Tackling Health Inequalities - the response of the Men's Health Forum

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The Men's Health Forum, the leading advocate of male health, in England and Wales welcomes this opportunity to respond to the Department of Health's consultation document, Tackling Health Inequalities. The Forum shares the Department's aim of reducing, and ultimately eliminating, health inequalities of every kind.

 Regrettably, however, the issue of health inequalities and gender is largely absent from Tackling Health Inequalities. Although gender is mentioned as a 'dimension' of health inequalities, this is not followed through in any significant way. The Men's Health Forum is particularly concerned about the virtual absence of any consideration of the health of men and boys from the document. This omission is surprising given the increased interest shown in male health shown by the Department of Health, the Health Development Agency and others in recent years. For example, in her foreword to the recently launched Men's Health Journal, the public health minister, Yvette Cooper MP, stated:

'Men die five years younger than women on average — it is one of the starkest health inequalities we face. Heart disease, cancer, high blood pressure, suicide and accidents are all generally more prevalent among men and men on average visit GPs less than women. Those on low income have the worst life expectancy of all, and the health gap between men on high incomes and men on low incomes has grown. …. I welcome the growing interest in men's health which will raise awareness and help tackle problems and inequalities. …. We need to tackle health inequalities wherever they occur. …. I am confident that, by recognizing the gender gaps in health, we can continue to modernize health promotion campaigns and health services to close them.' (Men's Health Journal 2001, Vol 1, No 1).

Because men's health is generally so poor, the Men's Health Forum believes that any strategy which aims to tackle health inequalities and to improve the health of the population as a whole must address male health issues. In this response to the consultation document, the Forum suggests how the Department of Health can help make 'men's health' no longer seem like a contradiction in terms.

The evidence

The data documenting the unnecessarily poor state of men's health is overwhelming. The Forum does not propose to list it all but instead to highlight some of the most significant data. 

Although this table compares men's and women's health, it is important to remember that the problems of male health will not be solved simply by making the statistics more equal. There are serious and specific female health issues that also remain unaddressed and women's health cannot be seen as a crude 'gold standard' for men to be measured against.

There is also evidence that shows the potential to improve male health through gender-sensitive and innovative interventions. This can be found in the Men's Health Forum's database of men's health projects throughout the UK. Some of these projects are referred to in this document but many more are not. The database can be accessed through our website, www.menshealthforum.org.uk.

DEVELOPING A PLAN FOR DELIVERING ACTION ON MALE HEALTH INEQUALITIES

Our response broadly follows the structure suggested by the questions posed by the consultation paper on page 39.

Children and young people

It is clear that boys and young men are more likely to die as a result of accidents and suicide than girls and young women. A large part of the explanation for this lies in the expectations of parents, other adults and society in general of how young males should behave. Traditional attitudes towards gender remain surprisingly and stubbornly prevalent. Boys and young men continue to be socialised to be tough and strong, to appear in control and to take risks. This creates obvious dangers — with respect to dangerous driving, for instance, or experimentation with alcohol — and makes it harder for young men to ask for help with any kind of physical or emotional health problem. Young men are particularly reluctant voluntary users of any kind of health care service.

Tackling this problem is a long-term project. In part, deep-seated socio-economic changes — women's increasing independence and participation in the workforce, for example, as well as the decline of traditional 'male' industries (mining, manufacturing, agriculture, etc) — will help change gender roles and expectations.

But there is also a need for interventions designed to demonstrate that boys and men can adopt a wider range of roles. These interventions could include:

·        Encouraging and enabling men to be more involved and active fathers. For example, midwives and health visitors could do more to acknowledge and develop the role and contribution of fathers.

·        Providing parenting and childcare information that addresses bringing up boys. To enable boys to become more emotionally literate, for example, it is important for parents to encourage their sons' emotional expressiveness rather than attempt to repress it.

·        Challenging homophobia and sexism. Traditional gender roles are held in place by homophobia and sexism — these ideologies determine the boundaries for what is considered acceptable and normal male behaviour. The potential for work in schools to tackle homophobia and sexism is enormous.

It is also important to develop health and health-related services that are more attractive to young men. This requires:

·        A new way of thinking about young men, seeing them more as individuals often with significant unmet needs rather than simply labelling them as part of a problem group.

·        Better information and training for staff to enable them to work more effectively with young men.

·        More extensive outreach work is needed with young men, taking services to the venues where they are more likely to feel comfortable.

·        Services to be marketed in ways that are more likely to be appealing, using appropriate language and imagery.

