Evaluation of the pilot phase of an Aboriginal and Torres Strait Islander Male Health Module

Aboriginal and Torres Strait Islander males have identified a lack of male-specific health services and programs as barriers to their capacity to access primary care (Adams 2002; Wenitong 2002). Concerns are that there are not enough Aboriginal and Torres Strait Islander male health workers and that the few men working in such roles are often burnt out and leave the service due to unrealistic expectations (Bulman and Hayes 2011). There are calls for male-sensitive professional courses that would enable the Australian health workforce generally, and those servicing Aboriginal and Torres Strait Islander people in particular, to be more responsive to the needs of Aboriginal and Torres Strait Islander men (Australian Government Department of Health and Ageing 2010a; Wenitong 2002). To date, there has been little evidence for gender-based approaches to increasing the engagement and participation of Aboriginal and Torres Strait Islander men in primary health care, both as service consumers and providers. This paper evaluates the pilot phase of an Aboriginal and Torres Strait Islander Male Health Module (hereafter, the Module) designed to equip Aboriginal and Torres Strait Islander Health Workers (hereafter, Health Workers) with the necessary skills and expertise to enable them to play leadership roles in making services and programs more accessible for Aboriginal and Torres Strait Islander males.

It is widely acknowledged that men experience higher levels of illness and injury and die younger than women (Australian Institute of Health and Welfare 2011). A men’s movement has emerged internationally, over the past four decades, which seeks to offer analyses of what has gone wrong for men and explore how this can be addressed. This movement has seen the establishment of a range of ‘self-help’ and ‘self-improvement’ initiatives, such as men’s clinics, sheds, meetings and conferences, and the growth of men’s support groups; since the 1990s, Aboriginal and Torres Strait Islander men have formed support groups designed to promote their own health and wellbeing and those of their communities (Tsey et al. 2002). In 2002, there were 100 Aboriginal and Torres Strait Islander men’s groups across Australia (McCalman et al. 2010). The vision of Aboriginal and Torres Strait Islander men has been to take responsibility themselves to improve the status of men’s health and play their rightful role as leaders, fathers, uncles, husbands and grandfathers (Briscoe 2000). They have adopted a diverse range of strategies, including discrete men’s clinics, men’s programs within Aboriginal health services, men’s business camps, sobriety groups, sports initiatives, parenting projects and men’s support groups (Working Party of Aboriginal and Torres Strait Islander Male Health & Well Being Reference Committee 2003), which have subsequently been adopted in the 2010 National Male Health Policy (Australian Government Department of Health and Ageing 2010a, 2010b). Mibbinbah Limited, the peak support agency for Aboriginal and Torres Strait Islander men’s groups Australia-wide, runs a national camp annually and supports the development and running of local and regional camps around Australia.

Andrology Australia was established in 2000 in response to an identified education need for Australian men on disorders of the reproductive system and associated conditions, namely prostrate disease (including prostate cancer), infertility, testicular cancer, sexual problems (including erectile dysfunction) and androgen use and abuse. Administered by Monash University, health and education experts from across Australia developed a collaborative strategy as a ‘centre without walls’ to raise the awareness of male reproductive health disorders through community and professional education programs and support of research (Holden and de Kretser 2003). Within this context, an Aboriginal and Torres Strait Islander Male Health Reference Group was established in 2002 to advise Andrology Australia on how best to make its activities relevant to the needs and aspirations of Aboriginal and Torres Strait Islander men. Comprising Aboriginal and Torres Strait Islander male doctors, nurses, community health workers, counsellors and other community leaders with considerable experience in health, the Reference Group was also selected to reflect urban, rural and remote Aboriginal and Torres Strait Islander conditions.

After 2 years of consultative work with Aboriginal and Torres Strait Islander male stakeholders, the Reference Group made two key findings. First, key existing mainstream men’s health education programs and resources (DVDs, posters, radio and television advertisements) and other social-marketing strategies were, in most cases, culturally inappropriate for Aboriginal and Torres Strait Islander people, especially those from remote settings. Second, the social, economic and cultural vulnerabilities of Aboriginal and Torres Strait Islander men meant that their health needs, unlike most mainstream Australians, was beyond health promotion that merely aimed to raise community awareness through information provision. It required significant actions that enabled the capacity of the Australian health workforce to improve access to health services more broadly for Aboriginal and Torres Strait Islander men.

The Reference Group recommended a need to develop a professionally accredited male-health training course specifically targeting Health Workers because of their potential roles as agents of change in Aboriginal and Torres Strait Islander primary care. Such a male-focussed health course would also make it more attractive for Aboriginal and Torres Strait Islander males to enter a health workforce traditionally dominated by women.

