Men's health literacy in Australia: in search of a gender lens.
Subject: Health care reform (Analysis)
Health literacy (Analysis)
Men (Health aspects)
Men (Reports)
Authors: Peerson, Anita
Saunders, Margo
Pub Date: 06/22/2011
Publication: Name: International Journal of Men's Health Publisher: Men's Studies Press Audience: Academic; Professional Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2011 Men's Studies Press ISSN: 1532-6306
Issue: Date: Summer, 2011 Source Volume: 10 Source Issue: 2
Geographic: Geographic Scope: Canada; Australia Geographic Code: 1CANA Canada; 8AUST Australia
Accession Number: 271664384
Full Text: Proposed Australian health system reforms allude to health literacy as a major lever for a 'well informed public' and helping individuals assume more responsibility for their health. New national men's and women's health policies also acknowledge, to varying degrees, the importance of health literacy, but with little indication of why gender might be relevant. This omission reflects the absence of a coherent evidence base on health literacy and gender in Australia as well as in countries where health literacy has been more extensively examined. A lack of consensus on approaches to defining, measuring, and reporting on health literacy adds to the difficulties. We propose that viewing health literacy through a "gender lens" would contribute to building a much-needed evidence base about men's health literacy.

Keywords: men, health literacy, gender, masculinity, gender analysis, Australia

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The past decade has seen increased attention on men's health, including men's concepts of health (Fletcher, Higginbotham & Dobson, 2002; Richardson, 2004; Robertson, 2006, 2007), how men engage with the health system (Galdas, Cheater & Marshall, 2005; O'Brien, Hunt & Hart, 2005; Smith, Braunack-Mayer & Wittert, 2006), and men's responses to preventive health and health promotion initiatives (Aoun, Donovan, Johnson & Egger, 2002; Arras, Ogletree & Welshimer, 2006; Burton, Walsh & Brown, 2008; Dumbrell & Mathai, 2008, Singleton, 2008; Robertson, Douglas, Ludbrook, Reid & van Teijlingen, 2008; Verdonk, Seesing & de Rijk, 2010; Victor, Ravenell, Freeman et al., 2011). Australian health system reforms (National Health & Hospitals Reform Commission [NHHRC]), 2009; Australian Government 2010a), and preventive health initiatives now under the guidance of the new National Preventive Health Agency (National Preventative Health Taskforce, 2009; Australian Government, 2010b; Department of Health & Ageing, 2010d) are proceeding in parallel with the implementation of a National Primary Health Care Strategy (Department of Health & Ageing, 2009, 2010a), Australia's first National Male Health Policy (Department of Health & Ageing, 2008a, 2010b), and an updated National Women's Health Policy (Department of Health & Ageing, 2008b, 2010c). The importance of health literacy has been acknowledged in two sets of recommendations (NHHRC, 2009; Department of Health & Ageing, 2009), but the absence of a national health literacy strategy means that research addressing health literacy continues to be uncoordinated. Complicating matters is an inconsistent approach to what "health literacy" means and how its relationship to health promotion, individual responsibility and empowerment should be understood (Tones, 2002; Nutbeam, 2008; Kickbusch, 2009; Wills, 2009).

There has been little systematic attempt to examine the relationship between health literacy and men's health outcomes, or even to relate health literacy to the health-and-gender literature (Peerson & Saunders, 2009b). The disparate evidence presents significant challenges, at least in Australia. Calls to extend the gender and health promotion evidence base (Keleher, 2004; Broom, 2008) and include gender as a factor in health promotion (Kolip, 2007; Smith & Robertson, 2008) suggest that it is timely to consider a similar approach to health literacy.

Such an approach should not be regarded as unusual. International calls for gender sensitivity in health have resulted in the promotion of gender analysis frameworks (to encourage the application of a "gender lens" to health policies and programs) (United Nations, 2006; Tiessen, 2007), and gender mainstreaming (integrating men's and women's health concerns in the design, development, implementation and evaluation of policies and programs) (World Health Organization, 2002a, 2008).

Britain's Gender Equality Duty Code of Practice (Equal Opportunities Commission, 2007) requires public authorities to promote equality of opportunity and fairness between men and women, consistent with specific goals and actions. These requirements prompted the British Department of Health (2008) to commission the Men's Health Forum to examine how women and men access health services, plus possible reasons for any differences. The report's findings and recommendations are intended to determine key gender health priorities for the Department of Health and the National Health Service. While Australia's health system has not yet performed such a systematic approach, the opportunity could be a logical step in implementing the new national men's and women's health policies.

In contrast to Britain--which lacks a national men's or women's health policy, but has enacted gender equality legislation for public organisations, including health services (Department of Health, 2010)--Australia has new national men's and women's health policies but no formal commitment to gender equality or systematic gender analysis or gender mainstreaming. Although "gender equity" is a foundation principle of the National Male Health Policy, it is unclear how this will be implemented. A Senate Select Committee report calls for legislative drafting instructions and administrative procedures involving central Government departments and agencies, to consider the impact of legislation and policies on both men and women (Parliament of Australia, 2009). As preliminary indications suggested, the Policy emphasises social determinants of health at the expense of increasingly compelling evidence on the role of gender in general, and masculinity in particular, as a significant influence on men's health (Saunders & Peerson, 2009).

In this paper, we argue that gender analysis applied to health literacy would be a useful tool for improving our understanding of health literacy for men. Our discussion considers: i) the concept of "health literacy"; ii) the relationship of health literacy and health; iii) gender and health; iv) using information about gender; v) gender and health literacy; vi) men's health literacy; vii) the importance of viewing both health and health literacy through a "gender lens"; and viii) Australian initiatives in the health literacy field.

