Men's Sheds: A conceptual exploration of the causal pathways for health and well‐being

Abstract Although men have a lower life expectancy than women, and are more susceptible to illness, they have been found to be less likely to engage in health‐seeking behaviour. Men's Sheds, as a gendered intervention, has been identified as an effective way to engage men in meaningful activity and gain social support from others. However, links between sheds and health and well‐being are not well‐documented, and evidence is lacking of the potential causal pathways to health generation. This study aims to develop a plausible empirically based causal theory of how Men's Sheds influence the health and well‐being of their participants and to set out future research directions to test this theory. Drawing on a scoping review of academic, peer‐reviewed journal articles published between 1990 and 2018, potential causal linkages between shed activity and health and well‐being outcomes are synthesised into a logic model framework. Sixteen relevant peer‐reviewed journal were identified from the academic literature. The data from the articles are predominantly self‐reported, and characterised by small sample sizes and/ or low response rates. Further, information is lacking on the demographics of Men's Shed participants and the contexts in which they exist. Most notably, while there is some evidence on the potential mental health and social well‐being impacts of shed activities, physical health is less documented. The study shows that there is a lack of reliable and systematic evidence of the potential causal pathways between Men's Shed activities and health and well‐being outcomes. In order to address research gaps, further research is required to test and develop the proposed theory and logic model.

a higher susceptibility to illness and mortality (Baker, 2016;Office for National Statistics, 2015;WHO, 2016). Illnesses found in men have been related to cardiovascular disease in older age (Jousilahti, Vartiainen, Tuomilehto, & Puska, 1999), alcohol consumption patterns (Gawryszewski & Monteiro, 2014), and poorer mental health and higher suicide rates in unemployed and retired men (Qin, Agerbo, Westergård-Nielsen, Eriksson, & Mortensen, 2000). Retired and unemployed men are also found to be at a greater risk of social isolation and loneliness than those who are employed (Flood & Blair, 2013;. With the loss of work can come the loss of colleagues, networks, social support and autonomy (Ormsby, Stanley, & Jaworski, 2010).
Although more predisposed to illness, men are less likely to engage in health-seeking actions than women, and more likely to participate in risky behaviours, such as excessive alcohol consumption (Baker, 2016;Davies et al., 2000;Mahalik, Burns, & Syzdek, 2007).
Men are also more likely than women to delay seeking help for mental health problems, such as therapy or counselling, for fear of scrutiny about their masculinity (Men's Health Forum, 2015). Consequently, men are often classed as a 'hard to reach' group for preventative health measures and harm reduction (Kirwan, Lambe, & Carroll, 2013). Research from the United Kingdom (UK) has evidenced the positive health outcomes of 'gender sensitive' health interventions, such as male-targeted sports programmes and mental health promotion (Hunt et al., 2014;Robertson et al., 2014). Nonetheless, the UK policy and practice has not yet engaged with the idea that male biology, attitudes and behaviour may require consideration to create male-friendly health interventions (Baker, 2016).
One potential solution to men's health provision is the 'Men's Shed' model. This community-based movement emerged in Australia, in the 1990s, as a response to the increasing concerns about men's health (Earle, Earle, & Mering, 1996;. Sheds are practical communal spaces, typically workshop areas that provide opportunities for men to take part in meaningful social and recreational activities that encourage skill sharing and informal learning (Ballinger, Talbot, & Verrinder, 2009;Crabtree, Tinker, & Glaser, 2017;Golding, Brown, & Foley, 2007;. Sheds provide access to social support and enable men to gain advice, and share experiences and concerns in an informal and unstructured environment. Sheds are particularly supportive in providing a socially acceptable masculine environment for men to socialise and gain a sense of male identity and belonging from their relations with other men 1 (Ballinger et al., 2009;Golding, 2015). This alternative health and engagement space is provided for men who might be reluctant to access formal healthcare (Golding, 2015); in particular, those marginalised through mental health issues, unemployment or negative life changes Morgan, 2010). Sheds are found to be predominantly useful for older retired men and those who are not engaged in employment, as a way of maintaining a masculine 'work-like' routine and sense of purpose, and to combat social isolation (Kierans, Robertson, & Mair, 2007;Moylan, Carey, Blackburn, Hayes, & Robinson, 2015;Waling & Fildes, 2017). Furthermore, in Australia, this model has also proved particularly beneficial for war veterans with ongoing physical and psychological health issues (Golding, 2011).
Though the concept of Men's Sheds began in Australia, the shed movement is growing globally, most notably in the UK, Ireland, Canada and New Zealand. Nevertheless, sheds are a relatively unexplored concept in academic literature, and evidence that exists originates from predominantly qualitative studies from Australia, based on small sample sizes and self-reported data. The links between sheds and health and well-being outcomes are not well documented; most notably, evidence is lacking in relation to the 'directions of causality' between shed activities and the potential resultant health outcomes (Milligan et al., 2013).  (Milligan et al., 2013(Milligan et al., , 2016, in this paper, we update these reviews and through the development of a logic model, provide new insights into the plausible causal pathways which will aid hypotheses development in narrowing down specific gaps in literature that require further exploration, and directions for future research. What is known about the topic • Men have a lower life expectancy than women, and are less likely to engage in health seeking behaviours.

