Men’s Health Interventions: Strategic Considerations

Delivered to Samantha Hartley-Folz (BC Healthy Living Alliance)

June 2014

Prepared by Laura Dale (CCS-UBC Cancer Prevention Centre)

Executive Summary Purpose This brief scoping review was conducted for the Working on Wellness (WoW) in Strategic Populations Initiative. WoW is a partnership effort aimed at reducing preventable cancers and other chronic diseases through promotion of overall wellness and healthy choices in the workplace. The review synthesized literature on effective health intervention considerations, particularly focusing on communication strategies, to better reach primary male dominated workplaces. Topics related to chronic disease and associated risk factors (tobacco use, inactivity, unhealthy eating and obesity) were examined. Method of Investigation A comprehensive search of MEDLINE, CINAHL, and PubMED was conducted for articles published in English between 2000 and 2014. Grey literature was identified using Google Scholar, ProQuest (Theses and Dissertations), and the Canadian Health Research Collection. Relevant articles’ citations were hand searched to find additional articles; snowball sampling proved to be most effective. Abstracts were excluded from review for the Men’s Health Chapter if the article pertained exclusively to men’s management of cancer, men’s sexual health (including gay and bisexual men’s health), young men (children and teenagers), or incarcerated men. Findings: Men’s Health Effective health promotion interventions recognize the heterogeneous nature of the male population. No man is the same; health promotion interventions should offer a variety of services to men and incorporate feedback into the intervention. Motivation to engage in health promotion often differs substantially between men; successful interventions measure men’s motivation prior to intervention enrolment. Men, who are in the earliest phases of a health journey, are often not willing to change their unhealthy behaviours. These men tend to express perceptions of invulnerability, health security, or have an external locus of health control. Given that these factors may correlate with their lower motivation to engage in healthy lifestyles, it is recommended that health interventions successively educate men on risk perceptions and health control awareness. In contrast, some men report healthy behavioural motivation owing to external factors. These external pressures, often social in nature, can be harnessed by health promotion interventions by designing optional team- oriented activities or acquiring a respected and relatable ‘healthy pioneer who will recruit and encourage participants to be healthy.

Health promotion interventions, in addition to increasing male motivation, must be implemented in a safe environment, where privacy and confidentiality are always respected. Also, interventions implemented at the workplace should respect busy schedules, by providing convenient and fast health promotion resources. Effective health interventions are consistently described as being enjoyable and personal. As such, future interventions should provide tailored and personalized health advice, include light competition, and consistently support male autonomy by encouraging men to set their own health goals. This report also details the importance of appropriate communication strategies to attract and retain male participants in health interventions. Effective communication often starts by providing men with relevant health messages and highlighting obvious health concerns, these health messages should always use straightforward and rational language, without traces of emotive claims. Some authors suggest avoiding obvious and directive health counselling, repetitive information, and medicalized language when communicating with men. Likewise, some health promotion interventions use stereotypical masculine belief systems (strong, independent, outdoorsy, logical, etc.) to encourage male participation. The aptness of this communication strategy is questionable; there is the risk of further isolating groups of men by encouraging stereotypical belief systems. Conclusion Given the limited literature published in the areas of men’s health, it is difficult to draw generalizable conclusions on effective communication and health intervention considerations. This report aims to guide health promotion interventions to better engage with primary male dominated workplaces. Ultimately, the most effective men’s health interventions are those that adapt to fit the needs of each community and to do this the needs of the population should be thoroughly examined before designing a health promotion intervention.

Men’s Health: Motivation Motivation is defined as the desire to ’do’; it is usually broken into three main categories: 1) Amotivation, 2) Extrinsic Motivation and 3) Intrinsic Motivation. Given that motivation is a fluid concept, and people can self-align into any motivational category, health promotion programs often target motivation to increase and maintain participant’s engagement. Health interventions should attempt to develop tailored motivational strategies for each participant (Hatchell, Bassett-Gunter, Clarke, Kimura, & Latimer-Cheung, 2013). The following paragraphs describe previously published, male- specific motivational strategies used in health promotion interventions. The focus of this section is to describe communication strategies and methods to motivate ‘amotivated’ or ‘extrinsically motivated’ men.

