriptive literature review related to HL, melanoma campaigns and males due to men’s higher mortality from this cancer Procedures: Practical and theoretical discussion of selected literature on men’s health and issues related to health messaging for men, with consideration of HL and SES Framed discussion using Health Belief Model, Stages of Change Model and Ecological Model of Health	Listed five literacy conscious steps from the National Cancer Institute to follow in a campaign. Noted that print materials may not be the most effective approach Highlighted qualitative research that showed men are receptive to messages about how their heath behaviors affect family members; flagged the tendency for men to believe health care is unnecessary unless they are having health problems; discussed various media strategies for messaging men and men’s uptake by age; recommended community partners such as Elks Club or similar places where men may socialize as well as workplace and sports settings, to educate men about melanoma. Men’s partners and wives must be part of messaging because 25% of melanomas in men are detected by partners. Subgroups of men, for instance, men with low education levels, men in the trades, older men and rural men have different HL needs and this must be addressed	Discussed the importance of sex and gender in reaching a target audience Recommended mixed methods national research with men as a first step in designing a campaign to reduce men’s disproportionate mortality from melanoma. Suggested research should ask men what stops them from doing skin inspections; who would be influential in checking moles; what kinds of materials men would use and in what settings do men prefer to discuss skin cancer prevention? Authors stated the need for the development of gender-informed health promotion programs about melanoma (e.g. that incorporate men’s preferences and feedback)
Empirical studies
Agho et al. (Agho et al., 2012) Health literacy and colorectal cancer knowledge and awareness among African-American males International Journal of Health Promotion and Education, 50, 10–19	Methods: Quantitative; descriptive statistics and correlations Sample: 142 African American males, 50 to 80+ years old. Procedure: Researchers conducted CRC education sessions at 25 local African American churches and then administered a survey to gather demographic data, CRC knowledge levels, and HL levels	Majority of the participants reported some difficulty understanding written instructions—hospital signs, appointment slips, directions on medical bottles and/or learning about their medical conditions. Low levels of HL correlated with reduced likelihood of being screened for CRC Men who were advised by a doctor to undergo colorectal screening had for the most part done so, showing importance of physician influence	No explicit discussion of sex or gender. The authors recommended future work involve female spouses in CRC education for men. Highlighted limits of written health promotion materials in the context of effectively targeting older men
Allen et al.(Allen et al., 2007)African American men’s perceptions about prostate cancer: implications for designing educational interventions Social Science & Medicine, 64, 11	Methods: Qualitative Sample: Focus group interviews with 37 US-based healthy African American men and 14 prostate cancer survivors. Fourteen key community informants were also interviewed Procedure: The three subgroups were compared to evaluate their knowledge about the prostate, elevated prostate cancer risk among African American men, and controversies about screening	Participants who were prostate cancer survivors had greater knowledge about prostate cancer than healthy men. Barriers highlighted by key informants and the healthy men cohort cited inadequate access to services, mistrust of the health system, poor relationships with providers and threats to male sexuality as the underpinnings of African American men’s low levels of knowledge	Findings were discussed in terms of gender and prostate cancer perceived as a threat to male identityImplicit was the need to level hierarchies to waylay top down approaches to HL. Instead, shared decision-making interventions were argued for, inclusive of African American providers while acknowledging the role of prostate cancer survivors in educating peers
Brittain et al. (Brittain et al., 2016) African American patients' intent to screen for colorectal cancer: do cultural factors, health literacy, knowledge, age and gender matter? Journal of Health Care for the Poor and Underserved, 27, 51–67	Methods: Quantitative; secondary analysis of data obtained from participants enrolled in a CRC intervention; independent variables were demographic data, health care provider trust, cancer fatalism, health temporal orientation, CRC knowledge (collected at baseline). HL collected six months after receiving intervention. Dependent variables intention to undertake FOBT and colonoscopy Sample: 817 African Americans, 51–80 years old. Non-adherent to CRC guidelines Males 384 (47%) Procedure: One sex comparison specific research question addressed; are there gender differences in health care provider trust, fatalism, health temporal orientation, HL and CRC knowledge?	Statistically significant differences in men’s lower HL and CRC scores were found compared to women. In contrast advancing age and being male were predictors of FOBT intention, and men were 1.7 times more likely than women to respond that they intended to have a colonoscopy in the next 6 months	Sex differences specific to HL and CRC incorrectly referred to as gender differences. Authors noted that gender has been neglected in research focussed on African Americans’ screening for CRC. No discussion of African American men in terms of masculinity or socio-cultural masculine norms Variables such as health provider trust and cancer fatalism defined as cultural variables
Clouston et al.(Clouston et al., 2016) A life course approach to health literacy: the role of gender, educational attainment and life time cognitive capability Age and Ageing, 46, 493–499	Methods: Quantitative; predictors of health literacy in old age included developmental indicators (adolescent cognitive and non-cognitive skills), adult cognition indicators (abstract reasoning, verbal memory and individual decline in abstract reasoning), socioeconomic indicators (parental SES, educational attainment, individual income) and demographic indicators (gender, marital status and household size) Sample: 2212 individuals, 72 years of age Males 1058 (48%) Procedure: Utilizing prospective secondary data from the Wisconsin Longitudinal Study, data from participants at ages 18, 25, 36, 53, 65 and 72 was collected. Health literacy was assessed using the NVS. To elucidate health literacy predictors, data from survey questionnaires was used	Almost half of male participants (47.5%) had poor health literacy. Findings indicated that women and men differed in risk for low health literacy in old age, with predictors unique to each sex. Men’s health literacy pathway was complex and includes cognitive decline in later life, which was not found with women	Lifelong predictors of health literacy were explicitly examined by gender. Rich insights of gender effects on health literacy were presented, highlighting the significant implications of specific predictors within the health literacy pathway, such as midlife cognitive decline, on men Although the risk of poor health literacy was high, and men tended to perform worse on the health literacy task, gender-specific solutions were not offered
Drummond and Drummond (Drummond and Drummond, 2010) Interviews with boys on physical activity, nutrition and health: implications for health literacy Health Sociology Review, 19, 491–504	Method: Qualitative study investigating the influence of masculinity in the context of boy’s health literacy, fitness and diet Sample: Three age-groups of Australian boys interviewed in small groups: N = 33 early childhood; N = 30 middle years; N = 26 upper primary years Procedures: Participants asked questions about fitness, sports heroes, physical activity and health beliefs. Inductive analysis of transcripts with masculinities theoretical lens	Main theme was that health meant specific foods to participants. Drawings of fruits and vegetables were common when asked to draw ‘health’ Overall, traditional gendered constructions of food for boys—females prepare and clean it up, etc.; the idea of healthy food and nutrition gendered in this context Boys in early childhood showed the most concrete gendered notions of physical activity: strong demarcation between what boys and girls could do. Boys equated food practices with feminized activity due to traditional role of their mothers in all aspects of food prep/shopping at home	Anchored in gender theory, which the authors took up in terms of HL Concluded the need to develop awareness of HL for boys and men beyond gender stereotypes of food and sport. Noted that policy documents use the term HL freely, however, what that means and how it connects to masculinity and its influence on boys and men’s health is undefined and undeveloped Recommended teaching nutrition and food awareness by delinking from stereotyped gendered constructs
