Are Men Shortchanged on Health? Perspective on Health Care Utilization and Health Risk Behavior in Men and Women in the United States

R. M. Pinkhasov; J. Wong; J. Kashanian; M. Lee; D. B. Samadi; M. M. Pinkhasov; R. Shabsigh

Disclosures

Int J Clin Pract. 2010;64(4):475-487. 

In This Article

Discussion

In our previous paper we have shown that men in United States have higher death rates for 12 out of the 15 leading causes of death. They die nearly 5.2 years younger and suffer more severe chronic diseases than women.[1–3] A number of previous studies have reported that men use less medical services than women.[8,11–13] In addition, several studies have shown that men in United States are more likely than women to adopt beliefs and behaviors that increase their risks, and are less likely to engage in behaviors that are linked with health and longevity.[14–18]

To our knowledge, although there have been a number of studies demonstrating distinctive patterns in utilization of health care and health risk behavior in men and women in United States, few have reported such practices in combination to analyze its impact on morbidity, mortality, and life expectancy differences between the two genders in this country.

Health Care Seeking and Utilization

There are a number of parameters that can measure health care seeking and utilization behavior in men and women. To account for all of them is an impossible task to do. Additionally, there are several biological, obstetrical and gynecological differences between men and women that inevitably necessitate women to utilize health care more frequently. For these reasons we chose to concentrate our efforts on analyzing physician office, ED, preventive care, physician home health, hospice care, hospitalizations, and dental visits for men and women in United States.

Research spanning several decades shows that in comparison with women, men use less physician services,[8,11–13] and use less long-term care over their shorter life span than women.[19] In addition, men are less likely to seek preventive healthcare measures than women.[10,20] They tend to make fewer physician visits even when their health status and socioeconomic levels are comparable to women.[21]

There are a number of explanations that could account for such differences in healthcare utilization. One explanation could be due to the fact that women have a greater willingness and ability to take care of themselves when they are sick and seek preventive care more often than men.[13] There are also several stereotypical masculine behaviors in which men are less willing to seek medical advice.[22–24] Men's importance on self-reliance, physical toughness, and emotional control all play in to their masculinity and inhibit their willingness to seek help from health professionals.[25] In fact, because of denial, embarrassment, and a desire to avoid a situation in which they are not in control, men tend to have less annual physical check ups.[31] It is, therefore, no surprise that '… many men fail to get routine check-ups, preventive care, or health counseling and they often ignore symptoms or delay seeking medical attention when sick or in pain.'[26] Moreover, men are more likely to be motivated to visit a physician for diseases that affect their quality of life most, including: baldness, sports injuries, or erectile dysfunction and are less likely to seek help for emotional symptoms or psychosocial problems.[27,28] Even then, healthcare providers further add to this problem by not spending much time on men's health issues during the usual clinic visit[32,33] and thus tend to give men less health information, fewer services, and less advice on how different behavior can improve health.[10] Men are provided with fewer and briefer explanations (both simple and technical) in medical encounters[38–40] and also receive significantly less physician time in their health visits than women.[39–41] Women, on the other hand, engage in far more health-promoting behaviors than men and have healthier lifestyle patterns.[14–18] In fact, there are some speculations that being a woman may be the strongest predictor of preventive and health-promoting behavior.[35–37]

Our more recent analysis is consistent with previous studies in which men are less likely to utilize health care services, and also tend to make less emergency department visits than women (Figures 1 and 2, respectively). Men are also less likely to utilize preventive care ( Table 1 ) than women. They are less likely have a dental visit than women (Figure 3). In addition, men are less likely to utilize hospice care (Figure 4) and have fewer hospital discharges than women (Figure 5). Some studies report that men tend to visit their doctor late in the course of a condition than women, which inevitably results in poorer outcomes.[29,30] Overall, we suspect that these practices contribute to their morbidity, mortality, and ultimately impact their longevity.

Health Risk Behavior

There are speculations in the medical science world that health behaviors have significant influence on one's health, and that modifying these health behaviors is 'the most effective way' to prevent disease.[34] To analyze the difference in health risk behavior between men and women in United States we looked at alcohol use and drinking pattern, prevalence of smoking, smoking habits and quitting patterns, non medical illicit drug use, and body weight status.

From our analysis, men are more likely to be current and regular alcohol drinkers, whereas women tend to be former infrequent drinkers and life-time abstainers (Figure 6). Alcohol inevitably can cause a number of acute and chronic health conditions ranging from motor-vehicle accidents to cancers and cardiovascular diseases. In fact, there is a tremendous amount of literature that associates alcohol with an increased risk of motor vehicle and bicycling accidents, falls, fires, sports-involved injuries, interpersonal violence, and self-inflicted injuries.[42–50] In addition, ER studies and police records show an association between use of alcohol and greater severity of injury and poorer outcomes.[51,52] Even though regular light-to-moderate drinking (1–2 drinks per day for 5 or 6 days a week) has been shown to have protective effect on the cardiovascular system, heavy (5–9 or more drinks on one occasion) drinking has been shown to have higher risks for major coronary events than abstainers.[53,59] In addition, in a few prospective studies heavy drinking has been shown to increase the risk of CHD in men and women.[54–56] In our observation, men in United States are more likely to be heavy, moderate, and light drinkers in comparison to women who are more likely to be infrequent and nondrinkers (Figure 7). Lastly, studies also show that alcohol drinking was associated with significantly elevated cancer risks including oropharyngeal, laryngeal, esophageal, stomach, colon and rectum, liver, and female breast, where the risk is greater with heavier drinking.[57–59]

Alcohol has also been associated with mortality. In 2005, alcohol-induced cause of death was reported in 21,634 persons in the United States.[2] However, this figure excludes unintentional injuries, homicides, and other indirectly related causes. The age adjusted death rate for alcohol-induced causes was 3.2 times higher for men than women.[2] There are some reports that observed an association between women and a higher risk of death from breast cancer.[59–62] However, such association is only true for heavy women drinkers, whereas light-to-moderate drinking was found to be associated with significantly reduced risk of death secondary to a lower risk of fatal cardiovascular disease.[59–62] In United States men are more likely to be moderate and heavy alcohol drinkers than women (Figure 7).

