Review

Keywords

Policy

Men’s health

Noel Richardson, PhDCentre for Men’s HealthResearch and Training,Institute of Technology,Carlow, Ireland

Paula C. Carroll, PhDCentre for HealthBehaviour Research,Waterford Institute ofTechnology, Ireland

E-mail:Noel.Richardson@itcarlow.ie

Online 7 May 2009

� 2009 WPMH GmbH. Published

Getting men’s health ontoa policy agenda - chartingthe development of aNational Men’s HealthPolicy in Ireland

Noel Richardson and Paula C. Carroll

Abstract

In January 2009, the Department of Health and Children in Ireland published a national men’s health

policy. The policy was developed following an extensive research and consultation process. The need for a

specific policy focus on men’s health was identified in Ireland’s National Health Strategy in 2001. This

prompted the Department of Health and Children to fund a 3-year men’s health research project, the

findings of which were launched at the first National Conference on men’s health in Ireland, which took

place in December 2004. An inter-Departmental and multi-sectoral Steering Group was appointed to

oversee the development of the policy. Under the terms of reference of the Steering Group, an extensive

and nationwide consultation process was undertaken with all relevant stakeholders. The findings from

this consultation process, together with an extensive review of the evidence underpinning the issues

raised, were then translated into concrete policy recommendations and actions. These recommendations

and actions address a broad range of men’s health issues and have implications in terms of gender-

mainstreaming men’s health across a number of government departments. This paper will describe the

background to the policy, outline the methodologies and key principles used for policy development and

summarise the key policy recommendations. It will also reflect on some of the key lessons learned and on

the challenges in terms of making the policy succeed. � 2009 WPMH GmbH. Published by Elsevier Ireland Ltd.

Introduction

The upsurge of interest and activity around

men’s health in Ireland in recent years mirrors

an international trend that has seen an

increased spotlight on men’s health.

The field of men’s health in Ireland has been

greatly strengthened in that time by research,

advocacy work and by a variety of grass-roots

work in both the statutory and community/

voluntary sectors. What has arguably been the

most significant development in the relatively

short evolution of men’s health in Ireland, has

been the recent publication of a national

men’s health policy [1]. The publication of

the policy, in January 2009, followed a com-

by Elsevier Ireland Ltd.

mitment, as set out in the National Health

Strategy [2] to develop a national policy for

men’s health. Whilst other countries (notably

the UK and Australia) have been to the fore-

front of men’s health in terms of developing

gender-specific programmes and a wider range

of practical initiatives in men’s health, Ireland

has become the first country in the world to

publish a national policy for men’s health. In

this respect, the publication of the policy

marks uncharted territory, but, it is hoped,

it will serve as a model of good practice and

provide leverage for the development of men’s

health policy initiatives in other countries.

This paper will present an overview of the

evolution of men’s health onto a policy agenda

Vol. 6, No. 2, pp. 105–113, June 2009 105

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106 Vol. 6, No. 2, p

in Ireland. It will describe the methodologies

and key principles used for policy develop-

ment and reflect on some of the opportunities

and challenges in terms of making the policy

succeed.

Focusing the spotlight on men’shealth

The case for a policy focus on men’s health is a

strong one. There has been a growing concern

in Western countries in recent years about the

burden of ill-health experienced by men. In

Ireland, male life expectancy is lower than that

of women (by almost 5 years) [3] and men have

higher death rates than women for most of the

leading causes of death and at all ages [4–6]. A

more careful examination of aggregated data

reveals substantial differences between differ-

ent categories of men, particularly in relation

to age [4–6] and socio-economic status [7,8].

Young men (15–24 years) are a particularly

high risk group [4–6]; suicide being the prin-

ciple cause of death among this group. This

contrasts with most other countries, where

suicide is more frequently observed in older

men [9]. Compared to men in the highest

occupational classes, men from the lower occu-

pational classes have poorer health outcomes

and experience significantly higher mortality

rates [7,8]. It is also well recognised in Ireland

[10] and internationally [11,12] that men are

often reluctant to seek help and continue to

present (too) late in the course of an illness.

