Enhancing Migrant Men’s Health:
A Systems Approach to Increasing
Access to Health Services
Alfonso Carlon
Center for Health Training
512-474-2166
Acarlon@jba-cht.com
20th Annual Midwest Stream
Farmworker Forum, November 18-20th, 1
Austin, Texas
Goal
Improve health outcomes for men…for
women.. children families communities
Overview
Gender and Socialization
Personal and Professional Attitudes
Comprehensive Planning Model
Implementation Challenges
Culture of Men
Health Effects of Men’s
Socialization
5
The very attitudes and behaviors that increase men’s
health risks…
…are considered normal and expected.
6
Compared to girls, boys are:
• Seen as stronger and less fragile
• Discouraged from seeking help
• Ridiculed and punished if they do seek help
• Encouraged to take risks
7
Six Major Health Risk Factors for
Men:
Fail to adopt health promoting behavior
Engage in risky behaviors
Adopt traditional stereotypes of masculinity
Conceal vulnerability
Perceive themselves to be invulnerable
Lack health knowledge
8
1. Men Fail to Adopt Health
Promoting Behaviors
Do not have regular, Eat less fiber and Are more often
routine health exams more fatty, salty food overweight
9
Use less
sunscreen
Sleep less and not as Do not do
well
testicular self-
exams
10
2. Men Engage in Risky
Behaviors
Driving
• Drive dangerously
• Speed
• Drive under the influence
of alcohol or drugs
• Wear seatbelts less often
11
Male Risk-Taking Behavior
In 2002, men accounted for:
• 89% of all pedal-cyclist fatalities.
• 69% of all traffic fatalities.
• 68% of all pedestrian fatalities.
In 2002, of drivers involved in fatal accidents:
• 25% of male drivers were intoxicated.
• 12% of female drivers were intoxicated.
Risky Lifestyles
• Engage in risky sports,
work, travel
• Carry weapons
• Have physical fights
13
3. Men Hold Traditional Beliefs
“Guys always want it.”
“Don’t be a sissy.”
Men who hold
traditional beliefs:
“All the guys are • have more sexual
doing it!.” partners
• don’t wear condoms
“Be a man!”
14
4. Men Conceal Vulnerability
Suicide Rates
Rate per 100,000
40
30
Males
20
Females
10
0
5 to 14 15 to 25 to 45 to 65+
24 44 64
Age
15
• Men delay getting help.
• 3 of 4 college men did
not get help for STDs from 2-
6 months after developing
symptoms.
16
5. Men Perceive Themselves to
be Invulnerable
Most men:
• believe their health is
“excellent” or “very good”
• report better health than
women, even though they
die younger and have higher
death rates.
• don’t think they are at risk
for illness or injury.
17
Men of all ages are at high risk for STDs and HIV, yet
they report little concern.
18
• Half the men with testicular
cancer are not diagnosed until
the advanced stage when it is
fatal or disabling.
Lance Armstrong
19
6. Men Lack Health Knowledge
• less knowledgeable about
health and diseases
• less experience with the
health care system
• reluctant to ask questions
20
How Gender Stereotypes Influence
Service Provision
• Men’s health risks are invisible
• Men receive inadequate information
• Men are given conflicting messages about
masculinity vs. health promotion in the
following areas:
– Violence
– Drinking
– Sexual activity
21
The Gender Health Gap
Life Expectancy, 2004
• Men dying 5.2 years sooner than women
• 1920: average age of men at death was 53/women
54.6
• 2004: 75.2 men/80.4 women
• More males than female are born 105-100
• By age 35, women outnumber men
• At age 100 women outnumber men 8-1
a. Men’s Health Risks are Invisible
• depression is not diagnosed in
many men.
• Mental health clinicians failed
to diagnose nearly two-thirds of
depressed men.
23
b. In medical encounters,
men receive:
• less information
• briefer explanations
24
c. Men are Given Conflicting
Messages
Drinking Sexual Activity
25
Key Points to Remember
• Men rarely seek make the most
medical help of every encounter
• Men deny or ask many open-
minimize symptoms ended questions
• Men are reluctant give lots of info
to ask questions
26
Male Sexuality and
Sexual Health
27
MSM or MSMSW?
28
30 Million Men Have Sexual
Problems
• Low sex desire
• Aversion to sex
• Pelvic steal syndrome
• Premature ejaculation
• Inhibited ejaculation
• Retrograde ejaculation
29
40% of men have impotence
problems by age 40
Contributing factors:
• Age
• Smoking
• Diabetes
• High blood pressure
• Prescription drugs
• Depression
30
Myth: “The Bigger, the Better”
31
Risky Sexual Behavior
Males tend to:
• Begin sexual activity early
• Between first intercourse and first marriage, typically
have around 10 years of being single and being
sexually active
• Have more sexual partners
• Have unsafe sexual practices
• Have sex under the influence of alcohol or drugs.
