gender and health class 2nd feb 2016

Slide 1

Gender and Health2nd Feb 2016

Dr Matt MaycockMRC|CSO Social and Public Health Sciences Unit, University of Glasgow

[email protected]

MRC/CSO Social and Public Health Sciences Unit, University of Glasgow.

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Session overviewTheories of gender and healthTheories of masculinity Theories of masculinity applied to a health promotion intervention - Fit for LifePractical application of theories of masculinity to a health promotion resource


DEFINITIONSSex biological or genetic differences between men and women. Largely universal.Gender socially/culturally constructed differences between men and women. Variable.Sexism the personal and institutional differentiation of power and status between the sexes which limit opportunities for girls and women. Gender/sex role pattern of behaviour a particular society expects from individuals of either sex. Learned through socialisation.


Recognising the Social Construction of GenderGender refers to womens and mens roles and responsibilities that are socially determined. Gender is related to how we are perceived and expected to think and act as women and men because of the way society is organised, not because of our biological differences.Gender and Health, WHO (1998:5)


THE SECOND SEXIn truth, to go for a walk with ones eye open is enough to demonstrate that humanity is divided into two classes of individuals whose clothes, faces, bodies, smiles, gaits, interests and occupations are manifestly different.Perhaps these differences are superficial, perhaps they are destined to disappear.What is most certain is that they do most obviously exist.Simone De Beauvoir 1953


Social explanations of gender differencesFeminine traits are de-valued and under-valued by society.

Women as relative beings woman as other.

Men are the unmarked or norm


Explanations Cont.The process of socialisation places men in a different position to women: a masculine (hegemonic) archetype Traditional notions of masculinity position men as breadwinners, risk takers (in terms of hazardous work industrial accidents, contact with harmful substances, and other pursuits such as sport, sex, violence and health damaging behaviours smoking and excessive alcohol intake) See Doyal, L. (2002) in Bendelow, G. et al (eds) Gender, Health and Healing. London:Routledge.


Social or Biological?Mens health is not a medical issue, it is societal argues White (2001:3)

Equally, argues Doyal (2002), this is the case for women also both nationally and globally.


Difference/sameness debateWhy should any difference if it exists, or we believe it to be constructed as disadvantage, particularly for women?If we are the same the problem of women's relative disadvantage and lack of power remains unresolved.What needs to be addressed is not are we the same or different, but what structures exist which convert this into disadvantage?


Gender & health inequalitiesWomen get sicker but men die quicker(Miers, 2000)

Morbidity rates are higher for women Mortality rates are higher for men


Statistically SpeakingLife expectancy is higher for women than men: in 2001 life expectancy at birth for women was 80.4 years compared with 75.7 for men.

Life expectancy for men has been increasing faster than for women: an increase of 4.8 years for men, and 3.6 years for women between 1981 and 2001.


More statsIn 2001 obesity levels were similar for both sexes: nearly half of men were considered overweight, compared with a third of women

Underweight: men 4%, women 6%

Men twice as likely to exceed recommended daily benchmarks for alcohol consumption (3-4 units daily for men, 2-3 for women)

Young men more likely to binge drink

Student drinking levels/behaviours revealed no significant differences between the sexes!


CRITIQUETHE PICTURE IS MORE COMPLEX

Age ranges are significant.

Men have higher rates of serious illness than women

Women have higher consultancy rates than men particularly GP contact


Impact on HealthWomen may still (just) have some advantage over men in life expectancy, may seem to get sicker (higher rates of morbidity), may be protected to some extent from CHD due to oestrogen levels but their changing patterns of behaviour are giving cause for interest and concern: women are becoming more like men, and thus experiencing similar health problems.


To examine gender differences in consulting in primary care in the UK population using routinely collected general practice data. To explore whether gender differences remain when consultation for reproductive reasons or treatment for common underlying morbidities are accounted for.



The crude consultation rate was 32% lower in men than women. The magnitude of gender difference varied across the life course, and there was no excess female consulting in early and later life. The greatest gender gap in primary care consultations was seen among those aged between 16 and 60 years. Gender differences in consulting were higher in people from more deprived areas than among those from more affluent areas. Accounting for reproductive-related consultations diminished but did not eradicate the gender gap. However, consultation rates in men and women who had comparable underlying morbidities (as assessed by receipt of medication) were similar


Conclusion: Overall gender differences in consulting are most marked between the ages of 16 and 60 years; these differences are only partially accounted for by consultations for reproductive reasons.

On average, men consulted less than women between the ages of 16 and 60 years, but not at younger and older ages.

After controlling for medication for common underlying morbidities (depression and cardiovascular disease), gender differences in the use of primary healthcare services reduce substantially and are modest.


