What Does Men's Health Education Look Like in Australian University Health Curricula? A Formative Evaluation and Future Enhancement Opportunities

Abstract

OBJECTIVES

Developing the capacity of the health system, and the practitioners within it, to provide quality gender responsive care to men and boys remains critical to advancing men's health, and reducing health inequities amongst men. The aim for this study was to undertake a formative evaluation of Australian university health curricula for men's health content and scope the opportunities for future enhancement.

METHODS

A two-stage evaluation first involved a review of online course information for a sample of medicine (n = 10), nursing (n = 10), pharmacy (n = 10), clinical psychology (n = 10), social work (n = 12) and public health (n = 15) university curricula for men's health and gender content and opportunities for curricula enhancement. Secondly, university staff completed a survey on the coverage of men's health in their course(s), and receptivity, barriers and facilitators to curricula enhancement.

RESULTS

The curricula review found no dedicated men's health courses, and men's health was referenced in the information for 10 of 1246 courses (0.8%) in 8 of 67 curricula. Gender was rarely referenced in course information, particularly for the disciplines of medicine, nursing, pharmacy, and clinical psychology. There was an average of 16 enhancement opportunities per curricula with 40% relating to communicating and engaging with men within healthcare. Seventy staff from 25 universities and all target disciplines validated the curricula review findings of limited dedicated men's health content. Eighty-three percent were receptive to curricula enhancement, facilitated by content integration into existing courses.

CONCLUSION

This review provides clear evidence that there are gaps, opportunities, and educator receptiveness for improving and implementing content regarding men's health education and gender responsive care in Australian university health curricula.

Introduction

Premature mortality accounts for a substantial proportion of the burden of disease in males. In 2022, nearly 2 in 5 (37%) male deaths in Australia were premature, occurring before the age of 75 years, with males representing 61% of all premature deaths.^1,2 This burden of disease is also disproportionately higher in underserved groups of men. As an example, Australian men who live in the lowest socioeconomic areas have a rate of premature death that is more than double that of those in the highest socioeconomic areas. ³ The leading causes of ill health and premature death for males include suicide, mental health conditions, substance use disorders, injuries, cardiovascular diseases, lung cancer and colorectal cancer. ⁴ Importantly, these causes are largely avoidable through preventative health programs and healthcare intervention. ⁵

Gender is a shared social determinant of health for men, women, boys, girls and gender diverse people, and gender inequalities drive this large-scale excess in premature mortality and morbidity globally.^6–8 The barriers to effectively reaching men through preventative health programs and early intervention is also largely understood to be influenced by gender and other intersecting social determinants of health. For men and boys, gender inequity is largely experienced through gender-restrictive norms that impact men's health behaviours, and access, engagement and experience of the health system. ⁹ As an example, masculine norms of stoicism and self-reliance may lead to men's delays in seeking help and accessing healthcare until crisis. ¹⁰ A propensity for non-disclosure, rationality, objectivity, and need for control may also lead to some men having dissatisfying experiences or dropping out of care if health concerns are missed or misunderstood by practitioners. ¹¹ Furthermore, a practitioner's own gender norms and biases may complicitly reinforce traditional masculine norms when engaging with men. This may lead to them not being receptive to men's needs and dismissing the role of masculinities and gender socialisation in healthcare interactions. ¹²

These gender norms, and the differences in health attitudes, behaviours, and outcomes that they translate to, necessitate a healthcare system that recognises and responds to the different ways men, women, and gender diverse people are socialised. Implementing gender responsive healthcare systems that privilege gender equity in their design and delivery of care, has the potential to advance rights to health and well-being for people, in all their diversities. A gender responsive healthcare system requires gender competent practitioners that acknowledge and respond to relational gender dynamics as a central part of person-centred care. These practitioners ensure that once men overcome gender socialised help-seeking barriers, they are met by health services and practitioners that can connect with them, respond to their specific health needs, and retain them within healthcare for optimal outcomes. ¹³ Importantly, they are able to do so by understanding the role of gender, in the diversity of men's patterns of health presentation, engagement and outcomes, along with the influence of their own gender bias. They then use these skills, alongside discipline specific knowledge pertaining to men's health, to tailor approaches to engaging with men and boys in addressing their health needs. This also serves to optimise the patient-provider relationship, and thus the satisfaction, adherence, and overall outcomes of men's healthcare.^14–18