Friedman et al.(Friedman et al., 2009) African American men’s understanding and perceptions about prostate cancer: why multiple dimensions of health literacy are important in cancer communication Journal of Community Health, 34, 449–460	Method: Mixed methods, qualitative focus groups and surveys Sample: N = 25 African American men-aged 45 and older in South Carolina who were not diagnosed with prostate cancer Procedure: Applied Nutbeam’s multidimensional health literacy framework to African American men’s understanding of prostate cancer information Health literacy was assessed using two validated tools, the modified Cloze procedure and the S-TOFHLA Individual and focus group interviews discussed prostate cancer risk, prevention and screening. Men were asked about preferred messaging, sources, format and content of good messaging about prostate cancer. Transcripts analysed for themes	Health literacy test scores revealed adequate levels but the interviews and focus groups showed the misunderstandings and misperceptions most men had about prostate cancer risk and causes Demonstrated how HL can fail by focussing on knowledge and print materials in some male communities where oral communication is more effective Men’s churches emerged as a source of information sessions for prostate cancer	Masculinity not overtly discussed even though the findings reflect masculine themes Men expressed discomfort talking about prostate cancer. Barriers to seeking information were embarrassment about the topic and fear of being seen as weak; lacking resources to see a doctor (American context) and lack of communication with family or friends about prostate cancer and screening Men expressed a preference for word of mouth information about prostate cancer prevention
Oliffe et al. (Oliffe et al., 2011) Prostate cancer support groups, health literacy and consumerism: are community-based volunteers re-defining older men’s health Health, 15, 555–570	Methods: Qualitative, ethnographic Sample: 54 male attendees from Canadian PCSGs, 53–87 years old, most of whom were retired (N = 44, 81%) and had received prostate cancer treatments (N = 50, 92%) Procedure: Individual interviews and participant observations at PCSGs to inductively derive what men said about health literacy and consumerism	HL-specific findings indicated that biomedical risk discourses and diagnostic measures including Gleason scores and PSA numbers were used to make treatment decisions. Understood also by participants was that these biomarkers were complex and their own experience may not reflect population-based statistics. The contextual use of health literacy and numeracy in this regard was mobilized by the men’s interactions at the PCSGs	The findings that men could increase HL within community-based PCSGs through other men as well as health care professionals presenting materials at the groups was linked to gendered understandings of men’s health. Specifically, the learnings at PCSGs ran counter to assertions that men are estranged from self-health and subordinate and marginalized in patient–provider interactions
Molina-Barcelo et al. (Molina-Barcelo et al., 2011) Giving voice to gender and socio-economic differences in CRC screening programmes European Journal of Cancer Care, 20, 669–678	Methods: Qualitative Sample: 56 Spanish, mixed sex, 50–69 years old, including 24 men (43%) comprising CRC program participants and non-participants of varying SES (manual and non-manual) Procedure: Eight focus group interviews wherein participants were matched by sex, program participation, and SES status	Formal comparison by sex, SES and participation in a CRC program. Findings indicated that CRC screening knowledge and beliefs about the disease were increased by program participation. However low SES was linked to HL issues and those factors along with being male were barriers to program participation	Sex differences analyses indicated that women were motivated to participate in the CRC program to avoid personal and family suffering while men were motivated by female partners. For non-program participants women indicated they were embarrassed and feared being diagnosed with CRC while men were found to have an attitude of carelessness about health, avoidance of doctors and fear of diagnostic tests The gender analyses confirmed participants’ alignments to traditional gender norms and relations wherein women took on health caregiver roles for the men in their lives while most men were reticent to seek professional medical help. The authors concluded CRC screening messages needed to be catered to gender and SES differences
Thompson et al.(Thompson et al., 2017) Understanding food vulnerability and health literacy in older bereaved men: a qualitative study Health Expectations, 20, 1342–1349	Methods: Qualitative Sample: 20 men, aged 65–90 years old, bereaved for at least 6 months Procedure: Individual face-to-face interviews were conducted that collected the changing experiences of food purchase, preparation and cooking during life course; significant events with potential impact on food preferences, consumption behaviors and nutritional intake, wife/partner illness/death impact on food preferences and services and support for nutrition. An interpretative thematic analysis approach was utilized with Nutbeam’s (Nutbeam, 2000) health literacy classification to frame findings	Hypothesized that participants would demonstrate food vulnerability attributable to a lack of health literacy. However, participants displayed a high level of functional, interactive and critical health literacy within this study, which potentially stemmed from the relatively advantaged characteristics of the sample Highlighted the gendered attitudes toward health literacy in relation to food, with men who identified with more traditional masculine roles expressing less interest in developing their interactive health literacy	A brief discussion of how the alignment of males to traditional gender roles may influence health literacy behaviors Some men described developing their nutritional health literacy skills in a positive manner, while others entrenched attitudes of gender identity resulted in negative or indifferent behaviors toward cooking, food and nutritional health literacy
Zanchetta et al. (Zanchetta et al., 2007) Patterns in information strategies used by older men to understand and deal with prostate cancer: an application of the modelisation qualitative research design International Journal of Nursing Studies, 44, 961–972	Methods: Qualitative Sample: 15 French-Canadian men 61- to 83-year old diagnosed with localized prostate cancer and recruited from Quebec and PCSGs Procedure: Individual interviews were conducted to collect men’s perspectives about their self-assessed functional health literacy as a means to evaluating social and cultural influences on participant HL levels (high, middle, low)	Partnerships within social and information networks were reported as crucial to men in understanding prostate cancer. They suggested the existence of affective and spiritual aspects of prostate cancer information shape how older men receive, live and deal with their health and illness. Highlighted the need to overcome two major barriers; professional medical language and the silence among men, in refuting linkages between men's formal education and health literacy levels	Rich description of men’s strategies for obtaining information to deal with prostate cancer. While challenges to traditional HL definitions were made and assertions that family and community organizations were key resources for men’s HL no explicit linkages to gender of sex analyses were made

Author/year	Methods	Findings	Sex and gender
Reviews
Davey et al. (Davey et al., 2015) The correlates of chronic disease-related health literacy and its components among men: a systematic review BMC Public Health, 15, 589	Methods: Systematic review (2003–13) of observational and experimental studies related to men’s health literacy, heart disease and type 2 diabetes Sample: N=9 international studies; USA, Asia, Portugal; none Canadian Article retrieval difficult b/c authors claimed as recently as 2009 the term health literacy was not used by some authors and the conceptual framework has no consensus	Majority of studies focussed on one aspect of HL: knowledge. Twenty correlates with HL were identified and rated as high, moderate or low. Only one, education, was assessed to show any strength of evidence Factors identified as important associates of HL were education, age, insurance status, income, marital status, overweight/obesity and access to primary care services. Increasing age was associated with lower HL	Authors pointed to the shortage of studies into men’s health literacy. Little attention paid to HL as a mechanism of prevention to reduce disease among men. Only 9 of 55 candidate studies focussed exclusively on men or stratified their results by sex Focussed on how an understanding of correlates of men’s health literacy is needed to develop gender strategies for health promotion to improve chronic disease burden among men