Why are women the main consumers of health care?Women assume main responsibility for contraceptionWomen encounter medical profession during pregnancy and childbirthWomen assume prime responsibility for well and sick childrenWomens anatomy is seen to be more complex than mens and appears to be more likely to succumb to health problems and illnessTraditionally women have been seen to be frail medicine has capitalised on womens perceived weaknesses ( from the vapours to pms)Women see themselves as ill more often than men


Hegemonic Masculinity, Raewyn Connell (2005)


Hegemonic Masculinity hegemonic masculinity - a form of masculinity that is dominant in society, establishes the cultural ideal for what it is to be a man, silences other masculinities, and combats alternative visions of masculinity. Hegemonic masculinity is a concept that draws upon the ideas of Gramsci. It refers to the dynamic cultural process which guarantees (or is taken to guarantee) the dominant position of men and the subordination of women. hegemonic masculinity - rejection of the idea that all men are the same


Hegemonic Masculinity Conta change from the concept of masculinity to the concept of masculinities allows meaningful distinction between different collective constructions of masculinity and identification of power inequalities among these constructions. Masculinities: Are actively constructed (not biologically determined)Are dynamic- change over timeHave negative impacts- be tough dont cry, can lead to disengagement, health problems, aggression, overwork and lack of emotional responsiveness.


Criticisms (V. Seidler)Leaves gender roles, and in particular patriarchy unchallengedLeaves out personal and emotional perspectives- emotional lives of men ignored. There is a danger of creating a fixed category of abusing men, rather than learning how pregnancy invokes unresolved emotional feelings in men Is often applied to research quite uncritically


Inclusive Masculinity, Eric Anderson (2009)


Eric Andersons theory of Inclusive Masculinity describes changes in the ways some men conceive of and enact their masculinity. Employing ethnographic methods and social-feminist thinking (14)

Inclusive masculinity, like hegemonic masculinity, frames gender (partially) in terms of power relations. However, it suggests a shift toward a more egalitarian conception of masculinity and a less rigidly vertical notion of hierarchy

Anderson claims that university-attending men are rapidly running from the hegemonic type of masculinity that scholars have been describing for the past 25 years (4). Inclusive Masculinity (2009)


Connells definition of hegemonic masculinityemerges as insufficient for describing the complexity of what occurs as cultural homohysteria diminishes. To rectify this shortfall, Anderson proposes inclusive masculinity theory, his own new social theory (7).

homohysteria describes the fear of being homosexualized,

diminishing homohysteria, which Anderson defines as combining a culture of homophobia, femphobia, and compulsory heterosexuality (7).

Inclusive Masculinity


Criticisms (de Boise, 2014) Misread hegemonic masculinity to be a type of person as opposed to a web or matrix of configuration

Assumes that hegemonic masculinity is inflexible and doesnt adapt to periods of low homohysteria

Assumes a singular dominant ideal, but Connell uses a multidimensional understanding of gender

Claims of a decline homophobia and homohysteria are questioned; can levels of prejudice be objectively established; are acts like same-sex kissing indicative of attitudes, is homophobia is really as insignificant as inclusive masculinity claims.


Prison masculinities and health in Scotland (post-doc)


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Can FFIT be adapted to attract men to positive lifestyle change in a prison? Football Fans in Training (FFIT) has helped overweight and obese men lose weight, improve diet, and increase physical activity (Hunt et al, The Lancet, 2014)


The Football Fans in Training (FFIT) programme is a group-based, gender-sensitised weight management, physical activity and healthy lifestyle programme which is delivered through Scottish Professional Football League football clubs. In this community setting, FFIT has attracted overweight and obese men and helped them to lose weight, improve their diet and increase physical activity. Following expressions of interest from other stakeholders, we wanted to see if a) FFIT could be translated to other settings, without compromising the integrity of the programme, and b) could engage different target groups within these novel settings. In this paper, were asking whether FFIT can be adapted to attract men to positive lifestyle change in a prison?

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Context

Prisons are largely all-male environments

p-FFIT delivered to men-only groups

Content

Info about science of weight-loss presented simply

Role of alcohol in weight management

FFIT logo branding

Delivery notes adapted to take account of prison contextStyle of delivery

PEIs have detailed knowledge of prison context

Participative and peer-supported learning

Encouraged male banter to facilitate discussion of sensitive topicsTesting feasibility of delivering an adapted version of FFIT, Fit for Life was delivered in two prison gyms over course of 10 weeks


These borrow heavily on the main FFIT adaptations.

Adapting FFIT for prisoners (p-FFIT) capitalises on the known appeal of football to this disadvantaged and excluded population,

Context

Content mention literacy issuesThis is quite different to the main FFIT study given that the p-FFIT participants supported quite a wide range of football clubs.

