Masculinity

The evidence suggested that men’s normative behaviour, lifestyle activities and social norms contribute to them putting their health at risk. Mahalik et al (2007) provided a societal perspective, suggesting that men who engaged in ‘traditional constructions of masculinity’, such as being regarded as a ‘risk-taker’ or a ‘workaholic’, were: more likely to engage in substance misuse and suboptimal dietary choices that subsequently affected their cardiac health; more likely to be exposed to violence and aggression; and/or less willing to access healthcare services. However, Robertson et al (2014) found that where men could be persuaded to attend weight reduction programmes with a sport or physical activity focus, their drop-out rates were lower than those of women.

According to Garfield et al (2008), concepts of men’s health are often concerned primarily with male-specific cancers, but should incorporate ‘a broader conceptualisation of health, health behaviours, and lifestyle choices’ and that understanding how a ‘masculine ideology affects men’s health is an important step toward providing effective care for men’.

Griffith et al (2016) discussed whether masculinity is either a ‘barrier or a portal to healthcare’. They explained how many men conceptualise health and masculinity, often not considering their well-being until ill-health affects an important part of their life such as work or relationships. Therefore, masculinity should be reframed as a portal to healthcare, for example by providing gender-sensitive waiting areas with literature for men, health promotion videos that are aimed specifically at men, and clinics that offer appointment times outside of 9am to 5pm working hours and which are run in sport centres or agricultural markets. These health promotion activities would complement the masculine ideology, and therefore attending health clinics would become normal for men who ascribe to a ‘masculine construct’ (Griffith et al 2016).

Courtenay (2000) explored the complexity of masculinity in relation to men’s healthcare beliefs and behaviours by considering how elements such as lower economic status, suboptimal education, sexual orientation and ethnicity all contribute to the health risks among men. For example, suboptimal education and lower economic status can negatively influence men’s health literacy and understanding of health needs, which in turn aligns with the normative masculine ideology of not needing to access healthcare services. Courtenay (2000) also discussed the health risks associated with men historically being regarded as the ‘stronger sex’ and therefore not requiring healthcare as often as women, who are often regarded as being more receptive to seeking advice and support when they are unwell.

Ethnicity

In the UK, one in four black men develop prostate cancer, making them more likely to develop this form of cancer than any other group (Prostate Cancer UK 2023), although the reasons for this are not fully understood. However, it does provide an example of how ethnicity influences men’s healthcare presentations.

In a King’s Fund report on the health of people from minority ethnic backgrounds in England, Raleigh (2023) explained that ethnicity is a complex concept, which is ‘defined by features such as shared history, origins, language and cultural traditions’, and that these need to be considered when interpreting the data on the life expectancy of men in different ethnic groups. As an example of this complexity, Raleigh (2023) identified that ‘most ethnic minority groups and foreign-born migrants in England and Scotland had lower overall mortality than white counterparts before the coronavirus disease 2019 (COVID-19) pandemic’. This was potentially attributed to smoking and alcohol consumption being lower among people from minority ethnic backgrounds, and the ‘healthy migrant effect’. This effect may be due to the selective migration of healthy individuals from a population and/or migration from countries that have low rates of smoking and alcohol consumption. However, Raleigh (2023) also noted that this reported mortality advantage in some people from minority ethnic backgrounds had been reduced and even reversed due to the COVID-19 pandemic. Raleigh (2023) also stated that any initial mortality advantage among migrants may be reduced over time because cultural assimilation can lead to lifestyle changes, for example the adoption of unhealthy diets and smoking.

Articles on mortality related to the COVID-19 pandemic have expanded the literature on men’s health and ethnicity. For example, Elliott et al (2021) identified links between COVID-19 and predisposing health conditions such as diabetes mellitus or obesity, and found that male sex and black ethnicity were associated with increased risk of COVID-19 death. The researchers also identified social deprivation as a cause of disparities in the risk of COVID-19 death (Elliott et al 2021).

