Coping strategies, concerns, and habits of Brazilian men in the COVID-19 context

Objective: To describe coping strategies, concerns and habits of Brazilian men during the COVID-19 pandemic. Method: Cross-sectional, descriptive and nationwide study, carried out in 2020 with a total of 1015 men living in Brazil. A descriptive statistic was used. Results: Young (41.2%), black (61.4%), highly educated (66.8%), high income (33.2%), living with family/ friends (49.7%) and formal workers (65.6%) predominated. As coping strategies predominated: exclusive use of the private health system (36.4%), support from family/friends (78.2%) and leisure (97.7%) and domestic activities (64.9 %). Social distancing (59.7%), economic (58.0%) and work situations (44.4%) were the main reasons for concern. Among the prevention/ control attitudes, hand washing (94.3%) and social distancing (91.0%) prevailed. Media consumption (84.6%) and health risk (65.4%) were the main increased habits. Conclusion: Brazilian men adopted coping strategies recommended by health authorities, with concerns and habits of potential risk to physical and mental health. Descriptors : Pandemics; COVID-19; Men; Strategies; Habits.


INTRODUCTION
COVID-19, a pandemic caused by the SARS-CoV-2 virus (Severe acute respiratory syndrome coronavirus 2), behaves as the greatest health challenge of the 21st century.Although the statistics are devastating in the world, particularly in Brazil the maintenance of high numbers of new cases and deaths is of great concern (1) .Until January 9, 2021, Brazil was already in the third position worldwide in number of cases and deaths.In this country, up to the same date, 8075998 cases and 202631 deaths were registered by COVID-19, which makes the daily epidemic complex and dramatic (2)(3) .
The pattern of distribution of cases is not homogeneous between different genders or age groups (4) .In Italy, seven out of ten deaths are men, whereas in Brazil this scenario is in the proportion of six in ten deaths (5) .From the analysis of laboratory tests of about 179 thousand people tested for COVID-19 in Brazil, Brazilian researchers identified that the infection in individuals aged 13 to 60 years old predominated among men.Men and older adults are at greater risk of evolving to severe conditions, and consequently to death, which needs greater attention from health professionals, as well as the reworking of the production of Nursing Care (6) .
So far, there is no robust evidence regarding the determinants of COVID-19 morbidity and mortality in the male population, although factors associated with lifestyle (7) , delay in seeking health services and even sexual behaviors have been identified as related to the occurrence of disease.For this reason, an important knowledge gap is seen in Brazilian and international literature on the subject.Furthermore, it reveals the expressive need to understand the factors that generate vulnerability of men in the pandemic context, which implies guidelines for the production of health and nursing care (8) , which justifies the performance of this study.

OBJECTIVE
To describe coping strategies, concerns and habits of men living in Brazil in the context of the COVID-19 pandemic.

Ethical aspects
The research was developed considering the ethical aspects, safeguarding anonymity, autonomy, freedom, beneficence and non-maleficence in all stages.For this purpose, the research project was approved by the Research Ethics Committee.The Informed Consent Form was offered in digital format and it was only after the electronic signature that the filling of the form was released through the online platform and free access.

Design, study setting and period
Cross-sectional, descriptive study carried out through a virtual environment, with men living in Brazil.In order to guarantee the accuracy, quality, reliability and transparency in the description of the study, the recommendations of the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) were adopted.The study was conducted between March and May 2020, that is, during the period of social distancing that was determined by health authorities in most parts of the country due to the COVID-19 pandemic.

Sampling and eligibility criteria
A total of 1015 men living in Brazil, with a cisgender, transgender and non-binary gender identity participated.The inclusion criteria were being an adult, literate men, with access to the internet, aged 18 or over.Men traveling internationally in Brazil were excluded.

Study protocol
Data collection took place through an electronic form on a free digital platform made available by Google Forms.Research participants were invited by sharing the link with the form via digital social media (Facebook, Instagram and WhatsApp).
The structured form was composed of thematic blocks to assess: 1-Sociodemographic characteristics (age, race/skin color, education, monthly income, living with) and occupational (work situation and employment relationship); 2-Aspects related to pandemic coping strategies (use of the health system, type of support during the pandemic and strategies to make coping easier); 3-Reasons for concern, attitudes and habits adopted during the pandemic.To guarantee the quality of the study, the Reporting of Observational Studies in Epidemiology (STROBE) was fulfilled.