1. Amotivation

An amotivated man lacks the intention to ‘act’. He may not be interested in or value the healthy ‘activity-in-question’. Unsurprisingly, when men report lack of interest, motivation or willpower for health promotion, they are unlikely to engage in a health promotion intervention (Loeb, 2003; O’kane, Craig, Black, & Thorpe, 2008). Furthermore, amotivated men often ignore serious health symptoms (Aoun & Johnson, 2002) and do not admit that they are suffering from a health problem (Egger, 2000). Psychological Correlates of Amotivation In order for health promotion interventions to engage amotivated men, a comprehensive examination of the specific factors contributing to amotivation should be conducted in each relevant population. By better understanding the population in question, health promotion interventions can tailor health communication to target specific concerns. Interventions should consider targeting some of the following psychological correlates to increase health behaviour motivation: Invulnerability

Amotivated men often report that they are immune to health afflictions (Davies et al., 2000; Meador & Linnan, 2006). In other words, men would not be willing to change their diet, for example, because they do not expect to suffer a heart attack.

Health Security

Amotivated men often report feeling secure in their current health status and believe that ‘healthy men’ do not need to engage in healthy behaviours (Melanson, 2008; Smith & Robertson, 2008). Additionally, some men tend to

downgrade the relevance of health concerns when talking about their own healthy lifestyles (Sloan, Gough, & Conner, 2010).

External Locus of Control

Amotivated men who have an external locus of control for health afflictions frequently display signs of apathy towards behaviour change [1,40]. In other words, men who believe that they will inevitably develop a disease are not motivated to engage in health promotion. For example, Okane (2008) found that a quarter of men in his study reported that they ‘had to die of something, so they might as well enjoy what they were eating’. Men with an external locus of health control show low levels of autonomy (independence or freedom), which also negatively correlates with health promotion engagement (Segar, Updegraff, Zikmund-Fisher, & Richardson, 2012).

Decreasing Amotivation It has been theorized that men have a general lack of knowledge and understanding about their bodies (Jeanfreau, 2011). As such, the most common technique used to increase motivation among amotivated men is through the provision of health education and awareness.

1. Health education should focus on men’s risk perceptions.

2. Health education should show men to what extent they have control over their health.

3. Health education should encourage reflective thinking. Reflective thinking, in

the form of ‘brain-storming activities’, can potentially decrease perceived external locus of health control. For example, men should be encouraged to think about all the ways they control their health on a daily basis and visualize themselves making the desired health changes.

2. Extrinsic Motivation

When a person is extrinsically motivated to take part in a health behaviour, they are doing so because they perceive it will lead to a separable outcome (Deci & Ryan, 2012). Men appear to be more extrinsically motivated than women (Duda, 1988), and as such, effective health promotion programs should tailor their interventions according to the type of extrinsic motivating factor most valued by the male participant. The following paragraph describes some previously identified extrinsic health behaviour motivators for men. Correlates of Extrinsic Motivation Social Pressure

Men often comment on the role their partner and/or health care provider

plays in influencing their own health behaviour change (du Plessis, 2012; Meador & Linnan, 2006; Short et al., 2014). Some men go so far as to even blame their partners or health care providers for their newly developed interest in health behaviour change (Egger, 2000). In this situation, men are able to justify their participation in a health behaviour without having to look weak, as they are simple being ‘coerced into doing so. Supportive colleagues and peers also appear to increase health behaviour change in men (Mahalik, Burns, & Syzdek, 2007; Meador & Linnan, 2006).

Social Benefits Men commonly report interest in health interventions because they wish to

gain social support, connection, and a sense of camaraderie with those in their community (Robertson, Witty, Zwolinsky, & Day, 2013; Wilson, Rodgers, Loitz, & Scime, 2006). Desire for social support appears to be highly motivating for those men in rural living environments (Kutek, Turnbull, & Fairweather-Schmidt, 2011). On the contrary, those men with limited social support express limited engagement in healthy behaviours. As such, limited social support is a barrier for engagement in many healthy behaviours, including healthy eating (Melanson, 2008).

Being a Role Model Men with families often reported interest in engaging in healthy behaviours

so they can be a good role model for children and family (Caperchione et al., 2012).

Health Benefits

Many men indicate that they engage in healthy behaviours for general health benefits (Loeb, 2003, 2004; Meador & Linnan, 2006); often these ‘health benefits are physical (i.e. weight loss or improved muscle tone).

