Health professionals’ perceptions of a group intervention to address men’s psychosocial distress

2.1 Design, setting, participants, recruitment and sampling

A qualitative methodology based on a phenomenological approach [26] was adopted and applied to the health professionals’ series of views on the GRUSE intervention. Focus groups were used as the information collection instrument. A total of 4 groups attended sessions which were held at primary health care centres in the region of Andalusia (Spain), between July 2023 and May 2024. Thirty-seven health professionals participated in this study. Two focus groups were composed of social workers (n = 21), i.e., those who conduct the GRUSE interventions directly, and two other groups were mainly made up of doctors (n = 8), nurses (n = 5), psychiatrists (n = 1), psychologists (n = 1) and health education technicians (n = 1) (Table 2). In terms of gender, 24 women and 13 men participated, with an average age of 54 years. The vast majority had extensive work experience and training in health and gender issues.

Participants were recruited from the eight provinces that make up the region of Andalusia, so contextual differences (rural-urban environment and socio-economic differences) were represented. However, a stratified purposive sampling [27] according to professional category was used to form the groups, as we were interested in collecting significant and in-depth information on each professional’s group intervention experience. The social work professionals were selected according to their group development practice: we were interested in including both those who had the most group implementation experience and those who had barely any. The rest of the health professionals were selected based on their involvement in group intervention, taking as a reference the number of male referrals since the GRUSE-men had begun. We sought to achieve maximum discursive variability using these criteria.

Potential participants were invited via telephone by the coordinator of the GRUSE program, based at the Andalusian Public Health Service (Spain) and a collaborator in the research, who explained the purpose of the focus group. All selected participants accepted the invitation; however, some were ultimately unable to attend due to work-related reasons or illness, which explains the unequal number of participants in each focus group (Table 2). The groups were organized according to the territorial areas corresponding to the health centers where the professionals worked.

2.2 Data collection

The participants completed a brief demographic and employment questionnaire to allow us to characterise the sample (Table 2). A semi-structured focus group script was elaborated. It fell into three blocks of open questions that guided the discussion: (1) GRUSE definition, origins, and evolution of the group intervention; (2) intervention weaknesses and strengths; (3) perception of its impact on men participants. Two researchers experienced in qualitative techniques conducted the focus groups, one acting as interviewer and the other as observer, the latter taking field notes on non-verbal communication and group dynamics. The moderator who conducted the focus groups was a middle-aged Spanish man with a background in anthropology and social work. The observer was a middle-aged Spanish woman with a background in social psychology. Both are university professors and researchers. The knowledge produced must be situated and contextualized within these subjective conditions [28].

The focus groups lasted between 60 and 120 minutes. All participants gave their written consent and were informed that their data would be anonymous and their testimonies confidential. Participation was voluntary and they were given the information sheet with the research references.

2.3 Data analysis

The focus groups were audio-recorded and transcribed verbatim for comprehensive reading and in-depth analysis. In addition, field notes were considered for analysis. We applied a thematic analysis [29] and first coded 25 significant and recurrent ideas found in the collected data. Once the codes were defined, they were reviewed and refined to ensure internal consistency and avoid overlaps or duplications. These codes were then structured and grouped into 5 analytical categories, which represent the central dimensions of the discourse. These categories emerged through the identification of conceptual relationships and patterns among the codes, allowing for the development of a solid and representative interpretative framework grounded in the empirical material. The thematic analysis was conducted inductively, adopting a bottom-up approach to data processing. To analyse the data, the Atlas.ti programme (version 24, Cleverbridge GmbH, Cologne, NRW, Germany) was used as a support tool.

3.1 Conceptualization of the GRUSE intervention

The professionals recognised that the GRUSE intervention has been consolidated over the years in the health system and is now valued as an effective resource to promote mental health. The first GRUSE groups focused on women and only later were male groups incorporated. Professionals therefore recurringly compared different groups and underscored gender differences regarding intervention participation and impact. They recognised that it was easier to involve women than men, because women attended medical consultations the most anyway, presenting non-organic somatic symptoms. The likelihood of offering them the resource was therefore also greater.

