Literature Review on Effective Sex- and Gender-Based Systems/Models of Care

January 30, 2007

Research Question 7: Targeting Boys and Men

7. How can programs targeting boys and men be created to recruit and retain them in the healthcare system? Are programs such as patient advocate or patient navigator more needed or more effective for men at getting them into the system and to needed care?

For our final research question, we consider the plight of men in the healthcare system. As has been previously noted in this report and elsewhere, a somewhat unexpected consequence of the women's health movement was that it has enabled a new and unique focus on men's health (Legato, 2006c). U.S. men's health has been described as in a "crisis" state because: 1) women live longer; 2) men have higher death rates on the top 10 causes of death; 3) men are more likely to be killed on the job; 4) women are more likely to visit a doctor; 5) addictions kill mostly men; 6) men face numerous barriers to the receipt of healthcare; and 7) men of color are worse off than white men (Community Voices, 2003).

Whether men's care is in crisis or not, this brief review certainly documents that men face a different set of needs than women in terms of access to care, use of care, and factors motivating them to receive care. In this final research question, we look at men's use of the healthcare system, barriers that interfere with men's care-seeking (including traditional masculinity), approaches to encouraging men to receive care, and example model programs for men's healthcare.

Men are less likely than women to use the healthcare system, and this is especially true for the use of preventive services. When men do present for healthcare, they are more likely to be experiencing critical health problems. As a result, the emergency room is a more common care site for men than for women. Men are also more affected by access barriers such as wait times, as was discussed in our response to question 2.

Men do not use the healthcare system as often as women: "There is a growing body of research in the United States (U.S.) to suggest that men are less likely than women to seek help from health professionals for problems as diverse as depression, substance abuse, physical disabilities, and stressful life events" (Galdas, Cheater, & Marshall, 2005). This finding holds for comparisons between men and women at all income levels, and for comparisons within disadvantaged ethnic groups:

According to the U.S. Department of Health and Human Services, National Center for Health Statistics, among both the poor and the rich, men are more likely than women to have had no recent contact with a health care provider. In addition, African American men are less likely than African American women to visit physicians, even when income is held constant. Even when health services are provided pro bono, men use them less than women (Mansfield, Addis, & Courtenay, 2005).

American men are "underrepresented as seekers of routine care," including making fewer annual care visits, having longer intervals between care visits, being more reluctant to seek care, and using less medicine (Alt, 2002). Access to care rates are even worse among young men: "Men ages 15-24 have lower physician visit rates than any other gender and age group and ... African American patients ages 15-24 have the lowest rates of any race-age group" (Rich & Ro, 2002).

Young men are especially unlikely to "receive reproductive health services such as counseling by a medical professional and testing for HIV or for other sexually transmitted diseases (STDs), even though they are likely to receive other health care services" (Ninger, 2000). In addition, "routine primary care clinics are ill-equipped to deal with the health issues of young men" (Rich & Ro, 2002).

When men do access care, it is through different channels than women. The more limited use of preventive care means that men more often receive care for critical issues. For example, a British study reported that "boys up until the age of about 16 years are taken to the family doctor by their parents but once their parents stop taking them, it is commonplace for men to avoid primary care unless they experience considerable pain or an illness has become too serious to ignore" (Banks, 2004). Thus, the emergency room is a more frequent source of care, especially for young, minority men (Rich & Ro, 2002).

Men are more reluctant than women to refer themselves to mental-health treatment. Additionally, men are more likely to receive mental-health treatment "through coercive means ... [especially] younger African American males who are often referred through social and legal systems" (Ro & Takeuchi, 2003). Disturbingly, "the police are involved in more than one-third of emergency room admissions and this police involvement has been found to correspond to higher rates of involuntary psychiatric hospitalization for men of color" (Ro & Takeuchi, 2003).

Numerous barriers interfere with men's care-seeking. These include men's perception that care is unnecessary, financial barriers, emotional barriers (e.g., fear, denial, and shame), poor communication, and racism.

