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How’s this for a primary health care reform? Engage men.

Australian men, on average, enjoy less healthy and shorter lives than women. As public health policy researcher and writer Margo Saunders writes in the post below, the poorer health and mortality rates experienced by many men are a reflection of various barriers to accessing health care and adopting preventive practices.

Here, she suggests that these barriers need to be addressed in more sophisticated and targeted ways. She asks:

Is it too much to hope that primary health care reforms might include forging more effective links between men and the health care system?


Margo Saunders writes:

Ensuring that men and women are able to achieve optimal levels of health requires recognising more than their biological differences. It means recognising that there are important differences in how men and women think of and experience ‘health’ and ill health, and in their patterns and preferences for engaging with health services.

The fact that Australia has separate national health policies for men’s and women’s health is an acknowledgement of these differences. The World Health Organisation also recognises that gender norms, roles and relations influence not only susceptibility to different health conditions and diseases, but they also have a bearing on access to and uptake of health services and on health outcomes.

Why men?

Men’s health is a particular concern because Australian men experience poorer health outcomes across a wide range of indicators.  Men suffer a greater burden of preventable disease and injury than women, are less likely to engage in preventive and health-promoting practices, and are likely to delay seeking medical assistance until later in the course of a disease or illness.

It was acknowledged more than 20 years ago that, ‘the doing of health is a form of doing gender’.  To a large degree, health practices and behaviours still align to gender constructs of traditional femininity (caring) and masculinity (stoicism). This is particularly relevant for men since manhood, unlike womanhood, is widely viewed as something that must be earned and demonstrated.  Men’s health practices – both in everyday life and in relation to health care — constitute one way of demonstrating masculine identity.  For many men, therefore, engaging with health services must be legitimised in the context of masculinity.

Of course ‘men’ are not a homogeneous group, and there are different concepts of ‘masculinity’ or ‘what it means to be a man’.  These concepts of masculinity intersect with  factors such as age, education, occupation, socioeconomic status, ethnicity and family background to influence men’s health-related attitudes and behaviours.  What does emerge from the men’s health literature, however, is a striking consistency in health-related attitudes, beliefs and behaviours among men across many cultures and countries, especially men who hold traditional views about masculinity.

There is evidence, from Australia and elsewhere, that adherence to traditional beliefs about manhood is the strongest predictor of individual risk behaviour over the lifecourse, and that masculinity beliefs are strongly related to adopting or avoiding preventive behaviours.

So when I refer to ‘men’, I understand that not all men have the same attitudes, beliefs and practices in relation to their health. However, it is sometimes necessary to talk about ‘men’ as a population group, and, in doing so, I follow the practice of many government and non-government organisations with a particular interest in men’s health. These include Foundation 49, Andrology Australia, the Department of Veterans Affairs, and the Government of Victoria.

Men and healthcare

In addition to being the subject of considerable research, men’s reluctance to access health care has been the topic of a recent lively discussion in The Conversation. While funding under the National Male Health Policy for Men’s Sheds and the longitudinal men’s health study has been welcome, funding support has unfortunately not extended to the other key initiatives: those which could effectively address the men’s relative avoidance of preventive practices and care and timely detection and treatment for health problems.

Although 80 per cent of Australian men saw a GP at least once during 2013-14, there are still plenty who wear their non-attendance as a badge of honour.  When they do see a doctor, men’s visits, compared to women’s, tend to be shorter and are more likely to focus on a ‘fix my problem’ issue. ‘Doorknob’ issues – the important underlying concerns that patients can’t bring themselves to mention until the consultation is nearly over–– tend not to be dealt with unless the doctor is particularly adept at asking the right questions and has time for the answers. It will be difficult for health care providers to overcome the denial or anxiety that many male patients have about their health unless there is a relationship based on trust and effective communication.

Masculine identity

The findings are now compelling that concepts of masculinity play a role in men’s health-related attitudes and behaviour, including prevention.  It is also understood that the performance of health practices involves demonstrations of masculine identity.  This means that health behaviours must also be seen as social practices.  Demonstrating masculine identity may include acting ‘irresponsibly’ in relation to health because this is seen as part of what defines ‘real men’.  These social practices can also involve not only engaging in high-risk behaviours and rejecting health-promoting practices, but also avoiding going to the doctor. When a man boasts, ‘I haven’t been to a doctor in years’, he is asserting his masculine identity by denying the need for care.

