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Impacts of a Documentary about Masculinity and Men’s Health

As part of a larger study, we developed a three-part documentary called Man Up that explored the relationship between masculinity, mental health, and suicide. In this study, we examine in detail the qualitative feedback provided by those who viewed Man Up, in order to gain a more in-depth understanding of its impact on them. A total of 169 participants provided qualitative feedback via an online survey 4 weeks after viewing Man Up. We examined their opinions about the show and whether they reported any changes in their attitudes and/or behaviors as a result of watching it. All the men who provided feedback on Man Up were overwhelmingly positive about it. The majority reported significant and profound impacts of viewing the documentary. They reported being more aware of others, more willing to help others, and more open about their emotions and problems, as well as demonstrating associated behavioral changes related to helping others and being more emotionally expressive. The data presented here demonstrate the potential for men’s health outcomes to be positively impacted by novel, media-based public health interventions.

. It is also plausible that conformity to masculine norms could contribute to the development of suicidal thoughts if men favor stoicism and self-reliance rather than seeking help and support from others when experiencing emotional or personal problems. Indeed, recent research has identified that self-reliance is uniquely associated with Australian men's suicidal thoughts (Pirkis, Spittal, Keogh, Mousaferiadis, & Currier, 2016).
It is possible that interventions that challenge men's conformity to harmful aspects of dominant masculinity, such as self-reliance and stoicism, and encourage men to be more open about personal problems and seek help may be effective in reducing men's suicidality. Gender-sensitive interventions have been successful in regard to violence and the spread of HIV; however, there is a paucity of research regarding men's mental health promotion interventions (Dworkin, Fleming, & Colvin, 2015). Recent research suggests that gender-sensitive mental health programs may hold some promise (Seaton et al., 2017).
To test the potential of a gender-sensitive media intervention, a collaboration was established between the researchers and an independent filmmaker to create and evaluate a public health media-based initiative called Man Up, which included a purpose-designed documentary; a media campaign across social media, newsprint, and radio; and a website (http://manup.org.au/). There have been many efforts to create social change through television; however, very few of them have been evaluated, and the understanding of how change happens is still in its infancy (Karlin & Johnson, 2011).
The documentary was the cornerstone of the Man Up initiative. The development of the documentary was premised on the theory of planned behavior that proposes that behavioral intentions are influenced by attitudes toward behavior, perceived behavioral control, and subjective norms (Ajzen, 1991). The documentary targeted Australian men and sought to demystify and normalize men's emotional experiences, emotional expression, and help seeking; challenge aspects of dominant masculinity related to self-reliance; and provide positive role models for change.
The Man Up documentary was a three-part presenterled television series. The presenter Gus Worland is a well-known Sydney radio and television personality. Gus is in many ways a typical Australian male; he is a rough and coarse, but he is also comfortable expressing emotion and talking about suicide and mental health. Through Man Up, Gus tried to uncover the possible causes of high suicide rates among Australian men. He visited various locations including a boy's secondary school, phone helpline (Lifeline Australia), support group for veterans, barber, rural radio station, outback cattle station, men's fashion magazine, speed dating night, and naked yoga class. He spoke to everyday men and women, farmers, ex-servicemen, men's health experts, and others. Throughout Man Up, the dominant masculine norms of self-reliance and stoicism were questioned and expression of emotion and help seeking were normalized. Gus met men from all walks of life who modeled positive behaviors such as talking about personal problems, expressing their emotions, and seeking help. The school visit involved a facilitated session with students that explicitly questioned the social pressures placed on boys and men.
Man Up was aired by the Australian Broadcasting Corporation (ABC), Australia's national public free-toair broadcaster, across three weeks in October 2016.
In order to evaluate the impact of the documentary, thereby increasing the evidence base for mental health interventions, a randomized controlled trial of the documentary was undertaken prior to the screening on national television. Participants were assessed on a range of standardized measures before and after viewing either the Man Up documentary or a control documentary. In short, responses to the standardized measures showed that men who viewed Man Up demonstrated an increased likelihood to seek help and recommend help and a reduction in the degree to which they conformed to masculine norms in comparison to those who viewed the control documentary (King et al., 2017). To gain a deeper and more nuanced understanding of the experience of watching Man Up, data were collected on participants' reactions to the show, including the parts they liked the most and the least; and any changes that they had observed in their own attitudes and behaviors that they attributed to watching it. The objective of this article is to analyze these responses using qualitative methods to further understand the impact of the documentary on participants especially in relation to masculinity and help seeking. The specific research question is the following: How did watching the documentary impact on male viewer's attitudes toward masculinity and help seeking?

