w7 Disc 2

Qualitative Health Research 2015, Vol. 25(12) 1648 –1661 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1049732314566323 qhr.sagepub.com

General: Article

Type 2 diabetes mellitus (T2DM) and coronary heart dis- ease (CHD) are chronic illnesses for which particular self-care strategies are recommended (Kerr et al., 2007). This is because adults with T2DM have heart disease death rates approximately 2 to 4 times higher than adults without diabetes (Egede & Zheng, 2002). Following an acute cardiovascular illness, outpatient cardiac rehabilita- tion (CR) is recommended (Taylor et al., 2004). Notwithstanding such assistance, men with T2DM are less likely to attend and complete CR programs (Banzer, Maguire, Kennedy, O’Malley, & Balady, 2004). In response, this article addresses an important knowledge gap regarding men’s responses to new health behaviors (Evans, Frank, Oliffe, & Gregory, 2011). Working within the tenets of critical realism and qualitative inquiry (Clark, Lissel, & Davis, 2008), we drew on insights from theories of gender and masculinity to illuminate mechanisms that contribute to men’s variable trajectories in CR. We con- sider factors influencing men’s struggles to identify sites for policy and practice innovation (Clark et al., 2012).

The following section introduces the broad social con- text informing this issue. This is followed by a discussion of the theoretical and empirical literature in gender and masculinity.

Background

The current economic limits to health care resources in Canada and internationally have stimulated great interest in helping individuals self-manage chronic disease (Newman, Steed, & Mulligan, 2004). In Canada, preva- lence of T2DM increases across the life span and is slightly higher in men up to the eighth decade. More than 50% of those diagnosed are of working age (Public Health Agency of Canada, 2011). Poor glycemic control is linked to higher incidence of stroke, heart attack, and

566323QHRXXX10.1177/1049732314566323Qualitative Health ResearchDale et al. research-article2015

1University of Toronto, Toronto, Ontario, Canada 2York University, Toronto, Ontario, Canada 3College of the Rockies, Cranbrook, British Columbia, Canada 4Princess Margaret Cancer Centre, Toronto, Ontario, Canada 5Ryerson University, Toronto, Ontario, Canada 6Women’s College Hospital, Toronto, Ontario, Canada 7Toronto Rehabilitation Institute, Toronto, Ontario, Canada 8St. Michael’s Hospital, Toronto, Ontario, Canada 9University of Alberta, Edmonton, Alberta, Canada

Corresponding Author: Craig M. Dale, Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, 155 College Street, Suite 130, Toronto, Ontario, Canada M5T1P8. Email: [email protected]

“I’m No Superman”: Understanding Diabetic Men, Masculinity, and Cardiac Rehabilitation

Craig M. Dale1, Jan E. Angus1, Lisa Seto Nielsen2, Marnie Kramer-Kile3, Cheryl Pritlove2,4, Jennifer Lapum5, Jennifer Price6, Susan Marzolini7, Beth Abramson8, Paul Oh7, and Alex Clark9

Abstract Exercise-based cardiac rehabilitation (CR) programs help patients with coronary heart disease (CHD) reduce their risk of recurrent cardiac illness, disability, and death. However, men with CHD and Type 2 diabetes mellitus (T2DM) demonstrate lower attendance and completion of CR despite having a poor prognosis. Drawing on gender and masculinity theory, we report on a qualitative study of 16 Canadian diabetic men recently enrolled in CR. Major findings reflect two discursive positions men assumed to regain a sense of competency lost in illness: (a) working with the experts, or (b) rejection of biomedical knowledge. These positions underscore the varied and sometimes contradictory responses of seriously ill men to health guidance. Findings emphasize the priority given to the rehabilitation of a positive masculine identity. The analysis argues that gender, age, and employment status are powerful mechanisms of variable CR participation.

Keywords diabetes; education, patient; gender; heart health; health care, users’ experiences; illness and disease, experiences; illness and disease, chronic; masculinity; men’s health; rehabilitation

Dale et al. 1649

heart failure (Harris, Ekoe, Zdanowicz, & Webster- Bogaert, 2005) in addition to higher rates of hospitaliza- tion and death (Deaton et al., 2006). To address a gap in risk modification (Kotseva et al., 2009), professional societies endorse a policy of systematic CR referral for high-risk patients (Grace et al., 2011). Through group and individual activities, CR assists adults to integrate exer- cise, diet, weight loss, and smoking cessation recommen- dations (Nielsen et al., 2012).

Low attendance and completion of CR by diabetic men portend the retention of grave health risks. With this growing population in mind, diabetic men’s perspectives might be particularly informative. However, the prospec- tive (Audulv, Asplund, & Norbergh, 2012) and compara- tive experiences (Evans et al., 2011) of men undertaking CR remain largely unexplored. This might be explained by the frequency of sex-based outcomes analysis in health services reporting (Galdas, Johnson, Percy, & Ratner, 2010). Albeit important, this lens typically neglects the sites and circumstances of everyday health work (Thorne, 2008). Forces constraining men’s self-care behaviors might remain active but concealed in categories compar- ing women and men (Schofield, Connell, Walker, Wood, & Butland, 2000).

In response to the above issues, gender theory has become relevant in chronic illness (Hart, Hunt, & O’Brien, 2007). Gender is an important dimension of health behavior as lifestyle modifications are adopted— and individually adapted—within different contexts, social positions, and relationships (Schofield et al., 2000). This suggests that any significant reformulation of health behaviors will concurrently alter gendered interactions, activities, and expectations across social settings. In tan- dem with this intersectional view, masculinity theory posits that the expression of gender is deeply entangled with context (Connell, 1995). This means that self-care practices must be understood within the material condi- tions and social relations in which they reside (Mahalik, Burns, & Syzdek, 2007).

In summary, there are gaps in understanding gendered health work in men with a T2DM + CHD complex. If, as some authors argue, gender and health are co-constituted and accounted for in everyday activity (Fenstermaker & West, 2002), then research must find ways to bring these circumstances forward. Next, we discuss relevant theo- retical approaches to gender and masculinity.

Theoretical Approach: Gender and Masculinity Theory

Gender Theory

A particularly important thread of health research was the disaggregation of sex and gender (Cameron & Bernardes,

1998). The argument holds that sex is a marker of the biological body. In contrast, gender is a social construc- tion of masculinity and femininity. Liburd, Namageyo- Funa, and Jack (2007) describe gender as the study of social relations—both among and between women and men. Here, social relations are the organization of every- day activities comprising the relative positioning of men and women. Gender then becomes a matter of ordinary interactions and expectations, linguistic convention, and tacit understandings (Charteris-Black & Seale, 2010). Whereas health promotion research typically categorizes and compares sex-based outcomes to health interven- tions, it is often much less attentive to the social relations of gender (Gelb, Pederson, & Greaves, 2012). This means that health services research typically dissolves the com- plex networks, gender relations, and differently distrib- uted resources that condition the possibilities for health in men and women.

Masculinity

Although concepts of masculinity have broadened health research, they are seldom discussed in the CHD literature (Emslie, 2005; Robertson, Sheikh, & Moore, 2010). Courtenay (2000) posits that masculinity is expressed in part through a lack of concern with health and physical limitations. Connell (1995) helpfully explains that men’s socialization to sport and certain occupations predisposes them to take bodily risks in the accumulation of power, expertise, and capital. In accomplishing these aims, male behaviors actively engage CHD antecedents (Emslie, Hunt, & Watt, 2001) and normalize ill health among men (Courtenay, 2000). However, contemporary gender researchers caution against essentialist views of mascu- linity (Coles, 2008). This resonates with recent perspec- tives on gender as a highly varied accomplishment. In other words, “doing gender” is a matter of situational competence (Jowett, Peel, & Shaw, 2012) and is central to understanding health disparities (West & Zimmerman, 1987).

