Promoting Adolescent Males' Health: Utilization of School-Based Youth Health Centers in Nova Scotia, Canada

Jacqueline C Gahagan^*, Timothy Jason^* and Carly Pender

School of Health & Human Performance, Dalhousie University, 6230 South Street, Halifax, NS Canada B3H 3J5

*Corresponding Authors:

Dr. Jacqueline C.Gahagan
School of Health & Human Performance
Dalhousie University, 6230 South Street
Halifax, NS Canada B3H 3J5
Tel: (902) 494-1155 or (902) 402-4295
Email: Jacqueline.Gahagan@dal.ca

 

Timothy Jason
School of Health & Human Performance
Dalhousie University
6230 South Street
Halifax, NS Canada B3H 3J5
Tel: (902) 494-1155 or (902) 402-4295
Email: researcher.analyst.tj@gmail.com

Received date: November 11, 2011; Accepted date: December 08, 2011; Published date: December 10, 2011

Citation: Gahagan JC, Jason T, Pender C (2011) Promoting Adolescent Males’ Health: Utilization of School-Based Youth Health Centers in Nova Scotia, Canada. J Community Med Health Edu 1:112. doi:10.4172/2161-0711.1000112

Copyright: © 2011 Gahagan JC, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Visit for more related articles at Journal of Community Medicine & Health Education

Abstract

The purpose of our mixed-methods study was to explore adolescent males’ perceptions of health service needs, utilization of youth health center services, as well as perceived barriers and facilitators to such utilization. The qualitative phase included interviews with educators and service providers, as well as youth of both sexes in order to gain preliminary information regarding the broader contextual issues related to males’ use of youth health centers. In-depth interviews were followed by separate focus group discussions with youth, health and social service providers, teachers and educators. The focus group discussions produced a number of key themes believed to influence youths’ decisions to access youth health centers, including: perceptions of help-seeking as a gendered social practice, lack of knowledge regarding the range of services offered by youth health centers, perceived stigma, and finally concerns related to issues of confidentiality and anonymity. Based on the qualitative analysis, the emergent themes were used to inform the development of a 76-item self-completion survey designed to provide an aggregate of male students’ perceptions of factors related to their use of youth health centers. Although more than 50% of the male respondents reported that they would feel comfortable using youth health center services in their school, only 16.5% had ever accessed a center, and only 5% indicated frequent use. The findings of this mixed methods study indicated a tension between certain gendered beliefs or what students should do in the event of a presenting health concern and intention or what students would do in the event of a health issue. This tension is governed, in part, by well-established gendered social norms and expectations regarding health seeking behaviors. Results also suggested a potential role for teachers and parents in further promoting youth health centers. Creating a supportive environment for male youth and normalizing male utilization of youth health centers represent necessary steps to addressing males’ chronic underutilization of these important services.

Keywords

Male adolescents; Youth health centers; Use of health services; Health seeking behaviors; Underutilization of health services; Gendered social norms; Mixed methods

Introduction

Despite calls for increased knowledge about adolescent males’ use of health services, including youth health centers (YHCs), limited evidence exists to assist policy and programming staff in augmenting access and use among this population. This remains an important public health issue particularly in relation to the fact that adolescent males are at greater risk (than females of the same age group) for alcohol use and related harms, accidental trauma, and violence including selfharm [1,2]. Males also contribute to the spread of sexually transmitted infections (STIs) and unintended pregnancies, which present serious concerns for female sexual partners [3-5].

Previous research has identified certain barriers to healthcare utilization by adolescents such as concerns related to privacy and confidentiality [6,7]. Importantly, adolescents who avoid healthcare for privacy reasons are at increased risk for depression, unwanted pregnancy, and STIs [8]. Additional barriers have been identified in the literature including gendered social norms [9,10] as well as deficits in knowledge about services [11]. School-based YHCs are noted in the literature as a potentially effective means of supporting at-risk youth in meeting their healthcare needs [12]. YHCs have been introduced in several communities in an effort to help address prevailing structural barriers among adolescents such as proximity to mainstream health services.

