Implications for health-care practice and service delivery

Self-management support is likely to be more accessible and acceptable to men when it takes account of valued aspects of masculine identities.

Findings from this review echo recommendations for self-management support to be tailored to individual preferences and lifestyles;^33,243 for men with LTCs, this is likely to involve consideration of their identity as a man. Health professionals and service commissioners might usefully consult with male service users about how to make existing support interventions more appealing to men and congruent with their identities.

It may yield benefits if self-management support is gender-sensitised in context (e.g. delivered in a trusted environment among peers), content (e.g. action-orientated), delivery style (e.g. a problem-solving/practical approach) and marketing (e.g. emphasis on purpose/tangible results). However, health professionals need to recognise that men are not a homogeneous group and that there is unlikely to be a ‘one-size-fits-all’ approach that meets the requirements of all male service users. Men and women may both benefit from particular intervention components/types (e.g. peer support, information sharing) if they have similar personal preferences and/or a shared illness experience, and men may also be willing to accept different types of interventions or activities once they feel they are in a trusted environment with peers, including interventions or activities which at the outset may have appeared to present some challenge to aspects of male identity.

Gender appears to have an impact on the effectiveness of self-management support.

Limitations in the data meant we were not able to provide a definitive answer to the review questions relating to effectiveness, and any recommendations in this regard therefore need to be tentative. As there is currently insufficient evidence to make strong statements about differential effectiveness in men, the focus for services should be on ensuring the accessibility and acceptability of self-management support interventions to ensure equitable uptake and engagement among men.

However, health professionals and those involved in designing interventions may wish to consider whether or not certain components and intervention types are particularly effective in men. In the current data that are amenable to analysis, evidence of effects on quality of life point towards men benefiting the most from interventions with a physical activity, education or peer support component, although more research is needed to fully determine and explore this.

Recommendations for future research

1. Clear and consistent reporting of components of self-management support interventions.
   Support interventions need to be clearly and consistently described by researchers using a shared language. It is suggested that researchers clearly report on whether or not an intervention was intended to target a specific behaviour change and report adequate detail to allow for coding with the BCT taxonomy, where applicable.
2. Understanding what interventions work in men and why.
   Clearly, further primary research is needed to examine which models of service delivery are most effective and cost-effective in providing self-management support to men. Any intervention developed should be theory-led, and our review findings point towards some broad BCT which could act as a starting point for testing the ‘active ingredients’ successful at promoting self-management in men. Parallel primary qualitative research is also needed to test theory and develop our understanding of what makes interventions, and their ‘active ingredients’, accessible and acceptable for men with LTCs. The complex and contextually dependent nature of men’s engagement with self-management support interventions highlighted in this review suggests that a study drawing on realist principles²⁴⁴ might be one method of analysis which might have utility.
3. Including gender in the analysis of effectiveness of self-management support.
   The ability to conduct the analyses was limited by a lack of consideration and/or poor reporting of gender as a moderator of outcome data in primary studies. Few studies provided outcome data separately for men and women. There is a need for researchers to consider gender consistently in their analyses and provide consistent and comprehensive reporting of outcomes by gender. Access to primary databases through archives or the supplementary material functions of online publications may be one way of facilitating such analyses, and concerns about power and precision may be managed through adoption of appropriate meta-analysis techniques.¹⁵⁷
4. Consideration of the cost-effectiveness of self-management interventions for men.
   There is a dearth of evidence on the cost-effectiveness of self-management interventions for men. Without an evidence base it is not possible to assess whether or not self-management interventions are cost-effective for males and females or whether or not gender affects cost-effectiveness. While the lack of evidence is surprising, it is conceivable that existing studies of self-management interventions in the UK could be accessed and retrospective analyses performed. All trials will collect data on gender and many cost-effectiveness analyses could be conducted by simply running a group analysis by gender. This would generate estimates of whether or not the intervention is likely to be cost-effective in men. Similarly, where funding is granted for evaluation of self-management interventions, it is suggested that researchers should consider the inclusion of gender as a pre-specified group analysis for the economic evaluation.
5. Consideration of men of differing age, ethnicity and socioeconomic background.
   The self-management experiences and perceptions of men of differing age, ethnicity and socioeconomic background need to be explored. Men are a heterogeneous group, yet consideration of how these factors intersect with men’s gender identities is rarely a focus of empirical research.
6. Understanding depression in men with LTCs.
   Depression is a prevalent comorbidity among those living with a chronic physical condition and is recognised in current National Institute for Health and Care Excellence guidelines.¹⁷⁶ Although several quantitative studies examined depression outcome measures, depression as a comorbidity was recognised in only one study included in our qualitative review. Studies tended to discuss addressing men’s ‘fears’ (e.g. of treatments or worsening health) and psychological processes (e.g. ‘coming to terms’ with a diagnosis or prognosis) rather than depression symptomatology or psychological morbidity per se. Further primary research is indicated to explore this under-recognised comorbidity in men.