Ankush Project report

Engaging Men In Health Services-A Literature Review Page 1

"HOW TO ENGAGE MEN IN HEALTH SERVICES"

A LITERATURE REVIEW

By

Ankush Mahajan Co op student

Under the guidance of

Neil Stephens Program Co-ordinator

South Asian Diabetes Prevention Program

FLEMINGDON HEALTH CENTER 10 Gateway Boulevard

Toronto ON M3C 3A1


CONTENT

TITLE PAGE NO

1 INTRODUCTION 3

2 OVERVIEW OR BACKGROUND 4

3 1. RESEARCH FOCUS

2. RESEARCH PROBLEM

3. RESEARCH QUESTION

4. RESEARCH AIM

6

9

9

9

4 RESEARCH METHODOLOGY 9

5 LITERATURE REVIEW

1. QUALITATIVE RESEARCH

2. QUANTITATIVE RESEARCH

16

16

17

6 REFERENCES 18


1. INTRODUCTION 1

"Women's health " has been a favourite topic of research for scholars since many decades

and women's health movement has been a strong force in healthcare planning , addressing

significant gaps in healthcare delivery, research, advocacy and policy. In contrast, there has

been less focus on equally important issues related to men's health, even though mortality

rates are consistently higher among men than women. Consequently, the issue of engaging

men has gained a great deal of global attention across the last two decades. The rise of media

attention and consistent commentaries depicting a ‘crisis in men’s health’ has been matched

by an increase in the publication of academic books and articles in the field. According to

Health Canada, there are enough evidence detailing men’s lower life expectancy in

comparison to women(1) , concern about high rates of male suicide (2) and recognition that

some modifiable ‘behaviours’ determine Canadian men’s differential health outcomes(3) .

There is also increasing awareness that something needs to be done to better promote the

health of men as part of the process of addressing current health disparities within Canada

(4). Yet, the reasons for these aggregated statistical differences, and how they might best be

addressed, are complex. To date, there is no Canadian network, or single point of contact, for

gathering research evidence, collating examples of good practice, or examining policy in

order to explore how best to promote the health of men in ways that work with (rather than

competing against) advances in promoting women’s health. Following similar articles that

have examined the state of men’s health promotion in Australia (5,6) the United Kingdom

(7,8) and compared cross-country contexts(9) , this Research project emphasis on how to

engage men in regular heath care system of Canada along with current state of men’s health

promotion in Canada.


2. OVERVIEW OR BACKGROUND 1

Canadian men, on average, can expect to live for 4 fewer years than women. For instance, In

Ontario life expectancy of male is 79 years compared to their counterpart , females, 84

years(10). Life expectancy data shows steady increase for both sexes , credit goes to

improvements that have percolated through society (i.e., labour laws, safety legislation,

smoking cessation, seatbelts and environmental campaigns). Though the gender gap is

gradually narrowing, women are still consistently living, on average, longer than men(11). In

Canadian culture, men are not conditioned to see their health as a priority. Unhelpful

stereotypes of independence, risk taking and "the strong silent type" make it difficult to

engage in positive health behaviour. An alternative explanation is found in the biological

point of view is that he impact of the Y chromosome on the male body and the influence of

testosterone on human behaviour.

A number of biologic, social and environmental factors contribute to this gap in average life

expectancy between the sexes, and there are several particular causes of early life loss.

