Men’s health: time for a new approach

Abstract

Background: Many men’s health outcomes are poor at the global level. Men have lower life and healthy life expectancies than women. They are more likely to die from cancer, cardiovascular disease, suicide, road traffic accidents and other major causes of death. They are more likely to smoke, drink alcohol excessively and eat a poor diet. In many countries and for many diseases, men use primary care services less effectively than women.

Objectives: The purpose of this article was to review the key data on men's health at the global level and explore explanations for men's outcomes, including health practices, use of services and health literacy and masculinities. The response of health organisations, the evidence of the impact of gender-sensitive interventions and the case for action on men's health were also considered.

Major findings: Despite the problems with men’s health, it has been largely overlooked by national and global health organisations. When organisations do focus on gender, action is usually targeted at women and girls rather than both sexes. There is an increasing body of evidence that sex-specific initiatives can also be effective.

Conclusions: If population health is to be improved, and if good health is a universal right, steps must be taken to improve men’s health as well as women’s. There is a role for male-targeted health policies (building on the lessons of national men’s health policies in Ireland, Brazil and Australia) as well as changes to service delivery. There is not a choice to be made between men’s health and women’s health: this need not be a zero sum game. Action is needed for both sexes and improving the health of men will also improve the health of women.

Keywords:

• Men
• Men’s
• Male
• Masculinity
• Masculinities
• Global

Men’s health outcomes

Globally, many key health outcomes are poorer for men than for women. In 2016, average male life expectancy at birth was 69.8 years compared to 75.3 years for women [1]. The difference in life expectancy at birth between men and women globally increased from 4.2 years in 1970 to 5.5 years in 2016. From 1970 to 2016, global mortality rates decreased for both men and women but more slowly for men. The male age-standardised death rate declined from 1724.7 to 1002.4 per 100,000, an annualised decrease of 1.18% per year. Age standardised death rates for women decreased from 1367.4 to 690.5 per 100,000, an annualised decrease of 1.49%.

At the global level in 2015, male age-standardised death rates were higher than for females for most causes. The overall age standardised cancer incidence rate in 2012 was almost 25% higher in men than in women, with rates of 205 and 165 per 100,000, respectively [2]. The age standardised cancer mortality rate was over 50% higher for men (126 for men compared to 83 for women). Death rates are notably higher in males for many specific cancers including tracheal, bronchus, lung, liver, oesophageal, bladder, laryngeal and mesothelioma.

The impact of cardiovascular disease on women’s health is under-recognised but the mortality rates are nevertheless higher for men. A recent study of data for 26 countries found that, in 2010, coronary heart disease mortality was, on average, about four times higher in men than in women aged 30–60; the ratio declined gradually but was still two times higher at ages 75–80 [3]. Stroke mortality rates were about 1.5–2 times higher for men than women up until 70 years and older after which the ratio was closer to unity.

The age-standardised death rate for diabetes mellitus in males is higher than for females in 61 (71%) of the 86 countries for which data is available on the WHO Mortality Database [4]. From 1980 to 2014, worldwide age-standardised adult diabetes prevalence increased from 4 to 9% in men and from 5 to 8% in women [5]. Over the same period, age-standardised adult prevalence of diabetes at least doubled for men in 120 countries and for women in 87 countries. It is estimated that, if post-2000 trends continue, age-standardised prevalence of diabetes in 2025 will reach 13% in men and 10% in women.

Males accounted for 82% of all homicide victims in 2012 and have estimated rates of homicide that are more than four times those of females (10.8 and 2.5, respectively, per 100,000) [6]. In high-income countries, three times as many men died by suicide than women in 2012, while globally the corresponding figure was almost twice as many [7]. There is a similar pattern for road traffic accidents: almost three-quarters (73%) of all road traffic deaths occur among young males under the age of 25 years [8]. There is also a large sex difference for deaths caused by occupational risks: 88% of deaths from this cause were male in 2010 [9].

