The Crisis in UK Men’s Health Promotion?

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Practical Considerations.

During the summer I took a short break in Fermoy, south west Ireland; sheltering from the rain in the town’s high street I noticed a doorway with a familiar Men’s Shed sign above it – and took the opportunity to pop in to talk to the men working in the Shed. Paul Philpott, one of the coordinators showed me around; it was familiar territory, similar to the Sheds I’d visited in Australia and the UK.

Sheds tend to reflect the identity of their locale and the interests of the men who live there, and Fermoy was no exception. Alongside the collection of tools and pallets – a common sight in any Shed, were two curraghs (traditional boats with hide or canvas stretched over a wooden frame) the men had built, and the offer of a cup of tea, which seems to be a greeting in any shed I’ve ever visited. On the wall was a leaflet from the Irish Men’s Sheds Association with the men’s health motto: Men don’t talk face-to-face; they talk shoulder-to-shoulder”.

Paul and the other genial men working at the Shed were familiar with the practical health promoting rationale for Men’s Sheds, if not the policy and the politics of men’s health. Ireland of course instigated the world’s first men’s health policy back in 2008 and have since extended its remit until 2021. Men’s Sheds and other male health promoting initiatives continue to grow and flourish in Ireland, reinforced by government policy and the clear rationale for its implementation contained within the policy.

Paul Philpott (left) and men from the Fermoy Men’s Shed, July 2017

Whilst there may be social and cultural differences between Ireland and the UK, both countries share a similar burden of male health-related concerns, yet unlike Ireland the UK has no men’s health policy and men’s health as a serious health subject has a Cinderella-like footing in the UK public health discourse. This is despite the efforts of the Men’s Health Forum, a charity part of whose purpose involves lobbying for policy and calling for significant action on men’s health and who have been doing so since the early 2000s.

Yet notwithstanding these efforts, no policy has been forthcoming and with no policy and therefore funding to implement policy, charities involved in men’s health work struggle both in terms of income generation to retain staff, and to make a case for their work.  And it’s not only charities that are struggling; a note of disquiet has been sounded over the past few months by the closure of the Centre for Men’s Health at Leeds Beckett University. The Centre was the only dedicated research centre for male health work in the UK and despite a campaign and protests by academics and others worldwide to halt its closure the Centre is no more. Again, lack of funding appears to have sounded its death-knell.

The Failure of Government.

The failure of successive governments to act on men’s health and provide dedicated policy is at the nub of what could be described as a crisis in UK men’s health promotion – indeed use of the term  ‘men’s health promotion’ itself could be described as a misnomer following the public health pogrom on practitioner-based health promotion departments during the latter years of the last Labour administration, and the transfer of Public Health from the NHS to Local Authority control during the Coalition government’s tenure. The term ‘health promotion’ isn’t applied in any official UK sense, rather there is a focus on ‘health improvement’ work, yet gendered approaches to health work rarely feature in mainstream health improvement initiatives that are largely commissioned by Local Authority controlled public health departments.

So how have we come to this? – this failure to act on the robust rationale for taking practical action on men’s health that has been recognised in other countries? Timidity by those lobbying for policy? Not pushing hard enough? Lack of public awareness of male health as an issue? – other than men’s reproductive cancers as representing men’s health in the public consciousness. Or an echelon of senior people within the Department of Health who will not recognise the need to act on men’s health despite the clear rationale for action? And ideologically entrenched perspectives that reinforce that lack of recognition? Or the weighting of the research itself towards hand-wringing perspectives on ‘ problematic masculinity’ and a dearth of research, guidance and training on practical ‘what works’? Others could be added, but let’s briefly examine some of the above.

The Men’s Health Establishment.

The Men’s Health Forum grew out of a Royal College of Nursing initiative, becoming a registered charity independent of the RCN in 2001. Its mission is to “improve the health of men and boys”. Whilst other major men’s health charities have focused on single issue concerns ( e.g. CALM on male mental health; Prostate Cancer UK as per its branding) MHF has encompassed a wider remit, establishing strategic relationships with the Department of Health, NHS England, and Public Health England. Its Patron is Professor Alan White and throughout its life MHF has maintained its research-based position via the Centre for Men’s Health and other academic establishments. It presents a respectable, professional aspect as the ‘go-to’ organisation for men’s health –  as it has to.

Men’s health in the UK needs a reputable body to represent it. You will not find the Men’s Health Forum taking up their pitchforks and marching on Public Health England, rather measured discussion  within the context of current policy, whatever the hue of government in charge. Whilst table thumping demands for a policy are not to be expected (although the MHF have called for one in their manifesto) it has to be asked why there has – in reality – been little progress by MHF on persuading the Department of Health to  instigate policy, whereas other countries have grasped this?