Cardiovascular disease is known to strike men more often and earlier than women(12). Some

proposed factors contributing to this disparity include poor nutritional habits, such as lower

consumption of fruits and vegetables and higher salt intake(12-14) poorer anger

management(15) and a higher likelihood of being overweight(11). A potential cardio

protective effect of estrogens has been hypothesized to account for part of the disparity in

cardiovascular disease between men and women16,17). Death by suicide is also higher

among men than women(18,19). Men are 3 to 4 times more likely to carry out suicide, with

the highest rates being among middle-aged men 18-40 years(20) Reasons for this have been

attributed to a greater willingness to use lethal methods, a reluctance to talk about emotional

distress or seek help for it, higher rates of alcohol use, and a greater tendency to move

quickly from thought to action. Males are generally considered to be higher risk-takers than

females. Indeed, motor vehicle accidents account for a high proportion of deaths among men

in their late teens and 20s. As well, men may be exposed to increased risk of death due to

occupational incidents. In particular, northern residents account for 35% of all workplace


deaths in British Columbia, and males account for nearly 94% of occupational deaths and the

vast majority of hospitalizations resulting from workplace incidents(22)

In addition to reduced life expectancy, men also have lower rates of health expectancy - the

number of years a person can expect to live in good health(23) As a society, we have grown

accustomed to the disappearance of millions of Canadian men from our daily lives - not only

from death, but also from illnesses that have rendered them too frail to contribute to their

full potential. The reality is that Canadian men spend their later years in poorer health than

their female counterparts. It is debatable whether this variability between the sexes in

different countries and localities is an issue of inequity, masculinity or biological inevitability.

Many chronic health conditions in men (estimated at 70%) can be attributed to lifestyle and

are potentially preventable. In most cultures, most men have been raised to adopt a

masculine role, with a focus on independence, fearlessness and strength. As a result, men are

generally less likely than women to seek help, or to acknowledge weakness or

vulnerability, with negative health consequences(24). It is generally acknowledged that men

are less likely than women to use healthcare services, with an estimated 80% of men refusing

to see a physician until they are convinced by their spouse or partner to do so(25,26)


3. RESEARCH FOCUS 1

For this Particular research project the central focus is on how maximum participation by 18-

40 years old men can be increased in accessing basic health care facilities provided by

various public funded or private community centers. the reason for focusing on this issue is

has been discussed above but again pointing out that average life expectancy for Canadian

Men is 4 years less than woman(1). Men experience a higher rate of premature death than

women in all leading causes of death. The dominant masculine gender role plays a part in

some men’s reluctance to access health care many people delay consulting their doctor, and

men tend to delay more and visit their doctor less often than women. Numerous population-

based (27) longitudinal and smaller-scale studies of health care utilisation (have indicated

that men of many different cultures in the Western world tend to delay visiting their doctor

for longer and use their services less often than women(28). However, a growing number of

exceptions indicate that the relationship between gender and help-seeking is more complex

than once thought. (29).


3.1 RESEARCH PROBLEM

"I know I have a problem but I will let them heal by themselves", "Macho man do not need a

doctor" , "I rarely go to GP", "I work long hours and I can't get an appointment to visit doctor"

This what we generally hear from community health workers when they talk about their

experience while dealing with men's health and men's lives that appear, at best, to be

extremely hesitant or, at worst, unwilling to seek medical help, despite a clear and pressing

need.

Unfortunately, men being less likely than women to attend primary health services is, to a

large extent, borne out in the research evidence. In general, GP practice consultation rates

with all clinicians are consistently higher among females compared to males except in the

extremes of age, i.e. the very young and the very elderly. In 2009, for example, around 1 in 16

females attended a consultation at a general practice compared with only 1 in 25 males (30).

Of greater concern are epidemiological studies that show men experience a higher rate of

premature death than women in all leading causes of death (White and Holmes, 2006). The

recently published European Commission (EC) report on The State of Men’s Health in Europe

(2011) adds further weight to these observations. The report provided an unprecedented

level of analysis of the health of the male population in the 27 member states of the EU (some