Participants
The trial took place prior to the screening of the Man Up documentary on television. Males aged over 18 years were recruited in early 2016 in Victoria, Australia. Participants were recruited via multiple methods including e-mail advertisements to university staff and students, and posters in: retail stores; sporting clubs; local school parent newsletters; and local community "buy, swap, sell" Facebook pages. Gender and age were self-reported. Only men who were at active risk of suicide (as assessed by the Adult Suicide Ideation Questionnaire [Reynolds, 1991] and the study psychologist) were ineligible to take part in the trial in order to minimize any potential unforeseen harm. However, no participants were deemed ineligible to take part.

Study Design
At 47 meetings with researchers, 354 participants provided written informed consent to take part in the research and then completed a set of standardized measures on an online platform designed for the study. Participants were then randomized to view either Man Up or a control documentary (a National Geographic documentary called Test Your Brain; National Geographic, 2016). Researchers were blinded to the allocation of participants. Participants viewed their allocated documentary at home and online (or at another place of their choosing). Four weeks after viewing, participants were sent an e-mail providing them with a link to complete a follow-up survey that included a repeat of the standardized measures and a series of purpose-designed closed and open-ended feedback questions about participants' perceptions of the documentary's impacts on their lives; 169 control and 168 intervention group participants completed the follow-up survey. A 4-week follow-up time period was chosen to allow participants time to reflect on the documentary and integrate its messages with their lives and to meet the demands of the overall project timelines. The questions were developed in collaboration between the researchers, experts in men's health, and the film production company with the aim of understanding the impact of the documentary on men generally and on their attitudes toward masculinity and help seeking specifically. Closed-ended questions were used so that men's responses to the documentary could be quantified, and open-ended questions were used to understand in more detail how men's responses came about and were experienced. The questions used to elicit men's perceptions of impact and their response rates are reported in Table 1.
Further details on the trial are described elsewhere (King et al., 2017).
The present article focuses on the responses of the 169 participants who were allocated to view Man Up. The trial received ethics approval from the University of Melbourne's Health Sciences Human Ethics Sub-Committee (ID: 1545590.4) (King et al., 2017).

Data Analysis
Closed-ended responses to questions were analyzed in STATA 13 for simple frequencies.
Thematic analysis of open-ended questionnaire responses was undertaken using NVivo Pro V.11. This method of qualitative data analysis is generally chosen when existing knowledge on the phenomenon is limited, which was the case for this data. In this method of analysis, preconceived themes play a more minor role than the themes that emerge from the data. Each participant's responses to all of the openended questions (see Table 1) were read by two of the researchers (KK and LR) and potential themes were noted and then compared. Considering all possible themes together, a coding framework was collaboratively developed by the same two researchers (KK and LR). Framework analysis, a content analysis method that involves summarizing and classifying data within a thematic framework, was then conducted to order the themes into an overarching framework (including first and second level themes) to make sense of the emerging themes (Green & Thorogood, 2014). The same researchers (KK and LR) independently coded the same 10% (17) of participants' responses to ensure a high level of agreement on coding the data. KK then coded the remaining data using this updated coding schedule. When necessary, KK consulted with LR to confirm agreement on particular data. The coded data were then read by second level themes to ensure these final themes were coherent and to code for the third level themes. The final thematic schedule used in analysis is reported in Table 2. For each of the first level themes, two quotes were selected to demonstrate participants' typical responses. Table 3 reports the demographic characteristics of the 169 participants who viewed Man Up and completed the 4-week follow-up questionnaire. Participants reported a mean age of 39 years, and most were heterosexual, born in Australia, and spoke English at home.