In more recent years, there has been an

increased focus on gender in the context of

men’s health. Whilst in the past, the focus on

gender and health in Ireland has tended to be

synonymous with women’s health [13], the sig-

nificance of gendered health practices (particu-

larly gendered patterns of help-seeking), have

more recently come to the forefront in the

context of men [10,14]. This reflects more

deep-rooted and widespread changes that have

occurred in gender relations. In Ireland, as in

other developed countries, the challenge to the

position of men in gender relations has resulted

in important changes in work practices, more

‘democratic family structures’ [15] and the con-

tinued blurring between more traditional male

and female roles.

There has been much debate and publicity

in recent years about men’s changing roles,

p. 105–113, June 2009

the notion of the ‘new man’, and the degree to

which men are choosing to embrace or resist

change. For example, whilst men are often

considered ‘hard work’ by health service pro-

viders by not caring for their health [16],

society continues to reward and honour

aspects of male identity associated with risk,

daring and foregoing safety, through gendered

systems within politics, work and sport. In

some aspects, we know that men want to

change. For example, while women continue

to have overall responsibility for managing

and caring for children [17], the vast majority

of fathers would prefer to work less in order to

spend more time with their children, citing

inflexible work practices and inadequate pro-

vision of paternity and paid parental leave as

barriers to achieving this [10]. Of course many

men are already embracing change and re-

defining their roles. Indeed the changing atti-

tudes and practices of some men have been

crucial to paving the way for potentially

greater choice for all men (and women) in

their work and family lives. By challenging

traditional notions of masculinity, many more

men can now, for example, fulfil their capacity

to be active, involved and nurturing partici-

pants in family life. Whilst there is evidence,

therefore, that old stereotypes of masculinity

are being broken down, this is often not with-

out concerted effort against financial, work-

place and cultural barriers.

Not all men in Ireland benefited from the

unprecedented economic boom during the

1990s [18]. Increasing economic disparity

between the rich and poor coincided with rapid

social change. The disintegration of rural com-

munities has resulted in isolation, difficulties

with access to services and specific adverse

consequences for the mental health of rural

men [19]. Such changes have occurred against

a backdrop in Ireland of an increasing shift

towards secularisation and individualism [20].

With the recent downturn in the economy in

Ireland, labour market vulnerability and lack of

security of job tenure are increasingly asso-

ciated with poverty and social exclusion, and

are issues that are now beginning to have a

much greater bearing on men’s health than

before [18]. The adverse effect of economic mar-

ginalisation was most clearly demonstrated fol-

lowing the collapse of the Soviet Union in 1991.

In the wake of increased inflation, unemploy-

ment and reduced wages, life expectancy for

Review

men in Russia declined by 6 years between

1991 and 1994 [21].

In summary, the increased attention on

men’s ill-health together with significant

changes and challenges to more traditional

male roles and to men’s sense of place in Irish

society, provide an important backdrop to the

development of men’s health at a policy level in

Ireland. The following section will outline some

of the more specific developments that fast

tracked men’s health onto a policy agenda in

Ireland.

Factors that created a momentumaround men’s health in Ireland

There have been a number of key develop-

ments, both international and national, that,

in conjunction with more grass-roots men’s

health work, have resulted in a raised profile

surrounding men’s health in recent years. At

an international level, there have been confer-

ences on men’s health in Australia, the United

States, Asia and Europe (including Ireland),

whilst Vienna will this year host the 6th World

Congress on men’s health. Other international

initiatives in recent years include the launch of

the International Society for Men’s Health, the

commencement of an international men’s

health week, the launch of the European Men’s

Health Forum and the introduction of three

academic journals devoted to men’s health.

There has also been an increased focus by

the World Health Organisation (WHO) on gen-

der mainstreaming in relation to health [22],

although, to date, this has had more of a focus

on women’s health than on men’s health.

Health Canada’s Gender-based Analysis Policy

[23] and the Gender Equality Duty Code of

Practice for England and Wales [24] also repre-

sent important examples of attempts by indi-

vidual countries to gender mainstream health.