Excessive alcohol use and its resultant deaths were found to decrease life expectancy at age 15 in Finland to 2 years in men and 0.4 years in women.[63] In addition, life expectancy in Russian men fell 6.3 years during 1990–1995 secondary to alcohol drinking.[64] Such level of decline was unprecedented both in Russian and in other industrialized countries and was attributed to excessive alcohol consumption that resulted in both directly and indirectly marked increases in death.[64] Studies on decrease in life expectancy secondary to alcohol consumption in US men and women were not found. However, since men in US are moderate and heavier drinkers than women (Figure 7), we suspect that it contributes to their morbidity, mortality and longevity.

Smoking is a major cause of a number of cancers, pulmonary, cardiovascular, and cerebrovascular diseases and has significant contribution to morbidity and mortality in men and women in United States.[65] Smoking has been shown to accelerate atherosclerosis, thrombosis, coronary artery disease, and cardiac arrhythmias. It was also observed that the relative risk of fatal MI in smokers was more than four times greater when compared to nonsmokers.[67] As demonstrated through cohort studies and meta-analysis smoking increases the relative risk of ischemic stroke by approximately two times.[68,69] Moreover, smoking contributes to a significant amount of cancer morbidity. Of some 4000 components of tobacco, more than 50 have been shown to be carcinogenic in both in vivo and in vitro studies.[70]

Smoking is responsible for many deaths in the United States. During 1997–2001 the estimated annual average death secondary to smoking was 437,902.[71] Of those 259,494 deaths were among men and 178,408 deaths among women.[71] Cancer as a result of smoking attributed for 158,529 (39.8%) of these deaths, cardiovascular disease accounted for 137,979 (34.7%) of the deaths, and respiratory diseases was responsible for 101,454 (25.5%) of the remaining deaths.[71]

Reduced life expectancy due to smoking has been shown in a number of previous studies as well. In a Danish National Cohort Study, the life expectancy at 20 years of age was reported to be 7 years less for heavy smokers than for nonsmokers in both men and women.[72] In Australia, in the mid-1980s, the difference in the life expectancies of 15-year-old males who had never smoked and those who were heavy smokers was estimated at 5.6 years.[73] There is also a Japanese study (NIPPON DATA 80) that suggested that smoking decreased men's life expectancy to a greater degree than women's.[74] In fact, Murakami et al. observed that the difference in the life expectancies of smokers and nonsmokers was 3.5 years in Japanese men and 2.2 years in Japanese women. In United States, even though the prevalence of smoking has been steadily decreasing since 1974–2006, men consistently continue to have higher prevalence of smoking than women (Figure 8). Men are also more likely to be current and former smokers, whereas women are more likely to have never smoked (Figure 9). Life expectancy in US was reported to be approximately 7 years less in smokers than that of nonsmokers.[75] In addition, data from Framingham Heart Study indicates that the difference in life expectancy at age 50 between nonsmokers and those classified as always smokers was reported as 8.66 years in men and 7.59 years in women. Lastly, numerous reports have also shown that ex-smokers who quit smoking had improved survival than those who did not.[76] Our analysis shows that men are less likely to quit smoking than women (Figure 10), which puts them at a greater risk.

It is, therefore, our belief that part of the contribution to difference in life expectancy between men and women has to do with the fact that smoking is more prevalent in men, they tend to be heavier smokers than women and are less likely to quit (Figures 8–10) which also contributes to their morbidity, mortality and longevity.

Although studies on illicit drug use in United States are not as popular as those on alcohol drinking and smoking, illicit drug use practices contribute to significant mortality. In fact, estimates from illicit drug use deaths in 2000 in United States show that 17,000 deaths were attributed to such practices.[77] Our analysis shows that lifetime non-medical illicit drug use is more common in men than women (Figure 11) which can negatively affect men's health.

In the last 30 years there has been an increase in the prevalence of being overweight and obese in much of the world's population. Among the developed countries around the world, United States has the highest prevalence of overweight and obese people.[80] In United States the prevalence of being overweight is higher in men than in women, whereas obesity is more prevalent in women than it is in men ( Table 2 ). Despite the higher prevalence of obesity in women than men ( Table 2 ), more recent trends show that men are catching up to women (Figure 12).

Being overweight and obese increases a person's risk of developing type 2 diabetes, hypertension, cardiovascular disease, cancer, back pain, osteoarthritis, and contributes significantly to morbidity in men and women in United States.[78–80]

In addition, numerous studies have shown that having a higher BMI has been associated with increased mortality and decreased life span even when the other risk factors are controlled for.[81–86] Obesity has been shown to have a substantial negative effect on longevity, reducing the length of life in severely obese patients by 5–20 years.[86] Moreover, both Stevens et al.[86] and Fontaine et al.[87] have shown that men had a greater number of years of life lost than women with comparable BMI.[87,88] It is, therefore, of no surprise that being overweight and obese can has an impact on a man's decreased life expectancy.

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