Goff (2019) provided further quantitative data on the link between ethnicity and health, specifically the effect of long-term medical conditions such as cancer, heart disease and diabetes. The researcher identified that type 2 diabetes is a major UK public health priority, and that its prevalence in people from minority ethnic backgrounds is around three to five times higher than in the white British population. Statistics published by Stewart (2022) also indicated that type 2 diabetes is more prevalent among men than women, with figures from 2020-21 showing that 56% of individuals with type 2 diabetes were male, compared with 44% of women.

While such quantitative numerical data on men’s health is available, there is a notable lack of studies on the qualitative aspects of men’s healthcare provision and ethnicity. One UK study by Mulugeta et al (2017) provided an insight into what they described as ‘cancer through black eyes’. This study found that culture, religion, alienation and negative health perspectives such as suspicions that healthcare services are primarily concerned with experimentation are ‘shaped by what being a black male means in society’. This in turn reflects how public health campaigns often do not reflect black men’s understanding of, or willingness to, access cancer services.

In terms of understanding the relationship between healthcare and ethnicity in the UK, a study by Robb et al (2008) found that embarrassment was a major cause of people from minority ethnic backgrounds not engaging in flexible sigmoidoscopy bowel cancer screening. Identifying this barrier to screening among people from minority ethnic backgrounds could promote discussions about how their reluctance might be overcome. The findings of this study also demonstrate the value of undertaking qualitative health studies in relation to ethnicity, which can identify the reasons why people might not access or engage with healthcare services.

Mental health and isolation

Men account for around 75% of all suicides in the UK (Office for National Statistics 2022). The topic of men’s mental health and well-being in terms of isolation, depression and suicide has been discussed and debated extensively in academia and mainstream media. However, Gagné et al (2022) found that before the COVID-19 pandemic there were few studies which documented trends in mental health. The researchers concluded that mental distress in young men (those aged 16-34 years) had risen steadily over the previous decades (1999-2020), with sharp peaks related to pandemic lockdowns and subsequent periods of isolation (Gagné et al 2022).

At the other end of the age spectrum, a report compiled by PHE and Age UK (2021) concluded that older men living in coastal areas may be particularly affected by social isolation and may find it challenging to access sources of care and support, to the detriment of their health.

As well as documenting the challenges related to men’s mental health, the evidence also provided some solutions. For example, Ogborn et al (2022) undertook a qualitative study that explored the primarily male domain of barbershops, examining barbers’ views on providing mental health support to their customers. The researchers concluded that the COVID-19 pandemic had negatively affected the mental health of barbershop customers due to isolation, but that barbershops had become venues where advice on mental well-being could be delivered by the barbers, who could also informally monitor customers for the signs of mental health issues. One example was the Lions Barber Collective, which was set up by Tom Chapman, a barber based in Torquay, England, to promote mental health well-being among men (Chapman 2019). Similarly, Nye et al (2022) cited the example of farming – a largely male occupation – and the use of livestock auctions to enable primary care services to access this hard-to-reach demographic, thereby supporting the health and well-being of men in the agricultural community.

Relevance of place

Men account for 85% of people ‘sleeping rough’ in the UK overnight (Office for National Statistics 2023). The literature exploring the concept of place in relation to men’s health emphasises issues around engagement and accessibility to services across urban and rural communities. Baker (2012) suggested that society behaves as if ‘men are somehow biologically programmed to die young and that there is little that can be done about it’. However, there are significant geographical and socioeconomic determinants such as being male and living in communities affected by deprivation that influence such adverse health outcomes, many of which are preventable (Department of Health and Social Care 2021).

In an urban environment, Curran et al (2016) referred to some male populations – such as those living in homeless shelters and/or recovering from substance misuse – as being hard to reach in terms of promoting physical activity and positive health behaviours. The researchers examined an outreach programme that worked with Premier League football community programmes in England to engage with men from such hard-to-reach groups. The programme organisers used sports venues as potentially attractive settings in which to ‘reach out’ to men in urban communities through the use of twice-weekly football sessions, which incorporated healthy living messages such as the benefits of reducing alcohol intake and adopting healthier diets (Curran et al 2016).

