Like many areas, reaching and engaging middle aged men in suicide prevention activities is an important objective for the Champs Public Health Collaborative. The Collaborative commissioned Everton in the Community and Edge Hill University to conduct an evaluation of funded projects and a rapid evidence review of the effectiveness of these interventions. This case study was done jointly with the National Suicide Prevention Alliance and forms part of our suicide prevention resource.
The result is a report outlining key learnings from NHSEI-funded suicide prevention projects delivered between February 2020 and June 2021 for middle-aged men (40-60 years old) living in Cheshire and Merseyside.
The purpose of the funding and projects was to prevent suicide among middle-aged men and improve their mental health and overall wellbeing. Twenty-seven community-based projects were delivered by various organisations in eight of the nine local authority areas in the region (Cheshire East, Cheshire West and Chester, Halton, Liverpool, St Helens, Sefton, Warrington, Wirral).
The projects varied in terms of the organisations and personnel involved, whether they were open to all middle-aged men in the local community, or whether they were targeted at specific demographic groups (for example, veterans, men of working age, men in businesses), or men with specific health conditions (such as mental illness, substance misuse).
Programmes also varied in their duration (including one-off events, weekly sessions), scale and intensity, and activities offered. Activities included sports and physical activities, cultural and creative activities, drama and theatre, gardening, counselling, workshops and mental health first aid.
National and local COVID-19 lockdowns had a significant impact on many of the original projects. Some were able to amend their delivery to engage and support men in suicide prevention activities, mostly online. However, most projects were prevented from starting at all until COVID-19 restrictions were sufficiently relaxed to enable some delivery to take place during the funding period.
Objectives and aims
Middle aged men continue to be a key local target audience for Cheshire and Merseyside public health, mirroring national priorities. It was important to evaluate what works effectively in engaging this sometimes hard to reach group.
The Champs Public Health Collaborative is sharing topline learnings and recommendations from the reports, with Rapid Review of Community-based men’s mental health and suicide prevention interventions’ (by Edgehill University et al 2021), and a report which outlines key learning from NHSEI-funded suicide prevention projects delivered between February 2020 and June 2021 for middle-aged men (40-60-years-old) living in Cheshire and Merseyside.
Local authority Public Health Teams were provided with funding and tasked with the responsibility to commission projects, following requests for expressions of interest. Everton in the Community and Edge Hill University were subsequently commissioned to support the projects with monitoring, evaluating and delivering workshops.
Funded projects were varied and included Mental Health First Aid training for businesses, sailing with Shadow Wind in Liverpool, bee-keeping with Bee Inspired and No Duff’s fitness and wellbeing for veterans.
Evidence was taken from three rounds of online stakeholder engagement workshops held between November 2020 and May 2021, an online expert by experience event in April 2021, and an end of project stakeholder workshop in June 2021. Overall, 18 workshops were held with all participating projects with additional one-to-one support provided, as needed, to project staff. Documentary evidence provided by projects was also reviewed where available.
The evaluation of funded projects concentrated on four areas:
Programme design and engagement methods
Men with lived experience of poor mental health and suicidal ideation and behaviours worked with projects to engage potential participants. This was regarded as central to the effective design of funded projects which were delivered by men for men.
In some projects men preferred discussing their mental health problems and other challenges with women (often in counselling and therapy-based sessions) alongside mentoring from men. Engaging women (particularly the partners of men) in project recruitment was also deemed important since they often encouraged men to seek support for their mental health.
Programme delivery methods
Most projects were either paused or did not start at all until the lifting of most COVID-19 restrictions. For some projects, online delivery of activities and support services further exposed the significant social and health inequalities identified by the impacts of COVID-19, while others continued in modified form. Experiences of digital poverty, limited access to digital technology and poor digital literacy were often significant impacts on project delivery. These experiences also impacted whether men were able to engage in the activities and were often shaped by poverty and significant social and health inequalities.
This was particularly true for men who lived in supported accommodation and/or were in recovery from substance misuse. There were several reasons why men did not engage as much with projects delivered fully online during the national and local lockdowns. These included concerns about trust, who might be able to listen to mental health disclosures virtually, and a reluctance to spend more time online after doing so for work.
Learning from COVID-19
Given the additional burdens placed on project staff to support COVID-19 cleaning protocols and physical distancing measures (often without appropriate funding), the importance of supporting the personal wellbeing and development of staff (including volunteers) delivering suicide prevention projects was frequently emphasised.
The benefits of establishing a regional network of stakeholders focused on suicide prevention
Workshops held with stakeholders and the established networks within and between local authority areas were particularly beneficial in helping to prevent suicide among men. The network enabled project staff to share learning and insight, identify common challenges and solutions to suicide prevention work in their local area and across the region, and raise project awareness through the No More Suicide website.
Challenges and their solutions
Many of the projects were impacted by the implementation of national and local COVID-19 lockdowns. This was because most projects intended to support men in face-to-face community-based settings where the host organisations were located. This mode of delivery had historically been most effective in supporting men.
Some projects were able to amend their delivery to engage and support men in suicide prevention activities online, or in small groups who accessed outside spaces within the rules of COVID-19 lockdowns. However, online only delivery was preferred by far fewer men compared to projects which involved in-person activity. This was typically because of the nature of men’s mental health and other support needs, digital literacy, and the complex nature of their lives.
However, most projects were paused until COVID-19 restrictions were relaxed so that in-person delivery could resume safely. Other projects which were able to develop hybrid (in-person and online) approaches began to pilot these to support men and test new ideas towards the end of the funding period. In one case, the provision of online support (typically mental health first aid training) throughout the COVID-19 lockdowns enabled the lead organisation to extend the scope of their normal activities and support more diverse groups of men.
