1

MEN’S HEALTH SOCIAL MARKETING

SEGMENTATION AND INSIGHT PROJECT

Findings from the scoping study

February 2014

2

CONTENTS Executive Summary ................................................................................................................................. 3

1. Introduction .................................................................................................................................... 5

2. Methods .......................................................................................................................................... 6

2.1 Overall project aims ................................................................................................................ 6

2.2 Approach ................................................................................................................................. 6

2.3 Enhancing rigour ..................................................................................................................... 7

2.4 Recruitment and sampling – Frontline staff and local resident interviews ............................ 7

2.5 Data collection ........................................................................................................................ 9

2.6 Data analysis ......................................................................................................................... 10

3. Results ........................................................................................................................................... 11

Figure 1. Final codes ...................................................................................................................... 15

4. Key themes - Men ......................................................................................................................... 16

5. Key themes – Health professionals .............................................................................................. 33

6. Segmentation ................................................................................................................................ 43

7. Push and Pull factors ..................................................................................................................... 48

8. Conclusions & recommendations ................................................................................................. 50

Glossary ................................................................................................................................................ 56

Appendix .............................................................................................................................................. 57

3

EXECUTIVE SUMMARY

Introduction: Haringey is an exceptionally diverse and fast-changing borough. Although Haringey is

the 4th most deprived borough in London there are large inequalities between the west and the east

of the borough. This results in large variations in life expectancy (9 year gap in life expectancy for

men). Encouraging early diagnosis and management (including lifestyle change) of major killer

diseases e.g. cardiovascular disease and cancer along with targeting men aged over 40 years will

have the greatest impact on reducing the gap in life expectancy.

Aims: Haringey Council aims to reduce the life expectancy gap within the Borough. In order to do

this, Haringey Council commissioned The NSMC to conduct a formative study to gain insight into the

barriers preventing men from accessing services, and ways in which these barriers can be overcome.

Therefore, the aims of this study were to:

Understand why men do not access primary care services that address the prevention and

detection of cardiovascular disease and cancer;

Gain insight into what would make preventative and early detection services more attractive

to men in the East of Haringey to close the inequality gap; and

Develop segments so that mapping work can be done against how specific services are

currently provided.

Methods: Before the primary study was conducted a review of the secondary data was conducted1.

The findings from the secondary review were used to inform the topic guide development. The

principles of grounded theory2 were used throughout the primary research to guide sampling, data

gathering, and data analysis. Focus groups, paired and individual interviews were conducted with a

total of 32 local residents living in the east of the borough. Recruitment continued until data

saturation was achieved. At the start of each interview, loosely structured, open-ended questions

were used. In order to pursue an idea or response, more detailed questions were subsequently

asked or prompts made. An additional 25 interviews were conducted with health professionals.

Findings: The findings were categorised into six key themes: 1) Awareness and knowledge of

preventative services; 2) Perception of services; 3) Lifestyle; 4) Masculinity; 5) Influencing factors;

and 6) Possible service improvements. Based on the key findings, three segments were developed.

These were based on the type of preventive service preferred by the participants. The segments

were not static, with participants changing segment based on life-stresses, awareness, and past

experiences. Despite the different segments, there were some basics of ‘good service’ which

overlapped each of the segments, including: clear understanding of what services are offered and

expertise, approachable and informed staff (ensuring the correct information is provided at all times,

1 The full findings from this review were detailed in a separate document.

2 The phrase ‘grounded theory’ refers to theory that is developed inductively from a body of data, rather than from the

preconceptions of the researchers. The approach is iterative, in that ongoing sampling, data gathering and data analysis inform each other over time, as tentative theoretical explanations are generated during data analysis, and subsequently tested through further data gathering.

4

including receptionists), immediate testing and follow-up, physical tests (e.g. blood tests, physical

examinations), choice of locations, after work and weekend opening times, and a non-judgemental

environment.

Conclusions: A number of actionable insights emerged from the data:

1. Across all the segments, there was a lack of knowledge as to what preventative services were

actually provided by primary care, or to which GPs could refer patients on to. There was also

confusion around the term ‘preventative’ - what it actually meant and who the services were

designed for.

2. It appeared that ‘fear’ and possibly ‘denial’ were influential. ‘Fear’ was not solely related to the

outcomes - what tests might find - but also the process. These fears were heightened if

individuals were attending GP services as GPs were seen as ‘generalists’ who would just refer to

a hospital specialist.

3. Men preferred to have physical examinations and tests (such as blood tests), as opposed to

simply ‘talking’ about their problems to the health professional.

4. Familial patterns, behaviours and cultural norms were seen to be important within families but

in terms of ethnicity no evidence was found that some ethnic groups are more or less likely to

access preventative services.

Recommendations: Based on the findings and on the push and pull analysis, a number of

recommendations are made. These predominantly focus on the ‘pull’ factors, as ‘pull’ strategies

need to be implemented before ‘push’ strategies begin.

Conducting basic service improvements to existing clinics, including training for receptionists and

health professionals to ensure they have the correct and up-to-date information to give to

patients; consistency in offering rapid results; open evenings and weekends; choice of locations

(for example, pharmacists and local community centres; physical tests being part of any check;

and booking follow-up appointments).

Addressing knowledge gaps to ensure that the basic service improvements are made. These

include: (i) mapping existing services against the segments and the basics of good service

elements (currently being undertaken for a limited number of services by The NSMC and

Haringey); (ii) establishing how each of the GP surgeries within the chosen wards currently refer

people; (iii) review past referral systems to understand how they worked in the past and what (if

any) is the current feedback link to the GPs; and (iv) review the effectiveness (including cost-

effectiveness) of the different modules of preventative service delivery.

The segments should be used to ensure that local services meet the needs of each of the

segments. The referral pathways should also be reviewed to ensure that each segment is able to

navigate the pathways successfully. Customer journey mapping could be used to identify any

barriers for each of the segments in the pathways and help streamline them. Existing services

should conduct work to determine which segment/s currently access their services.

From past experience at The NSMC, social marketing projects which have not engaged fully with

the stakeholders have been unsuccessful. Therefore, further stakeholder engagement work and

joint discussions with local GPs around possible solutions is highly recommended. The

stakeholder work should also involve co-production with the target audience so that any

interventions developed are customer-orientated.

5

1. INTRODUCTION

Haringey is an exceptionally diverse and fast-changing borough; nearly half of the residents

come from black and minority ethnic (BME) communities. Haringey is also the 4th most

deprived borough in London and the 13th most deprived in the country. However, the

borough stretches from the prosperous neighbourhood of Highgate in the west to

Tottenham in the east, one of the most deprived areas in the country. This results in large

variations in life expectancy between the west and east of the borough (9 year gap in life

expectancy for men).

Encouraging early diagnosis and management (including lifestyle change) of major killer

diseases e.g. cardiovascular disease and cancer along with targeting men aged over 40 years

will have the greatest impact on reducing the gap in life expectancy.

Many local projects aiming to tackle lifestyle factors to improve men’s health already exist.

For example, the community NHS Health Checks Programme and the men-only weight

management programme to name just a few. However, in general, local health

improvement interventions tend to be targeted based on deprivation rather than in-depth

audience insight. Most initiatives are offered in the east of the borough, where deprivation

and health inequalities are greatest.

Due to Haringey having limited insight into the male population at risk of cardiovascular

disease and cancer, plus their health seeking behaviour, The NSMC was commissioned to

use social marketing thinking and approaches to help address the current disproportionate

outcomes for males within the Haringey catchment area.

This report details the findings from the formative study (part of the scoping3 phase in the

social marketing process). Mapping of some of the existing services against the segments

and the basics of good service elements (currently being undertaken by The NSMC with

support from Haringey) and will be detailed in a separate document when the work is

completed.

3 Scoping is a term used in social marketing. It is the time at the start of a project when stakeholder engagement work is

conducted and formative research with the target audience/s is also completed.

6

2. METHODS

2.1 Overall project aims

Haringey Council aims to reduce the life expectancy gap within the Borough. In order to do

this, and to provide the correct services and ensure uptake of such services, Haringey

Council wish to gain insight into the barriers preventing men from accessing services, and

ways in which these barriers can be overcome.

Therefore, this project aims to:

1. Establish why men do not access primary care services that address the prevention and

detection of cardiovascular disease and cancer;

2. Gain insight into what would make preventative and early detection services more

attractive to men in the East of Haringey to close the inequality gap; and

3. Develop segments so that mapping work can reflect on how specific services are

currently provided.

The NSMC is delivering a number of training courses to increase local social marketing

knowledge and skills including provision of evaluation guidance on two local projects

targeting men. However this report focuses solely on the findings from the scoping study.

2.2 Approach

Principles of Grounded Theory were used throughout this study to guide sampling, data

gathering, and data analysis4. The phrase ‘grounded theory’ refers to theory that is

developed inductively from a body of data, rather than from the preconceptions of the

researchers. Therefore, findings from such studies should have high validity. The approach is

iterative, in that ongoing sampling, data gathering and data analysis inform each other over

time, as tentative theoretical explanations are generated during data analysis, and

subsequently tested through further data gathering. In this way, a circular process ensues in

which theory is gradually, but robustly, developed.

2.3 Enhancing rigour

Although qualitative studies can provide a rich data set, they are often criticised for:- i)

lacking scientific rigour, ii) being subject to researcher bias, iii) lacking reproducibility, and iv)

lacking generalisability. Therefore, the following strategies were employed:

4 Glaser, B., Strauss, A. (1967). The discovery of grounded theory. Chicago: Aldine.

7

Triangulation

This study used investigator triangulation. In this study, two researchers, from different

disciplines, designed the study and analysed the data.

Bracketing

Before beginning this study, all those involved wrote down prior beliefs and hypotheses

about the subject matter. Also, both of the researchers kept journal notes throughout the

data collection and analysis, recording their personal feelings and biases, which might have

influenced interpretation of the results.

Purposive sampling

Purposive sampling of different types of participants was used to increase the

generalisability of the study’s findings. At the start of the project, the team worked with

local community groups to establish links in the East of the Borough, then snowball

sampling techniques were utilised. Throughout the interviews, the researcher attempted to

adopt a passive role, asking few questions, but encouraging a continued narrative through

active listening. Care was taken to imply no special medical knowledge beyond that of the

level of an informed patient.

2.4 Recruitment and sampling

Following initial discussions with Haringey Public Health Department and analysis of the

demographics in Haringey it was decided that the sample would be selected from the wards

of White Hart Lane, Tottenham Hale and Northumberland Park. This was on the basis that

all three wards had among the lowest life expectancy rates for men, the highest premature

mortality rates from cancer and/or from circulatory disease and in both White Hart Lane

and Tottenham Hale, the lowest life expectancy at birth. Residents of all three wards came

from a broad range of ethnic groups and in Tottenham Hale, for example over 13% of the

residents were born in post 2001 EU countries in comparison to 9.8% for the rest of

Haringey.

In addition it was decided that the sample should include:

Men who did access preventative health services

Men who did not access preventative health services

The broadest range of ethnicities possible

Men between the ages of 40-74

Paired interviews consisting of the men plus their partner (or carer, for example

daughter, etc.)

8

Initially, it was considered that the sample should be divided and interviews arranged on the

basis of whether the men did or did not access preventative health services. However, it was

clear from the early interviews that the divisions were not that clear-cut. For example, as is

noted in the report’s findings, such behaviour might change, dependent on life events or

simply age. On a different paradigm, it was also clear that, particularly within the group

discussions, respondents often became animated through being challenged by other men in

the group whose behaviour was or had been different to their own. Importantly, this

approach also enabled the sample to include those who had not previously accessed

preventative health care, had been seriously ill and now accessed the services.

Setting

The men were recruited through:

The Irish Advice Centre

The Selby Centre

The Health Trainers

Haringey Homes

Haringey Federation of Residents Associations

Somali Mosque

Snowball recruitment

Of note is the exceptional support that both the Irish Advice Centre and The Selby Centre

gave to this project. Both these organisations provided access to a number of individuals

who through normal recruiting mechanisms, such as a professional social research

recruitment agency, would not have been contacted. Such individuals tended to be those

whose lives appeared ‘chaotic’ and who had turned to organisations such as advice centres

for help with housing, debt, substance misuse and so on.

Only a minority of the sample remembered being invited to their GP Practice for a Health

Check, a number of those interviewed were also under medical care for a range of

conditions such as diabetes, high blood pressure, high cholesterol and so on.

All of the local residents interviewed were given a £20 for their time. However, health

professionals were not reimbursed for their time.

For the health professionals, Haringey Public Health Department initially sent letters to all

five GP practices within the wards of White Hart Lane, Tottenham Hale and Northumberland

Park inviting them to take part in the study. The letters were then followed up by telephone

in order to make appointments. All five practices then requested a further email of

clarification about the project. Three practices agreed to take part in the project and two

refused. The three practices that did take part ranged from a small single-handed practice to

one that had a patient population of over 12,000.

9

Similarly the Health Trainers were sent an initial letter of invitation which was again

followed up by the researcher in order to make an appointment. It should be noted that the

Health Trainers were particularly helpful in selecting participants to the project from among

their clients.

Screening of potential participants

Potential male participants were screened using a short screening questionnaire on the

basis of i) area of the borough in which they lived; ii) age; iii) ethnicity; iv) current/past

service use; and v) occupation. This was done to ensure a wide mix of participants was

interviewed and that there was equal representation from the chosen wards.