290 million men). It revealed that infrequent use of and late presentation to health services is

associated with men experiencing higher levels of potentially preventable health problems

and, that male gender plays a significant role in the lifestyles and behavioural choices that

put men at greater risk of ill-health. It is clear to see how the behavioural norms associated

with the dominant masculine gender role might influence men’s interactions with health

services and hinder their ability to manage their health. Health beliefs and behaviours, such

as attending a GP surgery for routine health screening, are activities that represent gender in

the same way that other societal activities like playing sport, going to the pub, or wearing a

tie might do: it is a way for men to demonstrate their masculinity and, therefore, an

opportunity to enact the dominant masculine gender role. Numerous research studies have

found that pressure to adhere to the dominant masculine gender role can lead many men to


delay seeking medical help when experiencing the symptoms of a range of conditions

including heart disease, prostate cancer, testicular cancer and depression (Galdas et al,

2005). Other investigations have shown that men whose views of masculinity are strongly

aligned with the dominant masculine gender role have an increased risk for poor health and

fewer health promotion practices (Mahalik et al, 2007). In short, seeking help or engaging

with health care is perceived by many men as incompatible with the masculine ‘norms’ of

strength, stoicism and self-reliance; rather, such behaviour has the potential to make others

view them as vulnerable, dependent and weak. A particularly poignant example of this is

evident in a study conducted by Chapple and Ziebland (2002). They found that, among 52

men diagnosed with prostate cancer, many had been hesitant about seeking help for their

problems because they believed it was not ‘macho’ to seek advice about health problems,

that ‘boys don’t cry,’ and it was ‘not masculine’ to display signs of weakness. Evidence shows

that accessing primary care services poses a particular problem for many men, especially for

routine or preventive health care. In addition to the incongruence of seeking help with the

dominant masculine gender role, other obstacles to accessing primary care that have been

reported include services being available only during traditional working hours, lack of

flexibility in men’s working days, excessive delays for appointments, rushed consultations, a

lack of understanding of the process of making appointments, and men lacking the

vocabulary required to discuss sensitive issues (EC, 2011; White et al, 2011). The ‘feminine’

environment of the typical primary care surgery, e.g. being staffed predominantly by women

with mostly female-oriented literature available, has also been found to be problematic for

some men (EC, 2011). Although these barriers serve to illustrate that new approaches need

to be taken to address men’s health help-seeking behaviour and more effectively engage men

in primary care, it is vital that any new approach should not entrench or reinforce

stereotypes that all men are unhealthy or disinterested in their health (White et al, 2011).

Worryingly, health professionals have been found to be liable to gender-stereotyping;

viewing female patients as over-users of health services and men as stubborn and unwilling

to seek help; attitudes which could further discourage men from accessing health care

(Seymour-Smith et al, 2002). While the dominant masculine gender role undoubtedly has a

part to play in some men’s infrequent health service use, the relationship between men’s


health, the use of health services, and the enactment of masculinity is a complex one. Not all

men will adhere to masculine behavioural norms in the same way in similar situations. Age,

ethnicity, sexuality and socioeconomic status are a few of the factors that contribute to

differences in how men define and enact masculinity, and therefore how they view their

health and use health services (Galdas et al, 2007).

3.2 RESEARCH QUESTION 2

How to engage men between age 18 to 40 who do not use health services ?

3.3 RESEARCH AIM 2

This project will work upon the "problem", why some men appear to be reluctant to access

available health services. Finding reasons of low engagement by men in Canada.

Furthermore, developing some of the evidence-based strategies that can be practiced by

community health workers effectively to engage men in primary health care.

4. RESEARCH METHODOLOGY 2

'Engagement' is the dynamic process of sharing and connecting with men to achieve better

health. When developing strategies for engagement in health care we need to consider both

the system of health care provision and those who work in that system. This encompasses a

broad range of practitioners including, but not limited to, community health care providers,

hospital based workers, paramedics, educators, and anyone who needs to, or should

consider, the health of men in their service provision. In general practice it includes general

practitioners, practice nurses and managers, receptionists and medical students.


It should be recognised that much health related activity takes place outside general practice

in community health centres, hospitals, schools, and the workplace - without GP involvement.

This whole of community approach, offers opportunities to 'engage the unengageable' - the

'blue collar and singlet' group of men - the group with some of the worst health outcomes.