Andrology Australia subsequently coordinated the development of the Module, under the guidance and input of the Reference Group. The Module content was initially developed by the Monash University Department of Rural and Indigenous Health with clinical expertise provided by Andrology Australia. Independent review and input of content material was undertaken by individuals and peak associations to ensure the Module was consistent with current best practice (including the Australian Drug Foundation, Beyondblue: the National Depression Initiative and National Prescribing Service). The Module (which includes a facilitator guide and accompanying student manual) comprises 15 units across a range of health areas identified by the Reference Group as key issues brought to the group from their own constituencies. Sexual orientation among Indigenous men, for example, issues affecting ‘Aboriginal and Torres Strait Islander Gay Men (men who have sex with other men) and Sister Girls (Transgender)’ are addressed throughout the Module. More detail about the Module, including a content overview, can be found at: http://www.andrologyaustralia.org/health-professionals/aboriginal-health-workers/, verified 9 October 2012.

To evaluate the Module, three pilot workshops were implemented between January and December 2011.

• Workshop 1: A 1-day male-only ‘trainers’ workshop was conducted for those who will potentially teach or deliver the curriculum to health workers. Nine participants, from across rural and urban Australia, were drawn from a pool of 52 men attending the Mibbinbah annual 1-week Aboriginal and Torres Strait Islander Male Gathering in a Victorian rural community. Section 1 (Background to Effective Practice) with particular focus on social, emotional and spiritual wellbeing was workshopped with the group.

• Workshop 2: Two 3-h male-only workshops for Health Workers were held at a large North Queensland Aboriginal community-controlled health service. This workshop focussed on the potential learners or students of the course. Units 9 (Male-Specific Health Issues) and Unit 10 (Chronic Disease and Male-Specific Health Issues) were covered.

• Workshop 3: Two 1-day workshops for male and female health workers were held at a large Aboriginal community-controlled health service in rural Victoria. Sections 1 (Background to Effective Practice with particular focus on social and emotional wellbeing) and 5 (The Aboriginal Health Worker Role in Male Health) were covered.

Four sets of data were gathered for the evaluation.

• In-depth semi-structured interviews were conducted with two information-rich people closely involved in the curriculum conceptualisation and development to ascertain the rationale, assumptions and vision for the curriculum.

• A workshop questionnaire was administered to all participants at the end of each of the three pilot workshops. Apart from demographic data, the questionnaire elicited answers on the strengths and limitations of the curriculum objectives, content, learning resources, instruction methods and potential sustainability.

• Focus group discussion was facilitated by the lead evaluator at the end of each workshop further exploring the strengths, limitations and strategies to enhance the effectiveness of the curriculum.

• Participant observer field notes were taken by the lead evaluator at each of the three pilot workshops.

A qualitative thematic analysis was applied. All four datasets were transcribed and collapsed into one document and coded line by line (Denzin and Lincoln 2005; Braun and Clarke 2006). The Erickson’s (1986) data analysis template was used to search for emerging themes during the process of reading and re-reading the dataset. Initial readings provided an overview of the Module narrative: its origins, the curriculum-development process, contextual factors affecting the workshops, and the key issues and recommendations arising from each workshop. Subsequent readings identified consistently recurring themes across the combined data, which were then classified into broad thematic categories, each with its constituent sub-themes.

A total of 25 people participated in the pilot study (Table 1). Of these, 16 participated as ‘learners’ while nine participated as ‘trainers’. All nine trainers were male; six learners were female. The majority of participants were in the 40s and 50s age group. Except for two learners and a trainer, all study participants were Aboriginal and/or Torres Strait Islander.

Table 1.  Demographic characteristics of participants in the pilot study

Three main themes emerged from the analysis.

The overwhelming response across all three pilot study sites was that the course was highly relevant to the needs and challenges of Aboriginal and Torres Strait Islander health; one participant expressing a pleasant surprise that, ‘A training package specifically for ATSI [Aboriginal and Torres Strait Islander] men, wow, I didn’t expect it!’. As the first ever comprehensive accredited training package focussing specifically on Aboriginal and Torres Strait Islander male health, the course was seen as filling an important missing gap in workforce training.

The comprehensive and holistic approach taken to developing the model fits in well with Aboriginal and Torres Strait Islander peoples’ ways of thinking and seeing the world, evidenced by comments such as, ‘I think that it covers men’s health in a holistic way and does this in an appropriate manner’, ‘I think you’ve covered it well!’, ‘…I believe…issues [for men] are comprehensively addressed’, and ‘all aspects of this training are directed towards Aboriginal Health Workers’ engagement and service delivery to Aboriginal people’.