In order to ensure future practitioners are able to provide effective, gender responsive healthcare, foundational learning through undergraduate education is crucial. Recent evidence on the extent of Australian student preparedness for the provision of gender responsive healthcare for boys and men also emphasises this need. A survey of medical students from 17 of 21 accredited Australian medical schools found that only 7.2% felt thoroughly prepared to work with men in clinical practice, compared to 30.4% for women's health clinical practice. ¹⁹ Furthermore, more than half of the students reported being minimally or not at all prepared for providing different elements of gender responsive healthcare for boys and men. Consistent with these findings, two thirds of students reported minimal to no coverage of men's health in their medical education, and students were wanting more education around gender-competency for working with men. This suggests clear gaps in their curricula which underpins their lack of preparedness.

Indeed, the Australian Government's National Men's Health Strategy (2020-2030) ²⁰ acknowledges the need for gender responsive healthcare. This strategy provides a national framework for action on men's health in Australia, and calls for the integration of men's health education, through a gender lens, into medical, nursing, and allied health curricula, in order to improve the men's health knowledge, engagement, and male-centred practice of healthcare practitioners. The educational goal is to strengthen the capacity of the health system to provide quality care for all men and boys across all their health service encounters.

An understanding of what men's health education currently looks like across Australian university curricula, the gaps in content and opportunities for enhancement, and receptivity to such by educators themselves is first required. Of three published reviews of men's health curricula, only one was undertaken in the Australian context.^21–23 A range of methodologies were used across the studies to collect the data. The review by Holden et al ²¹ did not examine curricula directly but rather gained insights from students from one discipline (medicine) across four Australian universities. In addition, Young and Lempicki relied on a university staff survey with a response rate of 13% to draw conclusions about the presence of men's health curricula in accredited pharmacy schools in the United States. ²² The only available multidisciplinary curricula review is that by Giorgianni et al ²³ who systematically searched United States college and university medical and public health school curricula for dedicated men's health courses and supplemented this data for other health disciplines through staff interviews. Both biomedical and sociological aspects of men's health were considered, yet the reporting was restricted to dedicated men's health courses only. Consultation with university education staff has not been included consistently across prior reviews. This is important to include, as several authors recognise consultation as a fundamental requirement for effective curricula reform.^{.16,18,22,24–26} This consultation allows deeper insight into the syllabus of courses and provides an important engagement opportunity with key stakeholders in the curricula enhancement process.

The primary aim of this study was therefore to undertake a formative evaluation of Australian university health curricula for men's health content and scope opportunities for future enhancement, by way of a curricula review and through a survey of university educators. Given the focus on gender responsive healthcare, a secondary aim of the study was to review the curricula for broader gender-based content. Finally, those from the field of women's health have historically led the way in advocating for university health education curricula reform to improve women’s health competencies of health practitioners and therefore health outcomes for women.^16,25 A further secondary aim of this study, therefore, was to examine how well this advocacy had translated into practice, by concurrently reviewing the curricula for women's health content.

Methods

Study Design

The formative evaluation, undertaken between September 2022 and June 2023, entailed a two-step design. The first step was a review of online Australian university health curricula for men's health content and opportunities for enhancement. Australian university health curricula refer to the collection of courses provided to health profession students that are offered by Australian universities. In a health professional education context, we refer to men's health content that pertains to the approach to healthcare provision to achieve men's physical, mental and social health,^27,28 that, as defined by Baker and Shand, ²⁹ ‘takes account of the specific health needs, social contexts and the related health practices of men and boys’ in all their diversities. The review was undertaken for the key front line health disciplines of medicine, nursing, pharmacy, clinical psychology and social work. Public health curricula were also included given the profession's role in community health and health promotion, health policy and service design and delivery.

The second step of the evaluation was an online survey of Australian university educators from these disciplines to assess the coverage of men's health content in their curricula/course and receptivity to enhancement with men's health content. Staff provided informed consent online prior to undertaking the survey. The survey, including the consent procedure, was approved by the Bellberry Human Research Ethics Committee (Bellberry Ltd; #2022-10-1081).

A steering committee of clinical academics with discipline specific expertise in men's health and university education were selected to inform the development of the curricula review protocol. This included identifying appropriate university degrees for each profession, the development and piloting of the staff survey, and the interpretation of the review and survey findings.