THE CONCEPT OF "HEALTH LITERACY"

Debate continues about what "health literacy" actually means; whether the term refers only to patient-oriented knowledge and skills in health care settings, or "medical literacy" (Peerson & Saunders, 2009a), or whether it also encompasses health-related knowledge applicable to everyday life. This broader concept involves:

the ability to make sound health decisions in the context of every day life--at home, in the community, at the workplace, in the health care system, the marketplace and the political arena. It is a critical empowerment strategy to increase people's control over their health, their ability to seek out information and their ability to take responsibility. (Kickbusch, Wasit & Maag, 2005, p. 8)

Concepts of health literacy have also extended beyond individuals to include communities, environments, and policies. Such notions are not new. Australia's landmark health goals and targets framework notes that health literacy can enable people to take an active role in bringing about changes in environments that influence health (Nutbeam, Wise, Bauman, Harris & Leeder, 1993). According to the South Australian Health Literacy Alliance:

Health literacy also influences the nature and functioning of environments so that they encourage health and wellbeing. It's about thinking and acting in a healthy way for ourselves or as a community, even when the focus may seem far from health, for example in fashion, transport, or advertising. (Gravier, 2007, p. 17)

These broader concepts of health literacy are not limited to people's relationship with the health system, but are directly relevant to their ability to maintain good health and minimise their need for health services. They also reflect the view that health literacy is not exclusively an individual responsibility: health systems, services and professions are required to facilitate health literacy in the wider population. Health literacy is viewed as an asset necessary for the development of social capital and to address health inequalities (PHAA et al., 2009), as well as a key determinant of population health (Pleasant & Kuruvilla, 2008; Freedman, Bess, Tucker, Boyd, Tuchman & Wallston, 2009).

There are even differences here, however, with health literacy discussions in developing countries focusing more on women's disadvantages and need for greater empowerment, while concerns have been raised in developed countries about a perceived emphasis on neo-conservative ideologies regarding the roles of individuals vs the state (Galvin 2002; Crawford 2006; Henderson et al, 2009). In Australia, for example, the Senate Select Committee on Men's Health report recommended Governments introduce "programs that encourage boys to take responsibility for their health and well-being" (Parliament of Australia, 2009, p. x).

While measures of health literacy typically seek to assess individuals' skills and knowledge rather than their use, definitions of health literacy which avoid implications about use are relatively uncommon. Most definitions of health literacy include explicit or implicit assumptions that individuals have a desire for information and empowerment in relation to health and that once people have and understand information, they will use it in health-enhancing ways (Nutbeam, 2000; Rootman & Gordon-E1-Bihbety, 2008).

The World Health Organization's (1998, p. 10) definition of health literacy: "the cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand and use information in ways which promote and maintain good health" incorporates a notion of skills that determine motivation, but not the notion that this motivation may be a product of complex and inter-linked factors, both intrinsic and extrinsic. Indeed, motivation must be assumed when the "ultimate goal" of health literacy is to be promote greater independence and empowerment among individuals and communities (Nutbeam, 2000, p. 267). The problem, however, is that people may not be motivated to use their skills and information to promote health (Bates, Burton, Howlett & Huggins, 2009; Peerson & Saunders 2009a), or their motivation, skills and information may not be enough to outweigh other factors.

The motivation (if not the ability) to access, understand and use information to promote health is subject to a range of inter-related factors, such as an individual's health-related priorities (given other competing factors), responses to different information sources, beliefs about self-efficacy and response efficacy, and social and economic determinants. Mounting evidence that gender plays an important role in those factors, including how individuals, both singly and in groups, think about and prioritise health (Richardson, 2004; Robertson, 2007), suggests that gender is a factor influencing health literacy. If the evidence suggests, for example, that men are more likely than women to conceptualise and prioritise "health" in ways which mean that they are less "motivated" to "use information in ways which promote and maintain good health", and men are less interested in acquiring health-related "empowerment", then these aspects of health literacy need to be understood in the context of gender.

Concepts of health literacy which emphasise skills and abilities while avoiding presumptions about their application, and about the complex (and gendered) notion of motivation, are more consistent with concepts of other contextual literacies (e.g., media literacy, financial literacy, cultural literacy). For example, some definitions include the ability to participate in ongoing public and private dialogues about health (Zarcadoolas, Pleasant & Greer, 2005; 2006)--an element common to other contextual literacies. This distinction is important because it affects how we describe those individuals whose health-related knowledge and understanding do not result in behaviour which promotes and maintains good health. There is a difference, it could be argued, between what health literacy or other contextual literacies enables you to do and what it implies that you necessarily will do.

Insights from studies of other literacies (Nutbeam 2009b; Citi Australia, 2010) may help advance our understanding of the forces which support or undermine health literacy and its role in health-related decision-making. There is a particular need for more research exploring the relationship between health literacy and other factors (including gendered ones) in health-related decision-making (Peerson, 1998; Henderson, Ward, Coveney & Taylor, 2009).

All of these definitions reflect assumptions about the relationship between health literacy, health promotion and health outcomes, and about individual, social and environmental responsibilities for health improvement. The concept of health literacy continues to evolve, including a proposed dimension of "public health literacy" (Freedman et al., 2009). Ruger's (2010) concept of "health capability", prompted by questions such as, "Why have health literacy efforts been only moderately successful?," places health literacy alongside "health agency" in an approach which could help untangle ideas around individuals' motivation and application of health information.

Further consideration of the concepts and relevance of health literacy could lead to better-informed views about whether health literacy is a necessary but not a sufficient condition for promoting and maintaining good health, and whether the role of health literacy can be effectively reduced or displaced by other initiatives (e.g., making the healthy choices the "default" options and thereby reducing reliance on conscious choice) (Loewenstein, Brennan & Volpp, 2007; Thaler & Sunstein, 2008; Cabinet Office, 2010).