As noted, U.S. men are less likely to use preventive health services than women, despite their "similar levels of health insurance coverage" (Williams, 2005). A driving force behind this difference is a male desire to "project strength and to suppress vulnerability and need" (Williams, 2005). Likewise, men are taught to have high tolerance for pain, thus making it less likely they will feel justified in seeking medical care (Community Voices, 2003). For example, a Denver study of minority men found that "one-fifth of the respondents (20%) did not feel they needed to go to the doctor" (Whitley, Samuels, Wright, & Everhart, 2005).

Galdas, Cheater et al (2005) nicely summarize several other studies on why men ignore or downplay illness symptoms:

A UK study found 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. 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.

Economic barriers are another reason why men may not seek healthcare, especially minority men. Whitley et al. (2005) reported these findings from their study of minority men:

• "Of note, 30% of respondents aged 18-24 years cited lack of money as the reason they did not go to the doctor."
• "Economic barriers were identified as the predominant reason African-American men do not access healthcare. Specifically, the lack of a good job, lack of health insurance, and lack of co-payments were identified. Without financial resources, the African-American men stated that they were unlikely to seek healthcare unless absolutely necessary."
• Among Hispanic men, "time involved to access healthcare was identified as a significant barrier as it relates to lost work time and lost wages."

An additional economic barrier is lack of transportation, as minority men are more "likely to depend upon public transportation than White men" (Ro et al., 2004).

Men may also suffer disproportionately from fear, denial, and shame related to their health, and may be especially concerned about the perception that they are seeking care unnecessarily. A study of minority men found that men "often do not seek medical care until it is too late. The main reasons cited for this procrastination were fear and denial" (Whitley et al., 2005). This was true among African American men, who said they delayed care due to fear "until the symptoms cannot be ignored and the situation is an emergency," as well as among Hispanic men, who said shame is a "strong deterrent to seeking healthcare" (Whitley et al., 2005). Likewise, a study of black male adolescents seeking sexual health services found that "barriers included a fear of stigma and a loss of social status, shame, and embarrassment" (Lindberg, Lewis-Spruill, & Crownover, 2006). Stigma is especially a barrier to mental healthcare, "even when [men] perceive a need for help" (Ro & Takeuchi, 2003).

Men may be especially adept at blocking "the feedback loop by ignoring and denying problems":

The masculine pattern of independence and autonomy promotes denial of any need for help and possibly causes men to ignore symptoms of minor illness, stress, grief, and pain or, at least, to suffer in silence. For example, approximately 67% of men seeking general health care but denying any problems are diagnosed as ill by their physicians (Crose & Nicholas, 1992).

Because men do not use preventive services as often as women, they may be less familiar with the healthcare system and encounter greater communication barriers:

• "The lower prevalence of self-examination in men may reflect a more general deficit in health knowledge and perceived susceptibility, but it may also reflect gender biases in the attitudes and practices of health professionals. Less than 10% of men report being taught testicular self-examination compared with almost 65% of women who report receiving instruction in breast self-examination. This finding is supported by results from a survey of U.S. primary care doctors which found that while 86% routinely teach breast self-examination to women only 29% taught testicular self-examination to men" (Evans et al., 2005).
• "Men's health is often construed [by healthcare professionals] as in the hands of women, with men being perceived as childlike, passive and ignorant about health matters. ... Men only attend when they are in a state of ill-health. Women's greater contact with health services may facilitate higher levels of health-related knowledge" (Evans et al., 2005).

Racism is an access barrier for many men. For example, one study found that black men perceived racism as a concern and believed they were subject to "quality of care concerns and disparities in treatment due to economic factors" (Whitley et al., 2005). Additionally:

Health care providers are not immune to general societal and racial stereotypes of people of color in general. Providers who hold these unconscious preconceptions may interact with patients based upon preconceived notions and further alienate them. For non-English speaking men of color, the lack of appropriate interpreter staff represents a significant barrier to care. Beyond this, provider ignorance about the challenges of assimilation faced by new immigrants and misconceptions about particular cultural or religious practices may limit the value of medical advice and care (Rich & Ro, 2002).

The lack of trained interpreters is especially a problem for many minority foreign born persons, but especially the less educated and those seeking care that is more specialized.