Engagement in the community

It makes sense to focus on societal engagement of men because most of their health related

activity (Eg. work, education, recreation) occurs separately from primary health care, and

men's under utilisation of existing services demands solutions both outside that framework

as well as within it. Many men define themselves via their work, often feeling more

comfortable in the workplace than in health oriented settings such as community health

centres, hospitals, maternal and child health centres and general practices. Many indigenous

men still see the health delivery system as part of a powerful, authoritarian and threatening

complex that cannot be trusted. (Engaging men in health care Malcher, Greg. Australian

Family Physician 38.3 (Mar 2009): 92-5.)

Practitioners are beginning to discover that men do care about their health and are willing to

engage with primary and preventive care services if they are structured and delivered in a

way that is accessible, ‘male-friendly’ and responsive to men’s health needs. Although little

definitive evidence is available in the published literature on how to translate men’s interest

in their health into improvements in the uptake of health services (Robertson et al, 2008),

several small-scale initiatives designed to improve men’s engagement with primary care

point to some potentially effective strategies. Many of these initiatives have taken the

dominant masculine gender role into account in the planning and delivery of services. A

model that has proved to be particularly successful in a number of pilot studies has been the

provision of male-specific health assessments, often marketed as a male ‘MOT’ or ‘well-man

check’ (Linnell and James, 2010). Components of successful ‘MOT’ initiatives have typically

included the targeting of at-risk men (such as the over-40s) with written, personalized


letters of invitation, adopting a ‘one-stop’ approach to screening and assessment, providing

‘male-friendly’ written information, e.g. the Haynes Man: Owners Workshop Manual, and the

delivery of the service soutside the surgery environment such as in gyms, pubs or work

environments. Other strategies that have been reported as having some success in improving

the engagement of men in primary care include (Leishman and Dalziel, 2003; Wilkins et al,

2008; EC, 2011):

➤ Offering a wider range of opening times, including evening appointments

➤ Providing longer consultations and offering ‘popular’ tests such as cholesterol and blood

pressure checks

➤ Offering a comprehensive referral system.

➤ Developing male-specific advertising through posters, newspapers and radio.

Implementation of program

The first step in finding solutions is the recognition that men's health is a broad discipline in

which improvements need to occur in social, legal and educational spheres, and the medical

system. We need to stop blaming men for their worse health outcomes compared with

women's health outcomes, and expecting all men to respond to a particular model of health

promotion or marketing. The solution is to provide for differences in both male and female

health needs strategically (policy) and operationally (programs) throughout our health

services. In the United Kingdom this is called 'gender mainstreaming'

Initiation activities

A range of structured male rite of passage (initiation) activities, such as the Pathways to

Manhood program, challenge cultural stereotypes relating to masculinity. Rite of passage

programs help young men, with their fathers/mentors, step beyond the stereotypes to find

ways of positively expressing their masculinity. Research suggests that boys who have

participated in the pathways program have more confident communication and social skills,


stronger more supportive father relationships, increased respect for women, more

motivation to set goals and finish school, and more motivation to give back to the community.

As the impact of masculinity gone wrong is found in our ambulances, emergency

departments and cemeteries, the uptake of initiation programs becomes a health care

engagement issue. These programs can reduce potentially lethal risk taking or promote

engagement of health services. Health providers have a role in recommending such programs

to the families with which we are in contact. Workplaces should promote these programs,

and offer men the necessary time off to participate.

Community health services

Male perinatal depression is increasingly recognised, but is not reflected in early childhood

services such as maternal and child health centres, offering appropriate services to fathers.

Fletcher et al4 observed that, 'even a cursory scan of existing perinatal health services

reveals that few of them are designed to meet a father's specific needs'. A Victorian

Department of Human Services survey noted that 'barriers to increased engagement of

fathers included limited hours of operation and embedded cultural attitudes in some pockets

that make the service unwelcoming to fathers'. While some maternal and child health centres

are keenly working on engaging fathers, it appears that many are not. Perhaps it's time for

parent and child health centres - in function as well as name - to be adequately resourced to

deal with the multiple parenting roles now in existence and to provide help to both parents

for problems such as perinatal depression.