Data analysis
The Statistical Package for the Social Sciences software, version 23.0, was used for data analysis Absolute and relative frequencies were estimated for categorical variables and minimum and maximum values, in addition to mean and standard deviation (SD) for quantitative variables with normal distribution.
With regard to the characteristics related to coping with the pandemic and reasons for concern, to make the coping with the COVID-19 pandemic easier, most men reported using exclusively the private health system (36.4%),lack of support for coping with the pandemic (62.1%) and, of those who had support, the main source was family and/or friends (78.2%).Most men adopted some type of strategy to face the pandemic (97.9%) and the ones that predominated most were leisure (97.7%) and domestic activities (64.9%).Among the concerns, social distancing (59.7%), economic situation (58.0%) and work situation (44.4%) were the of Coping strategies, concerns, and habits of Brazilian men in the COVID-19 context  Sousa AR, Teixeira JRB, Mota TN, Santana TS, Santos SD, Merces MC, et al.
most mentioned.Regarding the concerns experienced by men, there were attitudes towards prevention and control of infection with the new coronavirus, with evidence for hand washing (94.3%) and social distancing (91.0%).The low adherence to the use of protective masks (23.6%) stands out (Table 2).
Considering daily habits of life that were carried out before the pandemic, most men reported an increase in at least one type of behavior (95.9%).Among these habits, there was a significant increase in the consumption of media (84.6%) and health risk behaviors (65.4%).Most did not stock food (65.4%) and adopted new health care habits (81.1%).(Table 3).

