Breaking Down Barriers

With International Men’s Day taking place on 19 November, we explore the health challenges men face. 

 For instance global estimates of diabetes-related lower extremity amputations between 2010 and 2020 reveal more than twofold amputations per 100,000 men compared to women. It’s therefore important that diabetic men have regular diabetic foot checks to ensure early detection of issues that may lead to amputation. 

 Jayne Robbie is a senior podiatrist specialising in diabetes at University Hospitals Birmingham NHS Trust, and senior lecturer and course lead at Birmingham City University. ‘Through my work in a secondary care high risk foot clinic in a large city teaching hospital, I see a lot of men with these long-term conditions,’ she explains.   ‘They are middle aged (55-69 years) white men, often single (divorced, estranged or bereaved) or living with elderly relatives. They frequently present their symptoms with uncontrolled diabetes, neuropathic ulceration, restriction to blood supply, non-healing wounds and sepsis.’

 Missed opportunities for preventative care / A wake-up call 

 Alarmingly, a quarter of men delay seeking help for health concerns, according to a study by Bupa Health Clinics. Among the reasons for this are ignoring the issue in the hope it would go away itself (58%), fear of bad news (36%) and having no time (14%) (Bupa, 2021).   The Movember Institute of Men’s Health also found that nearly two thirds of men wait more than a week with symptoms before visiting the doctor – and 31% will wait more than a month. In The Real Face of Men’s Health 2024 UK report, 62% men revealed they want to leave their healthcare practitioner due to a lack of personal connection (Movember, 2024). 

 ‘Men frequently present late or delay help seeking activities,’ Jayne explains. ‘They are often disengaged with their health – don’t take medication as prescribed and go to work when told to rest. They may have manual or low-skilled jobs, which makes it difficult to be concordant with treatment or attend appointments.’ 

 There are also underlying psychological factors to consider, says Catherine Bewsey, a counselling psychologist working at St Georges Hospital’s diabetic foot clinic in London. ‘They might be depressed and not motivated to seek help or find it stigmatising to go to their GP or podiatrist,’ she explains. ‘Topics like mental health can feel awkward or shameful, so conversations might be avoided. There’s also fear of vulnerability – if men have health concerns, it might be seen as a sign of weakness.’

 In contrast, she adds: ‘Some men on the wards may have a bravado attitude or fatalistic approach – what will be will be. Some actually justify having an amputation, while others say they didn’t take much notice of what they were told and couldn’t see the damage diabetes was causing. Getting bad news about risk of amputation is often a wake-up call.’ 

Protecting patient mental health 

 Catherine, who counsels patients through their diagnosis and treatment, says: ‘What can help protect a patient's mental health is written information about what to expect when they have an amputation. A lot of worries are around not knowing what's going to happen.  ‘If a podiatry team has access to a psychologist and/or they have attended psychologically informed training, it can help them to prepare patients. For example, I work as part of the pre-amputation pathway so if a patient needs an amputation they'll usually be offered the opportunity to see me. I try to help them process the loss.’   Their feelings may include denial, anger and guilt, Catherine says, adding that they can often bargain and ask to try another treatment before making an informed decision – whether to go ahead or refuse the amputation.  ‘Validating fears around amputation and reassuring patients that they will be supported throughout this journey is important,’ she adds. ‘Sometimes amputation is a big life event – it's like losing a part of yourself so it can challenge a person's concept of themselves.’ 

 It’s also crucial to involve family and carers and let them know what to expect, she adds. 

 A postcode lottery

 Practical barriers are also apparent. Paul Galdas, professor of men's health at the University of York, says: ‘The evidence shows that many men often delay seeking help not because they are unaware but because the system doesn’t work well for them. 

‘Issues such as long waits, inconvenient appointment times and crucially services that feel unwelcoming and unfamiliar often make it harder for a lot of men to get help. Social expectations around being tough, stoical or not wasting the doctor’s time add another layer. 

‘There's a lot of evidence that masculinities shape men's health-related behaviour, but the bigger story is how services respond, or fail to respond, to men’s needs based on this and other well-known barriers.’ 