| ME THODS
• Men's Sheds have been identified as a possible source of meaningful activity and social support that could contribute to health.
• Evidence is lacking on the potential causal pathways from Men's Shed activity to health generation.

What this paper adds
• Identified studies on Men's Sheds and health are based around small sample sizes and self-reported data.
• Clear research gaps are present, including the need for contextual-based data and evidence of physical health impacts.
• Further research is required to address research gaps and to test the proposed logic model.

| Data sources
A search strategy was developed using the keywords 'Men's sheds, sheds, male, health, well-being' and

| Analysis and logic model framework nature
A database was used to catalogue the details of the articles identified, including publication information, intervention type, shed inputs, and health and well-being outcomes described. The next step was to thematically synthesise and interpret this data into a logic model. Findings from the papers were coded and descriptive categories developed based on emerging commonly described themes (Thomas & Harden, 2008). A logic model is defined as 'a diagram of proposed causal linkages among a set of concepts believed to be related to a particular public health problem', and is typically used as a framework to organise and integrate information related to a particular research area (Earp & Ennett, 1991:164]. Inputs were defined as activities or processes within a shed that may affect the health and well-being of individuals involved with the shed (e.g. interaction with others, taking part in woodwork). Outcomes of the activities and processes described were divided into mediating variables, intermediate and long-term outcomes. Mediating variables were used to provide an understanding of the mediating relationship between the input and the health and well-being outcome (see Figure 2). For example, the provision of woodwork facilities (the input), led to shed members taking part in group woodwork activities alongside others (the mediating variable), which then led to intermediate-and long-term health and well-being outcomes.
Intermediate and long-term outcomes were used to describe the short-and longer term effects of shed activity and processes on health and well-being in a visual linear pathway. Key mechanisms that may contribute towards improved health and well-being in shed members were then identified.

| Paper sample
An electronic search generated 16 papers that were suitable for full review, as shown in Figure 1.
For the results section of this study, each paper will be referred to using an identification reference number, as shown in

| Demographic findings
Shed member samples from each study were typically described as retired or unemployed, with an age range of 18-91 years. Some Of the 16 selected studies, 4 were specifically related to the health and well-being of those who may already be classed as 'at risk' or already have existing health ailments [4,5,9,15]. Two studies looked only at the health and well-being of older participants over 65 years [4,15]: one studied men with long-term disabilities [9] and one study was directed at shed members with self-reported or diag- Specific demographic information was gathered from participants in 14 of the 16 studies, including: age [1,2,5,6,7,8,9,11,12,13,15,16], employment status [1,2,5,6,7,8,9,11,13,14,15

| Inputs/Intervention
The types of inputs described in each study were synthesised and three themes were identified: education and skills; socialisation and interaction; and inclusivity. The types of inputs and activities outlined in each of the shed studies identified in the review are shown in

| Mediating Variables
Mediating variables are outlined to give a clearer understanding of the relationship between the inputs of the sheds and the health and well-being outcomes reported.