A search on seek.com for men's health positions yielded seven results, compared with many

more for women's health. The lack of men's health programs is reflected in the low number

of men's health workers. Clearly, governments need to train and employ more men's health

workers.

In indigenous health care there is a dire need for the provision of separate areas for men, and

for male men's health workers.


Workplace based health care

Workplace health programs engage men successfully and lead to establishment of GP

relationships, as well as fostering reduced absenteeism, higher productivity, higher

workforce retention rates and healthier employees with better home lives7. Cultural changes

may include dietary improvement and changing men's expectations that they always be stoic

and that work demands over-rule health demands. Given the enormous potential benefits for

all men, but especially for some high risk groups (that is those in the lowest socioeconomic

strata), it would seem sensible for a number of trials to be funded to identify successful

models for national roll-out .

Men's health initiatives in Canada

Although several provinces support specific men's health initiatives, such as prostate cancer

awareness, depression or exercise/diet, none of the provincial or territorial health

ministeries promote any overarching strategies or initiatives to target men's health directly.

In 2002, Quebec commissioned the Comité de travail en matière de prévention et d'aide aux

hommes (Working committee for prevention and assistance to men); this group released a

report focusing on male health and social services. In 2004, the Committee made a number of

recommendations to the Quebec Ministry of Health and Social Services. These

recommendations included the development of specific strategies for addressing suicide,

where men are considered a priority client; and the development of public awareness

campaigns related to men's health, focusing on the need for men to conduct self-

examinations of their testicles, as well as prostate cancer screening and prevention. They

also recommended that services offered by the Ministry be adapted towards the needs of

men.

Until 2007, no federal government actions directly targeted men's health. This changed when

the Canadian Institute of Health Research (CIHR) sponsored the first national Canadian

conference on men's health and held a "Boy's and Men's Health" Seed Grant competition,

which led to the funding of 9 proposals. Awareness campaigns such as "Movember" have

helped to raise awareness of men's health issues within the mainstream population.


Movember has become one of the largest sources of funding for prostate cancer in the world,

and has recently expanded to increase awareness around male mental health.

In 2009, the Male Health Initiative of BC was launched as an umbrella initiative to facilitate

educational collaboration, broad spectrum research and the gathering, production and

dissemination of best practices or standards of care. The initiative also enabled the advocacy

of men's health issues at all levels of government. Most recently, in June 2014, the non-profit

Canadian Men's Health Foundation (CMHF) was established to inspire men to live healthier

lives. The goal of the foundation is to raise social awareness of largely preventable health

problems and to enable men, and their families to value men's health by providing them with

information and healthy lifestyle programs that will motivate them to truly hear, absorb and

act on it. This is achieved through programs, such as online health risk assessment tools and

ongoing awareness campaigns based on modern communications research, focus groups as

well as collaboration with other healthcare societies and associations to assist them to

activate their men's health campaigns. The Foundation's first national awareness campaign,

"don't change much," includes websites, social media, advertising and news coverage

directed at 30- to 50-year-old men, their partners and families. A Canadian Men's Health

Week now takes place annually in the days leading up to Father's Day.

Other interventions

Community men's health nights have a long tradition. They are likely to be most useful when

formally linked with long term men's programs which link primary care providers in health

centres and general practices.

'Men's sheds' are another intervention successfully operated in Australia which can also be

incorporated in Canadian Health System. There are over 100 in Australia providing a

supportive environment characterised by team activities, learning, belonging and mentoring.

For many of the men involved a major desire is to learn 'how to stay fit and healthy'. Sheds


represent a proven resource, one that has the capacity to help engage men who may be

marginalised or disinclined to participate in costly, competitive organised activity.