Age Considerations • Men of different ages have different extrinsic motivations. Some studies have

reported that younger men have a higher propensity to engage in healthy behaviours to improve fitness (Hankey, Leslie, & Lean, 2002) and maintain/develop an attractive body (du Plessis, 2012) compared to older men. Middle-aged men also reported engaging in healthy behaviours to prevent future disease, improve weight management and improve physical appearance (Caperchione et al., 2012; Hankey et al., 2002; O’kane et al., 2008; White, Conrad, & Branney, 2008).

• Even though physical appearance may be a motivating factor for some younger men, caution should be taken if attempting to advertise physical fitness as a means to develop an attractive body. Research has also shown that a large majority of men dislike interventions heavily focused on health

or on body shape (Verdonk, Seesing, & de Rijk, 2010).

Illness Avoidance

• Some men report personal fears associated with negative health outcomes (White et al., 2008). This extrinsic motivation is moderated by the severity of that health concern (Douglas, Greener, van Teijlingen, & Ludbrook, 2013). In other words, if men are extremely fearful of diabetes (for example) they may be highly motivated to consume a diet low in sugars.

Health Scares • Men reported being highly motivated to take part in health improvements

when faced with a health scare. Health scares can act as a wake up call (Aoun & Johnson, 2002; O’kane et al., 2008). Interestingly, these motivational health scares could have been a personal affliction, or one occurring in a family member or friend.

Test Results • Receiving negative test results (an indicator of poor health) acts as a highly

effective extrinsic motivator for men to engage in health behaviour change (Aoun & Johnson, 2002). For example, a major motivator for men to enter a dietary/weight loss intervention was being labeled as obese by an external party (Gray et al., 2009).

Embarrassment

• Some literature suggests that when men indicate feeling fearful or embarrassed about their health condition, they may be highly motivated to change their behaviour. This is commonly seen for body weight (White et al., 2008). That being said, interventions should not attempt to embarrass men to encourage behaviour change.

• Embarrassment as a result from an external source, such as a health intervention, may actually further stigmatize men and cause them to disengage in any health promotion activity.

Improving Extrinsic Motivation Health promotion interventions should consider including the following to increase male’s extrinsic motivation for healthy behaviours:

• Ask men to inform their family member and friends about the health promotion intervention, to encourage a supportive home environment.

• Include reminders for men who are acting as primary providers that they are taking part in healthy behaviours for their family and loved ones in addition to their own personal gains and satisfaction.

• Recruit ‘healthy leaders’ or ‘pioneers’ to motivate men in the workplace (A

Pringle et al., 2013; Alan Pringle & Sayers, 2004).

• Include biometric evaluations of participants’ health in promotion interventions. (e.g. provide participants with validated assessment tools to measure body mass index, blood pressure, and blood sugar levels).

• Tailor interventions for men in ‘transitional’ periods of life (e.g. becoming a father or getting a promotion), as men will need additional support and self-esteem improving services.

• Provide men with health risk information. Effective health messages for men first evoke high-perceived risk, then ultimately reduces fears and reassures control over the perceived danger associated with the health affliction (Hatchell et al., 2013). For example, a smoking cessation message should include information on the rates of lung cancer among men. This message should then inform men that by quitting smoking, the risk of lung cancer is reduced substantially (Patel & Barnett, 2011).

• Include age appropriate interventions (i.e. do not expect the promotion of a young attractive body to motivate older men to engage in healthy behaviours).

• Health promotion interventions should foster male autonomy.

3. Self-Efficacy

Self-efficacy is described as a person’s belief in his or her own ability to complete a task or reach a goal. Self-efficacy moderates both intrinsic and extrinsic motivation, and is an important factor when trying to improve men’s engagement in health promotion interventions. Improving Self-Efficacy Experience

• Health intervention programs should encourage men to set achievable health goals to encourage success. When men experience success, they report higher levels of self-efficacy. When men experience failure, their self-efficacy is lowered.

Modeling • When men see other men failing at a health behaviour change, personal self-

efficacy decreases and vice versa. Health interventions for men should consider featuring male success stories of other participants.

