Shifting paradigms: a social-determinants approach to solving problems in men’s health policy and practice

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 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

There is, of course, enormous interplay between these factors. Low socioeconomic status means lack of money, which obviously contributes to stress, and in turn is often linked, as cause or effect, to such things as limited job opportunities, expensive transport to access a suitable job, social exclusion, and alcohol misuse. This complexity no doubt adds to a doctor’s task when dealing with a male patient who has a clinical condition such as diabetes. Medication plus some exhortation about lifestyle is hardly an adequate or “scientific” response to a man in such circumstances.

• 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.

Although non-Indigenous men do not share the same experience of disadvantage or ill health as Indigenous men, socioeconomic status and the social gradient are factors impinging on the lives of all populations, including all men. Bad behaviour and hegemonic masculinity cannot explain these differentials in health status.

• 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.

• Health service providers should be aware of the particular stresses that men encounter and the physiological effects of stress. The professional response should be to work towards providing health-supporting work and social environments.

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

• Acknowledgement (whether tacit or explicit) of the employment status of men’s daily lives and, if employed, the physical and or psychological demands of the job, may go a long way towards helping a male patient develop a partnership with his doctor.

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

• Doctors should encourage men to maintain social support networks, or develop new ones, and have access to information about what support groups are available for men. Divisions of General Practice could encourage initiatives like The bloke’s book in their area.

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.

• Doctors need to support appropriate services for men at risk of suicide, and initiatives that list what help is available would be an invaluable aid.

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