HEALTH LITERACY AND HEALTH

From about 2000 (Nutbeam, 2000), much research in the United States, Canada and Britain focused on the intersection of low literacy (ie. the ability to read and write) and patients' understanding of basic health care information as well as low levels of "functional" health literacy (Lee, Arozullah & Cho, 2004; Paasche-Orlow et al, 2005; Safeer & Keenan, 2005). A similar focus has been adopted in recent Australian health literacy studies (Adams, Appleton, Hill, Dodd, Findlay & Wilson, 2009; Barber, Staples, Osborne, Clerehan, Elder & Buchbinder, 2009; Smith, Dixon, Trevena, Nutbeam & McCaffery, 2009; Jordan, Buchbinder & Osborne, 2010). The continuing debate about how widely "health literacy" should be defined (Nutbeam, 2008; Kickbusch, 2009; Wills, 2009) has contributed to inevitable problems of measurement (Baker, 2006; Hernandez, 2009; Mancuso, 2009).

Given that health literacy involves a "constellation of skills" (Berkman, DeWalt, Pignone, et al., 2004), establishing an evidence base has been particularly difficult. Major efforts have been devoted to developing a greater understanding of the relationship between literacy skills and health outcomes, specific behaviours and health care services (e.g., smoking, breast-feeding, alcohol use) (DeWalt, Berkman, Sheridan, Lohr & Pignone, 2004; DeWalt & Pignone, 2005), and "causal pathways linking health literacy to health outcomes" at patient and health system levels (Paasche-Orlow & Wolf, 2007). However, methodologically sound findings about the relationship between health literacy and health behaviours are elusive. Health literacy may be referred to both directly and indirectly with valuable insights found in discussions about specific conditions or initiatives (Davis, Dolan, Ferreira, Tomori, Green, Sipler & Bennett, 2001; Shaw, Huebner, Armin, Orzech & Vivian, 2008; Singleton, 2008). Commonly-used measures of health literacy rely on an individual's ability to read and comprehend medication and appointment instructions, and function within the health system (Baker, 2006)--abilities which may be a proxy for educational attainment. These measures may not capture alternative notions of health literacy, as the prevalence of non-print information means that accessing, understanding and using information to promote and maintain good health does not rely exclusively on the ability to read and understand written information (Entwistle & Williams, 2008).

Viewed as a whole, the health literacy and health literature leads us to five conclusions: i) low levels of health literacy (variously defined) can have a negative impact on the efficacious self-management and prevention of disease(s) with associated costs; ii) health literacy is influenced by multiple determinants including education, occupation, employment, class, culture, ethnicity, language, age and gender; iii) more information is required to determine the role of health literacy in influencing health outcomes, especially compared to other approaches and in relation to prevention; iv) health literacy contributes to social capital; and v) improving our understanding of health literacy and its relationship to health outcomes, for both individuals and population groups, in clinical settings and everyday life, will require progress on definitions, measurement and analysis.

GENDER AND HEALTH

The relevance of gender to health literacy is consistent with the long-held view that gender has a bearing on health. The oft-quoted claim that "the doing of health is a form of doing gender" (Saltonstall, 1993, p. 12), illustrates how close the relationship is, but not whether that relationship is recognised in practice (Williams, Robertson & Hewison, 2009).

Differences have been noted in men's and women's experiences and perceptions of illness, disease risk factors, health care, and preventive health behaviours (White & Cash, 2004; Bierman, 2007; Javanparast, Ward, Cole et al., 2010; Vart, 2010). Although the early emphasis on health and gender was on women's health, more recent consideration has been given to men's health issues (including cultural expressions of masculinity) with implications for men's bodies, health status and use of health services (Schofield et al., 2000; Richardson, 2004; Smith, Braunack-Mayer & Wittert, 2006; Smith, Braunack-Mayer, Wittert & Warin 2008a; Pease, 2009; Saunders & Peerson, 2009).

Despite major changes in gender roles and expectations of gender-appropriate behaviour of men and women in the past decade (Pease, 2002), indications that "fundamental aspects of traditional gender roles continue to exert an influence on trends in health-related behaviour" (Waldron, in Sabo & Gordon, 1994, p. 41) are strong and consistent (Schofield, 2004; Broom, 2008; Courtenay, 2009).

Overall, the international literature on quality-adjusted life expectancy and disability-adjusted life expectancy in developed countries indicates the persistence of poorer lifetime health outcomes for men compared to women in the same community (Tsuchiya & Williams, 2005). The social construction of masculinity serves as an important influence on health, illness and injury, and in prescribing and limiting men's lives (Gough & Conner, 2006; Smith et al., 2006; Mahalik, Burns & Syzdek, 2007; Pilkington, 2010; Springer & Mouzon, 2011). Studies and commentaries documenting the role of dominant concepts of masculinity on men's health are found not only in Australia (Pease, 2009), but also Russia (Pietila & Rytkonen, 2008), The Netherlands (Verdonk et al., 2010), Germany (Sieverding, 2002), Sweden (Mansdotter, Lundin, Falkstedt & Hemmingsson, 2009), Scotland (O'Brien et al., 2005, 2009), Ireland (Richardson, 2004), England (Robertson, 2006), and the United States (Wade, 2009; Springer & Mouzon 2011). Multi-disciplinary and disjointed research is creating a clearer picture of how "what it means to be a man" influences men's health and also intersects with other factors (e.g., occupation, socioeconomic status, ethnicity and culture) (Wardle, Waller & Jarvis, 2002; Roos & Wandel, 2005; Pease, 2009; Springer & Mouzon, 2011).

USING INFORMATION ABOUT GENDER

Although the available information about gender and health is expanding, particularly in relation to men's health, the advances have been predominately associated with identifying and describing the nature and causes of men's health problems (Department of Health (Victoria) 2010a) rather than developing more effective ways of improving men's health outcomes.

