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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