Evaluation Procedure

Curricula Review

The sample of curricula for the review were selected using the Times Higher Education (2022) university and subject rankings list. ³⁰ This approach was undertaken in order to reduce bias by using a globally recognised ranking system of Australian universities by each of our targeted disciplines. For each discipline (profession), a minimum of 10 curricula were selected from the highest-ranking Australian universities. The selection of the highest ranking universities was on the assumption that they may be more likely to have more comprehensive curricula. The expert steering committee was consulted regarding the universities chosen to ensure each university's curriculum was regarded as comprehensive and held high impact within the respective discipline. Universities were excluded if course content information was not publicly available. Undergraduate degree curricula included nursing, medicine (MD, MBBS, BMedMD, MChD), pharmacy, public health, and social work. Postgraduate curricula included psychology (clinical psychology), public health (Master of Public Health) and social work. For further industry context, professional accreditation standards for nursing, ³¹ medicine, ³² pharmacy, ³³ clinical psychology ³⁴ and social work ³⁵ were also reviewed. Public health does not have accreditation standards in Australia.

Course summaries and learning outcomes for the core and relevant elective courses within curricula were extracted from each selected university website and tabulated in Microsoft Excel. A curricula review framework, adapted from that used by Miller et al ¹⁶ was developed to map men's health content found in these extractions to four learning categories: (i) practitioner–patient communication and engagement, (ii) biology and clinical practice, (iii) preventative health and health promotion and (iv) social determinants of health and wellbeing in order to best understand what men's health education looks like in curricula (Table 1). Separate instances of content referencing ‘gender’ and women's health content were also mapped to these learning categories. Alongside the review for existing content, potential opportunities to integrate men's health content into courses were also mapped to these four learning categories. Integration opportunities were defined as instances within courses where content could be enhanced by gender-oriented considerations of health needs, social contexts and healthcare practices (eg, engagement approaches), when providing care for boys and men. For example, in instances where course content covered practitioner–patient communication, but did not mention tailoring of such through a gender lens, this was noted as an opportunity to integrate men's health content on gender responsive communication strategies to effectively engage men during healthcare encounters.

Table 1.

Curricula review framework adapted from Miller et al. ¹⁶

Learning category	Definition
Practitioner–patient communication and engagement	The communicative aspects of clinical/professional practice. Includes communicating, engaging and partnering with the male patient in the care process using a male-tailored approach.
Biology and clinical practice	Pathophysiology and biology of physical, mental and behavioural conditions that are exclusive to males, or for shared conditions where there are sex- and gender-related differences (eg, heart disease, depression and suicide, substance abuse, trauma).
Preventative health and health promotion	Preventative health and health promotion strategies, including health literacy and self-care, access to care and services, screening, and lifestyle behaviours including risk taking and social networks.
Social determinants of health and wellbeing	Demographic and sociocultural determinants of health and wellbeing. These include gender, culture, education, income, life stage and the interactions between these factors that influence health and wellbeing.

The accreditation standards, that inform curricula, were also searched for references to men's health, gender, including gender competency, and women's health. Furthermore, the standards were examined to assess whether integration opportunities related to men's health and gender competency would align with current standards.

Staff Survey

The inclusion criteria for the staff survey were staff members currently responsible for Australian university curricula or course delivery (ie, discipline heads and deans) and teaching staff. Lists of relevant staff members were retrieved from relevant university websites during the curricula review. Staff were invited to complete the survey via email and were asked to forward the survey to colleagues in any relevant health discipline. Distribution to social work teaching staff also included the Australian Association of Social Workers newsletter and academic networks. Staff survey numbers were monitored to ensure adequate representation from each of the six target disciplines, and until data saturation was reached.

The survey comprised 18 questions designed to yield data that served to validate and supplement the findings of the curricula review (Supplementary file 1). In order of appearance, questions sought data on (i) the university, the discipline, degree, position, and, where applicable, course(s) taught by the staff member; (ii) the coverage of men's health in their course(s) and, if taught, a brief description of the content (open-ended); (iii) whether 10 specific men's health topics, selected by an expert steering group, were included in their course/curricula (categorical rating) and (iv) their perceived need for men's health content within their course/curricula (categorical), the preferred format(s) of the content (categorical and open ended), and any perceived barriers and the facilitators to potential curricula enhancement (open-ended). The use of open-ended questions was designed to elicit further information on their understanding of men's health in an education context and to optimise a stakeholder-informed needs assessment regarding curricula enhancement.