Public Awareness.

Men’s health is an issue hidden in plain sight, yet in the public perception it is an area largely dominated by men’s reproductive cancers. These are of course worthy subjects, yet their raised profile and the relative campaigning successes of the charities addressing them may mask the many other other serious issues affecting male health. The health of men and boys  is  a topic  that receives little public airing and when it does so usually concentrates on the aforementioned subjects. The public remain largely unaware and uneducated about male health concerns and have little motivation to call for government action. Try asking your local MP what they are doing about men’s health.

So how can greater awareness of men’s health and the issues affecting men be pressed into the public consciousness? Whilst MHF have largely taken responsibility for negotiating policy with ‘statutory health’, there may well be a case for a larger pressure group or lobbying body consisting of other organisations to press the case for policy alongside MHF.  The fledgling Men and Boys Coalition offer such a model, however the campaigning potential of some of the larger charities involved in men’s health related work (for example Movember) would be welcome within the Coalition, in terms of raising public awareness and  highlighting the need for policy in their campaign work. There is also a case to be made for other prominent organisations, businesses, and mainstream media not directly involved in male health work to campaign on concerns. There are some MBC commentators and  journalists such as Martin Daubney and Ally Fogg who do raise concerns in the media – but more needs to be done to raise awareness with the greater public.

Opening Doors – Pushing Policy.

So why have the Men’s Health Forum not succeeded in the push for policy? The rationale and need for action is conspicuously apparent in the sheaves of MHF documents and position statements produced over the past decade or so. Surely the Department of Health and Public Health England are aware of these? After all the MHF are their strategic partner. The movement towards gendered health policy has remained glacial and it could be speculated that  it may well be hindered by filibustering at senior levels within the Department of Health. For example, following a report by the Chief Medical Officer, Professor Dame Sally Davies on women’s health –“The health of the 51%: Women”, a reasonable proposal was submitted to the CMO by MHF Chief Executive Martin Tod in January 2016 to “consider addressing men’s health issues in your next annual report and making the case for some of the other much needed changes in the health system to improve the health of men and boys.”  

Martin Tod’s approach was logical; the CMO had taken a gendered approach to women’s health so surely men’s health deserved equal attention? Unfortunately the CMO’s response was discouraging and in light of events perhaps evasive; a reply was returned stating that work was already being undertaken on a genomics report, hence consideration of a men’s health report was deferred. The Men and Boys Coalition also supported the MHF approach with a further letter expressing disappointment with her response and urging her to reconsider  – receiving a similar answer.

This explanation would have been acceptable, except that the aforementioned genomics report turned out to be one on the health of the baby boomer generation and the single silo health issues affecting them; ie no sign of a gendered approach there. Or genomics. The Men and Boys Coalition again requested a report by the CMO in March 2017, highlighting the research and report-based backgrounds to the male health policies in the Republic of Ireland and in Australia and calling for a report on the health of UK men to act as a precursor to any future policy here. The CMO had, apparently, begun work on her next two reports and therefore declined a report on men’s health. Prevarication? Obfuscation? Or just the day-to-day demands of a busy department? Of course there are pressing demands within the Department of Health and it may be that the CMO’s report on Babyboomers and their health needs overrode any other considerations. Yet why a report on the health of women, and not one for men? With such a demonstrably serious topic and MHF as a ‘strategic partner’ it is not a mere case of “if they should have one, then so should we”. Men’s health it appears is low down on the list of strategic health priorities – yet why?

Gender Politics.

Could it be that the gender politics that fetter discussions about male and female issues have also become embedded at a senior level of the Department of Health? A shibboleth that  proclaims that women (and rightly so) deserve attention but that men only have themselves to blame for their health (perpetuating a mantra that men are bad/deficient) – and that nothing can be done? That a dominant research paradigm on male health – sociology-based  ‘masculinities’ focusing on men’s social pathologies rather than salutogenic, health creating approaches – and the dissemination of feminist perspectives on men’s health that have roots in ‘masculinities’-based work have permeated the higher echelons of UK public health thinking and influenced decision making?

This may seem very far-fetched, yet a glance at the movement towards policy in Australia shows that there is a precedent.  Professor John Macdonald, formerly working on public health education at Manchester and Bristol universities, is now a leading voice on men’s health work in Australia and a champion of a social determinants approach to men’s health; in a critique of that nation’s policy he points out that it is not good public health science to base a policy on a sole area of work – the social construction of masculinity.  In his critique Professor Macdonald identified the dominance of this school of thought in influencing critical thinking on male health: “So strong has been this influence that when a national men’s health policy was being discussed in 2009, anxieties were expressed that  “hegemonic masculinity” would not receive the importance that it should be accorded in the promised policy”.