Sample size

This study aimed to reach data saturation, the point at which no new themes are identified

and the emergent theory appears complete. It was of particular note, and unusual given the

nature of the project, that many of the final themes were evident in the early stages of the

interviewing process. Thus, although data saturation was reached early and after the first

wave of interviews, further interviews were conducted to ensure the initial summation was

accurate.

2.5 Data collection

Settings and interview schedule

The objective was to put participants at their ease during the interview. Local residents

were offered the opportunity to be interviewed in their own home or at an alternative

location more convenient to them, for example, a local community centre. All the health

professionals were interviewed in their place of work.

All participants were interviewed once between September 2013 and November 2013. The

median length of an interview with health professionals was between 45 minutes and one

hour, and between 50 minutes and an hour and a half with local residents. Focus groups,

paired and individual interviews were conducted with the local residents.

Recording the interview and interview structure

All of the interviews, except one, were recorded with permission. Participants were

informed of the intention to record the interview in the study information sheet. The

recorder was placed in a position clearly visible to each participant. It was clearly stated

when it was switched on or off.

Research questions

All discussions and interviews were based on topic guides developed in conjunction with

Haringey Public Health Department. As in all qualitative research, the guides were used as

an ‘aide-memoire’ and a general framework for discussion, ensuring that all themes were

10

covered with the necessary prompts but, at the same time, enabling discussions to be

spontaneous, flexible and responsive to the thoughts and opinions of those being

interviewed, thus allowing for full exploration of the issues. The guide used for discussions

with men and the paired interviews is shown in Appendix I and that used for healthcare

professionals is shown in Appendix II. The latter guide was also adapted dependent on the

nature of the healthcare professional being interviewed.

At the start of each interview, loosely structured, open-ended questions were asked. In

order to pursue an idea or response, more detailed questions were subsequently asked or

prompts made. The wording was not standardised, as the interviewers tried to use the

participant’s own vocabulary when framing supplementary questions.

2.6 Data analysis

Audiotapes were transcribed verbatim. The transcripts used accepted procedures for

indicating exclamations, pauses and emotion, providing additional information on how the

participants expressed themselves (Seale, 1997; Field and Morse, 1985)5. Transcriptions

were imported into the computer program NVIVO (Qualitative Solutions and Research Pty

Ltd, 2011)6.

5 Field, P., Morse, J. (1985). Nursing research: The application of qualitative approaches. Aspen: Rockville. Seale, C., Silverman, D. (1997). Ensuring rigour in qualitative research. Eur J Public Health, 7, 379-84.

6 Qualitative Solutions and Research Pty Ltd (2011). NVIVO. Victoria, Australia.

11

3. RESULTS

57 participants were included in the study. The sample consisted of 25 health professionals

and 32 local residents (28 men were interviewed and four women). As shown in Table 1, the

sample included those from a wide range of ethnic groups. However, it is acknowledged

there were some notable omissions – for example, those from Turkish, Pakistani, Chinese

and Vietnamese communities. In particular, it was observed that men within the Turkish

community were reputedly hard to recruit in this area due to their working hours. Further,

there was also some evidence that some ethnic groups, for instance, Chinese have their own

medical services and do not access NHS provision either curative or preventative. The

majority of the sample was unemployed or retired. The remainder were employed in a

variety of settings ranging from the theatre and IT to cleaning and gardening.

It is also acknowledged that there were both time and budgetary constraints in the

undertaking of this project and this again contributed to the lack of inclusion of some local

communities. On the other hand, the broad nature of the sample has provided an invaluable

overview across communities thus providing a framework with clear parameters for the

next stage of the project. Details of the health professionals are presented in Table 2.

Table 1. Local residents’ participant details

GENDER AGE ETHNICITY EMPLOYMENT STATUS MARTIAL STATUS

INDIVIDUAL INTERVIEWS

Male 59 Irish Unemployed Single

Male 50 Serbian Employed – IT worker Married

Male 44 Afro/Caribbean Unemployed Single

Male 72 White British Retired Married

Male 61 Irish Unemployed Widower

Male 53 Afro/Caribbean Unemployed Single (Separated)

12

Table 1 continued

GENDER AGE ETHNICITY EMPLOYMENT STATUS MARTIAL STATUS

Male -

Respondent was blind

58 Afro/Caribbean Unemployed Single (Separated)

Male 54 White British Unemployed Single (Separated)

PAIRED INTERVIEWS

Male/Female

- Female respondent had learning difficulties

53 and 42

respectively

Both Afro/Caribbean Both Unemployed Couple

Male/Female 57 and 61 respectively

Both White British Both Unemployed Couple

Male/Female 59 and 54 respectively

Both White British Male = Groundsman

Female = Cleaner

Couple

Male/Female 57 and 56

respectively

Male = White British

Female = German

Male = Actor

Female = Administrator

Couple

GROUP DISCUSSION - A

Male 40 Somalian Unemployed Married

Male 42 Somalian Unemployed Married

Male 40 Somalian Employed – runs a community programme

Married

Male 47 Djibutian Unemployed Single – has girlfriend

Male 48 Nigerian Unemployed Married

Male 46 Greek Cypriot Unemployed Married

Male 40 Indian Unemployed Single

13

Table 1 continued

GENDER AGE ETHNICITY EMPLOYMENT STATUS MARTIAL STATUS

Male 50 Polish Employed – Counsellor Married

GROUP DISCUSSION – B

Male 47 Afro/Caribbean Employed – IT Consultant

Single

Male 51 Afro/Caribbean Employed – Student Counsellor

Single

Male 76 Afro/Caribbean Unemployed Married

Male 46 Afro/Caribbean Employed – Driver Single

Male 66 Afro/Caribbean Retired – Civil Servant Single

Male 52 White British Unemployed Married

Male 40 Kosovan Unemployed Married

Male 55 Bangladeshi Employed – Retail Married

14

Table 2. Health professionals’ details

Surgery/Team Nature of Interview Professionals Interviewed

Practice A Mini-group discussion 2 x GPs

1 x Practice Nurse

Practice B Group Discussion 6 x GPs

2 x Registrars

1 x F2s

1 x Health Care Assistant

1 x Practice Manager

1 x Administrator

Practice C Mini-group Discussion 1 x GP

1 x Practice Manager

Health Trainers

Group Discussion 8 x Health Trainers

15

Content analysis

Due to the purposive nature of the sampling, a quantitative description of the qualitative

data would be inappropriate. However, the frequency with which particular comments were

made is indicated by terms such as 'all', 'most', 'many', 'some', 'a few', or 'one'. In content

analysis for all the interviews, data were coded into one or more of 49 initial categories. As

the emerging theory developed, the categories were refined. Finally, the emerging theory

stabilised, despite further data gathering and analysis – the point of data saturation. At this

point there were six key themes (Figure 1). All the key themes detail either barriers to

accessing preventative services or suggested ways to increase uptake.

Figure 1. Final codes

Key themes Code description

Knowledge of service provision, Health checks,

Perception of risk

Role of the partner, Past experiences

Complex life issues

Previous experiences of services, Trust

Fear and denial, Personal willpower, Physical

examinations

Awareness and

knowledge of

preventative

services

Masculinity

Influencing factors

Lifestyle

Perception of

services R A W

D A T A

P

R

E

L

I

M

I

N

A

R

Y

C

O

D

E

S

Possible service

improvements

Community testing venues, Workplace and

mobile testing venues

16

4. KEY THEMES - LOCAL RESIDENTS

4.1 Awareness and knowledge of preventative services

Considering the diversity of the sample, it was not surprising that there was a wide range of

knowledge and understanding of the term ‘preventative services’. There was not, however,

simply a range of knowledge in terms of actual service provision but a range of

understanding in terms of what the term actually meant.

At one end of the spectrum, it was evident that for a good number of the participants in the

study, the concept of ‘preventative services’ was new. During the interviews, it was often

necessary to explain what was meant by the term before any further discussion about

services they may or may not have accessed. For those at the other end of the spectrum,

although the concept was by no means a new one, it was clear that it was not necessarily

equated to present service provision.

Further, from the evidence there did not seem to be a clear relationship between a

willingness to access health care per se and a willingness to access preventative services.

Indeed, it was clear that many interviewees did not necessarily connect ‘preventative

services’ with health services more generally. For example one man who was a regular user

of the health service for a range of ailments had never thought about accessing primary care

for ‘lifestyle issues’:

“For that? To ask about those things? I mean you simply wouldn’t go for lifestyle

issues, would you?”

On the other hand, for another participant who had avoided medical services for ‘all his life’,

preventative provision was currently an alien concept but he believed that he might actually

attend if, for example, he were to be sent a letter of invitation.

“I would go, I have been to the hospital when they asked me to. They sent me a letter –

so I go if I am asked.”

Moreover, by no means all respondents necessarily equated a lifestyle issue such as giving

up smoking to be within the definition of ‘preventative services’.

“Well, I didn’t put two and two together and think stop smoking, preventative…”

4.1.1 Knowledge of Service Provision

It was significant that across the board, participants did not equate the health services

which they had accessed in the past with preventative health. Some participants did not

believe that preventative care should be within the remit of primary care and this view,

interestingly, cut across whether or not they were reluctant to or did access preventative

17

services. Others were simply surprised that such services could be accessed or were offered

in primary care.

“I mean if a man has that fear of going to his GP, then maybe he’s frightened and he

might go there for stopping smoking but if the GP then says you’ve got dysentery, he

doesn’t want to know that…so really you wouldn’t want to go to the GP as a GP in some

cases is the purveyor of bad news.”

“I may be wrong but if I go to the GP, they really want to deal with one issue and not

want to talk in general about my well being…or a lifestyle adjustment…I probably

wouldn’t dream of wasting my GP’s time with just talking about me but I did make a

point of going to have a blood test for prostate cancer and I was refused as I had had one

two years ago…I am going to change my doctor.”

Some argued as well that it might just be too much of a burden for GPs to provide such

provision on top of everything else that they were responsible for. It was only a minority

who appeared to equate GPs with preventative services.

“But if you put this on the doctor, it might be one sack that breaks his back…I mean if you

throw another bag of stuff on top, eventually you are going to break the camel’s

back…and you can’t put it on a hospital.”

“I don’t think they would have time for that sort of thing – unless you had definite health

problems.”

“Well, the GP would be my first thought because they are health professionals, they are

qualified and they are experienced.”

In terms of specific services, most acknowledged that GPs and primary care would be able

to provide advice on smoking cessation. Indeed, there were a sizeable proportion of

participants who had been told by the GP, the pharmacist or by the hospital to stop smoking

and a number, too, were aware of clinics and services in other parts of the Borough.

However, there remained a minority that felt that they still would not access the GP for

smoking and some were surprised that they actually could.

“Possibly yes and no. Because now you have got so many books, you have got so many

articles, you can go…so many CDs now [on] how to stop smoking…I wouldn’t rely on the

GP – you have to rely on yourself and your own will.”

“I don’t think my GP would run quit smoking classes though.”

This was also the case for alcohol where again many respondents felt that it was something

you should do on your own or attend Alcoholics Anonymous.

18

“I would guess that would be at Alcoholics Anonymous or something like that or a group

along those lines.”

It was also while talking about alcohol that one respondent pointed out why they simply

might not access such a preventative service, whoever ran it.

“If I was alcoholic and you know you’re alcoholic and somebody else telling you it winds

you up and you want to drink more.”

More interesting was the case of ‘fitness’ where there were only a very small minority who

believed that primary care would know anything about keeping fit. Most would go to a

leisure centre such as the one in Tottenham Green and if they were asked by somebody

else, their first instinct would be to refer them to a gym.

“I would not have known where to go previously. I might have gone to somewhere like

the Tottenham Green Leisure centre to see if they could give me advice.”

“If somebody came to me and said they were unfit and wanted to do something, I could

help them or, if not I could recommend a gym.”

A few of the participants had been told by a healthcare professional to lose weight.

Whereas a few of the participants stated that they might refer to the GP over weight issues,

others were more sceptical of whether they would be given the most appropriate advice.

“If I was overweight, I would probably see my doctor initially…it would be more medically

sound I think.”

“I believe that all the slimming clubs and the doctors have got it wrong, because you go

to slimming club, doctors, and they all tell you, you should lose slowly, and they say one

or two pounds a week. Well that to me isn’t slow, that is very fast weight loss. I aim to

lose about three or four pound a year, and I've done that for 13/14 years So I wouldn’t go

to the doctor about dieting, because I think she would muck up what I’m doing

successfully on my own.”

Even though many of the sample did not consider the GP to be the most appropriate

fountain of knowledge for a number of these services, they did expect to be referred and

argued that this was the reason they had approached the GP in the first place.

“My wife saw an advert in the local paper and you had to see the Health Trainer or the

GP and then they would authorise it so we get vouchers to do it free so that was I went

to the GP, to get referred….I mean GPs presumably would know where to point you for

all these things, wouldn’t they?”

“GPs should react to illness, but then if the illness is something that can be prevented,

GPs should point you to that place.”

19

“Well first of all you go to your doctors and he would advise you what to do and might be

able to refer you to someone else who is able to help you.”

This particular participant also complained that when he had been told about, ‘Active for

Life’, he had contacted his surgery for a referral but was told that they knew nothing about

it. It was only when he finally spoke to a particular doctor that he was able to obtain his

referral. It was also acknowledged that it might be hard for GPs to up-date their awareness

and knowledge of service provision on an on-going basis.

