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In 2009, Ireland became the first country in the world to publish a National Men’s Health Policy. Like the smoking ban, Australia soon followed, with countries as far afield as Brazil and Iran being more recent converts. One might well ask why this eclectic mix of countries has specifically identified men as a target population group at a health policy level? Yes, men have traditionally been to the forefront of all matters to do with health, but notably have been conspicuously silent about lobbying or campaigning for improvements to their health at a personal or individual level. Or so we thought.
In 2010, [the late] Prof Anthony Clare’s book (On Men: Masculinity in Crisis) broke this silence through his exploration of wide-ranging challenges and threats to masculinity in a post-feminist society. The period since then has been marked by an increased openness about men’s health issues. We have witnessed high profile men from the fields of sport, entertainment and politics speaking out and coming out about men’s issues. So why men? Is there a clear rationale for having a specific focus on men’s health? Are men in Ireland today really more receptive and open about health issues than their forefathers, or are there challenges still about engaging men in relation to health? What can we learn from more recent programmes and interventions within the broad field of men’s health that can inform our practice? These are some of the questions that this article poses and will be discussed in the wider context of some exciting developments in men’s health in Ireland in recent years.
The rationale for targeting men as a specific population group in the context of health is multifaceted and grounded in (i) life expectancy and mortality differences between men and women; (ii) health inequalities between different sub-populations of men; (iii) lifestyle and health behaviour differences between men and women; (iv) a perceived reluctance by men to engage with health services; and (v) a growing body of evidence supporting the need for a gender-specific or men-friendly approach in order to effectively engage men on health issues.
(i) Key men’s health statistics
Although male life expectancy in Ireland is increasing and the gap between male and female life expectancy is narrowing, male life expectancy remains four-and-a-half years lower than female life expectancy (78.7 and 83.2 respectively), and men in Ireland continue to have higher death rates for most of the leading causes of death (Table 1) and at all ages (Table 2).
While the gap in male:female mortality for all causes of death is consistent across all age groups, it is most pronounced between young men and young women, with suicide and road traffic accidents accounting in large part for this differential.
(ii) Health inequalities between different sub-populations of men
Whilst aggregated sex differences in life expectancy and mortality are important, it is, however, crucial not to overlook the substantive differences in health status between different categories of men. It is now well recognised that social, economic, environmental and cultural factors are key determinants of the health status of men. For example, compared to men in the highest occupational classes, men from the lower occupational classes have poorer health outcomes and experience significantly higher mortality rates. There is what can be described as a stepwise gradient, with ill-health and premature death increasing with each step down the social class scale, and the steepness of this gradient being particularly pronounced in men. Indeed, a recent ESRI report found this social class gradient has increased between the 1980s and 2000s. A report by the Institute of Public Health in 2011 on the impact of recession and unemployment on men’s health in Ireland demonstrated strong causal links between recession, unemployment and declining economic conditions, and the health and wellbeing of men in Ireland. There is also a range of other sub-populations of men, for whom health outcomes are significantly worse than the general population of Irish men. For example, the 2010 All-Ireland Traveller Health Study revealed that life expectancy for Traveller men was 15.1 years lower than their general population counterparts. In fact, at 61.7 years, life expectancy for Travellers was found to be at a similar level to that of the general population in the 1940s.
A similar picture is evident at a European level. The publication of the first State of Men’s Health in Europe report in 2011 highlights that across the EU 27 countries, over 630,000 male deaths occur in working age men (15-64 years) as compared to 300,000 for women and that these deaths are disproportionately concentrated among lower social class groupings. This high level of premature mortality has far-reaching repercussions, affecting not only industry and commerce, but also impacting upon the social and financial positions of families through the loss of what is still, in many households, the primary income earner. This is of particular concern in light of future population trends. Based on current projections, there will be nearly 24 million fewer working age men (aged 15-64 years) than at present across the EU by 2060 and an increase in the number of men over 65 by some 32 million.
(iii) So are men less healthy than women?
Men’s poorer lifestyles account for a high proportion of chronic diseases such as coronary heart disease, diabetes, stroke and some cancers. Approximately two-thirds of Irish men are either overweight or obese. Men’s diets are less healthy than women’s diets with men eating more fried foods and high-caloric items and less fruit and vegetables than women. Men are more likely than women to drink in excess of the recommended weekly limit and to binge drink. Men are also more likely to have a ‘positive’ AUDIT- C score, which indicates a harmful pattern of drinking. Despite this, men often view themselves as having better health than women, and young men in particular tend to minimise the potential consequences of practices damaging to their health and to see themselves as invulnerable to danger and to risk.
