Multiple themes emerged from the qualitative data acquired, which serve to illustrate how livestock auction marts encourage and facilitate help-seeking among farmers, particularly men. Due to interview themes overlapping between the various types of stakeholder interviewed, instead of presenting data separately for each, results are instead presented as themes which blend comments from all interview cohorts. The themes are as follows: perceived barriers to seeking help, impact of delayed help-seeking, the deconstruction of barriers to encourage new behavioral norms, evidence of impact and behavior change, shifts in perceived barriers and benefits, and peer-to-peer learning.
Of the 17 auction mart sites, two hosted permanent clinics, three hosted mobile clinics, four hosted ad hoc services (such as blood pressure checks) and seven revealed that they never hosted any primary healthcare services. The presence of a primary healthcare service services appears not to be dependent upon the size or location of the mart, but upon the individuals and local organisations involved in setting up the service/s. Mobile clinics travelled to several marts a week, although some marts allocate rooms to nurses who then travel between marts. If healthcare practitioners identify a health issue, the protocol is usually to advise that patient to then contact their own doctor, although direct referrals have occurred. Farmers with a pre-diagnosed condition tend to already be managing their condition with their family doctor. These were in the minority among our sample.
Many respondents knew of and/or had experienced health hubs on auction mart sites, but knowledge of such services was not universal, and several auction mart operators were not aware of the presence of primary healthcare services at other marts.
Perceived barriers to seeking help
According to respondents, the following determinants influence the help-seeking behaviors of people in the livestock farming community, particularly in relation to help from primary healthcare practitioners: attitude/culture, accessibility/convenience, work commitments and time constraints, and faith in primary healthcare provision more generally. None of these are mutually exclusive but some are more physical/structural while others are likely to have developed as a result of experience, indoctrination or other societal influences. All of these determinants were expressed as barriers, cited both by farmers and by other stakeholders within the auction mart community.
Attitudinal and cultural determinants were reported to play a significant role towards whether a farmer chooses to seek help for an illness or injury. A variety of factors contribute to what might be recognized as hegemonic masculinity, including pride, fear of being judged, or stoicism linked to a more integral identity of ‘being farmer’. Stoicism was referred to more often than any other determinant in terms of barriers to help-seeking.
‘The older generation of farmers, certainly they just keep going and going and going until they drop, and you won’t stop them […] Farming itself is like a disease’ (Farmer 18)
The suggestion was, among some interviewees, that the perceived severity of an illness or injury must be extremely bad before an act of help-seeking occurs.
‘I would persevere for a while […] You just don’t go to the doctor until you really think it is necessary’ (Farmer 26)
Several farmers spoke proudly of the fact that farmers are known for not seeking help. Their language suggested that differences in the perceived severity of an illness or injury imply that farmers who do not seek help for a particular issue were stronger than non-farmers who might be more inclined to seek help for a similar issue.
‘If you go into hospital they ask you what you do, and you say that you are a farmer […] they will admit to you that there must be something wrong with you because farmers don’t go to see about anything unless there is something wrong’(Farmer 24)
It was reported by some farmers that they had continued to work for several hours with injuries later diagnosed as broken bones or torn ligaments. Some were reported to have continued to work for days before seeking help.
Several respondents revealed that active behaviors towards help-seeking would be more likely to occur in response to pressure from a female family member, therefore diverting the decision-making process potentially associated with weaker, nonmasculine, feminized behavior away from themselves.
‘You have a wife who tends to book you in, so you have to go’ (Farmer 29)
This push–pull dynamic might be perpetuated in order to maintain ‘masculine capital’ but stoic behavior could also be a result of lack of trust or confidence in the health system. It may also stem from a fear of the unknown or what the implications of having the severity of an illness of injury confirmed might mean for them as individuals, for their family and/or for their business.
‘It is like going to the dentist, going to the doctor. It is the same sort of thing’ (Farmer 35).