Finally, awareness of the Health Trainers was limited, particularly if participants had had no

specific reason to access them. For example, perhaps following a serious illness some

participants had begun to work voluntarily for them in some capacity, maybe doing

outreach and awareness work. Others had been referred to them either through an

advertisement about smoking cessation or, less commonly by a GP. Among those who were

aware of the service, there was an assumption that others would know about them too. It

was of note, however, that this did not appear to be the case among those who had neither

self-referred nor been referred.

“Yes, people do know about them. They are fairly well known because we do a lot of

work signposting people to them.”

4.1.2 Health Checks

It was only a minority of the sample that had, to their knowledge, a NHS Health Check. It

was likely that some respondents had had them (from their description of checks they had

had) but were not aware of their name. Others seemed surprised that it was possible to

have a free ‘MOT’ on the NHS and believed that they would definitely accept the invitation if

offered.

“Well if I got this letter I would be surprised because I see my GP as somebody who helps

me in emergencies, so to even think about, oh my god, I can go and somebody will spend

time on me even though I’m not ill, just to talk about me and my future wellness and, you

know, just, you know I would feel very, very spoiled and I probably wouldn’t believe it.

And at this moment, I can’t actually believe that these letters really exist.”

Nonetheless, there appeared to be an understanding that some might be fearful of going.

“Yeah maybe you’d worry, this health MOT they say they’re going to look for cancer,

they’re going to look for this, they’re going to look for that and sometimes people some

are – I don’t think so much myself, but some people sort of worry about, you know, when

they see cancer and think, oh no, they’re going to find cancer in me.”

More interesting were those who tended to express ‘alienation’ from both society and from

any form of ‘authority’ but who believed that if they were offered such a check they would

20

go, not least, as one respondent argued, ‘because they sent me a letter’ as opposed to

necessarily understanding its content.

“I mean I would go if I got a letter…because I got a letter…but it would depend on how I

felt…I would consider the whole lot and I’d say to myself, well I know what scares me is

to find out something that you don’t want to hear but I think I would go.”

But some would clearly not attend.

“Yeah, well you get the letter, you read the letter and you put it aside and you just

completely forget about it.”

4.1.3 Perception of Risk

Participants varied as to whether or not they perceived themselves to be at risk in terms of

their health. Almost all argued that when they were younger they thought they were largely

‘invincible’. And this was also the case for those that had had a serious illness.

“No, at that time you think you’re strong and healthy. I thought I was Superman in a

way…”

“Before I had the heart attack, I actually thought that I was invincible. You have that

thing in your head where you actually think you are invincible. After it, you realise your

vulnerabilities and it is a humbling experience…If I go back to before, I wouldn’t have

done anything preventative.”

It also clearly came as a shock to those who had had a health scare but who actually

perceived themselves to be both fit and healthy.

“I was shocked when I had the heart attack because I did training every day…I have

realised it is not a complete cure for everything.”

“If it was me I had no real bad experience with the GP, it’s just that I didn’t feel the need

for a GP.”

Some of this group also described how every day was a ‘bonus’ for them but for many of

those interviewed, whatever their lifestyle and economic situation, there was a strong

sense that the more one aged, the more one worried about one’s health.

“As you get older, it is like a car, it starts, the parts begin the wear out so they need

fixing…but I would say, anyone over 70, they are on borrowed time, because all their

body parts are wearing out.”

“But as you are getting older, then you are a little bit more aware of things, what you do

and then what might happen to you as well.”

21

It was common during discussions across the board to hear this concern about becoming

older. This was the case even among those who would not willingly access healthcare

services, even though they may be under the supervision of healthcare services for a range

of issues. Overall, there was a general perception that illness was not supposed to occur

when you are young.

“I mean people in their 20s and 30s or something like that, they’re safe enough but when

you get older 40 and 50, it worries me. Sometimes I get very worried, actually I get

depressed, I say to myself, Jesus, how many years have I left? ”

“You are supposed to be young and fit…I don’t know I’d have to think back to when I was

young and, yeah, you are supposed to be extra strong at that age.”

4.2 Perception of services

4.2.1 Previous experiences of services

Integral to whether or not respondents considered that they would access health services,

preventative or otherwise, were the summation of their own experiences of health

professionals and provision. For some, their experiences had been largely negative,

occasionally based on childhood but, more frequently, as an adult. For this group, their

opinions and perceptions tended to be couched less in terms of whether the actual medical

care was ‘good’ but how they had felt they were treated and whether they had been

respected and treated appropriately as a person.

“And then I didn’t want to get angry with my doctor but I said to him, I know what is

wrong with my back, I said it was quite obvious, and then he got angry with me because I

questioned him…so I got angry.”

Others relayed how they knew of people who had had negative experiences and there was

particular upset when stories related to a child, either their own or that of an acquaintance.

Although it seemed evident that negative experiences or knowledge had an impact on their

perceptions of provision, it was unclear whether this worked in reverse. Partly, this was

because perceptions were clearly influenced by a range of other factors. Many told stories

of the difficulties of accessing appointments and waiting for inordinate lengths of time.

“I understand it can be frustrating if you think you have got something that needs

attention and they say, oh yeah, we can fit it in, in two weeks. Well it might be you are

going to get worse in that two weeks…But if you ask for an emergency appointment, it is

not what I would consider quick service.”

For those who appeared to have particularly complex lives, the situation seemed

unbearable. A few of the participants also felt that the waiting room exacerbated their fears

22

as there was always the danger of becoming ill by the mere fact you had to wait with other

people.

“When you turn up and you are waiting for hours and you are next in the queue and

they blank you, they leave you as if you don’t exist, you are invisible to them and then

they say, where have you been? It happens at the surgery and it happens at the

hospital…it could be life or death. And you say, I’ve been here all morning waiting for

you and then they say they can’t see you, call back tomorrow. It drives me mad.”

“I suppose because the Laurels has a big [waiting room], because it’s two surgeries in

one, and such a big waiting room, but the waiting room looks so clinical and it’s not the

sort of place that you want to sit. It almost feels like you’re sitting in a hospital waiting

room, or the old fashioned sort of hospital waiting rooms, because I know when I go to

the Royal London or the Chest, you know the Chest Hospital, it’s quite a friendly waiting

room but, you know, the Laurels’ waiting room is not friendly at all.”

Many of the participants also expressed the importance of receiving results as soon as

possible and preferably within 24 hours. This was particularly critical for those who did not

feel at ease with their GP or who did not like accessing health services.

“Say a doctor gave me an x-ray and he said come back next week and we will give you

the results. I’d say no, I want the result now please – I want to know what is wrong with

me now and they say, no we can’t do that. I’d say ok but I know I could be dead by next

week – they should say, all right then, come back tomorrow.”

“I kept saying to him the lump was big, and they said you’ve got to wait three months, if

it’s a cyst or if it’s cancerous I had to wait. Well when the bloke turned around and he

said you can come back in three months, I said just do it.”

Finally, it was clear that, in the main, participants did not mind whether they might see a

woman or a man health professional for preventative service provision so long as they were

experienced and professional. Most were happy too for a nurse to provide a health check or

the NHS Health Check on the assumption that they would be referred if necessary.

“I would say as long as they have expertise in this field.”

“I don’t think it bothers me that much either although I am not sure I would like to be

examined by a female doctor but I don’t know…it doesn’t matter actually.”

4.2.2 Trust

A key component of respondents’ perceptions of GPs and other health professionals

appeared to be the level of trust they had in both individuals and in the system. It was not

necessarily ‘trust’ in the sense of having confidence in the healthcare professionals’ medical

23

opinion but more a question of ‘feeling safe’ in their hands, and to a certain extent, that

they were ‘on the same side’. It was clear that this participant only felt safe with one GP.

“I don’t listen to other doctor. What the other doctors tell me, I ignore.”

Further, it appeared the lack of ‘trust’ in healthcare professionals also seemed to contribute

to the possibility of dismissing any advice people may be given. It was also clear that for a

number of the participants the lack of trust ran deep.

“When my time is up, he’ll take me, not you, not for you to give me advice. If I am going

to die, then I am going to, don’t sit there and say I am going to die next week, when you

know nothing about it…”

“I don’t trust them at all…I have been lied to all the time. They said [one time he was in

an ambulance] I would be better within a week. How the hell do they know? They can’t

tell the future…They tell you anything and lead to you to believe that.”

Another participant, who had recently lost his disability benefit entitlements, emphasised

repeatedly during interview that he did not voluntarily go to the doctors as he simply did

not trust them.

“What can I do…they call the shots and all I can do is listen to what they say…I am never,

ever keen on going near a doctor…I am nervous, what will they tell me next.”

Some of the participants felt that their doctors were indifferent. The older participants often

felt that this was new and that in the ‘old days’, doctors had more time for their patients.

“I’ve told him we can’t communicate. They used to talk to you but now, I actually said,

are you listening to me? I said why don’t you have the decency to tell me then…like

somebody on a bloody mobile, you’re talking to them and they are not listening…and he

is sarcastic…he looks at his computer and I call him the zombie…I just don’t trust him....it

is hard to trust people.”

“I always get the feeling that I’m not wasting the doctor’s time but I’m just kind of aware

that they’re very busy. They’re probably seeing people with a lot more problems than I've

got, and I’m always aware that I stick to the 10 minutes and then go. You know, I

wouldn’t want to start talking about other things or any other worries that I've got, I am

aware that I’m…I don’t think it’s come from me really.”

Of interest was the fact that a number of those who were recruited via the Irish Advice

Centre, argued during interview that they only ‘trusted’ their advisers who were based in

the Centre and who appeared to organise appointments (including with medical

professionals), arrange meetings and generally help their clients to deal with the complex

nature of their lives.

24

“Like I trust all people but I prefer to talk to the Irish Centre as they know mostly about

my agonies. They know my full history and I trust them 100%.”

Finally, for one individual participant, their experiences of the health system in the UK had

been somewhat different to that in Eastern Europe and had led to a level of scepticism

about primary care. During interview he contrasted his experience of treatment for the ‘flu’

and commented that ‘back home’ he would have been prescribed ‘injections’ but in the UK

he was not prescribed anything that he could not obtain either from pharmacist or through

the Internet.

4.3 Lifestyle

4.3.1. Complex lifestyle issues

During discussions, it soon became evident that a number of the participants had somewhat

complex lifestyle issues. Whereas the health professionals (see Section 5) made a direct link

between access to health services and ‘deprivation’, for a number of local residents it

appeared to be a question of their immediate priorities.

“I just take a day at a time, now and if I have a good day, I have a good day, if I have a

bad day that is it, it is a bad day. Like I say, if the old Bill came around looking for people

that used to stay in my place before…and they start banging on my door looking for

them, I think that is a bad day. But a good now will be plenty of food, no one to torment

me, no one comes near the door. I can listen to my music, chill out, have another

cigarette, have a drink in the house and that is it, that is what I call a good day.”

For those who were not themselves experiencing such direct concerns, it was clear they

were conscious of such issues.

“Because men are breadwinners of families, and our fear is when I go to hospital and my

condition worsens I've left my family in disarray.”

“If your health goes down, your financial situation will probably get worse. If your health

is not good you could actually lose time at work and your financial situation could be in

trouble…you have to connect the two, as good health is good for your financial wellbeing

as well.”

Certainly, taking the necessary time off work was often a problem.

“If you want to go to the GP you obviously need to take the day off first or morning off or

afternoon off. First of all you need to phone them or go there and then set up the

appointment, visit or whatever and I don’t want to wait until Thursday afternoon, I want

it now.”

25

More pertinently, for some of the sample, their ‘health’ was perhaps all they had left as one

participant pointed out.

“It’s you know, even though they get less money, they want to keep their lifestyle …if

they listen to the doctor he’s going to tell them to change their lifestyle and they don’t

want to. They want to hold onto that because it’s the only thing they’ve got left. Dignity,

yes…that’s the word I was thinking of, dignity yeah.”

“Yeah, lots of people like that, apparently they would not go to the doctor because they

think if they go to the doctor everything’s going to fall apart. That’s the same thing, they

don’t like going to the hospital because they think if they go to the hospital what would

happen is they would go there and they would never come out.”

“I think if we had kids, we’d be completely different…someone to fight for…we just have

nothing to fight for now.”

4.4. Masculinity

4.4.1. Fear and denial

Many of the participants talked about the fear and anxiety they felt when going to their GP.

This fear was especially felt when they were going reactively, with a problem that had been

of concern to them, often for many months, sometimes even years. A few of the

participants felt that it was sometimes better not to know and that living in denial was

preferable. Interestingly, this was less about fatalism, simply more about the fear of the

unknown and the attitude that ‘ignorance is bliss’.

“It’s not only the fear of the doctor; it’s actually the fear of ending up in the hospital as

well. Because if you believe or feel that if you end up in hospital there’s a good chance

you’re going to come out worse than you were when you went in.”

“I’m just kind of, well, I would say nervous, to be quite honest what makes me nervous is

what the doctor’s going to say to me. He might tell me something I don’t want to know.”

For a few of the participants, it also linked into their perceived role of the male in the

household. For these participants, the male was the head of the household, the

breadwinner, and as such could not afford to become unwell. This was more than concerns

around not being able to provide financially, but about status as the head of their

household, and their belief that ‘strong’ men do not become ill.

“It’s not even that, you’re invincible aren’t you. You’re a man, you can control it, you’re

all right!”

26

“It’s not a manly thing to [visit a health professional for screening], men don’t talk about

things like that, it’s not a man, women do it all the time but men don’t talk about those

types of things.”

“The GPs must improve the services and the quality of care, or they must also maybe

signpost in good time and diligently. Then the hospitals also must improve their services

so that men don’t fear going there. Because men are breadwinners of families, and our

fear is when I go to hospital and my condition worsens I've left my family in disarray.”