Geller et al. (Geller et al., 2006) Crafting a melanoma campaign to reach middle-aged and older men Journal of Cutaneous Medicine and Surgery, 10, 259–268	Method: Descriptive literature review related to HL, melanoma campaigns and males due to men’s higher mortality from this cancer Procedures: Practical and theoretical discussion of selected literature on men’s health and issues related to health messaging for men, with consideration of HL and SES Framed discussion using Health Belief Model, Stages of Change Model and Ecological Model of Health	Listed five literacy conscious steps from the National Cancer Institute to follow in a campaign. Noted that print materials may not be the most effective approach Highlighted qualitative research that showed men are receptive to messages about how their heath behaviors affect family members; flagged the tendency for men to believe health care is unnecessary unless they are having health problems; discussed various media strategies for messaging men and men’s uptake by age; recommended community partners such as Elks Club or similar places where men may socialize as well as workplace and sports settings, to educate men about melanoma. Men’s partners and wives must be part of messaging because 25% of melanomas in men are detected by partners. Subgroups of men, for instance, men with low education levels, men in the trades, older men and rural men have different HL needs and this must be addressed	Discussed the importance of sex and gender in reaching a target audience Recommended mixed methods national research with men as a first step in designing a campaign to reduce men’s disproportionate mortality from melanoma. Suggested research should ask men what stops them from doing skin inspections; who would be influential in checking moles; what kinds of materials men would use and in what settings do men prefer to discuss skin cancer prevention? Authors stated the need for the development of gender-informed health promotion programs about melanoma (e.g. that incorporate men’s preferences and feedback)
Empirical studies
Agho et al. (Agho et al., 2012) Health literacy and colorectal cancer knowledge and awareness among African-American males International Journal of Health Promotion and Education, 50, 10–19	Methods: Quantitative; descriptive statistics and correlations Sample: 142 African American males, 50 to 80+ years old. Procedure: Researchers conducted CRC education sessions at 25 local African American churches and then administered a survey to gather demographic data, CRC knowledge levels, and HL levels	Majority of the participants reported some difficulty understanding written instructions—hospital signs, appointment slips, directions on medical bottles and/or learning about their medical conditions. Low levels of HL correlated with reduced likelihood of being screened for CRC Men who were advised by a doctor to undergo colorectal screening had for the most part done so, showing importance of physician influence	No explicit discussion of sex or gender. The authors recommended future work involve female spouses in CRC education for men. Highlighted limits of written health promotion materials in the context of effectively targeting older men
Allen et al.(Allen et al., 2007)African American men’s perceptions about prostate cancer: implications for designing educational interventions Social Science & Medicine, 64, 11	Methods: Qualitative Sample: Focus group interviews with 37 US-based healthy African American men and 14 prostate cancer survivors. Fourteen key community informants were also interviewed Procedure: The three subgroups were compared to evaluate their knowledge about the prostate, elevated prostate cancer risk among African American men, and controversies about screening	Participants who were prostate cancer survivors had greater knowledge about prostate cancer than healthy men. Barriers highlighted by key informants and the healthy men cohort cited inadequate access to services, mistrust of the health system, poor relationships with providers and threats to male sexuality as the underpinnings of African American men’s low levels of knowledge	Findings were discussed in terms of gender and prostate cancer perceived as a threat to male identityImplicit was the need to level hierarchies to waylay top down approaches to HL. Instead, shared decision-making interventions were argued for, inclusive of African American providers while acknowledging the role of prostate cancer survivors in educating peers
Brittain et al. (Brittain et al., 2016) African American patients' intent to screen for colorectal cancer: do cultural factors, health literacy, knowledge, age and gender matter? Journal of Health Care for the Poor and Underserved, 27, 51–67	Methods: Quantitative; secondary analysis of data obtained from participants enrolled in a CRC intervention; independent variables were demographic data, health care provider trust, cancer fatalism, health temporal orientation, CRC knowledge (collected at baseline). HL collected six months after receiving intervention. Dependent variables intention to undertake FOBT and colonoscopy Sample: 817 African Americans, 51–80 years old. Non-adherent to CRC guidelines Males 384 (47%) Procedure: One sex comparison specific research question addressed; are there gender differences in health care provider trust, fatalism, health temporal orientation, HL and CRC knowledge?	Statistically significant differences in men’s lower HL and CRC scores were found compared to women. In contrast advancing age and being male were predictors of FOBT intention, and men were 1.7 times more likely than women to respond that they intended to have a colonoscopy in the next 6 months	Sex differences specific to HL and CRC incorrectly referred to as gender differences. Authors noted that gender has been neglected in research focussed on African Americans’ screening for CRC. No discussion of African American men in terms of masculinity or socio-cultural masculine norms Variables such as health provider trust and cancer fatalism defined as cultural variables
Clouston et al.(Clouston et al., 2016) A life course approach to health literacy: the role of gender, educational attainment and life time cognitive capability Age and Ageing, 46, 493–499	Methods: Quantitative; predictors of health literacy in old age included developmental indicators (adolescent cognitive and non-cognitive skills), adult cognition indicators (abstract reasoning, verbal memory and individual decline in abstract reasoning), socioeconomic indicators (parental SES, educational attainment, individual income) and demographic indicators (gender, marital status and household size) Sample: 2212 individuals, 72 years of age Males 1058 (48%) Procedure: Utilizing prospective secondary data from the Wisconsin Longitudinal Study, data from participants at ages 18, 25, 36, 53, 65 and 72 was collected. Health literacy was assessed using the NVS. To elucidate health literacy predictors, data from survey questionnaires was used	Almost half of male participants (47.5%) had poor health literacy. Findings indicated that women and men differed in risk for low health literacy in old age, with predictors unique to each sex. Men’s health literacy pathway was complex and includes cognitive decline in later life, which was not found with women	Lifelong predictors of health literacy were explicitly examined by gender. Rich insights of gender effects on health literacy were presented, highlighting the significant implications of specific predictors within the health literacy pathway, such as midlife cognitive decline, on men Although the risk of poor health literacy was high, and men tended to perform worse on the health literacy task, gender-specific solutions were not offered
