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Tough but not terrific: Value destruction in men’s health

Structured abstract

Purpose

The purpose of this paper is to investigate the role of masculine identity in generating value

destruction and diminished well-being in a preventative health service.

Design/methodology/approach

This research accessed five focus groups with 39 Australian men aged between 50 and 74

years. Men’s participation in the National Bowel Cancer Screening Program informed the

sample frame. Twelve Jungian male archetypes were used to identify different masculine

identities.

Findings

Thematic analysis of the data revealed three themes of masculinity that explain why men

destroy value by avoiding the use of a preventative health services including: rejection of the

service reduces consumer disempowerment and emasculation, active rejection of resources

creates positive agency, and suppressing negative self-conscious emotions protects the self.

Research limitations/implications

Limitations include the single context, bowel cancer screening. Future research could

investigate value destruction in other preventative health contexts such as testicular cancer

screening, sexual health screening and drug abuse.

Practical Implications

Practical implications include fostering consumer empowerment when accessing services,

developing consumer resources to create positive agency, and boosting positive self-

conscious emotions by promoting positive social norms.

Originality/value

This research is the first known to explore how value is destroyed in men’s preventative

health using the perspective of gender identity. This research also is the first to explore value

destruction as an emotion regulation strategy.

Keywords

Masculine identities, social marketing, value creation, value destruction, value co-destruction,

self-conscious emotions

Article classification

Research paper

Introduction

Much of transformative service research (TSR) literature is focussed on positive outcomes for

the consumer (Anderson et al., 2013; Blocker and Barrios, 2015). However, not all

transformative services have been able to effectively deliver improved well-being and

rewarding value for their consumers (Zainuddin et al., 2017; Leo and Zainuddin, 2017; Plé

and Chumpitaz Cáceres, 2010). Preventative health services struggle to engage men to adopt

and use their services, with less than optimal participation rates (Australian Institute of Health

and Welfare, 2018; Robinson and Robertson, 2010). Value propositions or offers to co-create

value presented to male consumers by preventative health services are often ignored or

rejected (Courtenay, 2000; Grönroos and Voima, 2013). Men have cited threat to masculinity

and emotions like embarrassment as reasons for avoiding health services (Consedine et al.,

2011; Leone et al., 2017; Yousaf et al., 2015). However, there is a gap in the literature

addressing how value might be created or destroyed in men’s health contexts. This paper

finds that indeed, in some instances, value is destroyed by male consumers through the

intentional and unintentional misuse of a service (Plé and Chumpitaz Cáceres, 2010; Leo and

Zainuddin, 2017). Value destruction in transformative services can lead to a diminishment of

consumer well-being such as decreased chance of disease detection which increases the risk

of illness and/or death (Leo and Zainuddin, 2017; Plé and Chumpitaz Cáceres, 2010). Health

literature indicates that some men avoid health services as these are perceived as help-seeking

(Leone et al., 2017). Help-seeking is often incongruent with masculine identity because

traditional masculine ideals include toughness, stoicism and self-reliance (Galdas et al., 2005;

Leone et al., 2017; Connell, 2005). Help-seeking can also translate to a perceived loss of

autonomy or control leading to reactance, the rejection of the service or positive health

behaviour to restore perceived control (Addis and Mahalik, 2003; Brehm and Brehm, 2013;

Fogarty, 1997). Despite this knowledge, to date there is little investigation examining the role

of masculine identity and the value destruction process when men reject or ignore

preventative health services.

Some preventative health services such as cancer screening services use social marketing

strategies to create value for consumers (Australian Institute of Health and Welfare, 2017a;

Zainuddin et al., 2011). Value could come from feelings of pride after completing a required

breastscreen for cancer detection or posting off a completed bowel cancer screening kit for

analysis (Australian Institute of Health and Welfare, 2017b). Perceived value is essential in

social marketing to deliver effective services to meet the consumer’s needs and thus influence

behaviour (Lusch and Vargo, 2006). Therefore, where value is reduced or destroyed for

preventative health consumers a loss of confidence in the service and lack of consumer

engagement or maintenance in help-seeking behaviour could be the result (Leo and

Zainuddin, 2017). It could be argued that, where preventative health services seek to co-

create value with male consumers, there is a risk of value destruction through a misuse of

organisational and consumer resources. The literature shows that men’s previous negative

experiences with health services have created barriers to future help-seeking and improved

well-being (Leone et al.; 2017; Weitzman et al., 2001). Additionally, reactance theory might

explain why men reject a service if it is perceived as a potential threat to their freedom and

autonomy (Addis and Mahalik, 2003; Brehm and Brehm, 2013). However, there is little

investigation from a services perspective of the rejection of preventative health service when

they are presented as value propositions through social marketing (Leo and Zainuddin, 2017).

There are also very few known studies examining value destruction or value co-destruction in

a health or preventative health context (Zainuddin et al., 2017; Robertson et al., 2014) and a

lack of understanding of how masculine identities can create or destroy value for men’s help-

seeking behaviours in preventative health. Therefore, the research question guiding this study

is: Why does masculine identity generate value destruction and diminished well-being in a

preventative health service?

The purpose of this paper is to investigates the role of masculine identity in generating value

destruction and diminished well-being in a preventative health service. Through thematic

analysis of focus group interviews with 39 older men, this research investigates the role

masculine identities play in mature men’s health beliefs and behaviours, finding that being

tough is not terrific for mature men’s health and well-being.

This paper has two key contributions for the emerging literature on value destruction in

service systems (Plé and Chumpitaz Cáceres, 2010; Leo and Zainuddin, 2017; Čaić et al.,

2018). First, value destruction in men’s health can be a strategy to restore the equilibrium for

men’s masculine identity by facilitating psychological control and emotion regulation. This

research finds that positive self-perceptions from traditional masculine ideals can be elicited

from negative health behaviours that destroy value in a service. Second, negative self-

conscious emotions can be suppressed through negative health behaviours that are enacted

through value destruction. Practical implications of this research include social marketing

approaches to minimise value destruction in men’s preventative health contexts that aim to

instead increase value co-creation through fostering consumer empowerment, promoting

consumer integration of resources and boosting positive self-conscious emotions.

Literature review

Transformative services and men’s well-being

As a transformative service, a preventative health service such as population-based cancer

screening aims to improve consumer eudaimonic well-being through improved individual and

collective health at all points of interaction (Anderson et al., 2013; Australian Institute of

Health and Welfare, 2017a). Such services seek to influence positive health behaviours from

consumers and increasingly adopt approaches that promote value co-creation between the

service and the consumer (Vargo and Lusch, 2004).

Value propositions, such as the early detection of cancer, aim to inspire consumers to co-

create value with a service in the consumption process, such as attending and participating in

cancer screening (Russell-Bennett, Previte, & Zainuddin, 2009; Vargo & Lusch, 2004). Value

propositions presented by cancer screening also include emotional value propositions such as

peace of mind when there is no detection of disease, and functional value propositions

because it is a free service (Zainuddin et al., 2013).

In many countries, including Australia, the U.S. and the U.K, men have low participation

rates in preventative health services, including free or low-cost services such as bowel cancer

screening (Oster et al., 2015; Yousaf et al., 2015; Davis et al., 2012; Chapple et al., 2008;

CDC, 2018, Weitzman et al., 2001; Baker et al., 2014). Globally, studies have found that

men utilise health services less than women, even when women’s reproductive health

consultations are considered (Manandhar et al., 2018; Hawkes and Buse, 2013; Courtenay,

2011). Courtenay (2011) states that U.S. men use fewer healthcare services than women and

are more likely to wait at least two years before contacting a physician. However, men have

higher rates than women of chronic and fatal disease such as heart disease, hypertension and

cancer. In their systematic review of 41 qualitative and quantitative empirical studies from

various countries on the barriers/factors in men’s medical help-seeking from health

professionals, Yousaf et al. (2015) found the overarching theme from these studies was that

men’s willingness to seek help is compromised or reduced by their adherence to traditional

masculinity norms. Avoidance of preventative health services because of threat to masculinity

potentially results in a reduced hedonic well-being as the decision to avoid health services

may be inspired by and/or result in fear, stress, strain, or tension (Anderson et al., 2013).