A few of the participants actually believed that going to a doctor would make them ill. This

was partly linked to denial, in that a doctor might find something wrong with them, which

they had never worried or noticed before. However, it was mainly linked to a form of

tempting fate; that they did not even dare risk ‘tempting fate’.

“When you go there you just feel sick straightaway, even if you’re not. I mean obviously

when you go there then you’ve got a lot of ill people around you, so the chance of you

getting flu is more…”

4.4.2. Personal willpower

Many of the participants smoked or had other risk factors, such as being overweight, not

exercising, and so on. In these instances, there was a general awareness about the risks

associated with smoking, etc. Many of the participants also felt that it was their personal

responsibility to deal with the issue, and that if they sought help from someone like a GP,

then they were showing a weakness. The participants talked about willpower, and having

the personal strength to deal with such things alone.

“You’ve just got to do it; it’s willpower isn’t it, you’ve just got to stop.”

“Someone who took drugs or alcohol or cigarettes who don’t need to take any medicine,

…you understand what you I mean, no one can help if someone is taking drugs, anyone

who is smoker, I need to smoke so no one else can stop me, I have to decide by myself to

stop it”

4.4.3. Physical examinations

One of the main barriers discussed for not accessing local NHS services, in particular GP led

services, was the belief that a GP would not actually run any tests, they would just sit and

talk to the men about their problems and ask around symptoms. It was believed that their

doctor would then prescribe medication based on this discussion. Many of the participants

felt that this was a poor way of diagnosing an illness, and this further lead to their distrust in

GPs ability.

“Exactly yeah, they don’t have to just sit there, they have to….test you properly.”

27

“[If] they’re going to examine me when I get there, I will go. But the reason, normally I

don’t go to the GPs, nine out of 10 times if you go to the GP I know that he will ask me

questions only. He will not come up, examine me, because you would expect the doctor

to come up and check you. You understand what I’m saying? If that doctor comes up to

you, have the equipment and checks exactly, you would feel basically that you’ve seen

the doctor.”

“And you feel more satisfied isn’t it? More satisfied when the doctor can examine you.”

“I’m registered with that GP nearly 20 years, and the times that I go to the GP, most of

the time I know that he will be sitting there, not coming up to me, asking me, you know,

once he asked me a question, I would rather see that he’s doing something, listening to

my heart beat or.”

“If they only talk to you and they’re not actually going to check you properly, then there’s

no point.”

The ability to diagnose based solely on a conversation was also questioned by some of the

participants, due to the limited time a GP has with each patient. They questioned whether

10 minutes was really enough time to diagnose and prescribe correctly.

“You know, it’s like what he said, yeah, it’s like making interview.. And you’ve got a 10

minute time slot.”

“Yeah, it’s like he’s in a hurry. How long have you been tack, tack, tack, take that. And

you feel under pressure as well, like he wants you to go quickly.”

Most of the participants spoke favourably of physical examinations, or more invasive tests,

such as blood tests. They often felt that this was a more effective way to diagnose. Some of

the participants told of past experiences where the GPs did not carry out any tests or

examinations on either themselves or a family member, resulting in hospitalisation and

usually emergency surgery.

“I've got a very good reason to not trust doctors. I mean a reason probably that you

wouldn’t believe, but a few years ago my son had headaches, and he was 10 years old at

the time, he’s now 17, and I took him the doctors and do you know what the doctor said,

he goes ‘oh it’s just a headache, you know, children have headaches, adults have

headaches, it’s no big deal, it’s nothing to worry about!’ Anyway a short time later I took

him to the opticians to have an eye test and he was later diagnosed with a brain

tumour.”

“I have some problems in the past with GP. I was very sick with my sinus, and then I just

go and ask him, and I got so much headache and I got sinus problem, you know, I could

feel it, you have to do something about that. She just got the towels and check my nose,

she said nothing wrong, you don’t have anything. And then a week after I went back to

28

my country, and as soon as I get off from plane I was feeling so sick, you know, and

straightaway I went in hospital and they make x-ray, and they just told me you’ve got

broken nose, you know, you’ve got so many problems, you need an operation. And it was

same kind of things, you know, just everything getting inside but nothing come out, you

know what I mean?”

4.5. Influencing factors

4.5.1. Role of the partner

The role of the partner, and their ability to influence and encourage men to seek help was

discussed. However, this was rarely unprompted. Findings were polarised around this issue.

A few of the men would usually listen to their partner (or partners), believing that their

partner loved them and was concerned, hence why they ‘nagged’ them to see a doctor if

they were unwell.

“Yeah, sometimes you need a little push anyway.”

“I've got to, she’s very dominant.”

“That’s positive though, I see that [nagging] as a positive, because she’s worried about

your health.”

“Men should listen to women, because it’s all sheer carelessness. A man has such a

macho image with me. The woman would go to a doctor and she doesn’t mind about it.

And if she’s ill she’ll go and see a doctor. But a man, another man, myself included,

we’re just all the time we’re stubborn, and we don’t want to even to let our friends know

that we’re not feeling well in case they might say oh [name]’s weak, he’s weak.”

In contrast, some of the men stated that they would never listen to their wife or girlfriend

and that their partner would have no influence over their decision to seek medical

attention. A few of the men said that if their partner consistently ‘nagged’ them, then finally

they might seek help or attend a service.

“If she asked you once then you’d said no, but if she was nagging you all day then you

obviously just say yeah all right.”

“No [I don’t have a girlfriend], but I wouldn’t listen anyway. It’s only if I think I need to

go I’ll go; if I don’t then I won’t.”

“Doesn’t make [a difference] for me, I don’t care, I have to take care of myself.”

The participants stated that their partners would only encourage them to seek medical help

if they felt there was something wrong with them. They would not proactively encourage

29

them to seek help for routine check-ups or lifestyle services, for example, weight

management services.

Overall, the role of the partner in help-seeking behaviour was most strongly influenced by

the type of relationship the men had with their partners. They were more likely to listen if

they had a close relationship.

Interviewer: “Do you listen to your girlfriend?

P1: It depends how much she nags you.

P2: No, how much you love her.”

“I feel with my wife yeah if any problem she help me and I help her a lot as well. I don’t

share with other men.”

A few of the men felt that they would prefer to listen to a friend rather than their wives on

such matters, although most men admitted that they rarely talk about health and

preventative care with their friends.

“Well it would actually; a man would listen to a friend faster than he’d listen to his wife,

because a man might say well she nags me now for the sake of it. But if you’re with a

friend, a good friend and he talks man to man to you, more or less, you are more inclined

to listen to him.”

“See it was very foolish because I was told by a good friend of mine, and he said to me

[name] he said, you’ve got to register with a doctor. He said if something serious

happens to you what are you going to do? And he said if you’re going to the hospital,

the first question they’ll ask you is who’s your doctor? So that kind of made me change

my mind, yeah I suppose you’re right, I’ll have to do it. So I did, you know, for my own

good.”

4.5.2. Past experiences

It was clear from the interviews that whether or not men accessed preventative services

was fluid in that there were evidently a number of factors that might change their behaviour

at any one time. These included a friend or acquaintance becoming ill and personal

experiences.

A friend or family member becoming ill, for some of the participants, was incredibly

influential in determining their own help seeking behaviours. This influence could either

encourage the men to seek help sooner, or go for a health check, or have the opposite

affect and make them more distrustful of health professionals.

30

“I don’t trust the doctors to be honest, because…I've had experiences, I have reason to

say that. Recently my boy had appendix, and we took him to the doctor and they keep

returning us home saying he’s okay, he had food poisoning. They didn’t do full

examination.”

“You know when doctors, GPs are like any other professional, there are a lot of good

doctors, there are a lot of good police officers, there are a lot of good footballers, but all

it takes is one bad experience.”

Interestingly, ethnicity did not influence peoples’ help-seeking behaviours. A strong

influence was their family and whether they were brought up in a family where their

parents went to a doctor, or sought help for lifestyle issues.

“My father was the same way. I never even heard him talking about it, here I don’t think

he was even registered with a doctor. I’m the same, I suppose I’m nervous going into a

doctor.”

4.6. Possible service improvements

4.6.1. Community testing venues

Across the board, there were lively discussions as to where would be the most appropriate

place to offer preventative health services. The most popular venue overall tended to be

community centres such as the Irish Centre or the Selby Centre.

“A nice community centre would be a useful place to be able to go and just talk to

someone and relax for a couple of hours…and all the men would say, let’s go down to the

community centre and have a chat with their friends but no one wants to go to the GP

unless they are actually ill.”

“Because people are relaxed when they are in their own community when they are in

their own area, so yeah, if it is a community centre…and their mates are probably going

there…egging each other one…much better than going to a GP surgery on their own.”

Others argued that shopping centres would be ideal but it was pointed out that many

shoppers may not wish to be interrupted, particularly if they were involved in purposeful

shopping.

“You see a shopping centre, I go there quickly and shop and then go, I wouldn’t have

time and I am not sure I would want time to do it there either.”

“I am not sure, because Wood Green is always hectic…hard to get in and out. You don’t

want to hang around there.”

31

In general, people made suggestions on the basis of where men congregated – hence,

churches, leisure centres, football stadiums, barber shops or pubs. However, in the case of

the latter, some thought that it would not make sense to pursue health checks in a pub

since men may not be willing to interrupt their social occasion they may become

‘aggressive’.

“In a pub it would not be a good idea. They have gone out to enjoy themselves with their

mates and if they get merry, they could be a bit aggressive or dismissive.”

“In the pub, I don’t think they would be interested, because people are there to drink and

not to listen to anybody talking about your health.”

Others, though, felt that it might work the other way.

“I mean you can get in with a team of blokes and you know after work they will go down

the pub and you say, no and they say you are a spoilsport and get pulled into it …so you

might actually go down for a health check.”

A small minority had also experienced or seen checks being carried out in pharmacies or in

Tesco’s and felt that had worked well.

4.6.2. Workplace and mobile testing venues

A further popular thought was that employers should take more heed and provide checks in

the work place. Among the sample in this study, none had any experience of this.

“I think there needs to be more emphasis on the workplace. It is in their interest to keep

their staff in good condition. Or more help with giving people time off for workers to

actually go to do preventative things or bring in people maybe to do checks within the

workplace.”

“The work place…employers they should have an interest that their staff are healthy…”

One couple had the idea of using a van, similar to that of breast screening, which would

then tour community areas, community events or even the work place.

However, critical to any provision would be that staff and providers of the service were

experienced and many thought they should be connected professionally to the health

service rather than volunteers.

“I think it’s probably quite good if it was sort of somewhat attached to your GP because

if the blood tests are done and there’s something wrong, you can go next door and your

GP can tell you that this is a problem. If you then have to go to other group of people and

you know, no I think it’s actually quite a good idea to have it sort of linked with your GP.”

32

Nevertheless, there was a minority of participants who argued that the issue was not that it

had to be staffed by a GP, per se, but that they had to be able to trust the staff. Some too

argued that it might be better to have all preventative services in one venue that might have

a ‘shop front’ or might be within a centre.

“They might not feel comfortable with a GP, telling them things…I mean if there were

people who had drinking problems to speak to that would be good…I would spill more

beans if there is loads of people there and not just a single GP.”

“You might drink, you may smoke, you may be overweight and it would be good to walk

into one place where you get all of that dealt with or all the advice you need in one place.

Rather than the doctor says well Tuesday you can see the stop smoking counsellor,

Wednesday, you can see the person who does the dieting and so on – so maybe it would

be good to have it in one place…It has got to be something separated and it has got to be

promoted so that people know to go there and that is where you go for information.”

“Smoking, drinking, madness, everything – a good place would be on the high street.”

Finally, respondents spontaneously suggested clear and explicit leafleting, board advertising

in local venues as well as on social media. Most believed that the adverts should be hard

hitting and provide an immediate connection to the individual such as exemplifying people

like themselves or showing a grandfather with his grandchild as has been done with the

diabetes campaign.

“I would produce a leaflet…I think it would be shock horror…because if it were too

flowery, the men wouldn’t read it…you know the one with, ‘Staying Alive’.”

33

5. KEY THEMES – HEALTH PROFESSIONALS

Included in this study were three GP practices and the local Health Trainer team. The three

practices varied in size. One was considered to be a small practice (by their terms of

reference) to one that had a patient population of over 12,000. All the practices described a

large proportion of their population as being “deprived” with one practice suggesting

anecdotally that at least 30% of their patients received benefits. All three practices

acknowledged that the target group of men between 40-74 was a key issue for them.

5.1. Issues in preventative service provision

There was an overwhelming consensus that GPs and their practices felt they were

responsible for the preventative services agenda. If not providing services themselves,

their role was that of ‘gatekeepers’ with a duty to signpost. At the same time, there was also

a strong body of opinion that felt their role was limited in that there was little they were

able to do about the more fundamental causes of poor health such as overcrowding, lack of

exercise, poor diets and so on.

“We don’t have anything to do with social conditions, about education and literacy, it is

nothing to do with us…we can give out information about what is best for them, support

them, refer them, advise them if they listen to us.” (Practice)

Further, a number believed that providing preventative services was particularly hard in

the east of Haringey.

“There is overcrowding, the people living on benefits are sedentary, they don’t do any

work, they don’t do any exercise – this area (east of the borough] the Council are

dumping all the people with the worst problems.” (Practice)

GPs also drew attention to difficulties considered to be the result of the nature of the

population. A proportion of the local population, for example, were believed to be

illiterate and levels of education were remarkably low.

