Anna Louise Shepherd, BSc, SRN, SCM, PGCertHV.
Health VisitorAs both a concept and social reality the evidence of the reciprocal relationship between poverty and resultant poor health status has been visible for some time. However, only relatively recently has the inequality of health status enjoyed by men and women been described (Calman, 1992).
As both a concept and social reality the evidence of the reciprocal relationship between poverty and resultant poor health status has been visible for some time. However, only relatively recently has the inequality of health status enjoyed by men and women been described (Calman, 1992).
Indeed, it has been suggested that when it comes to life expectancy there is no greater inequality than that between men and women (Cooper, 2001). On average, men die five years younger than women, and those in areas of social deprivation may die as much as 10 years younger.
In Northern Ireland the average man can expect to live for 74.8 years and a woman for 79.8 years (Southern Health Board, 2003). In addition, men are four times more likely to die from heart disease, accidents and suicide than women and have a higher risk of death from strokes, cancer and respiratory diseases (DeVille-Almond, 2000).
Men and their health
Perry (2000) suggests that, compared with women, men generally have less healthy diets and tend to engage in risk-taking behaviours, both of which can lead to health problems. While many diseases and illnesses can be prevented, diseases such as testicular cancer, which has a 90% cure rate if detected early, has doubled since the 1970s (DeVille-Almond, 2000).
In Ireland prostate cancer has risen from 9.75% in 1993 to 11.45% in 1998 (Men's Health Forum in Ireland, 2003) and, with 10 000 deaths a year, ranks as probably the most commonly diagnosed tumour among men and the second most common cause of death in men (Kirby and Kirby, 1999).
Yet, despite this, many men remain ignorant of the symptoms indicating disease and therefore do not seek help early. Webb (1999) suggests that the family car gets more attention than the health of the average man. Others have gone as far as to ask whether men are in danger of extinction (Meryn and Jadad, 2001).
It has long been argued that the principal reason for the low health status of men is that they are not interested in their health to the same extent as women. Banks (2001) contests this view, suggesting that men are indeed interested in their health and services if they are offered in a male-oriented manner. Local research undertaken in the Craigavon area by Connolly (2002) identified three factors affecting men's ability to seek medical help: culture and socialisation, fear or embarrassment, and a perceived lack of understanding by health professionals of men's health needs.
Whatever the merits of the debate, it appears certain that there is a growing awareness that health matters to men. However, cultural expectations and socialisation into the male role means that how men perceive health issues differs from that of women (Robertson and Williams, 1997) and, therefore, demands at least a gender-tailored response from health professionals. To this end it is argued that, in order to provide effective, trusted and respected services, we must adopt a pragmatic and flexible approach, using diverse and complementary methods with an approach that is client-led and needs-based.
Previous responses to men's health needs within primary care have traditionally focused on a medical model, inviting men to attend surgeries for screening (Athi and Debney 2001). This approach, suggests DeVille-Almond (2003), attracts the worried well and health-conscious only and rarely reaches men who are at greatest risk. Alternative approaches have attempted to take services to where men are (Stanley, 2001; Carey, 2002). Robertson and Williams (1997) state that 'work with men requires a variety of approaches in a variety of settings, being sensitive to the beliefs and actions of individual men and also the popular culture that informs their lives'.
Local needs and a local response
With a population of 120 000 the Craigavon and Banbridge Trust area is largely rural. The trust area also has a growing number of ethnic minority groups including about 1000 Chinese, 400 Asian people and, at any one time, about 100 people from the travelling community (NISRA, 2001).
Clearly identified groups of men with specific health needs have been identified within our area. One such group are farmers. Levels of stress experienced by farmers from rural areas of Northern Ireland have risen dramatically in recent years (Fowler and Gallagher, 2002).
In a recent survey (Ulster Farmer's Union, 2002) it was found that that this coincided with the rapid change and decline in the profitability of farming, which reached crisis proportions with the onset of bovine spongiform encephalopathy and the foot-and-mouth epidemic. Recent initiatives to offer farmers the opportunity to access health screening at convenient sites, such as cattle markets and agricultural shows, have found 65% of farmers with cholesterol levels over the recommended level and 30% with raised blood pressure. Suicides rates have also risen in this group of men (Coyle, 2001).
The local health action zone obtained joint financial backing from the Department of Agriculture and the Department of Health to set up a rural support network to offer farmers advice, support and assistance (Gill, 2002). With high risks of coronary heart disease, strokes and suicide in the local farming community, these men were specially targeted. As there was no suitable community centre in this isolated rural area, with the co-operation of the local publican, a meeting was held in the restaurant above a local pub. Pubs have been successfully used in previous outreach events described in the literature (Stanley 2001; Carey 2002).
Anxious to avoid falling into the trap of only appealing to the worried well (DeVille-Almond, 2003) the team decided to adopt an holistic approach, incorporating screening with advice and information but reaching out to where men are. Any programme devised would have to recognise the need to tailor services to men's perceptions of their health and to incorporate this. A multidisciplinary approach was used, bringing together community nurses, health promotion specialists, dietitians, specialist nurses, community pharmacists, voluntary groups and hospital nurse practitioners. Initially, a series of three men's health roadshows was offered in community centres in areas of urban disadvantage in Lurgan (Figure 1). After they had taken place, a number of requests were received for further events in the rural area.