Masculine identity

Western culture has configured a dominant masculinity that informs other constructions of

masculinity within the culture (Connell, 1995, 2005). This dominant masculinity is also referred to by

theorists such as Connell (1995) and Courtenay (2000b) as hegemonic masculinity, and “is the

idealised masculinity at a given place and time” (Courtenay, 2000b, p.1388) which subordinates

women and other masculine identities, influencing how men relate socially with women and other

men. There are varied configurations of hegemonic masculinity that are constructed differently for

each man (Connell, 2005; Courtenay, 2000; Connell and Messerschmidt, 2005). However, according

to the literature all constructions are informed by the hegemonic in some way, be it as a subordinate,

complicit, resistant, marginalised, or protest masculinity (Connell, 2005; Courtenay, 2000; Connell

and Messerschmidt, 2005).

Male archetypes are a useful way to operationalise different masculine identities. Carl Jung

(1968) extended the concept of archetypes based on his theory of a collective unconscious:

whereby all humanity is linked through shared understandings or instincts. From this

collective unconsciousness come archetypes (Jung, 1968). Archetypes are symbolic of the

multiple figures representative of human themes or aspects of the human character and have

male and female aspects (Jung, 1968; Morris and Schmolze, 2006).

While other theorists and researchers have built on the Jungian archetypes according to their

discipline, the 12 archetypes refined by Mark and Pearson (2001) were chosen for this

research because they have been adapted for marketing with relatable profiles and would

facilitate deeper insights into men’s attitudes, behaviours and masculine identities (Mark and

Pearson, 2001; Kunimoto, 2013, Tanrıverdi et al., 2009; Coetzee, 2012; Tallman, 2003;

Solomon, 2014) . Figure 1 represents the 12 male archetypes and their key mottos or

motivations.

Figure 1 Twelve Jungian male archetypes and their motivations

Free to enjoy life and be happy

“Love your neighbour as yourself”

“Power is everything”

To give form to a vision Ruler

Caregiver

To belong and fit in Regular

Guy

Comedian

Live in the moment Being in an

intimate relationship

Improve the world with mastery Magician

To make dreams come true

To destroy what is not working

Explorer

Outlaw

“The truth will set you free”

Thinker

“Don’t fence me in”

Innocent

Hero Lover

Creator

(Mark and Pearson, 2001; Solomon, 2014)

Masculine identity and health behaviours

Courtenay’s (2000) relational theory of gender in men’s health positions masculine identities

as social constructs that are shifting and varying, usually negatively influencing men’s health

beliefs and behaviours. However, although men enact masculinity differently depending on

age, ethnicity, social class, and sexuality (Courtenay, 2000), they usually aspire to the

dominant gender ideals, such as traits of strength, pain tolerance, and stoicism, conducive to

unhealthy behaviours (Courtenay, 2009; Mahalik et al., 2007; Manierre, 2015; Leone et al.,

2017; Berke et al., 2017). These ideals play a primary role in how men access preventative

health services (Leone et al., 2017). Vogel et al. (2011) found men who favoured traditional

masculine ideals were less favourable to accessing psychological health services. Leone et

al.’s (2017) study found that gender norms play a significant role in how men access health

services. Embarrassment was also a strong predictor in the study for men accessing health

care, evoking a perceived lack of control and some participants stating they felt “‘degraded or

demeaned’ by health care providers which often led to distancing themselves from health

care in general” (Leone et al., 2017, p.269). These studies examine the role of masculine

ideals and norms when men access or ignore health services indicating there may be a

destruction of value occurring (Vogel et al., 2011; Leone et al., 2017). However, there is a

gap in the transformative services literature, which this research addresses, on the role of

masculine identity in the destruction of value and diminishment of well-being when men

avoid accessing health services.

Reactance theory and health behaviours

Reactance theory is one psychological explanation for men’s motivations to noncompliance

or rejection of services (Fogarty, 1997; Greenberger and Strasser, 1986). In health literature,

reactance has helped explain why health warnings are ignored and positive health behaviours

rejected (Fogarty, 1997; Hall et al., 2016). Reactance theory proposes that in order to

recapture or prevent a perceived loss of freedom reactance motivates an individual to reject or

recapture that freedom or sense of control, in the case of patients through noncompliance

(Fogarty, 1997). Miller et al. (2006) found that psychological reactance was a predictor for

adolescents to reject antismoking messages and start smoking. When developing a

measurement scale for the reactance construct, Hall et al. (2016) found that reactance

weakens the effect of certain health warnings for smokers and non-smokers, like warnings on

a cigarette packet. When examining the role of social norms in the intentions of German

males when screening for prostate or colorectal cancer and the prediction of uptake of

screening behaviour, Sieverding et al. (2010) found irregular screeners with higher subjective

norms had lower likelihood of cancer screening and suggested this was reactance effects, and

that some subgroups reacted with reactance to perceived social pressure to participate in

screening. The study found that social norms play a significant role in men’s cancer

screening behaviour and intentions and therefore likelihood of reactance (Sieverding et al.,

2010). However, the study did not associate traditional masculine norms or masculine

identity with men’s social norms and their role in screening behaviour (Sieverding et al.,

2010). This research acknowledges that reactance might psychologically explain men’s

rejection of health services because of perceived threats to autonomy and control. However,

reactance does not fully explain the role of masculine identity when men are more likely to

reject a preventative health service than women which is the case for bowel cancer screening

(Australian Institute of Health and Welfare, 2017b, 2018). Additionally, from a services

perspective, if a consumer feels threat to freedoms or autonomy when engaging with a

service that is beneficial to their well-being, the value creation process has diminished

resulting in value destruction and reduced well-being, or well-being outcomes for the

consumer which warrant further investigation (Anderson et al., 2013; Grönroos, 2011).

Value creation and destruction in health services

In the emerging TSR domain, consumer well-being outcomes are the core focus when

examining interactions between consumers and services (Anderson et al., 2013; Gordon et

al., 2016). When service thinking is used in the design and delivery of social marketing

services, the consumer is invited to actively co-create value with the service instead of being

a passive recipient (Russell-Bennett et al., 2013; Vargo and Lusch, 2004). When the

consumer is a co-creator of the value of a service, such as a preventative health service, they

are usually participating and engaging with the service or service resource, increasing the

likelihood of improved consumer satisfaction and well-being (Black and Gallan, 2015;

Zainuddin et al., 2013). Co-creation of value between a consumer and health service enables

the consumer to be an active participant in their health care (Zainuddin et al., 2013; Vargo

and Lusch, 2004).

Plé and Chumpitaz Cáceres (2010) suggest that collaborative processes can equally destroy

value and well-being as create it. When resources that contribute to value creation are

accidentally or intentionally misused, mis-integrated, or if the value is not sustained or

integrated, there is a risk of value co-destruction and diminished well-being which negates

social marketing efforts (Plé and Chumpitaz Cáceres, 2010; Smith, 2013; Zainuddin et al.,

2017; Leo and Zainuddin, 2017; Plé, 2016, Lintula et al., 2017). When a consumer’s

consumption experience is devalued or diminished, and value perceptions reduced then value

is destroyed (Zainuddin et al., 2017). The destruction of value can occur from both the

actions or inactions of the service or the consumer entities (Plé and Chumpitaz Cáceres,

2010; Plé, 2016; Leo and Zainuddin, 2017; Anderson et al., 2013).

In preventative health contexts, if value is destroyed for consumers then loss of confidence in

the service, lack of engagement, lack of maintenance of positive health behaviours, and

potential negative effects on consumer well-being could result (Zainuddin et al., 2017; Leo

and Zainuddin, 2017). Given the low participation rates for health services such as bowel

cancer screening, this paper therefore focusses on the destruction of value rather than value

creation as the phenomena under investigation involves the avoidance of preventative health

services.

Theoretical discussion about the destruction of value in the value creation process is limited.

It could be argued that if a service is rejected or ignored, was there any value there to

destroy? Zainuddin et al. (2017) argue that while the absence of value creation does not

necessarily equate to value destruction, in a service context if the consumer’s consumption

experiences lead to diminished value perceptions, devaluation occurs. Consumer value

judgements of a good or service become more negative than positive and value is destroyed

(Zainuddin et al., 2017). Similarly, this research contends that when, after receiving the

service resource such as an FOBT kit, consumer value perceptions of the service are

diminished leading to rejection or ignoring the service, this has a negative impact on

consumer value creation, not a non-significant or redundant impact (Grönroos, 2011;

Zainuddin et al., 2017).