Men’s health practices

This excess burden of male mortality is in part explained by the health practices of men. Worldwide, the age-standardised prevalence of daily smoking in 2015 was 25% for men and 5% for women [10]. Total alcohol per capita consumption in 2010 among male and female drinkers worldwide was, on average, 21 litres of pure alcohol for males and nine litres for females [11]. Data from the Global Burden of Disease Study 2010 shows that, in that year, 72% of deaths from tobacco smoking were male as were 65% of deaths from alcohol. The majority of deaths from dietary risk factors were also male [9].

The under-utilisation of primary care services by men has been identified as a problem in many countries, especially in the Global North (which includes the USA, Canada, Western Europe, Australia, New Zealand and Japan). In the European Union countries, infrequent use of, and late presentation to, such services has been associated with men experiencing higher levels of potentially preventable health conditions and having reduced treatment options [12]. This is particularly the case for mental health problems. Studies in sub-Saharan Africa have reported similar findings about men’s use of HIV services and also found that men are proportionally less likely to test for HIV and begin treatment regimes and more likely to die while on treatment [13–15].

Men also tend to be less well-informed than women about health issues, including the symptoms of potentially life-threatening diseases. Women were more likely than men to recognise a range of common cancer symptoms, according to a study in England [16]. The largest gender difference was found to be for recognition of ‘change in the appearance of a mole’: the odds of recognising this symptom were 60% higher in women than men. In Uganda, research found that under half (46%) of men had heard of prostate cancer and only 10% had a good knowledge of the symptoms [17]. Awareness appears to be even lower in rural Zimbabwe: here, according to one study, only 21% of men had heard of prostate cancer and just 1% were aware that frequent urination was a symptom [18].

Overweight and obese men (with a BMI of 35 or less) in the USA have been found to have higher levels of weight misperception than equivalent women [19] and Canadian women have greater health literacy levels than men in regard to male depression [20]. A study of gender differences in lay knowledge of type 2 diabetes symptoms among community-dwelling Caucasian, Latino, Filipino and Korean Americans found that men were less knowledgeable than women: women were 60% more likely to report at least one symptom [21].

Men are not a homogenous group, however, and it is important to be aware of differences between men in different countries as well as between men within the same country. Age standardised tobacco male smoking prevalence rates range from 9% in Ethiopia and 11% in Panama to 59% in Russia and 60% in Sierra Leone [22]. A study of alcohol consumption patterns in 10 European countries found that mean daily alcohol intake in men varied from 10 g in the city of Umeå in north-eastern Sweden to 34 g in Copenhagen [23].

There is a clear social gradient in male risk-taking behaviours, according to a UK study. The proportion of professional men with four lifestyle risk factors was half that of unskilled manual men. (The risk factors analysed were smoking, excessive alcohol use, a poor diet and low levels of physical activity.) Similarly, the proportion of professional men with no risk factors was almost double that of unskilled men [24]. There is a similar pattern in life expectancy: men in the ‘Higher Managerial and Professional’ group had a life expectancy of 82.5 years in 2007–2011, six years longer than that of men in the ‘Routine’ group [25]. There are also disparities for gay and bisexual men who, in the USA, are more likely to report severe psychological distress, heavy drinking and moderate smoking than heterosexual men [26].

Masculinity/ies

Masculinity has a significant role as a social determinant of the health practices of men, both positive and negative. In fact, the term ‘masculinities’ is probably preferable to ‘masculinity’ because male identities are not fixed but vary with social class, age, ethnicity, culture, geography and over time.

The Global Early Adolescent Study, which covers 15 countries of widely varying levels of development, found that the gender norms boys learn in early adolescence – particularly the emphasis on physical strength and independence – make them more likely to be the victims of physical violence and more prone to tobacco and other substance abuse, as well as homicide. A study of men and women in the UK found that the more both sexes identified with ‘traditional masculinity, the more likely they were to exhibit damaging health behaviours; this finding was particularly strong for men [27]. Men who conform strongly to masculine norms also tend to have poorer mental health and less favourable attitudes towards seeking psychological help although, interestingly, not all masculine norms are equally implicated: men who place more emphasis on self-reliance or who have sexist attitudes appear to be most at risk [28].

