and screening services or diagnosing and treating potentially serious .... All primary care services have an important and shared role in improving men's access.
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Men and primary care: improving access and outcomes IAN BANKS AND PETER BAKER
rimary care services are not yet providing men with sufficiently effective prevention and screening services or diagnosing and treating potentially serious conditions soon enough. This is not just a UK problem – it affects Europe and, indeed, most of the world. In June 2013, the European Men’s Health Forum (EMHF) convened a roundtable meeting in Brussels of the widest possible range of primary care professions to identify the barriers to men’s effective engagement with primary care and, more importantly, how these could be overcome.
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CONSULTATION RATES In England, in 2008–9, females aged 15–80 years had significantly more consultations with GPs than males; the biggest gap was in the 20- to 44-year age group (Figure 1).1 A lower use of services by men can also be found in pharmacy and dentistry. According to the National Pharmacy Association, men visit a pharmacy on average four times a year compared to 18 times a year for women. The Adult Dental Health Survey for England, Wales and Northern Ireland 2009 found that women were more likely to have made an appointment with an NHS dentist in the past three years (62 versus 54 per cent). This pattern is repeated across Europe. In 2010, men consulted a primary care TRENDS IN UROLOGY & MEN’S HEALTH
15 Number of consultations per person-year
The authors discuss various approaches to identifying and overcoming the barriers to men’s effective engagement with primary care.
Males Females
10
5
0 0–4
10–14 20–24 30–34 40–44 50–54 60–64 70–74 80–84 90+ 5–9 15–19 25–29 35–39 45–49 55–59 65–69 75–79 85–89 Age band (years)
Figure 1. GP consultation rates by age and sex in England in 2008–91
physician less frequently than women, with the sex-difference gap ranging from about 5 per cent in the Czech Republic and Austria to 18 per cent in Cyprus and Greece.2 Men were particularly unlikely to attend for a preventive health check, a dental check-up or a sight test. DELAYED DIAGNOSIS There is evidence suggesting that men in the UK are diagnosed at a later stage than women for malignant melanoma, lung, bladder and other urological cancers,3 and later in Ireland for colorectal, lung and stomach cancers as well as malignant melanoma.4 Men are less likely to seek help for mental health problems even when they are experiencing significant levels of psychological distress; this may well help to explain the higher suicide rate in men.5
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Ian Banks, BSc, BAO, BCh MB, MSc, PhD, President, European Men’s Health Forum; Visiting Professor, University of Ulster; Peter Baker, MA, FRSPH, Independent Men’s Health Consultant Men over 50 are nearly twice as likely as women to have undiagnosed type 2 diabetes, which is indicative of insufficient screening in primary care.6 Diabetes UK has implicated poor use of health services in the increased risk of diabetes-related amputations run by white men living in poor areas.7 A Danish study based on almost 36 million GP contacts and 1.2 million hospitalisations in 2005 hypothesised that men’s lower use of GPs resulted in later diagnosis and therefore higher use of hospital services.8 At a time of austerity, this is as much an issue of economics as it is of equity or public health. www.trendsinurology.com
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However, other research has found that men do not wait longer than women before seeking help for headaches and back pain,9 and that there is little evidence of any association between sex and time to presentation for either upper or lower gastrointestinal cancers.10 It may be the case, therefore, that late presentation is a problem for many but not all conditions affecting men. BARRIERS TO ACCESSING PRIMARY CARE Men are deterred from using primary care by two interlocking factors. First, ‘seeking help or engaging with health care is perceived by many men as incompatible with the masculine “norms” of strength,
stoicism and self-reliance’ and they fear that it will make them appear ‘vulnerable, dependent and weak’.11 Men who share this belief may also be less aware than women of the range of symptoms that should trigger a consultation with a health professional. Second, men’s reluctance to access services makes them less willing to overcome the many practical barriers they experience, including the lack of extended opening hours, inconveniently located facilities, difficult-to-use booking systems and long delays between making an appointment and seeing the clinician, as well as unpredictable waiting times on the day
BOX 1. European Men’s Health Forum roundtable on men’s health and primary care: principal conclusions l Men currently use primary care services ineffectively, contributing to unnecessarily poor health outcomes. This is especially the case for men in disadvantaged groups l As the population ages, it is essential that more men are empowered and enabled to use services, and receive targeted prevention, to reduce their risk of arriving in old age with a range of diseases l All primary care services have an important and shared role in improving men’s access and outcomes l Government austerity programmes are increasing the pressures on primary care and prevention services and it is therefore important to make the economic case for greater investment in these services in order to improve men’s health l The barriers preventing men from accessing primary care must be addressed. These include opening hours, appointment-booking systems, cost (particularly for dentistry) and a perception that many services (especially pharmacy) are primarily aimed at women l Health professionals require training on men’s health, including on how to communicate better with men (including raising embarrassing issues), tackle the barriers that deter men from using services, and engage with their local communities l Investment is needed in bigger-scale outreach services for men, including through workplaces l Better integration of the primary care professions would improve the care of men and other groups whose needs have been overlooked l Improving men’s health literacy, including their symptom awareness, would encourage earlier use of services and better self-care l More men’s health champions and role models are needed to influence both professionals and men l There is good evidence that men will use targeted primary care services but there remains a need for more research into men’s use of primary care services and how it can be improved l National health policies should take specific account of men
