Communicating with men

Alan White PhD RN

Emeritus Professor of Men’s Health

a.white@leedsbeckett.ac.uk

@profalanwhite

“Communication skills teaching states the obvious

and then complicates it.”

Baharudin N, et al., Validation of the Communication Skills Attitude Scale ( CSAS ) Questionnaire in a Cohort of Malaysian Medical Students. J Clin Heal Sci. 2017;2:46–53.

“Risk communication, negotiation, and achieving agreement [for shared decision making] require high-level communication skills and demand high language proficiency.” (p5)

Ng CJ, Lee PY, Lee YK, Chew BH, Engkasan JP, Irmi ZI, et al. An overview of patient involvement in healthcare decision-making: A situational analysis of the Malaysian context. BMC Health Serv Res. 2013;13:1–7.

http://www.geekosystem.com/robot-butt-simulator/

Changing climate for therapeutics

• Men are becoming an increasingly important client group• Andrology

• Testosterone replacement therapy

• Management of male urological conditions

• Reproductive dysfunction

• Infertility

• Cosmetic / aesthetic surgery

• Gender reassignment surgery

Shared decision making

• Patient centered care

• Collaborative partnership as a goal of the doctor patient relationship

• Patient involvement in decision making

Lee YK, Ng CJ. The state of shared decision making in Malaysia. Z Evid Fortbild Qual Gesundhwes. 2017;123–124:66–8.

Patient involvement in shared decision-making (SDM)

• “Implementation remains challenging”

• Low health literacy among the public

• Inadequate health information to inform the public

• Paternalistic medical practitioners making decisions on behalf of their patients

• Lack of studies on how Malaysian public want to be involved in SDM and their healthcare experiences in decision making

• SDM is complicated by the cultural and language diversity in Malaysia

Ng CJ, et al., An overview of patient involvement in healthcare decision-making: A situational analysis of the Malaysian context. BMC Health Serv Res. 2013;13:1–7.

Health professional-patient communication practices in East Asia

• Asymmetrical doctor-patient relationships the norm

• Doctor-centered communication

• Traditional gender roles – lack of empathy from male doctors

• “the patients felt embarrassed, had not been treated seriously, were not understood, and not been given the autonomy to choose their treatment plan”

Pun JKH, et al., Health professional-patient communication practices in East Asia: An integrative review of an emerging field of research and practice in Hong Kong, South Korea, Japan, Taiwan, and Mainland China. Patient Educ Couns. 2018;101:1193–206.

Patient centered communication in an outpatient clinic in Malaysia

The most satisfied with communication were:• The less educated

• more poorly

• Short wait times,

• Same gender

• Same ethnicity (Malay’s most happy)

Azizam NA, Shamsuddin K. Healthcare provider-patient communication: A satisfaction study in the outpatient clinic at hospital Kuala Lumpur. Malaysian J Med Sci. 2015;22:56–64.

Patient Centered Communication and Patient Enablement

Azmaniza N, et al., Association of Patient Centered Communication and Patient Enablement. Eur Proc Soc Behav Sci EpSBS. 2016;

What patients want from communication with their doctor

• Greeted me in a way that makes me feel comfortable

• Treated me with respect

• Showed interest in my ideas about my health

• Understood my main health concerns

• Paid attention to me (looked at me, listened carefully)

• Let me talk without interruptions

• Gave me as much information as I want

• Talked in terms I could understand

• Checked to be sure I understood everything

• Encouraged me to ask questions

• Involved me in decisions as much as I want

• Discussed next steps, including any follow-up plans

• Showed care and concern

• Spent the right amount of time with me

Makoul G, et al., Measuring patient views of physician communication skills: Development and testing of the Communication Assessment Tool. Patient Educ Couns. 2007;67:333–42.

Physician’s intention to initiate health check-up discussions with Malaysian men

• Interview study with 52 Malaysian Primary Care Doctors from public and private practice

• The findings showed that PCDs in Malaysia have difficulty initiating health check-ups with men in primary care settings especially in areas perceived to be sensitive, such as, sexual reproductive and psychosocial health.

Tong SF, et al., Physician’s intention to initiate health check-up discussions with men: a qualitative study. Fam Pract. 2011;28:307–16.