Closed-Ended Responses
Responses from the closed-ended feedback questions are reported in Table 4. Participants reported a high level of enjoyment of the documentary (mean = 8/10). The vast majority also reported that the documentary had triggered changes for the better in them (142, 84%). A small number of participants (10, 6%) reported changes for the worse. Ten percent (17) of participants reported that the documentary did not trigger any changes in them, for the better or the worse.
Changes in attitudes were more frequently reported than changes in behavior. The most frequently endorsed changes in attitude were related to a deeper understanding of the pressures placed on men (131, 87%), broader views about what it means to be a man (110, 73%), and increased confidence to reach out to someone (105, 70%).
Two less positive options regarding attitudes were provided, which were less frequently endorsed: "I got thinking about how frustrated or sad I am about parts of my life" (74, 49%) and "I felt overwhelmed about making changes" (27, 18%). Items relating to behavioral changes were frequently endorsed, such as "I changed my behaviours or attitudes based on my new understanding of the 'man code'" (95, 63%); "I opened up to someone" (62, 41%); and "I invested time in making new friends" (41, 27%). Almost all of the participants (160, 95%) reported that they would recommend the documentary to family and friends.

Open-Ended Responses
Thematic analysis of participants' responses to each of the open-ended questions revealed that there were strong and consistent themes present in men's comments about the documentary as well as some less common threads. Comments were categorized by opinions of the documentary; impact of the documentary on self, including both attitudes and behaviors; general positive comments; and general negative comments. Each theme is described in more detail below.

Opinions of the documentary.
Men were asked about which parts of the documentary they enjoyed the most and the least and which had a positive or negative impact on them. In addition to describing the segments they most valued, men made some general comments on the documentary's format and style. Table 5 reports a brief description of each element of the documentary that received 10 or more comments and a count of positive and negative comments. From the quotes in Table   Table 1 Note. a Each question, except Questions 10 and 11, was available for all 169 participants to answer. Questions 10 and 11 were only asked to the 150 participants who answered yes to either Question 8 or Question 9.
5, it seems that men often found particular segments "powerful" or "enlightening." In terms of what they did not like, "contrived" and gimmicky segments were not valued. As reported in Table 5, the segments of the documentary that received the greatest number of positive comments were those related to Gus's visit to a boys' secondary school. These segments resonated strongly with participants, with many identifying them as the segments that they liked the most or that got them thinking the most. Many commented about how the segment had been thought-provoking and had triggered an emotional response.
"The parts in the school got me thinking about how male attitudes towards mental health are instilled in boys. " "The part about the young boys at school. Very moving, inspiring, raw and bringing to the surface the potential for men as well as the barriers we have in connecting or hiding emotionally." The behind-the-scenes visit to the Lifeline phone helpline also received many positive comments, with participants citing it as one of the segments that had the biggest impact on them. Participants liked seeing how the helpline was helping people.
"It was pretty powerful to see actual counsellors talking to people with mental health issues and trying their ultimate to help them." Interviews with people about the impact of suicide on a family or friends were also frequently mentioned, with many participants highlighting increased awareness of the impact of suicide on family and friends as a key learning from the documentary.
"The devastating impact [of] the suicide on family and friends. In particular that unanswered questions that it left behind." The naked yoga segment was most commonly cited as the part of the documentary that participants liked the least.
"Naked yoga just seemed to have no relevance to the doco." Participants commented that they enjoyed the realworld setting of Man Up featuring everyday men and the host expressing emotions in an honest way. It seems that this style facilitated participants' personal connection with the content. People made positive and negative comments about the host, Gus. Some participants appreciated his rough masculine nature that contrasted with his emotional openness, while others did not identify with him.
"The openness of the presenter to discuss male mental health." "He just wasn't a guy I could identify with." Although a small number of participants reported that they appreciated the variety of people and situations presented in the documentary, more participants commented on a lack of diversity among the men represented and an overemphasis on the typical "straight" Australian man with a lack of attention to men of varying cultural background or sexual orientation.
"Generally very white. Not representative of other non-white Australian males. Not much in terms of gender and sexual identity." Impact on self. A number of the open-ended questions asked men to elaborate on any changes that had occurred for them as a result of watching the documentary four weeks ago. Comments related to the impact of the documentary on participants are now described in more detail. Participants reported two areas of impact on themselves: changes in awareness of themselves and others and changes in behavior related to themselves and others.
Awareness change. The majority of participants (138, 82%) made a comment in their open-ended response that indicated that Man Up had triggered increased awareness for them. Most commonly, they reported an increased awareness of what other people may be going through, the prevalence of male depression and suicide, the importance of talking about feelings, and the need to get help. These themes are described in more detail in the following text. Increased awareness was less commonly reported in relation to issues related to raising children; the importance of social connection; self-awareness; and other lifestyle factors related to well-being. Participant comments were often forthright and revealing of personal life circumstances, feelings, and thoughts.
More aware of what other people may be going through. Forty-one percent (69) of participants spoke about how Man Up had changed the way they thought about people in their lives. Comments revealed a new compassion and concern for others. Many spoke about how the documentary had provided them with a new insight into the emotional lives of other people, which had, in turn, prompted a desire to help them.
"Made me more aware of what other people may be going through without me knowing." "It brought to the forefront of my attention how everyone is fighting a battle and as mentioned before, wanting people to know they can come and talk to me about anything." The prevalence of male depression and suicide. Fortysix percent (77) of participants reported that Man Up had provided them with more awareness and insight into the mental health issues facing men. Many seemed surprised to learn about the prevalence of depression and suicide. "Just got me thinking about how many people are affected by suicide." "I did not realise the prevalence of male depression and suicide across the social spectrum." Talking about feelings is important. Thirty-eight percent (64) of participants spoke about how Man Up had made them think about the way they express emotions and talk about personal problems with their family and friends. Many revealed a growing awareness of the importance of emotional expression and a new desire to be more open and to encourage emotional expression in others, especially children.
"As a parent of three children it has taught me that communication and talking about feelings is very important."