Asian women in the local community alerted the health team to another group of men when they approached health professionals regarding the running of a roadshow specifically for Asian men. Working through them, leading men in the Asian community were contacted and a men's health roadshow was arranged on a Friday afternoon, following 'Jumuah' when the men meet together for prayers in the community hall that serves as a mosque. As most of these men normally work long and antisocial hours, self-employed as market traders or in the food industry, it is difficult for them to make use of medical services easily. This event, fitting into traditional cultural patterns and endorsed by local religious leaders, made it possible for these men to attend. A variety of services were offered on the day, involving health promotion staff, community nurses, pharmacists, leisure centre staff, Action Cancer and ACCEPT, a mental health charity which offers advice, guidance, support and training for individuals recovering from mental illness.
Organising and running the first rural men's health roadshow
The rural area described in this paper lies on the shores of Lough Neagh, at the intersection of two health boards. As men living in this vicinity could be registered with any number of GPs in either board, it was decided that the most appropriate way of advertising the evening was through a poster campaign. These were placed in local shops and all doctors' surgeries; health visitors were also provided with flyers to distribute to fathers in the families they visited. Local schools and churches were also involved - they sent out flyers to families and announced the event at church services and in church newsletters.
An article was written for the local papers. Sponsorship was obtained from a variety of drug companies to cover the costs of blood cholesterol testing, which was provided by the Northern Ireland Chest, Heart and Stroke Association. A multidisciplinary team was invited to provide advice and information as well as screening on the night.
The evening provided a useful bridge between hospital-based services and community services through the involvement of a male nurse specialist in urology. The venue provided privacy, as the restaurant was partitioned up into booths. Table 1 lists the professionals involved in the evening and the services they provided. Forty-five men attended the event, but only 38 registered and only 28 completed the evaluation form.
After reflecting on the evening's organisation, it was agreed that we needed more than one professional to welcome the men, deal with registration and assist them to fill in the evaluation forms. This occurred because a large queue had built up waiting to enter, which made it difficult to complete the documentation at the outset. Although the health staff made attempts to encourage the men to fill in the forms later, this did not occur, as some left immediately after they had visited the stalls. This fact needs to be considered when evaluating the number of men that attended each stall and their feedback on which of them they found most useful (Table 1).
Evaluation on the night was positive. Some queues developed at booths where more time-intensive counselling was taking place, and several men were unable to see all the professionals because of limited time. All the men commented that the pub was an excellent venue. It offered privacy, while enabling the men to interact while they were waiting for each booth. One man's comments were particularly encouraging: he said that the night had been terrific - 'I would come back again and I would advise anyone to go'; another man said that 'there should definitely be more nights like this'.
It was encouraging that 21 men said that they would like to make changes in their lifestyle to improve their health after the evening (Table 2).
The men were asked if they needed support or more information as a result of the evening and health screening. Men were offered the choice of contacting their own GP regarding identified problems or being referred to the GP. All men chose to follow up the issues themselves. Feedback from some of the health professional involved highlighted several discrepancies between their records and those presented by the men. For example, two men were identified as having erectile dysfunction and were advised to see their GP. It was not clear from the paperwork completed by the men that they would do this, however. Nurses also noted that there was a larger proportion of men who were overweight and with raised blood pressure than was indicated by the men's own evaluations. This may have been because of the inability to get all the men to complete paperwork on the night, but it may also indicate their unwillingness at this time to accept the information. In future events health professionals' records of individual consultations could be more in-depth, although this has time and staffing implications.
The initiatives to promote men's health in the Craigavon and Banbridge Community Trust area outlined in this paper have proved successful and enjoyable ways for men to access health checks and health promotion. However, if we continue to provide one-off events on an ad hoc basis, we will fail to provide continuity, a criticism made of many men's health initiatives (Athi and Debney, 2001).
At government level, the then minister for public health, Yvette Cooper, stated the need to invest finances in more research on men's health issues and for improving access to primary health services for men (DeVille-Almond, 2000).
Perry (2000) suggests that, if we are to be effective in improving men's health, the emphasis needs to change to tackling the 'socio-economic, patriarchal and destructive social patterns' that characterise many men's lives.
At present, these evenings are offered because of a perceived need by health professionals and in response to requests from men. However, it is unrealistic to depend on the continuing goodwill of already overstretched staff. For this work to continue and develop commitment from management with a detailed strategy and funding is required.
Following the launch of the first Men's Health Forum by the RCN in 1994 the development of regional men's forums is encouraging, but local development in Northern Ireland has been slow.
This paper has described the proactive local response to perceived male health needs. While the initiative is not unique, it underlines the success and challenges that can be experienced by health teams striving to address gender-related health issues.
The multidisciplinary team who devised this initiative is very much aware of the amount of work that remains to be done and of the obstacles that prevent a clear path to the addressing of these needs. Consequently, the team is determined to establish relationships that will facilitate partnerships with representatives of local men of all ages, social and educational backgrounds, ethnic origins, religious persuasions and sexual orientation, to provide a male-oriented service.
Issues that pose obstacles to tackling the issue of men's health will take time and creativity to overcome both in the short and the long term. Problems include issues such as:
- Lack of interest in, or understanding of, men's health
- Lack of funding
- Resistance to seeing the gender imbalance in health issues
- Inadequate management support
- Working in isolation to raise the profile of men's health
- Lack of consensus on male health needs and the problems of engaging men (Luck et al, 2000).
However, the relative success of this initiative has galvanised the health team into continuing our efforts to ensure that resources are found to enable us to meet the needs we have identified.
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