A model for more effective work with young men on a wide range of health issues can be found in the Men's Health Forum's recent work on young men and suicide. A copy of the report, Young Men and Suicide, is available on our website.

Improving NHS primary care services

Men are generally poor users of primary care services. They attend less often than women — even allowing for women's higher level of access for contraception and pregnancy — and tend to present later in the course of an illness. This can mean that their health problems become harder to treat.

The reasons for men's reluctance to attend primary care include:

·        A belief that primary care is 'not really for them' — it is perceived to be a service primarily for women and children. This perception is reinforced by the fact that reception staff are almost always female and the frequent failure to display health information about men's health issues.

·        It is inaccessible to men in full-time work — a man's GP is likely to be based some distance from his workplace and appointments tend to be available only during normal working hours.

·        Men often believe that their role is to 'tough out' illness for as long as possible rather than admit to what feels like a 'weakness'.

·        Many men lack the confidence and even the language to discuss their health concerns with a health professional.

·        It is not unusual for men to be concerned that they would be 'wasting the doctor's time'.

·        Racism and homophobia are also an issue for some men.

There are several important steps that could be taken to improve men's access to primary care:

·        Increasing men's access to confidential and anonymous sources of health information, including telephone helplines and the Internet. The experience of the Impotence Association helpline and the malehealth.co.uk website suggests that men will use these types of services in relatively large numbers. They can provide important and useful advice and information and help men to feel more comfortable about taking the next step of accessing primary care.

·        Providing more primary care services outside of the traditional primary care setting. One recent innovation is the outreach clinic specifically aimed at men. Here, basic health checks and advice are provided by practice nurses or health visitors in a male-friendly environment. The evidence available suggests that outreach clinics are popular, detect potentially serious diseases (e.g. diabetes and hypertension) and result in more men seeing a GP. This type of intervention can be carried out in pubs, community centres, barbers' shops, garages, leisure and shopping centres and workplaces. The new NHS Walk-In Clinics are also a potentially important new service for men and they should be encouraged to target this group and evaluate their effectiveness.

·        Introducing more health promotion initiatives specifically targeted at men. For example, the Men's Health Forum is currently assessing whether a prostate health awareness-raising campaign in the workplace (Consignia) results in an improvement in men's knowledge and changes their behaviour, such as seeing a GP if they develop the symptoms of prostate disease.

·        Developing Men's Health Week as a key awareness-raising tool. The Week will be launched by the Men's Health Forum in June 2002 and would benefit greatly from the active support of the Department of Health and other major health agencies.

·        Requiring primary care trusts to introduce policies and practices that address gender issues, including male health. Separate targets could be set for males and females, e.g. in relation to tackling heart disease, obesity and excessive alcohol consumption.

·        Providing training for GPs and practice nurses on gender awareness, including male health issues. The recent work of Worcestershire Health Authority on men's health suggests there is considerable interest in education and training, especially from practice nurses.

·        Removing the restrictions on GP prescribing for NHS erectile dysfunction (ED) treatments. The current guidelines reinforce health inequalities — the incidence of ED is correlated with socio-economic status and men with low incomes who fall outside the framework are unlikely to be able to afford a private prescription — and will deter a substantial number from seeking treatment from their GP. This is a serious problem because ED is often a symptom of an as-yet undiagnosed but potentially dangerous condition, especially cardiovascular disease and diabetes.

The big killers - CHD and cancer

Men are more likely to die of heart disease or cancer yet very little is done to tackle this problem. Most of the health promotion work currently taking place on CHD is 'gender neutral' and, as such, is likely to be less effective as far as men are concerned. With the exception of work on male-specific cancers, the same is true of cancer in general. The National Service Framework on Coronary Heart Disease and The NHS Cancer Plan also take a generally gender neutral approach.

A recent editorial in the BMJ highlighted the problem with the NSF on heart disease:

'Although the framework acknowledges gender differences there is no clear recognition in the guidelines of how these are to be addressed. …. Gender must be seen as an important factor in health care planning and delivery. Coronary heart disease is a prime example of where there are known gender differences. We need investment in research and inclusion of gender within educational programmes, without which health professionals will remain ignorant of the problems created by gender neutral health care.' [A. White and L. Lockyer, 'Tackling coronary heart disease: A gender sensitive approach is needed', BMJ 2001;323:1016-7.]

We recommend that the Department of Health's strategic plans for heart disease and cancer should be more gender-sensitive in their approach. For men specifically, they should address:

·        Improving prevention. Men's lifestyles put them at particular risk of both these conditions and there is a clear need for more effective health promotion that encourages men to change their risk behaviours. For example, there are opportunities to develop projects in the workplace as well as the community on tackling male weight problems, an issue that has so far not been effectively addressed.