‘Men’s Health Means Masculinities?’

The masculinities based work has gained a de facto position in the UK as the only basis for men’s health work to the exclusion of other valid schools of academic thought and practical work. Yet, rather than engage in a reasoned debate or work with other academic disciplines and practitioners, some proponents of masculinities based work have acted like adherents of a fundamentalist doctrine when their status is challenged. This is played out in a global context; the emergence of a multidisciplinary male health course at the University of South Australia in 2014 and the reaction of feminist academics to it demonstrates the difficulties encountered when attempting to explore other academic and practitioner-based perspectives.

Does this really matter? After all there is an agreement across the academic divide that something needs to be done about men’s health; the real core debate is about the root causes of men’s poor health outcomes and hence what needs to be done to address this. This includes training and guidance for practitioners. Are we instructing practitioners to concentrate on addressing ‘hegemonic masculinity’ as endorsed via a Sociology Men’s Studies/Critical Studies on Men camp? Or a perspective that considers ‘male friendly services’ and improving the social determinants of male health – improving boys’ education, providing men with safe, secure employment and so on. And considering a biological basis for men’s actions as well as culture-based health practices? An approach more in keeping with the ‘Male Studies’ perspective  proposed in the University of South Australia course?

This is territory explored previously in other articles. The stark truth is that currently few UK agencies offer training on men’s health and there is no policy to drive training. Mengage’s training on male health considers all aspects of men’s health work; however our core work is currently concentrated on salutogenic (what creates and enhances health) and social determinants work, especially improving educational outcomes via male mentoring and teacher training.

Sociology, in terms of the socio-cultural context and health practices associated with male culture has valid contributions to make to men’s health work alongside other disciplines, yet it is nonsensical and derisory of other academic opinion for it to be considered as the only game in town in terms of explaining men’s health behaviours and concerns (e.g. see Dr John Ashfield’s perspective). Biological and related evolutionary psychology perspectives on gender are worthy of equal consideration alongside social determinants and work concerning salutogenisis . In a UK context, psychologists such as Martin Seager and John Barry are notable figures in an approach more in line with the Australian Male Studies perspective. Sociologists working in men’s health should perhaps be taking the lead offered by sociologist Anton Antonovsky who created the concept of salutogenisis rather than doggedly utilising Connell’s deficiency model of masculinities – a model that has been said to pathologise men.

Sir Michael Marmot, NHS Confederation annual conference and exhibition 2010 – Liverpool ACC

It is notable that in other areas of UK public health that work is heavily influenced by the social determinants work of Sir Michael Marmot, yet there is scant evidence of this in UK academic work concerning men’s health where the focus is very much on masculinity and where  this school of thought is the dominant paradigm. One consideration is that the Centre for Men’s Health and its long-standing association with the Men’s Health Forum has created a conduit for the dissemination and promotion of ‘men’s health means masculinities’  – reinforced  by conferences, training and a weight of academic papers exploring men’s health within a sociological framework.

Steve Robertson, Professor of Men, Health and Gender based at the Centre for Men’s Health is probably the foremost exponent of ‘men’s health means masculinities’ in a UK context.  Steve has also acted as a consultant to the Department of Health and the WHO. Undoubtedly Steve and similar advocates of this approach produce important work in the context of their own field of masculinities based work – yet a reading of texts in this field demonstrates a consistent refuting and challenge to any other field of academia that explores male health and offers alternative theory and proposals to the masculinities school.

Steve Robertson does at least acknowledge the importance of social determinants work in a recent paper   –  maintaining a stance that masculinities are crucial to understanding the social determinants of male health. It is difficult to see how competing schools of thought can come to a consensus on the “who, what, where, when, why and how” of men’s health when professional protectionism within academia prevents any meaningful discourse between different disciplines. It’s not far-fetched to postulate that senior academics  from any field are unlikely to admit that their answers do not provide solutions  when status and funding are at stake.

Maintaining the ‘men’s health means masculinities’ stance and intentionally or not buttressing it via the Men’s Health Forum and its association with the Department of Health may mean that the “it’s all men’s fault”/ “men are deficient” perspective is the only perspective on work with men that filters through to the higher echelons of public heath work in the UK. Australia and the Republic of Ireland have largely avoided this area of work in their policies, instead opting for more practical and strengths-based work, yet it is of concern that in a UK context that this one area of work is so influential.

Ideology or Realpolitik?

This influence can be seen in other related spheres of gendered work with males and in national politics; we need only to look at the clash between the Conservative MP Philip Davies and Labour MP Jess Phillips in the run-up to International Men’s Day in 2016. We must also consider that policy is  governed by the hue of the political party governing the country at any time and the principles guiding that party; ie if men’s health does ever surface as policy then it may be partly shaped by political ideology rather than pragmatic evidence.  Not only do we need policy, but it has to be the right policy based on hard evidence and not ideological gerrymandering.

