Research Policy and Planning: The journal of the Social Services Research Group – Vol 17 (3) 1999
Men’s experiences of health problems and services in North Derbyshire
Mick Bond North Derbyshire Health Authority
This workshop described a research project carried out in 1996-7 by the Research and Quality Manager and the Men’s Health Programme Manager in North Derbyshire Health Authority. A series of eight focus groups was run with men from different backgrounds and ages. These asked questions about what the man saw as the most important health problem they faced, access to services and barriers to men dealing with health issues. The men in the groups were interested in discussing health issues. The research did not identify one particular health concern across the groups. Men tended to talk to their partners first about problems. All the groups reported positive experiences of using GPs and hospital services. However there were problems about the lack of time in consultations, waiting times and issues around the communications skills of the person seen. Sexual health problems were identified as the most difficult to discuss, though for the school student group being overweight was mentioned. The ability of the person contacted to relate to the man was important. Here women were commonly seen as more sympathetic, but not in every case. Two main reasons were given as to why men delay seeking treatment more than women: one was the ‘macho’ culture; the other was fear of what they might be told and what would then happen. A wide range of suggestions was made about changes that were needed in local health services, one of the most common being the need for health education for boys from an early age. The research has been presented to the Health Authority and follow work on some of the issues is now in progress. Mention was made of other local initiatives such as the ‘Waist Watchers’ project, which encourages men at risk of a heart attack to lose weight and the few initiatives and reports produced elsewhere in the UK.
“I’m a bloke. I’ve got to manage (unemployed man)”
“I’m a man. I shouldn’t have this problem (council employee)”
Men’s health is a issue that is rarely considered it its own right even though there are a number of health indicators which suggest that men are disadvantaged compared with women. For example, life expectancy in men was over five years lower than in women in 1996 (74.6 and 79.7 years respectively) (1). This is a consistent finding throughout the industrialised world as well as within England over time – in fact, since 1881 when sex-specific death rates were first published. The sex difference in life expectancy widened in the post-World War 11 period and has remained fairly constant since that time representing a difference of about 10% (2). However in 1992, the Chief Medical Officer3 dedicated part of his report on the State of the Public Health to the health of men. This was the first time an official report had recognised men’s health as a major public health problem. He concluded by stating: “It is hoped that Regions and Districts will investigate ways to promote the health of men over the next few years”. Since then public health annual reports in the West Midlands (4), Calderdale and Kirklees (5), Oxfordshire (6) and Nottingham (2) have specifically featured male health needs at the population level. Furthermore, the UK government committed itself to “mainstream a gender perspective into all policies and programmes” following UN conferences earlier this decade. The NHS Executive took on this responsibility for the health sector(7).
In 1995, in response to this changed policy context nationally, the Health Promotion Programme Manager (Men’s Health) and the Research and Quality Manager at North Derbyshire Health Authority started to discuss the development of a local strategy for men’s health. The authority has considerable experience of getting the views of service users, so naturally part of this discussion centred on getting groups of men to talk about their experiences of using health services and the health problems that concerned them. Another was to get men to suggest changes that would improve things. The work was supported by a small group of staff who expressed an interest in the topic.
Space was found in the 1996/7 research programme for running the project, which aimed to discuss the issues indepth with men. The research would aim to reach men from different backgrounds and of different ages. A particular emphasis of the work would be on issues around access to services and delays in seeking treatment. It was agreed that the areas to be covered would include:
- participants’ main concerns about their health;
- who they discussed problems with first;
- the advantages and disadvantages of discussing problems with their GP;
- the positive and the negative aspects of the service they received, if they had had recent contact with a hospital;
- which health problems they thought that men find difficult to discuss and for what reasons;
- whether men find it easier to talk to other men or to women about their health problems and for what reasons;
- why men tend to delay seeking help for health problems longer than do women;
- what the health authority should be doing to change things in light of the discussion so far about access to health services.