In Ireland, much credit is due to a number of

key advocates who successfully made the case

for a specific policy focus on men’s health dur-

ing the consultation process for Ireland’s cur-

rent National Health Strategy [2]. This resulted

in a commitment by the Department of Health

and Children in the Strategy to ‘develop a policy

for men’s health and health promotion’ [2: 163],

and provided the impetus for much of the pre-

development work surrounding the policy. The

Health Service Executive in Ireland funded two

men’s health research initiatives [10,14], devel-

oped a number of regional men’s health strate-

gies [25–27] and currently funds a number of

community development related health pro-

jects throughout the country e.g. the Men’s

Development Network, the Gay Men’s Health

Project and the North Leitrim Men’s Health

Project. The Irish Cancer Society has ongoing

campaigns directed at increasing awareness

and early detection of cancers among men.

The Crisis Pregnancy Agency funded a number

of research initiatives with a focus on men,

including, barriers relating to men’s use of

sexual health services [28] and men’s experience

of sex, contraception and crisis pregnancy [29].

The Family Support Agency at the Department

of Social and Family Affairs has also funded

research on policy and practice issues in rela-

tion to vulnerable fathers [30]. The Institute of

Public Health published an ‘All-Ireland Men’s

Health Directory’ [31], which provides a very

worthwhile database of activity in the area of

men’s health on the island of Ireland. The Men’s

Health Forum in Ireland (MHFI) has been

engaged in men’s health work at an advocacy

level since 2002, and, in January 2004, launched

a comprehensive report on men’s health statis-

tics in Ireland [32]. Other reports that focused on

the statistics for men in relation to life expec-

tancy, mortality and morbidity [7,10] also pro-

vided a strong impetus and mandate for a policy

focus on men’s health.

Approach taken to PolicyDevelopment

Men’s health policy can be defined as,

‘A formal statement that defines men’s health as

a priority area, identifies targeted action and

provides a specific plan or framework for action.

It describes the procedures of institutions in the

statutory, community, voluntary and private

sectors, to promote men’s health, and defines

the accountabilities of the involved partners’

(adapted from Bull et al. [33]).

The approach adopted in the development

of Ireland’s national men’s health policy is out-

lined in Fig. 1. This approach was made up of

three distinct phases, pre-development, devel-

opment and maintenance and the methodolo-

gies used during each phase adhered to defined

criteria that meet international best practice.

Vol. 6, No. 2, pp. 105–113, June 2009 107

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Figure 1 Model adopted for Policy Development (adapted from (a) the Policy Development Process with Best Practices

model [34], (b) A Practical Guide to Policy Making in Northern Ireland [35] and (c) Bull et al. [33]).

108 Vol. 6, No. 2, p

The timeframe for the development of the

policy over each phase is outlined in Table 1.

(i) Pre-Development Phase

Following publication of a specifically commis-

sioned men’s health and gender research report

[10] at the first National Conference on Men’s

Health, an expert Men’s Health Steering Group

was convened to develop the national policy

with representatives from across a range of

government departments, statutory, commu-

nity/voluntary, advocacy and academic sectors.

Table 1 Key steps in the development of the natio

Pre-development phase

Research ) Jan 2002 – D

Men’s Health R

National Conference ) Dec 2004

1st National Co

Expert Steering Group ) Nov 2004

Appointment o

Development phase

Nationwide Consultation ) Feb – Dec 2

) National M

) Hosted se

) Targeted a

Review of Evidence ) Feb 2005 –

Bilateral Meetings ) January – Au

Meetings with

Maintenance phase

Implementation & Evaluation ) Jan 2009 – D

p. 105–113, June 2009

Under the terms of reference of the Steering

Group, it was agreed that following an extensive

nationwide consultation, both a Policy contain-

ing higher order recommendations and a spe-

cific Action Plan would be developed. Both the

policy and action plan were to be evidence-

based and integrated into existing government

policy.

(ii) Development Phase

In light of the lack of consensus in the wider

literature in relation to an established defini-

nal men’s health policy

ec 2004

eport ‘‘Getting Inside Men’s Health’’ [10]

nference on Men’s Health

f National Steering Committee

005

en’s Health Days

ven Focus Groups

nd Public Call for Submissions

December 2006

gust 2007

key stakeholders and other Government Departments

ec 2013

Review

tion of ‘men’s health’, the Steering Group felt

it imperative that a clear definition of men’s

health be adopted at the outset. One of the key

considerations in defining men’s health was

that policies outside of health have enormous

potential to increase the health and well being

of populations and to reduce inequalities by

creating supportive individual, physical and

social environments [36]. It was also felt that

there was a need to deviate from earlier defini-

tions of men’s health that tended to have a

narrow, disease focus [37], and to recognise

that ‘men’ are a diverse population (e.g. gay

men, poorer men, older men) with multiple

roles and identities (e.g. fathers, carers) that

need to be considered in terms of health.