To answer the question “is there a crisis in men’s health promotion?” the answer is “yes, there is” – however it is one that has accompanied the ongoing crisis in men’s health since this practitioner began work in the field. From a practitioner’s perspective the ongoing academic debate has hamstrung guidance in the UK, whereas other countries have considered the evidence and created cohesive policy and initiatives. Men’s health requires visible, practical measures that relate to  male heterogeneity and reach out to men, rather than the only game in town initiatives that address ‘toxic masculinity’ – a phrase that has been seized upon by both research and the media. That isn’t to decry the very real fact that there are men who  ‘do harm’ and that work with men who are problematic does require measures to address masculinity where it does or is  capable of causing harm. However, this has to sit within an integrated body of multidisciplinary work that is inclusive of other fields indicated by John Ashfield that include biology, anthropology, neuroscience, endocrinology, psychiatry,  and psychology. Sociology and the cultural context, particularly in the understanding of culture and the design of cultural and subcultural-based interventions has a part to play in this integrated perspective. Above all else any integrated perspective must be about the social determinants of male health and the salutogenic approach advocated by John Macdonald.

Since the author’s commencing practical men’s health work almost 20 years ago the patchwork of training and guidance in the UK on the subject has moved little. The Centre for Men’s Health and Leeds Metropolitan (as was) University did instigate higher education courses on men’s health – and the efforts of Professors Alan White and Steve Robertson in bringing this about are to be applauded, yet without a policy that enabled placement of practitioners in dedicated men’s health posts within public health departments nationally  – and the funding to set up sustainable initiatives that reach out to men, there is and has been  little call for  diplomas and degrees in men’s health and hence few skilled practitioners to guide local work.

Most male health promotion/improvement work has been undertaken by enthusiastic professionals on single silo health issues, often with little funding; good, localised work is often carried out but there is little documentation and dissemination of ‘what works’. The last time this was achieved nationally with Government endorsement was during the Blair Labour administration’s tenure when there was a brief interest in work with boys and young men and  guidance was produced by the now defunct Health Development Agency – but since that time, other than a series of books edited by Professor Alan White on practical men’s health  ( How to do it; Promoting Men’s Mental Health; Hazardous Waist ) the UK has little to show in terms of practical guidance – there is still no nationally recognised and nationally available course of study on male health and certainly not one that brings together the different strands of male health work to provide an integrated perspective.

What Next?

Having observed the men’s health field for many years and met and worked with people from both sides of the paradigm divide, this meeting of minds is unlikely to come about via academia itself. What it does require is Government action to dispassionately consider the evidence base and to learn from the work of the Republic of Ireland and Australia. The real starting point for this has to be a report by the CMO. The Men’s Health Forum, the Centre for Men’s Health and all other players in the field, academic and practitioner opinions aside, have to all be praised for their efforts to bring about an improvement in men’s health, however ultimately it is only Government and the agencies of Government who can provide the real key to addressing the crisis in men’s health. Only Government  can provide a policy that unlocks funding and paves the way for the creation of sustainable male health improvement work that can be adequately funded, well resourced, and documented and disseminated nationally.The current incumbent of the post has so far demonstrated little movement towards a report; we can hope that the CMO reconsiders, but it may be that men’s health will have to wait until a more sympathetic incumbent is in post until the UK finally shifts towards policy.

It would be useful to finish on a positive note. Other countries have demonstrated that a policy and the benefits derived from one are achievable – take a look at Peter Baker’s report and  the renewal of Ireland’s policy. The independent and international Men’s Shed movement has shown what is achievable in practical men’s health work without recourse to statutory assistance or motivation via research – men did it for themselves. In Australia, in Ireland – and a growing movement in the UK. We can look at sports-based initiatives, we can look at efforts to address the social determinants of health via improving boys’ educational achievement, we can look at work addressing Gay men’s health, or the health of BME men; we can look further afield at initiatives such as Tradies Tune-up in Australia or Mind ur Buddy in Ireland. There are many things that can be done, either learning from what has worked previously in the UK, or learning from other countries and translating initiatives where applicable into a UK context. Men’s health promotion is swaying but still on its feet. The great hope is that despite the inaction of Government that there are still a minority of organisations and individuals who recognise the need  to address men’s health and act on it –  and that whilst there are people at all levels of male health work willing to push for improvement in male health there may finally be recognition and a willingness in Government to look at health through the lens of gender and instigate policy. Let’s keep pushing.

Paul Hopkins, Director Mengage.