"I feel as though I am more comfortable sharing my feelings with family and close friends."
The need to get help. Seventeen percent (28) of participants said that Man Up had highlighted the importance of seeking help when needed, but about how this can still be a struggle to enact for men. They spoke about the tension they experienced between wanting to seeking help and negative attitudes toward seeking help, which had previously stopped them from reaching out.
"I liked the line that went something like: 'If your car was bogged you would call your mate first thing no worries but if it's something affecting your own mental health you won't.' Kind of just highlights that we're willing to ask our mates for help, but for something as important as mental health we still struggle to reach out." Note. *0 = not at all, 10 = very much OR will have a large impact; **N = 150.

"My attitude towards getting help definitely changed. I recognised that this is a health issue I have to change and it's easy to get help."
Behavior change. Thirty-eight percent (65) of participants made comments about changes they had made to their behavior since watching Man Up. Participants most commonly said they had made changes in the way they supported others and expressed their feelings or concerns to others. Less commonly, participants commented on the way they were being more emotionally expressive with the children in their life; making steps to improve social connections; seeking help; and making other positive lifestyle changes. Some participants reported that they had been trying to make changes but had not yet been able to enact them.
Reaching out. Fourteen percent (24) of participants spoke about how they enacted changes related to supporting other people. Participants were quite specific in their examples, describing times that they actively reached out to support family members and friends who were going through difficult times.
"It made me reach out to my brother who is going through a difficult relationship breakdown and make sure he knows I'm here for him." "I have noticed that when talking to other males I now pay more attention to what they are saying and how they are saying it, and have asked if they are ok more often." Trying harder to communicate thoughts and emotions. Ten percent (17) of participants cited ways in which they had made changes in the way they communicated their thoughts and feelings to the people in their lives, and they reported making efforts to have deeper conversations with loved ones and friends.
"I'm trying much harder to communicate my thoughts and emotions to my partner, and finding that he is supportive of this." "I have had a few much more in depth conversations with my male friends, particularly other dads. I feel closer to those friends." It's hard to change. Fourteen percent (24) of participants spoke about factors in their lives that were preventing them from making changes despite a belief in the value of doing so. Participants commented on the effort it takes to change deeply entrenched behaviors.
"I just want more time to make the changes I so badly want to make. I have been so busy at work, then working on all the little jobs on the weekend and raising 2 children under 4 years old. When I make more time, I look forward to making a few changes that will help me, my family and friends." "Despite all the good advice and recommendations I still really struggle to seek help or talk about my mental health anywhere or with anyone. The documentary was very good at making me consider these things but currently I'm just not in a place where I feel like I could ever do them." Note. a Excluding elements that received 10 comments or less.
Reinforced behavior. Twenty-four percent (41) of participants reported that the messages of Man Up were consistent with their patterns of thinking and behavior and that they were content with their lives as they were. As such, while agreeing with the messages of Man Up, they had not been prompted to create any change in their lives.
"It reinforced many things I have learned over the years." "I'd been thinking about the whole topic for a while and I feel I've reached a fairly solid conclusion of who I am as a person (and as a man). So I don't feel I've changed much, rather had those views and opinions reinforced." About half of the participants who reported no change in behavior also reported no changes in awareness (19, 11%). Many of these participants similarly commented that they perceived no need for change or that the documentary confirmed what they already knew.