There are a number of different methods that could have been used to obtain information on men’s health needs. All have advantages and drawbacks. We chose to use focus groups as they would allow participants to swap experiences and to ‘brainstorm’ solutions. However in doing this we recognised that it would be difficult to generalise the findings to the population of North Derbyshire.
Literature review and policy context
Neither assessing male health needs at the population level, nor investigating men’s views and experiences of accessing health services in general, appear to have been significant research activities in the UK to date. A Medline search of UK references since 1980 produced nothing of direct relevance, although searching more narrowly for research into particular services was more productive, for example, urological services and men with prostate problems or community services for gay/bisexual men living with HIV infection. However, the focus of such work is too narrow to be of direct relevance here.
Searches of the MRC and NHSE-Trent research databases for unpublished material also proved unproductive. Email enquiries sent to Intemet public health and health promotion discussion groups have to date identified three pieces of similar work in the British Isles and these are listed at the end of this article. They also picked up relevant work, including extensive health needs assessment programmes, in Canada and Australia. Perhaps the only other similar piece of research was undertaken between 1995 and 1997 in Kirklees by the local men’s health network with support and funds from the local health authority [reference needed]. Local men were asked to name a well-known male who typified both a healthy and an unhealthy man to them. Before a conference held to prioritise issues for action, a sample of local men were surveyed regarding their perceived needs. In 1998 Sheffield Health, Community Health Sheffield and Sheffield Men’s Health Forum jointly conducted more limited focus group research with two groups of men (older men and schoolboys).
The chosen method of running focus groups is one that has gained in popularity over recent years and has been
greatly used in the political process. The technique was first used in the 1920s in market research. Literature focus groups appears to concentrate more on technique than on their merits comparative with other methods. Kitzinger (8) describes the idea behind them as
‘..that group processes can help people to explore and clarify their views in ways that would be less accessible in a one to one interview’ (1995)
However the technique also has limitations as Khan et al (9) point out. They state that a group setting is not always ideal for encouraging free expression, samples tend to be small and purposively selected. Thus they not allow generalisation to larger populations. As with other qualitative methods the chances of introducing bias and subjectivity into the analysis are high.
Arranging the groups
Existing contacts in various organisations were approached for assistance in identifying focus group participants. Some were unable to help; including those based in industry. 68 men eventually took part in the following groups:
- older men from a men’s cookery group and a cultural organisation for older people;
- two groups with council employees from two of the local councils;
- a group of men on probation;
- school students;
- a group of gay and bisexual men recruited through a health service provider;
- a group of disabled men recruited through a service provider;
- a group of unemployed men recruited through a health service provider.
The focus groups took place in a variety of community settings around North Derbyshire. Two staff were involved in running them: one to ask the questions whilst the other took responsibility for the tape recorder and any problems. Participants were given refreshments and a contribution towards travel and child-care costs where appropriate. Health authority staff carried out tape transcription and subsequent analysis.
The results are presented in the order the research questions were asked during the focus groups.
Main health concern
Apart from asthma being common amongst the group of school students, there was no clear issue within or across groups, and with such diverse groups, this is hardly surprising. There were a number of concerns expressed around work issues from the two groups of council employees and the group of unemployed persons. These included work-related injuries, stress and, for those who were unemployed, issues around the feasibility of returning to work, in particular having been out of work for some time due to ill health. A number of health conditions came up, including prostate cancer, other cancers and heart conditions. The group of gay and bisexual men made specific reference to the problems of accessing local services appropriate to their needs. The topic of access to services also came up in the group of disabled men, who have specific needs, e.g. for some types of NHS staff to communicate more effectively. A number of participants expressed concerns about the future: for some of the council employees, this related to lasting the pace at work and a sense of their health state worsening as they get older and, for disabled men, remaining independent.
Who they spoke to first about health problems
In the vast majority of cases this was their wife or partner. At several stages in the focus groups some humour was injected into the proceedings, for example:
“Part of my discussions, first thing, is it serious enough to see the doctor or is it quicker to go to the undertaker, that’s my point of view, I think, like you say (older man).”