Value destruction

In the literature, when value is destroyed it is either referred to as value co-destruction (Plé,

2016; Plé and Chumpitaz Cáceres, 2010) or value destruction (Zainuddin et al., 2017; Gohary

et al., 2016; Leo and Zainuddin, 2017). Grönroos and Voima (2013) posit that value is

created by the consumer when using resources and that the process contributing to the

creation of value occurs in value spheres. Figure 2 demonstrates Grönroos and Voima’s

(2013) value creation spheres in the context of Australia’s National Bowel Cancer Screening

Program (NBCSP) distribution of Faecal Occult Blood Test (FOBT) bowel cancer screening

kits (Grönroos and Voima, 2013; Australian Institute of Health and Welfare, 2018). The

value spheres include the provider sphere, customer sphere, and joint sphere (Grönroos and

Voima, 2013).

In the provider sphere, potential value is created or facilitated by the provider, such as

creating and distributing the FOBT kit (Grönroos and Voima, 2013). Value is then created in

the customer sphere, as the customer chooses to either adopt a new behaviour or participate in

the service program, such as complete the FOBT kit (Grönroos and Voima, 2013). If the

customer chooses to reject or ignore the service, then value is destroyed, also occurring in the

customer sphere (Grönroos and Voima, 2013; Plé and Chumpitaz Cáceres, 2010). If the

customer chooses to accept the value proposition presented by the provider, such as complete

and return the FOBT kit for diagnosis, value creation moves from the customer sphere into

the joint sphere at the point where the customer sends the completed kit for diagnosis, thus

interacting with the provider (Grönroos and Voima, 2013; Australian Institute of Health and

Welfare, 2018). Therefore, this paper explores value destruction rather than value co-

destruction as the behaviour (avoidance of preventative health services) occurs in the

customer sphere (shaded section in Figure 2) and not the joint sphere (Grönroos and Voima,

2013).

Figure 2 Value spheres in bowel cancer screening using the National Bowel Cancer

Screening Program Faecal Occult Blood Test (FOBT) kit

Provider creates and distributes

FOBT kits

Customer receives FOBT kit in the

mail Customer completes kit and returns to

provider for diagnosis

Joint sphere Customer sphere Provider sphere

Customer does not complete FOBT kit

Providing service diagnoses completed

FOBT kit

Provider contacts customer with the result and options

(Grönroos and Voima, 2013; Australian Institute of Health and Welfare, 2018)

In preventative health contexts, the destruction of value for consumers will result in loss of

confidence in the service and lack of engagement or maintenance in help-seeking behaviour.

There are very few known empirical studies analysing value destruction or value co-

destruction in the health or preventative health context. Zainuddin et al. (2017) analysed

social media posts of participants relating to maintenance of positive mental and physical

health behaviours. The study identified barriers and facilitators to behaviour maintenance that

influenced value creation and value destruction (Zainuddin et al., 2017). Two barriers,

physical and mental discomfort, and time and effort, led to the destruction of both functional

and emotional value, and the lesser known epistemic value for participants trying to maintain

positive behaviour change for health (Zainuddin et al., 2017). Destruction of these value

dimensions risked behaviour abandonment (Zainuddin et al., 2017).

Value destruction in transformative health services for men

It could be argued that, where preventative health services seek to co-create value with male

consumers, there is a risk of value destruction and reduced well-being outcomes through a

misuse of organisational and consumer resources (Anderson, et al., 2013; Plé, 2016). Plé

(2016) identified 12 types of resources for consumers, such as emotional, temporal and

physical resources, which consumers can use when co-creating value with a service.

Resources can either be intentionally or accidentally integrated, not integrated, or mis-

integrated by services, service employees or customers to create or destroy value (Plé, 2016).

The literature shows that men’s previous negative experiences with health services have

served as barriers to future help-seeking (Leone et al., 2017; Weitzman et al., 2001). Equally,

the influences of masculine identity on men’s perceptions of value could build or destroy

value when accessing services, thus affecting men’s well-being. Unless there is an appealing

value proposition for men when accessing transformative services, and that value can be

maintained and not destroyed, men’s engagement with services will likely remain low.

To date, there is no known TSR literature examining the destruction of value through men’s

health behaviours and a lack of understanding of the role of masculine identity in creating or

destroying value for men’s help-seeking in transformative services such as preventative

health services.

Method

Research context

The context for this research was Australia’s National Bowel Cancer Screening Program

(NBCSP) (Australian Institute of Health and Welfare, 2018). Bowel cancer is the second

highest cancer cause of death in Australia, next to lung cancer, yet if treated in the earliest

stage has up to a 93% cure rate (Australian Institute of Health and Welfare, 2016; O’Connell

et al., 2004). Once men and women reach 50 years of age until aged 74 years, they

periodically receive in the mail a free Faecal Occult Blood Test (FOBT) kit to complete in

their home (Australian Institute of Health and Welfare, 2018). Since 2012 to 2015, only 36%

to 39% of those sent a kit completed the test and returned it, while 37% of males participated

in screening with the FOBT kit compared to 41% of females between 1 January 2014 and 31

December 2015 (Australian Institute of Health and Welfare, 2017a, 2017b). Overall in

Australia in the same period, men again had a lower participation rate than women

consistently through each age-group targeted; notably, just 26.4% in the 50-54 years age-

group participated in bowel cancer screening which is when the risk of bowel cancer starts to

increase, and screening behaviour should commence (Australian Institute of Health and

Wellbeing, 2017b).

Sample and data collection

This research used a qualitative design collecting data through five semi-structured focus

group interviews (N=39). A purposeful sample of thirty-nine Australian males aged between

50 and 74 years old was used. Focus groups occurred in a mix of metropolitan, regional and

remote locations. The context was male participation in the NBCSP. The sample was a

nominated sample of men who had not completed bowel cancer screening in five years or

more (Australian Institute of Health and Wellbeing, 2015). This criterion was indicative of an

aversion to accessing health services.

Data collection was part of a collaborative arrangement between Queensland Health and

Queensland University of Technology. As part of market research activities for an upcoming

state-wide social marketing campaign for bowel cancer screening, Queensland Health

implemented the focus groups for concept testing, permitting the researchers access to the

groups before and after the concept test stage. The researchers also contributed to the

development of the focus group guide and emailed participants information forms and

consent forms prior to the sessions. These forms were provided again to participants upon

arrival. Participants were also advised of their confidentiality rights according to the

Australian Market and Social Research Society (AMSRS) Code of Professional Behaviour

(AMSRS, 2019a).

The focus groups were semi-structured so the facilitator could probe or adjust phrasing to suit

the group. In order for the mature male participants to have minimal discomfort when discussing

bowel cancer screening and other personal health details and attitudes, a male facilitator moderated

all focus groups while the researchers observed the groups from another room through a video link

(Stewart et al., 2007). Participants were referred to by their first names only, encouraged to speak

freely and offered opportunity to contribute for each question. The facilitator was experienced in

focus group moderation and ensured dominant personalities did not hijack discussion. Each focus

group took a minimum of ninety minutes and participants were able to add further to

discussion at the end of the sessions. Queensland Health paid participants AUD$80 as an

incentive for their time and travel costs which is standard practice for market research participation

(AMSRS, 2019b).

Stimulus

The interview design for this research combined semi-structured focus groups with a

projection exercise in the form of individual handouts to be completed by each focus group

participant. The projection exercise was designed to reveal the masculine identities of each

participant through the use of 12 Jungian male archetypes (Mark and Pearson, 2001).

Through a third-person perspective, participants were asked to explain each archetype’s

screening behaviour and their likelihood to participate or not participate in bowel cancer

screening through the NBCSP. At the end of the focus group each participant was asked to

select the archetype they most identified with and explain why. The 12 male Jungian

archetypes were based on archetypes developed by Mark and Pearson (2001) for marketing

applications and were a useful typology to operationalise multiple masculine identities.

Procedure

Prior to focus group discussion relating to the archetype exercise, the male interviewer asked

participants general questions about their knowledge around bowel cancer screening, the

NBCSP and the Faecal Occult Blood Test (FOBT) kit, including whether or not they had seen

the kit or completed a kit. These questions enabled discussion among participants about their

own health beliefs and behaviours and facilitated the disclosure of different masculine

identities. Additionally, discussions during the concept testing for Queensland Health’s social

marketing campaign provided further opportunity for participants to self-disclose.