Another reason the Module was seen as relevant was its potential to promote Health Workers’ personal development and empowerment. Personal development leads to empowerment, which in turn enhances resiliency and wellbeing; all necessary to a health worker’s capacity to provide effective services. One respondent insightfully explained, in the context of the many problems facing Aboriginal and Torres Strait Islander people, that she responded to the opportunity to do the workshops ‘with enthusiasm towards bettering myself for my own behalf first’ allowing her to become ‘more confident in helping clients coming to the service’.

Closely related to personal development was enhanced capacity of Health Workers to facilitate access to health services for men − a major objective for development of the Module. Pilot participants described the Module as ‘a very useful tool to open our minds’, ‘[it] gives me understanding how to approach and speak to men’, ‘excellent, easy to understand’ and ‘[it] will be very good for new health workers’. They believed the module will help Health Workers to develop the necessary skills and expertise to facilitate service access for men. Some of the specific skills of value identified included the ‘male reproductive anatomy’, ‘learning how to diffuse a situation with an aggressive client’, ‘how to approach male issues and refer to appropriate services that can address them’, and working with other services in order to ‘remove barriers for Aboriginal and Torres Strait Islander men accessing services’.

Participants valued the relaxed and confident manner in which the pilot workshops were facilitated, in the words of one person, ‘with very little use of books, readings or writing but everybody just talking and exchanging ideas’, prompting another participant to describe the whole experience as ‘the most enjoyable workshop I have attended in a very long time’. Nevertheless, there was a feeling that there was too much emphasis on written assessment. As well as ensuring a balance between written, oral and other forms of assessment, there were calls for greater appreciation for ‘Aboriginal peoples’ rich traditions of storytelling as huge assets that learners bring into the course’ for facilitators to be encouraged to ‘use such resources both in the learning and in assessing the students’.

A range of other suggestions to improve the curriculum documents included the need to make the reproductive diagram larger, visual diagrams to accompany the case studies in the Student Handbook, 3-h duration per unit, red traffic signs to alert facilitators and students not only to gender-sensitive material but also to other sensitive information such as the removal of children from their families and massacres during white settlement, and using strengths-based language wherever appropriate in the curriculum.

The recommendation by the curriculum developers that female Health Workers should be able to access sections of the Module for their professional development, using male or female facilitators as appropriate, triggered considerable discussion and debate at each pilot site. The general consensus was that to improve access to health services for Aboriginal and Torres Strait Islander men required men and women working together in partnership, based on mutual respect and trust. The idea was consistently expressed that as Aboriginal and Torres Strait Islander peoples ‘we cannot think about men without thinking about women and the rest of the family’ because ‘men are part of the family’. There are many gender-specific issues that men and women will not discuss in front of each other. Hence, facilitators needed to be sensitive about how they delivered the Module in combined men and women sessions. Nevertheless, men and women doing the Module together was seen as a positive experience because, ‘it helped men to be honest’, ‘gave women a bit of insight into issues affecting men’, and ‘men understanding women and women understanding men so everybody is on same page’.

Although men and women found the experience of learning about men’s health valuable, male participants reported that it was not enough for them to know about their own health. They believed that just as it was beneficial for women to learn about men, it was equally important for them, as Aboriginal and Torres Strait Islander men, to learn about women’s health so they can better understand women. The experience of learning about their own reproductive health, especially the ‘links between our mind, body and emotions and our ability to function sexually and all the things that can go wrong’ was very useful. But to be able to have healthy and positive relationships with their wives, partners and girlfriends, they felt it was ‘important that men understand the functioning of the female reproductive health systems too and the things that can go wrong, for example, menstrual cycles and hormonal changes’. This way, they believed, men and women will relate better to each other, thereby experiencing healthier relationships.

Despite overall enthusiasm, the data analysis revealed deep fear among the pilot participants that the male health Module would end up like most Aboriginal and Torres Strait Islander programs, in the words of one person, ‘collecting dusts on shelves’ because of an inability to reach those who required it. Potential barriers to access included too many training programs targeting limited pools of Aboriginal and Torres Strait Islander male Health Workers, managers not allowing male Health Workers to attend training partly due to the difficulty of replacing them while they were away and partly because of the incorrect perception that men going away for training was simply an excuse to have fun, and the high heterogeneity of Aboriginal and Torres Strait Islander Health Workers across Australia and the difficulty of catering for their diverse needs. Strategies to improve access to the Module beyond the existing, relatively small, male Health Worker workforce included incorporating the Module into school curriculums so young males aspiring to become health workers could take it in their final year, and targeting local, regional and national men’s support groups and associated sporting clubs as community education.