The province of Nova Scotia, situated on the east coast of Canada, currently has a network of 52 school-based and school-linked YHCs, which offer a wide range of services and programs such as health promotion and counseling [13,14]. In the Cape Breton District Health Authority (CBDHA) region of Nova Scotia, YHCs provide physical, mental, reproductive, and preventive health services to students at several high schools in rural and urban Cape Breton communities. Despite the proximity of YHCs to in-school students, male students rarely use these important health services [15].

The purpose of this exploratory, mixed methods study was to examine adolescent males’ utilization of YHCs in the CBDHA region. Both qualitative and quantitative methods were employed to better understand both the micro- and macro-level contextual factors associated with adolescent males’ health seeking behaviors, as well as low rates of YHC utilization. Specifically, this study sought to address the following research questions:

1. What are males’ perceptions of health service needs, acceptance of YHC services, and barriers to and/or facilitators for YHC use? and 2. How do these perceptions and barriers affect actual usage and intention to use YHCs?

Determining the perceptions associated with males’ use of YHCs can provide valuable information for informing local health policy and programming decisions concerning how to improve access to YHCs for male adolescents.

Materials and Methods

Phase 1: Qualitative

In the initial qualitative phase of this study, the research team utilized a variety of available channels to inform potential participants about the purpose of the research. Educators and health/social service providers were recommended by participating community partners and collaborators based on their knowledge of YHCs and adolescent health. In addition, information about the study was posted and circulated among YHC staff. Youth, educators and health/social service providers were instructed to contact the project coordinator for information about the study and to schedule an interview. The project coordinator selected specific dates, times, and locations and confirmed these with interested community partners/collaborators. Additional information about the study, along with an information sheet about the study, was provided to potential participants at the start of in-depth interviews and focus groups.

The interviews and focus groups commenced once participants provided their informed consent. The interviews were recorded and transcribed verbatim with all personal, identifying information removed prior to analysis. Transcripts were then coded to facilitate data management and analysis. The constant comparative method of analysis was used, which involved simultaneous inductive and deductive analyses. Conceptual labels and codes were conceived and organized into a codebook used during the analysis, which assisted in identifying key themes and patterns in the data. Based on the key issues to emerge from interviews with male (n=22) and female (n=25) youth, teachers and educators (n=3), and health and social service providers (n=4), the initial interview guides were subsequently revised by members of the research team for use with the focus group sessions with each of three groups: health and social services providers (n=4), teachers and educators (n=3), and male youth (n=8).

Phase 2: Quantitative data

Based on key themes to emerge from the qualitative analysis, a survey instrument was developed and pilot-tested to assess its utility. A sub-sample of male students1 in grades 10, 11, and 12 at one of 16 high schools in Cape Breton were asked to voluntarily complete the survey and provide written comments regarding the overall layout, content and readability of the instrument. One week later, the survey was re-administered to the same students who were again asked to provide feedback on its layout, content and readability. The survey was revised following pilot testing to enhance the clarity of instructions as well as improve the layout and readability of the questions. The structure and design of the survey and individual likert-scale questions directly reflected and represented consistent themes that arose during the qualitative phase. For example, certain questions were purposely constructed and revised to represent the theme of gendered norms and help seeking (“I think that most males who get sick should try to tough it out”). Given that the purpose of this survey was to provide policy and programming stakeholders with aggregate descriptive statistics on YHC utilization among a large sample of male youth that would complement the qualitative findings, the psychometric properties of the instrument during the pilot test phase were not assessed. However, a full psychometric analysis of the survey in order to establish its utility in future research is underway and will be presented in a subsequent paper.

Male participants for the final data collection were recruited from four schools located within the CBDHA, a region in the north east of Nova Scotia. We used a non-probability sampling technique that included all eligible and available male students (n=~1600). Based on previous survey research in the CBDHA region [16-17], we anticipated a 70% participation rate (~1120 respondents). Pre-study power calculations confirmed the adequacy of the sample size. The median subject age was 16 years and 90.8% of participants were between the ages of 15 and 17 years. The median school grade was grade 11 with participants somewhat evenly distributed across grades 10 (37.1%), 11 (30.3%) and 12 (32.7%).