Both age and gender were frequently referred to in relation to the expression of stoicism, with older males (typically over the age of 55 years old) considered more likely to delay help-seeking as compared to younger farmers or women in farming. However, two female farmers out of the six interviewed demonstrated similar stoicism to the males regarding seeking help for physical health conditions.
‘[What do you think about the […] nurses?] Never had anything to do with that aspect [Have you not?] No [So if you get sick what do you do?] Usually get right on your own’ (Farmer 6 – female)
‘I’ll only go if I really have to’ (Farmer 25 - female)
Another female farmer compared her attitude to help-seeking to that of her husband and her son, who were also farmers, stating that she and her son would be more likely than the older male in the family to seek help from friends and family if their mental health were to suffer.
‘My husband is one of those. He won’t talk to people, he’s not as good as me and my son at talking to people and saying how he feels’ (Farmer 1 - Female)
Similar attitudes of stoicism related to mental health were displayed by a number of older respondents although several farmers across a range of age groups, as well as auction operators, admitted to having experienced challenges with their mental health. Two respondents openly discussed experiences of depression and the management plans they had in place with their GPs. Seeking help from a practitioner was regarded as a suitable help-seeking route, but many stated a preference to talk to a rural chaplain, friends or family members before a professional. A minority of respondents expressed irritation at the use of terms such as ‘mental health’, dismissing recognition of such issues as weak or overly sensitive. Several older, male farmers expressed discomfort or preferred not to discuss the topic, using dismissive verbal and body language.
Loss of faith in service provision
A small proportion of respondents commented on feeling let down by the services that are available to them, either through treatment routes proving to be ineffective, or by the format of appointments being regarded as increasingly unfriendly.
‘He was under the doctors about that, but it didn’t seem to do him any good and I think he’s lost a bit of faith’ (Farmer 1)
A loss of faith, again, became particularly pertinent with regards to mental health treatment. A small number of respondents highlighted that, according to their experience, several individuals were known to have fallen through the gap in terms of receiving appropriate treatment. In such cases, individuals were more likely to seek help from partners, spouses, other family members or the community.
The second most cited determinant likely to impede the ability to seek help from a healthcare professional was accessibility/convenience. Many of the farmers interviewed lived in rural or semi-rural locations and had to travel to local towns or villages in order to see a health professional. Farmers tend to work long hours  and choosing to take time out is frequently regarded as detrimental to the business, especially where animals require tending to. In addition, several respondents acknowledged that attendance at a local surgery required the extra effort of changing out of cumbersome, dirty work clothes which proved off-putting to some due to the extra time required to carry out this effort.
‘It’s just time isn’t it […] You need to get changed you can't, you know, you can't go into surgery like this, can you?’ (Farmer 13)
Accessibility emerged frequently as an issue, again attributable either to the rural location of a farmer’s home or infrastructural barriers within a town which might be inaccessible for farming vehicles.
‘If you were to go into town from the auction with trailer or something, it is a nightmare to get to the doctor’ (Farmer 42)
Work commitments and time constraints
The average working week for a farmer in the UK is approximately 65 h a week , a number which exceeds the average actual weekly hours of work for full-time workers (pre-COVID) which stood at 36.2 h a week . For farmers working with animals, the working day can be further complicated due to milking or feeding times or seasonal commitments such as calving or lambing.
‘As a farmer, you are in a position where you can’t take a day off. There is nobody else to do the job. So, if you are crawling, you have still got to go and feed those animals’ (Farmer 41)
Combined with the more general work obligations of farm work, work commitments and time constraints are high on the list of determinants influencing farmer behavior regarding help seeking.
‘I would go to the doctor, but you have to keep on working, don’t you?’ (Farmer 8)
Several respondents highlighted the likelihood that a livestock farmer would be more likely to attend to the welfare of their animals in place of their own, prioritizing their own health and wellbeing below that of their livestock.