“It is not to be underestimated that some of our patients have very poor levels of

education and understanding of facts about health that you would think were obvious

aren’t...I have had patients extremely overweight with BMIs in their 40s, 50s and

sometimes 60s and [they were] genuinely surprised when I say this is impacting on your

health, genuinely surprised that their knee pain and back pain is related to their weight

and genuinely not understanding. I think most do know about smoking though, but you

have to understand the level of education and a lot of our patients are illiterate,

particularly Turkish and therefore their chances of learning English are slim.” (Practice)

34

“Some men are aware but most men don’t know here how important it is until they fall

sick and by that time it is a bit late…” (Health Trainer)

Here, and in other discussions in the study, the link between preventative health care and

deprivation was debated. One GP considered that one of the key problems for them as

health care professionals was grasping the issue when it was presented.

“Beware the person that doesn’t come in very often because when they do come in and

they’ll be going on and on about a hurt shoulder, and it might be the very last thing and

once they’ve gained your trust, they think oh she’s listening to me, they might say oh

yeah and I did have… I've also got this problem. And it’s immensely irritating as a health

professional, but actually that last little thing medically is the biggest problem, that they

just thought they would tag on. And that’s the danger in general practice, we’re busier,

we’re pushed more, we’ve got higher demand, we’ve got the same number of patients

but much higher demands, so we’re always struggling with time.” (Practice)

“One patient must have been here four or five times rambling on about his housing but

the fact that he is a walking time bomb and smoking 40 a day and I have only just picked

him up as he then came in as an emergency and he hadn’t thought to mention his

increasingly bad angina until his fourth visit…really it was just a ‘by the way’ when I

wouldn’t do his housing.” (Practice)

The transient nature of the population seemed to compound the problem. One practice

reported that they took on at least 30/40 new patients a month.

“You start with something and then they are gone – holiday, or gone abroad or just

moved again… You can give a new diagnosis of diabetes and then you know, they

disappear and then we don’t know what happens.” (Practice)

For one practice what was of greater concern was the unregistered population, such as

the homeless or those leaving prison.

“There is no evidence base for the NHS Health Checks changing morbidity or mortality

anyway, because we only see the worried well and the ones that ‘present’. So I would like

to know how many of those men [are] out there, who are not registered with a GP…I

mean the ex-prison population – there is no liaison from prison. Who is registering the

homeless patients and if the Government gets its way with registering patients, we will

be the new immigration service too.” (Practice)

Not surprisingly, time and capacity was clearly an issue for all healthcare professionals

interviewed and especially in the case for preventative services.

“People are not interested in preventative services and I have not time to go into the

details…if you take half an hour to see a patient we can do that – but they want us to see

35

100 patients in one hour – the time factor is the most important – now we are

pressurised with the amount of work, it is impossible.” (Practice)

“Difficulties are mainly the time. We have to spend time on that as well as everything

else…patients don’t always respond and we have to catch them – most of the time it is a

game.” (Practice)

“I think it depends on the GP – I have come across GPs who do specialise in exercise or

whatever but it is the time factor and how quickly they can get them through the door so

they just want to deal with what is in front of them.” (Health Trainer)

As a result, some respondents felt that other GPs may not be as vigilant with preventative

services as they might be.

“I think in larger practices, the problem may be the doctor will think I will only do the

doctor’s job, that is, if the patient presents with something…and different doctors have

different agendas.” (Practice)

Almost all practice staff interviewed believed that GPs were overburdened and some also

believed they were somehow unfairly targeted.

“Coming back to public health, there is sometimes this view that primary care is a

general sink. If they want to start primary prevention programmes then that’s fine but

they need to be resourced and we don’t have any spare time or spare staff…and

sometimes we get a bad press and there is some stunning general practice going on in

Haringey and it needs to be captured and supported.” (Practice)

“As usual they dump it on the GP to do everything and I think we are doing enough.”

(Practice)

5.2. Current preventative services offered

Healthcare professionals reported that there was a range of provision within the surgeries

themselves with the largest practice offering not only smoking cessation, cancer screenings,

diabetic care, family planning but walking and exercise classes. All three said they would

regularly refer to exercise classes, Active for Life and weight management centres.

The NHS Health Check additionally seemed to be an integral part of their practice and

practices and was offered to all new patients as well as to other patients. Surgeries also

reported that they had been carrying out the Checks long before it was made mandatory. It

was hard during interviews to be precise about take-up but the GPs interviewed were

confident that the percentage was high because if people did not attend, copious messages

were sent. With this approach, one surgery believed that only 10% of the target group age

did not attend.

36

In addition, surgeries also ran checks on their register and followed up any ‘alerts’ on the

system. It was, though, evident that the Health Trainers were not used as a referral point for

all surgeries and their usage varied widely. In one surgery, for example, they were based in

the surgery, but in another the GP thought it was not necessary to refer since they did all

the work themselves.

“We don’t send as we don’t need to – we do whatever we can to manage our patients.

We know them but they are not relevant here because we see the patients and we do

everything for them. We do it here – they will listen to their own doctor, own GP first.”

(Practice)

It was apparent that this particular surgery also believed that it was their duty to take

responsibility for the whole of the patient care.

“If you are dedicated you will do maximum service – it depends if I want to work or not to

work – if I want to refer I sit down” (Practice)

During interviews the Health Trainers also commented that not all GPs referred to them.

This was believed to be in part because there remained a lack of understanding as to what

they did and partly that it might be hard to understand the service unless GPs and

practices had actually used it.

“Often they don’t refer clients or patients to us or they have low levels of referrals…but I

think it is down to understanding. I think maybe they just don’t understand the service

properly...” (Health Trainer)

“Because it is a new role, the understanding of a health trainer isn’t there unless they

have used the service – it is just getting to know the service is available.” (Health Trainer)

Additionally, it was acknowledged that another issue was that their service was one of many

services available in the borough and thus perhaps confusing for GPs.

“As far as I know they [GPs] are introduced to new programmes all the time, so it is

something about smoking, something about losing weight, etc. And we are just one of

those programmes and sometimes something short term.” (Health Trainers)

Some Health Trainers felt that whether their service ran smoothly with practices also was

dependent on who their clients spoke to at the surgery – for example, a new Practice Nurse

may not be aware of their services. More critically, the difficulty appeared to be the

potential effects of a lack of understanding of the service.

“So sometimes we have to go through the GP like a referral to Slimming World or Weight

Watchers – and our clients then experience problems getting on those programmes

because the GP doesn’t understand what their client is asking for and doesn’t know us or

37

the programme so the clients are basically bouncing backwards and forwards between

us and GPs explaining what they want and what we have said.” (Health Trainer)

It was also argued that the name ‘trainer’ implied (erroneously) they were fitness trainers

but more common was the view that the real issue was that GPs, even if they were aware of

the service itself, were not aware of the service’s level of effectiveness.

“In the end it is by results…I think what really will speak is when patients have gone back

and said they have just lost x amount of weight and I’ve been seeing a health trainer or

whatever. That is probably going to be more effective than any other bits that we can

present.” (Health Trainer)

Providing and monitoring feedback to GPs was also something they believed would be

helpful, but time and capacity were again critical in this.

It was noteworthy that similar to the male respondents, healthcare professionals did not, in

general, feel that it was possible to be specific about whether their patients or clients were

concerned if they saw a female or male health practitioner. The majority felt that it would

depend on the individual patient and indeed the nature of the health concern.

5.3. Attendance and access to preventative services

During discussions there was a continuous debate as to why men did not access

preventative services. Generally, healthcare professionals did not segment men into those

who attended preventative services and those that only came for a particular health

problem. The concern for them was that in their view not attending health services (of any

sort) was the issue.

Although one surgery commented they were seeing patients for Health Checks, especially

men that otherwise would not have come to the surgery, most argued that the patients

who probably needed the care the most were the ones that did not attend.

“40-75 with no pre-existing conditions and that’s quite important for men because you

might hit a group that would not come in for anything else…but I remember our nurse

saying they are all slim, fit, healthy, they are not necessarily the people we wanted to

get…but it is those who are the less literate that are among those we are trying to get

hold of.” (Practice)

“The ones that really need the services, the really crunch ones just don’t come.” (Health

Trainer)

“If they have no previous history, they say everything is ok, they don’t need to come as

they are fine…so they think it is a waste of time for a check-up to come here. I don’t have

any symptoms…I’m all right so why should I come and waste my time.”

38

Given that a sizeable body among the healthcare professionals agreed that the problem was

indeed linked to deprivation, the overall consensus was that the problem was socio-

economic.

“I think it is the deprivation – health is simply not at the top of their agenda and of

course health literacy – they are not educated.” (Health Trainer)

“It is not one group that stands out…it is more about the socio-economic demographics

rather than the mix itself…it is about deprivation and the men here use services in a

chaotic way so they come and then withdraw.” (Practice)

“They come in about their housing – they are just more worried about something else

than about their health.” (Practice)

Most also agreed that there were additionally a number of other factors that were integral

to this behaviour. The reasons frequently cited for not accessing health services was both

‘fear’ and, as a corollary to that, being ‘macho’.

“I think there is a fear factor – men tend to have this very masculine approach – a macho

image. I think they are scared but it could also look like a weakness…it’s like they are

men, they are strong and they can’t get sick.” (Health Trainer)

Health literacy and health awareness were both thought to be key factors, with many

Health Trainers believing that men liked to feel they could cope on their own and deal

with their own health. It was additionally reported by members of the Health Trainer team

that there were members of some communities who would self-diagnose and use home

remedies.

“They want to do it on their own, that is why they don’t present until they are actually ill

because they try to manage themselves.” (Health Trainers)

“Some of them don’t like going to the (Health Trainers) because they say, I know better

than what she says.” (Practice)

It was the Health Trainer team, too, who believed that some communities in Haringey had

their own medical service provision such as the Turkish and Chinese communities on the

assumption that their own services were more appropriate. However, the overwhelming

majority of professionals believed that ethnicity was not a factor in whether men did or did

not access services, although as already indicated, language and literacy were thought to

play a small part.

Others believed it was work pressures, time, or even just laziness. Some argued, too, that

younger men were less likely to access health services than their older counterparts but the

vast majority put forward the notion that it was not possible to describe a ‘typical’ non-

attendee. It was simply ‘men’.

39

“They might be working, they might not, language is another thing, they might move,

they might not have time, thinking about other things, they might be lazy, ignorant,

anything…so many reasons.” (Practice)

Most believed too that, apart from illness itself, it was hard to pinpoint particular triggers

that would encourage men to attend. A common factor highlighted was the influence of

women.

“Unless their girlfriend or wife sends them they won’t come to us…sometimes, it is like

their wife has just dragged them in. One woman told me that she had said that once her

husband was so ill that she had to close the door and say, leave him outside and say that

unless he goes to the doctors he was not going to be allowed back.” (Health Trainer)

“I had one the other day being literally dragged by his mother to sort out his

weight…they just don’t come until they are ill.” (Practice)

Others believed that friends or colleagues could be influential particularly if they had

experience of illness themselves.

“Those that have experience of illness or somebody close to them, they become

ambassadors…or a friend that has passed away…they realise that they need to start

taking better care of their health.” (Health Trainer)

5.4. Potential Solutions

Among the practices there was a debate aired as to whether there was enough preventative

provision presently available. At one end of the spectrum were those who felt that the

present system was inadequate, for example, with only one nutritionist available in the

borough. At the other end, were those who felt that the key was to make better use of the

currently available services.

“There are preventative services but there are not enough…there is only one nutritionist

covering the whole of Haringey and that is not enough….they need to develop

more…perhaps meditation and yoga. In a nutshell, they should have more preventative

service, where it is really needed, in deprived areas. Public Health is just not committed.”

(Practice)

“So maybe it is just reinforcing public health…supporting the existing staff but I just don’t

know how public health could do that but supporting the staff who are doing it day in

and day out rather than trying to create new services.” (Practice)

Further, most considered that the voice of the doctor still held authority.

40

“We have been very negative about our chaotic population but actually the doctor’s

word is still very important.” (Practice)

“If a doctor says something to our patients, they do take it on board.” (Practice)

The role of general practice was equally thought to be crucial in preventative care when

men accessed the surgery for healthcare. Across all three surgeries there was a strong view

that when dealing with those patients who would not normally access preventative services,

the essential ingredient was to provide access immediately on the basis that if future

appointments were booked, they would not attend.

“You have to strike when the iron is hot…if you are telling them your BP’s too high, in a

week, they are probably not going to be bothered, they might be a bit scared, but do it

there and then. In a week they will think it probably isn’t important.” (Practice)

“It is about locality. So with our patients who are chaotic, if you can grab them, what you

will find we do is we literally sometimes just take them…It is something about not giving

them appointments in ten or 15 days, when chaos has consumed them, it is about a

service right here and now and you can come with me now and I will tap on the

door…and that is very powerful.” (Practice)

“You need to give them advice there and then…people won’t go if you refer – you need

to see people the same day…you have to book them in then because otherwise they

won’t come.” (Practice)

“They will say they didn’t come in for those things but for a sore throat but we make sure

the nurse sees them otherwise they are gone.” (Practice)

In one surgery, for example, they were able to provide such a service.

“There is somebody in our surgery that does smoking cessation clinics and you can

literally walk them out of your room and into a clinic if she has got a free

appointment…and our smoking cessation is successful because it is here in the surgery.”