It was within this social determinants

approach, and with due regard to the gendered

nature of men’s health, that the Steering

Group adapted previous definitions from Aus-

tralia [38] and the UK [39], and defined a male

health issue in the policy as;

‘any issue that can be seen to impact on men’s

quality of life and for which there is a need for

gender-competent responses to enable men to

achieve optimal health and well-being at both

an individual and a population level’ [1: 17].

By defining men’s health in a broad and

holistic way, this made explicit the need for

health-focused interactions among policy

makers across a number of different sectors.

One of the challenges, therefore, that the Steer-

ing Group faced was to examine policy more

broadly – education, employment, environ-

ment, social policy etc – and to explore how

men’s health could be advanced in synergy

with other government department policies

and programmes, within and beyond the

health sector. This, at the outset, also pointed

to the need for a sustainable mechanism in the

context of men’s health that would co-ordinate

and monitor the work of different government

departments and agencies in addressing men’s

health policy issues, following publication of

the policy.

The key recommendations contained in the

policy cover the following areas:

� E

stablishing appropriate structures to sup-

port an integrated and intersectoral

approach to men’s health

� P

romoting an increased focus on men’s

health research

� P

romoting and marketing ‘men’s health’

� T

argeting health information to men

� P

romoting a gender-sensitive approach in

the delivery of health promotion pro-

grammes to men

� P

roviding training in men’s health

� I

ncreasing men’s participation in health and

the caring professions

� B

uilding gender-competent health services

in:

- primary care

- cancer prevention and cancer screening

- mental health

- sexual health

� D

eveloping supportive environments for

men’s health in:

- the home

- schools and third level institutions

- the workplace

- social spaces

� S

trengthening community development

work to support men’s health

A number of key theoretical and philosophi-

cal principles informed the development of

the policy. The policy:

� i

s firmly positioned within existing govern-

ment policy (inter-sectoral/inter-departmen-

tal) and has invested in an extensive

consultation process to develop strong part-

nerships with existing policy across a num-

ber of government departments

� p

laces a firm focus on the gendered nature of

key men’s health issues (e.g. alcohol, obesity,

mental health, access to services) and pro-

motes men’s health within a mainstreamed

equality agenda with a gender focus [22–24]

� a

dopts a social determinants approach

� t

argets interventions at both an individual

and a population level

� i

ncorporates a community development

approach

� f

ocuses on prevention as well as cure

� a

dopts a strengths perspective

� s

eeks to support men to become more active

agents and advocates for their own health

The level of consultation engaged in for this

policy was extensive, comprising four distinct

phases with a strong focus on research. The

framework adopted throughout each phase

mirrored the five guiding principles of the

Ottawa Charter [40] and was an adaptation of

that proposed by the UK Men’s Health Forum in

their policy paper [39]. These principles span the

Vol. 6, No. 2, pp. 105–113, June 2009 109

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110 Vol. 6, No. 2, p

five areas in which the health of any individual

may be affected and, therefore, allowed for the

analysis of health needs, as well as structuring

actions to meet those needs, with due regard to

the broader determinants of health.

� P

Ta

Gr

Co

He

Ac

Re

Sp

W

Lo

Go

Ot

Un

M

Fe

To

p.

hase 1 comprised six men’s health days

that were held in strategic locations all over

Ireland, and which consulted with all key

stakeholders in the statutory, community

and voluntary sectors. Five workshops, each

reflecting a different theme of the Ottawa

Charter, were facilitated by the same facil-

itator at each of the six days. This ensured

continuity throughout the process and that

this phase of the consultation was seen as an

overall process rather than as discrete days.

� P

hase 2 comprised the hosting of a series of

focus groups with subpopulations of men

whose voices were not represented at the

men’s health days.