In October of 2009, trained members of the research team administered the finalized 76-item surveys to a sample of 1607 male students enrolled in grades 10, 11, and 12 across four schools in Cape Breton. Male students from grades 10, 11 and 12 were informed of the survey and invited to the school auditorium or cafeteria to voluntarily complete it. Trained members of the research team briefed all attending students and obtained written informed consent prior to administration of the surveys. The Dalhousie University Human Research Ethics Board approved this study.

Results

Reported use and intention to use YHC services

This section summarizes male respondents’ prior use, current use and intention to use YHCs and linked health services. Information from this section can be used to determine the current state of YHC utilization by adolescent males in the CBDHA. Despite the fact that YHCs offer services for both males and females, the qualitative findings revealed that very few males in fact access YHCs in their schools. In contrast, most female participants confirmed prior access of YHCs for multiple services. Interestingly, some male participants reported knowing neither the location of their local YHC nor available health services.

This information was replicated in the quantitative findings (Table 1). According to the survey results, relatively few male adolescents access YHCs; however, greater percentages responded that they would still “feel comfortable using YHCs” (50%) or “would go to a YHC with a sexual health concern” (40.2%) if necessary. Many respondents also indicated that they “had never had a need to use the YHC” (50.6%), which parallels respondents’ reports of infrequent previous and current use of YHCs. This implies that either males experience few health concerns during adolescence or, and more likely, that males are reluctant to access youth heath centers despite experiencing health concerns. Interestingly, 94% of respondents who reported that they currently frequent YHCs had also visited YHCs in the past suggesting that prior use of YHCs may be associated with current usage.

Table 1: Percentages of Participants Reporting Use and Intention to Use YHC Servicesa,b

Perceptions of YHC utilization

This section includes themes and survey items that represent perceptions of male utilization of YHCs including whether and how YHCs should be accessed by male and female students. Although both male and female interview participants acknowledged that males could access the centers (i.e. YHCs are accessible to both males and females), YHCs were still largely perceived as places for females. During focus group discussions, most respondents described prevailing fears of ostracization from visiting a YHC, while females noted a lack of peer support for male utilization of YHCs. For many male participants, accessing a YHC contradicted certain beliefs regarding the way in which males should behave in health-related situations. These findings reinforced the assertion that males’ decisions to access YHCs are constrained by their perceptions of help-seeking as a gendered social practice. These tensions are illustrated in the quotes below.

Interviewer: So if you did [access], what do you think would happen?

Male participant: Everyone would stare at me.

Male participant: Why is a guy here? Like, this is for girls. I think they would think that it’s kind of their privilege to come here, not as much for guys. -3YM

Male participant: Males have a more of a rougher image. We don’t want to show signs of weakness ‘cause it feels emasculate to us but, like kind of that, we don’t want to be the one to try to go down and feel feeble or feel weak about ourselves, and girls are, well some girls are more feminine and they don’t really have that tough image that they try to keep. -7YM

The related survey results for this section are presented in Table 2. Similar to the qualitative findings, results showed that YHCs are viewed by many males as a place where “both males and females feel they can go for help” (68.9%). Nevertheless, male adolescents still fail to utilize YHC services. Notably, 81% of respondents who responded that they “would feel comfortable using YHCs” also reported that “YHCs are places where both females and males feel they can go for help.” This suggests that respondents who would feel comfortable using YHCs are more likely to view YHCs as accessible services to both males and females. It should be mentioned that these particular survey items appeared to produce a certain degree of uncertainty or ambiguity as indicated by the high percentage of midpoint or neutral responses. It is possible that these types of questions generated a conflict between what students should (e.g. access the local YHC) and would do (e.g. avoid) in the event of a health issue.

Table 2: Percentages of Participants Reporting Perceptions of YHC Utilization

Knowledge of YHCs and related services

Insufficient or inaccurate information about health services represents a frequently cited barrier to accessing health services [11]. This barrier was also identified in the current study. Both the qualitative and quantitative findings revealed an association between prior and current use (of YHCs) as well as awareness of and intention to use YHCs. Interview participants recounted having received information about YHCs through a variety of means including classroom presentations from YHC staff, high school orientation, school announcements, and posters in the hall. This information (or males’ interpretations of the information) subsequently shaped their perceptions of local YHCs and intentions to access these centers. Participants often seemed unaware of the range of YHC services, staff qualifications, and intended clients. Female participants appeared better informed than males, which may reflect adolescent females’ increased contact with YHCs. The health centers were also frequently misperceived as sexual health clinics by several male interviewees. A general “fear of the unknown” consistently emerged as a common theme during interviews and focus groups discussions, which is believed to negatively impact males’ YHC usage. These themes are illustrated in the quotes below.