The Real Face of Men’s Health 2024 UK report, which Paul contributed to, also revealed disparities between the most and least deprived areas in the UK. It found that men living in areas of Birmingham, on average, are more than 3.5 times as likely to die prematurely than those in Beckenham. 

‘The gaps between men in the most and least deprived areas are definitely one of the biggest challenges in relation to men's health in the UK – men's life expectancy in different areas can differ by nearly a decade,’ he says. 

‘It can feel like a postcode lottery, but it's really about structural inequality. Men in poorer areas face higher health risks and greater barriers to care, yet have fewer resources to protect their health.’ 

Changing the narrative / Awareness into action 

 So, what are the solutions to fixing the relationship between men and accessing healthcare? 

First and foremost, Paul says: ‘It’s too simple to say men are unaware of health problems and we're working hard to change this narrative that it is somehow the fault of men individually. Most men know when something is wrong, but they often minimise symptoms or put off acting because of work, family pressures, or fear of wasting time in the system. 

‘Awareness is often there, the problem is turning that awareness into action. We don't just need more campaigns, we need real changes in services to better meet men where they are at and support them to take appropriate action to look after their health and wellbeing.’ 

Crucially, he explains: ‘We need to stop blaming men for not turning up and start reshaping services so they fit better with men’s lives. That means flexible access, clearer communication and framing health as something that enables men to do the things they value for example, work, time with family and sport.’ 

This year, the UK government revealed it is in the process of developing England’s first ever men’s health strategy as part of its 10-year reform plan for the NHS. It aims to bring a renewed focus on preventing adverse health outcomes and reducing health inequalities for men (see Resources). 

Paul is working closely with the Department of Health and Social Care as co-chair of the national Men’s Health Academic Network, advising on the Men’s Health Strategy for England and ensuring it is evidence-led and focused on outcomes that improve men’s lives. 

‘The Men’s Health Strategy is an opportunity to move from isolated projects to a joined-up approach across the NHS,’ he explains.  

Making a difference 

 The role of podiatrists in encouraging men to take action in terms of their health is important. ‘Podiatrists are well positioned to make a difference because foot problems are visible and affect daily life,’ Paul says.   ‘General approaches that have been shown to work include keeping the conversation practical – for example link foot health to staying active, working without pain, or keeping up with family. Use straightforward language, focus on solutions and connect foot issues with wider health concerns like diabetes or circulation that disproportionately affect men.’ 

 Jayne agrees: ‘Podiatrists are uniquely placed as they have regular appointments with patients over extended timeframes to have difficult conversations or discuss sensitive matters.’   However, she says: ‘They need support or training about how to frame these conversations for the best effect. Also, building links with interprofessional colleagues or multi-disciplinary teams can ensure there is a cohesive message and reinforcement of any education. Patients need an advocate too and podiatrists can often help them to navigate their ulcer journey.’ 

 Non-compliance is admittedly a challenge. ‘People can be quite resistant to change,’ Jayne says. ‘Understanding motivation and possible reasons is sometimes a way to gain some influence. My experience is that if you are confident, non-judgmental and consistent in your message, you can sometimes get results. 

 ‘Engaging men sometimes requires novel approaches so talking about what they are comfortable with – music tastes or the latest sports scores are sometimes ways in.’   When it comes to mental health, podiatrists can – and should – signpost patients to GPs or mental health professionals. However, they can practise active listening and suggest places to find help. If in doubt, check the HCPC guidance (see Resources).  Catherine is hosting a webinar on 6 November to help podiatrists become more psychologically informed. For more information and to sign up, go to:  

Men’s health and wellbeing charity The Blue Ribbon Foundation was born after co-founder and chairman Jonathan Prince recognised that men don’t do health as well as women. ‘We try and encourage men to be more health and wellbeing aware,’ he says.   ‘Wellbeing is not just the absence of ill health, it’s about how you’re feeling and that’s vital because it can affect a person’s mental health.’ 

 Jonathan urges men to maintain friendship groups and keep healthy and fit. ‘The key is that you leave someone with a message. It’s up to them to act on it,’ he says.  

Jonathan adds. The Blue Ribbon Foundation is part of a national network of charities supporting men’s health. ‘Collaboration can have more of an effect than an individual voice’. 

 Source: Katie Smith