� P

hase 3 consisted of an invited (n = 94) and

public call for submissions through the

National Press.

ble 2 Summary of participants in Phase 1–3 of c

oup

mmunity, Voluntary & Statutory representation:

� Community groups or workers

� Traveller men

� Older men

� Gay men

� Disadvantaged men

� Disabled men

� Fathers

� Homeless men

� Rural men

� Young men

� Immigrant men/refugees

� Clergy

alth services

ademia

searchers

orting bodies and local sports partnerships

orkplace representatives

cal authorities

vernment departments

hers

known organisations & individual men

ale

male

tal

105–113, June 2009

Qualitative methodologies were used

throughout the consultation process and data

were thematically analysed. All relevant stake-

holders, from a diverse range of organisations

to individual men, were represented through-

out the three phases of consultation (see

Table 2).

The consultation process was extremely

well received and welcomed by all those

who participated. Every attempt was made

to ensure that the process was as fair and

transparent as possible, thus enabling all par-

ticipants to share their experiences and to

bring their particular issues to the policy

table. Despite the diverse backgrounds of

those who participated, there was a strong

consensus that much needed to be done at a

policy and practice level to enable men in

Ireland to take increased responsibility for,

and to be more proactive about, their health.

Almost one third of participants were female,

reflecting the strong support of female health

and allied health professionals for men’s

health in Ireland.

onsultation process

Number Representation (%)

51 10

15 3

24 5

6 1

80 16

6 1

15 3

2 0

16 3

27 5

6 1

8 2

128 26

32 6

8 2

9 2

36 7

3 1

3 1

10 2

15 3

343 69

157 31

500 100

Review

Before embarking on the final phase of

consultation, an extensive review of both

the national and international literature on

men’s health was then conducted to establish

the efficacy of translating the issues raised

through the consultation process into policy

recommendations and actions. Particular

attention was paid to the men’s health lit-

erature on gender and health inequalities,

with a view to framing policy recommenda-

tions and actions within a mainstreamed

equality agenda with a gender focus. While

the issues raised did guide the review of the

literature, it was not solely limited to those

issues. Other issues that emerged from the

wider literature on men’s health were also

considered for inclusion in this policy. This

review also took cognisance of (i) the

scope within existing policy documents to

promote men’s health; (ii) the stakeholders

who would commit to implementing policy

at various levels; (iii) the steps to be taken

and the key actions needed to ensure the

implementation of policy initiatives; and

(iv) an anticipation of the possible barriers

to developing and implementing a men’s

health policy.

� P

hase 4 consisted of bilateral meetings with

key government departments to determine

the key stakeholders who would agree and

commit to the Recommendations and

Actions that were contained in the policy.

Prior to these meetings, a draft policy and

action plan was circulated to each govern-

ment department in advance, with follow-up

meetings being held with each department.

The dissemination of the policy has begun

via a variety of media that include local and

national media coverage at the time of the

launch, online availability (http://www.dohc.

ie/publications/national_mens_health_policy.

html), the international men’s health fora net-

work and, indeed, this publication. Follow-up

briefings and workshops are planned with

relevant government departments and key sta-

keholders. There is also ongoing training of

health service providers, community workers

and academics in the area of men’s health.

(iii) Maintenance Phase

The Implementation Group that is to be

appointed to oversee the implementation

and evaluation of the policy [1: 45], will be

responsible for monitoring and evaluating the

policy and aligning the policy implementa-

tion to ongoing research findings. Evaluation

of the policy must give consideration to the

collection of data that is aligned to the policy

recommendations and actions. The Depart-

ment of Health and Children in Ireland is to

be tasked with co-ordinating the implementa-

tion of the policy at an inter-departmental

level.

Lessons Learned

A number of key lessons were learned in the

development of the policy that may inform

others hoping to embark on a similar path.

The importance of identifying men’shealth as a priority area

This paper has outlined the role of research,

advocacy, local policy initiatives and a range of

grass-roots work in creating a momentum

towards the development of a national men’s

health policy in Ireland. However, the impor-

tance of naming men’s health as a priority area

in the national health strategy cannot be over-

stated. This provided the mandate and copper

fastened the political will to bring the policy to

fruition.