Male participant: When I was in grade nine we were kind of taught that health centers were for sexual health and stuff like that, not really physical or mental health. -4YM

Male participant: …I never went to this health centre before, but I think it’s because most males are unsure of what procedure the nurse is going to do and they don’t really know what’s going on in here, they’re kind of nervous of what’s going on. -7YM

In contrast, a comparatively high percentage of survey respondents not only appeared to know the location of their local YHC but also believed that that they could obtain free condoms and access additional services (e.g. tobacco use intervention services) at YHCs. Table 3 presents the survey findings for this section. Not surprisingly, 97% of respondents who reported prior use of YHCs also reported knowing where the YHC is located in their school. It is likely that experience using certain YHC services (e.g. treatment for mental health issues) introduces students to other potential services (e.g. treatment for tobacco use) and thus encourages repeat visitations especially for students with comorbid health issues. In the absence of complete information, respondents may view YHCs as merely sexual health centers and hence may be less likely to use YHC services for additional health concerns.

Table 3: Percentages of Participants Reporting Perceptions and Knowledge of YHCs

Gendered help-seeking and social norms

This section includes themes and survey items that represent perceptions and/or beliefs about gender-related health issues and help-seeking behaviors. The majority of participants described socially regulated gender expectations that mediate and limit males’ health seeking behaviors. Even students with an awareness of gender norms and their influence were affected by these norms and spoke of their role in the maintenance and enforcement of such norms. This quote illustrates the gender differences in social conduct surrounding health seeking issues.

Female participant: I just think that girls have more communication with their parents and teachers . . . Guys will just kind of hide it. They won’t really tell anyone, they won’t ask anyone’s opinion on it, but the girls will want to get checked out. -7YM

The majority of male participants reported that their potential YHC use would be unsupported by peers unless they used specific services. For example, it was considered socially acceptable for male participants to access a YHC when trying to stop smoking, manage anger, or obtain condoms. It was also regarded by participants as somewhat acceptable for males to access YHCs when experiencing a severe health issue only after they had exhausted all other options and delayed seeking help in an attempt to deal with the issue on their own. Respondents also noted that a male’s presence in the waiting room of a YHC would appear unusual unless there was a clear reason for the male’s visit. Both males and females viewed this belief as a potential access barrier for males.Adolescents’ understandings of gender appropriate health seeking conditions and services were related to their perceptions of male gendered social norms.

According to the survey results (Table 4), most respondents appeared to display a certain health maturity or intelligence in knowing how to proceed or react when confronted with a health concern. For example, the majority of participants believed that it is “important for males (and females) to get tested for STIs” and “would discuss the problem with a partner.” Conversely, very few reported that males “should not worry about their health” and “would wait as long as possible before going to a doctor about sexual health concerns.” Nevertheless, respondents were still generally unlikely to discuss the concern with a male friend and visit a YHC. Over 50% of all respondents disagreed that “people would think that they are weak if they used a YHC in their school” and over 75% of all respondents disagreed that “males should not think about their health.” Despite these findings, male students underutilize YHC services. The lack of male utilization of YHC services may be related to ambiguous and/or conflicting feelings with regard to the gendered nature of help-seeking behaviors.

Table 4: Percentages of Participants Reporting Health-Related Beliefs and Behaviors

Perceived barriers

This section describes the perceived barriers that may prevent male students from accessing YHCs. During the in-depth interviews, it became evident that many male students avoid using YHCs because of perceived gender- and peer-based stigma or discrimination. Male utilization was often viewed as unusual and thus drew unwanted attention from peers. Some participants suggested that males who access the centers may be viewed as weak and thus subject to ridicule, while others rationalized that the only reason a male would access a YHC was if he had a sexually transmitted infection; contributing to even greater stigmatization. These themes are demonstrated in the following quote (Table 5).

Table 5: Percentages of Participants Reporting Perceived Barriers to YHC Use

Interviewer: Are there any other specific reasons why you think males may not want to use these services?