The Men and Cancer Report (https://www.ncri.ie/publications) attributed poor lifestyle behaviours as the principal cause of why men are at greater risk of getting cancer, dying from cancer, and having significantly lower survival than women (Figure 1). The report highlighted the urgent need for more targeted and gender-specific lifestyle interventions that focus on those sub-populations of men most at risk.
Health promotion and preventative efforts need to start with boys. In recent times, there has been some good evidence of substantive positive change in boys’ lifestyle behaviours. According to the Health Behaviours among School-aged Children (HBSC) survey of 11-17-year-old children in Ireland, there was, between 1998 and 2010, a statistically significant decrease in the percentage of boys who reported (i) that they currently smoked (21.2 per cent – 11.9 per cent); (ii) that they had been drunk (34.8 per cent – 29.7 per cent); and (iii) that they had used cannabis in the last 12 months (14 per cent – 10.2 per cent).
(iv) Are men slow to go to the doctor?
It is also well documented that men tend to be slow to recognise symptoms of ill-health and to present late to health services, leading to higher levels of potentially preventable health problems among men and fewer treatment options. A recent Quarterly National Household Survey reported that, with the exception of the 70+ age category, men had fewer GP consultations than women in the previous 12 months – women on average had 1.5 times more consultations than men. Some 34 per cent of men had no GP consultation in the previous 12 months compared with 19 per cent for women. A Danish study, which demonstrated an overall pattern among men of lower contact rates with GPs but higher hospitalisation and mortality rates, led the authors to conclude that men react later than women in seeking help for severe symptoms, resulting in higher rates of hospitalisations among men for the causative condition. The proportionally greater use of primary care services by women in the early years reflects the provision of antenatal care, contraception and screening services that are more likely to habituate women into regular contact with health services. The general absence of male-targeted healthcare programmes hinders the surveillance capability for men’s health problems and men’s ability to identify as participants in health care. Perhaps not surprisingly therefore, many men eschew traditional interpersonal medical consultations and instead opt for online medicinal products, an increasingly worrying trend given the risk of exposure to potentially harmful counterfeit drugs. Men’s poorer knowledge and awareness of health also points towards the need for targeted health information to be delivered to men.
(v) Do we need to approach men differently?
It is also crucially important to focus on key gendered aspects of men’s health, and to consider men and women as more than simply biological categories, constituted solely by biological differences. Such an approach enables us to recognise how different patterns of gender conditioning impact upon the value that men place upon their health and how they manage their health within the healthcare system. For example, numerous studies have highlighted how men tend to avoid seeking help when they are unwell because of fear of being labelled feminine or effeminate. This can be particularly pronounced in the case of a mental health issue. It has also been shown that men who engage in health damaging or risk behaviours often do so to prove their masculinity to others.
And yet, while men are often considered ‘hard work’ by health service providers by not caring for their health, society continues to reward and valorise aspects of male identity associated with risk, daring and foregoing safety. For example, men continue to dominate those industries that have high levels of occupational injury and death – the construction industry, work involving heavy machinery or work conducted in heavily polluted environments – yet this has traditionally been taken for granted as normal and expected masculine practice, as ‘men’s work’.
The extent to which men endorse ‘traditional’ or ‘dominant’ definitions of masculinity is related to unhealthy behaviours such as poor diet, excessive alcohol consumption, and non-use of health services. Men’s depression and other mental health problems often remain under-detected and undertreated. For example, it has been argued that male depression is often manifested through more ‘acceptable’ male outlets, such as alcohol abuse and aggressive behaviour. With depression being implicated with over half of suicides, this gives rise to the anomaly that although women are diagnosed with depression about twice as often than men, men are two to three times more likely to die from suicide. Gender has also been identified as a key factor in men’s late presentation to health services, with help-seeking having connotations of femininity or weakness.
So what’s new in men’s health?
Encouragingly, there has been a raft of positive developments in men’s health at a research, policy and practice level in recent years. At a research level, there has been a dramatic increase in men’s health research publications across a broad range of disciplines from urology to andrology to sociology, with both dedicated men’s health journals, numerous men’s health themes and features within the broader literature and several international conferences on men’s health. At a policy level, Ireland’s pioneering role in men’s health policy development has been described by the British Medical Journal as “a particular source of inspiration for other countries”. Ireland’s efforts are currently informing the development of a WHO-led men’s health policy framework at an EU level. The policy has been instrumental in creating a vision and an identity for ‘men’s health’ and in acting as a blueprint and a resource for practitioners. The most critical factor in the transition from policy development to implementation has been the adoption of gender-specific and strengths-based approaches associated with governance and accountability, advocacy, research and evaluation, leadership, capacity building and partnerships. Among the more notable or flagship developments have been:
(i) ENGAGE – Ireland’s National Men’s Health Training Programme
ENGAGE is a comprehensive one-day training that aims to increase participants’ understanding of best practices in engaging men with health and social services and aims to address what many would regard as the current deficit in gender sensitive service provision for men. Developed by a partnership of statutory, academic and community organisations, and complemented by the development of toolkits and best practice guidelines on how to effectively engage men, the programme has played a pivotal role to date in building capacity among service providers to engage more effectively with men and boys at both an individual and an organisational level.