Health and gender researchers propose that illness weakens men’s self-concept because it distances them from productive sources of masculinity (Hart et al., 2007). Because illness work is culturally associated with women and the domestic sphere (Galdas et al., 2010), men might find acceptance of professional help stigma- tizing (Addis, Mahalik, & Mansfield, 2003) and discredit recommendations that threaten to undermine important social positions. In this instance, a masculine vernacular requires special consideration (Charteris-Black & Seale, 2010). Without a nuanced understanding of men’s responses to biomedical direction, lack of health work might remain puzzling (Oliffe, 2009) and intervention strategies elusive (Addis et al., 2003).

1650 Qualitative Health Research 25(12)

A Different Approach

Taken together, the abovementioned theories of gender and masculinity are resources for studying health behav- ior change. Critical realists embrace this notion of deep, complex causality and contend that different levels of reality interact to produce variable, context-sensitive out- comes. However, they caution that powers contributing to events are not always self-evident. With these points in mind, critical realists offer ethnographic and qualitative methods as potential approaches when investigating the interplay between social structures (gender) and health work (agency; Angus & Clark, 2012). For example, some researchers argue that diabetic men discursively mini- mize the consequences of poor disease self-management (O’Hara, Gough, Seymour-Smith, & Watts, 2013). Attuning to these events holds the potential to illuminate the sites and circumstances where “doing gender” and health becomes problematic (Drummond, 2003).

We work from this substantive and theoretical back- ground to report findings from a qualitative study of gen- der and co-morbidity in CR participants. The study included both men and women with T2DM and CHD, but here, the focus is on results for men.

Method

Recruitment and Data Collection

Following ethics approval at the participating institu- tions, 16 men were purposively recruited during the first 3 months of a CR program for variation in age, partner status, and socioeconomic position. Participants were screened through two CR programs in Toronto, Canada. One program was offered through an urban hospital- based outpatient service and the other in a suburban com- munity-based rehabilitation center. CR providers notified eligible participants of the study during rehabilitation ori- entation sessions. Those indicating interest were given a study informational package. Men were excluded if they were managing their T2DM with diet only and could not speak English. Following the provision of written informed consent, participants met interviewers in their home or the rehabilitation center. To protect the anonym- ity and confidentiality of participants, pseudonyms were assigned by the study team.

Two in-depth, semi-structured interviews were con- ducted about 4 weeks apart for a total of 32 interviews. The first interview obtained biographical details includ- ing the development of diabetes, CHD, and the circum- stances that prompted a CR referral. The second interview was conducted by the same interviewer and focused on the daily activities of blending a CR prescription with T2DM self-care. This was facilitated through the review of a 1-week activity journal kept by each participant

(Lapum, Angus, Peter, & Watt-Watson, 2011). To assist analysis of gender as a dimension of health behavior, par- ticipants were asked to expand on changes they found problematic. Here, questioning attended to the mainte- nance or disruption of reciprocal social activities (includ- ing intimate partnerships and employment) that comprise gendered connections and competencies (Danemark, Ekstrom, Jacobsen, & Karlsson, 1997).

Data Analysis

Interviews were transcribed verbatim and reviewed by the core research team (C.M.D., J.A., L.S.N., M.K.K., C.P.) in an iterative fashion. Initially, the analysis fol- lowed the tenets of ethnography (Atkinson & Hammersley, 2007) in obtaining men’s accounts in their own terms. In the search for an explanatory understanding of individual differences (Danemark et al., 1997), we used abductive reasoning, which involves moving from individual accounts or events to determine how they are part of more general contexts or structures; it seeks deeper and more developed interpretations through use of theories (Danemark et al., 1997). We followed qualitative analysis procedures to organize the data and reflexively explore the interviews. Memos were generated following each reading and circulated for discussion. Through a consen- sus process, men’s accounts were coded using qualitative software (QSR NVivo 7) and discussed extensively to refine emerging interpretations (Richards, 2005). To this end, we identified various typologies of experience (Atkinson & Hammersley, 2007) among male partici- pants, and began to compare their key contextual differ- ences using the lens provided by the above theories of masculinity and gender.

As we moved between theory and data, we also used an approach called retroductive analysis. Here, we con- ceptualized underlying conditions that contribute to par- ticipants’ divergent accounts. We used two strategies as outlined by Danemark and colleagues (1997) to think ret- roductively. First, extreme case analysis involved exam- ining instances that either fully exemplified or deeply challenged our emerging understandings. Second, com- parative analysis involved seeking out differences in the circumstances of participants, especially those grouped within the same typology. Both strategies enabled us to understand the range of masculinities and tendencies that emerge from various social, economic, and material contexts.

Participant Characteristics

The average age of male participants was 66 (range 53–79) and more than 50% were retired from employ- ment. More than half were born outside Canada, in

Dale et al. 1651

congruence with the culturally diverse metropolitan setting of the study. More than 60% had been living with T2DM for more than 10 years and were taking oral diabetic medication alone or in combination with injectable insulin (see Table 1 for demographic charac- teristics). The numbers of self-identified diabetic- related concerns that the men were managing in addition to CHD varied; erectile dysfunction and peripheral neu- ropathic pain were the most frequently mentioned (see Supplemental Table 1, available online at qhr.sagepub. com/supplemental).

Results

Here, we present the results according to the temporal flow of men’s interviews. In the first section, men’s accounts suggest a longstanding tactic of positional main- tenance, whereby personal priorities precluded attention

to a pre-diabetes designation. The silent and ambiguous nature of diabetes interacted with gendered occupational and domestic arrangements to inhibit new health behav- iors. With the development of overt T2DM and CHD symptoms, men described eroding control over mascu- line positions as medical diagnoses assigned new priori- ties. The second and third sections highlight early uncertainties in a CR program where men’s accounts diverged into described strategies of “push back” against medical intrusion or “working with the experts” to more advantageously reposition themselves in illness. Whereas all men defined a project of rehabilitating masculinity, age, gender, and employment conditions contributed to their varied paths toward cardiac rehabilitation.

Maintaining Position

As in other studies (Schwalbe & Wolkomir, 2002), men situated themselves in their first of two interviews by describing important career and personal accomplish- ments. Contemporaneous to these pursuits, they described how a T2DM + CHD complex quietly eroded bodily function. Characteristic of this period was prioritization of personal interests and tastes:

I have to be honest and say that I have not paid as much attention to the diabetic issues as I should have, starting from you know, when my doctor got blood work back on a physical exam. He had told me the previous year, he’d said, “you know, you are on the verge of becoming diabetic.” He said, “You are going to have to do something about it.” One thing that I used to do, I used to drink a lot of pop—not sugar free pop but the regular, sugary, dirty pop. (retired)

Similarly, another man interpreted early medical coun- sel “as a joke; it’s human nature because you don’t have any feeling. You don’t have a headache you know or something that hurts” (retired).