A number of men said that they would not talk to anyone for various reasons, or only when they were desperate, if at all:
“I think it’ll go away – think, oh, it’s going to improve (older man). “
“You usually keep a lot to yourself anyway. I’m one of them. I keep going and keep going and don’t say anything until, in the end, I’ve got to say something, because I can’t do any other (council employee).”
Others reported that there was a stage where they had to think things through themselves before they would seek help from others. Yet others said that, in some cases, particularly if they were living with chronic health problems, it was easier to go directly to a doctor, or clinic (gay/bisexual man), without discussing the problem with anyone else. In one case, this was true of a man with limited, previous contact with GPs, who thought at the time that he had a serious health problem (council employee).
Two participants (an older man and council employee) had a family member who was a nurse, whom they consulted about very personal issues. Another person said he talked to his mental health services support worker, others said friends or parents.
Experiences with GPs and recent contact with hospitals
Research studies of the general population (men and women) found similar views and experiences to those reported by men in these focus groups. By no means all participants had had recent contact with hospitals. Men in five groups reported positive experiences with their GPs and with hospital care:
“I’m very satisfied with the doctor I’ve got. I feel he’s got time for you. You can ask him anything. … I’ve got a lot of confidence in my doctor (older man).”
Commonly raised issues concerned the length of GP and worsening as they get older and, for disabled men, hospital waiting times, the brevity of GP appointments and the doctor/patient relationship, in particular communication and confidentiality. Less frequently raised hospital matters included: car parking at the local district general hospital; discharge arrangements when living on your own; mixed sex wards; cleanliness; staffing levels and methadone prescription policy.
Subjects men find difficult to discuss
Unsurprisingly, sexual health needs or problems came out ahead of all the others:
“we might talk endlessly about the performance of Chesterfield football team, but people don’t seem to confide in each other about worries in that [the sexual] department (older man).”
“anything within that region … from waist to knees (council employee). “
“A male’s virility, any more than a problem associated with your sex life, I mean, men don’t talk about those things do they? (council employee).”
The following was put forward to explain difficulty with talking about sexual health problems:
“these older men that’s got families and they’re king of the house and so forth, they don’t believe in talking about it. They’re just too embarrassed … to have their clothes taken off and have a female, who they’ve never seen in their
life, look at them (unemployed man).”
In contrast someone else explained their ease with talking about sexual health problems:
“I personally don’t mind, talk about anything, but, general, I suppose people are embarrassed about sexual problems … It doesn’t bother me, but I can understand why people are embarrassed by it (council employee).”
Others thought it would be difficult to talk about issues such as impotence and having a vasectomy. However, a few men were able to talk frankly about the latter:
“I didn’t do it just for myself. I did it for my wife as well and for my family, because we didn’t want any more children, but I didn’t want her to go through quite a major operation (council employee).”
Confidentiality was raised by the group of young men. They had mixed views on whether male or female doctors were easier to talk to about sexual health issues.
Two groups suggested that it would be easier if sexual health issues were discussed from an early age, so embarrassment was avoided later.
Emotional or mental health needs or problems
Men in three groups mentioned emotional or mental health issues as being difficult for men to talk about:
“there is a certain amount of shame associated with those sort of things (unemployed man)”
“I think mental health is difficult to talk about, because people don’t understand it fully … when you are suffering … there is a certain amount of shame that’s associated with those sort of things … it’s hard to admit that you are suffering in a way that shows you haven’t got it all together (unemployed man).”
Many men had difficulty with talking about emotional or mental health problems, because:
“psychological thing of it … if you feel nothing’s going right for you, it’s very difficult to do that and it’s very hard to be strong sometimes (unemployed man).”
“I think it is difficult to talk about, because when people say, ‘Why have you finished work?’ and it was very convenient with busting my leg to say that was one of the main reasons … I don’t know what to say to people. Well, I’ve been depressed and we have had some sudden deaths in the family … Because you feel like you have failed in that sense, not that you have, but it seems like that (unemployed man).”