We found one attempt to quantify some of the access barriers men face. The Barriers to Help Seeking Scale (BHSS) is designed to evaluate "barriers to men's help seeking" (Mansfield et al., 2005). The scale was found to have a factor structure, and differences in these factors explain much of the difference in men's perceived barriers to help-seeking:

The Need for Control and Self-Reliance subscale reflects concerns with self-reliance and autonomy. High scores on this subscale suggest that a man believes that seeking help for the problem in question would threaten his autonomy or ability to function independently. The Minimizing Problem and Resignation subscale concerns a cluster of barriers that keep people from seeking help because they do not believe that the problem they are experiencing is serious enough. ... The Concrete Barriers and Distrust of Caregivers subscale reflects the fact that concrete barriers, such as finances, lack of insurance, lack of transportation, lack of knowledge about the sorts of help available, and lack of trust in care providers, can prevent people from seeking help. ... The Privacy subscale has to do with concerns about emotional and physical vulnerability. ... Finally, the Emotional Control subscale is defined by barriers that revolve around concerns with keeping one's emotions under control and out of public view (Mansfield et al., 2005).

The model itself has not yet been empirically tested to determine whether these identified factors do indeed reduce actual access to care (as opposed to perceived access), but it provides a useful starting point for such a study.

One specific barrier to care that is worth more extended discussion is "masculinity."

There is a mounting research literature pointing towards "traditional masculinity" and/or "masculinity beliefs" as a significant variable influencing the help-seeking behaviour and health risk appraisal of men when they become ill. Indeed, theories prevalent among international men's health discourse contend that men are not permitted to be expressive in their illness behaviour, or are "unable" because of the construction of traditional masculinity, or an effort to conform to a socially prescribed male role where weakness and need for help are not believed to be masculine. Nurses need to be aware that, as a result of this "male socialization", men may react differently to health care services and health promotion messages, both in comparison with women and between men of differing age, social and ethnic groups (Galdas et al., 2005).

Here, we examine how masculinity might contribute to risk-taking and delayed care-seeking.

Masculinity is associated with risk-taking, which may negatively impact health: "Many men take risks with their health because risk-taking is one way men are brought up to prove their maleness to each other and themselves" (Banks, 2004). Additionally, "the social pressure to be fearless may also lead to risk-taking behaviors such as drinking and unsafe sexual exploits. ... [There is a] relationship between unhealthy behaviors and constructions of manhood" (Rich & Ro, 2002).

Men may delay seeking care because care-seeking interferes with their vision of maleness:

The idea of manhood significantly influences how men access health care. Men may view seeking health care as a display of weakness or failure. Men who are acculturated not to display emotions of fear may avoid any setting in which they may have to face fearful prospects like disease or medication (Rich & Ro, 2002).

Among Hispanic men, this reluctance is related to machismo (Whitley et al., 2005).

Additionally, traditional masculinity may cause men to downplay pain. For example, men have been found to "normalize" chest pain from a heart attack, "leading to significant delays in seeking help for their condition" (Galdas et al., 2005). This also relates to our earlier discussion about fear and shame. Men are reluctant to appear too "worried" about their health, so they may endure pain and wait to see if it will resolve itself before seeking treatment.

Overcoming these barriers and getting men in for care remains a challenge. Our review uncovered several possible approaches to this problem. These included using women to encourage men to receive care, encouraging the development of a medical specialty for men's preventive health (based on the model of annual well-women gynecological exams), and creating healthcare settings that are more appropriate for men.

Women are key access points to men's healthcare (Alt, 2002). As health decision-makers (women "make nearly three-quarters of all health care decisions-whether on health care for a family member or themselves" (Ignagni, 2001)), women are strong influencers on men's healthcare. For example, men are "were 2.7 times more likely than women to be influenced by a member of the opposite sex to visit a physician" (Norcross, Ramirez, & Palinkas, 1996). This difference may be part of the reason that men enjoy health benefits from marriage; wives positively influence husband's care decisions (Norcross et al., 1996). This makes women a natural point of intervention to affect men's care:

Anyone wishing to change the health behaviors of the American public in general and American men in particular, especially with respect to utilization of primary care services, would do well to target American women, first and foremost, as the most likely group to respond to such interventions with enthusiasm and interest, and to effect such changes in their families. This recommendation is consistent with those of previous studies seeking to identify members of social networks who are potentially instrumental in health promotion and disease prevention interventions that seek to change health-related behavior. In this context, it is our belief that women play a potentially critical role in encouraging men to seek primary care and other health services. ... Similarly, enlisting the support of women is seen as a potentially cost-effective means of encouraging men to utilize primary care services (Norcross et al., 1996).