A range of school based interventions (primary and secondary) designed to support boys and

young men at high risk of disengagement has the capacity to improve their social

connectedness and health, as well as their employment prospects.

The underlying key principle of engagement will continue to be the development of focused

activities in the comfort or activity zone of the target group. Some call this 'narrow casting',

which could be summarised as 'on their terms, on their turf'.


LITERATURE REVIEW

4.1 QUALITATIVE RESEARCH

There are number of qualitative research results showing evidences that men are less likely

to seek help in their health issues. Sharpe and Arnold (1998) yielded qualitative and

quantitative data through the use of focus groups, in-depth interviews and questionnaires on a

sample of 760 men from diverse occupations. The findings illustrated that men consistently

ignored health symptoms and avoided seeking help from the health services. For example, from

the questionnaire men agreed that ‘minor illness can be fought off if you don’t give in to it’

(64%); ‘I often ignore symptoms hoping they will go away’ (52%); and ‘I have to be really ill

before I go and see the doctor’ (75%). Similar themes have been found in a qualitative

semistructured interview study of 21 men who had discovered a testicular lump (Sanden et al.

2000). The findings revealed significant delays in men between discovery (of a testicular lump)

and treatment, attributed by the authors to men’s ‘wait and see’ attitude. For the men in the

study, seeking help was not an obvious solution. Akin to the findings of Sharpe and Arnold

(1998), Sanden et al. (2000) noted subjects regarded physical problems initially as something

that would cure themselves, like a cold, and seeking expert advice was regarded strange ‘for men

in general’. Richardson and Rabiee (2001) reported comparable findings in a qualitative study

employing a semi-structured interview schedule with small groups of young men aged 15–19

years. Based on the findings of three focus group interviews, the researchers concluded that:

…participants consistently equated health to physical fitness and help-seeking behaviour was

dictated by ‘social norms’. These demanded that a problem should be both physically and

sufficiently severe to justify needing help. GP’s were not a popular choice for confiding because of

discomfort associated with communication issues, unfamiliarity and feelings of vulnerability. In

some cases this was expressed using homophobic comments. (Richardson and Rabiee 2001, p. 3)


4.2 QUANTITATIVE RESEARCH

Researchers have documented that that men are less likely than women to seek help and

they are reluctant to seek help from health professionals for problems as diverse as

depression, substance abuse, physical disabilities and stressful life events. (Weissman &

Klerman 1977, Padesky & Hammen 1981, Thom 1986, Husaini et al. 1994, McKay et al. 1996)

Here are some evidences of quantitative research done by researchers in canada and all over

world. Men visited their general practitioner 67 million times in 1990, while women visited 143

million times in the same period (OPCS 1991). Cook et al. (1990) have also found that, across all

social classes, 10% of men aged 45–65 did not consult their GP over a 3-year period, and a

further 44% consulted on average twice a year or less. Similar findings have been noted in an

National Health Service (NHS) survey of younger men; 69% of men aged 18–24 had visited their

surgery in the preceding 12 months compared with 90% of women of the same age group (NHS

Executive 1998). Moreover, the same survey showed that only 58% of men in excellent health

attended their surgery, compared with 74% of healthy women, suggesting men are also poor

attendees for preventative medicine. In addition, there is evidence that men not only consult less

often than women, but their method of help seeking behaviour differs. Mo ¨ller-Leimku ¨hler

(2002) found that although minor emotional symptoms increase the probability of consulting a

general practitioner, physical symptoms were the determining factor for help seeking by men.

Corney (1990) has also found that, in contrast to women, men are less likely to report

psychosocial problems and distress as an additional reason for consulting. Lewis and O’Brien

(1987) note that men are also unlikely to be the first to seek help when there are marital, child-

care, or other relationship problems. Indeed, the ‘absent man’ has been noted in a variety of


other clinical settings, such as child health clinics, family planning centres and antenatal classes

(O’Dowd & Jewell 1998).


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Documents

Ankush Project report