The issue of being overweight was mentioned in the group of school students as being difficult to talk about.
Talking about general health problems
The following factors were put forward to explain difficulty with talking about general health problems:
“I don’t think we’ve been educated to talk about our health, mainly because, on the whole, men are relatively healthy (older man).”
“That’s what it is. Boys are encouraged not to cry and, ‘Don’t be a big baby’, but women are very forced out and if there’s something wrong, want to deal with it, don’t they? (older man).”
“I’m a bloke. I’ve got to manage (unemployed man).”
“I think all men are reluctant to talk about their health and I think we’re far more reluctant than women. I would think that gay men are more inclined to talk about their health than straight men or bisexual [men] (gay/bisexual man).”
Other factors were suggested to explain ease with talk about general health problems:
“I think we’re all of an age where we’re mature enough to talk about it (older man).”
“I think gay men find it less of a challenge (gay/bisexual man).”
Whether they find it easier to talk to men or women
A range of messages came across regarding this question, largely summed up by the following:
“I think it depends on the person (unemployed man)”
The range of responses divided into the following key groups.
- The patients ability to talk openly was greatly eased by the professional’s skill in communicating effectively and in establishing a rapport with him.
Differences in the personality of the individual were mentioned in three groups in relation to whom they would find it easier to talk to:
“type of personality that can come over and get other people to talk (older man).”
“I think it depends on the person, what their attitude is. I think professionally I would rather talk to a man … but I think in friends it’s easier with a woman (unemployed man).”
- Women, in general, are more sympathetic or easier to talk to about health problems.
“I’d say women are a bit more compassionate. [You can] talk to them about it, ill health – unless it is the motherly instinct in em (unemployed man).”
Some expressed views about talking to men generally:
“I think it’s easier to talk to men. I get embarrassed with women (school student).”
“It’s easier to talk to male friends … than my stepdad or even my proper dad, or my uncles (school student).”
“I couldn’t talk to my father (school student).”
“It would be easier to talk to a bloke, a man (man on probation).”
“If you were talking to persons at work, you would know which persons you could talk to, which would ridicule yer, which some of ’em would listen to you a bit more (unemployed man).”
- No preference for either sex.
Men in four groups expressed no particular preference:
“if you’re in hospital … it’s the feeling you get afterwards, that treatment you received and how well they made you and how well they treated you that counts to me. Whether it’s male or female [is] absolutely immaterial to me (older man).”
“I’ve had good experiences of both male and female doctors in terms of being able to talk to them … a lot of gay men probably prefer to talk to women, because they tend to be less homophobic than men (gay/bisexual man).”
“If I’m going to see a doctor in a medical capacity … I have no problems whatsoever explaining anything … Generally speaking, I get on better with women certainly than straight men, but as far as the medical is concerned, it would not make a difference to me (gay/bisexual man).”
- It depends on the health problem.
Men in four groups also mentioned that it would depend on what the actual health problem was:
“I think it’s easier to talk to older men, because they might be able to relate more to how you feel … It depends on what the matter is (unemployed man).”
“I would never … discuss an emotional problem with a male, straight doctor ever, because … I don’t think they’re capable, in my experience, of understanding or empathising at all (gay/bisexual man).”
“easier to talk to a woman.. but as soon as talk about ejaculation or erection, you just lost, because they can’t understand what you’re on (gay/bisexual man).”
“Getting back to the sexual side … that person might be more comfortable talking to a woman (unemployed man). “
“I’ve never had any trouble talking to them, because they’ve always basically been my age and upwards, but I think I would find it very, very hard to go in and speak to a female doctor that was 20/30 years younger … about sexual problems (unemployed man).”
“I certainly find out who’s on and gone back home, because it’s been a woman. Probably be too embarrassed to talk about things with a woman than a man (council employee).”
A consequence of some of these views was a delay in seeking help from health services.
- It depends on your mental state.