Social Persuasion

• Encouragement or discouragement of a family member, peer, colleague etc.

can directly influence men’s self-efficacy. Efforts should be taken to capitalize on group dynamics to educate men on health promotion(B. B. Campbell, Shah, & Gosselin, 2009).

Men’s Health: Intervention Characteristics Health promotion interventions should be: Safe and Confidential

Men consistently report the importance of ’safety‘ surrounding health promotion efforts. Desired interventions should not include derogatory language (Short et al., 2014) and communication needs to be confidential (White, Cash, Conrad, & Branney, 2007).

Respecting personal privacy and anonymity can be achieved in an online environment through an at home commitment programs (Egger, 2000; Robinson & Robertson, 2010).

In group-based health promotion interventions, promote a positive environment free from embarrassment (Alan Pringle & Sayers, 2004; White et al., 2008).

Suggestions by men to improve the safety and confidentiality of health promotion interventions includes the organization of small group-sessions (increases connections) [12], offering optional call-in centres (Davies et al., 2000), and always ensuring that the health setting is male friendly (Gough & Conner, 2006).

Convenient Men report interest in health promotion when it is provided in a convenient

location, such as a workplace or online (White et al., 2008). As such, health promotion interventions should ensure that they advertise why and how they are convenient.

For online health promotion environments, Robinson et al. suggest that it is important to supplement online content with offline content; it is inappropriate to always expect/rely on Internet connections (2010). Furthermore, all health intervention materials should be accessible after working hours.

Utilize text messaging, phone call reminders, and email prompts in addition to the main health promotion effort (Collins, Morgan, Warren, Lubans, & Callister, 2011).

Consider developing cellphone applications to supplement health promotion intervention as phone apps are often more private than computer based programs. There are many apps for men’s health, already developed a quick search by Porche (2013) found 134 apps for free or a small nominal fee.

Supplement healthy eating promotion interventions with appropriate

workplace resources (D. Campbell, Pyett, & McCarthy, 2007). Provide free fresh fruit and vegetables for men in lunchrooms to increase the convenience of health eating.

Ball (2001) investigated factors associated with physical activity in Australian men (and women) and noted that perceived convenience was a strong correlate of walking an exercise. Health promotion interventions may benefit from advertising the convenience of accessing all exercise facilities and physical activity opportunities (Ball, Bauman, Leslie, & Owen, 2001).

Fast A common barrier preventing engagement in health promotion interventions

expressed by men is lack of time. Men consistently report lack of time owing to working long hours, long commute times (Morgan et al., 2011) and family responsibilities (Caperchione et al., 2012).

Lack of time (in addition to limited skill levels) inhibits men’s ability to prepare healthy meals (Melanson, 2008) and also inhibits engagement in physical activity (Caperchione et al., 2012; Gittelsohn et al., 2010; Morgan et al., 2011; O’kane et al., 2008).

Men desire fast health interventions that take little after work hours (Robinson & Robertson, 2010), thus supporting the need for workplace based interventions which encourage flexible working hours (O’kane et al., 2008). Incorporation of health promotion interventions during the work schedule may also encourage physical activity engagement.

Cost Effective A strong deterrent for engagement in healthy lifestyle behaviours for men

includes the high associated costs (Loeb, 2003).

Cost of healthy foods is particularly off putting to men (du Plessis, 2012), given that convenient unhealthy foods are much more affordable and filling.

In northern communities, the costs of healthy foods are extreme (Gittelsohn et al., 2010). To compensate for the high costs, northern men often try to take charge of their diet through consuming local wild game, yet often run into different financial barriers with the increasingly expensive costs of hunting supplies.

Furthermore, to compound the financial difficulties associated with living in northern environments these men report lack of education surrounding dietary budgets. Ensuring that men are informed about budgets and ways to

affordably live a healthy life is a must.

Personal It has been made clear that men want personalized health interventions

(Gray et al., 2009; Short et al., 2014).

Health promotion interventions should be obviously tailored to men exclusively; exclusion of women’s health materials is highly effective. Also, some men associate feminine characteristics with words such as ‘health’, ‘diet’ and ‘mental wellbeing’, ultimately and unfortunately resulting in their immediate disinterest. Health promotion interventions should try avoiding these words.

Visual promotional material should exclude stereotypical feminine color schemes (light pinks, purples etc.) and should include photos of ‘male laypersons’.