(ii) International Men’s Health Week
Working in partnership with over 70 partner organisations, the Men’s Health Forum in Ireland co-ordinates International Men’s Health Week each year (typically the third week of June, preceding Fathers Day). Focusing on a different theme each year, the primary aim of the week is to increase awareness of the specific health needs of men and boys and to encourage them to think about their health and lifestyle behaviours. A parallel aim is to involve a broad range of health professionals and service providers in the early detection and treatment of health issues facing men. The week is now firmly established in the calendar of health awareness raising events in Ireland with an increasingly wider reach and profile each year.
(iii) Men and suicide prevention
A key priority of men’s health policy implementation to date has been in the area of men and suicide prevention. There has been an explicit focus on suicide in young men with significant reports (The Young Men and Suicide, and Engaging Young Men Project) and resource development making a major contribution to policy and practice in this area. In more recent times, attention has shifted to middle-aged men, with the focus of ongoing work being to develop a range of community capacity-building measures targeted at promoting mental health and preventing suicide among middle-aged men in Ireland. Another notable development in this area has been the ‘Mojo’ project (http://www.mojo.ngo).
Mojo is a 12-week suicide prevention training programme that addresses mental and physical fitness, as well as supporting participants to engage with local services, set goals, and develop a life plan.
(iv) Men’s Sheds
With over 400 Sheds in Ireland and approximately 10,000 members, Men’s Sheds have grown exponentially in recent years. Although not explicitly about health, evidence indicates that key features of Shed participation (ie, using and developing new skills, feeling a sense of belonging, supporting and being supported by peers, and contributing to community) contribute to men’s overall wellbeing. ‘Sheds for Life’ is a more recent and exciting new initiative from the Irish Men’s Sheds Association and supported by the HSE, which aims to support the physical and mental health and wellbeing of its members. As part of this initiative, a new dedicated men’s health website has been launched (http://malehealth.ie), which connects men to a wide range of health information and resources from over 40 leading health organisations.
(v) Knowledge translation and linking research to practice
One of the key features of national men’s health policy implementation to date has been the strong partnerships and collaborations that have developed between academic, statutory and community/voluntary sectors. Research and evaluation has been a cornerstone of men’s health. In addition to a broad range of peer-reviewed publications, there have also been significant research reports in areas ranging from suicide prevention and men and cancer (as cited earlier), the impact of unemployment on men’s health and farmers and cardiovascular disease.
The National Centre for Men’s Health at IT Carlow has played a central role in much of this work as well as key knowledge translation activities, such as the development of guidelines on tackling male obesity in the primary care setting, toolkits for service providers on how to effectively engage men and health information booklets targeted at specific male population groups (All available at http://www.itcarlow.ie).
Perhaps Prof Clare was right about a ‘crisis’ in masculinity? Arguably, in the context of men’s health, this may not be such a bad thing, in that it has challenged the way men think about and care for their health. Historically, the embodiment of a more traditional masculinity (stoicism, invulnerability, stiff upper lip etc) has presented many challenges to men caring for their health. As noted by retired psychiatrist Dr Ivor Browne in a recent RTÉ documentary – There’s nothing healthy about being well-adjusted to a profoundly unhealthy society! Likewise, being ‘well-adjusted’ to more traditional notions of masculinity, has constrained many men from leading healthy and fulfilling lives. That is not to say that masculinity is somehow toxic. Indeed, there are multiple ways of being masculine and we need to harness the resilience and strength that is at the cornerstone of masculinities in all our endeavours to promote men’s health. Rather than seeing men as ‘the problem’, the onus should be on practitioners to work with men and to take more account of the gendered ‘baggage’ that in some men underpins risky behaviours, reluctance to seek help and reticence to be more engaged or proactive about their health. Perhaps, the most important lesson we have learned from men’s health policy implementation to date is the need to adopt strengths-based approaches to engaging men that revolve around creating safety, trust, rapport, and meaningful relationships with men; using strong, positive messages that encourage men to engage with services without amplifying shame or blame; connecting positive masculine identities with being healthy and productive; reflecting the wishes of men to maintain control and to engage with services on their own terms and in their ‘own way’; and sharing men’s stories to show common challenges, to foster peer-support and to create a community of mutual help. Borrowing once again from Dr Browne’s philosophy of medicine, the practitioner’s role is not to ‘fix’ men but rather to facilitate and support men to fix themselves.
References on request