Data Analysis

Curricula review data and survey responses were analysed using descriptive statistics. Responses to the open-ended survey items assessing barriers and facilitators to potential curricula enhancement were analysed using inductive qualitative content analysis, utilising the approach of Elo and Kyngäs. ³⁶ This methodology enables qualitative data collection to occur with larger samples and situations where individual interviews and focus groups would not be feasible. ³⁷ In brief, responses to each question were reviewed and coded into distinct units of meaning, and codes were subsequently grouped into higher-order themes based on similarity ensuring categories were derived from the data. ³⁶ Under this approach, responses are coded into categories directly reflecting what is described by participants, rather than interpreting and coding responses by their underlying meaning. ³⁸ Consistent with the three phases of the content analysis process, one member of the research team (M.S.) first became immersed in the data (preparation phase), and using an open coding approach, collated responses that overlapped in meaning (organisation phase), which was then followed by the representation of data in the form of a conceptual map and categorical list (reporting phase) through discussion with a second author (M.M.). Following this process, consensus was reached amongst the research team regarding the categories of barriers and facilitators, and quotes shared, through discussions and the writing of this article. This collaborative approach throughout the analytic process enabled reflective and thoughtful engagement with the data. To ensure analytical and methodological rigour, the 21-item Standards for Reporting Qualitative Research (SRQR) ³⁹ was completed with all items fulfilled (Supplementary file 2).

Results

Curricula Review

The course information was reviewed for 1246 courses in 67 curricula from six disciplines, and 23 universities. There were no dedicated men's health courses. Men's health was referenced in the course information for 10 of the 1246 courses (0.8%) in 8 out of 67 curricula (11.9%) (Supplementary file 3). No references to men's health were found in medicine, nursing, or clinical psychology curricula, with all content found in pharmacy, public health and social work curricula.

Five of the 10 instances of men's health content were in pharmacy curricula, with all content mapped to the biology and clinical practice category. These references related to understanding and treating common conditions in male patients (most commonly reproductive health conditions). A men's health module (and women's health module) was included in one course, with the module amongst a series that focused on managing medical conditions and complications in specific patient groups. Three of the 10 instances were in public health curricula, with one reference in a course on ‘mental health and ageing’, and the other two in courses focusing on ‘gender and health’. Course summaries included explanations of gender as a social construct, gender as a determinant of health across men, women and non-binary people, and the need for gendered healthcare. The final two references were found in social work curricula where men's health was referenced in the context of masculinity and psycho-social problems.

By comparison, women's health content was referenced in the information for 42 of the 1246 courses (3.4%) across 25 of the 67 curricula (37.3%). Most courses that referenced women's health were in nursing and medicine curricula, and in the context of obstetrics and gynaecology, reproductive and perinatal health, and child and family health. Two of the nursing curricula offered women's health as a dedicated elective, and medicine and nursing curricula offered dedicated clinical rotations in women's health. The only discipline without any reference to women's health was clinical psychology.

Course information referencing gender was found in 72 of the 1246 courses (5.8%), across 28 of the 67 curricula reviewed (41.8%). This was not inclusive of courses that referred to men's or women's health content. Of these 72 references, the majority (71%) were in public health and social work curricula (20 of the 28 curricula) that related largely to gender theory, gender as a social determinant of health, and implications for lived experience and practice considerations. Eight of 40 clinical discipline curricula referenced gender as a consideration for presentation and differential diagnoses.

Across all disciplines there was an average of 16 men's health content integration opportunities per curricula (Table 2). Opportunities were noted across each year of the curricula (data not presented). Most integration opportunities were mapped to courses delivering education on practitioner–patient communication and engagement (40% of opportunities). This was particularly the case for the clinical disciplines and social work, with education opportunities relating to the gender considerations when engaging with men within healthcare. The next most numerous opportunities (30%) for integration of men's health content were mapped to courses that covered the social determinants of health. Specifically, it was considered feasible to enhance existing courses with content on sex and gender as major determinants of health and the intersection of masculinities with other sociocultural determinants to influence men's health and inequities in health for sub-populations of men. Fifteen percent of men's health integration opportunities were mapped to biology and clinical practice learning categories and 15% were mapped to preventative health and health promotion.

Table 2.

Summary of curricula review findings.