Drummond and Drummond (Drummond and Drummond, 2010) Interviews with boys on physical activity, nutrition and health: implications for health literacy Health Sociology Review, 19, 491–504	Method: Qualitative study investigating the influence of masculinity in the context of boy’s health literacy, fitness and diet Sample: Three age-groups of Australian boys interviewed in small groups: N = 33 early childhood; N = 30 middle years; N = 26 upper primary years Procedures: Participants asked questions about fitness, sports heroes, physical activity and health beliefs. Inductive analysis of transcripts with masculinities theoretical lens	Main theme was that health meant specific foods to participants. Drawings of fruits and vegetables were common when asked to draw ‘health’ Overall, traditional gendered constructions of food for boys—females prepare and clean it up, etc.; the idea of healthy food and nutrition gendered in this context Boys in early childhood showed the most concrete gendered notions of physical activity: strong demarcation between what boys and girls could do. Boys equated food practices with feminized activity due to traditional role of their mothers in all aspects of food prep/shopping at home	Anchored in gender theory, which the authors took up in terms of HL Concluded the need to develop awareness of HL for boys and men beyond gender stereotypes of food and sport. Noted that policy documents use the term HL freely, however, what that means and how it connects to masculinity and its influence on boys and men’s health is undefined and undeveloped Recommended teaching nutrition and food awareness by delinking from stereotyped gendered constructs
Friedman et al.(Friedman et al., 2009) African American men’s understanding and perceptions about prostate cancer: why multiple dimensions of health literacy are important in cancer communication Journal of Community Health, 34, 449–460	Method: Mixed methods, qualitative focus groups and surveys Sample: N = 25 African American men-aged 45 and older in South Carolina who were not diagnosed with prostate cancer Procedure: Applied Nutbeam’s multidimensional health literacy framework to African American men’s understanding of prostate cancer information Health literacy was assessed using two validated tools, the modified Cloze procedure and the S-TOFHLA Individual and focus group interviews discussed prostate cancer risk, prevention and screening. Men were asked about preferred messaging, sources, format and content of good messaging about prostate cancer. Transcripts analysed for themes	Health literacy test scores revealed adequate levels but the interviews and focus groups showed the misunderstandings and misperceptions most men had about prostate cancer risk and causes Demonstrated how HL can fail by focussing on knowledge and print materials in some male communities where oral communication is more effective Men’s churches emerged as a source of information sessions for prostate cancer	Masculinity not overtly discussed even though the findings reflect masculine themes Men expressed discomfort talking about prostate cancer. Barriers to seeking information were embarrassment about the topic and fear of being seen as weak; lacking resources to see a doctor (American context) and lack of communication with family or friends about prostate cancer and screening Men expressed a preference for word of mouth information about prostate cancer prevention
Oliffe et al. (Oliffe et al., 2011) Prostate cancer support groups, health literacy and consumerism: are community-based volunteers re-defining older men’s health Health, 15, 555–570	Methods: Qualitative, ethnographic Sample: 54 male attendees from Canadian PCSGs, 53–87 years old, most of whom were retired (N = 44, 81%) and had received prostate cancer treatments (N = 50, 92%) Procedure: Individual interviews and participant observations at PCSGs to inductively derive what men said about health literacy and consumerism	HL-specific findings indicated that biomedical risk discourses and diagnostic measures including Gleason scores and PSA numbers were used to make treatment decisions. Understood also by participants was that these biomarkers were complex and their own experience may not reflect population-based statistics. The contextual use of health literacy and numeracy in this regard was mobilized by the men’s interactions at the PCSGs	The findings that men could increase HL within community-based PCSGs through other men as well as health care professionals presenting materials at the groups was linked to gendered understandings of men’s health. Specifically, the learnings at PCSGs ran counter to assertions that men are estranged from self-health and subordinate and marginalized in patient–provider interactions
Molina-Barcelo et al. (Molina-Barcelo et al., 2011) Giving voice to gender and socio-economic differences in CRC screening programmes European Journal of Cancer Care, 20, 669–678	Methods: Qualitative Sample: 56 Spanish, mixed sex, 50–69 years old, including 24 men (43%) comprising CRC program participants and non-participants of varying SES (manual and non-manual) Procedure: Eight focus group interviews wherein participants were matched by sex, program participation, and SES status	Formal comparison by sex, SES and participation in a CRC program. Findings indicated that CRC screening knowledge and beliefs about the disease were increased by program participation. However low SES was linked to HL issues and those factors along with being male were barriers to program participation	Sex differences analyses indicated that women were motivated to participate in the CRC program to avoid personal and family suffering while men were motivated by female partners. For non-program participants women indicated they were embarrassed and feared being diagnosed with CRC while men were found to have an attitude of carelessness about health, avoidance of doctors and fear of diagnostic tests The gender analyses confirmed participants’ alignments to traditional gender norms and relations wherein women took on health caregiver roles for the men in their lives while most men were reticent to seek professional medical help. The authors concluded CRC screening messages needed to be catered to gender and SES differences
Thompson et al.(Thompson et al., 2017) Understanding food vulnerability and health literacy in older bereaved men: a qualitative study Health Expectations, 20, 1342–1349	Methods: Qualitative Sample: 20 men, aged 65–90 years old, bereaved for at least 6 months Procedure: Individual face-to-face interviews were conducted that collected the changing experiences of food purchase, preparation and cooking during life course; significant events with potential impact on food preferences, consumption behaviors and nutritional intake, wife/partner illness/death impact on food preferences and services and support for nutrition. An interpretative thematic analysis approach was utilized with Nutbeam’s (Nutbeam, 2000) health literacy classification to frame findings	Hypothesized that participants would demonstrate food vulnerability attributable to a lack of health literacy. However, participants displayed a high level of functional, interactive and critical health literacy within this study, which potentially stemmed from the relatively advantaged characteristics of the sample Highlighted the gendered attitudes toward health literacy in relation to food, with men who identified with more traditional masculine roles expressing less interest in developing their interactive health literacy	A brief discussion of how the alignment of males to traditional gender roles may influence health literacy behaviors Some men described developing their nutritional health literacy skills in a positive manner, while others entrenched attitudes of gender identity resulted in negative or indifferent behaviors toward cooking, food and nutritional health literacy
Zanchetta et al. (Zanchetta et al., 2007) Patterns in information strategies used by older men to understand and deal with prostate cancer: an application of the modelisation qualitative research design International Journal of Nursing Studies, 44, 961–972	Methods: Qualitative Sample: 15 French-Canadian men 61- to 83-year old diagnosed with localized prostate cancer and recruited from Quebec and PCSGs Procedure: Individual interviews were conducted to collect men’s perspectives about their self-assessed functional health literacy as a means to evaluating social and cultural influences on participant HL levels (high, middle, low)	Partnerships within social and information networks were reported as crucial to men in understanding prostate cancer. They suggested the existence of affective and spiritual aspects of prostate cancer information shape how older men receive, live and deal with their health and illness. Highlighted the need to overcome two major barriers; professional medical language and the silence among men, in refuting linkages between men's formal education and health literacy levels	Rich description of men’s strategies for obtaining information to deal with prostate cancer. While challenges to traditional HL definitions were made and assertions that family and community organizations were key resources for men’s HL no explicit linkages to gender of sex analyses were made

CRC, colorectal cancer; FOBT, fecal occult blood test; HL, health literacy; PCSG, prostate cancer support group.