Education and skills
The most commonly reported mediating factor for the provision of education and skills was the opportunity for shed members to share and develop their practical skills, such as carpentry or metalwork [2,8,11,14,15,16]. The latter helped to facilitate so-

Socialisation and interaction
The provision of space for socialisation and interaction predominantly provided the opportunity for shed members to improve their interaction skills and widen their social networks through meeting new people. In particular, Men's Sheds were identified as a socially acceptable place for men to meet other men while taking part in meaningful masculine activities [2,4,5,9]. One study also reported that having the opportunity to socialise and interact with others had

Inclusivity
Studies showed that sheds provided a supportive and inclusive environment for men of all backgrounds to attend, including those with physical or mental health issues [4,5,6,11,12,13,14,15,16]. It was found that this led to the mixing of shed members culturally and intergenerationally [2,13,14], and the integration of those with physical and learning disabilities [3,9,14] and mental health issues [2,5,10,14]. Studies showed that as a result of having an inclusive and supportive environment, men were attending the shed rather than drinking alcohol or taking drugs outside of the shed [2, 10, 14].

| Intermediate and long-term outcomes
Thematic analysis was used to refine the intermediate and long-term health and well-being outcomes that were identified in the literature into key themes (Thomas & Harden, 2008). This process involved sorting the inputs and health and well-being outcomes into themes based on their meaning, for example, grouping of the terms with similar meanings like 'social bonds', 'friendship' and 'meaningful relationships'. The most commonly mentioned themes were ranked, as presented in Table 3.
Health and well-being outcomes described in each study were organised into dimensions of physical health, mental health and social well-being as based on the World Health Organization definition of health (WHO, 1948). Although such distinct components of health are not always mutually exclusive and typically overlap, these themes have been interpreted separately to display a clearer picture of the health and well-being outcomes produced by sheds. In this review, both physical and mental health are related to the status of the individual, whereas social well-being is being described in terms of ways of living together with others, and was in which an individual is included in groups, community or wider society (Keyes, 1998 • Activities promoting an equal and inclusive space of acceptance • Disability and mental health support contracts/arrangements • Alcohol and drug free zones • Provision of health and well-being support • A place of refuge and safety and recovery

Number of articles that reported this outcome
Increased social bonds, quality relationships and friendships 11 Increased motivation to leave the house/ maintain a daily routine 9 Increased feelings of contentment, safety, security and relaxation 5 Improved fitness and mobility/ decreased sense of frailty 4 Escape/ respite from personal problems, pressure and responsibility 4 Increased health seeking/ improvement behaviours 3 Prevention of antisocial behaviour and re-offending 3 Improved relationships outside of the shed (e.g. family) 3

Number of articles that reported this outcome
Increased sense of purpose and meaning to life 11 Increased happiness and enjoyment 10 Increased sense of confidence, pride and achievement 9 Decreased social isolation and loneliness/reduction in social avoidance 9 Increased feelings of identity, value and self-worth/esteem 9 Increased feelings of belonging and inclusion 4 Decreased feelings of anxiety, stress, depression and suicidal thoughts 3 TA B L E 3 The synthesis of intermediate and long-term health and well-being outcomes a decrease in instances of violence, however there was no evidence to show this [10]. Therefore, this study was included as links between alcohol use and violence have already been widely substantiated in public health literature (Bellis & Hughes, 2011;Graham & Livingston, 2011).

