Improving men’s health in Ireland: building capacity among front-line health workers to engage men: good practice brief

IMPROVING MEN’S HEALTH IN IRELAND: Building capacity among front-line health workers to engage men GOOD PRACTICE BRIEF Summary Towards gender sensitive service provision for men Noncommunicable diseases are the leading cause of death and disability among men in Ireland and are underpinned by men’s poorer lifestyle behaviours and underutilization of health services. Ireland’s National Men’s Health Policy (2008–2013) identified building capacity among front-line service providers as an essential but neglected component of developing effective strategies for engaging men in self-care. In order to tackle this deficit in gender sensitive service provision for men, ENGAGE, Ireland’s National Men’s Health Training programme, was developed. The comprehensive one- day training is based on an experiential learning and reflective practice approach, combined with mechanisms for feedback and peer support during and beyond training. ENGAGE has improved service providers’ knowledge, skills and capacity to engage and work with men and to deliver more gender- competent health services and programmes; boosted community outreach programmes to priority groups of men; and influenced the development of gender sensitive service provision. In Ireland, as in most European countries, men’s lower life expectancy is underpinned by higher death rates from noncommunicable diseases, the leading cause of death and disability among men. Substantive differences in health outcomes are also evident between different categories of men. For example, men from lower socioeconomic groups experience significantly higher mortality rates than men from higher socioeconomic groups, and this gap between rich and poorer men has been increasing. Other subpopulations, such as male travellers, gay, bisexual and transgender men, and farmers experience health outcomes that are significantly worse than the general population of Irish men. It has also been well documented that men who experience social disadvantage, marginalization and social exclusion experience a disproportionate burden of ill health. In addition to broader social determinants of health, engaging with the health system and self-management can lead to better noncommunicable Key Messages • Noncommunicable diseases remain the leading cause of death and disability among men in Ireland and are underpinned by men’s poorer lifestyle behaviours and underutilization of health services. • A comprehensive National Men’s Health Policy was launched to integrate gender-specifi c approaches into health policies, programmes and services, and meaningfully translate them into practice. • Building capacity among front-line service providers was a key policy direction to address the defi cit in gender sensitive service provision for men. • Promoting positive gender roles and supportive environments work better in engaging men in self-care than reinforcing negative gender stereotypes. • Investment in individual learning has led to organizational and culture change through evidence-informed tools to engage with men, a network of supportive peers, continual support and a platform to spread this learning within organizations. • Success factors have included (i) a clear mandate matched with funding and resources; (ii) comprehensive evaluation ensuring evidence of impact; (iii) adaptation and refi nement in response to emerging needs; and (iv) an explicit focus on peer support and mentoring. Noel Richardson1, Isabel Yordi Aguirre2 1 Lecturer, Department of Science and Health, Institute of Technology, Carlow, Ireland 2 Gender Adviser, WHO Regional Office for Europe 1 Building capacity among front-line health workers to engage men In response to these issues, Ireland launched its National Men’s Health Policy in 2009 (Department of Health and Children, 2009), which is underpinned by an explicit focus on gender-specific strategies and strengths-based approaches to community engagement and capacity-building measures to reach men. Much of the work has revolved around excellent partnerships between the statutory, community/voluntary and academic sectors, resulting in the creation of a strong evidence base. This has greatly strengthened the capacity of health policy to reach so-called hard-to-reach groups of men through community outreach approaches. This strategy has been unique in the WHO European Region and has influenced the development of the WHO regional strategy on the health and well-being of men, which is due for publication in autumn 2018. Historically, most gender-focused health policy initiatives and gender- mainstreaming approaches to health have been synonymous with women’s health. Despite a substantial body of evidence supporting the need for gender-specific approaches to reaching men with health programmes and services, often, these are not integrated in policies or fail to find any meaningful translation in practice. Capacity building at individual, partnership and community