Barriers to Recruiting Men Into Chronic Disease Prevention and Management Programs in Rural Areas

Abstract

Chronic disease is becoming increasingly prevalent in Canada. Many of these diseases could be prevented by adoption of healthy lifestyle habits including physical activity and healthy eating. Men, especially those in rural areas, are disproportionately affected by chronic disease. However, men are often underrepresented in community-based chronic disease prevention and management (CDPM) programs, including those that focus on physical activity and/or healthy eating. The purpose of this study was to explore the experiences and perceptions of program delivery staff regarding the challenges in recruitment and participation of men in physical activity and healthy eating programs in rural communities, and suggestions for improvement. Semistructured interviews were conducted by telephone with 10 CDPM program delivery staff from rural communities in Southwest Ontario, Canada. Time and travel constraints, relying on spouses, and lack of male program leaders were cited as barriers that contributed to low participation levels by men in CDPM programs. Hiring qualified male instructors and engaging spouses were offered as strategies to increase men’s participation. The results of this study highlight many of the current issues faced by rural health organizations when offering CDPM programming to men. Health care organizations and program delivery staff can use the recommendations in this report to improve male participation levels.

Background and Research Question

Chronic disease affects a large proportion of the North American population, although it is not distributed equally (Centers for Disease Control and Prevention, 2009; Public Health Agency of Canada, 2013). While men outnumber women in those with (and at risk for) chronic disease, men who live in rural areas have higher rates of chronic health conditions than those in urban areas (McGannon, Busanich, Witcher, & Schinke, 2014). Research has reported that community-based chronic disease prevention and management (CDPM) programs that promote healthy eating and physical activity have been effective in reducing the risk of chronic conditions in adults (Bucksch & Schlicht, 2006; Loader, 2010; Nunan, Mahtani, Roberts, & Heneghan, 2013). Men in general are often underrepresented in such programs (Jeffery, Adlis, & Forster, 1991; Naslund, Fredrikson, Hellenuis, & de Faire, 1994; Pagoto et al., 2012). In response, there is a growing body of literature examining men’s perspectives of health promotion programs, which have reported, among other things, that the perceived femininity of such programs represent a significant barrier to participation (Coles et al., 2010; Hunt et al., 2014; Morgan, Warren, Lubans, Collins, & Callister, 2011; Robertson et al., 2013). There are no studies to date that have explored the perspectives of program delivery staff on the provision of CDPM programming to men in rural areas, either in an individual or group (dual-gender or male-only) context. The purpose of this report is to explore rural program delivery staff’s perceptions of the barriers to male recruitment and participation in CDPM programs. Additionally, suggestions for program improvement were also explored.

Method

Semistructured telephone interviews were conducted with a convenience sample of community-based CDPM program delivery staff (n = 10) in health and community organizations (n = 10) in Ontario, Canada. Participants included allied health professionals, health promotion specialists, and recreation center managers. All participants practiced in communities (n = 10) with populations of less than 40,000. A research assistant used a script to probe participants with questions regarding the barriers to effectively recruiting and sustaining the participation of men, and suggestions to improve recruitment and participation outcomes. Interviews were recorded and transcribed verbatim. Questions were designed by the research team specific to the current research question. All interviews took less than 30 minutes to complete. CDPM programs were defined as community-based interventions that addressed either (a) a known risk factor for chronic disease, including but not limited to physical activity and/or healthy eating or (b) behavior change strategies (e.g., self-monitoring) to help manage any diagnosed chronic condition. An independent evaluator with experience in qualitative research performed thematic analysis of the data without the use of analytic software.

Results

Delivery staff noted several barriers related to male-only and dual-gender CDPM program recruitment. For example, many of the group-based programs offered by community health workers were led by female instructors, which staff noted as a potential barrier to male participation. Spouses were also mentioned as important sources of information, support, and encouragement for men’s participation in community-based CDPM programs; if a spouse was unaware of a program then often so was her male partner. Several participants also highlighted time and travel restrictions as barriers specific to working men, who often had a limited number of hours in which participation was possible. Combined with the increased potential for longer travel distances to recreation centers or family health teams in rural areas, this posed a notable disincentive to participate. Additionally, many of the interviewees served farming communities, which they suggested posed unique challenges. One participant noted that farmers did not usually participate during the harvesting season because of the increased importance placed on work commitments. Additionally, some participants perceived that male farmers were reluctant to participate in nutrition programming because they felt like they already possessed a large breadth of food-related knowledge and that dietary counselors may criticize the products of their livelihoods (e.g., pork, beef, butter). According to many participants, the accumulation of the barriers noted above resulted in substantially lower participation rates in men compared with women in rural settings. As such, the human and financial resources required to offer such programs was often at odds with the number of men that would likely participate.

In terms of suggestions for improving male participation that corresponded with the barriers presented above, several interviewees suggested that hiring male program instructors might increase men’s willingness to participate in CDPM programs. Additionally, promoting such programs to men’s spouses was highlighted as a potentially useful recruitment strategy.

Discussion and Recommendations

Time and travel constraints, the lack of male program leaders, and reliance on spouses for health information and support were all identified by program staff as barriers to male participation in CDPM programs. The reportedly low participation levels of men made the justification of male-specific CDPM programs challenging. Additionally, participants noted that it was particularly challenging to recruit male farmers, due to their seasonal time commitments and the expectancy that their produce may be criticized. Based on these findings, there are several modifications to program delivery that could improve the participation rates of men in CDPM programs offered in rural settings. It could be expected that offering CDPM programs led by men, marketing programs to spouses, reducing the stigma of attending health programs, offering programs at convenient times and places (especially during the farming off-season), and increasing staff sensitivity in relation to the ways local foods are portrayed would increase participation rates in this population. As no demographic information on those served by the program delivery staff was collected, the generalization of participants’ perceptions should be done cautiously.