Participants were also given worksheets to complete during the sessions where they could

provide their selections of archetypes, and the archetypes’ health behaviours and emotions.

Questions included in the guide pertained to value destruction and emotions and were

designed to investigate how value is destroyed for different masculine identities when

considering accessing a service and the emotions triggered and regulated when presented

with a service resource, such as a FOBT kit (Tracy & Robins, 2011). For example: What do

you think this character’s attitude is to seeking help for health-related issues? and So why do

you think they would feel that emotion? Where does it come from? These questions were

designed to encourage participants to project their opinions of the different archetype’s health

beliefs and behaviours, including intentional or accidental mis-integration or misuse of a

service, without implicating themselves in the scenarios (Agee, 2009; Plé, 2016).

Analysis

Data analysis was a six-staged thematic analysis where inductive and deductive coding

generated themes from extant literature and then the data to understand the phenomenon

(Boyatzis, 1998; Fereday and Muir-Cochrane, 2006). Relevant codes inductively found in

theory and existing research pertaining to the theoretical frameworks of this research

informed a codebook (see Appendix A) (Boyatzis, 1998; Fereday and Muir-Cochrane, 2006).

This codebook was tested against the raw data to identify initial themes and add codes

(Boyatzis, 1998; Fereday and Muir-Cochrane, 2006). Data were scrutinised, constantly

comparing and sorting codes to get an understanding of what was being conveyed (Fereday

and Muir-Cochrane, 2006; Corbin and Strauss, 2008; Marshall and Rossman, 2016). Utilising

data management tool N-Vivo software and manual spreadsheet analysis of the projection

handouts, themes and patterns were identified (Fereday and Muir-Cochrane, 2006). Table I is

the participant profile table. Participant names have been changed to preserve anonymity.

To further ensure validity in the data analysis, the researchers acknowledge that upon

commencing the research they undertook this research aware that preconceived beliefs and

biases about men’s preventative health behaviours may have influenced the coding process

(Creswell and Miller, 2000). However, the six-staged thematic analysis of data ensured the

literature provided the theoretical framework for coding and interpretation, providing a more

analytical approach to data analysis (Crowe et al., 2015). The epistemology of the research

sits in the post-positive paradigm and regards all findings as true until proven false by

subsequent research (Guba and Lincoln, 1994).

Table I Participant profiles

Participant Name*

Occupation Relationship status

Parental status

Location Retirement status

Self-identified Archetype

1: Julian School teacher Single 1 adult child

Metropolitan

Semi-retired

Thinker

Participant Name*


Parental status



2: Morris Internal Auditor Married 3 children

Metropolitan

Previously retired

Regular Guy

3: Alf Engineer 2 children

Metropolitan

Caregiver

4: Garth IT Married 2 children

Metropolitan

Thinker

5: Frank Engineer Married 0 children

Metropolitan

Thinker

6: Karl Prison chaplain Separated 0 children

Metropolitan

Thinker/Creator

7: Harry Engineer/Military

Single NA Metropolitan

Retired Thinker

8: Dale NA Widowed 2 adult children

Metropolitan

Thinker

9: Gordon NA Married NA Metropolitan

Retired Innocent

10: Tom NA Married Yes Metropolitan

Retired Creator

11: Nigel NA Married 2 children

Metropolitan

Semi-retired

Caregiver

12: Grant Self-employed Married 2 adult children

Metropolitan

Not retired Explorer/Comedian

13: Noel Employed Married 2 children

Metropolitan

Not retired Thinker

14: Rick Employed Married 3 children

Metropolitan

Not retired Regular Guy

15: Gavin Employed Engaged 4 children

Metropolitan

Not retired Explorer

16: Doug Employed Married 8 children

Metropolitan

Not retired Thinker

17: Don Truck driver Divorced NA Regional Not retired Thinker18: Ryan Project Manager Married 2 adult

childrenRegional Not retired Thinker

19: Luke Titles office Single NA Regional Not retired Magician/Comedian

20: Joseph NA Partnered 3 children

Regional NA Thinker

21: Chad Handyman Married adult children

Regional Not retired Creator

22: Isaac Mechanic Partnered Regional Not retired Thinker23: Scott Steel Industry Separated 1 Adult

childRegional Not retired Thinker

24: Joel Financial advisor Married 2 adult children

Regional Not retired Thinker

25: Dwayne

Safety consultant Divorced Regional Not retired Caregiver

26: Troy NA Married 2 adult Regional Semi- Creator/Ruler

Participant Name*


Parental status



children retired27: Baz Military/Security Divorced Regional Retired Innocent/Regular

Guy28: Jimmy Aircraft refueler Married 2

childrenRegional Not retired Regular Guy

29: Neville Local Government

Married adult children

Regional Retired Innocent

30: Tim Plumber NA adult children

Regional Retired Thinker

31: Craig Self-employed Single (Gay) 0 children

Regional Not retired Explorer

32: Henry Community work

Married Remote Not retired Regular Guy

33: Ned City Council Married Remote Not retired Ruler34: Paul Employed Married 2 adult

childrenRemote Not retired Regular Guy

35: Bert Employed Married 2 children

Remote Not retired Regular Guy

36: George Dept. of Agriculture

Married 3 adult children

Remote Not retired Thinker

37: Alex NA Married Remote NA Explorer38: Bluey Shearer NA NA Remote NA Explorer39: Ben Employed Married 4 adult

childrenRemote Semi-

retiredRegular Guy

* Names are pseudonyms

Findings

Analysis of the projection exercise found that masculine identities identified as most likely to

destroy value and thus have negative health beliefs and behaviours were the Outlaw, the

Ruler and the Explorer. When asked to self-identify with an archetype, most participants

identified with the Thinker (15), which was predicted to have positive health beliefs and

behaviours. Social desirability may have influenced the self-identifying results as the exercise

occurred after the projection activities and discussion (Fisher, 1993). The Regular Guy (7)

and the Explorer (4) were the next archetypes participants most identified with. The Regular

Guy was predicted to have normative health behaviours in the projection exercise. Those who

identified with more than one archetype were not counted in the self-identification tally.

Three key themes were identified to explain why men destroy value by avoiding the use of a

preventative health service, namely, the free bowel cancer screening service. The themes

address the research question: Why does masculine identity generate value destruction and

diminished well-being in a preventative health service? The first theme is the reduction of

consumer disempowerment and emasculation, the second is creation of positive agency and

the third is the protection of the self through emotional suppression

1. Rejection of the service reduces consumer disempowerment and emasculation

The older Australian men in this study who deliberately avoided accessing a preventative

health service rejected attempts made by the government-run service to engage in the cancer

screening process. These men expressed a mistrust of the service, deliberately misused the

service resource, and perceived the service as undermining their physicality. The service

delivery approach was constructed by some men as related to their masculine identity,

leading to value destruction in two stages: firstly, when the men received the resource in the

mail and secondly, when they misused or did not use the resource (Plé and Chumpitaz

Cáceres, 2010; Plé, 2016; Courtenay, 2000).

The service’s process for delivering the resource, the bowel cancer screening kit, requested

men, who did not have a history of bowel cancer, to access the service by completing the

screening kit. Through completion and deployment of the resource, by posting the kit back to

the program, men were being asked to access a health service with a health enquiry even

though they believed they were well and did not need help (Australian Institute of Health and

Welfare, 2017b). There was an implication, because of their age, participants might be ill or

not healthy which is seen as a sign of weakness and so disempowers their masculine identity

(Chapple et al., 2004; Galdas et al., 2005; McVittie and Willock, 2006; Ricciardelli and

Williams, 2011). This is demonstrated in the following exchange:

Interviewer: “So tell me what you know about bowel cancer screening [or] heard prior to

today and how you’ve heard it.”

Harry: “Don’t need it. Send it back. It is a waste of time.”

Morris: “Junk mail.”

Garth: “I received a kit in the mail for my 50th birthday.”