Table 1:

Open in new tab

Annotated bibliography—men’s health literacy

Author/year	Methods	Findings	Sex and gender
Reviews
Davey et al. (Davey et al., 2015) The correlates of chronic disease-related health literacy and its components among men: a systematic review BMC Public Health, 15, 589	Methods: Systematic review (2003–13) of observational and experimental studies related to men’s health literacy, heart disease and type 2 diabetes Sample: N=9 international studies; USA, Asia, Portugal; none Canadian Article retrieval difficult b/c authors claimed as recently as 2009 the term health literacy was not used by some authors and the conceptual framework has no consensus	Majority of studies focussed on one aspect of HL: knowledge. Twenty correlates with HL were identified and rated as high, moderate or low. Only one, education, was assessed to show any strength of evidence Factors identified as important associates of HL were education, age, insurance status, income, marital status, overweight/obesity and access to primary care services. Increasing age was associated with lower HL	Authors pointed to the shortage of studies into men’s health literacy. Little attention paid to HL as a mechanism of prevention to reduce disease among men. Only 9 of 55 candidate studies focussed exclusively on men or stratified their results by sex Focussed on how an understanding of correlates of men’s health literacy is needed to develop gender strategies for health promotion to improve chronic disease burden among men
Geller et al. (Geller et al., 2006) Crafting a melanoma campaign to reach middle-aged and older men Journal of Cutaneous Medicine and Surgery, 10, 259–268	Method: Descriptive literature review related to HL, melanoma campaigns and males due to men’s higher mortality from this cancer Procedures: Practical and theoretical discussion of selected literature on men’s health and issues related to health messaging for men, with consideration of HL and SES Framed discussion using Health Belief Model, Stages of Change Model and Ecological Model of Health	Listed five literacy conscious steps from the National Cancer Institute to follow in a campaign. Noted that print materials may not be the most effective approach Highlighted qualitative research that showed men are receptive to messages about how their heath behaviors affect family members; flagged the tendency for men to believe health care is unnecessary unless they are having health problems; discussed various media strategies for messaging men and men’s uptake by age; recommended community partners such as Elks Club or similar places where men may socialize as well as workplace and sports settings, to educate men about melanoma. Men’s partners and wives must be part of messaging because 25% of melanomas in men are detected by partners. Subgroups of men, for instance, men with low education levels, men in the trades, older men and rural men have different HL needs and this must be addressed	Discussed the importance of sex and gender in reaching a target audience Recommended mixed methods national research with men as a first step in designing a campaign to reduce men’s disproportionate mortality from melanoma. Suggested research should ask men what stops them from doing skin inspections; who would be influential in checking moles; what kinds of materials men would use and in what settings do men prefer to discuss skin cancer prevention? Authors stated the need for the development of gender-informed health promotion programs about melanoma (e.g. that incorporate men’s preferences and feedback)
Empirical studies
Agho et al. (Agho et al., 2012) Health literacy and colorectal cancer knowledge and awareness among African-American males International Journal of Health Promotion and Education, 50, 10–19	Methods: Quantitative; descriptive statistics and correlations Sample: 142 African American males, 50 to 80+ years old. Procedure: Researchers conducted CRC education sessions at 25 local African American churches and then administered a survey to gather demographic data, CRC knowledge levels, and HL levels	Majority of the participants reported some difficulty understanding written instructions—hospital signs, appointment slips, directions on medical bottles and/or learning about their medical conditions. Low levels of HL correlated with reduced likelihood of being screened for CRC Men who were advised by a doctor to undergo colorectal screening had for the most part done so, showing importance of physician influence	No explicit discussion of sex or gender. The authors recommended future work involve female spouses in CRC education for men. Highlighted limits of written health promotion materials in the context of effectively targeting older men
Allen et al.(Allen et al., 2007)African American men’s perceptions about prostate cancer: implications for designing educational interventions Social Science & Medicine, 64, 11	Methods: Qualitative Sample: Focus group interviews with 37 US-based healthy African American men and 14 prostate cancer survivors. Fourteen key community informants were also interviewed Procedure: The three subgroups were compared to evaluate their knowledge about the prostate, elevated prostate cancer risk among African American men, and controversies about screening	Participants who were prostate cancer survivors had greater knowledge about prostate cancer than healthy men. Barriers highlighted by key informants and the healthy men cohort cited inadequate access to services, mistrust of the health system, poor relationships with providers and threats to male sexuality as the underpinnings of African American men’s low levels of knowledge	Findings were discussed in terms of gender and prostate cancer perceived as a threat to male identityImplicit was the need to level hierarchies to waylay top down approaches to HL. Instead, shared decision-making interventions were argued for, inclusive of African American providers while acknowledging the role of prostate cancer survivors in educating peers
Brittain et al. (Brittain et al., 2016) African American patients' intent to screen for colorectal cancer: do cultural factors, health literacy, knowledge, age and gender matter? Journal of Health Care for the Poor and Underserved, 27, 51–67	Methods: Quantitative; secondary analysis of data obtained from participants enrolled in a CRC intervention; independent variables were demographic data, health care provider trust, cancer fatalism, health temporal orientation, CRC knowledge (collected at baseline). HL collected six months after receiving intervention. Dependent variables intention to undertake FOBT and colonoscopy Sample: 817 African Americans, 51–80 years old. Non-adherent to CRC guidelines Males 384 (47%) Procedure: One sex comparison specific research question addressed; are there gender differences in health care provider trust, fatalism, health temporal orientation, HL and CRC knowledge?	Statistically significant differences in men’s lower HL and CRC scores were found compared to women. In contrast advancing age and being male were predictors of FOBT intention, and men were 1.7 times more likely than women to respond that they intended to have a colonoscopy in the next 6 months	Sex differences specific to HL and CRC incorrectly referred to as gender differences. Authors noted that gender has been neglected in research focussed on African Americans’ screening for CRC. No discussion of African American men in terms of masculinity or socio-cultural masculine norms Variables such as health provider trust and cancer fatalism defined as cultural variables
Clouston et al.(Clouston et al., 2016) A life course approach to health literacy: the role of gender, educational attainment and life time cognitive capability Age and Ageing, 46, 493–499	Methods: Quantitative; predictors of health literacy in old age included developmental indicators (adolescent cognitive and non-cognitive skills), adult cognition indicators (abstract reasoning, verbal memory and individual decline in abstract reasoning), socioeconomic indicators (parental SES, educational attainment, individual income) and demographic indicators (gender, marital status and household size) Sample: 2212 individuals, 72 years of age Males 1058 (48%) Procedure: Utilizing prospective secondary data from the Wisconsin Longitudinal Study, data from participants at ages 18, 25, 36, 53, 65 and 72 was collected. Health literacy was assessed using the NVS. To elucidate health literacy predictors, data from survey questionnaires was used	Almost half of male participants (47.5%) had poor health literacy. Findings indicated that women and men differed in risk for low health literacy in old age, with predictors unique to each sex. Men’s health literacy pathway was complex and includes cognitive decline in later life, which was not found with women	Lifelong predictors of health literacy were explicitly examined by gender. Rich insights of gender effects on health literacy were presented, highlighting the significant implications of specific predictors within the health literacy pathway, such as midlife cognitive decline, on men Although the risk of poor health literacy was high, and men tended to perform worse on the health literacy task, gender-specific solutions were not offered