Discipline	Curricula	Courses	Curricula (courses) referencing men’s health	Men’s health integration opportunities					Curriculum (courses) referencing women’s health	Curriculum (courses) referencing gender
				Mean no. per curriculum	Mean % of opportunities by learning category a
					COMM	BIOL	PREV	SOCD
Medicine Undergraduate	10	157	0	23	36	22	16	25	8 (16)	2 (6)
Nursing Undergraduate	10	228	0	24	34	19	12	35	6 (7)	4 (7)
Pharmacy Undergraduate	10	203	4 (5)	13	47	23	15	15	2 (3)	0
Clinical Psychology (Postgraduate)	10	144	0	9	67	13	6	14	0 (0)	2 (2)
Public Health (Undergraduate/Postgraduate)	5/10	217	2 (3)	9	13	8	33	46	6 (12)	10 (27)
Social Work Undergraduate/Postgraduate	10/2	297	2 (2)	17	43	3	11	43	3(4)	10 (30)
Total (mean)	67	1246	8 (10)	[16]	40	15	15	30	25 (42)	28 (72)

^a COMM: practitioner–patient communication and engagement; BIOL: biology and clinical practice; PREV: preventative health and health promotion; SOC: social determinants of health and wellbeing.

There was no reference to men's health, women's health, gender (or gender competency) in the accreditation standards for nursing, medicine, pharmacy and clinical psychology. Gender was referenced twice in the education standards for social work. These standards stipulated that gender identity should be considered in relation to human development/behaviour (standard 5.1), and that gender should be considered in the context of discriminatory structures and practices (standard 4.5).

Staff Survey

Survey responses were received from 70 university staff across 25 universities (Supplementary file 4). Medicine was the most commonly represented discipline (24.3%) and course coordinator was the most common position held by respondents (57.1%). Most staff were responsible for one or more courses within a degree (64.3%).

Fifteen respondents (21%) reported no coverage of men's health content in their course, with 42 (60%) reporting generic men's health content (ie, content comparing health outcomes for men relative to women) only and 13 (19%) reporting dedicated men's health content (ie, content exploring men's health in-depth). Consistent with the curriculum review, most dedicated content detailed by respondents related to understanding and treating male sexual and reproductive health conditions (Supplementary file 3).

Forty-four respondents (83%) were receptive to future curricula enhancement with men's health content. Five (9%) respondents (3 from public health [all of curriculum, environmental health course, global health course], 1 from medicine [all of curriculum] and 1 from physiotherapy) indicated that men's health content was sufficiently covered in their curricula. Only 4 (8%) respondents (2 psychology [course – psychology skills and application; workplace readiness and Internship]; 1 medicine [medicine Internship] and 1 health [clinical leadership/management] indicated that men's health content was not relevant to their curriculum or course.

Excluding when the topic was considered not relevant to their curriculum/course, for 7 of the 10 men's health topics, approximately half (46%-58%) of the respondents indicated that the topic was covered (Table 3). The most commonly reported topic covered (58%) was social determinants of health and wellbeing informing health equity approaches for men.

Table 3.

Staff reported coverage of men’s health topics.

Men’s health topics (by order presented in survey)	Relevant to course/curriculum		Not relevant to course curriculum
	Yes included (% when relevant)	Not included
Men’s health help-seeking behaviours, service access and preferences	23 (47%)	26	11
Tailoring of communication styles when engaging with men in practice	18 (37%)	31	11
Tailoring of health literacy, health promotion and prevention programs for men (eg, exercise/lifestyle, smoking cessation)	26 (51%)	25	8
The role of masculinities and gender socialisation in men’s health	18 (36%)	32	9
Social determinants of health and wellbeing informing health equity approaches for men, including those from marginalised backgrounds (eg, CALD, LGBTQIA+)	30 (58%)	22	7
Fathering and fatherhood	7 (16%)	36	15
Domestic and family violence	23 (50%)	23	14
Andrology – male reproductive system and urological problems unique to men	22 (49%)	23	15
Priority health issues for men including conditions where men are over-represented (suicide, injury, addiction, diabetes, social isolation)	24 (56%)	19	6
Aboriginal and Torres Strait Islander male health and wellbeing	25 (46%)	29	5

The three topics least likely to be reported by respondents as being covered in their curriculum/course were (i) tailoring of communication styles when engaging with men in practice (37%); (ii) the role of masculinities and gender socialisation in men's health (36%); and (iii) fathering and fatherhood (16%).

