Adopting a social-determinants approach to frame professional responses to the health needs of any population needs little justification. There is now a vast amount of evidence that physical and mental health are deeply influenced by the social, economic and cultural contexts of people’s lives over their lifespan. Health and illness can no longer be reduced to biological functioning or malfunctioning, or, indeed, to personal behaviour.1-4 Typical examples are the links between diabetes or cardiovascular disease and social context.5-7 Such perspectives on population health have led to the growth of social epidemiology — the study, not only of the spread of disease in communities, but of the contextual circumstances of both disease and health: the social, cultural and political environments which either foster or threaten the health of populations and subpopulations in our societies.8,9 Here, I argue that adopting the well known “social determinants of health” perspective would assist in evidence-based development of men’s health policies and practice.
I believe that there are several factors impeding the development of an effective health policy for men. These include a relative lack of evidence, narrow or inappropriate definitions of men’s health, and underlying assumptions about the impact of men’s behaviour on their health.
In the past few decades, much work has been done to improve women’s health and to incorporate into professional practice a fuller understanding both of women’s life contexts and their perspectives of their own health. The Australian Longitudinal Study on Women’s Health, which commenced in 1995 with funding to study a cohort of 40 000 women over a 20-year period, is going some way towards supplying evidence to ensure good quality outcomes for women.10 Until such evidence-based research exists for men, there is a tendency to make do with opinion-based approaches.
At present, at both national and international levels, I believe there is an emphasis on only a limited number of physiological, psychological or social pathologies of males, including those related to the prostate and erectile dysfunction, as well as domestic violence and men’s alleged reluctance to “get in touch with their feelings” or “make use of services”. The agenda of the most recent World Congress on Men’s Health and Gender in 2005 gives an indication of Western society’s policy and practice in men’s health: clinical issues predominate, especially urological problems (specifically, to do with the prostate) and erectile dysfunction (http://www.wcmh.info/).
In an attempt to expand the vision of men’s health, some researchers have suggested that we build on gains made in women’s health practice by conceptualising men’s health practice in terms of gender and health.11-13 However, closer scrutiny suggests that this may be just another way of addressing women’s health concerns — specifically, gender inequalities and the impact of discrimination on women’s health — rather than men’s health concerns. The preface to a World Health Organization technical paper on gender and health says:11
. . . recently there has been a shift from an exclusive focus on women to a focus on gender, that is, the socially constructed differences and the power relations between women and men, as a determinant of health.
From this perspective, then, gender as a determinant of health could be seen as factoring a consideration of the unequal balance of power between men and women into our policy and practice.
This an important consideration, but does it encompass all the perspectives we might need in determining whether we are providing adequate services to meet the health needs of boys and men?
When writers try to broaden the biological perspective, often what is presented is a “gender-relations approach”13 — a consideration of men’s socially conditioned oppressive behaviour and specifically “hegemonic masculinity” (the dominance of men over women).14 The power imbalance between men and women is sometimes used to explain men’s health, including why men die at an earlier age than women.
An example of this concern with men’s negative behaviour, as an important factor to consider in men’s health, is found in the men’s health policy of the Doctors Reform Society of Australia (DRS).15
The DRS recognises that there are particular issues for men which affect their health. These issues can arise from the process of socialisation to compete and dominate in social and political spheres which can foster violence. As a result of this, many men experience a number of psychological difficulties, a reluctance to acknowledge and address their own health issues and diffidence in approaching health services.15
There is a whole body of literature which seeks to explain the poorer health of men compared with women as being a result of “masculinity”, something endogenous (within men), and their adoption of unhealthy male stereotypes,13,16 rather than taking into account exogenous (exterior) factors. This “pathologising perspective” can turn attention away from other social and political influences on health.
Recently, this “blaming men” perspective has been challenged in Australia, in the context of improving health services for men. Rather than trying to “re-educate” men who are reluctant to seek help and use health services, a preferred approach would be providing health services that better meet the needs of men.17
In forming effective men’s health policy, there is clearly room for a more evidence-based scientific approach and a wider, more appropriate view of men’s health. I propose that the “social determinants of health” approach provides such a framework for conceptualising men’s health policy and planning men’s health services.4
According to the WHO, the 10 main social determinants of health in our society today are social gradient, stress, early life, social exclusion, work, unemployment, social support, addiction, food, and transport.2
The health-threatening impact on patients of these social determinants of health should be acknowledged. Taking these factors into account would encourage doctors to see presenting patients in the context of their lives.