Harry: “Oh aren’t you lucky!? (sarcastic) Well ‘Happy Birthday’!” (Laughter)

Additionally, accessing health services when well is regarded as a non-masculine or feminine

behaviour in relation to hegemonic masculine ideals (Ricciardelli and Williams, 2011;

Courtenay, 2000). Participants whose masculine identities aspired to the hegemonic

masculinity may have perceived accessing preventative health services when healthy as not

only contrary to their identity, but emasculating and disempowering (McVittie and Willock,

2006; Ricciardelli and Williams, 2011; Fleming et al., 2014). This is demonstrated in the

following quote:

“Because most blokes will do it themselves, but they don't like being told. You can ask me to

do something but if I don’t want to do it I’m not going to do it.” (Paul)

As a possible demonstration to regain control of their identity and avoid disempowerment,

participants often claimed to have tossed the screening kit into the rubbish when it arrived in

the mail or put it aside, left sitting in a visible position unopened. The service in this study,

the NBCSP, makes preliminary contact with eligible consumers, advising of the kit’s eminent

arrival, and encouraging consumers to complete and return the kit (AIHW, 2015). Therefore,

the disposal or ignoring of cancer screening kits is a deliberate misuse of the service

resources by participants where value is destroyed for the consumer.

Consumer well-being outcomes are diminished as participants are forfeiting the opportunity

to screen for potential disease which has a high cure rate if detected early (Anderson et al.,

2013; Australian Institute of Health and Welfare, 2017b, 2018; Zainuddin et al., 2017). This

action reflects Courtenay’s (2000) social constructionist perspective on gender and health

where men construct their masculine identity through their health behaviours. Men in this

study who deliberately and proudly discarded government funded cancer screening resources

appeared to do so as a means of empowerment and an attempt to exercise control over their

masculine identities. By rejecting and dismissing the health service’s attempts to engage, men

are constructing their gender in the masculine arena (Courtenay, 2000). This is demonstrated

in the following quote:

“If you come out with the big stick with the GP sort of saying you know ‘take the test, take

the test’, some people like me are going to say, ‘well nuts to you, I’m not going to do it’. Just

out of principle to say I don’t want to be forced to do it.” (Frank)

The men’s rejection of the service was conveyed by some as an act of control or regaining

control. Control, including control of the self, is central to masculine identity (Yousaf et al.,

2015; Galdas, 2009). Identity control theory supports Courtenay’s (2000) perspective

explaining why identity and behaviour are linked (Carter, 2014). How one conceptualises

one’s own gender in comparison to the gender roles in society, such as masculinities drawn

from hegemonic masculinity, influences actions that contribute to gender construction such as

health behaviours (Courtenay, 2000; Carter, 2014). One seeks to avoid negative emotions that

come from behaviour that is perceived as contradictory to the aspired gender role by

providing cues to oneself and others about what behaviour is acceptable, thus maintaining

control of one’s identity (Carter, 2014). When participants’ masculine identities are based on

the hegemonic, accessing health services such as cancer screening conflicts with gender

ideals where such behaviour is deemed as feminine or non-masculine (Courtenay, 2000), and

is rejected to retain control of their identity (Carter, 2014). This is demonstrated in the

following exchange when participants predict the opinions of the Outlaw archetype:

Frank: “Well I said ‘shame’ with regard to an Outlaw, because then he has to admit he’s not

as strong as people have perceived him to be.”

Interviewer: “What do you think his take could be on men who do complete this health kit?”

Morris: “Wuss.”

Harry: “Toughen up guys.”

These findings also support the literature on reactance where noncompliance is a strategy to

restore control and reduce perceived threats to freedom (Addis and Mahalik, 2003; Brehm

and Brehm, 2013; Fogarty, 1997). Additionally, disempowerment theory, where power is

asserted unconventionally by those at risk of feeling inadequate, could also be seen to explain

why participants reject preventative health options through deliberate misuse and dismissal of

the resource (McKenry et al., 2006). While usually applicable to relationships with domestic

violence, in this scenario participants jeopardise their own healthfulness to avoid

disempowerment (McKenry et al., 2006). Proclaiming the service to be “junk” or “rubbish”

and actively disposing of or misusing the screening kits, participants’ assertion of power is

counterproductive to their own well-being:

“I treated my kit as junk mail, just another piece of rubbish in the mail. Put it to one side.

Okay, my wife died of cancer, my mother died of cancer, my brother died of cancer and my

wife’s sister is dying of cancer. Still doesn’t make any difference to me. …I don’t see that as

applicable to me. I mean people try to say to me ‘give up smoking’ right, and some people

did and some people didn’t. It’s just a choice. (Stronger) You know, I want to live my life as

my life is and not plan for my dying…so yeah if I end up dying on chemo well that’s my own

fault. Look I don’t have to explain it.” (Morris)

In summary, when participants’ masculine identities were threatened by disempowerment

and emasculation, through loss of control of identity, value was destroyed in a degenerative

process at the potential cost of the men’s well-being. Value destruction first occurred when

participants perceived the delivery of the service resource and approach of the service system

to be a threat to their personal power. Value was destroyed further by participants who

deliberately misused the resource by discarding or not opening screening kits. While value

was destroyed, participants’ disempowerment was avoided and masculine identity, according

to participants’ self-conceptualisation, is controlled. This value destruction process resulted in

reduced well-being outcomes for participants as they were not receiving potential health

benefits from the early detection of disease.

2. Active rejection of resources creates positive agency

Many participants cited being too busy to complete their kits, put off by the complex self-

initiated procedure, resulting in kits unopened, discarded, or not completed. Therefore,

customer resources, such as time and effort, and service resources such as the FOBT kit, were

deliberately not integrated by participants in the value creation process (Plé, 2016).When

examining customer participation through a service-dominant logic perspective, Plé identified

up to12 potential customer resources that may be used in the value co-creation process. Three

of these customer resources, temporal, customer ability and customer willingness, were

required of participants in this study when approached by the NBCSP service, to facilitate

creation of value so improved well-being could occur (Plé, 2016). When the consumer

refuses to integrate their resources and the resources of the service in a value co-creation

process because of diminshed value perceptions, value is destroyed (Plé, 2016; Lintula et al.,

2017; Zainuddin et al., 2017).

Through the rejection of resources, participants’ demonstration of agency enabled value

destruction in the resources, positively positioning their masculine identity in relation to their

dominant masculine ideal. Past research on value destruction in the TSR domain has

identified the negative outcomes of the phenomenon for consumers (Zainuddin et al., 2017;

Leo and Zainuddin, 2017; Lintula et al., 2017; Čaić et al., 2018). However, data from this

research indicates a short-term positive benefit to the consumer from the destruction of value

which is compelling. Positioning theory posits one can actively create an identity to position

oneself or be positioned in relation to dominant or subordinate cultural or social discourses

such as gender (De Visser and Smith, 2006; Harré et al., 2009). Through the deliberate non-

integration of consumer and service resources, participants used negative health behaviours to

position themselves closer to the hegemonic masculine ideal of a ‘real man’ (De Visser and

Smith, 2006; Connell and Messerschmidt, 2005). For instance, Harry deliberately discarded

his screening kit as worthless, citing a belief that placing attention to preventative health

activities such as cancer screening would evoke the onset of disease:

“I’ve only seen the outside packaging. I haven’t opened it, I’ve put it in the bin…Waste of

time, effort, and money. If you focus on it [cancer], you’re going to attract it.” (Harry)

This destruction of value is also a demonstration of autonomy and control, where participants

exercise agency around their bodies and health outcomes. Agency is a key characteristic of

masculinity as it facilitates personal power and autonomy (Connell and Messerschmidt, 2005;

Pietraszkiewicz et al., 2017). The literature has shown that agency is usually positively linked

to well-being and healthy behaviours (Hammarström et al., 2015; Pietraszkiewicz et al.,

2017; Sloan et al., 2015). Independence and decisiveness are usually positive or socially

desirable agency traits (Bartz and Lydon, 2004; Sloan et al., 2015). However, when

participants in this research demonstrated agency through active rejection and destruction of

the service resource, such behaviour could be seen as negative, having a detrimental effect on

well-being. Nonetheless, participants exercised this agency to positively position themselves

closer to the hegemonic ideal; stoic, tough and resilient, without apparent concern for their

health or well-being (Courtenay, 2000). This is demonstrated in the quote below:

“No, I've never taken it [the FOBT] though. If I get cancer, I don't want any treatment. In

fact, I’ve signed an enduring medical directive to say don’t give me anything. (pause) In

actual fact, I don't want to know.” George

3. Supressing negative self-conscious emotions protects the self

Self-conscious emotions of shame, embarrassment, guilt, and pride were identified by men in

this study when discussing their health behaviours, the behaviours of male family members,

and the projected behaviours of male archetypes (Tracy and Robins, 2004). In particular these

emotions were a self-protection strategy that led to value destruction. This is demonstrated in

the quote below which refers to the Hero archetype:

“I had because of embarrassment. The Hero is everyone’s hero and he wants to be seen as

everyone’s hero and this is not a terribly heroic thing. Collecting your poo and putting it in a

thing is not a particularly heroic image. So, the hero doesn’t to do that, he doesn’t want to be

seen to have that vulnerability there.” (Rick)

Some men cited potential feelings of guilt and shame as deterrents to accessing the screening

service as the prospect of a cancer diagnosis would be seen as a weakness or result in failing

to be the main family support. Participants suppressed embarrassment and shame associated

with the screening process by avoiding using the screening kit, while some boosted their

pride by enacting masculine ideals like stoicism and toughness also through the avoidance

and rejection of the cancer screening service, thus destroying its value through emotion

regulation (Gross, 2002). This is demonstrated in the following exchange when participants

discuss the health behaviours of the Ruler archetype:

Interviewer: “What are some other words there around the Ruler?”

Doug: “Arrogant.”

Rick: “Ego”

Grant: “Who is the boss? I’m bulletproof. I don’t need that.”

Noel: “So I wouldn’t take the test.”

Tracy and Robins’ (2004) model for the process of self-conscious emotions places identity

goal congruence and incongruence as respective triggers for positive and negative self-

conscious emotions. As identity goals such as masculinity are learned or constructed usually

early in life and then throughout life, they would most likely dwell in System 1 thinking

according to Kahneman’s (2011) theory of two-system thinking, prompting automatic

responses such as self-conscious emotions when they are either threatened or reinforced

(Kahneman, 2011; Connell, 1995; Courtenay, 2000). For instance, Troy’s father’s System1

thinking automatically generated the self-conscious emotion pride, which prevented him from

considering health advice from his family:

“My dad died of prostate cancer. And my mum and myself, we could not get him to move to

even go and get it looked at. But his best mate at work, who was the last one to find out, was

the one that moved Dad. So, if you understand kind of what I mean. When it’s fellas, when

it’s guys, I think it’s a different kettle of fish. And because Dad was the patriarch of the

family, the last thing he was going to do is have Mum, or my sister, or me or anybody telling

him how he should be running his life or his family.” (Troy)

The rejection or delayed use of a health service could be seen as a behavioural response to

suppress negative self-conscious emotions to protect the participants’ sense of self which is

generated by their masculine identity (Tracy and Robins, 2004; Gross, 2002).

Based on Norman et al.’s (2003) protection motivation model, the drive to protect the self

usually applies to positive health behaviours that protect the body. However, the need to

protect masculine identity can be a stronger need than mature men’s health needs (Courtenay,

2000). Participants’ strategies to regulate emotion through behaviour responses destroyed

value of the service as failing or delaying to use the kit could result in the unknown onset of

disease, deleterious to their well-being (Plé and Chumpitaz Cáceres, 2010; Gross, 2002). Men

therefore appear to use the emotional regulation strategy of suppression (Gross, 2002) to

avoid experiencing the negative self-conscious emotions that conflict with their masculine

identity (Tracy and Robins, 2004). When negative emotions are suppressed, well-being is

reduced as positive emotional experiences, such as relief from a clear health check, are also

reduced (Gross, 2002). For instance, when predicting the self-conscious emotions the Outlaw

archetype might experience when receiving a bowel cancer screening kit in the mail, some

participants speculated the Outlaw would feel shame and not use the kit, attempting to hide

any weaknesses:

Grant: “Shame. He doesn’t want to be found out. He’s tough and strong and doesn’t want to

be exposed.”

Tom: “He’s trying to hide”

Interviewer: “What is he trying to hide do you think?

Doug: “His image.” (agreement from the group)

…

Noel: “There’s no kryptonite for him”

Gavin: “If he is, that would be weakness if he was sick.”

A summary of how masculinity can destroy value and reduce well-being in mature men’s

preventative health is shown in Figure 3. The findings indicate that for some men, a

hegemonic masculine identity destroys value in a preventative health service by allowing

men to maintain a sense of control, create agency and protect the self.

Figure 3 Destruction of value for men’s well-being in preventative health

Diminished well-being in mature men’s preventative

health

Masculine identity

Destruction

of value

Theoretical implications

This study contributes to the scarce literature on value destruction for service systems (Plé

and Chumpitaz Cáceres, 2010; Lintula et al., 2017). The research provides a new perspective

on the phenomenon as value destruction has been shown to be a mechanism by which male

consumers restore homeostasis in their gender identity when encountering preventative health

services. This equilibrium reinstatement can be explained by two theoretical contributions:

firstly, value destruction restores psychological control, and secondly, value destruction is an

emotion regulation strategy.

Value destruction restores psychological controlTo avoid disempowerment and emasculation from contravening their masculine ideals the

participants in this research were likely to misuse resources, thus regaining control of their

health behaviours. Previous empirical studies and theorists in the health, psychology and

gender fields of study have established that control, including physical, emotional, and

identity control, is central to traditional masculine identity (Yousaf et al., 2015; Galdas, 2009;

Courtenay, 2009; Carter, 2014). To date, value destruction or value co-destruction has not

been examined in the services field from the perspective of consumer gender identity.

Palumbo (2017) has theorised that while patient disempowerment can discourage some

patients’ participation in value co-creation, patient empowerment can lead to value co-

destruction in a healthcare setting. Palumbo’s (2017) position is drawn from the service-

dominant logic perspective which assumes the consumer and service interact to co-create

value (Vargo & Lusch, 2004). This research examines value destruction occurring in the

customer sphere according to Grönroos and Voima’s (2013) value spheres. The destruction of

value sits with the consumer as a means to reduce disempowerment.

Additionally, participants’ rejection of the service and refusal to contribute their own time

and effort (Plé, 2016) destroyed value to create the perception of agency. This noncompliance

has parallels with the reactance literature that finds similar responses when patients have

perceived threats to freedoms (Fogarty, 1997). Our findings go beyond prior research using

reactance theory to add further explanation for men’s non-participation in preventative health

services. Specifically, we found for men whose masculine identity aspired to the hegemonic,

traditional masculine ideals had a role to play when rejecting or ignoring a preventative

health service. Value destruction not only explained reclaiming of perceived freedoms, it also

explained restoration of men’s masculine identity according to the hegemonic ideals of

stoicism, self-reliance and control in preventative health contexts. In addition to the

importance of masculine identity as an explanation for non-participation in health screening

services, this research also identified the suppression of emotions (emotion regulation) as an

additional mechanism. Gender and psychology literature has also found that agency is a key

characteristic of hegemonic masculinity as an enabler of personal power and autonomy

(Connell and Messerschmidt, 2005; Pietraszkiewicz et al., 2017). To date, consumer

perceptions of agency has not been identified in services literature as a driver for value

destruction.

Value destruction as an emotion regulation strategy

Masculine identities in this research suppressed negative self-conscious emotions such as

guilt or embarrassment, or boosted positive self-conscious emotions such as pride, by

rejecting or misusing the resource through value destruction, thus maintaining dominant

masculine ideals. Protection or maintenance of masculine identity in relation to traditional

masculine ideals through regulation of self-conscious emotions and subsequent destruction of

value was more important for some masculine identities than their physical health and well-

being. Psychology literature has found identity congruence to be influential in emotion

regulation such as suppression or reappraisal (Tracy and Robins, 2011; Gross, 2002). Tracy

and Robins (2011) state that to avoid experiencing negative self-conscious emotions such as

shame or guilt, one may reappraise an event as incongruent with their identity, such as

reappraising positive help-seeking behaviours as contradictory to masculine ideals, thereby

justifying value destruction. Gross (2002) found that, in emotion regulation, reappraisal is

more beneficial emotionally long-term to suppression. In this research, the masculine

identities who suppressed their negative self-conscious emotions through continued rejection

of the service and destroying its value, rather than reappraising the service to align with

masculine ideals, were foregoing improved well-being in order to protect and maintain their

hegemonic masculine ideals.