The importance of consultation inpolicy development

The consultation process and, in particular,

the men’s health days hosted in the first phase

of this process, proved to be a forum that, in

itself, furthered the cause of men’s health in

Ireland. These events created an environment

whereby those working in the area of men’s

health could generate or strengthen existing

networks, share available information pertain-

ing to men’s health and raise the profile of

ongoing work at a grass-roots level. The overall

consultation process was a crucial component

in developing a partnership model for men’s

health in Ireland.

The need for patience in policydevelopment

The timeframe for developing the policy far

exceeded what was originally anticipated and

greatly challenged the patience of the secretar-

Vol. 6, No. 2, pp. 105–113, June 2009 111

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112 Vol. 6, No. 2, p

iat responsible for drafting the policy! Policy

development, by its very nature, is a slow

process, as it involves engaging with and seek-

ing support from a number of diverse govern-

ment departments and statutory and

community/voluntary agencies. A particular

challenge for the men’s health policy was

the fact that many of these stakeholders did

not consider men’s health their business.

Therefore, education and advocacy, particu-

larly at a departmental level, was an integral

part of the policy process and at times it was a

‘‘hard sell’’. At many junctures it was necessary

to retake the very first step of addressing the

need for a policy on men’s health. Phase 4, in

particular, involved, in some cases, multiple

meetings with key stakeholders to agree

accountability in relation to the Recommenda-

tions and Actions in the policy. Whilst this

lengthened the process considerably, it was

crucial in the context of partnership building

and in bringing the overall process to fruition.

Perseverance and patience were the corner-

stones to building partnerships across all sec-

tors and garnering support for the

implementation of the policy.

Policy development is an inherentlypolitical process

Sutton [41: 10] considered the policy develop-

ment process as a:

‘chaotic procedure, dominated by political, prac-

tical and socio-cultural forces’

While consultation is an essential compo-

nent of any policy development process, it

does create an expectation for action among

those who participate and our experience has

been that the political process does not allow

for every expectation to be met. Policy devel-

opment is essentially about competing needs:

(i) as represented by disparate organisations

and individuals who make the case for their

needs to be met (e.g. community activists and

social workers versus health service provi-

ders); and (ii) in terms of a limited pool of

resources at government policy level to meet

such needs. For a ‘need’ to be translated into a

policy action, it also requires a strong evidence

base. Therefore, while the men’s health policy

has the potential to achieve a great deal for

men in Ireland, it cannot purport to meet the

expectations of all those who contributed to

p. 105–113, June 2009

the policy development process. In keeping

with existing government policy, the men’s

health policy has prioritised the needs of the

most vulnerable and marginalised men in

society.

Conclusion

The publication of a national men’s health

policy in Ireland is a significant and important

step in being the first national policy to pro-

vide a clear blueprint and an unequivocal

evidence base for tackling men’s health.

Undoubtedly, there will be much national

and international interest in the progress of

the policy in the years to come. Many chal-

lenges lie ahead in the implementation of this

policy. Not least of these is the harsh economic

climate in which the policy has been published

and the reduction in public spending that is

currently being implemented across all gov-

ernment departments. It is imperative, there-

fore, that the policy dovetails with existing

policy across different government depart-

ments and that all potential sources of funding

and resources are targeted by focusing on

collaboration and partnership in developing

men’s health work. There is also the challenge

of making an explicit case for men’s health as a

productivity issue, by promoting a healthy

male workforce as a more productive work-

force. One of the key promotional and market-

ing challenges for men’s health policy in the

future will be to reverse the paradigm that

help-seeking is synonymous with weakness in

men, and rather to portray good health main-

tenance and prompt help-seeking as being part

and parcel of being a man – achieving opti-

mum vitality, vigor and productivity, and

enabling men not just to be productive in their

work, but productive also in the many other

roles that they play [42]. The principal chal-

lenge involved in monitoring and evaluating

the policy will be to apply a cost–benefit ana-

lysis that should highlight the value of early

interventions and a more preventative

‘upstream’ focus on men’s health. Finally, in

the context of a gender relations approach to

men’s health, there is the ongoing challenge of

convincing all stakeholders that improving

the health of men can have both direct and

indirect benefits for women and children and

for society as a whole.

Review

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