Social gradient, the first-listed social determinant of health, most clearly challenges any attempt to reduce health to biomedical malfunction or poor behaviour (or both), and thereby remove it from the social and political domains. Social gradient underpins the other social determinants of health. Men of lower socioeconomic status are highly represented in low-paid jobs, which often demand considerable physical output, such as labouring and mining. A consideration of social determinants makes the issue of disadvantage integral to our understanding of health. Wilkinson and Marmot, the editors of the WHO document,2 talk of disadvantage being absolute or relative and having many forms, including “being stuck in a dead-end job”, insecure employment, trying to bring up a family in difficult circumstances, and living in poor housing. Disadvantage can also be the result of discrimination and racism, and one cannot speak of the health of men and boys in Australia without acknowledging the parlous state of Indigenous men’s health. These data have been used to illustrate the enormous inequalities in health that can exist within the same country: Indigenous men in Australia have a life expectancy of 56.3 years, about 20 years less than that for non-Indigenous Australians.
Men’s health should be seen in the context of their economic and social opportunities, and the effects that these have on men’s health should be addressed directly.
Stress is the second of the social determinants of health.2 The accumulation of stress without sufficient time and support to manage it erodes human health.18 The life context of many of the men presenting to health services is often stressful: long commuting times, job insecurity, lack of control in the work environment as well as a lack of a sense of being valued, and pressure to provide adequately for the family are all important stressors in men’s lives. The periods of anxiety that these stressors produce can affect both physical and mental health.2 With the advent of the recent industrial reforms in Australia, I believe there is a need to investigate the potential negative impact of these changes on the health of men and the families they provide for.
Employment has already been mentioned as a crucial determinant of health, especially for men in lower socioeconomic circumstances. The jobs available to such men may involve high demands but lack of control, a combination shown to carry particular health risks.2 The workplace is often the context in which men find their self-esteem enhanced (or diminished). Retrenchment and retirement can have a serious impact on their health. Wilkinson, writing of inequalities and health, stresses the importance of a sense of being valued if we wish to maintain good levels of health.19
Social support and inclusion or exclusion can have a positive or deleterious effect on a person’s health.20,21 Psychoneuroimmunological research, exploring the impact of the social environment on mental and physical health, has demonstrated measurable effects on the body’s immune system.
Men generally have a less extensive social network than women and stronger networks should be encouraged, not least for men after retirement.22 The excellent publication The bloke’s book, published by Blacktown City Council in New South Wales, lists such services as there are for men in that area, including supportive groups for older men, like “OMNI — older men, new ideas”. This book is an excellent example of good practice, and a must for the consulting room of all general practitioners in that area.23
Suicide rates are very high in Australia, with men from 25 to 44 years most at risk.24 Like health and illness, its causes are complex but the social determinants of health framework offers us a perspective so we can move forward and begin to examine factors in society that may contribute to this situation, rather than just attributing it to masculinity.
In Australia, only the state of New South Wales has a men’s health policy.25,26 The Australian Medical Association has recently taken an interest in encouraging a national men’s health policy and has a position paper on the topic that adopts a life-cycle explanatory framework.27 Both help us move way beyond the “blaming” perspectives. An approach based on the social determinants of health will complement this beginning and hopefully influence the formulation of a long-awaited national men’s health policy.28
Abstract
The lack of an evidence base for formulating men’s health policies means existing programs and practices for men are influenced by prevailing cultural norms concerning men or habitual health service attitudes towards them.
Factors impeding the development of an effective health policy for men include a preoccupation with limited clinical perspectives (an emphasis on the prostate and erectile dysfunction) and a common assumption that all health problems in men are a result of “masculinity” and “men behaving badly”.
Viewing men’s health in terms of gender and health and the socially constructed differences between men and women is important, but does not provide all the perspectives required for meeting men’s health needs.
A “social determinants of health” approach to men’s health would help Australia and Australian medical practitioners move away from policies and practices that perpetuate negative views of men and ignore the complexity of their health problems. The result would be a more evidence-based approach to men’s health policy, and the likelihood of improved health outcomes.