Across multiple accounts, the ambiguous nature of early diabetes precluded preventative health practices. The preservation of social and economic positions, even in the face of serious illness, was evident when one man described the first of three heart attacks:

It was a Saturday night and it started about 5:30, the [restaurant] was packed. I know I’m having a heart attack but I gotta get through this or this restaurant’s going to be a mess, so I went back out and I made it until nine o’clock and then I walked over to the hospital. (employed)

A strategy of masculine positional maintenance, rela- tive to others, was also evident in the account of another participant who had a successful professional career. The manner in which he literally and figuratively positioned himself was deliberate:

Table 1. Demographic Characteristics of T2DM Men in CR.

Characteristics n (%)

Age (years), M (range) 66.3 (53–79) Born in Canada 7 (43.7) Number of self-reported co-morbidities,

M (range) 3 (1–6)

Hospitalization in last 12 months 11 (68.75) Years formally diagnosed with T2DM <10 years 6 (37.5) 10–15 years 3 (18.75) >15 years 7 (43.75) Prior diabetic education 12 (75) Self-identified CR goals Diet 16 (100) Exercise 14 (81) Smoking cessation 6 (37.5) Medication reduction 3 (18.75) Stress management 2 (12.5) Marital status Married/partnered 14 (81) Divorced 1 (6.25) Widower 1 (6.25) Employment status Retired 9 (56.25) Employed 5 (31.25) Seeking employment 2 (12.5) Household income <20,000 3 (18.75) 20,000–40,000 3 (18.75) 40,000–60,000 2 (12.5) 60,000–80,000 3 (18.75) 80,000–100,000 1 (6.25) >100,000 4 (25)

Note. T2DM = Type 2 diabetes mellitus; CR = cardiac rehabilitation.

1652 Qualitative Health Research 25(12)

You keep them down a little bit. When I had, when I was learning my business, I had a higher chair and your chair was low, so when I negotiated, I was always looking down at that guy and I had the edge. (retired)

In this circumstance, masculine rivalry afforded ben- efit and risk. One man explained this circumstance as the mechanism behind his diabetes. In his case, a particularly caustic relationship with a manager coincided with changes in his health. The gendered nature of masculine competition comes through his description of their differences:

I guess he’s the one that made me become diabetic. [He] didn’t have a college degree, and he didn’t like people with college degrees. . . . The guy, you couldn’t speak to him technically, he had these ideas, the wrong ideas. (retired)

In these accounts, an evaluation of the past locates ill- ness antecedents in occupational relations and contexts. A level of entrenchment emerged as men described defen- sive positions in response to expertise, status, or security threats. Retired participants were particularly clear in noting how occupational arrangements advanced serious illness.

Health ambiguities. Men explained that they believed their early inattention to a diagnosis of T2DM resulted in significant disease and this contributed to a sense of moral inadequacy. One retired man summed this up when he said he needed CR to “correct me [because] I screwed my heart”; yet, men also suggested the dangers of T2DM were initially indefinite. Past assignment of a borderline or pre-diabetic diagnosis was described as a mistaken reprieve from health behavior change:

I kept on doing the stupid things that I was doing before. But they’ll warn you—one thing that I wish I should’ve done. I should’ve learned, I should’ve educated myself about everything. I should—like I’m doing lately now. Like that, that problem with the kidneys. If I’d known that blood pressure and high sugar would kill the kidneys, I would have stopped this a long time ago. (employed)

Here, a pre-diabetes label created a liminal position that made it difficult for men to situate themselves as healthy or chronically ill. A retired participant further explained, “all the damage was done then. I am only finding this out now.” Informational sessions provided in CR prompted men to reinterpret earlier inactions as spectacular mis- reading of the body:

I felt a tingly . . . pins and needle sensation in my chest and it kind of spread down my arm [but] that’s all it was . . . then I went to sleep. (retired)

A developing awareness of bodily messages was described as a gradual journey. One retired man said he had only become “conscious [of my body over] the last four, five years. Before I was not.” As diabetes evolved from silence to debilitating CHD symptoms, a state of reprieve had ended. This realization occurred for some when breathlessness made normal activities a challenge. For another participant, these bodily messages empha- sized past indiscretions:

It became worse by taking that donut and smoking, coffee, all that. I think so. I don’t know if there were other reasons, maybe, but diabetes yes. I didn’t do this type of [blood glucose] checking. I didn’t monitor my blood sugar. (retired)

In following a similar realization, another retired man used his newly found free time to “control my diet, doing exercise as I should have done it a long time ago.”

Domestic situations. Domestic skills and reciprocally arranged gender divisions of activity were important influences in disease development and rehabilitation efforts. Diabetic education repositioned, as destructive time, the years in which the body was improperly main- tained. For many, this meant healthy food was not judi- ciously selected or consumed. However, the complex implications of proposed lifestyle change presented in CR were not lost on one single father with a school-aged child at home. His awareness that spouses confer benefit was emphasized by a memory of his mother attending to his diabetic father. In reference to his father’s diabetes management, he said, “my dad was perfect, my mother made him perfect.” This resource gap in his present life backgrounded his statement that dietary change was a complex social project. Feeling overwhelmed with his own lack of support, he described difficulty in sustaining a new dietary regimen:

If I had a partner that was in [CR] with me, loved me enough that she took it to heart and did the shopping and the whatever, I would come home and I would start . . . I would probably not cheat [on my diet]. (employed)

Men were directed to alter their dietary habits, but simul- taneous pressures to maintain gender practices and com- petencies threatened to undermine these changes.

The skills of judicious food selection and preparation, both highly valued components of a new repertoire of health work practices, were in many (but not all) cases part of a distinct gendered division of household labor. Food was acknowledged as the domain of women where “the better gender has control” over the kitchen. In sequence, one man’s reliance on his wife generated an impasse when he could not negotiate a compromise on

Dale et al. 1653

the content of the family diet. The perpetuation of old tastes and routines made his CR prescription difficult to sustain:

I have a cardiovascular problem and food is the worst thing that ever happened . . . and for me it’s hard to control the food. Food, food is a problem, big problem. (employed)

This man’s wife was the principal cook in the home. Her preferences for pasta, bread, and meat generated marital tension because their meals lacked the ingredients and portions deemed healthy, despite her co-attendance at diabetes education sessions. In contrast, two other men explained how their atypical culinary expertise was a response to their partner’s gendered deficits. For exam- ple, one employed man stated that his wife was “spoiled” because she had never learned to cook. Similarly, a retired participant noted how his wife could not “find the kitchen.” In all of these cases, the kitchen was contested terrain and not a customary site of “doing masculinity,” but one where the men compensated for their wives’ shortcomings.

With the above narratives in mind, the evident benefits of partnership in domestic health work illuminated sensi- tive aspects of men’s relationships. Activating the advice received in CR involved interpersonal work of knowl- edge transfer and a renegotiation of domestic routines. However, those without direct involvement in domestic cooking activities were at a disadvantage. Although some men recalled receipt of diabetic dietary instruction years or decades prior, this information did not shift into action until a significant health crisis ensued. In a contemplative statement, one widower explained that his project of dietary correction in CR required reevaluation of his domestic skills:

Well, I don’t know how to cook. . . . I don’t know what’s going to happen. (retired)

Like others, this man’s lack of nutritional competencies became apparent through a detailed account of his mar- riage. Biographically, his wife held sole responsibility for food preparation in the kitchen. However, her death left him without the knowledge and skill to fend for himself. To follow CR recommendations, he went to significant effort and expense to buy prepared food that would meet his dietary goals.