DISCUSSION
This is the first Brazilian study to raise substantial data on the ways of male experiences regarding the use of coping strategies, in addition to the characteristics of the concerns raised and the habits developed since the advent of the pandemic in the country where they live, which makes this innovative study.
The findings of this study showed the adoption of coping strategies recommended by the health authorities, which confirmed, in high prevalence, the emergence of male mobilizations to deal in a combative way in face of the disruptive phenomena caused and imposed by the pandemic and obtained recreational and domestic aspects in its composition.Furthermore, the results showed characteristics related to behavior and health control existing in the reasons that led men to raise concerns in the  Note: SUS: Unified Health System -Sistema Único de Saúde.
To be continued face of the pandemic.The exercise of health care practices was noteworthy, which are based on the prevention and control of infection and viral transmission based on the insertion of sanitary measures recommended by the authorities, despite the reduced adherence to some of them, this in the period in which men were investigated.Furthermore, the findings showed the establishment of new habits adopted and incorporated into daily life by men living in Brazil, and this fact occurred in high prevalence after the advent of the COVID-19 pandemic.Among the habits adopted by the men, those aimed at consumption stood out, in this case, the media, and focused on the use of health risk behaviors, such as the use of alcohol and other drugs.
A relevant aspect to be analyzed about the COVID-19 pandemic is the social determination of the disease, as social conditions have played a significant influence on people's attitudes towards coping with the disease, as well as the emergence of concerns and fears (9) .And this occurs especially in men (10) , which in addition to having the highest rates of infection, complications due to the disease, for example, the Severe Acute Respiratory Syndrome, hospital admissions and deaths (3) , has expressed more clinical and behavioral outcomes unfavorable when compared to women (4,(11)(12)(13)(14) .It is relevant to emphasize that this study points out in its results expressive social markers regarding the analysis of male behavior in health and, in this case in particular, the health and disease process, both related to SARS-CoV2 and COVID-19.This provides an important epidemiological and social basis for the clinical understanding and socio-cultural phenomena of men in the context of the pandemic, information that can be consumed by professionals in Nursing, health and related areas.
Thus, it was found that the sample investigated is young, a marker that may generate greater vulnerability to infection and to the spread of SARS-CoV2.The literature indicates that among the younger population, adherence to disease control measures has been lower (15) .Therefore, unfavorable clinical outcomes are observed in relation to COVID-19, such as the increase in the number of new cases and the impacts on mental health.In addition, the fact that younger men are more likely to adopt/maintain health risk habits, such as abusive consumption of alcohol and other drugs, in addition to smoking (12,15) , which makes them even more vulnerable to outcomes unfavorable to health during social isolation, which is necessary in the pandemic period.
The most prevalent race/color among the men investigated was black, which includes black and brown individuals.Race/color is an important marker of analysis of the pandemic phenomenon, especially due to the expressive marks of structural racism in force in the country where the research was carried out.During the pandemic, both in Brazil and in other countries, black and brown men are the most vulnerable to COVID-19, as well as the difficulty in accessing health care (16)(17) .It is worth mentioning that during the advance of COVID-19 around the world, outbreaks of racism, stigma and xenophobia were amplified in the communities, compromising the psychosocial well-being and the right to dignity, life and citizenship of these people (18)(19) .
Most men had an income of five minimum wages or more, possibly configuring themselves as middle and upper middle class.However, about 20% of the sample is composed of men who live with only one minimum wage, which shows the disparities that exist in facing the pandemic.Brazil is a country where there is a high concentration of income, accentuating social inequities, with the wealthiest population having the most access to health services, the highest level of education and the best living resources.In contrast, people with lower incomes often live in unfavorable social conditions, which points to the reflection of the markers that generate social inequalities related to COVID-19 (20) on the need to target actions focused on their social and health demands.
The prevalent sexual identity among the participants in this study was homosexual, which requires a look at the vulnerabilities that are overlapping in this population group, strongly crossed by disparities in access to rights and weaknesses in socio-affective support networks, such as family.Thus, during the COVID-19 pandemic it has been identified that the LGBTQIA + population, especially among gay men (men who have sex with other men) has been more vulnerable to having their psychological wellbeing affected (21)(22) .
When analyzing who the men lived with, the findings showed living with family/friends during the pandemic, which may result in greater protection against the impacts of social isolation on people's mental health, culminating in the maintenance of satisfactory rates of psychosocial well-being (23) , as well as in the development of positive attitudes and effective and healthy coping strategies (24) .In this regard, it was identified that one in four of the respondents lived alone, a situation that may disadvantage healthy coping with the pandemic, making them more susceptible to loneliness, that is: romantic in having no one to share their emotions with, prolonged boredom experience, the inaccessibility to the socioaffective network, the difficulty in handling decision conflicts and confinement (25)(26) .This is an issue that is ambiguous and relevant.The LGBTQIA + population usually experiences family conflicts related to their sexual orientation.In this context of the COVID-19 pandemic, due to the measures of social distancing, gay men started to spend more time at home, therefore, home and family life may not necessarily be a friendly and healthy environment for them, emphasizing the psycho-emotional suffering for facing intense pressure from the family for their non-heterosexuality (27) .
Regarding the reasons that generated concerns among men during the COVID-19 pandemic in Brazil, it was found that physical appearance, distance from social contact, lack of leisure, lack of physical activity, sexual inactivity, the economic, family, work, love and emotional relationships are the most expressive.However, the social distancing, the situations, both economic and work, were more evident.This reflects the current Brazilian scenario, which is facing a serious budget crisis that joins the new phenomena caused by COVID-19.In this scenario, it is emphasized that the abrupt disruptions in daily relations and in the maintenance of the productive workforce, which were caused by the pandemic, have had a deleterious impact on psychosocial well-being (28)(29) .
In countries such as Bangladesh, India and Colombia, COVID-19 has had a serious impact on the mental health of the population, with a high rate of suicide, especially among men (30)(31) .The construction of masculinities, loss of ability to work, difficulty in subsistence, abrupt reduction in income, weaknesses in social security, changes in daily life and in the situation of occupational health are elements that must be valued, since they are issues related to the outbreak of negative emotions and feelings among of men, which is also influenced by personal belief systems (10,(32)(33) .
In relation to strategies for coping with the pandemic, most men reported having leisure and domestic activities.The pandemic and social isolation imputed changes in the population's routine in general, added to the significant impacting changes in the mental health situation (34) .With the greater availability of time, there was a greater investment in leisure activities and domestic work.Many families, due to the need for protection, ended up dismissing domestic workers and started to assume these functions.These activities became central and re-signified people's routines, which could be strategies for reducing anxiety and psychological distress (35) .As an example, in Spain, being a man and practicing leisure activities was associated with less anxiety and depression symptoms (34) .
The babelic scenario, which emerged in Brazil and in the world as a result of the pandemic, has demanded from men attitudes and behaviors to make coping easier and prevent situations harmful to physical and psycho-emotional integrity.It is challenging, in a country with such social inequality and territorial extension, to develop effective individual and collective coping strategies.Even so, a joint effort was evidenced, through changes in daily behavioral styles due to the imposed social isolation, to minimize the consequences caused by social confinement.It should be noted that in a period of social confinement, the population trends, in the short or long term, to present a sedentary lifestyle, which favors body overweight and the appearance of comorbidities associated with greater cardiovascular risk (35) , as well as psychosocial disorders such as anxiety and depression (31) .Nursing workers are responsible for implementing interventions with a focus on reducing degrading impacts, especially on the physical and mental health of this public (19)(20) .
Restrictions on social contact due to the COVID-19 pandemic increased levels of stress and feelings of anxiety in the general population.As a result, media consumption has been increasing substantially, corroborating the results of this study, and has been observed in most countries around the world, since it is the option accessible to most people to minimize the deleterious impacts on mental health, expanding the possibilities of social interactions.However, the problematic use of certain online applications, even as an alternative to compensate for negative feelings and stress, can culminate in hypervigilance and anxiety, especially among men -who are more likely to increase the consumption of games and erotic platforms.This change in the consumption of media can represent a risk for mental disorders or can be considered a functional phenomenon and limited in time, requiring longitudinal monitoring to produce more robust evidence (36) .
Most men established as social attitudes towards coping with the pandemic social distancing and positive behavior, considering that evidence has reinforced that the restriction of social contact is the basis for the prevention and efficient control of the spread of the virus, which significantly reduces the mass transmissibility to the population (33)(34) .Social isolation, combined with isolation of cases, is essentially effective (37) , which reinforces the importance of health professionals and services to encourage the adoption of this strategy to confront COVID-19.
Countries such as Singapore, South Korea and Japan recorded successful experiences, as they adopted early measures such as social distancing, in addition to showing that the immediate implementation of these recommendations, in line with rigorous case management and mass diagnoses, positively influenced the course of transmissibility, resulting in a lower morbidity and mortality rate due to COVID-19 (38)(39) .
With regard to effective methods of prevention and control to reduce the progress and spread of SARS-CoV-2, recommended by the Ministry of Health of Brazil and in line with the WHO, converging the fact that most men have adopted personal care practices, such as hand hygiene with soap and water and/or 70% sanitizer, body hygiene, food and household hygiene, and the use of masks.These measures for the prevention of contamination are recommended based on evidence that has emerged through experience in previous epidemics in the world (37) .Therefore, the pandemic event can be seen as a trigger for potentialities for self-care, mobilizing men to give more attention and, consequently, to exercise self-care practices.
However, It is noteworthy that of all the effective measures to avoid contagion, with regard to the use of masks, there was low adherence by men, which may be involved in different dimensions, such as factors of human behavior, self-perception of invulnerability, difficulties in accessing the acquisition, discredit and/or denial of the disease, underestimation of individual responsibility, habits and cultural belief systems that reflect the resistance of men in adopting the recommended protective measures and even the creation of safe strategies for coping (31)(32).
It is important to note that it is already known that the use of the mask associated with social distancing is highly effective in coping with the disease.There is evidence that the chance of transmission of the virus is 2.6% in people who maintained a physical distance of one meter or more.At a distance of less than one meter, the risk of contagion reaches 12.8%.Regarding facial masks, the same study found that the correct use can also result in a great reduction in the risk of infection, with 3.1% of chances of contagion with the use of protection, against 17.4% in people who did not use the mask.Therefore, it appears that this attitude is liable to change, considering the period of data collection, as well as the positive data regarding the adherence to other coping strategies.As knowledge about the disease advances, as well as interventions by health professionals and the media, it can promote greater awareness of the importance and effectiveness of using masks to control and reduce the spread of COVID-19 (40) .

Limitations of the study
This study has limitations related to the cross-sectional design adopted, making it impossible to establish cause/effect.The data collection in a virtual environment also limited the analysis of the phenomenon only to the population with the most favorable socioeconomic situation, excluding men who did not have access to digital technologies and who were possibly experiencing difficulties in effectively adhering to the strategies for coping with the pandemic.

Contributions to Health and Nursing
The findings of this study contribute substantially to the advancement of scientific knowledge and practice in health and nursing in the face of the pandemic context, especially with regard to the of way it has affected the male population.The data may serve as a basis for structuring strategic, contingent and programmatic actions, both during and in the post-pandemic period.In addition, it constitutes an important subsidy for the advancement of the implementation of the National Policy for Attention to Men's Health.

CONCLUSION
Finally, it was identified that men adopted as the main coping strategies the exclusive use of the private health system, the support of family/friends and the practice of leisure and domestic activities.The reasons for concern involved the restriction of social interaction, both economic and work situations.In addition, attitudes towards prevention/control showed adherence to social distancing, hand washing and use of 70% sanitizer.Still, there was an increase in habits related to the consumption of media and health risk behaviors.Thus, Brazilian men adopted coping strategies recommended by health authorities, with concerns and increased habits with potential risk to physical and mental health.
Coping strategies, concerns, and habits of Brazilian men in the COVID-19context  Sousa AR, Teixeira JRB, Mota TN, Santana TS, Santos SD, Merces MC, et al.
Coping strategies, concerns, and habits of Brazilian men in the COVID-19context  Sousa AR, Teixeira JRB, Mota TN, Santana TS, Santos SD, Merces MC, et al.

Table 2 -
Distribution of men according to characteristics related to coping with the pandemic and reasons for concern, Brazil, 2020 (N=1015)

Table 3 -
Distribution of men according to increased habits during the pandemic, Brazil, 2020 (N=1015)

Table 2 (concluded) of Coping strategies, concerns, and habits of Brazilian men in the COVID-19 context
Sousa AR, Teixeira JRB, Mota TN, Santana TS, Santos SD, Merces MC, et al.