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itself. Some men are also deterred by what they perceive to be a ‘feminine’ environment, especially in pharmacies. There are some specific groups of men that are likely to face additional barriers to accessing primary care. Low-income men in employment tend to have less flexible working hours and may lose pay if they take time off to attend an appointment. Men who are homeless, have been recently released from prison or who are travellers are much less likely than the general population to be registered with a GP. A study of new migrants to the UK from countries with a high incidence of tuberculosis also found that women were 44 per cent more likely than men to register with a GP.12 ADDRESSING THE PROBLEMS It is possible to tackle these problems; we now know that men will use primary care services that meet their needs. By providing a male-specific service that is also open in the evenings, the Camelon men’s health centre in Scotland succeeded in attracting significant numbers of men, particularly from its target group: men in their 40s, living in deprived communities. In the Netherlands, De Boer Men’s Health and Care provides a similar well-used clinic that men access primarily for help with sexual dysfunctions and lower urinary tract symptoms. Pharmacies can also deliver services effectively to men. The Birmingham ‘Heart MOT’ service, delivered via 23 community pharmacies, succeeded in screening more than 1130 clients aged 40–70, almost two-thirds of whom were male (the main target group for the project). There is evidence that the Healthy Living Pharmacy model, which aims to tackle health inequalities by addressing a range of health and wellbeing issues, attracts more men than conventional pharmacy services. Almost half of those using the New Medicines Service – a free advice service for people
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taking a new medicine for a long-term condition – are men; this suggests that men will use pharmacy for a dialogue if they perceive it to address an immediate and clearly identifiable need. 2.
The EMHF roundtable brought together representatives from European and national organisations representing general practice, dentistry, optometry, pharmacy, occupational health and nursing. It reached 12 principal conclusions, which will form the basis for an EMHF work programme (Box 1). This is being taken forward with EU officials and professional organisations at the Europewide level; EMHF will also be organising similar roundtables within individual states to help them develop primary care services that work better for men. Declaration of interests: none declared.
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Hippisley-Cox J, Vinogradova Y. Trends in consultation rates in general practice 1995/1996 to 2008/2009: Analysis of the QResearch® database. QResearch and
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NHS Health and Social Care Information Centre, 2009. https://catalogue.ic.nhs.uk/ publications/primary-care/general-practice/ tren-cons-rate-gene-prac-95-09/trencons-rate-gene-prac-95-09-95-09-rep.pdf White A. The state of men’s health in Europe. Extended report. European Commission, 2011. Lyratzopoulos G, Abel GA, Brown CH, et al. Socio-demographic inequalities in stage of cancer diagnosis: evidence from patients with female breast, lung, colon, rectal, prostate, renal, bladder, melanoma, ovarian and endometrial cancer. Ann Oncol 2013; 24:843–50. Clarke N, Sharp L, O’Leary E, Richardson N. A report on the excess burden of cancer among men in the Republic of Ireland. Irish Cancer Society, National Cancer Registry Ireland and Institute of Technology Carlow, 2013. Kapur N, Hunt I, Lunt L, et al. Primary care consultation predictors in men and women: a cohort study. Br J Gen Pract 2005;55:108–13. Diabetes UK. Men twice as likely not to know they have diabetes. 2 November 2009. www.diabetes.org.uk/About_us/
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News_Landing_Page/Men-twice-as-likelynot-to-know-they-have-diabetes Diabetes UK. White men in poorer areas at highest risk of diabetes-related amputation. 15 March 2013. www.diabetes.org.uk/ About_us/News_Landing_Page/White-menin-poorer-areas-at-highest-risk-of-diabetes -related-amputation Juel K, Christensen K. Are men seeking medical advice too late? Contacts to general practitioners and hospital admissions in Denmark 2005. J Public Health 2008; 30:111–3. Hunt K, Adamson J, Hewitt C. Do women consult more than men? A review of gender and consultation for back pain and headache. J Health Serv Res Policy 2011;16:108–17. Macleod U, Mitchell ED, Burgess C, et al. Risk factors for delayed presentation and referral of symptomatic cancer: evidence for common cancers. Br J Cancer 2009; 101(Suppl 2):S92–S10. Galdas PM. Man up: engaging men in primary care. Practice Nursing 2013;23:10. Stagg HR, Jones J, Bickler G, Abubaker I. Poor uptake of primary healthcare registration among recent entrants to the UK: a retrospective cohort study. BMJ Open 2012;2:e001453.
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