Delivery stress the impressive work of the PEIs

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Methods

Prison A

Delivered to 18 prisoners by prison Physical Education Instructors (PEIs)

Data collection Observations of all 15 sessionsInterviews with participants who completed programme (n=9)Interviews with participants who did not complete (n=3)Focus group with PEIs (n = 1)

Delivered to 21 prisoners by community coaches from a professional football club

Data collection Observations of all 12 sessionsInterviews with participants who completed programme (n=9)Interviews with PEIs and staff (n=3)

Prison B


18 men were recruited to p-FFIT, a pilot version of FFIT adapted for the prison setting, by prison physical exercise instructors. P-FFIT was delivered in the prison gym by PEIs over the course of 15 weeks (including baseline measures and a graduation week).We evaluated p-FFIT to assess the programmes potential to recruit prisoners to lose weight and become more active, improve health behaviours and deliver physical and mental health benefits.

Data collection included:Collection of a number of objective, self-report and biomarker measures (at baseline, post-programme, and at 6, 9, and 12 months)Observations of all 15 sessionsInterviews with participants who completed the programme Interviews with men who do not complete the programme A focus group with the PEIsThere is significant movement of prisoners within the prison system, which makesmeasuring participants challenging.

Ethical approval was gained from the College of Social Science, Glasgow University and NHS Greater Glasgow and Clyde West of Scotland Research Ethics Board.

Due to time restrictions, we wont be reporting the results of the quantitative data or PEI focus group in this presentation.31

Health in prison contextsContext-specific challenges to prisoners mental and physical well-beingThe prevalence of overweight and obesity among male prisoners in the UK is unacceptably high (Herbert et al, 2012)Many prisoners do not take given opportunities to eat healthily and exercise regularly and are less likely to achieve recommended minimum PA guidelines (Herbert et al, 2012)


Men living within prisons experience many context-specific challenges to their mental and physical well-being, which are often compounded by lifetime disadvantage that makes the adoption of healthier practices particularly difficult.

The prevalence of overweight/obesity among male prisoners in the UK is unacceptably high (even though previous substance misuse can lower BMI for some prisoners).

Despite being given opportunities to eat healthily and take part in PA, many prisoners choose not to do so, and they are less likely to achieve recommended minimum PA guidelines than non-incarcerated men.

National recommendations suggest using prison settings to promote PA, healthy eating and wellbeing.

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Prison masculinitiesIn (largely male) prisons environments, there are performances of masculinity that are structured in hierarchical ways in reference to both orthodox/hegemonic' and 'inclusive' masculinitiesOrthodox/ hegemonic masculinity" inclusive form of masculinity based on social equality for gay men, respect for women, and racial parity and one in which... men bond over emotional intimacy" (Anderson, 2008, 604)"masculine performance labeled as orthodox attempts to approximate the hegemonic form of masculinity, largely by devaluing women and gay men." (Anderson, 2005, 338) (Bourdieu, 1998) (Connell, 1995) Inclusive masculinity


*Towards the end of the programme fidelity declined noticeably (I have removed this as a bullet on slide but you could just say it instead)

I have also taken out coaches from the 4th bullet as we havent mentioned anything about external coaches before this.

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Prison is an ultramasculine world where nobody talks about masculinity. (Sabo et al 2001, 3)

a hegemonically defined hypermasculine and heteronormative environment with an abundance of alpha males, sexism, and violence. (Jenness and Fenstermaker, 2013, 13)

prison facilities are a particular kind of institutional setting, one that actively resists the diversity of masculine practices and identities. (Curtis, 2014, 121)places of great humour and playfulness, of friendship and camaraderie, of educational enlightenment, of successful therapeutic intervention. (Jewkes, 2013, 14).

in their mutual support and encouragement, it was also possible to discern sublimated forms of intimacy. Certainly, the vivid and joyful ways in which prisoners engaged in collective exercise, and the sheer amount of physical horseplay among younger prisoners, pointed to submerged emotional sentiments. (Crewe et al, 2013, 11)Orthodox/ hegemonic prison masculinitiesInclusive Prison masculinities




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Orthodox masculinities in the context of the Fit for Life programmeI can understand aboot guys being apprehensive an that, ken I think when, especially wi everybody else in the hall, ken, an youre goin and theyre goin aye, goin tae fat club, an a this carry on, ken whit I mean? So I could imagine people being apprehensive aboot it, eh. (Prison A - P2)I was hammering everybody fae the word go. I'm the sort o' person, see once I get up there I don't like anybody beating me, you know? Determined an' that, you know? (Prison B - P11)Ken what I mean? Ill parken, Ill... Ill takeIll partake in anythin eh? And as I say when, ken when I got there I was like that, right, fair enough. I mean youre only putting your view forward. I mean were in a hostile situation here, eh? And people dinnae want tae speak forward in case the boy, hes a fucking idiot, excuse my French. (Prison A - P11)


Read through inclusion and exclusion criteria.

Elevated BP = systolic160mmHg and/or diastolic100mmHg (Ive taken off slide)

This give a sense of the sorts of prisoners we were trying to attract to the programme, although participants did not have to meet all three inclusion criteria.

