MEN’S HEALTH SOCIAL MARKETING
SEGMENTATION AND INSIGHT PROJECT
Findings from the scoping study
February 2014
1
CONTENTS
Executive Summary................................................................................................................................. 3
1.
Introduction .................................................................................................................................... 5
2.
Methods .......................................................................................................................................... 6
3.
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
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
2
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.
3
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 costeffectiveness) 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.
4
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.
5
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.
6
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.)
7
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.
8
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
9
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.
10
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)
11
Table 1 continued
GENDER
Male -
AGE
ETHNICITY
EMPLOYMENT STATUS
MARTIAL
STATUS
58
Afro/Caribbean
Unemployed
Single
(Separated)
54
White British
Unemployed
Single
(Separated)
Both Afro/Caribbean
Both Unemployed
Couple
Male/Female 57 and 61
Both White British
respectively
Both Unemployed
Couple
Male/Female 59 and 54
Both White British
respectively
Male = Groundsman
Couple
Male/Female 57 and 56
Male = Actor
Respondent
was blind
Male
PAIRED INTERVIEWS
Male/Female 53 and 42
- Female
respondent
had learning
difficulties
respectively
Male = White British
respectively Female = German
Female = Cleaner
Couple
Female = Administrator
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
12
Table 1 continued
GENDER
Male
AGE
50
ETHNICITY
EMPLOYMENT STATUS
MARTIAL
STATUS
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
13
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
14
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
R
A
W
D
A
T
A
P
R
E
L
I
M
I
N
A
R
Y
C
O
D
E
S
Awareness and
knowledge of
preventative
services
Perception of
services
Lifestyle
Masculinity
Influencing factors
Possible service
improvements
Code description
Knowledge of service provision, Health checks,
Perception of risk
Previous experiences of services, Trust
Complex life issues
Fear and denial, Personal willpower, Physical
examinations
Role of the partner, Past experiences
Community testing venues, Workplace and
mobile testing venues
15
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
16
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.
17
“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.”
18
“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
19
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.”
20
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
21
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
22
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.
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“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.”
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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!”
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“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.”
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“[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
27
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
28
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.
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“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.”
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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.”
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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’.”
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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)
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“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
34
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.
35
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
36
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.”
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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 socioeconomic.
“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’ nonattendee. It was simply ‘men’.
38
“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.
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“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.
40
“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
41
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)
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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.
43
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.
44
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.
45
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.
46
Figure 2.
Segmentation illustration
Segment 1
Segment
2
Segment
3
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.
47
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 strategies 8 ‘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.
48
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)
PUSH
Clear understanding around what services are
offered and how to access them
PULL
PREVENTATIVE
HEALTH SERVICES
Professional and friendly service
Immediate results
Family norm
Physical tests
Perception of risk
Life events/experience of others
Already seeing a GP for health care
Clear terminology used to explain ‘preventative’
services
DESIRED BEHAVIOUR:
Attending local
preventative health
services
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
49
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
50
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 services 10. 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
51
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
52
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.

53
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 non54
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.
55
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.
56
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
1. General background information
Approx
Timings
5 mins
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
57
live, employment status etc
o
mentioned
General lifestyle questions:

Exercise/ sport, socialising, smoking,
drinking etc
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?
5 mins
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
o
Probe whether information is sought and,
if so, from where eg
friends/family/internet/books/leaflets/he
Ensure there is adequate
alth professional etc
probing about how they
perceive illness, the extent to
Where would you tell a friend to go for
information? (Probe as above)
which they worry, whether
they leave it to the last
Which source of information do you think is
minute or seek advice early
the most reliable? (Probe as above but check
but ensure to distinguish
whether it depends on the health problem)
between preventative vs
What sort of health problem makes you
reactive behaviour
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
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
What action have you taken about your
present health concerns?
58
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
5 mins
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?
This is to explore their last
medical journey and check for
any inconsistencies with the
above. Again look for
impressions, experiences,
feelings and perceptions
What sort of relationships do they have with
59
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
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
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 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
10 mins
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
60
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
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
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)
61
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.
15 mins
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
If not, why not?
o
Probe for reasons, how they felt and why
Did they want or need more information?
o
Probe as above
Look for triggers at all times
for reasons why they might
attend or might not and look
for triggers of behaviour 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?
62
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
63
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
o
Probe for profiles eg young/old, fit/unfit,
smokers/non-smokers, marital status,
those from different cultural communities
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
15 mins
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
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
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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
5 mins
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
65
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
Aim to understand context of
surgery, particularly
demographics, whether transient
population etc
3 mins
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?
66
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 5 mins
to be ‘preventative’ services and
aim to distinguish between the
views of the surgery as a whole
and those of the individual
professionals
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?
5 mins
Try to differentiate between
different preventative services. If
it differs why is this so in their
view? What are the underlying
factors?
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
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
Give details
Use NHS Health Checks, ‘pop-ups’
etc as prompts if need be
Also note differences in opinions
67
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?
10 mins
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
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
7 mins
Refer and connect to what they
said above and possibly is
appropriate deal with solutions to
different groups of men looking
68
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?
3 mins
THANK AND CLOSE
69