A related approach is to encourage men to care for themselves because of their devotion to their families. One study found that men "cited family obligations as the primary reason for paying attention to their health" (Whitley et al., 2005). Women may be an especially effective way to reach men for care in settings where men and women receive care in the same locations, as women can schedule men's appointments along with their own.

However, there is a risk in using women as a primary access point to reach men; it devalues men's experiences and neglects the needs of unattached men (including many minority men), and might inadvertently reinforce an obligatory caretaker role for women, where women are expected to put others' needs first. Thus, a case can be made that it is more important to teach men how to meet their own care needs instead of relying on women as a means to care for men.

Another approach to improving men's care is to create a natural home for men's preventive care in the same way that gynecological care provides a natural home for such care for women. Alt (2002) argues that women's annual well-woman exams include general health topics, and that men should be similarly encouraged to have an annual well-male exam. Such an exam would have a "larger agenda as a prevention-oriented, abbreviated, comprehensive medical history and physical exam" (Alt, 2002).

One argument for a medical home for such an exam is the field of andrology: "Andrology is a discipline of basic science and clinical medicine that focuses on the normal physiology and disease states of the male reproductive system" (Ranking, 2005). As Ranking (2005)

argues:

The time is certainly ripe to consider expanding andrology in the U.S. to encompass a wider range of men's health issues outside of reproductive health. Having a formal recognized sub-specialty will forward these efforts in providing a single clinical face for men's health, providing for a standardized men's health curriculum in medical schools, and a standard set of practice guidelines for health professionals. In that way, it would be clear to men seeking services where to turn for comprehensive primary care.

Another approach to getting men in for care is to create healthcare settings that are more appropriate for men: "Provision of health promotion that resonates with the mechanistic ways men perceive their bodies might also make a difference" (Banks, 2004). For instance, "the best-selling Haynes' Man Manual (UK, Ireland, Germany Finland), produced in the format of a car repair manual is a good example" (Banks, 2004). Other approaches include the following:

Healthcare services, especially primary care services, should be provided in a way that is consciously "male-friendly", e.g. opening hours outside working hours, male-interest magazines available in waiting areas, information displays aimed at men. Men would also be more likely to use services that are quick and convenient which should be provided by: offering more primary care services in nontraditional settings, e.g. the National Health Care walk-in clinics in the United Kingdom are already proving to be more attractive for male patients than GP surgeries; developing the potential of high street pharmacies, which are underused by men, to provide information, advice, and guidance for self-treatment specifically targeted at men; installing outreach services in places where men already meet and feel comfortable, e.g. pubs, social clubs, sports venues and, most particularly, workplaces; encouraging confidential and anonymous sources of health advice, e.g. helplines, websites, which might act as a "stepping stone" towards men's use of primary care; guiding healthcare professionals away from stereotypical notions that disadvantage men and discourage men from using services (e.g. "men are better able to cope with pain"; "men should be brave in the face of distressing news about their health"; "men bring illness and injury on themselves by their behaviour") (Banks, 2004).

A demand for such male-specific settings was noted in one recent study of adolescents (Lindberg et al., 2006). In addition to providing settings that are more appropriate for males, another approach is to go to men where they "live and gather" with "appropriate mechanisms to insure contact with health professionals when health problems (e.g., hypertension) are identified" (Viera et al., 2006).

We found several examples of model programs for men's health. While not as numerous as CoEs, CCOEs, or women's health centers, these approaches are becoming more frequent. Their aim is to create an environment that is more appropriate for men's care and more appealing to male clients. Like early women's health centers, these efforts are more focused on creating appropriate settings for men's care than on delivering gender-specific medicine per se.

Several men's health programs have been sponsored by the WK Kellogg Foundation through the Community Voices project. Among them: Grady Health System, Atlanta, project for teen boys; Baltimore City Health Department's Men's Health Center, offering free services to uninsured males of all ages; Boston Public Health Commission, serving young men of color and recently incarcerated men; Northwest Mississippi Regional Medical Center, offering comprehensive men's care; Camillus House Men's Behavioral Health Initiative Miami, providing services to minority men; and Denver Health, which launched a men's care initiative (Community Voices, 2003).