More positively, the importance many men attach to physical fitness can be beneficial to their health. There is evidence that men, once engaged in behaviour change programmes (e.g. weight loss), are more likely than women to have positive outcomes [29], perhaps because of their propensity to focus on the achievement of specific goals. There is evidence that African American men with ‘traditional masculinity norms’ around self-reliance are significantly less likely to delay blood pressure screening [30]. A study found that fire-fighters constructed their gender identity around having a fit body in order to work effectively. They therefore perceived help-seeking as a way of preserving their masculinity, rather than as a threat to it [31]. Men who do not normally use health services, or who do so reluctantly, because they feel inhibited or constrained by male role norms often change their behaviour when the services are designed and delivered in a way that is gender-sensitive.

The response of health organisations

In a review of the social determinants of health in Europe for WHO, Professor Michael Marmot argued that national governments should develop strategies that ‘respond to the different ways health and prevention and treatment services are experienced by men [and] women … and [ensure] that policies and interventions are responsive to gender [32]. In a subsequent report on health inequalities in the UK specifically, Marmot highlighted the fact that deprivation has a greater negative impact on men’s health outcomes than women’s and called for a greater policy focus on men’s health to help tackle this [33]. The head of WHO’s gender, equity and human rights group has also written about the importance of ‘capturing the different experiences of men and women’ [34].

Historically, however, there has not been a strategic response to the health problems facing men either globally or in the overwhelming majority of countries. An analysis of the policies and programmes of 11 major global health institutions, including WHO, found that they did not address the health needs of men [35]. A complementary study of 18 Global Public Private Partnerships for Health (e.g. GAVI, Global Road Safety Partnership and TB Alliance) came to similar conclusions [36].

The UN’s Global Strategy for Women’s, Children’s and Adolescents’ Health (2016–2030) overlooks boys and world leaders at the 2016 G7 Ise-Shima Summit in Japan made important commitments to improving women’s health but did not mention men, or how they could be engaged to support improvements in women’s health. The European Commission did publish a major report on the state of men’s health in 2011 but it did not include any recommendations for action and has not yet led to any observable changes in policy or practice. A report by the European Parliament’s Committee on Women’s Rights and Gender on promoting gender equality in mental health and clinical research, published in 2016, has been criticised for largely overlooking men and boys and adopting a definition of gender that effectively includes only women and girls [37].

There are some signs of progress, however. National men’s health policies have been developed in Australia, Brazil, Iran and Ireland. An independent review of the Irish policy found that, overall, it made a significant and important contribution to making the issue of men’s health more prominent, providing a framework for action and achieving change, although its impact was much stronger in some areas than others and very weak in some [38]. In 2017, the policy was extended for a further five years and explicitly linked to the government’s over-arching public health policy, Healthy Ireland [39]. A review of the Brazilian policy suggested that it has reached over 1,000 municipalities and helped to catalyse a men’s health movement in Brazil and more widely in Latin America [40]. The Australian policy has been credited in particular with supporting the Australian Men’s Sheds Association, developing health promotion resources for men’s sheds and establishing a national longitudinal study in male health.

In 2017, WHO-Europe announced that it planned to publish a strategy for men’s health for the 53 countries in its region [41]. This is expected in late 2018. Also in Europe, the European Commission in 2015 launched a three-year project – GenCAD – which aims to improve the understanding of sex and gender differences in chronic diseases, using cardiovascular as an example, to highlight these differences regarding treatment and prevention activities in European countries [42].

The Department of Health in England appointed the Men’s Health Forum as a strategic partner in 2009, a position it continues to hold alongside about 20 other NGOs. At a local level in England, Leeds City Council published in 2016 a major report on the state of men’s health in its area with recommendations for action [43].