Physical health
There were five studies where shed members stated any physiological health outcomes, and all of the data was self-reported [1,4,10,13,14]. The outcomes described frequently related to the improved physical health through increased in physical activity and decreased sedentary behaviour (shown in Figure 3). For instance, reported studies referred to increased movement and levels of fitness through leaving the house and taking part in manual labour-like activities. Crabtree et al [4] found that shed members were walking and standing more while at sheds, which had led to increased mobility and decreased feelings of frailty; this was not mentioned in any other studies.
A small number of studies reported that shed members decreased their alcohol and drug consumption as a result of being in a sober shed environment [10,14]; the long-term physical (or mental) health outcomes of this abstinence were not studied. With sheds described as an inclusive space to manage addiction to substances [2], this particular area of preventative health is still relatively unexplored. Cordier and Wilson [3] found that due to health professionals visiting sheds, there was an increase in health literacy among shed participants; nevertheless, it was unclear whether increased healthrelated knowledge led to improvements in physical health.

Mental health
The most commonly reported mental health outcome, mentioned in all 16 of the studies, was an increased sense of purpose and meaning to individual participants lives. This outcome was mainly a result of having a reason to leave the house and the addition of structure and routine to their lives, which gave them a meaningful place in society. A potential pathway to improved metal health is presented in in Figure 4.
An increased sense of purpose was commonly reported by those who were unemployed, retired or ex-prisoners, and those who had lost their 'work identity ' [11:4]. Activities that contributed to a sense of purpose included an opportunity to help others and 'give back' to the community [14,15], participate in masculine 'work-like' activities that mimicked employment [2,4,14], and being able to utilise and share skills and knowledge with others [11]. Having a sense of purpose and meaning was found to lead to increased feelings of selfworth and empowerment [14], increased sense of masculine identity [2,4,5,9], confidence and self-esteem [8,9] and a sense of independence and control in life [13].
Decreased depression and instances of suicidal thoughts was mentioned as an outcome of shed activities in 10 of the 16 studies, however, only by a small number of people within each sample [2,4,5,8,9,10,11,14,15,16]. This was related to having a safe place for mental recovery from trauma or addiction [10,11,14], keeping active and engaged in an activity and getting out of the house [2, 15], having an increased sense of self-efficacy, hardiness and resilience [4,5], being able to share problems and experiences with others, and gain social support [9, 10].
Further outcomes that may lead to improved mental health were an increased sense of pride, achievement and satisfaction from producing things of value, such as woodwork [4,6,15], and an increased confidence through the development of skills and educational opportunities [8,10]. Again, these areas were not investigated in detail.

Social well-being
A common social well-being outcome described in 14 of the studies was an increase in social networks and interactions as a result of attending a shed and taking part in activities [not mentioned in papers 3 and 7]. A greater sense of belonging from increased social networks was reported in seven of the studies [1,2,8,9,10,11,14].
Most notably, the term 'social inclusion' was described in relation to  [8,10,11]. Social support and solidarity from other shed members, the engendering of a safe and accepting environment, and the ability to share experiences of vulnerability were reported to increase the feeling of being included in a community [12,14,16]. In five of the studies, increased social networks and social inclusion was reported as leading to a decreased sense of social isolation, as shown in Figure 5 [4,8,11,12,13].
A small proportion of studies described indirect social well-being

| CON CLUS ION
The review has identified the literature that exists on Men's Sheds and health and well-being at this point in time, where sheds are still a developing concept. What has been produced represents a logic model with a clear visual indication of the possible directions of causality between shed activities and health and well-being. This allows for the potential formation of hypotheses on the ability of sheds to generate health in a way that is gender specific, and that caters for their specific needs and sensitivities.

ACK N OWLED G EM ENTS
The authors thank the Big Lottery UK, Medical Research Council and Economic and Social Research Council for assistance in conducting this research.

CO N FLI C T O F I NTE R E S T
No conflicts of interest have been declared.

E N D N OTE
1 For more detailed studies on masculinity and male identity, see Connell (2005) and Remy (1990).