Aboriginal and Torres Strait Islander Australian societies were traditionally characterised by gendered separatism based on complementarity and interdependence in the economic, political, social and spiritual domains of life (Huggins 1998; Martin 2001). Despite being historically deprived of Ancestral lore and social structures as a consequence of the colonising society (Huggins 1998; Martin 2001), in the 21st century the signifier of Aboriginal and Torres Strait Islander society is still the maintenance and nourishment of the community endorsed by the interdependence and complementary nature of the rights, roles and responsibility between men and women. Evidence suggests that Aboriginal and Torres Strait Islander male programs and spaces may be effective in culturally supportive ways of connecting men with one another (McCoy 2009). As many as 200–300 Aboriginal and Torres Strait Islander males across Australia are now part of a web-based network linked to Mibbinbah Limited, resulting in ‘bonding’ social capital by keeping men linked within the network on the one hand, and ‘bridging’ social capital by bringing in new men on the other (Bulman and Hayes 2011). The Module clearly builds on these and related male networks and initiatives to provide a well-informed male-specific resource for training Health Workers.

Health Workers form part and parcel of their communities and are not immune to the social-health problems often afflicting these communities, including intergenerational loss and grief, drug and alcohol abuse, depression and interpersonal violence. For professional training to be meaningful and relevant for Health Workers, they need to pay greater attention to issues of personal development, empowerment, resiliency and wellbeing, all found to constitute strong foundations for workforce development (Wallerstein 2006; Whiteside et al. 2006; Haswell-Elkins et al. 2010).

Best-practice dissemination strategies utilised for other Aboriginal and Torres Strait Islander health worker training programs have included partnerships between the developing organisation, registered training agencies and Aboriginal community-controlled and other health organisations. They involved incorporation of the training modules into broader Aboriginal primary health care certificates, development of training manuals, accreditation of the training, extensive community consultation (Adams and Spratling 2001) and commitment to strengthening program evidence bases through ongoing evaluation and appropriate dissemination of such findings (Watson and Harrison 2009). These strategies, as well as the potential on-line availability of the course, are being considered for disseminating the Module.

Aboriginal and Torres Strait Islander Australian health research has been predominantly descriptive and there have been few quality studies directed at testing the effectiveness of strategies for improving health outcomes (Sanson-Fisher et al. 2006). This makes pilot evaluations such as this a step in the right direction. However, it also highlights an urgent need to follow up the current pilot with a more substantive study assessing the medium to longer-term impact of the Male Health Module Australia-wide. This should help strengthen the research evidence base for Indigenous male-specific programs and spaces.

Overall, the Module was seen as highly relevant to the education needs of male Health Workers requiring little change to the content other than the minor suggestions, such as visual diagrams and alerts, identified in the evaluation. Indirectly, the method adopted to deliver the pilot workshops was also well received. Given that the majority of attendees were experienced Health Workers, consideration will need to be given to the delivery format to allow open dialogue and exchange of ideas between students from a range of backgrounds to enhance the student learning experience. Similarly, while the Module was designed specifically for men, the participation of woman for some elements would be encouraged if considered appropriate in the local setting. The flexibility of the Module, in terms of the content and delivery, are important features to further reduce the barriers to access that were also identified in this evaluation.

While this Module was developed specifically for Aboriginal and Torres Strait Islander Health Workers, a gender-based approach to men’s health education is lacking more broadly. The learning from the development of this module, from identified need, community consultation, through to pilot testing and delivery, could potentially be extended to other men’s health education to improve health outcomes for all Australian males, a concept that warrants further consideration.

The purpose of the project was to evaluate the pilot phase of Andrology Australia’s Aboriginal Male Health Module for Health Workers at pilot workshops to inform improvements to the training module as well as make recommendations to guide the wider implementation of the Module across Australia. The Module is a well-informed, useful resource that parallels the objective model rationale for developing an educational program (Tyler 1949). The evaluation findings and recommendations call for partnerships between curriculum developers, training providers and relevant Aboriginal and Torres Strait Islander male support networks to make the course accessible to men. The findings strengthen the evidence that when specific Aboriginal and Torres Strait Islander male-friendly health programs are available, improved health-seeking behaviours can occur.

At the time of this evaluation the Module was being mapped against competency standards for subsequent accreditation as a short course as part of the Certificate IV in Aboriginal and/or Torres Strait Islander Primary Health Care training for subsequent delivery through registered training organisations across Australia. As the only male-specific Health Worker education module currently available, it is imperative that ongoing support and resources are available to ensure accessibility and impact evaluation including value for money analysis in the longer term. This should fulfil the National Aboriginal and Torres Strait Islander Male Health Framework Revised Guiding Principles recommended in the 2010 National Male Health Policy (Australian Government Department of Health and Ageing 2010a).