In summary, men’s biographical self-positioning dur- ing the initial interviews indicated that occupational cir- cumstances and hetero-normative gender activities pre-conditioned their inattention to a preliminary diagno- sis of T2DM. Anecdotes pertaining to men’s middle years highlighted the economic imperatives and social value linked with breadwinning. Maintaining employment was

prioritized over medical directives to control T2DM. The subsequent development of serious CHD and ensuing CR referral imposed new health imperatives and a moral mal- position. As an example, one retired man declared, “[Diabetes] is the disease of lazy and idle people.” This message underscored the problem of prior inaction. However, it also proposed a problem of double jeopardy. Employment was a route to masculine independence. However, it could also promote lifestyle-related illness and a subsequent dependence on others. The following sections describe the two divergent approaches men took up to contend with this problem.

Push Back

In the weeks between the first and second interviews, men became more familiar with the principles of CR in addition to the gradual intensification of their exercise prescriptions, most commonly through enhanced walking and resistance training. However, this did not easily translate in all circumstances. Men described a lack of certainty about their ability to meet these evolving reha- bilitation targets. In response, two active positions of resistance came forth. The first position found men, regardless of their age and unemployment circumstances, addressing the early uncertainties of a new health regime via negative epithets and self-recrimination. The second position, occupied by men whose employment involved physical effort (superintendent, chef, nurse), was charac- terized by a tactic of “push back,” that is, discredit of health professionals, time demands, and diagnostic labels that comprise CR.

Early uncertainties. Both working and retired men used some degree of self-recrimination to suggest they were “lazy,” “useless,” or disorganized on initiation of their exercise prescription. The frustration encountered in the first few weeks of rehabilitation prompted one retired man to say, “I’m no Superman for crying out loud, I mean, I must be human.” Although participants were busy attending rehabilitation sessions, managing medica- tions and blood glucose levels in addition to myriad other medical appointments, some engaged in negative self- assessment. One man illustrated this position by sharing the internalized lecture he was giving to himself:

I mean, I’m 53 going on 12. . . . I’m a child when it comes to it. I’m the typical teenager that would much rather party than study kind of thing . . . instead of standing up, being a man and say “get your shit together,” which is what I should do but I’m not willing to. (employed)

One component of the preceding self-assessment is a masculine fear of appearing incompetent in adopting new

1654 Qualitative Health Research 25(12)

health behaviors. Other men suggested that the initial frustrations and failures in CR were best ignored. However, one employed man expressed a problem of overlapping and conflicting demands when he stated, “I don’t have the time, that’s my problem.” Given conflict- ing pressures of work, family, and CR, a perception of time constraint became overwhelming for some men.

Resisting labels. Reconstructing a positive masculine identity became an active tactic in response to the above pressures. Some men chose to reposition themselves by generating a sense of distance from the losses associated with disease. Because years of inaction had led to serious illness, one retired man shared, “I don’t want anyone to know.” The injurious nature of disease labels linked up with the concept of poor self-control where one clinician informed a few participants, “when you’re diabetic you’re like an alcoholic.” Embarrassment over the control of his diabetes required another man to take leave from his pro- gram following a hypoglycemia-related fall on the walk- ing track:

A couple of people grabbed me because they thought I was going down and I felt worthless. I totally felt useless. I didn’t have much to eat that day which was my fault. My energy wasn’t there. I just . . . too much was on my mind. I took the following week off. (under-employed)

Resisting negative labels and associations with disease was also demonstrated by men working in physically tax- ing jobs, who sought to differentiate themselves from older, retired men encountered in the CR center. One man verbalized his anxiety about messages emanating from aging male bodies:

I think I went [to the CR exercise clinic] once. They’re 80 and I’m 50 and I’ve got the same problem. I didn’t last long doing it. (employed)

Being concurrently stripped of health, economic produc- tivity, and youth proposed an erosion of masculinity. Powerful losses reflected on aging male bodies spoke to younger men of a masculine crisis and a jarring disloca- tion from a positive self-image. This was manifested in an inclination to walk away from devalued or disturbing labels and spaces.

Rather than experiencing a moral loss for poor physi- cal performance, some men discursively shaped the interview as an opportunity to reverse the focus of defi- ciency to implicate CR programming in general and car- diovascular clinicians in particular. They turned the tables by positioning biomedical care providers as cul- prits; clinicians were portrayed as offering inadequate

time, information, and solutions. As one example, the imposition of attending supervised exercise sessions at only those times designated by the CR center opened a space for resistance:

I walk a huge 90,000 square foot building [at work], walking around [and] around. “Oh, that’s not good enough, you’ve got to go to your walking exercises.” I’m panting, huffing and puffing [at work]. I’m not an 80 year-old who sits on the bench at home and rocks the chair and watches TV. (employed)

Other men felt the need to resist medical authority in response to perceived suboptimal health information. One retired man felt he was frequently “run out the door” by his general practitioner (GP) when seeking answers to diabetes-related erectile dysfunction. Because options were not accessible, he undertook what he described as an epic struggle with medical specialists to find solutions. He stated that he was subsequently “teaching” his GP about erectile dysfunction treatment. Understandably, this reversal of expertise in diabetic men’s health might help equalize a moral imbalance when one is labeled dis- eased. Another participant with mobility issues exempli- fied this when he said,

You want me to do this? You better get my legs fixed, okay? I can’t go out and do this on my own. You guys are the professionals here and if you want me to complete this program to your satisfaction then you’ve got to help me get my legs fixed. (retired)

Whereas a strategy of “push-back” might place clini- cians as the final arbiters of success, they might also be portrayed as failures if their clients are not well served. For example, several men reported uncontrolled pain as a limiting factor in CR. One participant explained,

When your GP does not believe that you’re having pain? I can’t do the program she wants me to do. She wanted me to start with half an hour, increasing my increments. I’m going back on May 20th. I’m supposed to keep a chart. You know I walk from here to A. Street and back if I have to do some shopping, stop off at the mall, and that’s the extent. I try to go to B. Street; I can’t. I’d be dragging ass and, you know, why put myself through that? (employed)

In this strategy, clinicians were not perceived as suffi- ciently responsive to the comorbid conditions that influ- ence CR performance. Men with immigrant backgrounds and middle class economic status more frequently sought out complementary and alternative medicines to reduce symptoms of pain. However, men such as the one noted above were left without recourse.

Dale et al. 1655

Uninhabitable positions. Men with severe musculoskel- etal or peripheral neuropathic pain faced particular exposures in the rehabilitation setting and these created an impossible position in the early CR period. For example, they described the embarrassment of being passed on the walking track because of a slow gait or diabetes-related foot pain. They were also required to document their slow pace and progress on weekly report forms. This prompted one man to opt out of this practice:

You know, and without getting into writing down details about every bloody step I take and I have no intention of getting involved in that, okay? (retired)

In the above case, this man found it preferable to have bodily performance metrics such as heart rate, blood glucose, and walking speed and distance recorded by experts who are “paid” to do so. However, such resis- tance might pose a barrier for CR teaching where fre- quent self-monitoring is used as potent experiential learning. When he sat down with his GP to learn to use a glucometer, he suspected the physician did not “know any more about this thing” than he did. His decision not to learn this skill was somehow reinforced by his per- ception of the GP’s inability to provide expert instruc- tion. This strategic repositioning served some men as a rationale for inaction.