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Inclusive masculinity within the context of the Fit for Life programmeI think it was a part ofit was being a part of a group. On the outside Im a lone person. Im no part of any group. So see learning in a group, and interacting wi people, and speaking to people in the group that kept me motivated as well. (Prison A - P11)it was important for me tae, for me tae do my thing and for me tae tell people that they was doing good at their thing, and encouraging them and pushing them and stuff like that. (Prison A - P3)Well youre having a laugh wi people and its like yous are losing a wee bit o weight an youre kinda like, its just youre no coming an youre no like if youre coming tae the gym, its like youre no the fattest person in the gym. So youre here and yous are all kinda fat, yous are all here for the same reason. (Prison B - P3)





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Embodied masculinity - The gym, muscularity and weightYouve gottae get big, aye, youve got a group, your group o guys, thats what theyre intae, their bodybuilding an theyre strength things like that. (Prison A - P8)You want everybody tae go intae a prison an' they all want tae dae the weights, they a want tae get big an' strong. That's what they all want tae dae. (Prison B P11)I actually get people that go like that, oh how long did it take you to get that [large] size? And this is the first time Ive ever trained in my life! Know what I mean? And Ive just worked hard at it, and worked hard, and I explain that to guys. I just, know what I mean? Guys were all wanting to get like me, and like as big as me kinda thing. (Prison B-P1)





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Changes to bodies and appearanceI think people in general do take a lot more care of themselves nowadays and it happens more in prison. So you're not automatically in inverted commas 'a poof' if you use face cream and keep yourself clean and... yeah. (Prison A - P4)When I lost weight I kind o'... I like tae keep my strength up an I felt as if when I was losing my weight that I was losing my strength as well, that my strength was falling away. (Prison B - P11)Some people don't care aboot themselves 'cause they're in the jail, they've hit rock bottom. (Prison A - P7)





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Orthodox to Inclusive masculinity - Group dynamicsI think it was a part ofit was being a part of a group. On the outside Im a lone person. Im no part of any group. So see learning in a group, and interacting wi people, and speaking to people in the group that kept me motivated as well. I mean I enjoyed the group. Its one of the biggest things Ill take away fae it has been involved in the group. (Prison A - P11)...you dinnae want tae be yourself, cause you just single yoursel oot, ken whit I mean? As I say you can put yourself the gither as a team an you take it on as a team, ken whit I mean? An you support each other through it. (Prison A - P2)Yeah, there was two lads in particular that were like really taking the piss an I didnt enjoy that bit. No-one had control over them. Dyou know what I mean? But other than that everything went really, really well. (Prison B - P5)





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Results - ActiGraph data Total Moderate to Vigorous Physical Activity (MVPA) (HMP Perth and Kilmarnock, Phase three)


For more on FFIT, please see (cf. Hunt et al (2014), A gender-sensitised weight loss and healthy living programme for overweight and obese men delivered by Scottish Premier League football clubs (FFIT): a pragmatic randomised controlled trial. Lancet, April)

We will present findings on the acceptability of the programme to prisoners and staff, and on the potential for such approaches to improve the health of a vulnerable group of men.

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Results - ActiGraph data: Sedentary time (HMP Perth and Kilmarnock, Phase three)




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Results - ActiGraph data: Step counts (HMP Perth and Kilmarnock, Phase three)




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Results - Self reported - Portion sizes (HMP Perth and Kilmarnock, Phase three (14 participants))




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Results - Self reported Self-Esteem (HMP Perth and Kilmarnock, Phase three (14 participants))




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Fit for Life - ConclusionsMasculinity has shaped the planning and the experience of engagement in the Fit for Life programme.

An approach to men's health similar to that taken by FFIT has the potential to be successfully adapted for secure settings.

A gender and context sensitised health promotion intervention has the potential to facilitate engagement with a cohort of hard to reach and disadvantaged men in a secure setting.

Performances of both hegemonic/orthodox and inclusive forms of masculinity were evident amongst men who took part in the Fit for Life programme.

Programmes such as Fit for Life have the potential to enhance more inclusive forms of masculinity.

There are many, often contradictory implications for masculinities in taking part in programmes to enhance health and wellbeing.




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Practical exerciseIn groups think about a health promotion resource in the form of a leaflet that will communicate men or boys about health.

Consider how the theory/s of gender/ masculinity will shape the resource Consider how you will design the leaflet in a gendered wayConsider about what subjects/issues you will cover


Masculinity and health the Haynes Man Manuals


with the majority of participants having maintained or put on weight between enrolment and session five47

Masculinity and health the Haynes Man Manuals


with the majority of participants having maintained or put on weight between enrolment and session five48

Questions/ Comments


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gender and health class 2nd feb 2016

Health & Medicine