Men find generic health behaviour change advice an unattractive feature of a health promotion intervention. Therefore, encourage health program ownership and never impose a ‘one size fits all approach. Participants should set their own goals and design their own health programs based on their personal interests (George et al., 2012; Hatchell et al., 2013; Plotnikoff et al., 2007).

Enjoyable Men desire fun and enjoyable health promotion interventions.

Men report being interested in taking part in health promotion programs

that include light humour and recreational activities (Egger, 2000; Gray et al., 2009; O’kane et al., 2008).

Develop interventions that are team spirited and have high levels of social interactions as they improve interest in and enjoyment of health-related activities.

Health promotion interventions should also support: Light Competition

• Light competition is a desirable health promotion intervention characteristic described by some men (Morgan et al., 2011). Inclusion of small prizes and encouragement from workplace camaraderie can also potentially increase men’s desire to commit to a health promotion program.

• Consider developing optional team-centred departmental in person

competitions (Verdonk et al., 2010) or online (George et al., 2012). These environments allow men to monitor their own healthy behaviours and those of their teammates (colleagues/peers) simultaneously.

• However, a cautionary note when promoting health competition among men is that there are many mixed studies about competition (A Pringle et al., 2013). Some studies have found negative health outcomes with the incorporation of competition, as such, health interventions need to know their populations.

Self-Monitoring Tools • Men appreciate the ability to track and monitor their health behaviours. The

ability to self-monitoring has shown to enhance adherence to long-term behaviour change among men.

• Keeping a health log is a good strategy for self-monitoring, albeit challenging. This strategy is commonly used in weight loss and dietary interventions (Taylor et al., 2013). These tools can act as benchmarks to remind men where they came from and how far they have gone.

• It may be beneficial to give men the option of how much monitoring they intend to do. For example, if a man is choosing to monitor his weight loss, a self-monitoring tool should require few mandatory and many optional monitoring benchmarks.

• For online health promotion environments, consider developing tools that visually track healthy behaviour progress, as opposed to simple written progress. For example, have software that tracks weight reduction (George et al., 2012; Short et al., 2014) and displays creative images of the weight loss (e.g. bowling balls lost).

Biometric Assessments Men tend to underuse primary care health services despite their

susceptibility to particular types of illness (Tudiver & Talbot, 1999). The available literature on male-specific health promotion interventions, although limited, favorability depicts the inclusion of biometric assessments in health promotion interventions. The inclusion of biometric assessments, such as blood pressure, stress management tools, and BMI assessments are highly valued by men and should supplement ‘lifestyle advice’ (Douglas et al., 2013; McMahon, Hodgins, & Kelleher, 2002).

Some health service providers in the UK have taken measures into their own hands to show that biometric assessments, such as blood pressure checks, cholesterol test, BMI assessments and screening for diabetes could be an enjoyable experience for men outside the clinic (Wood, 2011). Health nurses

visited men in a local pub, where they created a relaxing, non-medicalized environment to perform simple health checks. The nurses reported that after men’s initial apprehension, men queued up to receive the health check with their friends.

Similarly, the inclusion of cholesterol measurements to nutrition counselling in male university students proved to be highly effective at encouraging behaviour change when compared to the nutrition counselling alone (Davies et al., 2000).

Autonomy Men value health promotion programs that support personal autonomy

(Segar et al., 2012). As such, all health interventions should encourage men to make their own health decisions (Sloan et al., 2010) and control their health journey (Short et al., 2014).

Health promotion programs should also encourage informed health decisions (Gough & Conner, 2006) that could be achieved through educational sessions. For example, men could be taught how to read food labels so they can make informed, autonomous healthy food choices (Gray et al., 2009).

Health promotion programs should always include multiple avenues for behaviour change. Workplace health promotion programs could offer soccer drop-in clubs at lunch, weight training programs or walking meetings. This variety of health promotion programs can allow men to feel in control of what session to attend.

Online health promotion interventions should always provide links to additional information and resources to encourage men to direct their own healthy learning, when it best suits them (Gough & Conner, 2006).

Additional Intervention Considerations: Community Partnerships

Interventions should not only engage men, but also work with community groups, including local businesses, to improve the reach and effectiveness of the intervention. As suggested by Robertson (2013), it is key to include the community in the intervention as it has the potential to increase the interventions credibility. Subsequently, this could increase men’s willingness to participate in the project. This is sometimes described as mainstreaming the project.