Men also tend to adopt a ‘functional’ view of health, which involves waiting until a body part stops working before seeking medical attention.  For many men, ‘health’ and ‘health care’ are feminised spaces  — talking about, being concerned about, and consciously acting on health issues are things that women do and therefore conflict with traditional concepts of masculinity. See this comment on the article in The Conversation:

‘The only time these blokes seek medical attention is if they are bleeding.  They will go and get patched up at the hospital’s emergency department, but there has to be physical evidence of injury – not illness.
This is how it looks:  Illness is a weakness.  Illness is age.  Injury is a badge of honour.  Illness is pills, potions, fuss and dependence.  It is doing less.  Being careful. Injury is spitting in the eye of all of that.
Women are ill.  Women have “conditions”, ailments and afflictions. It is a topic of daily discussion.
And the weak.  Office workers and the like. Academics.  Doctors.  All whining about their giblets and their twinges as if anyone cares.
. . . [T]he chasm between “medical sense” and masculinity – at least in this very mythic Chips Rafferty context – is about a very different philosophical view of life – what it means to be alive, the quality of one’s life being determined by one’s capacity to persist – and that is increasingly alone.’

If part of what constitutes being a ‘real man’ is being unconcerned about the notion of health, then it is no wonder that men need ways of legitimating engagement with ‘healthy lifestyle’ advice or engaging with health services.  Where traditional masculinity means that ‘health’ cannot be done for its own sake, there has to be a good reason for prioritising health and wellbeing.  This problem is compounded because the idea of ‘health’ today carries moral connotations such that being a ‘good citizen’ means showing some concern for your health.

Reframing the message

Yet many men see ‘healthism’ as a threat to male autonomy and rebel against it in its many forms. My husband bristles with visible annoyance and resentment at TV advertisements which exhort him to quit smoking, eat healthy food, and get tested for bowel cancer.  He is among those men who refuse to undertake preventive screenings despite having a number of significant risk factors for chronic diseases; he is also reluctant to see a doctor for diagnosis and treatment of injuries or pain.

It is not just information that such men need – it is a particular type of information that gets to the heart of why doing certain things actually matters, particularly within the context of their priorities and belief systems.

They may need clear information about what the consequences of certain actions are – and to have this spelled out not only in terms of the consequences for their length and quality of life (with the latter usually considered more important than the former), but what the consequences would be for their ability to keep doing the things that are important to them.

The abstract idea of ‘health’ – or even ‘real men look after their health’ – may not be sufficient without the practical details about what it is likely to mean for them if they do not take certain actions (such as seek early detection or early treatment). With preventive screenings, it can be difficult for some men to even accept that there could be something wrong inside their bodies without them being aware of it. The belief that, “If it ain’t broke, don’t fix it” only works if you actually know whether it is broke.

Strengths, trust and autonomy

Men’s reluctance to access health care may be a manifestation of masculine self-reliance. Reluctance to engage with the health care system can also be a consequence of past experience and a lack of trust and confidence in medical advice, combined with expectations of certainty and clear-cut solutions.

Being told by a doctor to “Take this, and if you’re not better by next week, come back and see me”, can leave some male patients decidedly unimpressed.  As one man explained to me, “If the doctor paid me to fix a squeaky door, I’d guarantee that it was fixed, and if it wasn’t, I certainly wouldn’t charge again to come back and fix it!”

The masculine attributes of autonomy, control and responsibility mean that some men believe strongly that they are making a rational choice in avoiding going to the doctor. They argue that they are better off personally by not going, and that they are saving costs to both themselves and to the health care system by self-monitoring and self-managing. This recent comment in The Conversation proposes that men should avoid doctors by being informed self-managers of their own health:

‘Heart, diabetes etc, you’re way better off managing your own health than going to a doctor anyway, and anything they give you is going to be less effective than cleaning up your own act. High cholesterol and blood pressure, taking prescribed medicine should be the second last resort behind surgery. I will do everything in my power to avoid high blood pressure tablets or statins, you are much better off managing this in an informed way, and doctors aren’t particularly knowledgeable about diet, nutrition or exercise. There are much better sources for that.’

One problem is uninformed self-management.  A man weans himself off statins because he doesn’t believe that he needs them. No one may have explained to him, in a meaningful way, what the consequences might be of taking them or not taking them. So the deciding factor becomes the masculine view about dependency: “I don’t want to spend my life being dependent on having to take a pill every day.”

Combine this with the imperative to resist  perceived threats to masculine autonomy — including ‘being told what to do’ by governments and health groups — and you have a real problem: taking ‘individual responsibility’ involves asserting autonomy by not acquiescing to the commands of government agencies and ‘do-gooder’ health groups.

Some men are able to negotiate their way around these issues by ‘blaming’ their wives, (“Sorry, doc, I’m only here because my wife made me come”), but others refuse to ‘give in’ to women because that represents a denial of their masculinity, in addition to reinforcing health as a feminised space. So they continue to resist.

Family members can find themselves in an impossible position, standing by helplessly while men suffer and die from ailments, conditions and injuries which could have been successfully treated, if only they had presented earlier.

Meeting men where they are

There seem to be several ways around this.