“Women are more willing to participate and are more used to sharing problems and seeking support. Men tend to avoid these kinds of places where they have to speak in public and talk about their emotions with strangers.” (G3; P6; Social Worker)

“More women consult than men, and men are more reluctant to speak in public.” (G1; P10; Doctor)

The intervention was described as an important health system resource that offered an alternative to the medicalisation and “pharmacologisation” of psychosocial disorders.

“Personally, I think that GRUSE is an opportunity for men, because not everything has to be medicalised, pills are not necessarily a solution, there are other possibilities, such as taking part in a group. And the benefit comes precisely from participating in the group.” (G1; P11; Health education technician)

“I explain to them that they will be taught how to solve everyday problems, distress, nervousness, without taking medication and how to change their way of seeing things a little bit. You may learn to manage your life a little better if you go.” (G4; P1; Doctor)

However, it is argued that some professionals are less receptive to utilizing this resource, as it may be more convenient to prescribe medication or, from a more biomedical perspective, they may not believe in the benefits of alternative interventions that move away from medicalization.

“Some doctors are much more clinical, others more technical, others… So, I also believe that it is quite subjective, some professionals know how to delve deeper and detect the patient’s needs.” (G1; P1; Doctor)

The intervention is also conceived as a support platform providing emotional help and peer identification as they share their personal experiences. The group itself thus becomes an engine of change, fuelled by the relationships the participants build between themselves. The professionals highlighted how the group format allowed men to see themselves through the experiences of others.

“The group is hugely therapeutic…. The people who participate in the group are the main players; it’s down to the people who are in it. But we are not used to seeing the power of group work.” (G1; P9; Psychiatrist)

“Well, the group offers an essential function of support. I think you learn more in a group and it represents a basic work tool that we hardly exploit in primary care. We should use it more. Fortunately, though, it is being increasingly used.” (G1; P11; Health education technician)

3.2 Gender differences in participation

Practitioners perceived that women’s GRUSE have been more successful than men’s groups. The latter face multiple challenges: from difficulties in recruiting participants to socio-cultural resistance which inhibits men’s emotional expression in group settings. Gender discrepancy was constantly referred to in the discourses.

“… it is very difficult to reach men, for cultural reasons, in other words, it is much more difficult for men to open up and show their emotions because they have been brought up to be strong, and they have strongly internalised that.” (G3; P7; Social Worker)

“Men suffer as much as women, but they have been conditioned to hide it. Before talking about their emotions, they need to feel empowered to do so first.” (G4; P3; Psychologist)

The professionals emphasised that men are not used to sharing their emotions and problems, they attempt to solve them alone. Conversely, they explained that women were more willing to disclose personal experiences and to seek emotional support. In short, they believed that it was masculinity norms which stopped men from joining these groups, because they perceived as alien to their male identity.

“For me, there are two gender issues here: the obvious one, let’s say, patriarchal society, and another which underlies it all, the question of emotions. women have a huge advantage over men in the whole issue of emotions, and it lies at the heart of many problems we have to face.” (G2; P6; Social Worker)

“We all suffer from gender mandates. It seems that only women suffer from gender mandates, but men suffer a lot from gender mandates too. He has to be strong, he has to be proactive, he has to solve, he has to provide, he has to have status, he has to dominate. And, naturally, some men can’t carry that overload and break down.” (G4; P3; Psychologist)

Women’s groups are more established because they have been running for more years, but the time factor is not the only reason behind men’s low participation. There has been a constant recurrent connection between men’s difficulty expressing their emotions and masculinity norms. We understand that this sociocultural construct is modifiable and that it is precisely part of the GRUSE intervention.

3.3 Impact of the intervention on the men’s wellbeing

The professionals’ opinions revealed that men who succeeded at engaging with the group intervention experienced significant changes in different spheres of their lives. One common aspect they agreed upon was the improvement in the men’s emotional wellbeing, as they acquired skills to cope with stress in a healthier way. In this sense, the intervention helped men to challenge traditional masculinity norms, allowing them to explore and manage their emotions more effectively. Greater self-awareness was also underscored, as the men were able to identify difficulties which caused them distress in their daily lives. They also acquired skills and strategies to address these everyday problems.

