Health Help Seeking Behaviour and Health Care Services Utilisation of Bruneian Men: a Grounded Theory Study

Durham E-Theses Health help seeking behaviour and health care services utilisation of Bruneian men: a grounded theory study. IDRIS, DEENI,RUDITA How to cite: IDRIS, DEENI,RUDITA (2017) Health help seeking behaviour and health care services utilisation of Bruneian men: a grounded theory study., Durham theses, Durham University. Available at Durham E-Theses Online: http://etheses.dur.ac.uk/12438/ Use policy The full-text may be used and/or reproduced, and given to third parties in any format or medium, without prior permission or charge, for personal research or study, educational, or not-for-prot purposes provided that: • a full bibliographic reference is made to the original source • a link is made to the metadata record in Durham E-Theses • the full-text is not changed in any way The full-text must not be sold in any format or medium without the formal permission of the copyright holders. Please consult the full Durham E-Theses policy for further details. Academic Support Oce, Durham University, University Oce, Old Elvet, Durham DH1 3HP e-mail: [email protected] Tel: +44 0191 334 6107 http://etheses.dur.ac.uk 2 HEALTH HELP SEEKING BEHAVIOUR AND HEALTH CARE SERVICES UTILISATION OF BRUNEIAN MEN: A GROUNDED THEORY STUDY By Deeni Rudita Idris Supervised by Professor Simon Forrest Dr Sally Brown A thesis submitted for the degree of Doctor of Philosophy of Durham University March 2017 School of Medicine, Pharmacy and Health Durham University University Boulevard Stockton on Tees ABSTRACT Despite the growth in research on masculinities and health help seeking behaviour we have little idea of how gender and ethnicity intersect to inform health help seeking behaviour among men in multi-ethnic cultures. This paper presents findings from a PhD research project investigating how being a man in Brunei Darussalam, a country with a strong religious and diverse cultural society; influences men’s perceptions of and attitudes towards their health and health help seeking behaviour. Using Grounded Theory, this thesis reports a study that utilised semi structured interviews and focus group discussions with a total of 47 men and women from diverse ethnic backgrounds in Brunei Darussalam. Three key themes emerged from the analysis of interviews with men: 1) The physicality of health and its importance to masculinity; 2) “Ikhtiar” as a way of ‘doing masculinity’ in the context of experiences of ill-health; and 3) masculinity and legitimation of health help seeking. A core concept found in this study relates to the process by which men operate and re-negotiate their masculinity in relation to their engagement with health care services, particularly when their ability to perform masculine responsibilities are potentially jeopardised by ill- health. Themes emerging from interviews with women focused on the relationship between wives and husbands, and daughters and fathers, and the way caring responsibilities reinforced bonds within the family. Women saw men’s reluctance to use healthcare as ‘normal for men’, while men acknowledged that pressure from wives was a factor in their decision to seek help. This study contributes to the development of knowledge about masculinities and health in a geographical region where to date there has been no empirical research, despite the existence of epidemiological evidence indicating that men’s health needs are serious and appear to be unmet. Page II TABLE OF CONTENTS CHAPTER CONTENTS PAGE NUMBER Title page I Abstract II Table of contents III List of figures VI List of tables VII List of appendices VIII Glossary of key terms and concepts IX Statement of copyright XIII Acknowledgements XIV 1 INTRODUCTION 1.1 Introduction 1 1.2 Background of the study 4 1.3 The rationale for and significance of the study 26 1.4 Context of the study 35 1.5 Aim of the study 45 1.6 Research questions 45 1.7 Organisation of the thesis 46 2 LITERATURE REVIEW 2.1 Introduction 49 2.2 Locating engagement with academic literature in the grounded theory approach 56 2.3 Searching the literature: Methods 59 2.4 Search outcomes 65 2.5 Results and discussion 67 (A) Theme 1: The importance of being healthy to demonstrate conformity with cultural norms and social responsibilities associated with masculinity 69 (B) Theme 2: The intersection of age and masculinity, and their influence on patterns of health help seeking 73 (C) Theme 3: Reasons for accessing healthcare services 75 (D) Theme 4: Stigma attached to health problems as a deterrent to seeking help 79 2.6 Summary and conclusion 83 Page III PAGE CHAPTER CONTENTS NUMBER 3 METHODS AND METHODOLOGY 89 3.1 Methodology 89 (A) Research philosophy 91 (B) Research approaches 92 (C) Research strategies 94 (D) Research choice 95 (E) Time Horizons 95 (F) Research technique and procedure 118 3.2 Socio-demographic information about study participants 123 3.3 Challenges and 'lessons learned' from the recruitment phase 127 3.4 Methodological issues 148 3.5 Ethical considerations 154 3.6 Conclusion 154 4 DATA ANALYSIS 4.1 Introduction 155 4.2 Coding process 158 4.3 Management of the study data 187 4.4 Conclusion 189 5 RESULTS: FINDINGS & RESULTS 5.1 Introduction 191 5.2 FIRST CATEGORY: The physicality of health and its importance to masculinity 193 5.3 Summary 216 5.4 Conclusion 223 6 RESULTS: SECOND CATEGORY 6.1 SECOND CATEGORY: 'Ikhtiar' as a way of 'doing masculinity' in the context of experiences of ill-health 225 6.2 Summary 252 6.3 Conclusion 256 Page IV PAGE CHAPTER CONTENTS NUMBER 7 RESULTS: THIRD CATEGORY 7.1 Third category: Masculinity and the legitimation of health help seeking 258 7.2 Factors which legitimate men's engagement with public health services 274 7.3 Summary 293 7.4 Conclusion 298 8 DISCUSSION 8.1 Introduction 301 8.2 Summary of findings 302 8.3 Strengths and limitations of the study 319 8.4 Issues for further research 330 9 CONCLUSION 9.1 Introduction 323 9.2 The research question and study 333 9.3 Principles findings 335 9.4 Implications for the development of theory 338 9.5 Implications for policy and practice 342 REFERENCES 351 APPENDICES 369 Page V LIST OF FIGURES REFERENCE TITLE PAGE NUMBER Figure 1.1 Registered deaths by age group and gender 29 in Brunei Darussalam in 2011 Figure 1.2 Life expectancy in Brunei by gender from 29 1981 to 2011 Figure 1.3 Top causes of deaths in Brunei Darussalam 30 in 2012 Figure 1.4 Risk factors for non communicable diseases 31 in Brunei Darussalam Figure 1.5 Map of Brunei Darussalam 36 Figure 1.6 Closer view of Brunei Darussalam and its 36 districts Figure 1.7 Distributions of healthcare facilities in Brunei 43 Darussalam Figure 3.1 ‘Research onion’ 89 Figure 3.2 Flowchart of recruitment and data collection 102 process Figure 4.1 Iterative process involved in grounded theory 157 Figure 4. 2 Summary of the coding process 158 Figure 8.1 Weighing pros and cons of utilising formal 317 health care services Figure 8.2 Visual representation of the processes 318 involved in shaping the health help seeking behaviour of Bruneian men Page VI LIST OF TABLES PAGE REFERENCE TITLE NUMBER Table 3.1 Interview schedule – Pre- and post- pilot 109 focus group Table 3.2 Ground rules for focus group 111 Table 3.3 Socio-demographic details of participants 121 Table 3.4 Ethical principles 149 Table 3.5 Issues raised by the university’s ethics 151 committee Table 4.1 Initial coding using In-vivo coding 163 Table 4.2 Matrix used to conduct the comparison in the 170 analysis process Table 4.3 Example of focused coding process: 173 Formation of the first category Table 4.4 Example of focused coding process: 176 Formation of the second category Table 4.5 Example of focused coding process: 177 Formation of the third category Table 4.6 The formation of the theoretical code 182 Page VII LIST OF APPENDICES APPENDIX TITLE PAGE NUMBER Appendix 1 Systematic search using databases - Medline, 369 CINAHL and PsycINFO using EBSCOhost Appendix 2 Visual representation of the selection process 370 for papers included in review Appendix 3 Summary of studies included in the review 371 Appendix 4 Recruitment poster used in the study 383 Appendix 5 Participant information sheet for individual 384 interview Appendix 6 Participant information sheet for focus group 388 with men Appendix 7 Participant information sheet for focus group 392 with women Appendix 8 Consent form 396 Appendix 9 List of health centres in Brunei Darussalam 397 and contact person Appendix 10 Details of men involved in individual interview 398 Appendix 11 Details of men involved in focus group, 400 including pilot Appendix 12 Details of women participated in focus group 401 Appendix 13 Details of participants involved in dyadic 402 interview Appendix 14 Details of Self Certified Sick Leave for 403 government servants in Brunei Darussalam Page VIII GLOSSARY OF KEY TERMS AND CONCEPTS Ankylosing spondylitis: This is a chronic condition in which the spine and other areas of the body become inflamed ASEAN: This is an acronym for the Association of Southeast Asia Nations. It comprises of Brunei Darussalam Malaysia, The Philippines, Malaysia, Singapore, Thailand, Vietnam, Cambodia, Laos and Myanmar. This association was motivated by common fear of communism and to strengthen economic development in the region (Asean Secretariat, 2014). Bahasa Melayu: This is the national language spoken in Brunei Darussalam. Bertangas: A home based herbal spa. It is done in a traditional way and it uses different types of plants. Brunei Darussalam: This is the full name of the country where the study was undertaken.

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