(Practice)

“If [our Nurse] picks up a blood pressure of 200 over 110, she is not going to send them

off to see someone in the distance, she is going to put her head round a doctor’s door

and find a doctor to deal with it there and then.” (Practice)

There were a number of suggestions regarding new community services. The Health

Trainers, for example, considered that offering preventative services in the community in

venues such as pharmacists, barber shops, betting shops, pubs, community centres and

shopping centres and so on would be one of the most constructive ways forward. While

some also drew attention to the new project with Tottenham Hotspurs, others felt that the

work-place would be the ideal venue or a mobile van service that might tour the area.

41

“It is about changing the venue of where we would normally deliver our services…I think

if it was packaged up in a barber shop I think that is going to be more effective – while

they are sitting there waiting to get their hair done, they can have a Health Check or

whatever.” (Health Trainer)

“I mean, on a Saturday, maybe 30,000 men are at White Hart Lane. What a fantastic

target audience…it ticks all the boxes…” (Practice)

Mosques were thought to be a particularly good venue since they are ‘trusted’ and run by

community leaders. Out-sourcing services met with a certain amount of criticism from

GPs. First, it was felt it was not appropriate to apply such a generic approach. Second,

often such new services in the community were not sustainable.

“They should concentrate on and make better use of the services that are available

already – targeted input. I mean I don’t really see how you can usefully apply such a

broad brush to this problem in a meaningful way.” (Practice)

“My big anxiety is communication. So it pops up but it disappears and it is not

sustainable and people no sooner get used to it than it has gone again…I mean there was

a counselling service for Turkish speaking patients and that was a big fanfare and please

refer to us, but within a couple of months, I had a referral back and they said, we are

sorry but we only funded for 100 and we have 100 so no more referrals… is it still there

even?” (Practice)

Most importantly, it was argued that there had to be clear communication and contact and

checks had to be carried out by appropriate professionals who would then refer the

information back to the GP.

“They go to Tesco, they get the blood test, and then they say go to the GP and then you

have to repeat the whole thing again…it is good if they do it, they must do the whole

thing and send us the report. But they just claim the money and that is their main

purpose.” (Practice)

“If they have the check somewhere where we have the allied professionals on site, then

the next stage is done. Whereas my anxiety is the next stage never gets done…the

detrimental thing about Sainsbury’s and the pub is communication…” (Practice)

“The bloke can get his blood test done, told it is sky high, and if we don’t know about it,

he has imagined he has had his health check, so he has ticked that box, but it needs to be

talked through, what has happened, what needs to happen.” (Practice)

The evidence from the interviews indicated that the essential factor seemed to be a central

liaison point of someone could then refer on. Spontaneously suggested by one practice as

42

well as many of the male respondents themselves was to set up ‘wellbeing health clinics’

separate, but linked to the GP surgery.

“The clinic should be separate…but they should have a centre that we can send them to

– that is the best thing – patients could walk in and GPs could send them from the

surgery – send them then and there, but we don’t have the time to do it…” (Practice)

Above all, the overwhelming majority felt it was a question of education. One GP explained

how they had had to explain the bowel screening kit, another relayed how often they had to

try to help patients understand how to take prescriptions, that there might be a course of

drugs, or that they had to take them for life. But it was also argued that education and

information on lifestyle should not begin at 40 but when men were younger.

“There is always the patient who says, I have taken those blood pressure pills for a

month, I have taken those cholesterol tables, but I am better now and this is always

worse when things are asymptomatic…I say these pills are not a cure but they are to be

taken for life but they come back and have stopped the tablets.” (Practice)

“You know lifestyle does not suddenly change at 40…It is better to give information

beforehand so that prevention starts earlier.” (Practice)

43

6. SEGMENTATION

Based on the findings from the interviews, three segments have been developed. As shown

in table 1, a diverse sample was interviewed for this study. The role of ethnicity and religion

was frequently discussed, often unprompted by the interviewer, during the interviews.

Interestingly, it did not determine service uptake and help-seeking behaviour.

Therefore, the segmentation has been developed based on the participants’ desired ‘types’

of preventative services. Importantly, these are not ‘static’ segments, and people can move

from one segment to the other based on a number of particular circumstances, life events,

personal experiences or experiences of others, and perceptions of risk. They can also

overlap, and certain aspects of a service are important to all three segments – see Figure 2.

Critically, it is important to note that the behaviour of these segments does not necessarily

correlate as to whether or not they access medical provision in terms of clinical care rather

than preventative health.

SEGMENT 1: Willing to use GP-led preventative services

Segment 1 is more likely to react positively and attend preventative checks and services if

they know they are available and how to be referred on to such services. On the whole they

trust their GPs and other NHS professionals and are aware of the importance of health

checks. They also want to improve their health and “live longer”, so are interested in

preventive services, such as NHS Stop Smoking Services and weight management. However,

with the exception of the NHS Stop Smoking Services, they do not know about such services

or where to access them. They work hard and often work long hours, so need flexible

appointment times. Out of the three segments, they are the group that are most likely to

be proactive and respond positively to a personalised letter posted to their house offering a

health check.

Brian, 68, semi-retired, works 10 hours a week as a gardener

‘I am registered with a GP, like when we moved, we just did it without thinking, and we always

would register with a GP. We are lucky and have a really nice GP, very helpful and friendly, but I

know how busy doctors are. If I have a pain or feel unwell, I wait for a week, maybe more and see if

it gets any worse. If you think it’s trivial you expect it to get better, and then if it doesn’t or if it gets

worse then you go to the doctor. I don’t want to waste her time as she is very busy. They’re probably

seeing people with a lot more problems than I've got, and I’m always aware that I stick to the 10

minutes and then go. Years ago my mum would go to the doctor suffering with her nerves, and he’d

say sit down, let’s have a chat. And he would talk through probably a couple of problems, you know,

worries, you know, whatever, and he would give her that time to offload a bit. And I don’t think that

is what it’s about today. But I still think the doctor is a good central point, because from the doctor

I've been referred to the podiatrist.

44

I do discuss things with my wife, if I have a pain somewhere she sometimes goes on the internet and

has a look. But I don’t discuss it with my friends. I don’t want them to think I’m a wimp.

Basically I've smoked and drunk in my younger days, not now but for me it’s not all about keeping

healthy so that I live longer, it’s keeping healthy so I feel better tomorrow morning. I do consider the

long-term health benefits. I think about what I eat, how much I exercise, whether I walk or catch a

bus or that, I think my wife is a big influence on me there.

When I received a letter from my GP asking me to come in for a health check, I rang up and booked

an appointment. At the appointment, a nurse did all the checks. She did a good job but I still think

the doctor is the one with the big picture of your problems. But the nurse did tell me about a weight

management service just for men. I had never thought about it or even knew they ran such services.

SEGMENT 2: Need flexible services (open long hours and weekends and available at

community centres and other non-GP facilities)

Segment 2 also often work long hours and are proud that they are the head of the

household and are acutely aware that they are depended upon. They do not like the idea of

becoming ill and are nervous about visiting a GP, worried about what they might find. They

often talk about past negative experiences with GPs (either personal experiences, but

usually experiences of close family or friends). They find a GP setting rather formal; the way

you need to book an appointment in advance and the way the doctor interacts with them.

As with Segment 1, they lack knowledge as to what preventative services are available,

however, they want to be able to access health checks and other preventative services in

local community venues and centres. If one of the local community organisations employees

offered to book an appointment for them to have a check, and explained to them why they

should have such a check, they are more likely to attend as they trust the local community

groups. They would be happy to have checks and preventative services offered at other

local venues such as barbers shops and football stadiums. However, they still want a NHS

trained professional (male or female) doing the checks/running the services.

Aleksy, 50, works in IT

I work in IT. I enjoy it but it is very long hours, sitting at a computer all day. I used to smoke a lot and

enjoyed going outside for a cigarette with my colleagues. But since my daughter was born I have

stopped smoking.

My health so far is good, although I’m not checking it. But I would say I am worried about my health,

like most people are I guess. I go to the gym. But in spite of paying fees every month I’m not regular.

Especially now since spring it’s like on and off. When it’s the nice weather you just want to go out

socialising more.

I’ve got a GP but I don’t even know who my GP is anymore, as I never go. I mean I had a different GP,

really I had four, five, six GPs, because I was living in different parts in London. I was living

Shepherds Bush, Hammersmith, Ealing, Vauxhall, so I mean I got different experience with different

GPs.

45

I would only go to a GP for an appointment if it wasn’t serious. If I thought it was, I would go straight

to the hospital. I stood on a plug, the socket, went through my skin and I knew you could get blood

poisoning so I went straight to the hospital. The GP can help you up to one point and then why are

you going to the GP? Because he’s going to refer you to someone else who is more specifically

orientated to something.

When you go to your GPs you just feel sick straightaway even if you’re not. I mean obviously when

you go there then you’ve got a lot of ill people around you, so the chance of you getting flu is higher

there.

I don’t like to take anything, even if I have the flu I don’t take any medication. But you look around

and then you see people dying from cancer, dying from different things and so on, having a stroke,

having this - what worries me is that if I ever got something I will be a burden on my family. I think I

would rather not to have such conditions, I mean now I’m contradicting myself because I don’t go to

check myself and I don’t do anything, I mean even I find it contradictory!

If I want to find some information on a health issue, the first thing what I would do is use the

internet. I am not sure if I would tell my wife if I was sick or found something I was worried about,

like a lump; I don’t want her to worry.

SEGMENT 3: Need supported outreach (to increase preventative service up-take)

Segment 3 individuals’ often lead very chaotic lives and are currently unemployed (usually

long term unemployment7). Their response to a personal letter may be complex. At one

level, they are the least likely to respond to a personal letter inviting them for a health check

but, at another, they may well attend given it has been sent by the ‘authority’. At the same

time, they may have little understanding of any letter or why they have been invited. They

often have a deep-rooted distrust of authority, including the NHS. However, they may well

have a body such as a community centre or other individuals within the community whom

they trust. Understanding this is critical for this segment. This segment usually has the most

contact with local services, such as the housing and benefit teams. They are usually in

regular contact with their GP as they often have long-term conditions or have had problems

with addiction previously (for example, with alcohol). They need both an immediate and

responsive service that picks up on their lifestyle and supports them through any

preventative service provision.

Steve, 51, long-term unemployed

I sometimes go out. If I have to go, I always go with my wife because I suffer from dizzy spells and I

worry about falling over. I don’t like to go on the tube as I don’t fancy falling down the stairs or the

escalator. I’m on some medication - vitamin tables. I’m not sure what they are for, they’re little

white ones.

7 Both Segment 1 and Segment 2 could be unemployed as well, but a much smaller percentage.

46

I do worry about my health and my wife’s health. We don’t have a phone so last Christmas my wife,

she thought she was having a heart attack, so I had to go to the phone box to dial 999. First I went to

the corner shop, I said can you dial 999 and he said ‘no, go to the phone box.’ But the phone box

wasn’t working. I could hear them but they couldn’t hear me.

I went to the doctor a few weeks ago, but before that I didn’t see one for years. You see my old

doctor, Dr Brown, she’s a woman, I could talk to her. We communicated even though she’s a

woman. But I’ve not been well again and so I needed to see the doctor. But this new doctor, in the

end I didn’t really tell him anything, because I didn’t think he’d believe me and I felt embarrassed

saying anything to him. I’m not sure if he knew what he was doing, as he was looking at his

computer all the time.

I do like a drink and a smoke and the doctor, he did say cut down and things like that, because like I

say I like going home and watching telly or having a drink. He’s a bit sarcastic. That is why I can’t

communicate with him. But he didn’t say much and wouldn’t tell me to exercise, maybe just cut

down on smoking. He probably has information on that.

If I need help, my wife and I sometimes go to one of the local community centres. They’ve got loads

of information, and they’re very helpful here. We got evicted once because we couldn’t fill in the

forms, and housing manager filled them in for us and we still got evicted. It’s hard to trust people.

47

Figure 2. Segmentation illustration

Segment 1

Segment 3

Segment 2

The basics of good service: Clear understanding of what services

are offered and expertise, approachable and informed staff

(ensuring the correct information is provided at all times,

including receptionists), immediate testing and follow-up,

physical tests (e.g. blood tests, physical examinations), choice of

locations, after work and weekend opening times, a welcoming

and non judgemental environment.

48

7. PUSH AND PULL FACTORS

One way to identify key areas relevant for a social marketing plan is to look at the customer

‘push’ (i.e. what currently encourages people to use preventative services, and what they

think could encourage them to adopt the desired behaviour) and a service ‘pull’ (what

factors does a preventative service need to have to enable and attract people to use the

service). This notion can also be expressed as addressing both supply and demand.

By identifying insights from the study, approaches can be developed which ‘push’ people

towards the services, while then working with services to ‘pull’ them into and through the

service. See figure 3 below.

Based on other social marketing projects that have used push/pull strategies8 ‘pull’

strategies need to be implemented before ‘push’ strategies begin so that staff are prepared

to respond to people motivated to attend as a result of the elements of the social marketing

campaign that is ‘pushing’ them towards the service. ‘Pull’ strategies need careful planning

to engage, meet and deliver any training that may be required.

Equally, there should not be too much dominance on one strategy over the other, as this

can be detrimental9 – i.e. pushing people into a poor service will put those people who use

that service ‘off’ from using any part of that service in the future (and others they may tell

about this experience). Furthermore, this could be viewed negatively in a financial climate

where public money spent on ‘campaigns’ or ‘advertising’ (often the most visible elements

of a ‘push’ strategy) can be highly criticised. Likewise, a service that has improved itself to

‘pull’ people into it, but no one is triggered to use the service or does not know about it, will

also fail. Subsequently, push and pull strategies need to be harmonious to ensure a working

‘market’ (with supply and demand complimenting one another).

