Abstract
Epidemiologic studies and related literature consistently report that males have fewer years of life expectancy than females. Moreover, males experience fewer quality years of life in that they tend to live with greater rates of morbidity such as heart disease, cancer, and diabetes among other conditions. Causal evidence traditionally highlights the role of biology in determining the life course for males. However, emerging literature suggests that social determinants of health play a more central role in male morbidity and mortality, and thus contribute to health inequities between the sexes. The purpose of this article is to explore core concepts of social determinants of health as they pertain to male health inequities and provide a systematic conceptualization of how society has become encultured to view these inequities as “normative.” Strategies to improve male health are discussed using a logic model to illustrate male health advocacy in the face of the social climes of encultured health inequities.
Introduction: Defining the Issue of Healthy Inequity
The cloaks that they think protect them are in reality such tattered and transparent garments that they reveal their wearers in their naked incompetence. (Edgerton, 1971)
On Health Equality
Major pieces of legislation and policy positions on health and wellness recently have been authored, presented, and/or subsequently passed through various national agencies, most notably, the Affordable Health Care for America Act (2009), to bring about societal health equality. Health People 2020 cites the purpose to achieve “. . . health equity, eliminate disparities, and improve the health of all groups” as one of its four overarching goals (Keppel, Garcia, Hallquist, Ryskulova, & Agress, 2008, p. 2; U.S. Department of Health and Human Services [USDHHS], n.d.). Interestingly, in some sections of these documents, gender-specific wording is included, but sometimes at the exclusion of the other gender. For example, the Mikulski Amendment (Internal Revenue Code of 1986, 2009) requires all health plans to cover comprehensive women’s health, including preventative screenings (e.g., mammograms), most reproductive services (e.g., birth control), and at no cost to women. Notably missing (or omitted) from many of these documents is the focus (or lack thereof) on male health; the question becomes, why?
It appears the exclusion of men and boys from the larger debate on health equality has become “normal” in the sense that there is no specific need to focus on male-centered health care. Men often are excluded from national health objectives suggesting that only women are in need of comprehensive health and wellness services. Considering the seemingly purposeful exclusion of men and boys from the discussion of a true public health, we feel it is imperative to restate that in order to achieve health equality, both sexes need to be equally included in health promotion efforts.
This discussion will highlight morbidity and mortality disparities (vital statistics) seen between the sexes from a lifespan perspective and demonstrate that these outcomes are not necessarily bounded to biological differences between men and women, but primarily due to social determinants (education, mental health, occupational health). Furthermore, we will highlight the apparent normative acceptance that male health and wellness issues do not warrant the attention and resources as found in female health. A logic model is presented to assist researchers, community outreach professionals, and policy makers in understanding core upstream determinants specific to male health outcomes. This information can be used to promote and navigate true health equality between the sexes.
Birth Data
Starting at conception and moving throughout the lifespan of a male, differences and their resultant health-related disparities begin to forge the health of 50% of the world’s population. For example, there are more male fetuses conceived than females (115 males for every 100 females); yet more males are miscarried or stillborn (e.g., intrauterine fetal mortality; Brettell, Yeh, & Impey, 2009). If a male is born, the statistics concerning male morbidity and mortality do not improve. Sorenson (2011) notes that males are born with a numerical advantage relative to females with 105 boys born for every 100 girls in the United States and 107 for every 100 worldwide. However, excess male mortality quickly takes a downturn with a 7% higher fetal death rate; 21% more boys die within the first year of life (Messer, 2011), and by age 65, there are only 75 men for every 100 women (implications of this will be discussed later).
U.S. data are corroborated by findings from the European Union (EU), which has noted that overall birth rates of males (107 males to 100 females) is consistent throughout the EU; however, lower survival rates has led to an aging population model (European Commission, 2011). This is further supported by American and global data as well (European Commission, 2011; Kochanek, Xu, Murphy, Miniño, & Kung, 2011; Rajaratnam et al., 2010).
Life Expectancy and Mortality
Compared with females, U.S. males have higher mortality rates in 9 out of 10 leading causes of death including, heart disease, cancer, chronic obstructive pulmonary disorder, unintentional injuries (accidents), pneumonia and influenza, diabetes, suicide, kidney disease, and chronic liver disease (National Center for Health Statistics [NCHS], 2010). One in 2 males will be diagnosed with cancer in their lifetime (compared with 1 in 3 for females) of which, again, males have higher mortality rates (Jemal et al., 2009); see Table 1.