‘These folks will look after their own animals and then neglect themselves’ (Farmer support representative 4)
Respondents frequently stated that the lack of flexibility of available services did not match with the erratic nature of farming, creating general associations between attending in-person appointments and a sense of inconvenience. Several commented on the lack of availability of appointments, particularly in the case of mental health services.
‘When you are depressed, when you are at your weakest, you have to fight the bloody receptionist to get an appointment […] I went to the doctor with suicidal thoughts and they still don’t know whether I am alive or dead’ (Farmer 16)
‘Their only answer is to give you tablets […] They dull everything which is what they did for me, both the highs and the lows, but didn’t deal with the causes at all’ (Farmer 16)
Impact of delayed help-seeking
By delaying treatment due to any of the above reasons, a number of risks exist. These might be relatively temporary or minor and arise while recovering from an illness or operation. One farmer, for example, delayed seeking help for a hernia and due to the seriousness of the resulting operation, could not work for at least a month post-operation. This potentially impacts on the family, who may be required to work more, or on the farm income as somebody will need to be employed to cover the farm work.
‘He was sort of in self-denial […] He had two grown up sons and a wife and they just couldn’t get him to go and see about this hernia, and it just got so bad’ (Farmer 8)
Potential impacts might, however, be more severe, such as death.
‘A guy just up the road […] he had terrible stomach pains and he had a burst appendix and he died. But he wouldn’t go to the doctor and that was it and then the farm had to be sold’ (Farmer 24)
Deconstructing barriers to encourage new behavioral norms
The centrality of the mart to agricultural communities clearly remains significant for the many who have, or once traded in, livestock. Market day acts as a fulcrum around which many farmers organize their time and the sites upon which they are held have, as a consequence, been recognized by many as prime locations from which to base primary healthcare and other services.
'A livestock mart is a brilliant way to reach out (Farmer support representative 1)'
Where some format of health hub was present at a mart, the majority of farmers exhibited positive attitudes towards their existence, demonstrated by feedback ranging from acceptance to the active and consistent use of the service/s. One farmer advocated for a health service to be provided at every livestock auction mart.
‘It’s a lot easier to walk through that door than get on the phone, get an appointment with your local doctors to take the morning off' (Farmer 9)
Service professionals attributed this to a number of factors. Although many recognized the inhibiting role of stoicism among potential attendees, they believed that by aiding farmers to bypass the more structural issues, such as inconvenience, time constraints, work commitments, flexibility issues, appointment availability, and developing confidence in the service, stoicism as a determinant was weakened, and no longer acted as a barrier to help-seeking.
‘We’re there, it’s very quick, it’s convenient, there’s nothing mysterious about it, and they seem to like that' (Farmer support representative 2)
The ability to do this was principally attributed to the development of trust.
‘It takes time to build up trust. That’s why so many of these short-term projects fail in a way […] and certainly with the farming community, because it takes time for people to trust you enough. We’ve been so lucky with our nurses because we’ve had wonderful continuity […] Certainly, on the mental health side of things, it takes a lot of courage’ (Farmer support representative 2)
The implication is that trust develops as a result of consistency of service, patience, and time spent building relationships between practitioners and auction stakeholders.
‘Part of the secret of this is the regularity of it, the relationship building. You can’t just waltz into a situation and offer help and expect people to respond. The relationship and the trust is absolutely fundamental’ (Farmer support representative 6)
In many cases, it was also reported that effectual relationships could be built because those implementing the service at the practitioner-farmer interface were individuals who had some knowledge of farming, be it through coming from a farming family or simply being familiar with the agricultural community and the issues with which it is faced.
‘They’re from farming backgrounds but they’re nurses […] Now, how perfect is this?! Somebody who knows what a farmer is like and has the farmer-style conversation. You’ve got to be very, very direct with the farmer’ (Farmer support representative 1)
One farmer support individual, however, refrained from over-emphasizing the importance of a farming background for those running the health services on-site.