On the other hand, commercial marketing has made it a priority to understand and exploit the differences in how men and women access, interpret and apply information, leading to effective gender-specific marketing (Johnson & Learned, 2004). The continued success of gender marketing in the commercial sphere in contrast to less successful attempts to market health-related behaviours to men, was highlighted by men themselves during discussions to develop the National Male Health Policy (Department of Health & Ageing, 2010b).

Gender is commonly overlooked in both the design and evaluation of preventive health initiatives. A review of published health-promoting interventions targeting men found only 27 relevant studies; three reported on interventions specifically designed with men in mind (Robertson et al., 2008). (The review did not include studies discussing the impact of non-male-specific interventions on men.)

There seems little disagreement that, if health communication and initiatives for men are to reach their target, a greater focus on men as "health consumers" (Buckley & Tuama, 2010) would contribute to a more sophisticated understanding of the impact of gender and the construction of gender-appropriate messages, strategies, products and services. For example, studies of food choice and eating habits reveal the influence of gendered attitudes and perspectives, including masculine norms (Gough & Conner, 2006; Dumbrell & Mathai, 2008; Bates, Burton, et al., 2009; Henderson et al., 2009). How this information is used is, of course, another issue.

Various attempts to address health issues for men confirm that "gender knowledge is insufficiently translated into interventions ... and the gendered background of lifestyle behaviours ... is hardly taken into account" (Verdonk et al., 2010, p. 1). While much could be gained by focusing greater attention on how gender intersects with social class, ethnicity, age, martial status, sexuality, indigeneity, area of residence and occupational group (Schofield, 2004; Sen, Ostlin & George, 2007; Pease, 2009), existing surveys, evaluations and analytical studies often fail to identify or discuss gender at all (Peerson & Saunders, 2009b). "Controlling for gender", or simply not considering it, is more common than considering whether gender might be a relevant factor, either independently or in conjunction with other factors. This is true for studies where gender would be expected to be relevant (e.g., reading and understanding nutrition labels, engaging in physical activity programs, talking about the experience of disease), as well as for other potentially useful studies relating to disease prevention, treatment and management. Aggregating data for gender, or conflating sex with gender, means that differences between men and women (as well as any other categories or nuances of gender) may not be evident or addressed (Lin, L'Orange & Silburn, 2007; Johnson, Greaves & Repta, 2009). The tendency to refer to "patients" or "consumers" without reference to gender when reporting the results of research means that valuable opportunities for building an evidence base on gender are lost. These omissions are unhelpful, particularly given emerging evidence that beliefs and attitudes about masculinity are more influential than socio-economic status, at least in relation to preventive health care (Springer & Mouzon, 2011).

A more systematic consideration of gender is likely to benefit health literacy, health promotion, social marketing and public health. According to health literacy experts, there is an urgent need for further research, better targeted messages, and more gender-sensitive approaches to health literacy aimed at "pushing the right buttons" for men and women (Kickbusch et al, 2005, p. 19). It is encouraging that the discussion about social marketing for men's health has been reactivated (Courtenay, 2004; Robinson & Robertson, 2010; Rumm, 2005). Questions about what constitutes appropriate and effective health-related social marketing for men, and about the nature and direction of the relationship between health literacy and social marketing and health promotion (Robinson & Robertson, 2010) are important areas for further research and discussion.

GENDER AND HEALTH LITERACY

Health literacy has struggled to find a place in Australian and international discussions of health and gender (Peerson & Saunders, 2009b), and received little attention in the health inequalities literature. Various studies indicate there are gender differences in health literacy; men and boys are less knowledgeable than women and girls about health in general, specific diseases and their risk factors (Courtenay, 2000). Compared to women, men are less able or likely to access, interpret and apply information to maintain and improve health (Galdas et al., 2005; Australian Institute of Health & Welfare, 2008b; Department of Health [Victoria], 2010a), and men exhibit low levels of health literacy even about male-specific health issues (Arnold-Reed, Hince, Bulsara, Ngo, Eaton et al., 2008; Singleton, 2008; O'Shaughnessy & Laws, 2009-10), and in the face of national health promotion campaigns (Buckley & O Tuama, 2010). Understanding these differences is crucial in developing effective approaches to disease prevention and self-management.

Australia lags behind the United States, Britain and Canada in measuring health literacy at a population-level and for specific population groups, and in acknowledging the need to undertake gender analysis of the resulting data (Canadian Council on Learning, 2007; Jochelson, 2007; Barber et al., 2009; Peerson & Saunders, 2009a).

Australia's first population-based health literacy survey (Australian Bureau of Statistics [ABS], 2006), broadly defined health literacy as:

the knowledge and skills needed to understand and use information relating to health issues such as drugs and alcohol, disease prevention and treatment, safety and accident prevention, first aid, emergencies and staying healthy. (ABS, 2008, p. 5)

The survey contained questions measuring health-related activities in: health promotion, health protection, disease prevention, health-care and disease management, and navigation. The survey found that only 41% of Australians had adequate levels of health literacy, leaving 59% with health literacy levels considered problematic, including nearly one-fifth whose health literacy was at the lowest level (ABS, 2008).

Although health literacy was strongly correlated with age, education, occupation and income, it is not possible to draw any conclusions about the role of gender, because the ABS report includes minimal gender data or analysis. Overall, 48% of females (15-44 years) achieved adequate levels of health literacy, compared to 43% of males in the same age group (ABS, 2008, p. 8). A breakdown of health literacy level by sex in Australian states and territories is provided and differences based on labour force status show a higher proportion of employed females than males with adequate health literacy levels, and a higher proportion of unemployed males than females with adequate levels (2008, p. 11). Tabular data reveal some potentially interesting age-related gender differences, including lower levels of men's health literacy between the ages of 2044 years (2008, p. 19). However, gender is not highlighted in the ABS' discussion of the findings nor routinely included in tabular information (e.g., the use of the internet for health information). Where tabular data are distinguished by sex, only actual numbers and not percentages are given.