32
Trends In Men’s Health
2007 Leading Causes of Death
(MMWR, Nov 27th, 2009, Vol 58 No 56.1303 Quickstats)
Causes of Death Men Women
Heart 237.7 154
Cancer 217.5 151.3
Accidents 55.2 25.8
CLRD 48 36
Stroke 42.5 41.3
Diabetes 26.4 19.5
Flu/Pneumonia 19.3 14.2
Suicide 18.4 4.7
Kidney 17.8 12.5
Liver 12.7 5.9
Suicide 18.4 4.7
Homicide 9.6 2.5
The Racial Health Gap
Hispanic American males are:
• 16% less likely to receive treatment for prostate
cancer.
• More likely to die from accidents (3rd leading cause
of death, as opposed to 5th leading cause of death
for white/black males).
• 3.1 times more likely to die from homicide.
The Racial Health Gap
African American males are:
2 times more likely to die from prostate
cancer.
2.2 times more likely to die from accidental
death.
9.8 times more likely to die from homicide.
Few Men Make Sexual and Reproductive
Annual visits per 100 men Health Visits
25
20
15
10
5
0
15-19 20-24 25-29 30-34 35-39 40-44 45-54
Rank – Reasons Men Seek
Reproductive Health Care
• Urinary tract, penis, scrotum, or testicles
• Family planning
• Prostate problems
• STI
Rank – Reasons Men Seek
Reproductive Health Care
• STI 52%
• Urinary tract, penis, 20%
scrotum, or testicles
• Prostate problems 18%
• Family planning 8%
Reactions? Implications?
• Why do you think men are more likely than women
to have poor health outcomes?
• What messages does society give to men about
taking risks and seeking health care?
History of Increasing Male Involvement in
Reproductive Health in Texas
• 1990 Building Infrastructure
• 1998-2005 Community Based Projects
• 2003-2008 Clinic Based Projects
• 2010 – Texas Paradigm Shift
DSHS state GOAL to increase males served by 25% by
2013
Title X Family Planning Annual Report
(FPAR) 2008-2009
• 20% Increase in males seen in DSHS funded FP
clinics
• Male Gonorrhea testing up 36%
• Male Chlamydia testing up 23%
– Male Syphilis testing up 48%
• Male HIV testing increased 52%
Benefits of Providing Services to Men
• Addressing men’s own health needs
• Benefits of joint RH decision making
• Effective treatment of STIs requires men’s
involvement
• The need for men’s involvement in pregnancy and
parenting
• Opportunities to improve the lives of both men and
women
Defining Needed Services
• Information
• Skills
• Counseling
• Preventive health care
• Clinical diagnosis and treatment
(Sources: American Medical Association, EngenderHealth, Urban Institute and
others)
Challenges
• Nursing certification
• Clinic flow
• Providing male-friendly tests
• Outreach and in-reach
• Building community partnerships
Obstacles to Addressing Men’s Needs
• No consensus on standards for male sexual and
reproductive health care
• Provider reluctance to offer services for men
– Services focused on women and medical needs
– Lack of information about men’s needs
– Inadequate medical training
– Gaps in financing
(,
2005 Region II Male Involvement Advisory
Committee, DHHS, Office of Family Planning
Health Beliefs
Yours
Theirs
Cultural Dynamics Influencing the
Clinical Encounter
• Medical Model • Traditional Model
– Health absence of – Health harmony –
disease body, mind, spirit
– Prevention to avoid – Prevention not
disease recognized concept
– Seeks specialty – Seeks herbalist,
practitioners priest, shamans
– Decisions – individual – Decisions – family
– Disease bio-medical – Disease – god, curse
Cultural Dynamics Influencing the
Clinical Encounter
• Independence • Interdependence
– Individualism – Collectivism
– Individual interests – Individual interests
priority subordinate
– Reliance – nuclear – Reliance – nuclear &
family extended family
Cultural Dynamics Influencing the
Clinical Encounter
• Communication • Communication
– Informal – Formal
– Direct – Indirect
– Direct eye contact – Indirect eye contact
– Distance - – Closeness – builds
professionalism rapport
Cultural norms and values
• In which of these areas do you notice difference
between your own norms, the norms of your
organization, and the norms of your clients?
• In which of these areas do these differences impact
your work? How?
• What can you do to acknowledge/address the impact
of these differences?