‘I think it obviously helps if they have got an understanding of farming [but] as long it’s a, what I call a ‘nice’ person, in the sense that it’s a person you feel comfortable with and you can talk to, then I suppose it doesn’t really matter if they’re farming-related, or not’ (Farmer support representative 15)
For those implementing the service on-site, it was recognized that initial uptake of the service is likely to be slow due to the reticence of farmers to seek help due to all of the reasons outlined above.
‘The hardest thing is getting them across the threshold’ (Farmer support representative 11)
However, as trust is built, perceptions of service provision appear to positively adjust rapidly among mart attendees, usually resulting in not only new perceptions regarding help-seeking itself, but also new behaviors towards seeking help.
Perceptions of bringing primary healthcare services to the mart
The majority of farmers interviewed viewed the placing of health hubs at auction marts positively, with one farmer having suggested the need for it at their local mart unprompted. Stoicism was still exhibited, but again this might be attributed to expectations to stick to a cultural script within the setting rather than held as an actual belief. Deflecting its relevance to older farmers, for example, might an example of this.
‘I think probably it is a good idea having that health [hub] It is probably more of a question for the older people really’ (Farmer 42)
Those who have experienced some kind of healthcare provision at a mart tend to consider it of benefit, either to themselves or to the community as a whole.
‘I think it’s very good, I mean I’m not afraid because I have been there, I have been there, and I know what goes on’ (Farmer 22)
Those with no experience tended to be more skeptical.
‘Whether you have got bad health or you’ve got a problem of some sort I don’t think the auction is the place for it’ (Farmer 3)
And while only five farmers out of 42 regarded the placement of primary healthcare services within marts as a bad idea, on two occasions this was due to the potential lack of the efficient use of nurses rather than believing the concept itself to be poor.
Evidence of impact
Due to the strategy of the study, GDPR limitations, differences in record-keeping between service providers, and the fact that a number of relevant stakeholders had not been alerted to the arrival of the researchers, quantitative evidence of direct impact for each study site operating a health hub was not available. However, respondents from each cohort were able to describe the perceived impact of the presence of primary healthcare practitioners on-site. Where a permanent clinic was in place, the footfall was reported by service operators as being consistent, at the very least.
‘We have a drop-in clinic for farmers […] for the bulk of the day which allows farmers to drop in without appointments to have their health worries addressed and they do in considerable numbers' (Auction operator 1)
The only example provided that was described as poorly attended was attributed to the poor timing and short presence of a pop-up hub appearing once on market day.
'So, these people who were trying to do a trial and demonstrate that this is what people want buzzed off [before the sheep were loaded] And course, that immediately skews the statistics […] Well, you don’t just rock up and expect people to use what you’re offering first off […] You gotta stick at it. And I think, if they’d stuck at it, they would have found people' (Farmer Support representative 4)
Numbers of attendees at a health hub appear to vary according to the size of the mart, and how busy a site is on any given sale day. One farmer support organization provided an average figure of 54 people passing through a clinic each market day. Other sites also reported a consistent flow, with between 2 and 17 attendees per day, depending on the type of service offered. The services are always staffed by nurses, although some might also employ other practitioners such as physiotherapists or podiatrists. There was no evidence of any service offering prescription services or direct appointments with GPs on-site.
According to some of the nurses, results from the initial uptake of service provision mirrors results from the study 20 years ago [31, 34] as relatively high numbers of service attendees have significant health issues highlighted.
‘I can certainly think of one case, one auction mart, where the first time it was done, there were almost 30% of the farmers that were seen that were strongly advised that they must see their GP urgently’ (Farmer support representative 6)
The majority of conditions identified tend to be associated with blood pressure, high cholesterol, diabetes, addictions (e.g. alcohol or smoking) or poor dietary choices. These can all be indications of more serious issues. Other issues discussed included musculoskeletal, and in the case of female farmers, continence problems. For all of these issues, attendance at a mart-located primary healthcare service can facilitate a route to improved health.