Male participant: Maybe they think it’s generally for females for just contraceptive reasons so they may not want to come down ‘cause people might say oh you have a sexually transmitted disease or stuff like that so. -17YF

Participants also largely expressed concerns about confidentiality and anonymity when accessing services and disclosing personal issues to health providers. Fears related to both confidentiality and anonymity were greatest among those who had never used YHC services. Some students worried that healthcare providers would contact their parents and that their peers would discover why they had accessed a YHC. Male participants were more vocal than female participants regarding their privacy, especially related to their peers. As suggested in the quote below, these fears represent a considerable barrier to service utilization and are likely mediated or related to the aforementioned themes (i.e. gendered help-seeking and gendered social norms).

Male participant: Yeah, like with our community, it’s more smaller so a lot of parents know each other’s parents and stuff like that and they know each other, ‘cause they grow up with these people and they don’t want to, even if it’s confidential, they just don’t want to admit to somebody else that they may have a health concern. -2YM

Interestingly, those who had already accessed a YHC and thus had prior experience with YHC services did not perceive these barriers. As previously mentioned, experience and increasing feelings of comfort using YHC services may encourage repeat visitations:

Male participant: …They think that it’s, like, for condoms and birth control and all that stuff, but it’s just a place to feel comfortable and express your feelings. They’re not just here for regular, like, birth control and stuff. They’re here for everything. -16YM

The survey findings regarding barriers to YHC use were somewhat inconsistent. Contrary to the qualitative results, over half of the survey respondents disagreed that they “feel too embarrassed to use the YHC in (their) school,” “(are) less likely to use the YHC because (they) would have to sit in the waiting room with mostly females,” “think that the YHC is intimidating,” and “(are) worried that (their) parents might find out if (they) use the YHC.” These survey items all reflect fears of stigma arising from YHC use. The inconsistency between some of the qualitative and quantitative results may relate to characteristics inherent to the individual data collection approaches with closedended surveys preserving anonymity and focus groups facilitating more open and context-specific responses. Interestingly, almost 50% of the survey respondents also agreed that “… most guys are scared to use the YHC.” This finding suggests that certain respondents acknowledge the existence of stigma and gendered norms that determine health seeking behaviors, but may not necessarily be influenced by such norms. Over 50% of male students reported that “…school staff (otherthan my teachers) and most parents support student use of YHCs.” Thus, it is possible that school and parental support offset feelings of fear and thereby encourage use of YHCs.

Discussion

This study provides much needed insight into male youths’ actual utilization and specific perceptions of YHCs. In general, the combined qualitative and quantitative results indicate the influence of gendered social norms and expectations on help seeking behaviors, including accessing YHCs. These results are consistent with some earlier research that noted a connection between traditional masculine beliefs in adolescent males and decreased likelihood of obtaining health care [18]. Specifically, the qualitative data suggest that male students are socialized to avoid or resist seeking help. Instead, they are expected to conceal their emotions and health concerns in order to conform to traditional male gender norms (e.g. independence, strength, and emotional stoicism). Showing weakness and vulnerability, which are traits commonly associated with femininity, and engaging in health promoting behaviors contradict the socially desirable attributes of males. Young males are also unlikely to discuss health concerns with a male friend, possibly relating to gendered social norms that regulate male adolescents’ help seeking behaviors especially at younger ages [19,20].

Still, survey results indicate that YHCs are predominantly perceived as a gender-neutral health service. Just over half (51%) of male students indicated that they would feel comfortable using a YHC. The key to rationalizing these findings in light of the prevailing gender-based norms may rest in the inherent differences between belief and intention. Despite generally favorable impressions of YHCs, male adolescents remain unlikely to access these health services. Their resistance is largely in accordance with prevailing and deeply-rooted gendered norms, such as the implicit association of YHCs with females and the general lack of help-seeking among young males [19,21]. For example, many respondents reported that their male friends did not currently use YHCs but should use them to address health concerns. Moreover, males may be unopposed to accessing YHC services if necessary and if other options are neither present nor available. However, recognition of need may itself be impacted by pervasive, and perhaps unrecognized, gender biases.