Two men thought it would depend on what state they were in:
“Depends on the situation at the time … say, you are stressed out, or heading towards nerves playing up, you will always confide more then than you would normally and I don’t [think] it matters whether [they’re] male or female (council employee).”
“It’s like a psychological condition … like in terms of distress or trauma … that you tend to want to pour it all out, but in normal circumstances, you hold it all in (council employee). “
Why men delay seeking treatment
There seemed to be two main explanations put forward for this:
- Male bravado or a ‘macho’ image: a feeling that they would get over it or should not be ill in the first place.
“I’ve hidden problems in the past … I think yer think yerself well, I [‘m] not going wi’ this one, it’s too soft … well, I’m a man. I shouldn’t have this problem (council employee).”
“there’s a certain amount of bravado with some men. They don’t like to be seen to be complaining that they are ill or they think they’re ill (council employee).”
People opined about what lay behind this image:
“if … your upbringing has been so that you never have to shirk your responsibilities and your duties, I think you tend to just soldier on regardless … I think it’s best if you can get up and get on with what you are supposed to be doing and try and shake it off (council employee).”
“boys are brought up not to cry, not to show emotion “
“it’s the media … it’s always women’s health problems … it makes men think they don’t have health problems (gay/bisexual man).”
‘Many of the gay magazines do [cover health for men] (gay/bisexual man).”
- Fear about what they might be told or what might then happen.
“I sometimes think that a man puts off going to see doctors about things. We don’t go unless we have to … He might be frightened of what the doctor is going to tell him, I sometimes think (older man).”
There were also concerns expressed about the fear of losing a job, about the fear of the consequences of being off work (council employee and gay/bisexual man) and about the difficulties of taking time off work to see a doctor. However, as the following speaker pointed out, ignoring health problems was acknowledged to have serious consequences:
“Cemeteries are full of indispensable people, aren’t they? (council employee).”
Other views of what may delay seeking help
- embarrassment as a factor
- shame as a factor if the problem was mental health related.
Perceived differences between men and women
The following views were expressed about differences between men and women:
“Women understand changes in their bodies from an early age (older man).”
“I think it’s the way we are brought up, as i say. Women, I suppose, are brought up to understand what is going on and changing in their body from the age of 8 or 9 … we don’t have that problem as a man (older man).”
“Women can talk more openly about such personal issues and share them in more detail (school student).”
“Men don’t care as much about their bodies and take more risks and abuse their bodies more (school student).”
This was the final question of the session and raised a large number of issues. In four groups, the need for health education from an early age came up:
“could there be some basic understanding of your own health and well-being in some of the school topics … Could that not be put into some, into the curriculum or national curriculum? (council employee).”
In three groups, the following ideas were put forward by participants:
- health screening or a well man clinic;
- better information on services available;
- improved communication skills among service providers;
- more time in medical appointments.
Two groups raised issues about:
- increasing expenditure on health services;
- making men more aware of their bodies and conditions that could affect them.
A number of concerns came up in one particular group. One was emphasised: promoting service providers’ awareness of issues for gay and bisexual men. This was raised not only specifically for this group, but also to make the point that any strategy needs to cater for the needs of men in all minority groups:
“It’s what people have suggested. It has serious implications for training nurses, training of teachers and training for doctors, training for receptionists … I think it is seriously needed (gay/bisexual man).”
Other issues raised by one group only included:
- evening appointments for working people;
- access to NHS dental services;
- support for carers;
- more affordable sports and leisure facilities;
- reduction or abolition of NHS dental and optical charges;
- individual responsibility for a healthy lifestyle;
- encouragement from the NHS and employers.
Summary and conclusions
The research demonstrated that men are interested in talking about their health concerns and that issues such as access to services can be a major barrier to them seeking help at an early stage. Getting the views of users of health services is an increasingly important issue and is one in which men have as valid a contribution as any other group of users. The chosen research method gives an understanding of issues that are important to the men involved, but does not produce representative data in the way that a large scale survey would do.