Seasonality Health promotion interventions must consider the effect weather and

seasons have on health, especially those programs being implemented in

northern and remote communities.

A systematic review conducted on the relationship between physical activity levels and seasonality unsurprisingly found poor weather to be a physical activity barrier for both men and women (Tucker & Gilliland, 2007).

Some more obvious methods to encourage physical activity levels in challenging weather conditions includes advertising: 1) facilities that allow for indoor activities (e.g. swimming or squash) or 2) ‘winter activities’ (cross country skiing or ice fishing).

Some less obvious methods to encourage healthy behaviours in challenging weather conditions includes: 1) encouraging men to shovel driveways and side walks rather than using a snow blower 2) encourage fathers to play outside with their children, or 3) providing healthy and hearty soup recipes to combat the cold conditions.

Provide men with information on how to stay safe during the winter months. Provide men with information about the signs of frostbite and hypothermia and proper clothing layering techniques.

Blue-Collar Workers

Blue-collar workers may have a greater need for health promotion programs than white-collar employees (Bagwell & Bush, 2000). Unfortunately, many prevention initiatives have been least successful with blue-collar workers (Sorensen et al., 2014).

Structural issues within the industry needs to be considered when designing

health promotion interventions including consideration for long working hours, project-based work and living/working away from home (Du Plessis, Cronin, Corney, & Green, 2013).

o Health promotion interventions must include mental and social support systems to combat the increased isolation experienced by some workers as they commonly work away from home (Du Plessis et al., 2013).

Implementation of health promotion programs should involve long-term

engagement with working groups and employers. In an ideal situation, the involvement of the entire industry would allow workers to continue to receive the health promotion intervention regardless of job-related movement (Du Plessis et al., 2013).

Health promotion interventions conducted with blue-collar workers should consider integrating health promotion with occupational health and safety results.

o Sorensen (2012) found that an intervention addressing both health promotion and occupational health and safety resulted in a smoking quit rate among blue-collar workers that was comparable to that observed among white-collar workers. This rate was double the rate observed among health promotion only group. It was theorized that blue-collar workers may value occupational health and safety more so than personal health behaviours. Although this study did not exclusively examine blue-collar male workers, significantly more men then women were enrolled in the study.

Men’s Health: Communication Health promotion messages should target: Obvious Health Issues

Health materials promoting prevention or control of proximal health issues (such as body weight or digestive problems) are more accepted by men as reasons to change behaviours, as opposed to distant health issues (such as heart disease or cancer) (Egger, 2000; Segar et al., 2012).

Health Misperceptions Health promotion interventions should ensure that the communication of

health advice targets health misperceptions.

Some examples of common misperceptions identified by men include the notion that:

o Healthy eating is only important for those who are vulnerable (Melanson, 2008).

o Men should carry extra weight to ensure that they can protect their family (O’kane et al., 2008).

o Exercise is the only health behaviour needed by men to lose weight. Diet is not as important as exercise (Melanson, 2008).

Success • Recognition of successes, even small ones, such as meeting a goal could be a

good motivator for men to continue as it acts as a source of encouragement (George et al., 2012).

Health Concern Legitimacy Men often fear that their health concerns are not worthy of seeking medical

attention. Health communication messages associated with health promotion interventions should ensure that they legitimize men’s concerns and normalize their experience whenever possible (Mansfield, Addis, & Mahalik, 2003).

Examples of communication strategies include: o “A lot of men experience this concern, but don’t get help for it, which

makes the problem worse” (Mansfield et al., 2003).

Health promotion messages should be: Straightforward

Health communication with men during the entire duration of the health

intervention should be clear, concise, and practical (Coles et al., 2010; Gough & Conner, 2006; Taylor et al., 2013).

Examples of practical advice includes the provision of simple weekly meal plans (O’kane et al., 2008) that are inclusive of treat foods and beverages (alcoholic or otherwise).

Print/visual methods are a succinct way to get men to view health information but should not be relied on to encourage long lasting health behaviour.