levels is a critical component of both the process and outcome of positive engagement with men. Specifically, the need to build capacity among front-line service providers has been identified as an essential but neglected component of developing effective strategies for reaching men. ENGAGE, Ireland’s National Men’s Health Training programme, was developed to address this deficit in gender sensitive service provision for men. This comprehensive one-day training aims to increase participants’ understanding of best practice in engaging men with health programmes and services and was developed against a backdrop of: (i) poorer health outcomes and health behaviours among men; (ii) men’s underutilization of certain health programmes and services; (iii) challenges from service providers’ perspectives in engaging men; and (iv) increasing evidence in support of more gender-sensitive or so-called men-friendly approaches. In the review of the National Men’s Health Policy, ENGAGE emerged as a key pillar of policy implementation and was described as a “major and unique training resource with the capacity to reach significant numbers of front-line service providers” (Baker., 2015). A training of trainers [ToT] cascade model of delivery was adopted as the most effective and cost-efficient way of maximizing the diffusion of ENGAGE training to front-line service providers both in terms of number and geographical spread. To date, four ToT programmes have been delivered, and the programme has been the focus of both outcome (Osborne et al., 2016) and process (Lefkowich et al., 2016) evaluations. Candidates selected for the ToT programme (trainers) were required to have prior facilitation experience, represented a national geographical spread and included a mix of professions (primary care, health promotion, and community and voluntary disease outcomes. Evidence suggests that underpinning men’s higher mortality rates from chronic diseases are poorer lifestyle behaviours, including higher levels of alcohol consumption and binge drinking, higher rates of smoking and unhealthier diets. The rate of increase in male obesity is a particular cause of concern in Ireland. Men’s underutilization or delayed use of health services in the course of an illness has been identified as a principal challenge and priority for improving men’s health. With the exception of the 70+ age category, men in Ireland were found to have had fewer general practitioner consultations than women in the previous 12 months and were twice as likely to have had no general practitioner consultation in the previous 12 months. When men do consult a doctor, they are less likely to adhere to prescribed treatment. Service providers often see men as “hard work” or “hard to reach” and are unclear about the type of services to which men might best respond. This has led to calls for service provision to be informed by a better understanding of men’s beliefs, values and attitudes to ill health and their approach to using health services. 2 ENGAGE is now firmly established as a core and evidence-based component of the Health Service Executive’s suite of training courses in Ireland, and is recognized as having a key role in improving gender equality by transforming structures and policies that engage men in self-care. ENGAGE trainers remain active and delivered training to approximately 400 participants in 2017. Outcome evaluation findings suggest that ENGAGE succeeded in improving service providers’ capacity to engage and work with men and to deliver more gender-competent health services and programmes. Significant improvements were reported in terms of service providers’ (n=295) knowledge, skill and capacity to identify priorities for men’s health that could meet the needs of their organization, and to engage men in their services, and these were sustained up to five months post training. The vast majority of service providers (93.4%) reported that ENGAGE had impacted their work practice up to five months post training, with 39.3% having formally committed to men’s health in their workplans and/or conducting men’s health initiatives within their services (Osborne et al., 2016). More broadly, the success of ENGAGE can be measured by the exponential rise in community outreach programmes to priority groups of men. For example, ENGAGE was delivered to key stakeholders involved in (i) “Men on the Move” (a community-based physical activity programme targeting overweight men), which has resulted in significant and sustained weight reduction, improved fitness and reduced cardiovascular disease risk among men (Carroll et al., 2018); (ii) “Farmers Have Hearts” (an outreach cardiovascular disease prevention programme), which found a high prevalence of multiple risk factors for cardiovascular disease among farmers (van Doorn et al., 2017) and has prompted a comprehensive follow-up intervention; and (iii) “Sheds for Life” (a health promotion programme delivered in Men’s Sheds), which builds on the inherent health- promoting nature of Sheds (Lefkowich & Richardson, 