8 Suckling, R, May 2010, ‘Early lung cancer intervention in Doncaster: Doncaster 3 week cough how to guide:

http://info.cancerresearchuk.org/prod_consump/groups/cr_common/@nre/@hea/documents/generalconten

t/cr_042781.pdf. Accessed January 2012.

9 See PSI, 2011, From Push to Pull: PSI/Rwanda – the Evolution of a Social Marketing Sales & Distribution

Approach: http://wsmconference.com/downloads/11S3S3%20David%20Walker.pdf. Accessed January 2012.

49

Figure 3. Push and pull factors

The customer is ‘pushed’ towards the service, and the service ‘pulls’

the customer through (remember that those who have been ‘pulled’

through a service they like, are likely to use that service again)

PULL

Professional and friendly service

Immediate results

Physical tests

Convenient, out of hours opening times and variety

of locations, including community venues

Non-judgemental environment

Support and constant follow-up through the referral

system

DESIRED BEHAVIOUR:

Attending local

preventative health

services

PUSH

Clear understanding around what services are

offered and how to access them

Family norm

Perception of risk

Life events/experience of others

Already seeing a GP for health care

Clear terminology used to explain ‘preventative’

services

PREVENTATIVE

HEALTH SERVICES

50

8. CONCLUSIONS & RECOMMENDATIONS

This piece of work contributes to the scoping phase of a social marketing project aiming to

reduce the current disproportionate outcomes for males within the Haringey catchment

area by increasing the uptake of preventative services.

The study identified three segments. They are not exclusive, as men can move between

them, depending on the situation, for example, due to changing life events or a positive or

negative personal experience, or experience of a family member. Despite the different

segments, there were some fundamentals of good service that overlapped each of the

segments.

8.1. Key insights

Lack of knowledge and awareness. Importantly, across all the segments, there was a

lack of knowledge around what preventative services actually were provided by primary

care, or GPs could refer on to. This was noted by the health professionals, and

corroborated by discussions with men. More important was not only whether they

equated GP service provision with preventative health but whether they even

understood the concept of preventative healthcare.

Fear. A key insight emerging from the study was around ‘fear’. The vast majority of

interviewees believed there was not a ‘typical man’ who did or did not access

preventative services. The evidence also revealed a number of clear reasons why men

between the ages of 40-74 did not do so. Across the board and in discussions with both

healthcare professionals and the men themselves there emerged a belief that men did

not access such services because they were ‘fearful’ of what they might find out. Some

interpreted this behaviour as ‘macho’ and this was evidenced by some of the men

reporting that they would not discuss health issues with their friends or colleagues. This

was because of a perception that illness was perceived as a weakness. In terms of

preventative services, it appeared that ‘fear’ and possibly ‘denial’ were more influential

in behaviour rather than being ‘macho’. ‘Fear’ was not solely about the outcomes -

what tests might find, but also the process, what would happen, would they end up in

hospital for further tests, etc. These fears were particularly acute if attending GP

services as GP were seen as generalists who would just refer you on to a specialist, and

then it was believed that you would end up having to go to hospital.

Whereas being ‘macho’ was highlighted as a reason why they would not access the

doctor for medical care as well as for preventative services, it seemed that the influence

of wives or girlfriends in pushing their partners to access the doctor tended to be the

case in the former scenario rather than the latter. Men might well be ‘cajoled’ into going

51

to health services for a particular health problem but this did not necessarily translate

into women influencing their decision to access preventative health services. Further,

unlike the issue of ‘fear’ or being ‘macho’, the importance of a female was rarely

brought up spontaneously.

In particular, the link between health and deprivation arose in many of the interviews.

A number of respondents thought that for those in dire straits - especially economically -

the top priority was not their health. Going to the doctor was simply something else to

do. In some interviews this idea was developed further with a sense that visiting

medical services might create a fear that they might ‘lose’ their health as well. Indeed it

was mooted that it is not the ‘men’ that are different but that individual circumstances

were the key drivers in this type of health behaviour.

Cultural norms in families. Such complexity was also to be found in looking at different

cultural communities. Certainly familial patterns, behaviours and cultural norms were

seen to be important within families but in terms of ethnicity no evidence was found

that some ethnic groups are more or less likely to access preventative services10. The

majority of respondents, including health professionals, believed that there may be

issues such as age, lifestyle and other factors as indicated above, but that it was simply

not possible to segment on ethnic grounds. Noteworthy, however, was a belief by some

health professionals that certain ethnic groups have their own medical and preventative

services – for example, the Chinese and Turkish communities.

Trust. Another insight was around trust. This was a further factor in interviewees’

perceptions with some respondents reporting that they had little trust in their GPs,

given previous experiences. It should be noted that, for some, this fed into a more

general perception (possibly lack of understanding) of how the NHS works. In this

instance, it tended to be members of the Eastern European communities who felt that

the GP would not tell them anything they did not know or could obtain from the

internet.

Linked to the trust issue, the men were distrustful of a diagnosis based on a discussion

with a doctor. Instead they preferred to have a physical examination, blood tests, or

some kind of clinical intervention.

Terminology and understanding of preventative services. A further key insight was that

preventative measures, and thus services, were not spontaneously connected to

‘health’. In this regard, discussing preventative health measures with some respondents

10 This was the case even taking into consideration the sample limitations

52

presented a number of issues and as that they had not previously accessed them this did

not, by any means, indicate a refusal to attend. It might actually mean they simply had

not been aware they even existed or that they knew what they were. However, on

prompting the majority, for example, were aware that smoking cessation could be

accessed via a range of services including the GP. Some felt this would be the case as

well for alcohol issues and weight loss but in terms of fitness and diet for instance few

would appear to consider the GP or even the NHS more generally as an information

source. Most tended to believe that in the case of fitness, their first port of call would be

a gym.

8.2. Possible solutions

In terms of solutions and how services could be made either more ‘accessible’ or more

‘attractive’ to respondents, there was a range of suggestions. On the one hand, there might

need to be improvements to current provision, for example, allowing GPs to have more time

to encourage access or to more readily promote such services. Among the health

professionals, there was a general view that there were adequate services but access was

the issue. However, one GP surgery felt that in an area like the eastern wards of Haringey,

more preventative services were clearly needed. The majority of respondents also

believed that it should and could be the responsibility of GPs to signpost to other services.

There was also some doubt among a few GPs as to their use of the Health Trainer team and

one surgery argued that they did not need to refer to them since they, as ‘quality’ GPs,

carried out the work themselves and thus they were not needed. The Health Trainers

themselves believed that once the local GPs knew and had experience of their work, then

the present system of referrals worked well but feedback from clients was essential as was

their own capacity to deal with an increased number of clients. There was also a view that

Health Trainers were perceived by other professionals simply to be one of a number of

services offered as opposed to specific provision.

Linked to this, was a suggestion, supported in many discussions, that it was important to

‘take the services’ to the community. A number of male respondents felt that they might

attend a centre that could have a ‘shop front’ on a main street to attend for preventatives

services. Others welcomed the idea of having ‘health checks’ in community centres,

shopping centres, barber shops, betting shops, pubs etc. With regard to places where men

‘socialised’ such as pubs, it was equally felt that most ‘men’ would not like to be interrupted

when they were being sociable.

Whereas the Health Trainers supported the idea of ‘services in the community’, a number of

GPs did not on the grounds that frequently such services would be provided but were not

sustainable, followed up inadequately with GPs having to ‘pick up the pieces’ or would

53

start and then close down after a period of time. More problematical was thought to be

provision of services for those who simply did not attend the GP or other medical services at

all, until it might be too late. In addition to services in the community, most respondents

believed raising awareness, information campaigns and education also to be key to service

uptake. Ensuring the information would ‘strike a chord’ (built on insight) was thought to be

essential.

8.3. Recommendations

All recommendations (detailed below) and ideas generated from this study’s findings need

to be co-produced and then pre-tested in the development phase with the target audience

and stakeholders/health teams working directly with patients.

Based on the findings and on the ‘push’ and ‘pull’ analysis, a number of recommendations

are detailed below. These predominantly focus on the ‘pull’ factors. As discussed in Section

Six, ‘pull’ strategies need to be implemented before ‘push’ strategies begin.

Basic service improvements

Improvements should be made to the existing preventative services within the borough by

addressing the basics of good service. The majority of these changes can be done at very

little cost. Recommended changes include:

a) Training for receptionists and clinic staff – focusing on meeting and greeting, ensuring

the correct information is provided to patients, etc. Training for the clinical staff should

include how to talk to a patient before referring them so the patient knows what to

expect;

b) Consistently offering a quick results service and promoting this on website and in any

promotional literature/in invitation letters sent to patients;

c) Reviewing opening hours to make a more flexible service and/or better sign-posting to

late night services available in the borough; and

d) At least one physical test should be included in any screening programme.

Knowledge gaps

To ensure that the basic service improvements are made, there are still some knowledge

gaps that need to be addressed. These include:

Establishing how each of the GP surgeries within the chosen wards currently refer

people (procedures, where they get their information about services, what

preventive services do they currently refer to, etc.); and

Look at current-referral systems to understand how they worked and what (if any) is

the current feedback link to the GPs.

54

Ensuring service provision for each of the segments

The segmentation work should be used to ensure that there are services to meet the needs

of each of the segments. The referral pathways should also be reviewed to ensure that each

segment is able to navigate the pathways successfully. Customer journey mapping work

could be used to identify any barriers for each of the segments in the pathways and help

streamline them.

Commissioning of preventive services

When preventative services are commissioned or the work retendered, the segments

should be shown and discussed with service providers and the providers should detail which

segment their service is for and/or how to ensure the service appeals to the other segments

also. In addition to this, work can be done with the existing service providers to review

which segment/s currently attend their services. In order to do this, a short survey will have

to be developed. By asking questions around psychographics (such as attitudes and beliefs,

etc) the survey, if administered to the users of the services, will be able to identify which

segment they belong to.

GP involvement

In addition to the service improvements detailed above, GPs need to feel involved and their

voice heard in any changes/future programmes that are developed. They need to feel that

they are a joint partner with the public health team, as opposed to changes “being forced

upon” them, which is what many of the nine GPs reported during this study.

Stakeholder engagement

From past experience at The NSMC, social marketing projects which have not engaged fully

with the stakeholders have been unsuccessful. Therefore, in addition to the work with GPs

further stakeholder engagement needs to be conducted with the community organisations.

This study highlighted the value of using such organisations to increase the uptake of

preventative services. However, as with the GPs, they need to feel that they are a joint

partner, and can input suggestions into how the process should work. The stakeholder work

should also involve co-production with the target audience so that any interventions

developed are customer-orientated. This could be done through the establishment of a user

group, or through accessing an already existing group.

Improved coordination between health professionals and other non-statutory

organisations

There are a number of non-statutory organisations based in the wards with connections to

the target audience. However, coordination and communication between these non-

55

statutory organisations and the NHS bodies could be improved. To improve integration and

ensure that all organisations are helping to ‘pull’ people through the services as well as

‘push’ them into the services, a series of workshops (ideally facilitated by an external body)

should be held to look at ways to improve the coordination and develop ‘push’ and ‘pull’

strategies that all parties support and will help implement.

56

GLOSSARY Triangulation: A method used by qualitative researchers to check and establish validity in

their studies by analysing a research question from multiple perspectives.

Purposive sampling: A commonly used sampling method. It is the selection of participants

according to preselected criteria relevant to a particular research question (for example,

men with a high BMI living in a certain geographical area). Purposive sample sizes are noften

determined on the basis of data saturation (the point in data collection when new data no

longer bring additional insights to the research questions). Purposive sampling is therefore

most successful when data review and analysis are done in conjunction with data collection.

Data saturation: Sometimes referred to as theoretical saturation - the point in data

collection when new data no longer bring additional insights to the research questions

Health literacy: Defined as the cognitive and social skills that determine the motivation and

ability of individuals to gain access to understand and use information in ways that promote

and maintain good health. This means much more than transmitting information and

developing skills to undertake basic tasks. By improving people’s access to and

understanding of to health information and their capacity to use it effectively, improved

health literacy is critical to empowerment.

Grounded theory: It aims to generate a theory that is 'grounded in' or formed from the data

and is based on inductive reasoning. This contrasts with other approaches that stop at the

point of describing the participants' experiences. In terms of data analysis grounded theory

refers to coding incidents from the data and identifying analytical categories as they emerge

from the data, rather than defining them a prior to beginning the research.

57

APPENDIX

Appendix I. Topic Guide

Local residents Notes:

This is the guide for use in the group discussions to be held with men. It will be adapted for

dependent on whether they are ‘doers’ or ‘non-doers’. It is not expected that individual interviews

will last more than one hour.

The format follows that of unstructured qualitative interviews in which the guide is used as only a

framework for discussion so that interviews are open-ended, flexible and responsive to what

respondents have to say, thus allowing for spontaneity and full exploration of the issues. It sets out

key issues to be raised, some possible lines of questioning and areas to probe. Probing will be

continuous throughout the discussions even when probes per se are not listed below. The order in

which issues are raised will tend to vary and questions will seldom be asked in the way they appear

on the guide.

Introduction to Discussions

The National Social Marketing Centre, have been commissioned by Haringey Council Public Health

Department to undertake a study to understand why men like yourselves may not wish to access

primary care services that address the prevention and detection of cardiovascular disease and

cancer and to gain insight into what would make such preventative health services more attractive

to men in the east of the borough.