An example of clear and concise nutrition messaging includes the UK inspired ‘Stop Light’ system for healthy eating. These labels colour-code nutritional information with red = high (enjoy once in a while), amber = medium (OK most of the time) and green = low (go for it). In other words, the more green on the label, the healthier the food choice.

Figure 1: An example of the nutrition ‘Stop Light’ system used in the United Kingdom Rational

• Try to stay away from emotional claims when designing health promotion interventions for men (Gough & Conner, 2006).

Desirable • A common barrier preventing men from taking part in a health promotion

intervention includes viewing intervention materials that promote ‘undesirable health behaviours’. Health interventions need to reframe health messages to be attractive to men. For example, men find health interventions that directly suggest they increase vegetable consumption, and/or decreased alcohol consumption, to be highly off-putting (Collins et al., 2011).

• Men also commonly report disinterest in dietary intervention programs because there is the belief that healthy foods, which they will be encouraged to eat are bland and monotonous and are not substantial (Melanson, 2008). Communication of dietary advice should visually present a variety of health food products in large ‘hearty’ quantities (Gough & Conner, 2006) with a highly savoury component.

• Another example of a highly desirable health behaviour change

advertisement reminds men what they are ‘missing out on’. • In the case of smoking cessation interventions, messages should highlight the

desirable outcomes of smoking cessation. Promotional material should identify all of the flavours a man is unable to taste because of his smoking habit or describe the improvements he may expect to see in his sex life if he quits smoking.

Figure 2: An example of an appropriate visual promoting physical health in an older and younger man. Tailored

Generally, men prefer tailored and specific health advice. Tailored advice appears to be highly effective in facilitating general health outcomes, including those for physical activity and dietary changes (George et al., 2012).

Ensure that the intervention is male specific yet also sensitive to other aspects of identity, such as ethnicity or gender (Robertson et al., 2013).

Ensure interventions include age specific information, particularly concerning visual images of age appropriate healthy bodies (Coles et al., 2010).

Scientific Men often report cynicism regarding health promotion messages from health

authorities (Gough & Conner, 2006; Melanson, 2008). Men also are untrusting of ‘scientific legitimacy’ (Egger, 2000). Ensure that health promotion efforts use ‘credible’ scientific sources deemed appropriate by the male community in question.

Health promotion messages should avoid:

Instructional or Directive Messages Men dislike being told to do i.e. ‘lose weight’ or ‘eat more healthfully’ as such,

creative approaches need to go beyond directive ‘advice only’ information sessions (Aoun & Johnson, 2002; McMahon et al., 2002).

Obvious Counselling In a review of male-specific physical activity programs it was found that a

high proportion of the programs included a counselling component (George et al., 2012). Counselling ranged from personal (GP led, trained counsellor led, group counselling, etc.) to impersonal (telephone, online forums, etc.) sessions. These sessions often encouraged men to set physical activity goals and identify/overcome barriers potentially contributing to increases in participants motivational readiness and increased self-efficacy (George et al., 2012).

There appears to be strong evidence to suggest that counselling is positively related to behaviour change. However, some authors do suggest caution when counselling men to change their behaviour. For example, it has been suggested that overt and obvious counselling sessions may be counteractive and may even deter male participation (Egger, 2000). Taking this into consideration, counselling sessions may benefit from being conducted in a relaxed and informal environment by a professional well versed in men’s health.

Repetition Health promotion programs should constantly try to ‘switch it up’ as men

have reported disinterest in repetitive information of limited nature (McMahon et al., 2002). Again, by allowing men to access health information on their own time, they can choose when and how to view repetitive health information.

Medical Language Wilson and colleagues coined the term ‘Health by Stealth’ which summarizes

an important consideration to take when focusing on men’s health (2013). This approach frames men’s health outside that of a medical lens. Causal down-to-earth communication is essential when dealing with mental health issues (Beckford-Ball, 2006).

Refer to ‘stress management’ techniques, rather than ‘mental well being’ and ‘personal health’ in health promotional materials (Gray et al., 2009; Segar et al., 2012).