·        Encouraging the use of health advice and primary care services. Men are often unaware of the symptoms of heart disease or cancers and delay seeking advice or help. This clearly increases the risk of serious illness and reduces the opportunities for effective treatment in the longer term. There is a need for innovation in both information and service delivery. Schools have a particularly important role in not only increasing boys' knowledge of specific health problems, e.g. testicular cancer, but in also increasing the skills and confidence needed for males to access services throughout their lives.

·        Developing appropriate services. The current structure of primary care services inhibits men's access to the health system. We have already stated our recommendations for making primary care more responsive to men. In addition, there is a specific need for a significant expansion of hospital-based urology services to meet the increasing demand from men with prostate cancer (as well as benign prostate diseases). It is anticipated that the number of men with prostate cancer will double by 2020.

Disadvantaged communities

Although men in general suffer from poor health it is vital that men are not seen as a homogenous group with one set of health problems and needs. It is essential that the inequalities within men's health are also addressed and that those men with the greatest health problems and needs receive particular attention.

Men in social classes 4 and 5

It is well-known that men in the 'lower' socio-economic groups experience the highest rates of morbidity and mortality. What is less often appreciated is that men's health appears to be particularly sensitive to deprivation. For example, a Joseph Rowntree Foundation study by Richard Mitchell and others concluded that if full employment was achieved in Britain, 2,504 lives a year would be saved among 16-64 year olds. 83 per cent of the lives saved would be male. The research also looked at the impact of a slight redistribution of wealth across Britain. This would prevent an estimated 7,597 deaths each year among under 65 year olds. Again, men would benefit disproportionately — 75 per cent of the lives saved would be male. [Richard Mitchell, et al, Inequalities in life and death: What if Britain were more equal? (The Policy Press; Bristol, 2000)]

We recommend:

·        The inclusion of male sections within HImPs or male-only HImPs. Gender as a determinant of health has been overlooked by the vast majority of HImPs and male health specifically has been addressed in just one HImP to date. Local strategic planning must include clear and specific targets to tackle social class inequalities related to men's health. The Men's Health Forum also believes that HImPs should adopt a similar approach for women's health.

·        Health Action Zones, Education Action Zones and Neighbourhood Renewal are all partnership approaches that have enormous potential for tackling health inequalities, including those related to male health. To date, Health Action Zones have shown little interest in developing men's health initiatives. The Department of Health should require Health Action Zones to address male health issues.

·        A role for local authorities. As providers of leisure, education, housing, environmental and social services, they have a potentially enormous role to play in developing men's health initiatives for men in disadvantaged groups. The Department of Health should inform local authorities of the importance of addressing men's health issues and suggest appropriate initiatives for local implementation.

Gay men

Gay men have a wide range of health needs, not simply related to HIV. For example, there is a higher prevalence of risk-taking behaviours relating to alcohol, smoking and drug use. Gay men experience higher levels of mental health problems and are more likely to attempt suicide. They are also less likely to access primary care because of perceived or actual homophobia.

We recommend:

·        Further research into the general health needs of gay men as these are currently little-understood.

·        Targeted health promotion initiatives to tackle risk-taking behaviours that are built on the experience of existing health promotion work with this community.

·        Health providers should receive training on developing policies and practices that meet the needs of gay men. It is important, for example, that primary care practitioners are aware of the health needs associated with the 'coming out' process.

Black and ethnic minority men

Some black and ethnic minority men are genetically more susceptible to certain conditions (e.g. sickle cell disease) while many others are prone to health problems related to risk-taking behaviours (e.g. Bangladeshi men are nearly twice as likely to smoke as men in the general population and Irish men are more likely to consume more alcohol). There are higher rates of heart disease in Indian, Bangladeshi and Irish men and higher rates of stroke in Black Caribbean, Bangladeshi and Indian men. Racism also impacts on health outcomes and has been recognized by the Department of Health as an issue in service provision. A general population approach will fail to meet the needs of these men and work with black and ethnic minority men must be informed by an awareness of ethnicity, culture as well as gender.

Concluding comments

The Department of Health's work on improving men's health within the inequalities agenda would significantly assisted by a decision to establish the proposed reference group on men's health. This could play a key role in developing policies and practices as well as helping to co-ordinate work on men's health across other government departments, including those with responsibility for education, transport, work, family life and social exclusion.

The Men's Health Forum believes that gender-sensitive health policies and practices represent the way forward, both for men and women. They provide the best means of ensuring that the NHS provides an equitable, accessible and efficient service for all.