In summary, men who found CR uninhabitable described strategies of selective or full non-participation in CR, allowing a more personally satisfying reinvest- ment of time in familiar social positions and routines. In this instance, pushing back might reestablish a sense of positive masculine identity by countering the expertise of CR professionals. Taking matters into their own hands meant self-adjustment of prescription drug dosages or adding alternative therapies to control symptoms of co- morbidity. Men’s concerns of insufficient time and reso- lution of medical problems revealed a disjuncture between lay and professional realities. Men who admitted irregular attendance or even intentions of dropping out also described negative self-appraisals and moral judg- ments of others, particularly the ageist views of other men encountered in the CR center.

Working With the Experts

In contrast to a small group of participants (<20%) who dropped out of their programs within the 1- to 2-month window of their participation in the study, remaining men praised the special attributes of the CR model and its cli- nicians. The personal and recurring attentiveness offered in CR was favorably contrasted to other care settings such as the GP’s office.

One retired man exclaimed that the personalized attention he received from CR clinicians changed his life. He stated that their position “in the forefront” of cardiovascular health offered him an advantage. Whereas this man might be subject to lost moral position because he was returning to CR a third time, his narrative accom- plishment was in positioning himself as “working with the experts.” He acknowledged that there is always new information and progressive treatment to which he wanted access. Thus, like other men, he favorably repre- sented himself as a wise consumer. Men taking up this stance were typically retired and married to highly sup- portive spouses. During the first few weeks of CR, accu- mulation and review of health information required one retired man to establish his own “mini-office.” Others similarly benefited from previous employment-related organizational abilities as they tackled changes sug- gested by an extended network of experts. This reliance on familiar skills generated a sense of competency and order in illness.

Being in a good place. The need to negotiate resources for most retired and married men was minimal. Partners and family monitored their progress, made meals, and accompanied them to medical appointments, although one retired man suggested, “I don’t ask for it.” Given this baseline support, the addition of CR professionals served as an extended network of personalized attention and an encouraging witness to rehabilitation efforts. For example, another retired man warmly recalled being congratulated on his “first mile” on the walking track. This highly interactive process suggested a sensitive approach to exercise training. In contrast to the hyper- masculinities that mark public exercise, one man found clinicians responded sensitively to his evolving performance:

No, it’s impossible [for them] to be [aggressive], with, you know, like I was saying before they’re professional people. They make you comfortable, they make you relax . . . very smart talk and gentle talk and it’s good. (retired)

Nevertheless, men who enjoyed a spirited sense of competition also found supervised exercise sessions ful- filled their needs. In describing this experience, one retired man explained how his competitive side ener- gized his CR goals, “I like a challenge; I like to try and beat people.” Passing other men on the walking track diminished his concerns about retirement and “slowing down.” The performative aspect of exercise was moti- vating and offered a sense of continuity with his past sporting identity, although it also verified other men’s descriptions of the humiliations of being bested by other men at CR.

1656 Qualitative Health Research 25(12)

Discussion

Attention to the early CR experiences of men with T2DM and CHD illuminates how problematic health improvement can be in spite of a life threatening diag- nosis. Through a focus on masculinity, this study identi- fied men’s diverse and sometimes contradictory responses to medical expertise in the first few weeks of a CR program. In acknowledging the multiplicity of men’s struggles, the findings unsettle essentialist notions of men as one homogenous group (Schofield et al., 2000). Moreover, findings contribute to an emerging understanding of how masculinity intersects with other social determinants of health (Dolan, 2011). Realist- informed analytic methods provided a strong basis to analyze everyday social and gender-related mechanisms in health improvement that are frequently obscured behind binary sex-based comparison (Pritlove et al., 2014). The realist approaches used here direct attention to the baseline resources necessary for men to be suc- cessful in chronic disease management.

We have identified how health disparities among T2DM men become active and visible when a critical health event manifests. Similar to other studies, men relayed how debil- itating outcomes of T2DM become clear retrospectively (Liburd et al., 2007). This suggests that age, employment status, and gender relations have a significant impact on men’s capacities to attend to matters of health. Masculine tendencies, such as a work orientation, might lead to delays in young or middle-aged men accessing support and incor- porating recommended health behaviors. Working and under-employed men with a T2DM + CHD complex might experience a type of double jeopardy as suboptimal uptake of expert health recommendations might eventually lead to the erosion of health and social position.

Williams (2003) argues that employment is a potent determinant of health. In this instance, the centrality of work to men’s health and well-being is complex. Individuals are necessarily drawn into the economy for survival. However, men often engage in high-risk (e.g., fireman) and status-oriented (e.g., chief executive offi- cer) positions. Whereas these occupations offer exem- plary masculine dividends (Courtenay, 2000), they also confer biological and psychosocial exposures that exac- erbate CHD (Price, 2004). Working weeks of 50 hours or more are now common (Kuhn & Lozano, 2008). Given that longer work hours nearly double the risk of CHD for men (Virtanen et al., 2012), CR participation might be advantageous. However, CR demands substantial addi- tional time and other resources to plan, travel to, and par- ticipate in prescriptive activities such as supervised exercise, educational lectures, and individual counseling. The intensifying demands of male employment might significantly impede a CR prescription.

With the above in mind, retired men might be opti- mally situated to benefit from CR. Masculinity is indeed affirmed because these older men have adequate time and other resources to attend rehabilitation and adapt health recommendations to their immediate context. Similar to other studies, this includes men who are partnered (Molloy, Hamer, Randall, & Chida, 2008) or have limited occupational conflicts (Marzolini, Brooks, & Oh, 2008). Their interpretation of CR programming might be gen- dered inasmuch as it supported rather than undermined masculine identity. The meanings of aging and retirement have received limited attention in health research (Evans et al., 2011). Lack of inquiry into the experiences of aging men (Fleming, 1999) might obscure mechanisms behind their successes in CR. Isolation accompanying aging might be mitigated by new social networks offered by rehabilitation programming. Furthermore, highly speci- fied goals for improved health might reconnect men to hegemonic masculine ideals of physical strength and competitiveness (Oliffe, 2006). These collective benefits might also contribute to older men’s resolve to adopt new health behaviors.

Consideration of men’s diverse responses to diabetes (Canadian Diabetes Association, 2013) and CR (Canadian Association of Cardiac Rehabilitation, 2009) policy is important because benefit is linked to successful adoption of lifestyle modifications (Alter, Oh, & Chong, 2009). Our findings align with other research acknowledging that the vast majority of chronic care occurs outside the clinic (Newbould, Taylor, & Bury, 2006). To be success- ful, individuals must hold basic competencies in techni- cal (e.g., nutrition) and interpersonal (e.g., social support) skills (Kelly, 2010). Because these resources might be culturally associated with feminine and domestic capital (Courtenay, 2000), it is suggested that health mastery might pose a gender conflict for some men with T2DM (Liburd et al., 2007).

Enacting new health behaviors in CR, such as dietary improvement, might shift men in a more androgynous direction (Connell & Messerschmidt, 2005). This means that novel effort in self-care management might be expe- rienced as an impairment of gender position because it encourages men to pay attention to domestic routines and skills deemed feminine. In contrast, placing occupational demands ahead of all other practices might be a tendency through which masculinity typically flows (Mahalik et al., 2007; Oliffe et al., 2013). The social implications of these countervailing imperatives might incite gender identity conflict. Undoing past health behaviors means undoing some dimension of gendered selfhood. The acti- vation of new behaviors, including dietary change, requires a shift in activity, but also identity. Early and troubling responses to CR by working and under- employed men suggest gender conflict might lead to

Dale et al. 1657

suboptimal lifestyle modification and program attrition (Marzolini et al., 2008).