Drummond and Drummond (Drummond and Drummond, 2010) Interviews with boys on physical activity, nutrition and health: implications for health literacy Health Sociology Review, 19, 491–504	Method: Qualitative study investigating the influence of masculinity in the context of boy’s health literacy, fitness and diet Sample: Three age-groups of Australian boys interviewed in small groups: N = 33 early childhood; N = 30 middle years; N = 26 upper primary years Procedures: Participants asked questions about fitness, sports heroes, physical activity and health beliefs. Inductive analysis of transcripts with masculinities theoretical lens	Main theme was that health meant specific foods to participants. Drawings of fruits and vegetables were common when asked to draw ‘health’ Overall, traditional gendered constructions of food for boys—females prepare and clean it up, etc.; the idea of healthy food and nutrition gendered in this context Boys in early childhood showed the most concrete gendered notions of physical activity: strong demarcation between what boys and girls could do. Boys equated food practices with feminized activity due to traditional role of their mothers in all aspects of food prep/shopping at home	Anchored in gender theory, which the authors took up in terms of HL Concluded the need to develop awareness of HL for boys and men beyond gender stereotypes of food and sport. Noted that policy documents use the term HL freely, however, what that means and how it connects to masculinity and its influence on boys and men’s health is undefined and undeveloped Recommended teaching nutrition and food awareness by delinking from stereotyped gendered constructs
Friedman et al.(Friedman et al., 2009) African American men’s understanding and perceptions about prostate cancer: why multiple dimensions of health literacy are important in cancer communication Journal of Community Health, 34, 449–460	Method: Mixed methods, qualitative focus groups and surveys Sample: N = 25 African American men-aged 45 and older in South Carolina who were not diagnosed with prostate cancer Procedure: Applied Nutbeam’s multidimensional health literacy framework to African American men’s understanding of prostate cancer information Health literacy was assessed using two validated tools, the modified Cloze procedure and the S-TOFHLA Individual and focus group interviews discussed prostate cancer risk, prevention and screening. Men were asked about preferred messaging, sources, format and content of good messaging about prostate cancer. Transcripts analysed for themes	Health literacy test scores revealed adequate levels but the interviews and focus groups showed the misunderstandings and misperceptions most men had about prostate cancer risk and causes Demonstrated how HL can fail by focussing on knowledge and print materials in some male communities where oral communication is more effective Men’s churches emerged as a source of information sessions for prostate cancer	Masculinity not overtly discussed even though the findings reflect masculine themes Men expressed discomfort talking about prostate cancer. Barriers to seeking information were embarrassment about the topic and fear of being seen as weak; lacking resources to see a doctor (American context) and lack of communication with family or friends about prostate cancer and screening Men expressed a preference for word of mouth information about prostate cancer prevention
Oliffe et al. (Oliffe et al., 2011) Prostate cancer support groups, health literacy and consumerism: are community-based volunteers re-defining older men’s health Health, 15, 555–570	Methods: Qualitative, ethnographic Sample: 54 male attendees from Canadian PCSGs, 53–87 years old, most of whom were retired (N = 44, 81%) and had received prostate cancer treatments (N = 50, 92%) Procedure: Individual interviews and participant observations at PCSGs to inductively derive what men said about health literacy and consumerism	HL-specific findings indicated that biomedical risk discourses and diagnostic measures including Gleason scores and PSA numbers were used to make treatment decisions. Understood also by participants was that these biomarkers were complex and their own experience may not reflect population-based statistics. The contextual use of health literacy and numeracy in this regard was mobilized by the men’s interactions at the PCSGs	The findings that men could increase HL within community-based PCSGs through other men as well as health care professionals presenting materials at the groups was linked to gendered understandings of men’s health. Specifically, the learnings at PCSGs ran counter to assertions that men are estranged from self-health and subordinate and marginalized in patient–provider interactions
Molina-Barcelo et al. (Molina-Barcelo et al., 2011) Giving voice to gender and socio-economic differences in CRC screening programmes European Journal of Cancer Care, 20, 669–678	Methods: Qualitative Sample: 56 Spanish, mixed sex, 50–69 years old, including 24 men (43%) comprising CRC program participants and non-participants of varying SES (manual and non-manual) Procedure: Eight focus group interviews wherein participants were matched by sex, program participation, and SES status	Formal comparison by sex, SES and participation in a CRC program. Findings indicated that CRC screening knowledge and beliefs about the disease were increased by program participation. However low SES was linked to HL issues and those factors along with being male were barriers to program participation	Sex differences analyses indicated that women were motivated to participate in the CRC program to avoid personal and family suffering while men were motivated by female partners. For non-program participants women indicated they were embarrassed and feared being diagnosed with CRC while men were found to have an attitude of carelessness about health, avoidance of doctors and fear of diagnostic tests The gender analyses confirmed participants’ alignments to traditional gender norms and relations wherein women took on health caregiver roles for the men in their lives while most men were reticent to seek professional medical help. The authors concluded CRC screening messages needed to be catered to gender and SES differences
Thompson et al.(Thompson et al., 2017) Understanding food vulnerability and health literacy in older bereaved men: a qualitative study Health Expectations, 20, 1342–1349	Methods: Qualitative Sample: 20 men, aged 65–90 years old, bereaved for at least 6 months Procedure: Individual face-to-face interviews were conducted that collected the changing experiences of food purchase, preparation and cooking during life course; significant events with potential impact on food preferences, consumption behaviors and nutritional intake, wife/partner illness/death impact on food preferences and services and support for nutrition. An interpretative thematic analysis approach was utilized with Nutbeam’s (Nutbeam, 2000) health literacy classification to frame findings	Hypothesized that participants would demonstrate food vulnerability attributable to a lack of health literacy. However, participants displayed a high level of functional, interactive and critical health literacy within this study, which potentially stemmed from the relatively advantaged characteristics of the sample Highlighted the gendered attitudes toward health literacy in relation to food, with men who identified with more traditional masculine roles expressing less interest in developing their interactive health literacy	A brief discussion of how the alignment of males to traditional gender roles may influence health literacy behaviors Some men described developing their nutritional health literacy skills in a positive manner, while others entrenched attitudes of gender identity resulted in negative or indifferent behaviors toward cooking, food and nutritional health literacy
Zanchetta et al. (Zanchetta et al., 2007) Patterns in information strategies used by older men to understand and deal with prostate cancer: an application of the modelisation qualitative research design International Journal of Nursing Studies, 44, 961–972	Methods: Qualitative Sample: 15 French-Canadian men 61- to 83-year old diagnosed with localized prostate cancer and recruited from Quebec and PCSGs Procedure: Individual interviews were conducted to collect men’s perspectives about their self-assessed functional health literacy as a means to evaluating social and cultural influences on participant HL levels (high, middle, low)	Partnerships within social and information networks were reported as crucial to men in understanding prostate cancer. They suggested the existence of affective and spiritual aspects of prostate cancer information shape how older men receive, live and deal with their health and illness. Highlighted the need to overcome two major barriers; professional medical language and the silence among men, in refuting linkages between men's formal education and health literacy levels	Rich description of men’s strategies for obtaining information to deal with prostate cancer. While challenges to traditional HL definitions were made and assertions that family and community organizations were key resources for men’s HL no explicit linkages to gender of sex analyses were made

Author/year	Methods	Findings	Sex and gender