“The main advantage is on a personal level. You can see improvements when the patient comes to the clinic, because he is physically and psychologically better, he can face life situations better, and he is not always settled in that sadness. They also accept that their masculinity does not mean that they have to be the head of the family, that they have to bring everything home, because they often feel bad if they don’t have a job. They are also brought to accept the separation from their wife, which causes them a lot of sadness and anxiety. Being separated from their children, from their home…, this affects them a lot emotionally. So, I think that accepting this whole situation helps them to improve their future life, both psychologically and physically.” (G1; P8; Doctor)

“Men use other means to deal with the emotional dimension that they were not connected to…, they learn to control their emotions. I remember once, during a visit, I was administering a questionnaire to a man who had done a GRUSE. The wording ‘control of emotions’ appeared in the questionnaire, and he suddenly became very serious and told me: Madam, there is a mistake here because it says ‘control’ and we have been taught that it’s not about controlling, it’s about managing.” (G4; P2; Doctor)

The professionals considered that the intervention facilitated the men’s ability to open up about dealing with emotions, learning that talking about them was not a sign of weakness, nor was it associated with being feminine. In fact, the social workers pointed out that the men gradually changed their way of expressing feelings as the sessions unfolded. This was clearly visible in the way they adopted a more emotional language.

“Well, my experience is that the platform helps men to allow themselves to connect with what is really happening to them. Rather than, let’s say, have superficial exchanges. The first contact is like dropping the armour so that they can allow themselves to enter a world of emotions, which is not easy at all. And, obviously, I work on gender issues, on what we are born into. You are dealt blue cards or pink cards, and those are the ones you have to play with. What interests me the most is that they know that they can open up, that they can enjoy being in contact, that they can express themselves, that they can ask things, that they can make mistakes. That they can show they are vulnerable, behind their strengths and hardness. Lately, the men were much more relaxed in the sessions. They were much more willing to talk and express themselves.” (G2; P5; Social Worker)

More specifically, the social workers’ discourses showed that they identified four key phases in the evolution of men’s attitudes: initial scepticism, adaptation to the group, acceptance of vulnerability and acquisition of strategies and learning for their personal wellbeing. Initially, the men distrusted the group, doubting that it would serve any purpose, but they gradually changed their attitude as they observed that other men shared similar experiences, thus diminishing their feelings of isolation and loneliness. This is when they began to realise that talking about emotions was not a sign of weakness and that they learned how to manage the difficulties of their daily lives.

“GRUSE men go against the norm. Usually it’s: I have an emotion that I don’t like, and I avoid it by drinking, by smoking. I have an avoidant attitude towards an emotion. GRUSE does the opposite: it confronts me with the emotion, it forces me to feel it, experience it, process it. And well, that’s a very powerful change.” (G2; P8; Social Worker)

It was again noted that despite men’s initial emotional reticence, conditioned by gender mandates such as “men don’t cry” or men should “be strong”, the group became valuable as a platform to express feelings and mutual empathy. It was highlighted that sharing experiences helped to process emotions, to be more open about them, and to learn skills to manage them better.

“At first, the men are reluctant to participate, but then they value the group as a safe arena where they can talk without being judged. As the group session progresses, they are the ones who ask each other how they are doing, they hug each other, and you can tell that they care about how they are doing from one week to the next.” (G3; P11; Social Worker)

Other reported groupwork benefits included the networks that the men built among themselves, leading to mutual support within and outside the sessions. Another factor was health and personal wellbeing. The biggest challenge is overcoming initial scepticism, but once in the group, men begin to value the platform as an essential support network both during and after the intervention.

“I can assure you that they share a connection afterwards, outside the group, because I met them in the village and I saw them together, and they told me that they were from the GRUSEs.” (G4; P4; Nurse)

“I agree with what you said about them feeling close, because they also have a common language. In the end, the GRUSE men get together, and they share a common language that they learned in the GRUSE sessions.” (G2; P3; Social Worker)

3.4 Difficulties in implementing the intervention with men

The difficulties identified can be grouped into three areas: (a) recruitment difficulties due to emotional stigmas associated with masculinity; (b) practical limitations such as session schedules; (c) personal self-limitations and personal predispositions.

Health professionals have highlighted the difficulties in recruiting and involving men in the group intervention, pointing out the low male participation rate in comparison to that of women.

“I have dealt with GRUSEs for many years through the social worker at my centre. I have in fact tried to refer men to the group session. But I have never been able to get any of them to go. In my case, they completely refuse to speak in public, to express emotions publicly. It’s complicated.” (G1; P6; Nurse)

The professionals believed that for men, taking part in a psychosocial distress treatment programme was associated with weakness and would thus be an admission of mental health problems, which would transgress masculinity norms.

