A UK men’s health project that took its strategies to betting shops, pubs and sports clubs is the focus of Bruce Yarwood’s article marking International Men’s Health Week
Being a man is a full-time, rigorous and dangerous occupation; men have dragons to slay, mammoths to hunt, damsels to rescue, and a whole host of other very important tasks to perform.
Is it any wonder men don’t have time for fluffy things like looking after their health? What is manly about that after all, real men have an image to maintain!
Men die earlier than women. They have more accidents, suicide, lung cancer, cardiovascular problems and, actually, almost all types of morbidity, except for female-specific conditions and those of the connective tissues which they often don’t live long enough to acquire anyway.
Additionally, health inequalities exist between men (not all men are created equal), differences based on factors such as ethnicity and socio-economic factors are well researched and documented. Such differences beg the question: why then is men’s health neglected? Is it the men themselves who create the barrier?
A commonly accepted stereotypical answer to the question is inherent in the opening paragraph (somewhat exaggerated by poetic licence and my flair for the dramatic). To assert such an answer is a convenient ‘easy out’ that encourages inaction. If we accept this as being true we are able to attribute the blame for men’s neglect of their health to the ‘nature’ of men themselves, and if it is the nature of the beast to self-destruct, then trying to change them is likely to change what is essentially being ‘male’.
In 2002 a grant of £1 million was awarded to a group of men’s health workers in the city of Bradford, Yorkshire, for their Health of Men (HoM) project that aimed to get men to use health services more. The development of the HoM services was the basis for a research project – carried out by Leeds Metropolitan University’s Centre for Men’s Health – that gives some interestingly contrary insights into the beasts that are men and their attitudes toward their health. (The health workers also wrote a book about their experiences called Men’s Health – How to Do It, edited by two of the university researchers.)
The lottery grant, along with matched funding from local trusts, enabled a broad range of cross-city outreach projects to be delivered. This was considered markedly different to the traditional health care systems delivered in clinics where health care professionals configure services for their own convenience. The expectation is that people will learn to use the service and will conform to its structures and ways of working. The HoM applied a reversal of this expectation, with the team generally going into the men’s environment (including pubs, barbershops, betting shops and sporting clubs) and engaging with the men on their terms. The team found this altered significantly the nature of the relationship they had with the men and the way the men used their services.
Key Findings From Men **
- There was a perception that the GPs were an ‘illness service’ where you went when ‘poorly’.
- The men were reluctant to ‘bother the doctor’ with what they perceived to be trivial or potentially embarrassing problems.
- A common response was that they would ‘go if it was needed’ but the tendency was to ‘see what it’s like tomorrow’. Some men seemed to have a lack of confidence in the doctor’s ability, with a ‘what do they know?’ mentality present.
- The men did not see the GP surgery as a place they felt comfortable talking about the kinds of issues they would talk to the HoM team about.
- There was anxiety in some of the younger men that the GPs were too close to their families, so there was a strong possibility that parents or others might get to know that they had been to the surgery.
- Health centres don’t fit with the way that men like to work; men make more snap decisions. They worry about this ache or pain and when they do decide to do something about it they want to do it there and then, a spontaneity that is rare or difficult to manage at a health centre.
- Health centres tend to close early and not open at the weekend, so there appear to be barriers to the working man in accessing clinics. This is a specific problem for men as they are more likely to be working full-time, more likely to be working over 48 hours a week and less likely to have a job that includes flexitime.
Key Findings From Team Member Interviews **
- The team tended not to discuss men’s health in terms of disease processes or life expectancy, more in terms of lifestyle and public health issues such as smoking, alcohol and drugs.
- Where health issues were identified as being particularly problematic for men, such as the issue of prostate and testicular cancer, hypertension, diabetes, etc, these were from an educational or screening context rather than from a treatment perspective.
- Men do care about their health, whether it be their physical, sexual or emotional health.
- Men are more than willing to discuss issues such as fatherhood, relationship problems and other broader issues as well as their physical health, but lack the opportunities to discuss these concerns with health professionals.