The report of the 2003 health literacy survey in the United States (Kutner, Greenberg, Jin & Paulsen, 2006) is also disappointingly light on gender analysis, although it includes several tables with gender information. The results for health literacy scores and factors including self-assessed health status and sources of health information are presented, yielding a potentially valuable set of data for further analysis. For example, the tabular data indicate that women who get "a lot" of information about health issues from health professionals attain a higher level of health literacy than do men in the same circumstances, but reliance on this source of information was not associated with the highest health literacy levels for either men or women (Table E-23, 2006, p. 56). Men who got "a lot" of health information from family, friends or co-workers had higher health literacy scores than those who obtained "a lot" of this information from health professionals, while these sources of information were less significant for women (Table E-22, 2006, p. 56). These data deserve further investigation, given published and anecdotal evidence that men are more receptive to health-related information conveyed in less formal and direct settings (Malcher 2009; Parliament of Australia, 2009), and may have different approaches to information-seeking (Boudioni et al., 2001; Smith et al., 2008a).

While females tend to score higher than males on some elements of population-level health literacy surveys, survey results are not strongly consistent across different measurement tools, and discussions of data from these surveys have not generally identified gender as a key determinant of health literacy (Paasche-Orlow et al., 2005; ABS, 2008). These findings may be influenced by the research focus and measurement tools which are not geared to capture complex aspects of health literacy in everyday life (Sanderson et al., 2009; Hernandez, 2009). The disjunction between survey reports (downplaying gender) and issue-specific studies (confirming the importance of gender) suggests that more attention should be given to who, how and what is being measured as well as more careful consideration of gender in data analysis.

MEN'S HEALTH LITERACY

Although not necessarily captured in conventional "health literacy" measures, multidisciplinary research focussing on specific health issues, lay perspectives of men's health, and discussing "masculinity" and men's health, suggest fundamental differences in how men and women access, interpret, and apply health-related information. In other words, there are gender differences in "health literacy" (Holland, 2005; Ilic, Risbridger & Green, 2005; Youl, Janda, Lowe & Aitken, 2005; Kaneko & Motohashi, 2007; Bates, Burton, Howlett & Huggins, 2009; Gill, Hill, Adams et al., 2010). Understanding these differences is crucial in designing and implementing health education and health promotion initiatives, and providing an evidence base for primary health care (AIHW, 2008b; Yen et al., 2010).

The nexus between men's health and health literacy research has not been well illuminated: health literacy has been an insignificant focus in men's health research, and men's health has received little attention in health literacy research (Peerson & Saunders, 2009b). In early 2011, a Google search for "impact of health literacy on women's health" produced 128 items; a search for "impact of health literacy on men's health" results produced no items. A 2009 analysis of the impact of health literacy on women's health (Shieh & Halstead, 2009) has, as yet, no apparent "male" equivalent.

Articles on men's health rarely acknowledge "health literacy" as a keyword or subject. However, they may report how men (or specific groups of men) access, interpret and apply health-related information on specific diseases, screening initiatives or surgical procedures (Boudioni et al., 2001; Richardson, 2004; Oliffe, 2007; O'Shaughnessy & Laws, 2009-10). Database searches (Ovid, PubSearch, Medline, Proquest) in 2007-08 using the keywords "men", "men's health", "health literacy" and "gender" produced few papers overtly addressing men's health literacy, thus lending support to claims of a limited evidence base and atheoretical understanding for men's health literacy with implications for men's health overall (Peerson & Saunders, 2009b). Indeed, observations that "disciplinary silos" present barriers to an integrated empirical understanding of men's health (Smith & Robertson, 2008) imply the situation characterising men's health literacy reflects men's health generally.

Lay perspectives of health and ill-health suggest that men (particularly <50 years) are poorly motivated to obtain and apply information about prevention (Donovan & Egger, 2000; Buckley & O Tuama, 2010), but there are unresolved questions about the reasons: do men's perspectives, attitudes and beliefs, grounded in notions of manhood, constitute an insurmountable barrier? Beliefs about fate, luck, and genetic predisposition to health problems (Keeley, Wright & Condit, 2009), which are commonly but not exclusively expressed by men from lower socio-economic backgrounds (Robertson, 2007; Buckley & O Tuama, 2010; Springer & Mouzon 2011), are also likely to reduce motivation by separating illness from individual responsibility. Men's limited health knowledge is also "associated with underuse of health care and ... unhealthy behaviours" (Courtenay, 2003, p. 14). As a population group, men may self-monitor their health and be receptive to "credible health information" (Smith et al., 2008a) incorporating "facts and scientific respectability" (Donovan & Egger, 2000), communicated in ways that reflect qualities valued by men (Smith, Braunack-Mayer, Wittert & Warin, 2008b). It is possible that men's anecdotal claims of "self-monitoring" reflect a desire for self-reliance and to avoid: i) going to the doctor and heating "bad news" about their health status (e.g., high cholesterol, obesity, cancer diagnosis); ii) receiving unwelcome advice about "lifestyle" changes; or iii) engaging in formal health systems which make them uncomfortable (Buckley & O Tuama, 2010). Greater insight into the tensions between health behaviours and masculinity would benefit health promotion and social marketing efforts (Robertson, 2007; Verdonk et al., 2010).