First, we need a more ‘salutogenic’ approach to men’s health. This means harnessing and building on men’s strengths in ways which re-frame the ‘negative’ aspects of masculinity as attributes which make it permissible, and even necessary, to engage in health-promoting practices.

Second, we could and should be doing much more to take health and health care (including preventive screenings and nutritious food) to where men are rather than expecting men to come to where these are.  This has not only practical benefits but also supports the idea of giving men permission, within the context of ‘what men do’, to talk about and do health-related things.  In the words of a 35 year old male office worker: “We want to be healthy– but we don’t want to go to any trouble over it.”

Third, communication is a real issue, in both health care settings and in messages about prevention and early detection. While it is important to encourage men to access health services, health services also need to know how to reach out to, communicate with and engage with men when they do come through the door.

The health system could do much better at communicating with men about physical and mental health – and this usually means creating an environment in which it is easy to talk about physical and mental health issues, and providing communication which is logical, factual and directional, with a focus on what is tangible and actionable.

What passes for ‘information’ from governments and health organisations about things like bowel cancer screening also needs a major overhaul. Health information and social marketing need to be based on an understanding of the barriers and drivers for men’s health-related attitudes, beliefs and actions and how these differ among different groups of men.

A middle-aged male in the construction industry needs health information from someone he can identify with. This might not be Ita Buttrose or the Commonwealth Chief Health Officer, whose names appear on letters from the National Bowel Cancer Screening program. You don’t have to be a marketing guru to know that, regardless of what you are selling, communication and behaviour change are most effective when they are linked to ‘core emotional truths’ of the target audience. Concerted attempts to raise the levels of health literacy also need to take gender into account.

Fourth, an MBS item for a health assessment for older men, aged 55 and over, could be a useful way to encourage men to see a GP. There is currently a health assessment for people aged 45-49 years who are at risk of developing chronic disease, a type 2 diabetes risk evaluation for people aged 40-49 years with a high risk of developing type 2 diabetes, and a health assessment for people aged 75 years and older. That leaves the age group 50-74 unaccounted for.

The recent recommendation for an MBS item covering a combined health check for cardiovascular, kidney disease risk and diabetes could be useful. A young men’s health check, currently being advocated by Andrology Australia, could also provide an important opportunity to engage with men at an early stage.

Fifth, GP practices could look seriously at ways to effectively engage with their male patients, both generally and with a focus on those who have ‘fallen through the cracks’.  One option would be to trial a system involving a carefully-worded personal letter inviting these patients to see their GP. There is some evidence for the effectiveness of personally-addressed letters to men from their doctor, and more research is warranted.  Among the helpful resources designed to advise on engaging and communicating with men are those developed by Andrology Australia and the Victorian Government.

Even without a specific health assessment item, it should be possible for GPs to do much more to initiate contact with male patients whom they have not seen for some time — especially those who have previously identified health problems or risk factors.

Priority groups would include men of the relevant age who have not done a faecal occult blood test for bowel cancer, men who have stopped renewing their prescriptions for ongoing medication, and men who have either not undergone requested pathology testing or have not attended to discuss the results of previous tests.

For some patients, following up may require more than just a letter (or new technology’s functional equivalent) – it may require a follow-up phone call if there is no response to the letter.  Attempts at follow-up would also need to acknowledge that cost is an issue for many men, especially where there is a lack of bulk-billing practitioners.

Time is also a factor for men who are employed or who are carers, especially given that GP appointments do not reliably run on time. These issues would need to be considered, but I do not believe that they are insurmountable. Men themselves comment that they receive reminders from their dentist, from their optician, and from their motor vehicle mechanic, but never from their GP.

A call to action

Australian men have a shorter life expectancy than women, and seven of the 10 risk factors that contribute most to the burden of disease are more common in men than women.  Any serious effort to improve health and to address health equity must include attention to the health needs of both sexes and responsiveness to the differences between them. We need gender-sensitive approaches rather than gender-neutral ones.

Men’s relative reluctance to access health care services stands in stark contrast to the range and severity of the problems that affect them. Addressing the ‘silent crisis’ of men’s health will require a greater focus on the gendered nature of health attitudes and behaviours in current models of health psychology and behaviour change, and within the public health agenda and health services.

The Australian Men’s Health Forum’s Call for Action on Male Health in Australia urges health professionals to acquire a better understanding of factors influencing male health and health-seeking behaviours and guidance on how to better structure clinical and management practices to encourage engagement of males.

With so much talk of primary health care reforms, is it too much to hope that these might include forging more effective links between men and the health care system?

Margo Saunders is a Canberra-based independent public health researcher and policy analyst with particular interests in men’s health, health literacy and health communication. She is an Associate Member of the Freemasons Foundation Centre for Men’s Health (Adelaide).

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