“One may think “Wah, this doctor is really good, I come for one issue but he looks into me as a whole” But most of the patients, 9 out of 10 will be thinking, I come for a knee problem, my leg problem and he’s looking at my third leg. You know what I mean? So it will sound as if, ‘is this doctor correct’? I may be a subject of discussion amongst a group of patients, laughing about what kind of mentality that doctor has. I got to be very very careful because this is the Asian set-up”

-50 year-old male private doctor

Tong et al., (2011)

Tong et al., (2011)

• HCP as the main decision maker

• HCP as a guide to patients’ decision making

• HCP as a facilitator to family involvement

• Patients prefer HCPs to make the decision

• Patients prefer to make the decision themselves

http://www.telegraph.co.uk/news/worldnews/asia/india/8340679/Indian-man-with-39-wives-94-children-and-33-grandchildren.html

“One implication for practice is the need to develop Malaysian patient decision aids which are adapted to suit the culture, address unique patient concerns, and present unbiased information on locally available options” (p8)

“There is a need to develop a culturally-sensitive model of shared decision making which frames the shared decision making process as part of the hierarchical doctor patient interaction in an Asian clinical context” (p9)

Lee YK, et al. To share or not to share: Malaysian healthcare professionals’ views on localized prostate cancer treatment decision making roles. PLoS One. 2015;10:1–11.

Communication About Active Surveillance for Prostate Cancer

• An array of masculine ideals, including stoicism, denying illness, and respecting expertise

• That men do not engage health and illness information easily but instead need time to process and respond (or not) to what has been said.

Mróz LW, et al., Masculinities and patient perspectives of communication about active surveillance for prostate cancer. Health Psychol. 2013;32:83–90.

“Therapeutic communication can assure men that they can sustain AS and delay treatment, while communications rendering threat are likely to increase men’s anxiety and reduce their interest in, and adherence to, AS” (p89)

[clinicians need to be reflexive and adapt to the needs of their patients]

Mroz et al., 2013

Medical mistrust in healthcare in southeast Asia

Choy HH, Ismail A. Indicators for medical mistrust in healthcare–A review and standpoint from southeast Asia. Malaysian J Med Sci. 2017;24:5–20.

From the patient perspective, the physician’s low mastery of interpersonal skill is perceived as incompetence

“What a reasonable patient wants to know, not what a reasonable doctor wants to say”

https://www.supremecourt.uk/decided-cases/docs/UKSC_2013_0136_Judgment.pdf

Nadine Montgomery (Appellant) v Lanarkshire Health Board (Respondent) (Scotland)

Male socialisation and male beliefs

The link between gender and health

• Gender norms, roles and relations can influence health outcomes and affect the attainment of mental, physical and social health and well-being

• Health care, in terms of its provision and its access by men and women is influenced by the expectations of health professionals, patients, and the public (candidacy)

http://www.who.int/news-room/fact-sheets/detail/gender 2015

Being a man is:

• Both stable and fluid (Butler, 1990)

• Performative – you have to constantly perform your gender in different settings• Everyday talk (Edley & Wetherell, 1997)

• Embodied actions (Kehily, 2001)

• Relational – it is influenced by, and influences, other people (Connell & Messerschmidt, 2005)

• Influenced by peers and society (Frosh et al., 2001)

• Linked to identity and is easily threatened (de Visser, 2006)

• Affected by intersectional factors (age, class, ethnicity, race, disability, sexuality) and social determinants (socio-economic factors, housing, education, employment) (White et al.,2011)

Journal of Men’s Health 2008

5(4):350-355

Perception of masculinity amongst young Malaysian men

• Qualitative study with 34 Malaysian university students aged 20-30 years

• Having a good body shape

• Being respected

• Having success with women

• Being a family man

• Having financial independence

Fazli Khalaf Z, Low WY, Ghorbani B, Merghati Khoei E. Perception of masculinity amongst young Malaysian men: a qualitative study of university students. BMC Public Health. 2013 ;13:1062.

Ismail SFS. In Pursuit of Mr. Right: Constructed Masculinities in Malay Teen Magazine. Procedia - Soc Behav Sci. 2014;155:477–83.

Representation of masculinity in a teen magazine

• The male’s voice is dominant in shaping the behaviours of the females

• Desirable men are those who are traditional, mature, physically appealing, financially successful and caring.