Reflections and learning
In addition to learning from these projects, the research team conducted a rapid review of publicly available peer-reviewed evidence of community mental health and suicide prevention programmes for middle aged men.
A list of top tips for projects was developed by the team.
- The preferred staffing of programmes, including by volunteers and peer mentors/supporters, should be discussed with men during the design, delivery and evaluation of programmes.
- Embedding learning and insight from men with lived experience into all elements of programmes is important for intended participants.
- The provision of hybrid or blended (in-person and online) delivery methods should be considered, with appropriate support provided to men transitioning back to in-person sessions. Alternative methods and support should be provided to men experiencing digital poverty and those who have limited access to digital technology and have poor digital literacy.
- Relevant targeted communication strategies should be adopted to engage men, with social media and other online promotion being provided alongside more traditional methods for those unable to access newer technologies.
- Informing and encouraging partners, families, and friends to motivate men to engage in appropriate mental health services and programmes is one effective way of recruiting men.
For local areas
- Previous practice of supporting place-based, community-centred, approaches to the delivery of targeted mental health programmes for men should be expanded and embedded into the development of local integrated care systems.
- Using local investment to respond to the mental health needs of men in communities, based on local needs assessments, can represent good value for money and be an important mechanism in improving mental health and in the prevention, treatment and recovery from mental illness.
- Programmes should connect to the newly formed network of organisations which developed out of this evaluation and other local support systems to share learning, insight and resources.
For sub-regional organisations
- Further developing place-based, community-centred, approaches to the delivery of targeted mental health programmes for men should be considered as part of the development of local integrated care systems.
- Investments in small-scale projects with limited funding, staffing and expertise in monitoring and evaluation might compromise the organisation’s ability to engage, as expected, in planned evaluation and learning activities. This needs to be considered against the provision of a small number of universally delivered programmes where measures of impact and outcome production could be more robustly evaluated by the host organisation(s) or external bodies.
- Organisations may wish to connect to the newly formed network of organisations which developed out of this evaluation and other local support systems to share learning, insight and resources.
Recommendations for programme design features
The following are recommendations which compile features of programmes or groups that have been most successful in engaging men in community mental health and suicide prevention programmes and have generated the most favourable outcomes. Full references are available in the Champs Public Health Collaborative’s report.
The intervention should be delivered in a safe setting where men routinely reside.
Programmes engaged men in settings that juxtaposed statutory service provision and were often locations of ‘male appeal’, so where men typically present themselves, were familiar, accessible via public transport and non- medical. Settings included sports facilities, workplaces and other community settings (e.g. Men’s Sheds).
Use language familiar to men
The language used in male mental health interventions or programmes is particularly important and contributes to successfully engaging men. Using language that avoids stigmatising attitudes, is male-oriented and not seen to be feminised (e.g. ‘building mental fitness’ rather than ‘mental health’), associated with sports (e.g. calling the participants ‘players’, the sessions as ‘fixtures’), and uses humour is more likely to increase familiarity and maintain engagement.
Deliver male-only sessions in male communities
Interventions should be taken into, and embedded within, the communities in which the target population is to help develop trusting relationships between the participants and the programme facilitators. This is particularly important for those working with marginalised groups within the community (e.g. LGBTQ+ and ethnic minority groups).
Providing a male familiar environment offers promise and promotes engagement and inclusion by normalising mental health and reducing stigma and discrimination.
The programme facilitators characteristics
Those responsible for delivering and facilitating the programme are often identified as key contributors to the success by being approachable and responsive to the needs presented by the group. Moreover, facilitators who had a willingness to work with men, characteristics including being non-judgemental and supportive, respectful, empathetic, genuine, passionate and adaptable and dressed in appropriate clothing (e.g. sports/club kit, construction work gear).
Use delivery staff with lived experience
Delivery staff who had experiences of mental illness were appreciated by programme participants who were able to relate well to the experiences being presented, so delivery staff with lived experience should be actively included in programme design and delivery
Using a group-based environment
Group or team-based environments facilitated the delivery of mental health programmes and a place to talk about mental health related topics where personal experiences or illness diagnosis were not judged. Using a group-based setting develops a sense of togetherness and a sense of belonging while increasing social capital, which contrasted men’s experiences of social isolation and loneliness.
Use an activity and include goal setting
Activities that appeal to men (sports, physical activity, construction, gardening) are often reported as a crucial ‘hook’ to engaging men who are typically under- reached. Using an activity reduces stigma and creates a positive outlet for emotions, encourages social interactions among the men that will assist in improvements to their mental health and offers opportunities for feelings of achievement, meaning and worth.
Deliver the intervention at an accessible time
Men in Cheshire and Merseyside often work shift patterns or unsocial hours. Interventions or programmes should consider this and offer sessions during early and late evenings and weekends.
Be aware/understand the social environments and personal experiences of those in the area/region
When developing and implementing an intervention, the social environments and the personal experiences of the men in those areas should be considered to ensure that the personal needs of the men are addressed and the intervention is meaningful.
Embed partnership working and co-production across all phases of programme development and implementation
Partnership working and participant co-production enables organisations with different skills and knowledge to come together and design and implement programmes, with benefits including credibility, increased resources, and extended reach. All partners should be sensitive to designing interventions and include attitudes which are positive to working with men to help with their mental health. Co-production also ensures that the programme continually meets the needs of its target group population.
Have an established exit route
All interventions or programmes (particularly those that have a set period of time for delivery) should have an established exit route to reduce dependency. Suitable exit routes include assisting the men into other programmes or projects within your organisation or the community or assisting the men into opportunities for further training that enable the development of skills necessary for future employment.
National Suicide Prevention Alliance
This case study was done jointly with the National Suicide Prevention Alliance and forms part of our suicide prevention resource.