Reviews
Davey et al. (Davey et al., 2015) The correlates of chronic disease-related health literacy and its components among men: a systematic review BMC Public Health, 15, 589	Methods: Systematic review (2003–13) of observational and experimental studies related to men’s health literacy, heart disease and type 2 diabetes Sample: N=9 international studies; USA, Asia, Portugal; none Canadian Article retrieval difficult b/c authors claimed as recently as 2009 the term health literacy was not used by some authors and the conceptual framework has no consensus	Majority of studies focussed on one aspect of HL: knowledge. Twenty correlates with HL were identified and rated as high, moderate or low. Only one, education, was assessed to show any strength of evidence Factors identified as important associates of HL were education, age, insurance status, income, marital status, overweight/obesity and access to primary care services. Increasing age was associated with lower HL	Authors pointed to the shortage of studies into men’s health literacy. Little attention paid to HL as a mechanism of prevention to reduce disease among men. Only 9 of 55 candidate studies focussed exclusively on men or stratified their results by sex Focussed on how an understanding of correlates of men’s health literacy is needed to develop gender strategies for health promotion to improve chronic disease burden among men
Geller et al. (Geller et al., 2006) Crafting a melanoma campaign to reach middle-aged and older men Journal of Cutaneous Medicine and Surgery, 10, 259–268	Method: Descriptive literature review related to HL, melanoma campaigns and males due to men’s higher mortality from this cancer Procedures: Practical and theoretical discussion of selected literature on men’s health and issues related to health messaging for men, with consideration of HL and SES Framed discussion using Health Belief Model, Stages of Change Model and Ecological Model of Health	Listed five literacy conscious steps from the National Cancer Institute to follow in a campaign. Noted that print materials may not be the most effective approach Highlighted qualitative research that showed men are receptive to messages about how their heath behaviors affect family members; flagged the tendency for men to believe health care is unnecessary unless they are having health problems; discussed various media strategies for messaging men and men’s uptake by age; recommended community partners such as Elks Club or similar places where men may socialize as well as workplace and sports settings, to educate men about melanoma. Men’s partners and wives must be part of messaging because 25% of melanomas in men are detected by partners. Subgroups of men, for instance, men with low education levels, men in the trades, older men and rural men have different HL needs and this must be addressed	Discussed the importance of sex and gender in reaching a target audience Recommended mixed methods national research with men as a first step in designing a campaign to reduce men’s disproportionate mortality from melanoma. Suggested research should ask men what stops them from doing skin inspections; who would be influential in checking moles; what kinds of materials men would use and in what settings do men prefer to discuss skin cancer prevention? Authors stated the need for the development of gender-informed health promotion programs about melanoma (e.g. that incorporate men’s preferences and feedback)
Empirical studies
Agho et al. (Agho et al., 2012) Health literacy and colorectal cancer knowledge and awareness among African-American males International Journal of Health Promotion and Education, 50, 10–19	Methods: Quantitative; descriptive statistics and correlations Sample: 142 African American males, 50 to 80+ years old. Procedure: Researchers conducted CRC education sessions at 25 local African American churches and then administered a survey to gather demographic data, CRC knowledge levels, and HL levels	Majority of the participants reported some difficulty understanding written instructions—hospital signs, appointment slips, directions on medical bottles and/or learning about their medical conditions. Low levels of HL correlated with reduced likelihood of being screened for CRC Men who were advised by a doctor to undergo colorectal screening had for the most part done so, showing importance of physician influence	No explicit discussion of sex or gender. The authors recommended future work involve female spouses in CRC education for men. Highlighted limits of written health promotion materials in the context of effectively targeting older men
Allen et al.(Allen et al., 2007)African American men’s perceptions about prostate cancer: implications for designing educational interventions Social Science & Medicine, 64, 11	Methods: Qualitative Sample: Focus group interviews with 37 US-based healthy African American men and 14 prostate cancer survivors. Fourteen key community informants were also interviewed Procedure: The three subgroups were compared to evaluate their knowledge about the prostate, elevated prostate cancer risk among African American men, and controversies about screening	Participants who were prostate cancer survivors had greater knowledge about prostate cancer than healthy men. Barriers highlighted by key informants and the healthy men cohort cited inadequate access to services, mistrust of the health system, poor relationships with providers and threats to male sexuality as the underpinnings of African American men’s low levels of knowledge	Findings were discussed in terms of gender and prostate cancer perceived as a threat to male identityImplicit was the need to level hierarchies to waylay top down approaches to HL. Instead, shared decision-making interventions were argued for, inclusive of African American providers while acknowledging the role of prostate cancer survivors in educating peers
Brittain et al. (Brittain et al., 2016) African American patients' intent to screen for colorectal cancer: do cultural factors, health literacy, knowledge, age and gender matter? Journal of Health Care for the Poor and Underserved, 27, 51–67	Methods: Quantitative; secondary analysis of data obtained from participants enrolled in a CRC intervention; independent variables were demographic data, health care provider trust, cancer fatalism, health temporal orientation, CRC knowledge (collected at baseline). HL collected six months after receiving intervention. Dependent variables intention to undertake FOBT and colonoscopy Sample: 817 African Americans, 51–80 years old. Non-adherent to CRC guidelines Males 384 (47%) Procedure: One sex comparison specific research question addressed; are there gender differences in health care provider trust, fatalism, health temporal orientation, HL and CRC knowledge?	Statistically significant differences in men’s lower HL and CRC scores were found compared to women. In contrast advancing age and being male were predictors of FOBT intention, and men were 1.7 times more likely than women to respond that they intended to have a colonoscopy in the next 6 months	Sex differences specific to HL and CRC incorrectly referred to as gender differences. Authors noted that gender has been neglected in research focussed on African Americans’ screening for CRC. No discussion of African American men in terms of masculinity or socio-cultural masculine norms Variables such as health provider trust and cancer fatalism defined as cultural variables
Clouston et al.(Clouston et al., 2016) A life course approach to health literacy: the role of gender, educational attainment and life time cognitive capability Age and Ageing, 46, 493–499	Methods: Quantitative; predictors of health literacy in old age included developmental indicators (adolescent cognitive and non-cognitive skills), adult cognition indicators (abstract reasoning, verbal memory and individual decline in abstract reasoning), socioeconomic indicators (parental SES, educational attainment, individual income) and demographic indicators (gender, marital status and household size) Sample: 2212 individuals, 72 years of age Males 1058 (48%) Procedure: Utilizing prospective secondary data from the Wisconsin Longitudinal Study, data from participants at ages 18, 25, 36, 53, 65 and 72 was collected. Health literacy was assessed using the NVS. To elucidate health literacy predictors, data from survey questionnaires was used	Almost half of male participants (47.5%) had poor health literacy. Findings indicated that women and men differed in risk for low health literacy in old age, with predictors unique to each sex. Men’s health literacy pathway was complex and includes cognitive decline in later life, which was not found with women	Lifelong predictors of health literacy were explicitly examined by gender. Rich insights of gender effects on health literacy were presented, highlighting the significant implications of specific predictors within the health literacy pathway, such as midlife cognitive decline, on men Although the risk of poor health literacy was high, and men tended to perform worse on the health literacy task, gender-specific solutions were not offered