While the research cannot claim to represent all groups of men, it did cover a wide age range, differing employment status and two minority groups (gay/bisexual men and men with a disability). There were no men from an ethnic minority in any of the groups and this is a weakness of the research. However, research has been done on the health needs of the main ethnic minority groups in North Derbyshire, so some information on men’s needs exists locally.
With these qualifications, the main findings about men’s health needs and experiences were:
- apart from asthma being common amongst the group of school students, there was no clear health issue within or across groups;
- a number of participants expressed concerns about the future: for some of the council employees, this related to lasting the pace at work and a sense of their health state worsening as they get older, and for some disabled men, remaining independent;
- most men reported talking to their wives or partners first in order to seek help for their health problems. However, many men also reported delaying talking to anyone often until they could ignore it no longer;
- positive experiences of GP and hospital care were reported across all groups. The concerns expressed reflected those found among other men and women in similar general population studies. By no means all the men, however, had had recent hospital contact. Frequently stated concerns included the lack of time during a GP appointment, the length of time they had to wait for a GP or hospital doctor appointment and issues to do with communication and confidentiality;
- sexual health problems, e.g. impotence, and emotional health problems, e.g. not coping with life, were reported in a majority of groups as being the types of issues men find it most difficult to talk about. Being overweight was mentioned in the school student group;
- a range of factors were seen as important for men when deciding whom to approach: how effectively the person related to them individually was the one reported most often. In general, women were commonly viewed as being more sympathetic to talk to about health problems, but not in every instance;
- two main reasons were given to explain why men delay seeking help more than women: (1) the macho culture that gave rise to an expectation that they would get better anyway, or shouldn’t be ailing in the first place; and, (2) fear of what they might be told and what might happen next. Embarrassment was mentioned as a delaying factor in relation to sexual health problems and, if the problem was mental health related, shame was reported;
- many suggestions were made about the changes needed to improve the provision of health services to men. The most common one was the need for health education among boys at an early age;
- stress at work and the stress of actual or potential unemployment were raised as issues.
Research on its own does not produce change. The report recommended that the Health Authority included the issue of men’s/boys’ health in the Health Improvement Programme and took sex differences in health into account in the planning and commissioning process, including Primary Care Groups. A further literature review about effective ways of dealing with the types health problems males find most difficult to talk about and seek help for and delayed help-seeking among specific groups of males has been started. This work will look at the major causes of public health problems in the male population of North Derbyshire: cardiovascular disease and stroke, smoking among young men, work-related stress, including redundancy/unemployment, and accidents.
- Calman, K. (1998) The State of the Public Health for 1997. London: HMSO.
- Wilson, S (1998) The Report of the Director of Public Health for 1997. Nottingham: Nottinghamshire Health Authority.
- Calman, K. (1993) The State of the Public Health for 1992. London: HMSO.
- West Midlands REA. (1995) Agenda for Health: Report of the Regional Director of Public Health for 1994. West Midlands: RHA.
- Worth, C. (1998) The Director of Public Health’s Annual Report for 1997. Huddersfield: Calderdale and Kirklees Health Authority.
- Director of Public Health (1997) Health Strategy for Oxfordshire 1997-2002. Oxford: Oxfordshire Health Authority.
- NHSE Conference (1996), Making Gender Matter in Health Care and Health Promotion. September.
- Kitzinger, J. (1995) Introducing focus groups, British Medical Journal, (311) 299-302.
Information from Internet discussion groups
- A PhD-level investigation into men’s access to primary health care services is now in the early planning stages at the University of Lancaster. Contact: Steve Robertson
- The Wessex Institute for Health Research and Development, University of Southampton, is conducting a study looking at how gay men define quality in relation to accessing and using primary health care. Contact: Dale Webb
- The European Institute of Women’s Health in Dublin in conjunction with the National Health Agency is setting up research groups of rural and urban men to identify issues in relation to health needs prior to a possible national study of men’s health needs. Contact: Bernadette Keating.