While Zainuddin et al. (2017) found that for consumers of social marketing services,

emotional value along with functional value and even epistemic value can be destroyed by

barriers to behaviour maintenance in a value destruction process, the existing service research

investigating value destruction or value co-destruction has not yet examined the role of

emotion regulation in value destruction (Lintula et al., 2017).

Managerial implications

This research aims to provide practitioners and service providers greater understanding of the

potential risks to well-being through value destruction processes in service encounters. Three

practical approaches that leverage the revealed themes are suggested: foster consumer

empowerment when accessing services, develop consumer resources to create positive

agency, and boost positive self-conscious emotions by promoting positive social norms.

Foster consumer empowerment when accessing services

While health services seek to engage with consumers, consideration as to where points of

contact occur with older men could minimise disempowerment and threats to masculine

identities. Participants expressed a preference to being approached by their doctor about

preventative health options. Additionally, in this environment when an individual’s

perception of free choice and control is maximised, thus sustaining their involvement,

reactance will likely be reduced (Fogarty, 1997). Social marketing activities such as mass

media and targeted campaigns could encourage older male consumers, through empowering

messages and imagery, to initiate contact with their doctor or health service provider where

they are presented with health service options, such as cancer screening, thus gaining

empowerment and retaining control of their masculine identity. This could be supported by

clinicians and service providers who ensure perceptions of control and free choice are

maintained in service delivery. Hall et al. (2016) found that imagery rather than text warnings

were more effective to motivate smokers to quit. However, reactance could weaken their

impact if they conveyed a threat to freedoms (Hall et al., 2016). If during consultation the

consumer choses to decline the services offered, there is still an opportunity for direct

interpersonal communication and exchange between service provider and consumer,

minimising reactance and the potential for value destruction (Fogarty, 1997; Zainuddin et al.,

2017).

Develop consumer resources to create positive agency

To ensure consumers use their own resources such as time and effort in a value co-creation

process, health services could assure consumers through social marketing activities that their

resource contribution was of value, thus adding to their eudaimonic well-being (Anderson et

al., 2013). Activities could include simplified instructional devices and positive targeted

communications aimed at boosting consumer confidence in accessing and using service

resources and reducing stigma related to hegemonic masculine ideals. Services could also

aim to interact directly with male participants, inviting them to connect with services earlier

and become co-creators of value with consumers rather than services just being value

facilitators (Grönroos and Voima, 2013). For instance, the NBCSP has only several indirect

interactions with consumers in the value creation process including a generic introductory

letter and the FOBT kit delivery (Australian Institute of Health and Wellbeing, 2017b). The

program could compliment service delivery with a personalised direct communication one

month after kit delivery, such as a phone call or personal email, to confirm the kit arrived and

the consumer understands what is involved in completion.

Boost positive self-conscious emotions by promoting positive social norms

Health services should aim to avoid triggers of negative self-conscious emotions through

messaging that prompts shame or guilt responses, and instead influence positive self-

conscious emotions in older men such as pride and empathy when accessing health care

(Tracy and Robins, 2004). Government messages that are perceived as manipulative,

prompting negative emotions such as guilt, can also be met with reactance (Hall et al., 2016;

Miller et al., 2006). For instance, rather than using shame and guilt appeals in emotive

campaigns that discourage negative health behaviours, social marketing approaches could

utilise positive health messages delivered by peer influencers and establish social norms

among men where preventative health screening is acceptable. These social norms could be

spread through men’s health programs such as Movember and Men’s Sheds (Australian

Men's Shed Association, 2018; Movember Foundation, 2018).

Limitations and future research directions

The first limitation of this research was the use of the single context to identify value

destruction in men’s preventative health behaviours. The Australian National Bowel Cancer

Screening Program (NBCSP) is one of the few preventative health programs freely available

to males which has consistent epidemiological surveillance of program use (Australian

Institute of Health and Welfare, 2018). However, the program is only available to males and

females aged 50 years to 75 years, and surveillance does not include other similar bowel

cancer screening services such as Bowel Cancer Australia’s Faecal Immunochemical Test

(Bowel Cancer Australia, 2019; Australian Institute of Health and Welfare, 2018).

Additionally, females also have low participation in the program, although not as low as

males (Australian Institute of Health and Welfare, 2017b, 2018) which indicates masculine

identity is not the only explanation for noncompliant behaviours. Future research could

investigate the role of value destruction and other identities, such as feminine identities or

cultural identities in the destruction and co-destruction of value in services. For instance,

Indigenous services, women’s screening services and services targeting other vulnerable

cohorts. From a men’s health services perspective, further research could examine the role of

masculine identity and value destruction in other preventative health contexts and with men

from different age-groups such as prostate cancer screening, testicular cancer screening,

sexual health behaviours or alcohol and drug abuse. The Australian Medical Association has

called for more research and initiatives to develop improved access to services and increase

awareness-raising of services for men (Australian Medical Association, 2018).

The second limitation of this research was the use of focus groups for data collection. Focus

groups may not be considered as naturalistic as other qualitative forms of data collection such

as observational or ethnographic data collection, as the focus groups occur at a set venue and

not in the participant’s everyday life (Marshall and Rossman, 2016; Tausch and Menold,

2016). However, insights around health beliefs and preventative health behaviours such as

bowel cancer screening are unlikely to be revealed in a participant’s everyday life

(Wilkinson, 1998). There is also a risk of dominant personalities affecting group dynamics

and influencing responses or that participants may not be comfortable disclosing personal

details about their health behaviours. To reduce these risks, the researchers assured

participants verbally and through an information flyer sent prior to group attendance that

disclosures were confidential and identifiable data would be anonymised. Any potential

undesirable group dynamics were adeptly managed by an experienced focus group facilitator

who ensured fluid group discussions. However, while the group dynamics of the focus group

enabled fluid discussion, there was also a possible risk of social desirability bias occurring

when it came time for participants to self-identify with an archetype in the projection

stimulus (Fisher, 1993). The Thinker was the archetype most favourably discussed before this

task as sensible and analytical. This archetype was then selected most often in the self-

identification stage. This may have been minimised if participants were asked to select the

archetype they align with before focus group discussions began.

The third limitation of the study was the uncertainty about the classification of an individual

who ignores or rejects a resource, such as a health screening kit as value destruction. Value

destruction first requires value to be created (Plé and Chumpitaz Cáceres, 2010) and it is not

clear whether value creation has indeed occurred before a screening kit remains unused. This

research has followed the argument of Zainuddin et al. (2017) that when a consumer's value

judgements of a service are diminished during their consumption experience, then value

destruction has occurred. This research assumes that value has been created by the consumer

upon receipt of the kit, as part of their value consumption experience (Grönroos, 2011);

however, this assumption was not explicitly tested. Further research is needed that takes a

process approach to the use of kits to more clearly illuminate the value process and perhaps

distinguish different pathways of responses to the receipt of kits: value creation, value

destruction and zero value creation. This is a new path in transformative service research that

would benefit from further investigation and clarification.

Masculinity has a significant influence on men’s health-related behaviours (Courtenay, 2009;

Doyal, 2001; Courtenay, 2011). The health beliefs and behaviours of females who adhere to

masculine norms, masculine women, can also be negatively affected by traditional

masculinity (Untal, 2016). However, this research refers to the health beliefs and behaviours

of biological males, or men, as health statistics referred to in this article, including Medicare

and cancer incidence data pertain to the male or female sex, not genders (Australian Bureau

of Statistics, 2017a; Australian Institute of Health and Welfare, 2017a). To date, in

preventative health contexts sex and gender have identical classifications, particularly in

epidemiological data collection (Australian Institute of Health and Welfare, 2017a;

Australian Bureau of Statistics, 2017b; Australian Bureau of Statistics, 2017a). Future

research examining effects of masculinity on health behaviours could accommodate the

different identifications to nonbinary genders (Whyte et al., 2018).