Why men’s health has, as yet, not been addressed by most national governments and international health organisations has not been studied and there are no known published statements from policy-makers which provide any insight. It is possible, however, that the explanations are rooted in a lack of sympathy for men because of male power and privilege and, in particular, the extent of male violence (especially against women). There might be a belief that men should take responsibility for their risk-taking and reluctance to seek help for health problems. Historically, particularly among clinicians, there has been an assumption that men’s health is largely about urology with a focus on prostate health, testicular cancer, sexual dysfunctions and hypogonadism. There has also been a lack of knowledge among health professionals generally about how to engage men effectively combined with pessimism about the possibility of achieving change.

Men have not organised themselves to advocate for improvements in health services. There are now national men’s health organisations in several countries (e.g. Ireland, United Kingdom, Denmark, USA, Australia, New Zealand, Germany, Malaysia, Canada) as well as three international groups (European Men’s Health Forum, Movember and Global Action on Men’s Health) but these are mostly small in scale, tend to involve professionals only and do not mobilise men in a way that puts pressure on politicians to take action. The largest and best-resourced men’s health organisation, Movember, has succeeded in generating significant funding for research but has not adopted an advocacy role.

The case for action on men’s health

The WHO has adopted a human rights-based approach to health. Its Constitution enshrines ‘the highest attainable standard of health as the fundamental right of every human being’ [44]. This suggests that there is a clear ethical case for measures to improve the health of men as well as women. The UN’s Sustainable Development Goal (SDG) 3 seeks ‘to ensure health and well-being for all, at every stage of life’. This Goal specifically includes specific commitments to reducing by one third premature mortality from non-communicable diseases (NCDs), promoting mental health and well-being, strengthening the prevention and treatment of substance abuse, including narcotic drug abuse and harmful use of alcohol, and halving the number of global deaths and injuries from road traffic accidents. The Goal also aims to ensure universal access to sexual and reproductive health-care services, including for family planning, information and education, and to improve the implementation of the WHO Framework Convention on Tobacco Control. None of these goals can be achieved without taking account of the health of men. The development of the WHO-Europe strategy has been largely prompted by the SDGs.

Healthier men would reduce the economic costs of lost productivity and health treatments. Men’s premature mortality and morbidity has been estimated to cost the United States economy approximately USD 479 billion annually [45]. An assessment of the cost-savings that would accrue in Canada if there was a 1% annual relative reduction in the proportion of middle-aged men and women who smoke tobacco, consume hazardous or harmful levels of alcohol and have excess weight in the period 2013–2036 found that there would be a cumulative reduction in the country’s economic burden of over CAD 50.7 billion [46].

Improving men’s health would also improve women’s health. This is most obvious in the case of sexual health – if men can be prevented from developing sexually transmitted infections, or are diagnosed and treated sooner, that must be beneficial to women’s health too. High mortality rates in men impact on women, especially in lower income households and countries, through the loss or incapacity of the primary breadwinner, usually a man [47]. This can have a hugely detrimental effect on partners and children. They may have to take on caring responsibilities, limiting employment and educational opportunities and reducing current and future income. Three-quarters of all poor households in Bangladesh affected by the road death of the head of the household reported a decrease in their living standard and 61% had to borrow money as a result of the death [48].

Addressing men’s mental health issues, including alcohol and drug misuse, could contribute to a reduction in male violence against women, children and other men. A WHO report suggested that, in the USA and in England and Wales, victims of domestic violence believed their partners to have been drinking prior to a physical assault in 55 and 32% of cases respectively. In Australia, 36% of intimate partner homicide offenders were under the influence of alcohol at the time of the incident while in South Africa, 65% of women experiencing spousal abuse within the last 12 months reported that their partner always or sometimes used alcohol before the assault [49].

BOX

The case for action on men’s health can be made on the following grounds:

(1)	Evidence. The problems with men’s health are now well-established as are their causes.
(2)	Ethics. Optimal health and well-being is an inalienable human right.
(3)	Effectiveness. Improved men’s health would contribute to better population health and help the delivery of health targets, including the SDGs.
(4)	Economics. Better men’s health would result in financial savings for health systems and the wider economy.
(5)	Engagement. There is growing body of knowledge about how to develop and deliver men’s health promotion and clinical services that engage men.
(6)	Equity. Men’s health is in many respects unnecessarily poorer than women’s and is a significant equalities issue.