‘We have had two young people, actually, one of whom smoked very heavily and, as a result of having a health check and getting a bit of a wakeup call, he’s managed to stop smoking. And another guy - young man, who was quite overweight - it shook him into thinking carefully, much more carefully, about his diet and he’s slimmed down and at a much more comfortable weight […] One of our nurses […] she’s picked up countless people who’ve been pre-diabetic’ (Farmer support representative 15)
However, while a constant presence and the build-up of trust was referred to by a number of respondents as being important to encouraging new help-seeking behaviors, even pop-up hubs occurring infrequently were said to have been worthwhile in terms of numbers. This would most likely be what was referred to as a ‘quick MOT’ and involve blood pressure monitoring.
‘She didn’t give me any names, but they took blood pressure of about thirty-five/six people and I think there were about two/three referrals from it as well’ (Auction operator 25)
One farmer revealed how the presence of a pop-up hub on-site encouraged her to accept a vaccination that she would otherwise have been unlikely to pursue independently.
‘This is where I had my flu jab […] Well it saved me, you know, getting changed and going down to surgery [Would you have got it anyway?] I don’t think I would have, no’ (Farmer 13)
In addition to reports of high attendance levels, respondents stated that marts also benefit from the presence of a primary healthcare service due to unexpected health-related events.
'It’s going to be a busy day today. Somebody will collapse out there [Really?] Oh yeah, we know that. That’s why we’ve got a second defibrillator coming. We’ve got one out here. Now we’re getting a second one' (Farmer support representative 14)
Such collapses were reported to stem from heart attacks, diabetes-related incidents or epileptic fits, among other things. Farmer support organization respondents, including nurses, also revealed how crucial a space to discuss issues with a nurse were for the benefit of mental health. It was reported as being a common occurrence that individuals would state that they were seeking help for a physical issue, but that this would develop into a conversation exploring mental health issues. One nurse reported it just as likely that people were seeking help for physical conditions as they were for mental health issues.
Due to the open access nature of the healthcare services provided at most mart sites, meaning that registration with a particular practice or region is not required in order to utilize the service, anybody attending or working at the mart is able to benefit.
‘I went myself three or four months ago […] I did yes, and I was quite shocked. I had high cholesterol and things weren’t maybe what they should be' (Auction operator 21)
One farmer support organization representative suggested that primary healthcare services in their current format are not fit for purpose for rural communities.
‘I think GPs surgeries or health boards […] should be reaching out to rural communities rather than sitting in hospitals and GP surgeries waiting for people to come and see them […] Discriminatory isn’t the right word, but it provides a very lesser service to rural people than it does to other people’ (Farmer support representative 1)
Shifts in perceived barriers and benefits
Respondents recognized that behavioral norms commonly influencing the likelihood of an individual to attend a GP practice were destabilized by the placement of the service at the mart. While stoic attitudes were demonstrated by farmers at the inception of an initiative, these soon shifted among the majority.
‘They just don’t want to do it [go to the doctor] and that is it. But they are more likely to go to the heath van if it is here, yes’ (Farmer 35)
‘[Do you think if they didn’t go in there they would go and visit their local GP?] Probably not no [Why do you think that might be?] Because they are scared of doctors […] When she [the nurse] first arrived when the market opened, no one really went in there but they did start, and now I think sometimes they come to market just to go in there and see her' (Auction operator 2)
The suggestion is that a fear of doctors or medical practitioners is dissipated by the format offered at the mart.
‘Farmers using [the healthcare service at the mart] will never go to the doctor and get it done and I think it is quite interesting’ (Auction operator 21)
This is likely due to farmers getting to know those providing the service, trust being developed between service providers and the auction community, witnessing and talking to other farmers who have previously used the service, and breaking down barriers through word of mouth.