2016). These examples demonstrate that ENGAGE has been effective in influencing the development of gender sensitive service provision and has significant implications for practice elsewhere. Impact sectors). Each trainer was required to commit to deliver three, one-day ENGAGE training days to front-line service providers. Trainers were provided with a comprehensive ENGAGE training resource pack and promotional material, and all service providers who attended ENGAGE training received certification. Post training, technical assistance was offered to trainers in the form of co- facilitation with either an experienced ENGAGE facilitator or later a mentor who was an experienced trainer. There were ongoing communication and support from the ENGAGE coordinator, including annual trainer refresher meetings and sharing of reflective practice. Trainers received periodic updates of the online resource repository. Table 1. Impact of ENGAGE EN G A G E 400 participants trained in 2017 Impacted the work practice of 93.4% of service providers Improved service providers’ knowledge, skills and capacity to identify priorities for men’s health and to engage men in their services Boosted an exponential rise in community outreach programmes to priority groups of men in Ireland 3 Baker, P. (2015). Review of National Men’s Health Policy and Action Plan 2008-13: Final report for the Health Service Executive. Retrieved from: http://www.mhfi.org/policyreview2015.pdf Carroll P, Harrison M, Richardson N, Robertson S, Keohane A, Kelly L et al. (2018). Evaluation of a Gender-Sensitive Physical Activity Programme for Inactive Men in Ireland: Protocol Paper for a Pragmatic Controlled Trial. Journal of Physical Activity Research 3:20–7. Department of Health and Children (2008). National Men’s Health Policy 2008–2013. Dublin: Department of Health and Children (Ireland). Available at: https://health.gov.ie/blog/publications/national-mens-health- policy-2008-2013/ Lefkowich M, Richardson N (2016). Men’s health in alternative spaces: exploring men’s sheds in Ireland. Health Promot Int. doi:10.1093/heapro/daw091. Lefkowich M, Richardson N, Brennen L, Lambe B, Carroll P (2018). A process evaluation of a Training of Trainers (TOT) model of men’s health training. Health Promot Int. 33:60–70. doi:10.1093/heapro/daw056. Osborne A, Carroll P, Richardson N, Doheny M, Brennan L, Lambe B (2016). From training to practice: the impact of ENGAGE, Ireland’s national men’s health training programme. Health Promot Int. doi:10.1093/heapro/daw100. van Doorn D, Richardson N, Osborne A (2017). Farmers Have Hearts: The Prevalence of Risk Factors for Cardiovascular Disease Among a Subgroup of Irish Livestock Farmers. J Agromedicine. 22:264–74. doi: 10.1080/1059924X.2017.1318728. References Contact us © World Health Organization 2018 This brief is part of our work programme on strengthening the health system response to noncommunicable diseases. For other good practice briefs, visit our website at http://www.euro.who.int/en/health-topics/Health-systems/health- systems-response-to-ncds. • Noncommunicable diseases remain the leading cause of death and disability among men in Ireland and are underpinned by men’s poorer lifestyle behaviours and underutilization of health services. Much of this is avoidable through more eff ective policies. • A comprehensive approach has been essential. The National Men’s Health Policy was launched to integrate gender-specifi c approaches to health programmes and services and meaningfully translate them into practice. • Building capacity among front-line service providers through ENGAGE, Ireland’s National Men’s Health Training programme, was a key activity within this comprehensive health strategy to address the defi cit in gender sensitive service provision for men. • Positive gender roles and supportive environments work better than reinforcing negative gender stereotypes. ENGAGE has evolved from simply informing gender sensitive service provision for men to a more gender transformative role in contributing to gender equality, by challenging harmful gender roles and norms and developing supportive environments to engage men in self- care. • Investment in individual learning has led to organizational and culture change. Giving front- line service providers evidence-informed tools to engage with men, a network of supportive peers, continual support and a platform to spread this learning within organizations can have a transformative impact on the norms of organizational practice related to men’s health. • Success factors instrumental in sustaining and maintaining momentum were: (i) continuing to have a men’s health policy mandate, which has been signifi cant in securing the requisite funding and resources; (ii) conducting a comprehensive evaluation, thus ensuring that the programme is evidence based; (iii) adapting and refi ning the programme in response to emerging needs; and (iv) having an explicit focus on peer support and mentoring. Lessons learned All rights reserved. Document number: WHO/EURO:2018-3394-43153-60424 4