Respondents indicated one or more preferred formats for men's health content with findings similar cross-discipline. Forty-four (61%) respondents selected resource toolkits (lectures, readings, case studies), 30 (48%) selected online modules, 26 (42%) selected lecture or lecture series, 17 (27%) selected dedicated placements and 6 (10%) selected dedicated electives.

The inductive content analysis of educator's open-ended responses resulted in four main perceived barriers to curricula enhancement with men's health content and four main facilitators. The facilitators offered feasible solutions to the perceived barriers (Table 4). A crowded curriculum, with it being ‘jam packed’, and there being ‘only so much space for new content’ was the most frequently reported perceived barrier (n = 20). The integration of men's health content within existing courses rather than dedicated men's health courses was the most reported facilitator of enhancement (n = 27). The use of ‘Case studies that draw out issues relevant to men's health’ and the ‘the voices of men regarding their preferences around engagement in therapy’ and incorporating ‘lived experience from diverse voices…ensuring that every unit has a “client voice” section could add this (men's health) focus’ were recommended to add context. A lack of interest, relevance and receptivity amongst educators was the second most reported perceived barrier (n = 10), with one staff member commenting that there exists ‘a false narrative that men's health is already over-represented’, along with other staff suggesting that educators ‘may not see the content as relevant’ to their courses (Table 4).

Table 4.

Staff insights into barriers and facilitators for curriculum enhancement with men’s health content.

Barriers to curriculum enhancement	Exemplar quotes	Facilitators of curriculum enhancement	Exemplar quotes
Crowded curriculum	‘The biggest challenge is space in the curriculum’. (Psychology)	Integrating content within existing courses	‘It would be more effective to integrate a “male health flavour” within current course by extending the taught areas. … and sign posted through revised learning outcomes and reflected in case-based learning and assessment’. (Medicine)
Lack of staff interest or receptivity	‘It has some relevance and could be better covered, I think, but there is a lack of will to do so – there is interest in women’s health and women’s issues but nobody really thinks about men’s health in our program, even though in our area our populations of interest are most often predominantly male’. (Public Health)	Updates to accreditation standards as core competencies to improve receptivity, And Advocacy, education & training for staff on the need for men’s health content	‘The most impactful way of changing the psychology curriculum at all levels is to include competencies in our accreditation requirements- this drives our curriculum, so advocating to the Australian Psychology Accreditation Council’. (Psychology)
Lack of men’s health expertise and resources and support	‘Lecturer support/capacity to integrate the content within their existing teaching activities. … may be lacking’. (Medicine)	Provision of free accessible men’s health resources that don’t require discipline expertise to deliver	‘If you provide free curriculum resources, including video’s and class activities, from easily accessible promoted website or via a respected health organisation,….. I would check them out’. (Public Health)
Potential sensitivities of prioritising men’s health over other population groups	‘Sufficient balance with women’s health and ensuring sufficient representation for other population groups’ (Medicine)	Advocacy, education and training for staff on the need for men’s health content	‘Of course, men/boys are also members of other groups e.g. elderly, adolescent, low SES, Aboriginal, refugees, immigrants LGBTIQA+ etc and so thinking about the issues within that matrix may be helpful. Also the intersection with other perspectives is important – e.g. domestic/family violence impacts women and children too’. (Medicine)

Advocacy related to clarifying the need and promotion of resources was considered important (n = 4). Four staff emphasised that the most impactful way to influence attitudes and understanding and standardise delivery was through formal updates to competencies within accreditation standards, citing ‘standards relating to cultural responsiveness and interprofessional education as successful examples of this’. A lack of ‘expertise to teach it (men's health)’ (n = 4) and navigating sensitivities around prioritising content on men's health over other priority groups (n = 4) were posed as barriers. One lecturer predicted that ‘the question of why we have focussed on men's health may be asked versus women's health focus’. Complementing these barriers as potential facilitators were the provision of freely accessible (n = 2) and signposted men's health educational resources that did not rely on expertise to deliver, and promoting men's health learning enhancements contextualised through an intersectional lens wherever feasible (n = 4) to align with Universities’ focus on equity and diversity and as one respondent noted ‘will help students appreciate the balance of vulnerability and need’.