“Men don’t want to share their feelings because they see it as a sign of weakness, going to the doctor and saying what you need is taboo, because it’s as if you have a weakness.” (G1; P8; Doctor)

Another identified barrier was time constraints. The session schedule usually coincided with most men’s working hours, reducing their possibility of access to the intervention programme. Some, however, considered that the schedule incompatibility was used as an excuse not to attend.

“They always give the excuse that they have work in the morning, but the truth is that it is very difficult for them, especially to open up. When you ask them, they sometimes tell you the problems they have, but I think they are too embarrassed to tell other people. That’s why they don’t want to attend.” (G1; P8; Doctor)

Practitioners equally acknowledged their own difficulties or self-limitations in engaging and referring men to join a group, which also explains the low male participation rate. They explained that because they assumed that men would be less receptive to this type of intervention, they failed to offer it perhaps as frequently as they did to women.

“I am a doctor, and I work in a health centre. I know about it, and I refer a lot of women to GRUSE groups, but I didn’t actually know that there were male GRUSEs. In reality, no male group has been set up in my health centre.” (G1; P5; Doctor).

“I have referred women to our social worker, but I have never referred men.” (G1; P4; Doctor)

One narrative was that women were seen as emotionally open and men as emotionally reserved. This gender discrepancy conditioned the way in which professionals perceived each group intervention. A critique of traditional gender roles is clearly visible in the discourses, but at the same time they are based on an essentialist view of masculinity as an obstacle to participation.

It was also observed that GRUSE was implemented differently across health districts. This depended on the availability, willingness, or training of professionals both to refer men to groups and, in the case of social workers, to lead and manage a group.

“It also depends on each person’s availability and involvement, and I think that, at least for me, based on what I have found with my colleagues in primary care, some people are more open to referrals than others.” (G1; P1; Doctor)

“I know that social workers also find it a bit more difficult to get involved in a man’s group than a woman’s group. There seems to be a certain fear of working with men, being a woman.” (G1; P9; Psychiatrist)

“I have done GRUSEs with men and it’s a bit of a surprise. You start out a little concerned, you’re thinking, I don’t know, because you’re used to doing GRUSEs with women, which is easy, known territory, and you have that barrier of facing men, right? And then you’re surprised at what they are capable of in a group.” (G3; P10; Social Worker)

3.5 Improvement strategies

At the health system level, health professionals widely support the potential of the GRUSE intervention to promote mental health. However, low referral rates and consequently, men’s limited access to these groups hamper their overall effectiveness. This is why health professionals warn about the need to achieve higher male referral rates and involvement through the recruitment strategies.

“…regarding referrals, we have to look for other strategies. When we mention referrals in the team, sometimes there are none at all. This year, when we opened the men’s GRUSEs, we received many referrals from the mental health services and from associations. The association network can be another way to get men to be referred to us; I’m saying this to suggest new strategies.” (G2; P10; Social Worker)

Similarly, the need to adjust timetables to facilitate men’s attendance and make their working hours compatible with the group sessions was raised.

“Another issue is schedule availability. Timetables are set for the groups and sometimes they interfere with the men’s working schedules. This is also an obstacle. And that’s why some men say ‘I can’t come on that day’ when the group is proposed to them. There are many kinds of limitations.” (G4; P2; Doctor)

Social workers highlighted the need to make the intervention visible and legitimate within the health care system. They also pointed out the importance of collecting data and evaluating the intervention results, in order to not only demonstrate but also disseminate its impact on both men and women.

“On the one hand, I believe that the administration, the public authorities should disseminate the strategy more widely. On top of that, social workers are not communicating the results of the GRUSE sessions. The results obtained and the problems are not being divulged out there.” ​(G3; P7; Social Worker)

This highlights the need to promote specific professional health training on the important role of the gender perspective. And self-knowledge building platforms should be created, so that professionals can reflect on their personal positions and avoid perpetuating traditional gender roles.

“It’s important for professionals to be involved, but they also need to be trained as well as be given opportunities for self-exploration. If we don’t look inwards, we don’t change inside as people and as professionals, that’s why training in self-knowledge is necessary.” (G2; P6; Social Worker)