"Although I enjoyed the documentary there was no trigger for any change in my outlook in life. Now at 70 years of age I am very content with my life"
Other comments. Participants made other positive and negative comments that were unrelated to the other themes, and few participants commented on negative impacts of Man Up on themselves.
Other positive comments. Forty-nine percent (83) of participants made other general positive comments about Man Up or their involvement in the trial that were unrelated to any other themes. Many participants used effusive language to provide their positive feedback.
"It was a really well presented documentary that I feel will resonate with many men." "Very well made, very easy to watch and understand, and an incredibly important topic." Nineteen percent (32) of participants spoke of the need for Man Up to be seen by a large audience in order for its positive impact to spread throughout the community.
"I hope this is seen by a really large proportion of the population and that there is lots of discussions of these issues." "I hope the documentary is shared and viewed widely and has a dramatic impact on men's health and wellbeing in this country." Other negative comments. In addition to some negative comments about the host and a perceived lack of diversity in the documentary that have been previously described, other negative comments were either of a general unspecified nature (39, 23%) or were in regard to the length of the documentary (20, 12%). While some of these participants had also made other positive comments about Man Up, some simply did not engage with the content.

"It just wasn't for me." "It's a good documentary but pretty long (not to mention in parts). Might be hard to get people to sit through the whole thing."
Negative impacts on participants. A small number of participants (8, 5%) reported that Man Up had a negative impact on them. They spoke about it raising negative feelings and thoughts about suicide.
"Suicide wasn't on my mind that much when I watched the documentary. I do think about it a bit more now."