Discussion

This formative evaluation of Australian university health curricula found limited reference to men's health in a review of online course information (10 of 1246 courses) across 67 curricula, and no dedicated men's health core or elective courses. Across the clinical disciplines, curricula typically comprised understanding and treating male-specific or common conditions in men including those relating to the prostate, reproduction and pubertal development and sexual function and dysfunction. While sporadic, men's health content from a gender and health equity perspective and other social contexts was restricted to public health and social work curricula. Despite these limited references, opportunities for men's health content integration were readily identified across the four interrelated learning categories, with most mapped to courses delivering education on practitioner–patient communication and engagement. This aligned with the staff survey data, where the least commonly-taught men's health topics were tailoring of communication styles when engaging with men in practice, the role of masculinities and gender socialisation in men's health and fathering and fatherhood. Most staff were also receptive to enhancement of their curricula with men's health content. Based on the findings, we propose an interdisciplinary men's health curricula enhancement strategy that has, as its core, foundational learning on communicating and engaging with men. This proposed interdisciplinary strategy would consist of cross-cutting men's health education content, that is developed by a combination of theories, methodologies and perspectives, which can be applied into curricula across these disciplines. This can act as a conduit to delivery of content in the three other learning categories, augmented with discipline-informed understandings of sex and gender- considerations of health needs, sociocultural contexts and healthcare practices, when providing care and delivering health promotion programs for boys and men.^16,23,40

Results of the present evaluation accord with prior reviews of coverage of men's health in health curricula.^22–24 This study applied a similar methodology in order to review curricula and seek educator insights for a range of key front-line health professions. In doing so, evidence was collected that supports an interdisciplinary approach to future curricula enhancement. Importantly, these prior reviews were conducted almost a decade ago. The overlap between the current findings and prior results suggests that while some progress may have been made to enhance education on understanding and treating men's reproductive and sexual health and other conditions common in men, the standardised inclusion of the gendered considerations of men's health in curricula remain few and far between; a problem which has persisted for decades. This is despite sex and gender being recognised as key determinants of health, and ongoing advocacy for more than a decade for a health system more focused on gender responsive care within a person-centred care approach as a solution to health inequities. ⁴¹

Women's health was more commonly referenced in course information (42 occurrences) relative to men's health, and this included for dedicated courses. Content included that on obstetrics and gynaecological health, and early childhood, gender equity and women's health in particular social contexts. These findings highlight the benefit of long-term investment in education reform initiatives led initially by women's health researchers, educators and advocates, however progress is needed on integrating a consideration of sex and gender and social determinants more broadly within all of the clinical disciplines.^{14,16–18,23,42} Increasingly it has been clarified that innovation around gender and health does not exclusively equal women's health and that the same approach serves to meet the different health needs of men and gender diverse people. ⁴³

While limited, there were good examples from three public health courses on men's health and gender as a social construct and determinant of health, and two social work courses describing how masculinity plays out in health settings. The sporadic nature of such courses likely arose due to lecturer interest rather than an imperative to teach topics through a gender lens that reach all students, through national teaching standards. Nevertheless, the review did highlight the opportunity for interprofessional sharing of insights regarding sex and gender and intersectionality of men's health into contemporary educational resources on gender responsive practice considerations when working with men.^16,23,43,44

Not unexpectedly, as front-line health professions, the most common men's health content integration opportunities were mapped to the learning category of communicating, engaging (and partnering) with men in healthcare. Importantly, such integrations would align with, but also offer important amplification to, well-established accreditation standards and best practice competencies that relate to tailoring of engagement strategies through person-centred care.^16,24,45,46 Indeed, research emphasises the importance of the ‘short window of opportunity’ many health professionals have with their male patients to engage them in the process, build trust and rapport and make them feel heard, supported and motivated to continue with treatment. ⁴⁷ Getting this initial dyadic interaction right is known to avoid premature and costly dropout from care. As such, essential to this process is ensuring healthcare communication and engagement is underpinned by a gender responsive approach to the relationship, taking into account each man's masculine identity and experiences.^14,47,48 Therefore, as noted by Miller et al, ¹⁶ a cross-cutting curriculum enhancement, aiming to upskill health professionals on best-practice approaches to optimising the therapeutic alliance has the greatest application before students head into clinical rotations and placements. As a first training priority, targeting this workforce readiness will particularly benefit those men who, for gendered and intersecting social reasons (eg, class, culture, sexuality), are hard-to-reach and engage in care.^23,29,40,49