Leading Causes of Mortality in U.S. Males With Male-to-Female Disparity Rates.
All males, all ages.
Age-adjusted death rate per 100,000 (United States).
Likely because of females having a longer life span.
All causes of death, male to female.
Males in the United States live approximately 5.2 years less than females and 2.5 years less than the overall U.S. population average (Mensah, Mokdad, Ford, Greenlund, & Croft, 2005). There are more pronounced disparities in minority men with Black males living 7.6 years less than the national average, 5.6 years less than White males, and a startling 10.2 years less than all females (IOM, 2002). Interestingly, newer data from 2006 show that Latinos may have a relative life expectancy advantage compared with other groups of males living slightly above the overall population average and 2.6 years more than all males (NCHS, http://www.cdc.gov/nchs/). However, these data do not indicate quality of life, making it difficult to assess any true relative health advantage in this demographic.
In comparison with the EU, data are similarly dismal with 5- to 8-year gaps between the genders (European Commission, 2011). Data, however, conflict when life expectancy between the sexes is temporally compared. National data from the United States and some from the EU show roughly a 1-year gap between males and females in 1920; a gap that steadily increased until present (Figure 1). In fact, males lead in excess mortality in all age categories (0-85+ years old; NCHS, http://www.cdc.gov/nchs/). In 1920, women were more likely to die in childbirth and from related complications (Miniño, Xu, & Kochanek, 2010). Improvements in maternal and child health led to greater overall life expectancy. Similarly, males continued to work in high-risk occupations and the gap likely widened in the 1940s through the 1970s because of excess mortality in males involved in war efforts (i.e., World War II, Korea, and Vietnam). Clearly, social determinants play an important role in male health outcomes and also how health is perceived. Life expectancy is an important variable to study, however, perhaps more important in this discussion than the years of life, are the quality of life in those years.
Graph of life expectancy discrepancies in males and females 1920-2006.
So what is the cause of the widening life expectancy gap between males and females? Some biological factors may predispose males to higher risks for mortality, such as testosterone, thereby increasing risk of cardiovascular disease and stroke (Vanberg & Atar, 2010). Testosterone also is implicated in aggressive and risky behavior in males (Haddad et al., 2007; Pope & Katz, 1994). However, this trait always has been present in men. Therefore, perhaps the focus of male health disparity research should shift from physical to social determinants.
Physiology
The male brain is different in structure to that of the female brain. The influence and levels of hormones also distinctly affect the male brain (McCarthy et al., 2009). Take for example the amygdala, part of the brain’s limbic system, which is involved with emotional learning, memory, gender expression, sexual orientation, social interaction, and even compulsive behavior. Research has confirmed that males tend to have larger amygdalas, which may predispose them to reacting more impulsively in various situations (Zhang et al., 2011). The androgen testosterone also is implicated with male aggression and impulsivity (Haddad et al., 2007; Pope & Katz, 1994). Taken together, biologically, males may be more likely to be impulsive and react with more aggression; however, these reactions need not be negative, but they may lead to men to perform riskier behaviors and thus threaten their health and wellness. A focus on changing social structures, influences, and learned behaviors may be more feasible in ameliorating biological impulses.
Similarly, biologically males are predisposed to cardiovascular disease earlier in life because of the effects of testosterone (e.g., higher blood cholesterol/low-density lipoprotein lipid profiles; Haddad et al., 2007; Vanberg & Atar, 2010). Testosterone also has been implicated in higher resting blood pressure, which can predispose males to stroke (Vanberg & Atar, 2010). The vast majority of issues affecting male health outcomes, however, are socially based and not biological in nature (Kochanek et al., 2011). The latter speaks to the importance of this review in addressing the enculturation of how male health and outcomes are perceived by society in general.
Disproportionate rates of physical ailments leading to morbidity and premature mortality warrant further exploration and remediation, however there seems to be a complete lack of any coordinated comprehensive effort to lessen the health burden experienced by males. The next sections will highlight areas of social inequalities as they affect male health.