These projects are aimed at improving men's health status. For example, Denver Health aims "to increase access and affordability to healthcare services, to reduce health disparities, to improve seamlessness of care to men, and to influence public policy for men's health" (Whitley et al., 2005).

Another effort to reach men is the New Generation Health Center, which opened a clinic for young men's sexual health in 2000. The clinic had previously served mostly women. It used trained male peer educators as part of its efforts to reach men (Raine, Marcell, Rocca, & Harper, 2003). To prepare for this change, the clinic surveyed employees, offered male services training, and changed the atmosphere to be more suitable for males (Raine et al., 2003).

The clinic was successful in attracting patients. Sexual partners were a key avenue for males to learn about the clinic, and many young men actually came in with a partner (Raine et al., 2003). One of the clinic's conclusions about this effort was that "'in-reach' efforts targeting female clients may be a cost-effective way to bring male clients to family planning clinics" (Raine et al., 2003). This finding highlights the potential of women to encourage men to access care services.

A final example of a men's health clinic targets Hispanics:

Nuestros Hombres, launched in February 2001, is a collaborative project led by Texas-based Bienestar Familiar and the Cancer and Chronic Disease Consortium. The project's aim is to increase health education, disease prevention, and access to basic health services for Hispanic men. Health education goals are accomplished through bilingual public service announcements, newsletters, and a pool of volunteers sharing their health care experiences. Promotoras, bilingual health education and community outreach workers, also contribute to education efforts. ... Nuestros Hombres emerged out of a need to address health concerns of Hispanic men, a group that experiences the lowest rates of health insurance and regular access to primary care of any major ethnic-gender grouping in the U.S. The project works to change the attitude that Hispanic males should just "take it like a man" when it comes to tackling health issues. Nuestros Hombres is committed to providing non-threatening environments where Hispanic men can talk openly about issues affecting them and their families. It is the hope of Nuestros Hombres that changes in the health decisions and attitudes of Hispanic men will teach Hispanic boys to have a higher regard for health issues and, ultimately, make health a priority (Rich & Ro, 2002).

The focus of this research question was determining how men can be recruited and retained in the healthcare system, including whether men have special needs in terms of access to care that must be addressed. From this review, it does appear that men face additional barriers to care, perhaps the most important of which is a generalized male reluctance to seek preventive or routine care. This reluctance puts men at risk because it means that they are more likely to delay care until their need for it is critical, by which time multiple opportunities for prevention and early intervention may have already been missed.

This assessment is mostly based on anecdotal evidence, however, as we did not uncover any studies that systematically identified access patterns for men and women and where they differ. The most comprehensive review on this topic we found suggested that while

many studies note the relative under use of health services and symptom reporting by men in comparison with women, conversely, many also find an increase in help seeking in men compared with women, or indeed, no significant difference in help-seeking behaviour between genders. The evidence suggests that occupational and socioeconomic status, among others, as more important variables than gender alone. Such inconsistency in the research literature is unsurprising given the widespread differences in study design and samples investigated (Galdas et al., 2005).

We found several examples of programs to encourage men to receive more preventive care, and several of these examples use approaches we identified as having potential. These include creating settings that are more appropriate for male patients and utilizing women as an avenue to reach men. We also uncovered a promising model, the Barriers to Help Seeking Scale, which detailed a potential five-factor solution to potential barriers to access for men. This model, however, remains to be empirically tested.

In short, while there are suggestions that certain approaches may be more appropriate for men than for women, there is a shortage of evidence to definitively answer this question:

The dearth of studies integrating masculinity and men's perceptions into the investigation of help-seeking behaviour represents a significant gap in the literature. To date, no research has explicitly investigated whether men's perceptions of masculinity influence their decision-making processes with regard to seeking help when they experience ill health. In sum, there is little empirical evidence supporting effective interventions to tackle male reluctance to seek help (Galdas et al., 2005).

Thus, there is still a great deal of research which needs to be conducted on men's unique healthcare needs. As we will discuss next, such needs may best be addressed in the context of gender-specific medicine.

Current as of March 2007