Controversial Communication Considerations: Use of Masculinities Many health promotion interventions play on stereotypical masculinities to attract men. A good example of an intervention, which capitalized on these masculinities, is the Ministry of Transport check for men. This intervention used the analogy of a man’s body to a car. Testing blood pressure is likened to ‘checking oil levels’, skin cancer checks to ‘rust checks’, and potential problems with testicles are likened to ‘dirty spark plugs’, etc. The promoters believe this model appeals to men as it raises health issues in a language and framework that men can relate to, making the checks as non-medical and non-threatening as possible (www.menshealth.co.NewZealand). It is well established that multiple ‘masculinities’ are likely to exist among a diverse male population. Unfortunately, the dominant form of masculinity discussed in the literature can be seen as a distinctly western perspective (Galdas, Cheater, & Marshall, 2005). Playing with these masculinities can often perpetuate stereotypes and exclude men who do not align with these masculinities. If health promotion interventions choose to address constructions of masculinities, it is suggested that they be paired with cognitive interventions to modify men’s masculine-related cognitive schemas (Mahalik et al., 2007). For example: “if it is determined that a man constructs a healthy diet to mean “eating like a girl”, cognitive techniques such as a history review (e.g., his father’s unhealthy eating led to weight gain, back problems, and heart disease) and exploring the logic of behaviour change (e.g., ‘eating better will lead to doing better at work and having more energy for my family’) might be useful in modifying his personal constructs to promote a healthier diet (e.g., “I don’t want to have the health problems my father had, I want to be energetic at work and home, and eating a healthy diet can help with these concerns” (Mahalik et al., 2007).

In-Depth Health Communication Examples

Improving Men’s Smoking Cessation Efforts A comprehensive literature review of Men’s smoking cessation interventions concluded that there are only a few descriptive studies examining smoking cessation outcomes in male-only populations. The majority of smoking cessation interventions are non-sex and non-gender specific and included generic behaviour cessation, coping and relapse prevention strategies. Okoli (2011) suggests some of the following considerations to improve male-specific smoking cessation outcomes(Okoli, Torchalla, Oliffe, & Bottorff, 2011):

1. Determine Masculine Alignment: Assess and tailor interventions depending

on how closely a man aligns with gender stereotypes or masculine ideals. Assessment could be through the Bem Sex-Role Inventory (http://faculty.sunydutchess.edu/andrews/bem_sex.htm) or the Conformity to Masculine Norms Index (Mahalik et al., 2007).

2. Include Stress Reducing Techniques: Stress and smoking are highly correlated in men.

3. Focus on Expectant and Recent Fathers: Cautiously educate men on the

effects of smoking on foetal/new born health. There are only a few studies examining the use of infant health as a primary motivator for smoking cessation in fathers, and negative consequences have not been thoroughly examined.

4. Target Men With Families: Highlight how smoking cessation efforts would result in role modeling for children and family members. Try to encourage men to think about how smoking influences their relationships.

5. Role Reverse: For men who have partners who smoke, encourage them to

consider reducing their smoking habits, to act as a role model for their partner. Educate men on the effects smoking has on their partners and how partner support can encourage smoking cessation.

Improving Men’s Mental Health Improving men’s mental health is exceptionally challenging given that even the use of the word ‘mental health’ is often off-putting (Robertson et al., 2013). One creative way to improve men’s mental health includes provision of educational material designed to ‘help men, help their friends’. This strategy will educate men without making them admit to having mental health concerns. Men should be educated on indicators of male suicide so they can help a friend in need (These suggestions are from the Center for Suicide Prevention Resource Toolkit (Korhomen, n.d.)): Warning Signs

1. Depression (Often manifested through irritability, anger and hostility)

2. Risk-Taking Behaviours

3. Avoidance Behaviours Risk Factors

1. Alcohol and Drug Abuse

2. Social Isolation

3. Help Seeking Reluctance

Finally, men should be informed on the following protective factors for male suicide so they can offer support when necessary:

1. Social Support

2. Peer Programs

3. Stable Domestic Environments

4. Proper Diagnosis and Treatment Behaviour Change Resource Examples: General Behaviour Change: • http://manupcanada.ca/ • http://men.northernhealth.ca/ Depression Resources: • http://win.niddk.nih.gov/publications/PDFs/Getting_on_Track.pdf • http://www.mensdepressionhelpyourself.ubc.ca/ • http://issuu.com/mensdepression/docs/middle-age-men?e=7956660/ 262640 Smoking Cessation: • http://facet.ubc.ca/ General Health Information: • http://www.aboutmen.ca/

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