• With a ‘soft trait’ where the men are depicted as sulking – ‘a common trait understood by most Malay females’

The experience of symptoms of depression in men vs women

• Men reported higher rates of anger attacks/aggression, substance abuse, and risk taking compared with women. Analyses using the scale that included alternative, male-type symptoms of depression found that a higher proportion of men (26.3%) than women (21.9%)(P = 0.007) met criteria for depression.

• Analyses using the scale that included alternative and traditional depression symptoms found that men and women met criteria for depression in equal proportions: 30.6% of men and 33.3% of women (P = 0.57).

Martin LA, Neighbors HW, Griffith DM. The Experience of Symptoms of Depression in Men vs Women. JAMA Psychiatry 2013;70:1100.

Health literacy

‘The cognitive and social skills which determine the motivation and ability of an individual to gain access to, understand and use information in ways which promote and maintain good health’

www.who.int/healthpromotion/about/HPR%20Glossary%201998.pdf

Men’s Health Literacy

• Limited health education in schools

• Lack of male focused health literature

• Absence of health from men’s magazines

• Restricted chances of discussing health with friends

• Internet main source of health information (and women’s magazines).

Barriers and facilitators to screening

• Heterosexual self-presentation

• Avoidance of femininity

• Self-reliance

• Seeking help only when disease is severe, and

• Avoidance of illness

Teo CH, Ng CJ, Booth A, White A. Barriers and facilitators to health screening in men: A systematic review. Soc Sci Med. 2016;165:168–76.

Facilitators for screening

• Partner’s role

• Perceived risk

• Wanting to stay healthy to take care of family

• Non-invasive screening procedure and

• Physicians' gender

Teo CH, Ng CJ, Booth A, White A. Barriers and facilitators to health screening in men: A systematic review. Soc Sci Med. 2016;165:168–76.

Gender of the doctor and patient

• Female physicians, because of patients’ pre-existing stereotypes and expectations or actual differences in physicians’ behavior, or both, receive somewhat different communication from patients than male physicians. It is also likely, considering that social influence is usually mutual, that physicians, male and female alike, are in turn influenced by how their patients behave toward them.

• The broad interactive pattern suggests that physicians are more engaged with their female patients, both cognitively, providing more information, and affectively.

Hall JA, Roter DL. Do patients talk differently to male and female physicians? A meta-analytic review. Patient Educ Couns. 2002;48:217–24.

https://twitter.com/manoamanochile

Training needs for doctors and nurses

SEGUE Framework for communication

• Set the stage,

• Elicit information,

• Give information,

• Understand the patient’s perspective, and

• End the encounter

Makoul G. The SEGUE Framework for teaching and assessing communication skills. Patient Educ Couns 2001;45:23–34.

Brown RF, Bylund CL. Communication skills training: describing a new conceptual model. Acad Med. 2008;83:37–44.

The Memorial Sloan-Kettering Cancer Center Comskil Model for Communication Skills Training

Heron’s 6 categories of intervention

• Authoritative• Prescriptive

• Informative

• Confronting

• Facilitative• Cathartic

• Catalytic

• Supportive

Heron, J., 1986. Six category intervention analysis. 2nd revised edition. Human Potential Research Project, University of Surrey, Guildford

Transactional analysis

Eric Berne (1964) Games people play http://www.ericberne.com/

Noble LM, et al., Consensus statement on an updated core communication curriculum for UK undergraduate medical education. Patient Educ Couns. 2018;101:1712–9.

Communication curriculum wheel.

http://alex.simulaids.com/?ic_name=healthcare&ic_creative=banner&ic_id=hc_ALEX_0417

http://www.rcgp.org.uk/~/media/Files/GP-training-and-exams/Curriculum-2012/RCGP-Curriculum-3-07-Mens-Health.ashx

1 Primary care management • How you manage your contact with patients, dealing

competently with any and all problems that are presented to you

2 Person-centred care• Understanding and relating to the context of your patients

as individuals, and developing the ability to work in partnership with them.

3 Specific problem-solving skills• The context-specific aspects of general practice, dealing

with early and undifferentiated illness and the skills you need to tolerate uncertainty, and marginalise danger, without medicalising normality.

4 A comprehensive approach• How you as a general practitioner must be able to manage co-

morbidity, co-ordinating care of acute illness, chronic illness, health promotion and disease prevention in the general practice setting

5 Community orientation• The physical environment of your practice population, and the need to

understand the interrelationship between health and social care, and the tensions that may exist between individual wants and needs and the needs of the wider community.