Findings presented here also extend other research- ers’ assertions that the socially active nature of medical information is underestimated (Getz, Kirkengen, Hetlevik, Romundstad, & Sigurdsson, 2004). For some men, medical labels and health teachings interact with socioeconomic and gendered factors to generate a vari- ety of discursive strategies. Tactics of “push back” and “working with the experts” highlight the importance of men’s positional maintenance as well as the predica- ments encountered when masculine competency is threatened. By reevaluating past routines and priorities as contributors to disease, CR teachings might incite identity dilemmas and undermine masculine comport- ment (Charmaz, 1994). In response, men may literally and metaphorically walk away from the encroachment of medical knowledge to reestablish a sense of normalcy in customary practices.

As it pertains to medical labels, participants in this study indicate the language of biomedicine poses an impediment to early health change. Accommodation of a T2DM diagnosis can take years or decades because of the disease’s insidious nature alongside busy adult working lives. This means that proactive risk modification is not always inspired by an initial medical assignment to a pre- diabetic or borderline status. Ironically, these labels do not invite men to take an active position. Where food is often seen as the domain and skill of women, men are late to understand their disadvantage. In response to these issues, the initiation of new health behaviors might be delayed until a major health crisis occurs. In light of these findings, the use of pre-diabetic labels warrants reconsid- eration in clinical practice.

In the first few weeks of a CR program, diabetic male participants asserted variable interest and capacities for exercise. In this instance, exercise-based CR program- ming might circumvent certain men’s concerns. With this point in mind, some employed men bypassed CR altogether as a route to rehabilitated masculinity. Similarly, differently abled men opted out of negative performance exposures in CR exercise. Finally, some men were returning to CR for a second or third encoun- ter. In all of these instances, T2DM men resumed old positions and routines that essentially reexposed them to the antecedents of illness. These events underscore the intense and enduring struggle to integrate recommended lifestyle modifications. Furthermore, these events unsettle the notion of individual health “choice.” The complex socioeconomic and relational struggles implicit in men’s accounts encourage consideration of the resources and competencies supporting successful rehabilitation.

The findings presented here might be helpful for health providers and policy-makers in identifying tar- gets for innovation (Figure 1). Current policy recom- mendations encompass higher rates of CR referral (Grace et al., 2011). However, the drive for greater pro- gram throughput might overstep the gendered “self” in chronic disease management (Thirsk & Clark, 2014). Adapting programs for those newly diagnosed with T2DM would begin to address men’s insights into the late activation of new health behaviors. Establishing a sense of “working with the experts” for solutions and skills could be enhanced through educational topics addressing men’s stated priorities, including chronic pain, nutritional proficiencies, and sexual health. Innovative educational modules and distance-learning methods might respond to identified time pressures and the desire for episodic support.

Although this analysis represents the struggles of a diverse group of Canadian diabetic men with CHD, the findings might not be generalizable to other CR partici- pants or settings. Limitations include insufficient num- bers of men who were unpartnered, widowers, and gay. The use of critical realist and qualitative approaches might also direct the focus away from psychological or affective issues such as anxiety and depression associated with diabetes and CHD. However, these issues were not the focus of this study. Strengths include good representa- tion of typical age groups in CR, including men older than 75 years of age. Future CR research might focus comparatively on a variety of health determinants among men of different ages including gender (stigma associated with aging bodies), relational status (degrees of isolation and support), and socioeconomic position (working ver- sus retired adults).

Conclusion

Health and gender are everyday social accomplish- ments. Masculinity and gender theory offer an intersec- tional view to very real and influential mechanisms in men’s uptake of expert health advice. The social and material circumstances that perhaps contribute to a T2DM + CHD complex, such as the demands of employment, might be the context for men’s health modification efforts. Accordingly, the resources and competencies men require in self-care will vary along- side age, occupation, and relational status. Efforts to proactively identify individuals experiencing rehabili- tation challenges might offer the opportunity to target novel approaches. Helping men attain a greater sense of self-efficacy and success might act to reduce the bur- dens of retained health risks, including recurrent illness and death.

1658 Qualitative Health Research 25(12)

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported by a grant from the Canadian Institutes of Health Research (CIHR) Grant IGO-86110.

References

Addis, M. E., Mahalik, J. R., & Mansfield, A. K. (2003). “Why won’t he go to the doctor?”: The psychology of men’s help

seeking. International Journal of Men’s Health, 2, 93–109. doi:10.3149/jmh.0202.93

Alter, D. A., Oh, P. I., & Chong, A. (2009). Relationship between cardiac rehabilitation and survival after acute cardiac hospi- talization within a universal health care system. European Journal of Cardiovascular Prevention & Rehabilitation, 16, 102–113. doi:10.1097/HJR.0b013e328325d662

Angus, J. E., & Clark, A. M. (2012). Using critical realism in nurs- ing and health research: Promise and challenges. Nursing Inquiry, 19, 1–3. doi:10.1111/j.1440-1800.2011.00580.x

Atkinson, P., & Hammersley, M. (2007). Ethnography: Principles in practice (3rd ed). London, England: Routledge.

Audulv, Å., Asplund, K., & Norbergh, K. (2012). The integra- tion of chronic illness self-management. Qualitative Health Research, 22, 332–345. doi:10.1177/1049732311430497

CHD = coronary heart disease CR = cardiac rehabilitation SES = socioeconomic status T2DM = type 2 diabetes mellitus

Men Pushing Back Against the Experts

Diabetics withdraw from CR at a higher rate than non- diabetics

Gender Conflict Time constraints Negative clinician appraisal Undesirable labels Inhibiting performance

Age ≤ 65 years Gender/Masculinity Musculoskeletal limits Pain intolerance Limited dietary skill SES Employment age Manual labour Divorced/Widower/ Dependents

Men Working With the Experts

Diabetics withdraw from CR at a higher rate than non- diabetics

Gender Alignment Time control Positive clinician appraisal Scientific utility Competitive goals

Age ≥ 65 years Gender/Masculinity Past sporting roles Pain tolerance Dietary support (spouse) SES

Retired

Professional

Partnered

CR Policy and Practice Recommendations

Current Policy Increase referral rates for hospitalized patients to CR (Grace et al., 2011)

Suggested Policy Target adults newly diagnosed with T2DM to abate CHD development

Suggested Practices Address age-relevant health impediments

Facilitate physical (pain), interpersonal (support) and technical (food skill) self-management

Expand access through distance (e- learning) and episodic refresher modules

Empirical Theory

free data

Actual Participant accounts

Real Generative mechanisms

Diabetics withdraw from CR at a higher rate than non-diabetics (Banzer et al., 2004)

Figure 1. Summary findings and recommendations for CR policy and practice. Note. CR = Cardiac rehabilitation.

Dale et al. 1659

Banzer, J. A., Maguire, T. E., Kennedy, C. M., O’Malley, C. J., & Balady, G. J. (2004). Results of cardiac rehabilita- tion in patients with diabetes mellitus. American Journal of Cardiology, 93, 81–84. doi:10.1016/j.amjcard.2003.09.017

Cameron, E., & Bernardes, J. (1998). Gender and disadvantage in health: Men’s health for a change. Sociology of Health & Illness, 20, 673–693. doi:10.1111/1467-9566.t01-1-00124

Canadian Association of Cardiac Rehabilitation. (2009). Canadian guidelines for cardiac rehabilitation and cardio- vascular disease prevention: Translating knowledge into action (3rd ed.). Winnipeg, Manitoba: Author.