Discussion
This article presents an analysis of closed and open-ended data collected from 169 male viewers of the Man Up documentary. The aim of the article was to determine how watching the documentary impacted on male viewers' attitudes toward masculinity and help seeking. Participants reported that as a result of viewing the documentary, they had changed their view about what it means to be a man and gained a deeper understanding of the pressures placed on men to conform to a particular way of being a man. Participants reported that Man Up had triggered increased awareness of mental health and suicide; other people's emotional experiences; the importance of expressing feelings; and the importance of seeking help. About one third of participants said that Man Up had triggered behavioral changes in the way they supported others and expressed their emotions or concerns to others. Some participants felt frustrated about parts of their lives or felt overwhelmed about making changes. To a lesser degree, there were negative comments, which were mostly of a general nature and related to a perceived lack of diversity among the men featured and the length of the documentary. A small number of participants reported negative impacts. The changes in attitudes seen here are no small feat, given that shifting people's attitudes is notoriously difficult (Kelly & Barker, 2016).
Many men reported that they enjoyed the real-world setting of Man Up, which provided insight into the reallife emotional experiences of the presenter and everyday men. Their honesty and vulnerability served to expose a side of men that they had perhaps experienced themselves, but may not have witnessed in others. Many participants also commented on the insights they gained into the impact of suicide on family and friends left behind, which provided them with valuable information about the emotional lives of others. It seems that Man Up opened men's eyes to the emotional lives of other people and made them realize that it is normal, and acceptable, for men to experience emotional problems at times. The fact that many participants reported having enacted changes in their lives is an indication of the degree to which participants had integrated the messages of Man Up and were willing to now act in ways contrary to societal pressures.
The school visits also strongly resonated with participants. It seems that these segments, which directly challenged dominant masculine norms with a group of teenage boys, worked to connect participants personally to the messages of Man Up as they reflected on their own experiences and thought about the possibilities for change with young people. The visit to the Lifeline phone helpline call center was also a pivotal segment for many participants, which may have served to demystify and destigmatize help seeking.
Of course, the benefits of Man Up are only useful if people watch it. Fortunately, participants indicated very high levels of enjoyment from viewing Man Up and an almost unanimous willingness to recommend the documentary to others. The study did not look at the longer term impacts of viewing, and comments can only be made on the short-term impacts on participants. The negative impact experienced by the small proportion of Man Up viewers in this study highlights the need for interventions such as these to be sensitively presented and accompanied by information regarding sources of help. It should be noted that participants in this study were provided with psychologist support, as needed, throughout the study. However, no participants requested this support. Options for help were also provided for viewers when Man Up was screened on television and throughout the accompanying media campaign.
The lack of diversity within the sample is a limitation of the study that may reduce the generalizability of the findings presented here. Indigenous men and non-heterosexual men were underrepresented, for instance. The reasons for this are not known; however, it is important that future interventions aim to be more inclusive of these groups of men given their increased risk of suicide both in Australia and internationally (WHO, 2018). It is also acknowledged that men who chose to participate may be a biased sample with an interest in men's health. Richer data could have also been obtained using in-depth interviewing; however, this was outside of the scope of the study. Despite the limitations of open-ended survey data, the findings are still useful given the large number of participant responses, the combination of quantitative and qualitative findings, and the fact that participants were provided with and utilized an opportunity to contribute their opinions and experiences.
The 4-week time period, as mentioned, was chosen to allow participants time to integrate the documentary's messages with their lives. This was considered important, as the documentary sought to challenge potentially longheld views of masculinity that are impacted by a person's social context. Surveying participants at different time frames may have provided further insights.
The themes that emerged in the data indicate that Man Up had an impact on the men who viewed it in terms of awareness raising and attitudinal and behavioral change. In sum, these men were now challenging the masculine norms that have been associated with negative mental health outcomes and were translating this into behavior change. There were some indications that while change was desirable, it was nonetheless difficult for some, with some participants feeling frustrated or overwhelmed; however, this may also act as an impetus for change. Hopefully these changes will lead to improved mental health outcomes and reduced suicidal thoughts and behavior for these men over time and also for the community after its screening on national television in October 2016.
The findings here contribute to an emerging body of knowledge around the need for mental health interventions that explicitly target men and focus on gendered social roles around help seeking and mental health treatment. HeadsUpGuys in Canada and the Real Men. Real Depression campaign in America are two such examples (Ogrodniczuk, Oliffe, & Beharry, 2018;Rochlen, McKelley, & Pituch, 2006). Consistent with previous research, the findings here confirm that campaigns may be most effective if they feature hypermasculine men; acknowledge men's reluctance to seek help; and incorporate traditional masculine norms and values into help-seeking depictions (Rochlen et al., 2006). In addition, these findings suggest that appealing to men's sympathies toward the current generation of boys may be particularly effective and that interventions that use a "reality"-based format are well received.
The negative responses to the "naked yoga" segment of the documentary are worth considering in relation to future interventions. It may be that these negative reactions are symptomatic of a deeper seated homophobia within participants, which may be acting as a barrier to friendship and intimacy among men (Connell, 2005). Future interventions must consider whether to actively challenge this homophobia, and risk negative reactions, or avoid it and risk not addressing a key barrier to men's friendships. Further research is needed in this area to determine the best way forward.
In sum, television documentaries provide enormous potential to improve men's health outcomes not only due to their ability to reach and educate large audiences without relying on them to seek help but also for their ability, as suggested here, to act as agents of positive change for individuals and, ultimately, communities. Continued evaluation of public media interventions is essential to elucidate the specific impacts experienced by viewers and create an evidence base for future interventions. Ideally, longer time frames for evaluation and more in-depth data collection techniques will enhance our understanding of how (and for how long) change is brought about.