‘They were doing this health check in the café and they weren’t getting folks to go. Farmers are shy, but once one or two has gone… So, I have talked to a lad next to me and I said come on, I said you go, and I will go, and they will get a few to go then. And so, I went there and I had my health check […] They had a full run of folks all day then going, once they get started. And that is good’ (Farmer 40)
It is also attributable to the convenience provided by the service, breaking down significant structural barriers in place as discussed previously.
‘Farmers are hopeless at going to hospital or the doctors, absolutely hopeless […] Whereas they can come in and drop off their stock at eight o’clock. If they are hanging around to wait for the sale that starts at ten, they generally go for a bit of breakfast and then they can pop back, drop into the clinic, discuss something if they have got a concern and get referred or get it dealt with’ (Auction operator 27)
One respondent suggested that prior to the existence of nurses at the mart, they might have been more likely to go to their doctor, but now rely more on the nurses at the mart than their own general practice doctor.
‘[Why do you think it’s super?] Because you don’t have to book an appointment to see your doctor or a practice nurse [Do you tend to go to the doctor now or do you come here first?] I come here first […] You can more or less see one of these nurses or both of them right away, no waiting for 15 or 20 days or however long it is for an appointment’ (Farmer 5)
There were suggestions among some of the farmer respondents that older farmers might be more inclined to use the services at the mart, but no quantitative evidence exists to support this.
‘Dad does use the health center here […] I probably wouldn’t think of using this one to be fair' (Farmer 2)
‘More for elderly farmers that wouldn’t be going to the doctor’ (Farmer 35)
Some nurses working in health hubs confirm that their patients tend to be older, but they attribute this to the fact that it tends to be the older member of the family who attends the mart, while younger members stay at home on the farm. However, they report that it is not uncommon for younger people to use the service.
Even where health provision exists at a mart, sometimes the stoicism is still too strong to concede to a new behavior, and it cannot be guaranteed that all mart attendees will utilize any primary healthcare services provided.
The effect of peer-to-peer influence appears significant with regards to service utilization, as respondents made it clear that the close-knit nature of the auction mart community facilitated relationships, networks and perceptions of the standing or status of others. One respondent who had never heard of or experienced a healthcare service at a mart expressed negative sentiments towards the concept, due to the potential to be judged if witnessed visiting a nurse by peers.
‘If you went to see the nurse, everybody would be ‘Oooo, he was at the nurse today, what’s wrong with him?’ (Farmer 33)
However, this sentiment was less common than expected and for all respondents who had experienced such a service, perceptions remained extremely positive.
‘It is a nightmare to get to the doctor. You get a doctor’s appointment at whatever time and if you get held up or something changes at the auction and you can’t get there. Whereas if there is someone [at the auction] you can ask if it’s alright if you come back in an hour or whatever. So yeah, I think [a health hub] is probably, is something that would be a good idea’ (Farmer 42)
Several respondents referred to the potential for peer-to-peer influence to help embed service use as part of the everyday mart experience, a potential recognized by auction operators, farmers and farmer support representatives alike.
‘Their mates would be looking interested, and because the nurses record their results on a little take away slip, they would then go and compare notes and their friend would come along and have a check’ (Farmer support representative 2)
‘Because their friends are doing it, everyone else is doing it’ (Farmer 17)
The placement of primary healthcare services at a mart site, among all other recognizable services and activities affiliated with agriculture or rural life, acts to legitimize help-seeking behavior among mart attendees and promote a shift in the ‘cultural script’ currently adhered to by many farmers related to help-seeking . However, one respondent suggested that this might only be a temporary suspension of behavioral norms rather than contributing to more permanent change in belief systems and behaviors, as outside of the mart space, male farmers would fall back on the displacement of decision-making to a female family member.
‘Without the market somebody is going to have to be persuaded by his wife to go and see the doctor’ (Auction operator 25)