MCN Immunization Initiative:
Summary of Community Based In-Depth Focus Groups
with Adult Indigenous Migrant Men (CHEC, Jan 2007)
• Theme 1: Vaccines-primarily for children, possibly women
• Theme 2: Limited knowledge of how vaccines work-occasional
confusion with injectable medications-very occasionally with
illegal drugs
• Theme 3: Efficacy/importance of immunizations; strong
suspicion for US and Mexican Healthcare systems
• Theme 4: Language & Literacy are barriers for delivery of
health information
• Theme 5: Men tend to use healthcare services and know less
about healthcare in the US than women
Assessment Activity
• Choose partner, interview each other (5 mins each). Listen for
“key” words
• Think about a man in your life-one you know well, consider
his psychological and emotional profile. Knowing this man,
what can you share about his beliefs, attitudes, actions
regarding health and healthcare?
• What would a service provider need to do to enroll your guy?
Summary
• Staff bring own attitudes, biases and perceptions to
their work
• Some feel conflicts between duties as professionals
and their own personal morals, beliefs and values
• Staff can help clients live healthy lives without
imposing their own value judgments or gender
biases
• Staff can increase comfort level by learning more
about men's’ issues and need for health services
Comprehensive Service Delivery
Model
Male Health Program
Training of
Staff
Clinic
Outreach
Environment
Making Services Accessible To Men
• Program
• Facility
• Staff
• Clients
• Community Partners
Questions To Address Program Barriers
• Are men involved in planning?
• Do materials include information on
services for males?
• Is there a male-specific outreach program?
Questions To Address Program Barriers
• Is your program involved with youth
organizations?
• Have you done outreach to male-serving
agencies and programs?
• Have you accessed multiple funding
streams?
Questions To Address Facility Barriers
• Is the environment welcoming to men?
• How easy is it make an appointment?
• Is there at least one male on staff?
• Are all forms gender neutral or separate for
males and females?
• Are there materials that address men’s health
issues?
Look at Clinic/Physical Environment
The challenge: how to make a family planning clinic that
traditionally served only females appealing to both young men and women?
•Signage and Promotion—includes men and gives
clinic a “male identity”
•Staff marketing—receptionists & clinicians inform
everyone of services for males
•Visual Messaging - Display images that portray
men positively and that guys like (sports, etc)
•Literature - Stock male magazines; brochures &
information men find interesting
•Change the channel to something other than the
WE Network or Lifetime
•Hide the stirrups!
Restructuring the clinic environment
• Clinic hours convenient for males
• Policies, procedures, protocols
• Forms - medical history write-up
• Staffing - hiring key positions, board members,
• Job descriptions include service to men
• Effective referrals
Environment
Happy confident staff!
Promotores: They Act as
Health Advocates for the
Community
• Training promotores de
salud
• Ethics & Confidentiality
• Presenting and
Communication
• Culture & Diversity
• STD’s /HIV Education
Staff Training .
Questions to Address all Staff
• Orientation training on men’s issues?
• Benefits, importance and priority to provide
services to men?
• Informed about services, eligibility, billing,
protocols to provide services to men?
Questions to Address Staff’s Comfort &
Confidence
• Provide education and counseling to men and/or
couples?
• Clinical services to men?
Is Clinical/Counseling Staff Prepared to
address…
• Gender role stereotyping & sexism
• Power & control in sexual relationships
• Risk taking behaviors
• Violence in intimate relationships
Is Clinical/Counseling Staff Prepared to
address…
• Men’s perception of there own sexuality
• Health-seeking behaviors & preferences
• Changes through life cycle
• Dynamics in couple’s negotiation and decision
making
In-Reach
What is In-Reach?
• Conducting “Outreach” in the Clinic
through the patients, staff, and vendors
• Being “Marketers” of the male services
you offer
Women are the gatekeepers to
Men’s Health
Number One Referral: Women
• Promote Male Services to Women
– Promote male services in bathroom stalls,
counseling rooms, make flyer specifically for women:
“Attention Ladies: medical services now available for
men”
“Get your man tested…his health is your health”
Outreach
Outreach VS. Media
• Free Television Shows
• Free Radio
• Free Internet Magazines/
Website
– “MySpace”
– “Facebook”
20th Annual Midwest Stream
Farmworker Health Forum, November
17-20, 2010, Austin, Texas
Club Outreach
• Night Clubs
Bars
“Condom Man”
& “Condom Girl”
20th Annual Midwest Stream
Farmworker Health Forum, November
17-20, 2010, Austin, Texas
Where do we go from here?
• What is our commitment to serving men?
• What services do we offer men now?
• What new services can we offer?
• Who are the leaders in the community?
Where do we go from here?
• Who can we collaborate with?
• What are the benefits?
• How do we get approval for new services?
• Do we have the right staff?
• Where can we get funding?
Questions y mas Questions!
Male Friendly Organizational Assessment
(handout)
Alfonso Carlon, Acarlon@jba-cht.com
Mil gracias!