While it could reasonably be argued that improving men's health literacy is a necessary (but not a sufficient) condition for improving men's health (Peerson & Saunders, 2009b), more information is needed about the role of masculinity, motivation and empowerment in relation to men and health literacy. Men's "functional" view of health may result in treatment being sought at a late stage when their symptoms are more acute and severe, harder to treat, and potentially associated with co-morbidities and additional risk factors. Expecting men to access and apply information to reduce risk(s) of disease or an asymptomatic condition is a bigger request, especially given the influence of gendered norms on men's health (Courtenay 2004; Saunders & Peerson 2009). Learning how to more effectively communicate health information to men (Smith et al, 2008b) would have important implications for both policy and practice (Robertson, 2007; Malcher, 2009; Department of Health (Victoria), 2010a). Obstacles such as the perceived inconsistency between preventive health and masculinity mean that the challenges are more complex (Mahalik, Walker & Levi-Minz, 2007; Sloan et al., 2010; Buckley & 6 Tuama, 2010; Springer & Mouzon, 2011). It is for these reasons that a "gender analysis framework" would be particularly valuable in illuminating the role of masculinity in men's health and men's health literacy, and informing improvements in men's health status.

A "GENDER LENS" FOR HEALTH AND HEALTH LITERACY

Health

Gender is a significant factor in the quality and duration of life (Emslie & Hunt, 2008). Yet serious attention to gender analyses in health (and other) contexts, has occurred only relatively recently and in response to concerns about women's health, not men's (Schofield, 2004; Sen et al., 2007). The final report of the World Health Organization Commission for the Social Determinants of Health (2008) highlights issues around gender equity but has been criticised for failing to acknowledge gender as an issue for men and men's health (Bates, Hankivsky & Springer, 2009), although more detailed discussions were promised in a separate report (Sen & Ostlin, 2009).

In the Madrid Statement, the World Health Organization (2002b) includes various gender-related principles: gender equity; gender equality; gender as a key determinant of equitable health status; mainstreaming gender equity in health; diversity; multi-sectoral and multi-disciplinary involvement; and participatory process. Gender analysis remains noticeably absent from the current international debate on health literacy.

The overall aim of applying a "gender lens" to health policies, initiatives and information is to improve gender equity in health and address both men's and women's rights to health. Gender analysis (or "gender mainstreaming") incorporates a gender perspective into all policies, programs, planning and actions at all levels and stages. The application of gender and health frameworks involves gender monitoring (collecting and analysing data), gender impact assessment, and gender awareness raising (Women's Health Victoria, 2009).

Gender analysis frameworks are increasingly used by governments and agencies to ensure policies and programs are more responsive to gender differences (Health Canada 2000, Schofield et al., 2000; O'Brien & White, 2003; Equal Opportunities Commission, 2007; Asia Pacific Economic Forum, 2008; Smith & Robertson, 2008). In some instances, gender analysis frameworks have originated from government departments or non-government organisations focussing more on women's rights or diversity, and less on men (often in the absence of a specific unit on men's issues) (Ministry of Women's Affairs, 2001; Status of Women Canada, 2002; Office for Women's Policy, 2005; Office for Women (Queensland), 2009; Women's Health Victoria, 2009). This may be due to: i) historical reasons given the influence of feminism since the 1970s; ii) unequal power relations between women and men; iii) expanding evidence that women experience illness and injury differently to men; iv) greater funding of women's health services; v) political will; and vi) acknowledgment of women's need for empowerment in all aspects of their lives. Other jurisdictions and agencies have developed a gender analysis framework addressing both men and women, underpinned by a set of principles, for use by policymakers (e.g., England, Canada, Ireland, New Zealand, Asia Pacific Economic Cooperation, Oxfam, Royal Tropical Institute) (World Health Organization, 2002a, 2008; Department of Justice, Equity & Law Reform, 2008).

In Australia, where gender analysis frameworks or gender mainstreaming are not common, it is easy to see how gender issues have not been evident in discussions of health literacy. There are, however, examples of the gender lens concept for health policy being promoted in Australia and New Zealand (Goodyear-Smith & Birks, 2003; Office for Women (South Australia), 2004; Smith, 2007; Australian Women's Health Network, 2008; Public Health Association of Australia, 2008). In Victoria, there is expanding attention to the importance of a gender lens to inform policy and programs by the Department of Premier & Cabinet, and Department of Health (formerly the Department of Human Services [DHS]). Of note, the Department of Health (DHS 2008) simultaneously uses a "gender and diversity lens" in its approach to health policy, and provides workshops for its staff and health professionals in the wider community. However, greater efforts are needed to sensitise stakeholders including health professionals, policymakers and researchers to its importance (Ostlin, Eckermann, Mishra, Nkowane & Wallstram, 2006).

Health Literacy

Gender analysis frameworks provide important opportunities to better understand men's and women's needs and perspectives for accessing, interpreting and acting on health-related information (Schofield et al., 2000; World Health Organization, 2002a, 2008; O'Brien & White, 2003; Office for Women (South Australia), 2004; Department for Community Development, 2005; Equal Opportunities Commission, 2007; Office for Women (Queensland), 2009).

Certainly if "health literacy matters", a key challenge is to identify the various individual, social and cultural factors influencing health literacy. This includes gender and its influence on education, language, the media, marketplace, sources of health information, workplace, family and other relationships (Institute of Medicine, 2004; Rootman & Ronson, 2005; Rootman & Gordon-El-Bihbety, 2008), as well as "perceived susceptibility", "cues to action" and "barriers to action" (Aoun et al., 2002).