YHCs are in a prime position to provide a variety of health promotion interventions, particularly among students who may not otherwise access mainstream healthcare. Still, normalizing YHC usage represents a formidable task, given the evident challenges surrounding it. Only about one-third (30%) of survey respondents reported that they would “go to the YHC for help,” which is noteworthy considering rates of morbidity and mortality during adolescence are largely preventable and tend to increase with age [#]. Participants noted that visiting a YHC could be interpreted by peers as a sign of weakness or that the male accessing the YHC requires treatment for a sexually transmitted infection. Nearly half (46.4%) of survey participants agreed that “most (males) are scared to use a YHC.” Furthermore, students may consider YHC use a covert (i.e. embarrassing) activity as suggested by the survey results that indicate students’ wishes to keep YHCs in a quiet area of the school.

To better serve the health promotion needs of students, the YHC environment should be assessed to ensure that it is equally welcoming to both males and females. Creating a supportive environment for males and normalizing male utilization of YHCs are necessary steps to addressing the unequal use of YHC services. In 2007, Marcell and colleagues suggested two approaches to completing these tasks: (1) examining and reshaping the male role to promote the belief that seeking healthcare can be a sign of strength, and (2) promoting and providing health services in a way that is more congruent with the traditional masculine role [23]. Effectively reaching males with messages about YHCs will require a comprehensive health promotion strategy that addresses the gender-related barriers to accessing services and involves multiple stakeholders (lead by an advisory committee including students) within the broader school community. Health promotion messages must be monitored and evaluated over time to determine their effectiveness. For example, the qualitative data from this study identified teachers, coaches and athletes in the schools as positive role models whose endorsement of YHCs could lead to increased YHC utilization, particularly among males. Parents may also aid in YHC promotion as they play a critical role in facilitating male adolescents’ access to primary healthcare. It is encouraging to note that few male students feel that “…school staff (other than my teachers) and parents oppose student use of YHCs.”

Health promotion messages should be primarily directed at younger students. Ott’s work [24] and the qualitative data from this study support this suggestion as a means of ensuring that both males and females are familiarized and acclimatized with health promotion services offered, which may help to reduce gender biases in utilization. Early exposure to YHCs may also serve to ameliorate students’ misunderstandings of YHCs, as well as their concerns about privacy and confidentiality. These findings and their implications for health promotion practice add to the literature surrounding males’ use of health services, and address a need for information on how adolescent males access and use such services. Although the findings of this study regarding young males’ help-seeking behavior are somewhat disheartening, fostering a healthy relationship between students and YHC services is within reach. The health promotion implications of such a relationship may have a lasting impact on school and community health, and will go a long way to improving the gendered nature of health care service use that persists in adult populations.

Several limitations of this study design should be noted. First, the focus groups may have produced response biases associated with perceptions of “peer pressure” and/or demand characteristics. Second, despite the rigorousness of our approach, the survey instrument has not yet been statistically validated. As such, results should be interpreted as an aggregate of the data and used as such. And finally, certain elements of the survey procedure (e.g. length of surveys and administration) may have distorted responses. Despite these limitations, this exploratory study provides important health information that can be further examined in future research.

Acknowledgements

This project was funded by the Nova Scotia Health Research Foundation and conducted by Dalhousie University, in collaboration with the Cape Breton District Health Authority, Cape Breton-Victoria Regional School Board, and Cape Breton University. We would like to thank the following people for their contributions to the research: Dr. John deRoche, Dr. Gordon Flowerdew, Dr. Don Langille, Ms. Mary Beth Leblanc, Dr. Andrew Link, and Ms. Evelyn Schaller. Above all, we extend our sincere thanks to our research partners in Cape Breton and the participants of this study for offering their time and contributing their perspectives to this research.