6 A holistic approach• Your ability to understand and respect the values, culture, family

structure and beliefs of your patients, and understand the ways in which these will affect the experience and management of illness and health. care, and the tensions that may exist between individual wants and needs and the needs of the wider community

Communication skills and the patient-doctor relationship

• MENT1.1 Recognise that men are less likely than women to discuss their health problems with their GP for emotional, cultural and gender related reasons.

• MENT1.2 Communicate non-judgmentally to help reduce any embarrassment or emotional difficulties when attending for treatment.

• MENT1.3 Focus on communication strategies to help improve the ability of male patients to disclose their health concerns. This may include detecting whether a male patient prefers to see a male doctor.

• MENT1.4 Recognise the particular patient-doctor communication challenges when younger men attend for treatment.

RACGP Men’s Health Curriculum http://curriculum.racgp.org.au/media/12296/menshealth.pdf

Role of mobile devices in doctor-patient communication

• Appointment reminders, medication adherence, disease control, and test-result notification

• Clinic attendance improved by 11% on average and medication adherence by 22% on average. • Statistically small, but clinically important

Kashgary A, et al., The role of mobile devices in doctor-patient communication: A systematic review and meta-analysis. J Telemed Telecare. 2017;23:693–700.

eHealth communication

• Family Doctors view:• In principal in favour of making an appointment, sending appointment

reminders and screen to screen contact

• Barriers include communication problems, lack of financial compensation, lack of time and technical skill to implement in daily practice, privacy issues, lacked personal contact

• Patients view• Liked the idea, but many not aware of the service

Peeters JM, et al., Use and Uptake of eHealth in General Practice: A Cross-Sectional Survey and Focus Group Study Among Health Care Users and General Practitioners. JMIR Med Informatics. 2016;4:e11.

Can be a good way to reach out to young men, especially those who have difficulty with normal services Women greater users of health information on-lineNeed to get men to find the resource – marketing, social mediaThe design has to be attractive and fit for purposeNeed men to have the health literacy skills to use the health promoting materialStill issues in getting disadvantaged men to use the service

Young Malay males in rural areas – media exposure

• Television (97.22%), Astro is their number one choice, preferring movies, news and sports. 8pm to 11pm daily.

• Newspaper (94.44%) - Harian Metro, (sports segment)

• Radio (88.99%) Malay language Era channel, 8am to 11am

• Internet (69.44%). YouTube and Facebook are their main choices, and 8% of the respondents claimed that they use the Internet for more than four hours a day.

Ghani Y, Haidzir NA. Understanding Media Exposure among the Ethnic Malay in Malaysia for the Purpose of Communicating Road Safety Messages. Procedia - Soc Behav Sci. 2014;155:63–8.

Running a campaign

• Young men - More likely to enquire than seek solutions. More embarrassed talking about health/less likely to seek support

• New dads - Own health often loses out to other more immediate family pressures. Asking about health and seeking solutions

• Middle-aged men - Health more of a priority – starting to impact on day-to-day life. Enquiring and also more solution-focused than younger males

• Older men - More often dealing with health in an ongoing way. Seeking solutions/advice, for example concerning self-care. More likely to seek information alongside personal support

Robinson M, Robertson S. Health information needs of men. Health Educ J. 2013;73:150–8.

Highly commended in the 2017 BMA Patient

Information Awards.

"This resource uses a well-established format to

present the facts about alcohol. It uses pictures and

figures alongside clear explanations to outline its core

message. I liked the partnership with the specialist

charity Drinkaware and the commitment to user

involvement is evident. The tone of the resource is

well-judged: it acknowledges the appeal of drinking

alcohol but outlines its dangers without ‘nagging or

moralising’. The tips are practical and useful.”www.menshealthforum.org.uk

https://www.thecalmzone.net/

The importance of getting communication right

• Reaching out and targeting the man ‘on the street’

• Getting men engaged with screening and other health campaigns

• Persuading them to come to you when something is wrong (or even better, to prevent problems)

• To get the right diagnosis

• To ensure adherence to the regime

• To be prepared to take over and self care

Conclusion

• More than teaching techniques / skills - there are communication theories, but much comes down to personal awareness and the clinicians perception of the patient and their needs

• Men have issues with health literacy as many will not have been exposed to the ideas before

• It is not just about telling, it is about ensuring they understand

• Improvements in men's awareness of their health can improve self-care, family health and help prevent future problems