At the "macro" (strategic) level, research that is not gender-sensitive is not good research, and policies overlooking gender differences are more likely to perpetuate inequalities than to address them successfully (Kickbusch, 2007). Indeed there is substantial evidence at the "micro" (operational) level that the failure to consider men's needs and perspectives predictably results in disappointing outcomes (e.g., bowel cancer screening, physical activity, nutrition) (Victorian Auditor-General's Office, 2007; Australian Institute of Health & Welfare, 2008b; Burton et al., 2008; Flitcroft, Salkeid, Gillespie et al., 2010; Javanparast, et al., 2010; Saunders & Peerson, 2010; Vart 2010). If men are to become more "engaged" in their health, then health professionals, policymakers and researchers involved in men's health will benefit from a better understanding of men's lay health concepts, attitudes, priorities and decision-making (Peerson, 1998; Aoun et al., 2002; Gill & Wijk, 2004; Smith et al., 2008b). Even media reports of men's and women's attitudes and behaviour during the multiple Victorian bushfires, Australia (in February 2009) have implications not only for our understanding of gender differences and subsequent health implications (e.g., access to income, employment, housing) but also for gendered approaches to health literacy. Consider the claim that the "prepare, stay and defend or leave early" policy exposes a faultline between husbands and wives," where "fleeing" is seen as a weakness and staying to fight is "a macho thing:"

Most commonly, mothers and wives ... choose to lose the lot rather than risk life and limb. Husbands and men, out of stubbornness or machismo, believe they can beat the threat and prefer to stay to save the castle. The policy's suggestion of fight or flee makes it harder for men to walk away. (Legge, 2009)

Gender differences in this type of decision-making also related to men's and women's distinct interpretation and application of information, health (protective) behaviours as well as gender relations in everyday life (Schofield, 2004; Johnson et al., 2009). "He thought he knew everything and I knew nothing," one woman said about her husband's reaction to the bushfire. "He'd been there 78 years. He was a man. He knew more than me" (Legge, 2009).

AUSTRALIAN INITIATIVES

Although proposed Australian health system reforms cite health literacy as a major lever to help individuals assume responsibility for their health (NHHRC, 2009), health literacy has received little attention in Australia compared to Canada, the United States or Britain. Australian health literacy research has focused on patients in clinical settings, with incidental information appearing in studies devoted to other issues. Recent strategic frameworks reflect the lack of a coherent evidence base around health literacy and gender as well as an uncoordinated approach to health literacy.

The National Health & Medical Research Council (2008, p. 443) states it will "meet the challenge of improving health literacy to identify the most effective ways of engaging the community", without indicating how it intends to do this, whilst acknowledging the role of health literacy in enhancing relations between patients and health professionals. The National Primary Health Care Strategy (Department of Health & Ageing, 2009) and the National Health & Hospital Reform Commission (2009) note higher health literacy levels will assist individuals in managing their own health, and propose that health literacy be addressed through school curricula and community-based initiatives. The National Preventive Health Strategy briefly mentions health literacy as part of a suite of approaches to ensure a "well-informed public" (National Preventative Health Taskforce, 2009, p. 56). It is too soon to know how the new Australian National Preventive Health Agency, which will implement the Strategy, perceives its role in relation to health literacy. The Australian Primary Health Care Research Institute acknowledges the need for more research attention to patient-centred care as well as "health literacy and patient self-management" in primary health care (Yen et al, 2010).

Health literacy is discussed in various ways in Australia's new national policy documents for male health and women's health, and is mentioned only indirectly in the Senate Select Committee on Men's Health report (Parliament of Australia, 2009). The National Women's Health Policy (Department of Health & Ageing, 2010c) devotes a separate section to health literacy, in which the particular issues faced by older as well as culturally and linguistically diverse women are highlighted. The Policy acknowledges the broader application of health literacy but still focuses on engagement with the health system.

The National Male Health Policy uses the term "health literacy" as a synonym for "awareness" (Department of Health & Ageing, 2010b, p. 21). The Policy notes: i) the association of lower health literacy levels with limited preventive health behaviour; ii) the relatively low levels of health literacy for Australian men; iii) men living in major cities have higher levels of health literacy than men in outer regional and remote areas; and iv) "There are considerable gaps in male health awareness, or health literacy, around risk factors, age-related disease risk, and symptoms of chronic disease, which are important prerequisites for making change" (2010b, p. 6). The Policy calls on "policy developers, program managers and health service deliverers" to "ensure that new programs and services are tailored using health promotion messages in language that groups of males can readily relate to" (2010b, p. 17). The improvement of health literacy is highlighted as a particular priority for health promotion initiatives targeting adolescent and young Australian males (e.g., the development of health promotion material "in language young males relate to" and delivered "in settings relevant to young males") (2010b, p. 19).

While these statements are admirable, their limitations indicate the slow rate of progress in relation to an Australian discourse and policy development on gender, health promotion and health literacy. As Nutbeam (2009a) has pointed out, it is now more than 15 years since national goals and targets for health literacy were first proposed in Australia (Nutbeam et al., 1993), and our collective understanding of health literacy has grown considerably since that time. A health promotion strategy plan released 10 years ago urges "approaches to men's health promotion should ensure that the provision of information is designed to promote health literacy" (Victorian Health Promotion Foundation & Hayes, 2001, p. 20). Insights from men's health promotion interventions in the early 1990s (e.g., the important values, language and symbols of subgroups), have foreshadowed later experimental interventions and "lay epidemiology" of men's health (Gill & Wijk, 2004; O'Brien et al., 2005, 2009; Roos & Wandel, 2005; Robertson 2006; Singleton, 2008; Sloan et al., 2010; Verdonk et al., 2010).

There is little evidence, however, that health literacy--or certainly gendered health literacy--will be a priority in implementing the national men's and women's health policies (Department of Health & Ageing, 2008b; Saunders & Peerson, 2009). Without a formal framework for gender sensitivity, it will be particularly difficult to ensure the systematic inclusion of gender in planning, implementing and evaluating health education, health promotion and disease prevention strategies (Dobbinson, Haymark & Livingston, 2006).

While it is encouraging that at least three Australian States (Victoria, New South Wales, South Australia) have also developed men's health strategies or action plans (NSW Department of Health, 1999, 2009; Department of Health (South Australia), 2008; Department of Health (Victoria, 2010b), consideration of health literacy does not extend beyond calls for health systems to provide "health care, health promotion and information which appropriately addresses the health needs of men and improves their health outcomes" (NSW Department of Health, 2009).