Drummond and Drummond (Drummond and Drummond, 2010) Interviews with boys on physical activity, nutrition and health: implications for health literacy Health Sociology Review, 19, 491–504	Method: Qualitative study investigating the influence of masculinity in the context of boy’s health literacy, fitness and diet Sample: Three age-groups of Australian boys interviewed in small groups: N = 33 early childhood; N = 30 middle years; N = 26 upper primary years Procedures: Participants asked questions about fitness, sports heroes, physical activity and health beliefs. Inductive analysis of transcripts with masculinities theoretical lens	Main theme was that health meant specific foods to participants. Drawings of fruits and vegetables were common when asked to draw ‘health’ Overall, traditional gendered constructions of food for boys—females prepare and clean it up, etc.; the idea of healthy food and nutrition gendered in this context Boys in early childhood showed the most concrete gendered notions of physical activity: strong demarcation between what boys and girls could do. Boys equated food practices with feminized activity due to traditional role of their mothers in all aspects of food prep/shopping at home	Anchored in gender theory, which the authors took up in terms of HL Concluded the need to develop awareness of HL for boys and men beyond gender stereotypes of food and sport. Noted that policy documents use the term HL freely, however, what that means and how it connects to masculinity and its influence on boys and men’s health is undefined and undeveloped Recommended teaching nutrition and food awareness by delinking from stereotyped gendered constructs
Friedman et al.(Friedman et al., 2009) African American men’s understanding and perceptions about prostate cancer: why multiple dimensions of health literacy are important in cancer communication Journal of Community Health, 34, 449–460	Method: Mixed methods, qualitative focus groups and surveys Sample: N = 25 African American men-aged 45 and older in South Carolina who were not diagnosed with prostate cancer Procedure: Applied Nutbeam’s multidimensional health literacy framework to African American men’s understanding of prostate cancer information Health literacy was assessed using two validated tools, the modified Cloze procedure and the S-TOFHLA Individual and focus group interviews discussed prostate cancer risk, prevention and screening. Men were asked about preferred messaging, sources, format and content of good messaging about prostate cancer. Transcripts analysed for themes	Health literacy test scores revealed adequate levels but the interviews and focus groups showed the misunderstandings and misperceptions most men had about prostate cancer risk and causes Demonstrated how HL can fail by focussing on knowledge and print materials in some male communities where oral communication is more effective Men’s churches emerged as a source of information sessions for prostate cancer	Masculinity not overtly discussed even though the findings reflect masculine themes Men expressed discomfort talking about prostate cancer. Barriers to seeking information were embarrassment about the topic and fear of being seen as weak; lacking resources to see a doctor (American context) and lack of communication with family or friends about prostate cancer and screening Men expressed a preference for word of mouth information about prostate cancer prevention
Oliffe et al. (Oliffe et al., 2011) Prostate cancer support groups, health literacy and consumerism: are community-based volunteers re-defining older men’s health Health, 15, 555–570	Methods: Qualitative, ethnographic Sample: 54 male attendees from Canadian PCSGs, 53–87 years old, most of whom were retired (N = 44, 81%) and had received prostate cancer treatments (N = 50, 92%) Procedure: Individual interviews and participant observations at PCSGs to inductively derive what men said about health literacy and consumerism	HL-specific findings indicated that biomedical risk discourses and diagnostic measures including Gleason scores and PSA numbers were used to make treatment decisions. Understood also by participants was that these biomarkers were complex and their own experience may not reflect population-based statistics. The contextual use of health literacy and numeracy in this regard was mobilized by the men’s interactions at the PCSGs	The findings that men could increase HL within community-based PCSGs through other men as well as health care professionals presenting materials at the groups was linked to gendered understandings of men’s health. Specifically, the learnings at PCSGs ran counter to assertions that men are estranged from self-health and subordinate and marginalized in patient–provider interactions
Molina-Barcelo et al. (Molina-Barcelo et al., 2011) Giving voice to gender and socio-economic differences in CRC screening programmes European Journal of Cancer Care, 20, 669–678	Methods: Qualitative Sample: 56 Spanish, mixed sex, 50–69 years old, including 24 men (43%) comprising CRC program participants and non-participants of varying SES (manual and non-manual) Procedure: Eight focus group interviews wherein participants were matched by sex, program participation, and SES status	Formal comparison by sex, SES and participation in a CRC program. Findings indicated that CRC screening knowledge and beliefs about the disease were increased by program participation. However low SES was linked to HL issues and those factors along with being male were barriers to program participation	Sex differences analyses indicated that women were motivated to participate in the CRC program to avoid personal and family suffering while men were motivated by female partners. For non-program participants women indicated they were embarrassed and feared being diagnosed with CRC while men were found to have an attitude of carelessness about health, avoidance of doctors and fear of diagnostic tests The gender analyses confirmed participants’ alignments to traditional gender norms and relations wherein women took on health caregiver roles for the men in their lives while most men were reticent to seek professional medical help. The authors concluded CRC screening messages needed to be catered to gender and SES differences
Thompson et al.(Thompson et al., 2017) Understanding food vulnerability and health literacy in older bereaved men: a qualitative study Health Expectations, 20, 1342–1349	Methods: Qualitative Sample: 20 men, aged 65–90 years old, bereaved for at least 6 months Procedure: Individual face-to-face interviews were conducted that collected the changing experiences of food purchase, preparation and cooking during life course; significant events with potential impact on food preferences, consumption behaviors and nutritional intake, wife/partner illness/death impact on food preferences and services and support for nutrition. An interpretative thematic analysis approach was utilized with Nutbeam’s (Nutbeam, 2000) health literacy classification to frame findings	Hypothesized that participants would demonstrate food vulnerability attributable to a lack of health literacy. However, participants displayed a high level of functional, interactive and critical health literacy within this study, which potentially stemmed from the relatively advantaged characteristics of the sample Highlighted the gendered attitudes toward health literacy in relation to food, with men who identified with more traditional masculine roles expressing less interest in developing their interactive health literacy	A brief discussion of how the alignment of males to traditional gender roles may influence health literacy behaviors Some men described developing their nutritional health literacy skills in a positive manner, while others entrenched attitudes of gender identity resulted in negative or indifferent behaviors toward cooking, food and nutritional health literacy
Zanchetta et al. (Zanchetta et al., 2007) Patterns in information strategies used by older men to understand and deal with prostate cancer: an application of the modelisation qualitative research design International Journal of Nursing Studies, 44, 961–972	Methods: Qualitative Sample: 15 French-Canadian men 61- to 83-year old diagnosed with localized prostate cancer and recruited from Quebec and PCSGs Procedure: Individual interviews were conducted to collect men’s perspectives about their self-assessed functional health literacy as a means to evaluating social and cultural influences on participant HL levels (high, middle, low)	Partnerships within social and information networks were reported as crucial to men in understanding prostate cancer. They suggested the existence of affective and spiritual aspects of prostate cancer information shape how older men receive, live and deal with their health and illness. Highlighted the need to overcome two major barriers; professional medical language and the silence among men, in refuting linkages between men's formal education and health literacy levels	Rich description of men’s strategies for obtaining information to deal with prostate cancer. While challenges to traditional HL definitions were made and assertions that family and community organizations were key resources for men’s HL no explicit linkages to gender of sex analyses were made

CRC, colorectal cancer; FOBT, fecal occult blood test; HL, health literacy; PCSG, prostate cancer support group.

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