Canadian Diabetes Association. (2013). Canadian diabetes association 2013 clinical practice guidelines for the pre- vention and management of diabetes in Canada. Toronto: Author.

Charmaz, K. (1994). Identity dilemmas of chronically ill men. The Sociological Quarterly, 35, 269–288. doi:10.1111/j.1533-8525.1994.tb00410.x

Charteris-Black, J., & Seale, C. (2010). Gender and the lan- guage of illness. New York: Palgrave Macmillan.

Clark, A. M., King-Shier, K. M., Thompson, D. R., Spaling, M. A., Duncan, A. S., Stone, J. A., . . . Angus, J. E. (2012). A qualitative systematic review of influences on atten- dance at cardiac rehabilitation programs after referral. American Heart Journal, 164, 835–845.e2. doi:10.1016/j. ahj.2012.08.020

Clark, A. M., Lissel, S. L., & Davis, C. (2008). Complex critical realism: Tenets and application in nursing research. Advances in Nursing Science, 31(4), E67–E79. doi:10.1097/01.ANS.0000341421.34457.2a

Coles, T. (2008). Finding space in the field of masculinity: Lived experiences of men’s masculinities. Journal of Sociology, 44, 233–248. doi:10.1177/1440783308092882

Connell, R. W. (1995). Masculinities. Berkeley: University of California Press.

Connell, R. W., & Messerschmidt, J. (2005). Hegemonic mas- culinity: Rethinking the concept. Gender & Society, 19, 829–859. doi:10.1177/0891243205278639

Courtenay, W. H. (2000). Engendering health: A social con- structionist examination of men’s health beliefs and behaviors. Psychology of Men & Masculinity, 1, 4–15. doi:10.1037/1524-9220.1.1.4

Danemark, B., Ekstrom, M., Jacobsen, L., & Karlsson, J. C. (1997). Explaining society: Critical realism in the social sciences. New York: Routledge.

Deaton, C., Kimble, L. P., Veledar, E., Hartigan, P., Boden, W. E., O’Rourke, R. A., & Weintraub, W. S. (2006). The synergistic effect of heart disease and diabetes on self- management, symptoms, and health status. Heart & Lung: The Journal of Acute and Critical Care, 35, 315–323. doi:10.1016/j.hrtlng.2006.05.005

Dolan, A. (2011). “You can’t ask for a Dubonnet and lem- onade!”: Working class masculinity and men’s health practices. Sociology of Health & Illness, 33, 586–601. doi:10.1111/j.1467-9566.2010.01300.x

Drummond, M. J. N. (2003). Retired men, retired bod- ies. International Journal of Men’s Health, 2, 183–199. doi:10.3149/jmh.0203.183

Egede, L. E., & Zheng, D. (2002). Modifiable cardiovascular risk factors in adults with diabetes: Prevalence and missed opportunities for physician counseling. Archives of Internal Medicine, 162, 427–433. doi:10.1001/archinte.162.4.427

Emslie, C. (2005). Women, men, and coronary heart dis- ease: A review of the qualitative literature. Journal of Advanced Nursing, 51, 382–395. doi:10.1111/j.1365- 2648.2005.03509.x

Emslie, C., Hunt, K., & Watt, G. (2001). Invisible women? The importance of gender in lay beliefs about heart problems. Sociology of Health & Illness, 23, 203–233. doi:10.1111/1467-9566.00248

Evans, J., Frank, B., Oliffe, J. L., & Gregory, D. (2011). Health, illness, men, and masculinities (HIMM): A theoretical framework for understanding men and their health. Journal of Men’s Health, 8, 7–15. doi:10.1016/j. jomh.2010.09.227

Fenstermaker, S., & West, C. (Eds.). (2002). Doing gender, doing difference: Inequality, power, and institutional change. New York: Routledge.

Fleming, A. A. (1999). Older men in contemporary discourses on ageing: Absent bodies and invisible lives. Nursing Inquiry, 6, 3–8. doi:10.1046/j.1440-1800.1999.00002.x

Galdas, P. M., Johnson, J. L., Percy, M. E., & Ratner, P. A. (2010). Help seeking for cardiac symptoms: Beyond the masculine–feminine binary. Social Science & Medicine, 71, 18–24. doi:10.1016/j.socscimed.2010.03.006

Gelb, K., Pederson, A., & Greaves, L. (2012). How have health promotion frameworks considered gender? Health Promotion International, 27, 445–452. doi:10.1093/ heapro/dar087

Getz, L., Kirkengen, A. L., Hetlevik, I., Romundstad, S., & Sigurdsson, J. A. (2004). Ethical dilemmas aris- ing from implementation of the European guidelines on cardiovascular disease prevention in clinical prac- tice. A descriptive epidemiological study. Scandinavian Journal of Primary Health Care, 22, 202–208. doi:10.1080/02813430410006693

Grace, S. L., Chessex, C., Arthur, H., Chan, S., Cyr, C., Dafoe, W., . . . Suskin, N. (2011). Systematizing inpatient refer- ral to cardiac rehabilitation 2010: Canadian Association of Cardiac Rehabilitation and Canadian Cardiovascular Society joint position paper endorsed by the Cardiac Care Network of Ontario. Canadian Journal of Cardiology, 27, 192–199. doi:10.1016/j.cjca.2010.12.007

Harris, S. B., Ekoe, J. M., Zdanowicz, Y., & Webster-Bogaert, S. (2005). Glycemic control and morbidity in the Canadian primary care setting (results of the diabetes in Canada eval- uation study). Diabetes Research and Clinical Practice, 70, 90–97. doi:10.1016/j.diabres.2005.03.024

Hart, G. J., Hunt, K., & O’Brien, R. (2007). “Standing out from the herd”: Men renegotiating masculinity in relation to their experience of illness. International Journal of Men’s Health, 6, 178–200. doi:10.3149/jmh.0603.178

Jowett, A., Peel, E., & Shaw, R. (2012). Sex and diabetes: A thematic analysis of gay and bisexual men’s accounts. Journal of Health Psychology, 17, 409–418. doi:10.1177/ 1359105311412838

1660 Qualitative Health Research 25(12)

Kelly, M. (2010). Chronic illness, labelling and stigma and pre-diabetes. Retrieved from https://www.nice.org.uk/ guidance/ph35/resources/ep-2-illness-labelling-and-ill- ness-experience2

Kerr, E. A., Heisler, M., Krein, S. L., Kabeto, M., Langa, K. M., Weir, D., & Piette, J. D. (2007). Beyond comorbidity counts: How do comorbidity type and severity influence diabetes patients’ treatment priorities and self-management? Journal of General Internal Medicine, 22, 1635–1640. doi:10.1007/ s11606-007-0313-2

Kotseva, K., Wood, D., De Backer, G., De Bacquer, D., Pyörälä, K., & Keil, U. (2009). Cardiovascular pre- vention guidelines in daily practice: A comparison of EUROASPIRE I, II, and III surveys in eight European countries. The Lancet, 373(9667), 929–940. doi:10.1016/ S0140-6736(09)60330-5

Kuhn, P., & Lozano, F. (2008). The expanding workweek? Understanding trends in long work hours among U.S. men, 1979–2006. Journal of Labor Economics, 26, 311–343. doi:10.1086/533618

Lapum, J., Angus, J. E., Peter, E., & Watt-Watson, J. (2011). Patients’ discharge experiences: Returning home after open-heart surgery. Heart & Lung: Journal of Acute and Critical Care, 40, 226–235. doi:10.1016/j. hrtlng.2010.01.001

Liburd, L. C., Namageyo-Funa, A., & Jack, L. (2007). Understanding “masculinity” and the challenges of managing type-2 diabetes among African-American men. Journal of the National Medical Association, 99, 550–552.