This will be a fairly informal session that is anticipated to last no more than an hour. In order to

obtain an accurate record, I would like your permission to record the discussion. The tape and the

resultant transcript will be accessible only to the study team. Your views will not be linked with your

name when the research is reported and Haringey Council will have absolutely no records or details

of any of the participants in this project.

Description/questions Comments for Interviewer Approx

Timings

1. General background information

Introductory questions:

Brief life details

o Eg Age, marital status, ward where they

Gauge general life details but

see whether and to what

extent general health is

5 mins

58

live, employment status etc

o General lifestyle questions:

Exercise/ sport, socialising, smoking, drinking etc

mentioned

2. General Health Issues

Can you talk a little bit about your health?

Are there any health issues that are concerning you?

o Probe whether concern is about themselves or whether family/friends etc

What do you normally do if you are worried about your health?

o Probe whether information is sought and, if so, from where eg friends/family/internet/books/leaflets/health professional etc

Where would you tell a friend to go for information? (Probe as above)

Which source of information do you think is the most reliable? (Probe as above but check whether it depends on the health problem)

What sort of health problem makes you worry?

o Probe whether it is the ‘known’ or the ‘unknown’ problem

At what point do you see a professional, if at all?

o Probe whether it is immediately, leave it to the last minute and whether it depends on the nature of the health problem etc

Do you have a health concern at the moment?

o Probe why they might be concerned, the trigger for the concern, what they have done so far etc

What action have you taken about your present health concerns?

Important to note how they

talk about their health

whether dismissive, whether

concerned. At this stage, keep

the conversation broad but

remember to pick up on issues

later in the discussion

Ensure there is adequate

probing about how they

perceive illness, the extent to

which they worry, whether

they leave it to the last

minute or seek advice early

but ensure to distinguish

between preventative vs

reactive behaviour

Check whether they mention

any barriers or enablers such

as family pressure vs ‘feel’

healthy, time vs making time

and so on

Key is to establish the triggers

that prompts them to seek

help

5 mins

59

Is this what you would have normally done?

o Probe whether present health concerns differ in any way from previous ones. If not, why not?

Refer to comments above,

probe any inconsistencies and

unpick factors that might

trigger seeking help. Also

attempt to distinguish

between reactive and

proactive behaviour

Also check to see whether

their attitudes have changed

as they have got older ie 40-74

is a wide age range

Important to establish what

they themselves would do as

opposed to friends/family etc.

Again look for any

inconsistencies

2a Experiences of Health Professionals

When did you last see a medical professional?

o Probe for who and why, giving details of experience

How long had you had the concern before you saw a professional?

How often do they see their GP?

What sort of relationships do they have with

This is to explore their last

medical journey and check for

any inconsistencies with the

above. Again look for

impressions, experiences,

feelings and perceptions

5 mins

60

their GP?

o Probe whether sessions are perfunctory, rushed and what their feelings and perceptions are etc

What is their surgery like?

o Probe for good/bad things, opinions about different members of staff and so on

If they have a health concern would they feel able to contact the GP?

o Probe when it is difficult and when it is not

How do they feel more generally about contacting health professionals?

o Probe for difficulties and why they have that perception

Do they see themselves as generally fit?

o Probe what they might do to keep fit or what they could do

Would they consider asking a healthcare professional about it?

Probe for who and also whether they have ever asked for help about this

Check against previous

comments and again listen for

triggers

Check for perceptions about

GP, surgery but also

distinguish between different

professionals eg Nurse, GP,

HCA

Again refer to comments

above

Check to see whether they

regard fitness and lifestyle as

part of health

Check the extent to which

they are aware of preventative

health care and preventative

services

3. Specific Experiences

Are they aware of any services offered on the NHS that are designed to prevent illnesses such as heart disease or cancer?

o Smoking, lifestyle, keeping fit, health trainers etc

o Probe for knowledge and who they think the services are for. If not for them, probe also for details of types of people

Although specific, leading

them through the process of

the NHS Health Check will

reveal their response to

preventative care. Listen for

underlying factors, refer and

link in to comments above

10 mins

61

who they think they are for

Have they heard of the NHS Health Check that is now offered to all those over the age of 40?

If yes, have they been contacted by the surgery about it?

o Probe for experience of this and obtain details of process including: how they were approached

Can they remember what happened?

o Probe for whether they responded giving reasons why, how long before they responded and so on

o If they did not respond, probe why this was so, how they felt about it, what it triggered in them, whether they feel that if the GP is the place for such checks and so on

Did they want or need more information?

o Probe for what information they wanted and why and from whom ?

Can they remember how many times they were contacted by the surgery?

Were they contacted again?

o Probe how they felt about being contacted again, whether it changed their minds and why. If not, check feelings and response

If they attended, where they referred for follow up treatment eg Health Trainers, smoking cessation, weight management etc?

o Did they attend? (Probe as above)

Be aware of terminology and

assumptions. It will be

important to check the extent

to which and what they

understand about the term

‘preventative’ care

Check too to see if they

consider the preventative

services they are aware of are

for people ‘like them’. If not,

who are they for?

Seek out triggers for

responding/not responding,

point at which they went and

so on

62

Information may be important

in that the letter may not have

been clear to them what it

was for

Also check for responses to

follow-ups and feelings and

perceptions about this

2b. Other measures

Have they been asked to attend the surgery for anything else?

o Why? Eg COPD/asthma checks, smoking, weight management, exercise programme, Health Trainers etc

o Probe for process and their reactions to this etc

Did they attend?

o Probe again for the process eg if they responded, why, how they felt, who carried out the checks and so on.

If not, why not?

o Probe for reasons, how they felt and why

Did they want or need more information?

o Probe as above

Can they remember if they were followed-up?

o Probe as above and whether they changed their minds, at what point time and why?

In contrast to Health Checks or

something like bowel cancer

screening where, in both

cases, patients are

automatically written to, other

preventative services tend to

be as a result of either the

follow up of a Health Check,

when the GP has a ‘pop-up’ on

his screen or when the surgery

‘checks’ their register. It may

well be important to make this

distinction

Look for triggers at all times

for reasons why they might

attend or might not and look

for triggers of behaviour as

above

15 mins

63

Have they ever been asked to attend follow-up appointments or referred elsewhere for ‘lifestyle issues’

o Probe for what, details of what happened, why and how they felt

Bowel cancer will only apply

to older men but it is

important to seek out whether

different types of invitation

change their responses. Check

for any inconsistencies

If they have been asked to

attend for different things,

check what they are, why they

did or didn’t go and seek out

different reasons for different

services if relevant

Check also to see if they have

been called in because of their

lifestyle (although they may

not refer to it as this), how

they regard this, whether they

attend and if so, whether they

attend the subsequent referral

and so on. Also check to see

whether they regard this as

different from other

preventative services and if so,

why. Check for triggers of

behaviour

Asking about ‘lifestyle’ issues

is very sensitive so it needs to

be asked very carefully indeed

64

2c. Attitudes

What do you see as the possible benefits of having preventative health checks?

o Probe for reasons such as longer life, better to treat early

And what might be the disadvantages?

o Again probe for reasons such as ‘better not to know’ fear etc

Why do you think many men of your age do not go? (Refer to responses above to check for contradictions or any inconsistencies etc)

Which type of man, in your view does not go?

o Probe for profiles eg young/old, fit/unfit, smokers/non-smokers, marital status, those from different cultural communities

o Also probe for less tangible factors such as perceptions of men who might go eg does it affect their ‘macho’ image, does it mean they are the ‘worried well’ and so on

What do you think might make other men go?

o Probe for suggestions eg nature of healthcare professional – eg nurse, HCA, GP, easier access to GP (and what this actually means), being ‘told to’ by family members, especially the wife

o Peer influences

o Work colleagues

o Family

o Running with the pack etc

What would make you go?

Where do you think the best place is to have preventative health services?

o Probe for possible other locations such as at a chemist/pharmacy, shopping centre etc giving advantages and disadvantages

It may also be useful here to

ask why it might benefit

others as well as themselves

Also it is key to listen for

inconsistencies and to see if

there is a distinction between

why they think others may not

go and why they may not go.

They may also talk about

others in lieu of themselves.

May need to build up to the

critical question of why they

do not go (if this is the case).

Can they generalise or is it

about specific services?

Also be careful to check for

both tangible and less tangible

reasons such as for example,

those who smoke, unfit etc vs

being ‘nagged’ by the wife,

not being ‘macho’ or being a

‘wimp’, self indulgent etc

Probe very carefully for what

might make them go too with

the above in mind

15 mins

65

And you?

o Probe for feelings and reasons why

Who do you think should have responsibility for preventing illnesses such as heart disease or cancer?

o Probe again whether they see health professionals as being the place/people who deal with preventative care?

3. Conclusions

In their view, what could GPs do to encourage

men like yourself to take up Health Checks and

preventative programmes?

And what advice would you want to give to

those that make the decisions about initiating

preventative health services?

THANK AND CLOSE

5 mins

66

Appendix II. Topic Guide

Health professionals Notes:

This is the guide for use in the group discussions to be held with GPs. It will be adapted for Health

Trainers, Practice Nurses and/or Health Care Assistants (HCAs) as appropriate. It is relatively

focussed on the basis that their time will be very limited.

The format follows that of unstructured qualitative interviews in which the guide is used as only a

framework for discussion so that interviews are open-ended, flexible and responsive to what

respondents have to say, thus allowing for spontaneity and full exploration of the issues. It sets out

key issues to be raised, some possible lines of questioning and areas to probe. Probing will be

continuous throughout the discussions even when probes per se are not listed below. The order in

which issues are raised will tend to vary and questions will seldom be asked in the way they appear

on the guide.

Introduction to Discussions

The National Social Marketing Centre, have been commissioned by Haringey Council Public Health

Department to undertake a study to understand why men do not access primary care services that

address the prevention and detection of cardiovascular disease and cancer and to gain insight into

what would make such preventative health services more attractive to men in the east of the

borough.

This will be a fairly informal session that is anticipated to last no more than an hour. In order to

obtain an accurate record, I would like your permission to record the discussion. The tape and the

resultant transcript will be accessible only to the study team and every effort will be made to make

sure that your views cannot be linked with your name when the research is reported.

Description/questions Comments for Interviewer Approx

Timings

1. General background information

Introductory questions:

Brief details of surgery – size, make-up, demographics of area etc

How would they describe the health in general terms of their patient population?

o And men in particular?

Aim to understand context of

surgery, particularly

demographics, whether transient

population etc

3 mins

67

Note whether they think there is

anything ‘different’ about the

men in the east of the borough

and, if so, why? What?

2. Preventative Services - General

What preventative services are offered by your surgery?

Are they able to provide an estimate of the percentage take up of such services?

Try and gauge what they consider

to be ‘preventative’ services and

aim to distinguish between the

views of the surgery as a whole

and those of the individual

professionals

5 mins

2a. Access to Preventative Services

In general, can they categorise who accesses preventative services?

o Probe for which services and for which type of illness?

Are they able to categorise those that don’t?

o Prove for which services and which types of illnesses?

In their view, is it possible to categorise those who they feel may come at the ‘last minute’?

o Give details

And those that access preventative services early on?

o Give details

Try to differentiate between

different preventative services. If

it differs why is this so in their

view? What are the underlying

factors?

Aim to seek out differences

between those that do access and

those that don’t. In their view,

what differentiates them? Age,

ethnicity, level of education,

gender, those working/not

working, with partners/without

etc

Use NHS Health Checks, ‘pop-ups’

etc as prompts if need be

Also note differences in opinions

5 mins

68

between different levels of

professionals.

3. Possible Barriers

Why, in their view, do men between the

ages of 40 and 74 not take-up

preventative services?

What factors play a part in this?

Probe for both intangible and

tangible factors such as

perceptions of service provision,

‘fear’ of finding out, reluctance to

‘enter the system’ vs time, work,

awareness of role of GP,

knowledge of GP services etc

Seek out different reasons for

different groups/segments of

men.

Does it make any difference

whether the men are old vs

young or, alternatively, fit vs unfit

and so on

Key to seek out what they

perceive the triggers to be for

men to attend preventative

services

Again, note differences in

opinions between different levels

of staff

10 mins

4. Potential Solutions

In their view, what do they believe their surgery could do to improve the uptake of preventative services among men?

In their view, what would make such

Refer and connect to what they

said above and possibly is

appropriate deal with solutions to

different groups of men looking

7 mins

69

services more attractive to men?

o Probe for which services and what

they might do?

In your view, to what extent should

‘preventative’ work be the responsibility

of primary care?

Do they think there are any particular

difficulties for the surgery in offering

such services?

In their view, is there a difference in

engaging men and women in

preventative work? If so, what?

In your view, where should the responsibility and implementation of preventative programmes lie?

at patterns, themes, unpicking

the factors

Probe also for whether such

services could be managed

differently by the surgery eg

process, staff involved, times of

appointments, follow-ups within

the surgery as well as with

patient etc

Probe also for potential use of

other locations for screening

(shopping centres, pharmacists

etc)

Try and seek out whether to what

extent they believe they and/or

primary care should be

responsible for preventative

services

But continue to probe at all times

for what they could do within

their own constraints (perceived

or otherwise)

Probe to uncover underlying

issues ie time/finance/transient

populations vs perceptions.

Probe too whether there any

differences in engaging men and

women and whether there may

be staff/patient issues

5. Conclusions

If you were responsible for the Health and Well Being initiative, what approach would you take to preventative checks?

THANK AND CLOSE

3 mins