Away from the urban environment, access to healthcare for farmers and agricultural workers in rural communities is negatively influenced by what Mungall (2005) described as ‘distance decay’. This term describes a reduced use of healthcare services due to the distance people in rural communities need to travel to see a GP or attend hospital, as well as the economic implications of travelling, which can negatively affect health due to these individuals not seeking support for long-term health conditions.

Many coastal communities in England have distinct origins due to their seaside location, involving either fishing (towns such as Fleetwood, Whitby and Brixham) or the leisure industry (towns such as Torbay, Blackpool, Padstow and Margate). Bird (2021) identified that such coastal communities have shared health challenges such as suboptimal housing, higher-than-average alcohol and substance misuse issues, and significant areas of social deprivation, all of which affect the health of the community as a whole. Several studies have found that white working-class men living in these coastal communities are considered ‘left behind’ in terms of economic change, access to employment opportunities and the reduction in secure low-skilled work (McDowell 2003, Skeggs 2004, Wenham 2020), all of which are influential factors in the health inequalities experienced by men, particularly alcohol dependency and liver disease, diabetes, heart disease and chronic lung disease (Asthana and Gibson 2022).

Similarly, McDowell and Bonner-Thompson (2020) stated that English coastal towns are among ‘the most deprived towns in the country, with levels of economic and social deprivation often exceeding those of the inner areas of large cities’, thereby emphasising the challenges experienced by healthcare providers in these areas.

Access to services

In 2014, only 53% of men in the UK accessed the bowel cancer screening tests that were provided as part of a national screening programme (UK Health Security Agency 2014). Despite health screening being easily accessible to men in the 60 years and over age group, uptake remained low, raising questions about why screening programmes are not always effective for men, and why neglecting to access screening for conditions such as bowel cancer has become normal behaviour among many men (UK Health Security Agency 2014).

Access to healthcare is no longer provided on a solely face-to-face basis but is increasingly accessed virtually. George et al (2013) explored the use of social media in healthcare and suggested that digital technology can enhance patient self-management and communication between patients and healthcare professionals. However, Nogier (2021) asserted that any benefits of social media to men’s health have to be balanced with the disadvantages, citing the example of ‘influencers’ on social media who promote the use of e-cigarettes and ‘vaping’ as a healthy alternative to smoking cigarettes, despite the long-term health effects of e-cigarettes being under-researched at present.

Bonner-Thompson and McDowell (2020) posed the question of how young men from coastal communities who experienced financial pressures, lower educational attainment and social deprivation could be assisted to develop the skills to use social media platforms and engage with healthcare services. Galdas et al (2014) suggested that healthcare professionals could enable these men to access healthcare and take responsibility for their health issues through the use of online self-management support programmes. These programmes run over several weeks or months and involve men with long-term health conditions being supported to become experts in their own care by peers from the same or similar social demographic.

Another innovation was described by Whitty and White (2011), who implemented a male health service for delivering health promotion interventions in a rugby club in Leeds, England. This service provided health check clinics on match days within the rugby stadium, and a weight loss programme on non-match days at the club’s training ground. The interventions proved beneficial partly because they were delivered in an environment where men felt comfortable, as well as providing healthcare professionals with a clearer insight into what was effective and what was not so effective. For example, matchday smoking cessation programmes were not effective and were moved to non-match days at the training ground.

Alternatively, Baker (2016) detailed evidence that gender-sensitive nursing interventions aimed at men can be effective, and that local strategic initiatives may be necessary to improve men’s access to healthcare services. Measures include extending primary care opening hours to enable men to access healthcare services when they have finished work and delivering men’s health checks in their place of work. This not only provides ease of access, but also may encourage other men to view accessing healthcare as a normative masculine behaviour rather than a ‘weakness’.