The absence of research into men’s health in Brunei Darussalam highlights the need for this study. As I will describe in greater detail in chapter three, where I deal with the methods and methodological issues and the overall philosophical approach to the empirical research, this absence and an interest in social practice, attitudes and above all meanings given to Bruneian men with regard to health and health help seeking, implies that there is no better way to start this work than speaking to men themselves and thereby trying to understand what they do if they are feeling unwell and their experiences of using healthcare services.
Furthermore, hearing what women have to say about this issue is also significant, as it may help to put men’s comments into context. It also allows the exploration of roles that women play in men’s life and
how these women see these roles. It also allows me to understand how the dialogic around the men’s relationships with women works. I am optimistic that this, first of its kind, study will be able to spark further interest in men’s health related research in Brunei Darussalam.
The significance of this research is further enhanced as it mounts its investigation from the perspective of the local culture and its unique ethnic mix and other associated psychosocial, economic and physical factors, which subsequently will bridge the gap in knowledge on men’s health help seeking behaviours and practices in Brunei Darussalam. This altogether fulfils the aim of generating new knowledge in the form of theory which has been identified as most deserving of research efforts (Birks & Mills, 2011).
This study has the potential to benefit policy makers and health care professionals, providing them with locally relevant information supporting the design and development of a more comprehensive men’s health service and health promotion programmes that are both sensitive to gender and ethnicity and tailored to the needs of Bruneian men. In turn, this means that this study has the capacity to impact on the realisation of the country’s ‘Vision 2035’ which aims to provide proper care for all citizens of Brunei Darussalam in order to achieve a quality of life that is among the top ten nations in the world(Ministry of Health Brunei Darussalam, 2012).
Finally, this research also benefits a wider international audience by generating substantive and new data on Bruneian men’s health help seeking behaviours and practices. It also contributes to our understanding of the utility of a masculinities approach to conceiving of and understanding male identities and their relationship to and impact on health help-related behaviour and practices. Furthermore, this study helps to identify areas for future research into men’s health in Brunei and potentially stimulate research collaboration with neighbouring countries.
(i) Brunei Darussalam and the status of Bruneian men’s health
In Brunei Darussalam, as mentioned above there has been no research into how health help seeking behaviour and practices relate to masculinities, despite worrying epidemiological evidence about health needs among men. The registered number of deaths in 2011 (Jabatan Perdana Menteri, 2011) (Figure 1.1) reveal a significant disparity between male and female mortality. This is reflected in every age range, such that in most cases there are a higher number of male than females dying. A total of 1,235 deaths were recorded with a breakdown of 695 and 540, males and females, respectively.
Figure 1.1: Registered deaths by age group and gender in Brunei in 2011.
Looking at the life expectancy by gender from 1981 to 2011 (Hj Md Said, 2012) also revealed a similar pattern (Figure 1.2).
Figure 1.2: Life expectancy in Brunei by gender from 1981 to 2011.
A further investigation of the causes of death in Brunei shows that it is non-communicable diseases and lifestyle factors that contributes to most of these deaths. According to the Ministry of Health in Brunei Darussalam (2012), the four leading causes of deaths in 2012 were cancer, heart disease, diabetes mellitus and cerebrovascular diseases. All were predominant in men as shown below (Figure 1.3).
Figure 1.3: Top causes of death in Brunei Darussalam.
Critically Figure 1.3 reports that for the three non-sex specific cancers higher numbers of men than women being affected. Notably, men were also disproportionately represented in deaths attributable to accidents.
A further report by the World Health Organisation from 2014 (World Health Organization, 2014) on risk factors for non-communicable diseases (NCD), the number one killer in Brunei, revealed a further disparity between the men and women in Brunei as shown below (Figure 1.4).
Figure 1.4: Risk factors for NCDs in Brunei Darussalam.
To arrive at a safe inference about these striking gender disparities, it is essential to look at the population of Brunei as a whole and its gender ratio to get a clearer picture on the context. According to the most recent published census held in Brunei in 2010 (Department of Statistics, 2011), out of a total 414,000 people, 219,000 were males and the remaining 195,000 were females. It was further noted that the population has been growing steadily by an average of 2%
annually and that there has always been more males then females recorded in the statistics.
Thus, as this data seems to show, if it is not merely biological factors, which account for the gender differences in health, morbidity and mortality, then the rationale for considering the influence of gender itself becomes still stronger.
Another reason for embarking on this study is due to my personal in interest in this area. The area of men’s health and particularly their health help seeking behaviour was first introduced to me when I was doing a Masters degree at the University of East Anglia, United Kingdom in 2010. I became aware of the significance of gender when assigned the task of appraising a qualitative research paper entitled “You ain't going to say…I've got a problem down there’:
workplace-based prostate health promotion with men” (Dolan,
Staples, Summer, & Hundt, 2005). This paper discussed men’s perception of a workplace delivered health promotion programme in raising their awareness of prostate cancer. I remember feeling intrigued by the paper. Once I started reading, issues including “ that’s how it is with man” and “masculinity” and how these affect men’s attitudes and behaviours towards their health and consequently their health outcomes started to emerge from my engagement with the paper. Naturally, being a man myself, I could not help but to reflect on the personal significance of the research. I
saw some immediate similarities and was able to relate to the findings well and also began to understand where other men were coming from. I also somehow began to feel sympathy for men and I became very curious and started to question the situation in my own country. This curiosity lead me to conduct some searches of the database, seeking information about any kind of men’s health related research undertaken in Brunei. There was none. I started to think about the various things that I could do to help. Ultimately, I realised that as an academic working at the national university in Brunei, I could conduct research in this area supported by the advantages of having access to resources and expertise. I considered this could be my contribution to addressing the health needs of Bruneian men.
My interest was further galvanised when I reflected on my previous experience in clinical practice working as a nurse in hospital in Brunei. I had observed the behaviour of Bruneian men towards health maintenance and health help seeking. My observations showed that in comparison to women, the majority of men came to the hospital to seek treatment rather too late or when their condition had already deteriorated. Interestingly, I reflected that this trend had been most apparent amongst men from the Malay and Iban community and not so common amongst Chinese men. When I enquired about the reason, the Malay and Iban men often said that they did not think their concern was sufficiently serious to warrant
seeking medical help. However, interestingly, discussion with Chinese men about their health conditions suggested that they paid greater attention to their health than any other ethnic group in Brunei. This further triggered me to ask how cultural and ethnic differences may play into masculinities and health.
I also remember my experience growing up as a Malay boy and the level of pressure I felt under to meet the expectations and norms associated with being male. I was brought up in a specific gender orientated environment in which, as a boy, I was expected to be strong and therefore not cry like my younger sister, for whom crying was seen as appropriate. Based on personal experience and observations, this cultural norm of “boys should be strong and should
not cry” seems to be shared amongst the Malay community. This led
me to consider the importance of socialisation and acculturation and the extent to which ‘deep’ learning might be associated with adult behaviours amongst Malay men in Brunei.
Naturally, curious about these questions coupled with my excitement and enthusiasm, I decided to take this interest further by embarking on this area for my PhD research area and possibly make it my career after the completion of this PhD.