References

1. Courtenay WH (2000) Behavioral factors associated with disease, injury, and death among men: Evidence and implications for prevention. Journal of Men’s Studies 9: 81-142.
2. Courtenay WH (2003) Key determinants of the health and well-being of men and boys. International Journal of Men’s Health 2: 1-30.
3. Kann L, Kinchen SA, Williams BI, Ross JG, Lowry R, et al. (1998). Youth Risk Behavior Surveillance - United States, 1997. MMWR CDC Surveillance Summary 47: 1–89.
4. Miller WC, Ford CA, Morris M, Handcock MS, Schmitz JL, et al. (2004) Prevalence of chlamydial and gonococcal infections among young adults in the United States. The Journal of the American Medical Association 291: 2229–2236.
5. Miller WC, Swygard H, Hobbs MM, Ford CA, Handcock MS, et al. (2005) The prevalence of trichomoniasis in young adults in the United States. Sex Transm Dis 32: 593–598.
6. Coker TR, Sareen HG, Chung PJ, Kennedy DP, Weidmer BA, et al. (2010) Improving Access to and Utilization of Adolescent Preventive Health Care: The Perspectives of Adolescents and Parents. J Adolesc Health 47: 133-142.
7. English A, Ford CA (2007) More Evidence Supports the Need to Protect Confidentiality in Adolescent Health Care. J Adolesc Health 40: 199-200.
8. Lehrer JA, Pantell R, Tebb K, Shafer M (2007) Forgone Health Care among U.S. Adolescents: Associations between Risk Characteristics and Confidentiality Concern. J Adolesc Health 40: 218–226.
9. Addis ME, Cohane GH (2005) Social scientific paradigms of masculinity and their implications for research and practice in men’s mental health. J Clin Psychiatry 61: 633-647.
10. Courtenay WH (2000) Engendering health: A social constructionist examination of men’s health beliefs and behaviors. Psychology of Men and Masculinity 1: 4-15.
11. Davies J, McCrae BP, Frank J, Dochnahl A, Pickering T, et al. (2000) Identifying male college students perceived health needs, barriers to seeking help, and recommendations to help men adopt healthier lifestyles. J Am Coll Health 48: 259-267.
12. Cusworth WS, Kerns S, Lyon A, Bruns E, Cosgrove T (2010) Impact of School- Based Health Center Use on Academic Outcomes. J Adolesc Health 46: 251- 257.
13. Nova Scotia Health Promotion and Protection. Youth Health Centers
14. Youth Health Centers Subcommittee of the Children and Youth Action Committee (2008) Standards for Youth Health Centers in Nova Scotia. Halifax, NS: Nova Scotia Health Promotion and Protection.
15. Langille DB, Asbridge M, Kisley S, LeBlanc MB, Schaller E, et al. (2008) The relationship of sex and risk behaviors to students’ use of school-based health centers in Cape Breton Nova Scotia. J Paediatr Child H 13: 605-609.
16. Langille D, Rigby J, Bartlett L (2006) School- based health centers in Cape Breton: gathering evidence to inform policy and practice. Report prepared for Cape Breton District Health Authority. Dalhousie University.
17. Langille D (2006) A consultation process to develop a survey instrument to assess adolescent health in Nova Scotia. Report to the Nova Scotia Health Research Foundation. Dalhousie University.
18. Marcell AV, Ford CA, Pleck JH, Sonenstein FL (2007) Masculine Beliefs, Parental Communication, and Male Adolescents’ Health Care Use. Pediatrics 119: 966-975.
19. Gahagan J, Rehman L, Barbour L, McWilliam S (2007) The preliminary findings of a study exploring the perceptions of a sample of young heterosexual males regarding HIV prevention education programming in Nova Scotia, Canada. Journal of HIV/AIDS Prevention in Children and Youth 8: 135-153.
20. Gahagan J, Barbour L, Mc William S (2006) Making Space for Young Heterosexual Males: Gender and HIV/AIDS Prevention Education. Centres of Excellence for Women’s Health Research Bulletin 5: 12-13.
21. Galdas PM, Cheater F, Marshal P (2005) Men and health help-seeking behavior: Literature review. J Adv Nurs 49: 616-623.
22. Eaton D, Kann L, Kinchen S, Shanklin S, Ross J, et al. (2006) Youth Risk Behavior Surveillance - United States, 2005. MMWR CDC Surveillance Summary 55: 1-108.
23. Marcell AV, Ford, CA, Pleck JH, Sonenstein FL (2007) Masculine Beliefs, Parental Communication, and Male Adolescents’ Health Care Use. Pediatrics 119: 966-975.
24. Ott M (2010) Examining the Development and Sexual Behavior of Adolescent Males. J Adolesc Health 46: S3–S11.

--