Conclusion

This paper has introduced the lens of gender identity, specifically masculinity, to

transformative service research and the role masculinity plays in value destruction and

diminished consumer well-being in preventative health services. Demonstrating that the

masculine ideal of toughness is not necessarily terrific for men’s health, this paper has

provided an empirical contribution to better understand the motivations and barriers for

mature men when accessing transformative services when they are healthy, and the complex

yet fundamental role the construction of masculine identity can play in men’s health

behaviours. This research has identified three key themes linking masculine identity to the

destruction of value when mature men access or refuse to access preventative health services;

avoidance of disempowerment and emasculation by maintaining control, creation of positive

agency, and suppression of negative self-conscious emotions. Some practical managerial

solutions linked to these themes that utilise social marketing solutions are offered which, if

implemented, would contribute to the improved future well-being of mature male consumers

of transformative services by minimising value destruction. Theoretical contributions to the

emerging TSR literature on value destruction include value destruction as a strategy to restore

balance in men’s masculine identities in men’s preventative health through firstly facilitating

psychological control, and secondly enabling emotion regulation.

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Appendix A

Sample of codebook

Research Question: Why does masculine identity generate value destruction and diminished

well-being in a preventative health service?

Table AI Sample of codebook

Code Common words/phrases

Description of how to identify the code

Customer value type (Holbrook, 2006; Russell-Bennett et al., 2009; Vargo et al., 2008)Customer value: Extrinsic (Holbrook, 2006)

Economic value I will do the test because it is free

Social value I am setting an example to other blokes by doing the test

Customer value: Intrinsic (Holbrook, 2006) Self-oriented value

Hedonic value Doing the test makes me feel good about myself/ gives me peace of mind about my health

Other-oriented value

Altruistic value Doing the kit will make my family feel better/ saves the state money further down the track

Customer Value: (Russell-Bennett et al., 2009)

Social value I felt it was my duty to do the test

Emotional value It will be relief to know the results / it is better not to know the results

Functional value It is free / easy to do the testAltruistic value It is the right thing to do…

Value creation (Dann, 2010;Vargo & Lusch, 2004; Lusch & Vargo, 2006; Russell-Bennet et al., 2009; Vargo et al., 2008; Grönroos & Voima, 2013)Creation of value

Create value It was worthwhile completing the kit

Co-create value They/The Government sent me the kit so I completed it and sent it back to them for their diagnosis

Code Common words/phrases

Description of how to identify the code

Pre-consumption I expect my kit will arrive soon../ I haven’t received a kit

Consumption I took the samples required..Post-consumption Once I received my test results..

Value destruction & co-destruction (Plé & Chumpitaz Cáceres, 2010; Smith, 2013; Zainuddin et al., 2017; Leo & Zainuddin, 2017)Destruction of value

Devaluation I gave up on screening..

Value destruction It was too messy/complicated to do the kit / I didn’t understand what I had to do

Value co-destruction

I didn’t like being told to do it so I didn’t do it

Value destruction process (Leo & Zainuddin, 2017; Zainuddin et al., 2017; Plé & Chumpitaz Cáceres, 2010)

Incongruent resource application: mismatch of resources with needs

The information provided was difficult to understand / the testing process was confusing for me

Misuse of resources

Misuse of firm resources: Accidental misuse

They sent me this kit and I don’t know how to do it

Intentional misuse They sent me this kit and I haven’t heard anything more about it

Discomfort Physical discomfort

The process of taking a sample is uncomfortable

Mental discomfort Completing the kit is stressfulTime & effort Time It takes too long to do the test/take samples

Effort It is awkward and messy doing the test

Note: Not all codes utilised in this study are presented here. This sample codebook merely provides examples of how to identify value destruction.

Appendix B

Stimulus for projection exercise:

Character Description Motto Goal Fear Personality/Icon Screen? The Innocent The Innocent believes that life does

not need to be hard. The Innocent promises that you can get out of the fast lane and truly enjoy your life.

“Free to be you and me” To be happy Doing wrong Tom Hanks, Forrest Gump, Disney, Mickey Mouse

The Explorer The Explorer, by nature, goes out seeking a better world. Motivated to a deep desire to find out what in the outer world fits with their inner needs.

“Don’t fence me in” (or “Take this job and shove it”)

To experience a better, more authentic and fulfilling life

Becoming trapped

Star Trek, The Lone Ranger, Harry Butler

The Thinker The Thinker has his own way of finding paradise. He has faith in the capacity of humankind to learn and grow in ways that allow us to create a better world. In the process he wants to be free to think for himself and hold his own opinions.

“The truth will set you free”

To use intelligence and analysis to understand the world

Being duped, misled or ignored

X-Files / Fox Mulder, Dick Smith, Al Gore, Albert Einstein

The Hero The Hero saves the day when everything seems lost. He triumphs over evil, adversity or a major challenge. In doing so he inspires others. Heroes generally want to make the world a better place.

“Where there’s a will, there’s a way”

Exert mastery in a way that improves the world

Weakness, vulnerability and wimping out

Nelson Mandela, John F. Kennedy, Luke Skywalker, Steve Irwin, Donald Bradman.

The Outlaw The outlaw is enticed by forbidden fruit. He likes getting away with things. If he can’t get what he wants in a healthy and socially acceptable way, he my turn to illegal or unethical strategies. AKA The Rebel

“Rules are meant to be broken”

To destroy what is not working

Being powerless

Billy the Kid, Ned Kelly, Rambo, Robin Hood

Today’s date Group start time Location Your first name:

Character Description Motto Goal Fear Personality/Icon Screen? The Magician Searches out the laws of how things

work and applies these principals to getting things done. Most likely uses his powers or skills to heal the mind, heart and body. Also seeks out the fountain of youth and secret to longevity. Motivated by personal transformation.

“It can happen” To make dreams come true

Unexpected negative consequences

Yoda, Darth Vader, Gandalf, Merlin, Wayne Bennett, Deepak Chopra.

The Regular guy/gal

An ordinary person, just like everyone else. Working class and wears ordinary attire and is put off by elitism.

“All men and women are created equal”

To belong and fit in

Standing out, appearing ‘a tosser’ and being rejected as a result

The Castle/ Michael Caton, Johnathan Brown (AFL), the Unknown Soldier, Paul Newman

The Lover The Lover gives all sorts of human love – parental, friendship, spiritual. Romantic love is the most important. Always active in intense and personal relationships. The Lover is appreciative of others but dislikes competition.

“I only have eyes for you”

Being in a relationship with people

Being alone, a wall flower – unwanted or unloved

Cary Grant, Richard Gere, Casablanca/ Humphrey Bogart, The Great Gatsby/Jay Gatsby

The Comedian Anyone who loves to play or act up. The Comedian calls us to come and play with each other. They enjoy life and interaction. They love being the life of the party!

“If I can’t dance, I don’t want to be part of your revolution”’

To have a great time and lighten up the world

Boredom and being boring

Chevy Chase, Will Farrell, Graham Kennedy, Rodney Rude, Shane Bourne, Roy and HG

The Caregiver The Caregiver is compassionate and generous and wants to help others. They fear instability and difficulty not so much for themselves but for others. Their worst fear could be something happening to a loved one.

“Love your neighbour as yourself”

To help others Selfishness and ingratitude

Bob Hope, Fred Hollows, Tim Costello, Mrs Doubtfire/ Robin Williams

Character Description Motto Goal Fear Personality/Icon Screen? The Creator Often seen as the artist, the writer,

the innovator or the entrepreneur. Their passion is self-expression in material form. They are often compelled to create or innovate – anything else and they feel stifled. Can express creativity in their clothing, homes and offices. Can be very self-critical.

“If it can be imagined, it can be created”

To give form to a vision

Having a mediocre vision or execution

Richard Branson, Pro Hart, Bret Whiteley, Ric Birch, Baz Luhrmann

The Ruler The Ruler knows the best thing to do to avoid chaos is to take control. It is also the best thing to do to keep one’s family and friends safe. The Ruler understands that the way things look can enhance powers – so is interested in things of status and prestige. Can be a King, corporate CEO, president or prime minister of a country.

“Power isn’t everything. It’s the only thing”

Create a prosperous, successful family, company or community.

Chaos and being overthrown

Rupert Murdoch, Bill Gates, George W Bush, Barack Obama, Kerry Packer.

Likely screener Driving emotion to screen Likely non-screener Driving emotion not to screen

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Select from these emotions: SHAME, GUILT, PRIDE, EMBARRASSMENT, JEALOUSY, EMPATHY, ARROGANCE

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