The flow-on effect of communicating and engaging with men as core training for all students is that it may then be applied in subsequent disciplinary and sub-speciality settings across the clinical health and social care and public health curricula. Engaging with men around fathering and fatherhood is a key example offered given that this was reported in the staff survey to be least likely covered in relevant courses. Building rapport and engaging with men around sexual and reproductive health, fathering and fatherhood, and their biomedical, physical, mental and social care needs, reduces barriers to such care and has the potential to impact the life-long health outcomes for men.^50,51 Importantly the resultant benefits extend to partners and families, potentially leading to trans-generational health impacts. ⁵²

University staff offered potential solutions for curricula enhancement in the short term and longer term. In the short term, integration of a lens of men's health into existing courses as micro-learnings was recommended rather than attempts at dedicated courses that were proposed as unfeasible amidst packed curriculum. To facilitate this, staff saw the value of a central online repository of reputable and flexible men's health education resources to accommodate contemporary pedagogies. This initial content development was proposed to be best supported by a concurrent advocacy campaign with students and educators alike to promote awareness of the value of gender responsive healthcare, and training support packages for implementation. These recommendations align with input received from educators and students in previous curricula enhancement initiatives and those of the 2018 International Sex and Gender Education Summit.^{14,16,17,24–26,46} The longer term, systemic approach that was recommended to embed men's health content within curricula is through national accreditation standards. These solutions offered by staff will need to be supplemented with further in-depth stakeholder engagement to develop implementation strategies.

A review of the professional accreditation standards for the clinical disciplines of nursing, medicine, pharmacy and clinical psychology revealed that gender competency has yet to make its way into such standards. This consequently translated into only a limited number of references to gender in curricula learning outcomes across the clinical disciplines. In contrast, the education standards for social work referenced gender twice and this was reflected in the higher number of references to gender in course information. While the men's health content integration opportunities identified could be aligned with existing education program accreditation standards, the additional inclusion of standards related to gender competency that recognise sex and gender as key determinants of health, would ensure that men's health, along with women's and non-binary health, appear in learning outcomes and consistently taught in Australian university health curricula across all relevant disciplines.

Limitations

There are several potential limitations of this evaluation. The curricula review was undertaken in a sample of curricula for each discipline as it was not feasible to review all relevant university curricula. The review of curricula from the highest ranking universities, in the Time Higher Education (2022) subject rankings list, was based on the assumption that they were more likely to have comprehensive curricula, but this was not verified. Furthermore, the review was limited to publicly available, online course information. While this information should reflect the subject matter taught, it is possible that other curricula, and course materials (eg, lectures, readings, case studies), not reviewed in this audit, may contain men's and women's health or gender and health content.

The quantification of men's health content integration opportunities relied on some subjective judgement as to what qualified as an ‘opportunity’. Nevertheless this data was deemed important to inform the rationale for future enhancement of existing health curricula.

The staff survey provided further insight into the extent of coverage of key men's health topics, although it is recognised that consultations would offer more depth to this information. There may also have been survey sampling bias in that those staff with positive views in relation to men's health education needs may have been more likely to participate. Given the small numbers, data was not segmented by discipline however staff across all disciplines did indicate that when men's health content was taught, it was mostly generic, lending support to the curricula review conclusion of limited dedicated men's health content. Individual lecturer motivations and expertise are also likely to influence the content delivered to students independent of course information offered which may have explained the inconsistent results across sampled curricula. These staff, with relevant interest and expertise, offered to be touch points for future curricula enhancement planning. Finally, for study feasibility, the curricula reviewed were restricted to those for a sample of health professions accessed by men. It is acknowledged that for broad health workforce education initiatives, future reviews should include an expanded range of disciplines.

Conclusions

In conclusion, dedicated men's health education content, particularly delivered through a gender lens, is likely to be absent, or at best sporadic, across Australian university health curricula. This formative evaluation, involving a good coverage of Australian universities, confirms gaps in education and provides an important basis from which to pursue opportunities to enhance men's health knowledge and training of future health professionals in gender responsive healthcare for men. This includes a focus on integrating interdisciplinary content on approaches to communicating and engaging with men. As recommended by educators, the goal will be to work with course coordinators, universities and accrediting bodies to propose efficient and sustainable short-term and longer-term strategies for national interdisciplinary curricula enhancement. This work is critical to advancing men's health, and reducing disparities in health outcomes by reaching and helping those men who experience poorer health not only in Australia, but globally.