It is possible that as implementation strategies for these various scenarios continue to develop, frameworks may emerge for assessing and addressing health literacy. A gender lens would be an invaluable tool in helping to understanding how, to what extent, for whom, and in what circumstances health literacy is a factor in improving and managing health. This would represent an important contribution to ensuring that both men and women are able to fulfill their health potential.

CONCLUSION

Australia has a long way to go before it fully embraces the concept of health literacy, despite its inclusion in a landmark national health document 18 years ago (Nutbeam et al., 1993). Our knowledge base of Australians' health literacy remains patchy (ABS, 2006, 2008; Adams et al., 2009; Barber et al., 2009; Smith et al., 2009), as does our understanding of how far health literacy can take us, especially in the absence of other structural and environmental changes. In response to frustration with the limited impact of approaches which rely on giving individuals the skills and knowledge to act in health-enhancing ways, we are now seeing, particularly outside of Australia, increased interest in the use of approaches such as "behavioural economics" and "nudge" theory, which seek to influence decision-making in ways which have been long been utilised by the commercial sector (Cabinet Office, 2010; Thaler & Sunstein, 2008).

With the current focus on disease prevention, questions for future research extend beyond "medical" or clinically-based health literacy and include: i) the role of health literacy in promoting and maintaining good health for men and women in everyday life; ii) how health literacy for men and women can be most effectively improved; and iii) whether the role of health literacy can be reduced or displaced by making healthy choices the "default" option (Thaler & Sunstein, 2008; Cabinet Office, 2010). It has been noted that,

strategic policy in health literacy is poorly articulated in Australia, system-wide responses are limited and health professional training and understanding underdeveloped ... the benefits and problems have begun to be identified but strategies to develop health literacy and their effectiveness and cost effectiveness so far have received less attention. (Bush, Boyle, Ozolins & Soto, 2009, p. 14)

Whilst there is increasing attention to the role of health literacy in issues ranging from preventive health to disease self-management to citizen and community empowerment, the ability to draw clear conclusions about health literacy in relation to men's health remains limited. Leaving aside the current lack of consensus over the meaning of "health literacy", there are three fundamental reasons for this: i) information relevant to health literacy and gender is spread across disparate and often obscure literature; ii) the absence of links between the research and discourse (e.g., health literacy, disease management, preventive health, health and gender, men's health and masculinity); and iii) the lack of a gendered perspective in the approaches to the measurement and analysis of health literacy.

What we do know about the differences between men's and women's health-related perspectives, attitudes and behaviour strongly suggests that casting a gender lens on health literacy would be beneficial. We know, for example, that men (as a population group and as subgroups of men) view "health" in particular ways (Galdas et al., 2005; Smith et al., 2007; Richardson, 2004; Robertson, 2007), have different patterns of health system use, are less knowledgeable than women about health in general and about specific diseases and their risk factors, exhibit low levels of health literacy even in relation to male-specific health issues, and are less likely to access, interpret and apply information to maintain and improve health (Galdas et al., 2005; AIHW, 2008a; Bates, Burton, et al., 2009). Overlaying such information onto deconstructed notions of "health literacy"--including information-seeking and concepts of health-related motivation and empowerment--would provide an important contributor to better understanding and addressing men's health.

Approaches to health literacy and to health literacy research have been characterised, with few exceptions, by a lack of gender awareness. Health literacy is relevant to men's health outcomes, but the disparate evidence base and lack of gender-sensitive analyses present problems for developing a coherent and theoretical approach. A gender lens is important for informing improvements in men's health and men's health literacy.

We need a better understanding of how concepts of "masculinity" and "men's culture" are expressed (Connell, 2000; Courtenay, 2009) and how they influence men's health literacy. Whilst statistics continue to reveal men's poor health (Department of Health (Victoria), 2010a), surprisingly there is limited acknowledgement that men as individuals and as a population group are likely to benefit from gender-sensitive responses supported by a national policy promoting evidence-based, multi-faceted and coordinated initiatives (Saunders & Peerson, 2009). In Australia, a gendered perspective on health literacy would fit easily into the broader context of health policy initiatives.

Gender-based analyses should be routine in all health research on the grounds that merely "controlling for sex" is not acceptable. It is necessary to determine whether sex (biological), gender (socially constructed), or both are relevant factors and, where differences are found, to explore contributing factors (Bierman, 2007)

Better information is also needed about men's health literacy in health care settings and everyday life, and its relationship to other factors. A gender lens would enable us to answer key questions about whether health literacy holds intrinsic value for men and functions as a factor in men's health, with implications for whether and how to direct resources.

Twelve years ago, Bird and Rieker (1999, p. 753) asked: "How would health policies and health-related social policies address men's and women's concerns differently if gender were better understood?" Casting a gender lens over health literacy should contribute to finding the answers. Doing so will involve finding out more about: i) "masculine" attitudes and perspectives impacting on men's health, particularly multiple and changing masculinities; ii) the role of men's (and women's) health literacy in men's health; iii) how men's health literacy can be most effectively influenced; and iv) how much emphasis should be placed on influencing men's health literacy, as opposed, or in addition to social, occupational, environmental and market reforms which may improve health at community and population levels.

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ANITA PEERSON (a,b,d) and MARGO SAUNDERS (c,d)

(a) School of Health and Social Development, Faculty of Health, Deakin University, Geelong, Victoria, Australia.

(b) Faculty of Health, Deakin University, Geelong, Victoria, Australia.

(c) Public Health Policy Consultant, Canberra, ACT, Australia.

(d) Affiliate Member, Freemasons Foundation Centre for Men's Health, University of Adelaide, Adelaide, South Australia, Australia.

Correspondence concerning this article should be sent to Dr. Anita Peerson, School of Health and Social Development, Faculty of Health, Deakin University, Geelong--Waterfront, Geelong, Victoria, Australia. Email: anita.peerson@deakin.edu.au

DOI: 10.3149/jmh.1002.111
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