Mahalik, J. R., Burns, S. M., & Syzdek, M. (2007). Masculinity and perceived normative health behaviors as predictors of men’s health behaviors. Social Science & Medicine, 64, 2201–2209. doi:10.1016/j.socscimed.2007.02.035

Marzolini, S., Brooks, D., & Oh, P. I. (2008). Sex differences in completion of a 12-month cardiac rehabilitation pro- gramme: An analysis of 5922 women and men. European Journal of Cardiovascular Prevention & Rehabilitation, 15, 698–703. doi:10.1097/HJR.0b013e32830c1ce3

Molloy, G. J., Hamer, M., Randall, G., & Chida, Y. (2008). Marital status and cardiac rehabilitation attendance: A meta-analysis. European Journal of Cardiovascular Prevention & Rehabilitation, 15, 557–561. doi:10.1097/ HJR.0b013e3283063929

Newbould, J., Taylor, D., & Bury, M. (2006). Lay-led self- management in chronic illness: A review of the evidence. Chronic Illness, 2, 249–261. doi:10.1177/1742395306002 0040401

Newman, S., Steed, L., & Mulligan, K. (2004). Self-management interventions for chronic illness. The Lancet, 364(9444), 1523–1537. doi:10.1016/S0140-6736(04)17277-2

Nielsen, L. S., Angus, J. E., Lapum, J., Dale, C., Kramer-Kile, M., Abramson, B., . . . Clark, A. (2012). “I can’t just fol- low any particular textbook”: Immigrants in cardiac reha- bilitation. Journal of Advanced Nursing, 68, 2719–2729. doi:10.1111/j.1365-2648.2012.05975.x

O’Hara, L., Gough, B., Seymour-Smith, S., & Watts, S. (2013). “It’s not a disease, it’s a nuisance”: Controlling diabetes and achieving goals in the context of men with type 1 diabetes.

Psychology & Health, 28, 1227–1245. doi:10.1080/088704 46.2013.800516

Oliffe, J. (2006). Embodied masculinity and androgen depriva- tion therapy. Sociology of Health & Illness, 28, 410–432. doi:10.1111/j.1467-9566.2006.00499.x

Oliffe, J. (2009). Health behaviors, prostate cancer, and mascu- linities. Men and Masculinities, 11, 346–366. doi:10.1177/ 1097184X06298777

Oliffe, J., Rasmussen, B., Bottorff, J., Kelly, M., Galdas, P., Phinney, A., & Ogrodniczuk, J. S. (2013). Masculinities, work, and retirement among older men who experience depression. Qualitative Health Research, 23, 1626–1637. doi:10.1177/1049732313509408

Price, A. E. (2004). Heart disease and work. Heart, 90, 1077– 1084. doi:10.1136/hrt.2003.029298

Pritlove, C., Angus, J. E., Dale, C., Seto Nielson, L., Kramer- Kile, M., Lapum, J., & Clark, A. (2014). Getting beyond the binary blues with Bourdieusian theory and realist method- ology: The complexities of gender comparison in cardiovas- cular rehabilitation. Unpublished manuscript, Lawrence S. Bloomberg Faculty of Nursing, University of Toronto.

Public Health Agency of Canada. (2011). Diabetes in Canada: Facts and figures from a Public health perspective. Ottawa: Author. Retrieved from http://www.phac-aspc. gc.ca/cd-mc/publications/diabetes-diabete/facts-figures- faits-chiffres-2011/pdf/facts-figures-faits-chiffres-eng.pdf

Richards, L. (2005). Handling qualitative data: A practical guide. London, England: Sage.

Robertson, S., Sheikh, K., & Moore, A. (2010). Embodied mas- culinities in the context of cardiac rehabilitation. Sociology of Health & Illness, 32, 695–710. doi:10.1111/j.1467- 9566.2010.01249.x

Schofield, T., Connell, R. W., Walker, L., Wood, J. F., & Butland, D. L. (2000). Understanding men’s health and ill- ness: A gender-relations approach to policy, research, and practice. Journal of American College Health, 48, 247– 256. doi:10.1080/07448480009596266

Schwalbe, M. L., & Wolkomir, M. (2002). Interviewing men. In J. F. Gubrium & J. A. Holstein (Eds.), Handbook of inter- view research: Context & method (pp. 203-220). Thousand Oaks, CA: Sage.

Taylor, R. S., Brown, A., Ebrahim, S., Jolliffe, J., Noorani, H., Rees, K., . . . Oldridge, N. (2004). Exercise-based rehabilitation for patients with coronary heart disease: Systematic review and meta-analysis of randomized con- trolled trials. American Journal of Medicine, 116, 682–692. doi:10.1016/j.amjmed.2004.01.009

Thirsk, L. M., & Clark, A. M. (2014). What is the “self” in chronic disease self-management? International Journal of Nursing Studies, 51, 691–693. doi:10.1016/j.ijnurstu.2013.10.008

Thorne, S. (2008). Chronic disease management: What is the con- cept? Canadian Journal of Nursing Research, 40(3), 7–14.

Virtanen, M., Heikkila, K., Jokela, M., Ferrie, J. E., Batty, G. D., Vahtera, J., & Kivimäki, M. (2012). Long working hours and coronary heart disease: A systematic review and meta-analysis. American Journal of Epidemiology, 176, 586–596. doi:10.1093/aje/kws139

West, C., & Zimmerman, D. (1987). Doing gender. Gender & Society, 1, 125–151.

Dale et al. 1661

Williams, D. R. (2003). The health of men: Structured inequali- ties, and opportunities. American Journal of Public Health, 93, 724–731. doi:10.2105/AJPH.98.Supplement_1.S150

Author Biographies

Craig M. Dale, RN, PhD, is an assistant professor in the Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada.

Jan E. Angus, RN, PhD, is an associate professor in the Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada.

Lisa Seto Nielsen, RN, PhD, is an assistant professor in the Faculty of Health, School of Nursing, York University, North York, Ontario, Canada.

Marnie Kramer-Kile, RN, PhD, is an assistant professor in the Health, Human and Family Programs, School of Nursing, College of the Rockies, Cranbrook, British Columbia, Canada.

Cheryl Pritlove, BHSc, MSc, is a research associate at the ELLICSR: Health, Wellness, and Cancer Survivorship Centre at the Princess Margaret Cancer Centre, Toronto, Ontario, Canada.

Jennifer Lapum, RN, PhD, is an associate professor in the Daphne Cockwell School of Nursing, Ryerson University, Toronto, Ontario, Canada.

Jennifer Price, RN, PhD, is an advanced practice nurse in the Women’s Cardiovascular Health Initiative, Women’s College Hospital, Toronto, Ontario, Canada.

Susan Marzolini, PhD, is a scientist at the Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada.

Beth Abramson, MD, is director of the Cardiac Prevention and Rehabilitation Centre and Women’s Cardiovascular Health in the Division of Cardiology at St. Michael’s Hospital, Toronto, Ontario, Canada.

Paul Oh, MD, is Medical Director of the Cardiovascular Prevention and Rehabilitation Program and a Scientist at the Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada.

Alex Clark, RN, PhD, is a professor and associate dean of research, Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada.