COVID-19 in Brazil: Are there any differences in Mental Health Literacy between young and aged men?

Abstract Objective: to analyze the Mental Health Literacy of young and aged men living in Brazil in the COVID-19 pandemic context. Method: a qualitative study conducted with 87 men by means of an asynchronous online survey. The data were processed in the NVIVO12® software, structured with the Collective Subject Discourse method and analyzed through Anthony Jorm’s theoretical concept of Mental Health Literacy. Results: six central ideas emerged from the analysis of a synthesis discourse on the components of the Mental Health Literacy, namely: Ability to recognize specific disorders or different types of psychological distress; Knowledge and beliefs about risk factors and causes; Knowledge and beliefs about self-help interventions; Knowledge and beliefs about available professional help; Attitudes that facilitate recognition and the search for adequate help; and Knowledge on how to seek information on mental health. Conclusion: there are differences in the mental health literacy of young and aged men living in Brazil during the COVID-19 pandemic. Aged men were more competent for mental health care management and protection than young men, in relation to the Mental Health Literacy levels.


Introduction
Due to the effects on mental health of the global population caused by the COVID-19 (Coronavirus Disease 2019) pandemic, a significant number of people became mentally ill. A number of studies indicate a high prevalence of mental disorders such as anxiety, depression, loneliness, sleep disorders, phobias, panic and post-traumatic stress in the population (1)(2)(3) . Regarding gender, data on men's mental health in the COVID-19 pandemic context (4)(5) are still discrete.
In this sense, knowledge of the preventive measures related to mental health and recognition of the symptoms and treatment modalities for mental disorders is fundamental, in addition to enabling support to people suffering these conditions (6) . This perceived behavior is defined as Mental Health Literacy (MHL). Although little discussed in Brazil, MHL has been emerging in health promotion, mainly in view of the vulnerability related to mental health imposed in the pandemic context (7) .
The MHL concept emerged in Australia in the late 1990s (8) , where authors defined it as the knowledge and beliefs about mental disorders that assist in their recognition, treatment and prevention. Since then, researchers around the world have shown a growing interest in this phenomenon, leading to the evolution of the conceptual definition of MHL. Currently, MHL refers to the knowledge and skills required to promote mental health (9) , and it is divided into four components, namely: understanding how to achieve and maintain good mental health, understanding mental disorders and their treatments, reducing the stigma related to mental disorders, and increasing the effectiveness of the search for help (10)(11) .
Low MHL levels exert an influence on the treatmentseeking behavior and self-management of the population's psychosocial problems, reason why it is relevant that health professionals act assertively in the promotion of MHL (12)(13) . With regard to gender, the stereotyped culture of the male model of strong active men who do not get sick still prevails in the Brazilian social construction (12) .
"Hegemonic masculinity" can be an impediment to high MHL levels in this population segment, as men tend to complain less, deny pain and weakness, and hide physical and psycho-emotional frailty (13) . There is diverse evidence that men only seek help when pain becomes unbearable or incapacitating and when it affects work performance (12) .
As for the age-related MHL barriers, older adults gain prominence in the pandemic for presenting changes resulting from senescence and senility, but mainly due to the potentiation of ageism and stigmatizing attitudes to aged individuals by part of the population. In addition to that, necessary measures such as social distancing become important to prevent spread of the virus, but bring about complications to the routine habits and mental health of this group (14) .

Infodemics also have important repercussions
for the mental health of the population, mainly that of older adults (15) . It is verified that, at a moment like this, full of uncertainties and excesses of information in all forms, including fake news, a rapid change in the world population's behavior is necessary to reduce the impacts generated to mental health in the face of COVID-19 (16) .
Therefore, adequate MHL levels have never been as important as they are today.
From this perspective, by recognizing that this problem confers a significant attention focus to global public health, it is recommended to strengthen the strategies for mental health protection and promotion (17)(18) , both during the course of the pandemic and in the postpandemic period, with maximization of the MHL levels across the populations. Therefore, it is understood that developing MHL can prevent acute and chronic mental health problems and protect men from adopting toxic masculinity models.
The COVID-19 pandemic warned about the existing gaps in the MHL levels of the male population and exposed the need for an analysis to identify the state of this phenomenon in the countries, especially those where this topic has not yet been addressed, such as Brazil.
Thus, the guiding question of the study was the following: How is the MHL of young and aged men configured in the COVID-19 pandemic context in Brazil? Given this question, this study aims at analyzing the MHL of young and aged men living in Brazil in the COVID-19 pandemic context.

Study design
A qualitative study, structured in discursive analysis (19) and following the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines (20) .

Scenario and participants
The study was carried out in a virtual environment, 44 years old) and aged (from 60 to 90 years old) subjects was used (21) .
Following the snowball sampling criteria (22) , two men from each region of the country were recruited for the study, through digital social networks (Facebook ® , Instagram ® and WhatsApp ® ), one young and one aged per region, totaling 10 participants (we chose the most populous state in each of the five Brazilian regions).
These were the first participants and were called "seeds".
Each participant received a link containing the Informed Consent Form in virtual format and the research form and was instructed to invite other men from their social network (without interference from the researchers) until a significant sample was obtained. Data collection was terminated when theoretical data saturation was reached, where, as new testimonies were included, two researchers independently carried out a continuous data analysis process through compilation and grouping of the topics identified (23) . This double analysis allowed identifying similar topics, with theoretical saturation achieved in 53 testimonies of the young individuals and 34 statements of the aged subjects, represented by the absence of new elements in the treated material, data co-occurrence, convergence and complementarity (24) . A third researcher reviewed the material and ensured theoretical saturation by analyzing the theoretical density and reliability of the results. Data coding was supported by the NVIVO12 ® software, with organization in charge of two researchers, which made it possible to process the material, create "nodes" -thematic codes, organize, identify and systematize categories and subcategories based on identified topics (25) .

Data collection and analysis
The methodological analysis was structured by the Collective Subject Discourse (CSD) technique, which is configured in a form of social representation, in which common sense knowledge is present in the opinions and also in the stances adopted by a subject in everyday life (26)(27) . This form of social representation can be understood as a synthesis of a stranger, approaching empirical reality.
Therefore, in this study, line-by-line reading of the data was used, as well as location of discursive fragments and their relationships, convergences and complementarities, as a way to derive the Key Expressions, subsequently grouping the data, in the search for the Central Ideas and their anchorages. Finally, the synthesis-testimonies were structured, from the junction of the individual testimonies, written in the first person singular, in order to express the collective group under study, in consideration of men's representation (19,(26)(27) .
As this was the investigation of a single phenomenon with different population segments (young and aged men), the same methodological technique was used (19) , complying with scientific rigor, as a way of apprehending and explaining the specificities found in each age group.
In this sense, a Synthesis-Discourse of structuring character was evidenced, comprised by six Central Ideas: Knowledge on how to seek information on mental health.
The Central Ideas emerged from junction of the data, from the location of the collective discourse -data of greater expressiveness -density, deepening and representation of the investigated reality (26) , presented in both groups under study, expressed in the study in a separate way, namely: Young men's CSD and aged men's CSD. After the methodological analysis, an analysis and/or theoretical interpretation of the material was performed, supported by the theoretical framework proposed by Anthony Jorm, which conceptualizes and structures the MHL components (10)(11)28) .

Results
The study included 87 men living in Brazil (53 young and 34 aged) between 25 and 33 years old (young) and from 63 to 72 years old (aged). The young men were mostly of cisgender gender identity and heterosexual sexual identity, characteristics similar to those of the aged men. In relation to race/skin color and marital status, most of the young men self-declared as brown-skinned and single, while the aged subjects mostly self-declared as white-skinned and married. Both groups presented higher education level and work contracts in the public service. They reported having different incomes: between 3 and 4 minimum wages in the young men and above 5 minimum wages in the aged subjects. The men's territory of residence was also different: the young men mostly lived in the Northeast region, with a higher concentration in the states of Bahia and Pernambuco, and the aged men were from the Brazilian Southeast region, with a higher concentration in the states of São Paulo and Rio de Janeiro. The young men lived with family members (parents and/or siblings), while the aged subjects lived with their spouses, and both live in urban areas.

Health Literacy components of young and aged men
The male experience in the everyday experience of the COVID-19 pandemic in Brazil explained the CSD of young and aged men that brought to light the MHL components, which are supported by six discursive categories of Central Ideas, described below. CSD: "From management to protection: Explaining the distinctions in the Mental Health Literacy components for young and aged men."   (Aged men's CSD). Although clinical recognition may not be sufficient by itself to benefit the patients, it is a first step towards effective action (8)(9)(10)(11)28) .

Discussion
The presence of erroneous stereotypes regarding mental health, in relation to the adoption of early care and protection measures, was found in this study. The young men showed slight concern related to their mental health situation in the face of the pandemic, even though they recognized risk factors and causes for mental health and have harmful repercussions, which leads to certain disbelief in the phenomenon (pandemic) and in its severity and complexity for mental health. Such beliefs, probably intensified by the action of gender hegemonic male normalization (29)(30)(31) , can alter the patterns of the search for help, response to the treatment and even management of the individual symptoms, in addition to strengthening limiting beliefs that young people are unwavering, resistant and unattainable regarding the psychosocial impacts (28) .
A broader perspective of the mental health concept was observed in the aged men's CSD, which is related to their experience in the world and is not restrictive to the ailments experienced in the pandemic. Such characteristic can confer greater skills to analyze and face inabilities to deal with new situations and major uncertainties (32)(33) . Regarding this aspect, it is already known in the literature that aged men are more vulnerable to COVID-19, with very high morbidity and mortality rates (34) . However, in relation to mental health, our results revealed that this population segment is more adherent to and concerned with the disease prevention and control measures, which are closely www.eerp.usp.br/rlae 7 Moreira WC, Sousa AR, Cardoso RSS, Queiroz AM, Oliveira MAF, Sequeira CACJ.
related to the link with the networks (support, socioaffective, health care), when compared to young men.
Men's mobilization in the search for self-help interventions in mental health was recognized. This mobilization elucidated the development of "first-aid skills in mental health" (28) , directing them to face the experience in the pandemic, based on the acquisition and construction of knowledge and beliefs. Among the young men, our results verified the use of positive attitudes with a focus on leisure and entertainment and body practices and, among the aged men, maintenance of a balance in mental health, expressed in meditative and self-knowledge practices.
Self-help skills are essential for self-management in mental health, as well as the recognition of when and how to implement them (8)(9)(10)(11)28)  Knowledge on how to help others is a component related to MHL (9)(10)(11)28) . A Swiss survey found that the population has difficulty dealing with mental disorders, stating that they do not know how to behave, are afraid of making mistakes, do not have enough knowledge to offer support or have stigmas related to mental health problems (36) . It is understood that public beliefs about professional help can affect the search for help by other people. Professional help for mental health problems is more likely to occur when another person recommends that assistance be sought, so that the opinions of other important people about the treatment can also exert an influence (28) .
In relation to the beliefs of the population and professionals about mental disorders, it is known that the latter have specialized knowledge, largely based on diverse scientific evidence and expert consensus, while the population has a variety of beliefs based on personal experiences, media reports and informal knowledge sources. However, the analysis of the public beliefs does not reveal any general factor corresponding to MHL but a series of factors that, through those beliefs, point out that mental disorders are better treated by medical and psychological interventions or changes in lifestyle (28) .
In In this sense, accessing health information becomes easy for a relatively young sample with potentially high affinity for the online environment, where information is easily accessible at any moment. However, it requires the individual's ability to filter the diverse information in terms of veracity and precision (37) , with the need to develop higher digital literacy levels (38) and MHL among the younger populations (39) . and breakups of family and affective bonds (40)(41) . In in the logic that it is fundamental to devote attention to mental health, managing and protecting it. However, it is a scenario that has not yet been explored in depth among men (42) .
The low literacy level in the young and literate population indicates certain vulnerability of people with mental health problems with regard to the perception of difficulties taking care of their own health (37,43) . In pandemic times, difficulties can be oversized and establish barriers to understanding, support and coping in the mental health scope. Such MHL levels can be present and cause male invisibility, not placing the mental health position in the transversality of life, which was already historically evidenced among the men's narratives, due to the oppression systems imposed by machismo, by patriarchy and by the social construction of a hegemonic masculinity model (4,8) .
It is important to highlight that previous studies have evidenced that low MHL is associated with male gender, advanced age (> 60 years old) and schooling level, suggesting that older adults present a lower mental health literacy level than younger adults, including less precision in identifying symptoms of mental disorders and treatment modalities (44)(45)(46) . However, our study does not support such conclusions, as it evidenced that aged men, regardless of their schooling level, showed higher MHL levels when compared to younger men. This fact can be explained by the environmental influences, such as proximity to someone who has a mental disorder, which facilitates obtaining adequate information regarding the strategies for promotion, treatment and education in mental health (46) .
When working with subgroups of men, it was evident that structural inequalities in health require political attention from the government to effectively tailor and direct efforts to promote men's MHL and health promotion programs, particularly with regard to mental health and to adapt the existing health education tools to focus on specific men's health problems, including depression, suicide and stigma (47)(48)(49) . contextualized with each individual's reality (50)(51)(52) .
It is noted that the task of strengthening the MHL

Implications for the practice and research
We emphasize that, to the present day, this is the to the strengthening of more resilient societies in the post-pandemic period. Thus, it corroborates with the need to expand the actions directed to men's health and to the field of study in masculinities and MHL, so essential for advancing the public policies (57) .
It is recommended to conduct future research studies that contribute better understanding, as well as to develop interventions that aim at promoting and expanding each of the MHL components in the male population. To this end, new studies must be carried out to obtain the best possible evidence, using validated assessment instruments and including follow-up periods.

Conclusion
There is an important distinction in the MHL levels between young and aged men, which made the ability to recognize specific disorders or different types of psychological distress more present among aged men than among young subjects, a situation that is also repeated in relation to the knowledge and beliefs about risk factors and causes, as well as to the knowledge and beliefs about self-help interventions to be adopted within the scope of mental health self-management and protection due to the pandemic context experienced.
The generational category proved to be influential in MHL, when evidencing that aged men expressed knowledge and beliefs on the professional help available for access in the pandemic context, elucidated attitudes related to the practicalities for recognizing mental health problems and also for seeking diverse information related to mental health, when compared to young men, which reveals that, due to insufficient MHL, young men can be more vulnerable to mental illness in the pandemic than aged subjects. It is inferred that aged men may have higher MHL levels due to their history and to the different experiences underwent throughout life that add wisdom and, consequently, expand the MHL levels.