Evidence of impact

The importance of gender-sensitivity in the design and delivery of health services to men has been highlighted in three important UK studies published in 2014. The first, a study of the Football Fans in Training (FFIT) initiative in Scotland, was the first large-scale men’s health programme evaluated by means of a randomised controlled trial. The researchers concluded that FFIT demonstrated that ‘an evidence-based programme, gender-sensitised in context, content, and style of delivery, offers one strategy to support weight loss in men’ [50]. The success of FFIT has led directly to the roll-out of a similar programme, EuroFIT, across 15 top-flight football clubs in Portugal, Norway, the Netherlands and UK supported by European Union funding of almost EUR 6 million.

The second study examined the effectiveness of weight management programmes for men. A systematic review of the evidence found that the key components of effective programmes for men differ from those for women – men prefer more factual information on how to lose weight, for example, and more emphasis on physical activity – and, for some men, the opportunity to attend men-only groups may help. The study also found that weight loss programmes for men may be more successful at engaging men if provided in social settings, such as sports clubs and workplaces [29].

Finally, a systematic review of experiences and perceptions of self-management support in men living with a long-term condition highlighted the importance of taking a gender-sensitive approach to service provision [51]. The review identified a number of key considerations important in helping to optimise interventions to be more accessible and acceptable to men. Chief among these was ensuring that support is congruent with key aspects of their masculine identity. The review showed that in order to overcome barriers to access and fully engage with interventions, some men may need self-management support interventions to be delivered in an environment that offers a sense of shared understanding, connectedness and normality, and involves and/or is facilitated by other men with a shared illness experience.

Next steps

The next major challenge in the men’s health field is to persuade policy-makers and providers at local, national and international levels to take the action that is needed to make a difference. This can be best achieved through advocates from all backgrounds working together through multi-disciplinary networks and fora. It is important that advocates are not just professionals but include a wide variety of lay people, for example as local health champions. NGOs can play an important role in making the case and also engaging wider support for action.

The response to men’s health cannot be solely medical – and certainly not just urological in focus – but rather a ‘whole systems’ approach which includes contributions from health providers as well as from workplaces and education, housing and transport services among others. This approach already underpins Ireland’s national men’s health policy.

The relationship between men’s health and women’s health – and the importance of addressing gender in its true and full sense – must be foregrounded. There can be no attempt to claim special victim status for men, no attempt to blame women or feminism for the lack of attention paid to men’s health and no attempt to present ‘doing’ men’s health or women’s health as a binary choice. Men must champion women’s health and women’s equality at the same time as they call for action to address men’s health.

Men’s health policies and strategies are essential at local, national, regional and global levels. They can serve to raise the profile of the issue, offer a framework for action and provide a benchmark for evaluating impact and holding services accountable for their performance. As well as men’s health policies, other policies (e.g. on diabetes, cardiovascular disease or cancer) should take account of male-specific issues and needs. The existing national men’s health strategies provide lessons for the development of similar policies elsewhere and the forthcoming WHO-Europe strategy will, hopefully, prove to be both a catalyst and a blueprint for action.

Training in men’s health for practitioners (both pre- and post-qualification) and policy-makers – is important as is the ability for the workforce to access up-to-date statistics, research and information about men’s health, including details of effective public health interventions. The research effort needs to be better funded and broadened in scope well beyond clinical issues. More academic research centres are needed to develop expertise and accelerate research in the social determinants of men’s health and to identify effective approaches and interventions.

Taken together, these steps would help to end men’s health inequalities, a problem that has been hiding in plain sight for far too long.

Disclosure statement

No potential conflict of interest was reported by the author.

Notes on contributor

Peter Baker, MA FRSPH, is director of Global Action on Men's Health (www.gamh.org), a NGO that brings together organisations and individuals in a network whose mission is to create a world where all men and boys have the opportunity to achieve the best possible health and wellbeing wherever they live and whatever their backgrounds. Peter Baker has written widely on men's health issues including for the WHO Bulletin and the Journal of Global Health.