- The team did recognise there was a difference between how younger men and older men saw their health; there is a tendency for men to take the body for granted until age becomes a factor.
- The use of ‘incentives’ (such as time out of work, free condoms, or special events) was very helpful.
- The team were able to link the men to other services, either to explain how the systems worked or through direct referral.
- It is important to be seen as a professional with expert knowledge and to be offering the services that men want.
If we are to address health inequalities, men require targeting with education and services specific to their needs. There are also of course health inequalities that exist between men based on factors such as ethnicity and socio-economic factors. These and other factors suggest that whatever interventions are planned should be placed within the context of social and environmental interventions rather than purely through a medical model.
Social and Environmental Factors
There is also evidence that the World Health Organisation’s social determinants of health affect men more than women. The ten determinants are: social gradient, stress, early life, social exclusion, work, unemployment, social support, addiction, food and transport.
Some of this may be due to men’s ability (or inability) to talk about and address the emotional aspects of their lives, as well as the resulting poor health. In this, masculinity and male socialisation has a negative impact, reinforcing cultural beliefs men hold about being strong, not needing help, not discussing feelings, etc. Social expectation plays a part, often being reinforced by both men and women.
Access to Primary Care
This all feeds in to the other problem about men and health – their reluctance to access health services until it is absolutely necessary or too late. Evidence shows that men do not use GPs to the same extent as women. Nor do they use dentists, eye clinics, screening or pharmacies to the same degree.
GPs provide good diagnostics and treatment, but to access these you must first recognise a problem yourself. Men are less inclined or able to do this. Statistics also show that in terms of mortality and factors that significantly affect it, like smoking and excessive drinking, married men do better than widowed or divorced men. Women are protective of men’s health by encouraging them to use services, caring for them emotionally and even making appointments for them at the GPs.
Lessons learned ***
- From the HoM study it is possible to identify key lessons:
- Men do care about their health.
- Tackling health inequalities in men from different socio-economic and cultural groups is possible as men will access health services for screening and preventive care if it is made available at a convenient time and place.
- Moving out from the health centre brings primary care to many more individuals, but men will attend clinics if given a medical reason or a specific appointment is made for them.
- Working with industry and community-based services is effective at opening new avenues for the delivery of primary care.
- The time it takes to set up services is longer than for women due to the need for the credibility to be built up and ‘word of mouth’ support to grow. Incentives are often necessary to get the men engaged.
- Health screening alone is only part of the effectiveness of the service; by giving men time to talk in confidence allows for a much wider range of health issues to be identified.
- Anonymity is as important as confidentiality for young men.
- Practitioners engaging with men in their settings need specific skills.
- Male-oriented resources need to be developed and tested.
- Having a team with a range of expertise enabled a broader range of activities to be supported.
Men’s Health in New Zealand?
The reality is in New Zealand we appear to be no better than anyone else in dealing with men’s health. There are New Zealand practitioners valiantly engaged in attempting to redress the inequality. But I see little evidence of coordination of effort and distribution of resources – and our statistics remain poor. What I do see however is a growing recognition that this is an issue requiring attention, commitment, leadership and – based on the initiative and study highlighted above – an entirely different approach to the one we have traditionally adopted. International Men’s Health Week (June) is an opportune time for health care providers, leaders, managers and politicians to take notice.
In preparing this article I have leaned very heavily upon the work of the HoM and the Centre for Men’s Health of Leeds University, and I wish to thank and congratulate them for their tremendous pioneering efforts and for the insights they have made available.
Bruce Yarwood is a registered nurse who, among other things, works at Menz Medical. His major concerns are men’s and travel health.
* An enigma is a type of riddle generally expressed in metaphorical or allegorical language that requires ingenuity and careful thinking for its solution.
** Men’s Health – How to Do It, edited by David Conrad and Alan White, Radcliffe Publishing (2007).
*** The Bradford & Airedale Health of Men Initiative: A study of its effectiveness in engaging with men, by Alan White, Keith Cash, David Conrad and Peter Branney, Centre for Men’s Health, Leeds Metropolitan University (2008).