Social Norms and Gender Scripting
Despite the physiological differences between the sexes causing differences in health outcomes, the role of social conditioning of males also has been suggested to play a more important role in how males interact with their environment, and ultimately, and how it contributes to worse health outcomes as compared with females (Addis & Mahalik, 2003). Many people are familiar with the term boys will be boys, but what does this really mean? Most societies have a social expectancy as to how males should be raised and interact. This “gender script” is an expectation for male and female behavior. Essentially, males learn how to be males through a complex process of enculturation and gender norming (Cialdini & Trost, 1999).
Most societies consciously and subconsciously rigorously protect said scripted gender roles and norms (Courtenay, 2000). For example, boys are wrapped up in blue blankets whereas girls sport pink. Boys will play rough and with trucks, whereas girls will nurture their dolls. Boys should eat hearty portions, whereas girls should exercise modesty and restraint in their choice of food. Men will be the breadwinners and providers, whereas women will tend to the home and family. Men are more likely to react to stress with reactive measures and violence whereas women are likely to be harmed by the violence. Men will push limits whereas women will provide a moral compass. Although the boundaries of the demarcated gender roles are blurring slightly because of various sociocultural movements in recent history, such as women’s liberation and other civil rights achievements, the roles are still well defined, partly because of the repeated normalization of such roles over the millennia.
So the question remains: Do these scripted gender roles contribute to health inequities between the sexes causing men to live sicker and die sooner as seen in the statistical evidence above? Certainly, many stereotypes exist (of which the former are no exception); however, to truly understand why males have poorer health outcomes across the board, it is important to explore how enculturation and the role of social expectations can lead to attitudes of males being content with their present place in health outcomes and other measures of quality of life.
Education
Educationally, males are an increasingly disparate group as compared with females in the United States. Women and girls have performed remarkably well in the educational system with greater retention rates, higher rates of graduation from high school and college, and greater employment opportunities based on a college degree (Buchmann, DiPrete, & McDaniel, 2008; Lewin, 2006). Conversely, only 65% of boys graduate from high school in the United States and some argue that it is the educational system that promotes male disengagement (Bound et al., 2010; Lewin, 2006; Parkin, 2007). It is difficult to assess why boys and men are less likely to do well in school; however, there are many controversial hypotheses. One such hypothesis by Parkin (2007) points to how school curricula are structured. For example, throughout most of a boy’s early education (Grades K through 6), the teacher is likely to be a woman, therefore boys may not relate as well. Furthermore, boys tend to thrive on competition such as activities and examinations, but are less apt to be engaged with lectures and routine coursework (Parkin, 2007).
Other researchers point to boys being more likely to be identified and diagnosed with a learning disability or having behavioral issues such as attention deficit disorder (Simpson, Cohen, Pastor, & Reuben, 2008). Data from the NCHS confirmed that boys were more likely to have parent’s contact school or health care providers about emotional and/or behavioral difficulties, twice as likely to be prescribed medication for attention deficit disorder / attention deficit/hyperactivity disorder, and be labeled and treated for additional behavioral and emotional issues other than with medication (Simpson et al., 2008).
Additionally, boys are more likely to sit in the back of the classroom, have less acute hearing than girls of the same age, and are more likely to become agitated in warmer climates (female teachers tend to keep the classroom a bit warmer than male teachers; Parkin, 2007). Boys of low educational ability also have been suggested to be attracted to more aggressive and sensation-seeking behaviors than boys who are more academically engaged (Bijvank, Konjin, & Bushman, 2011). Do schools inadvertently structure curricula that cater more to females, which may lead to boys becoming less academically engaged as suggested by Parkin (2007)? Furthermore, how can these types of social settings help define the narrative that normalizes such disparate performances between the sexes?
Mental and Emotional Health
Autism and autistic spectrum disorders affect boys nearly four times more than girls with some rates as high as 10 to 1 for all spectrum disorders (Brun et al., 2009). Boys lag in speech development, are more likely to be diagnosed with dyslexia, and identified with attention deficit disorder and attention deficit/hyperactivity disorder. Twenge and Nolen-Hoeksema (2002) found boys aged 8 to 12 years were more likely to score higher on a depression inventory than girls of the same age in a large, 60,000-person sample. This sociocultural phenomenon is not simply a Western issue, but one that pervades many countries and their respective cultures. For example, Macdonald, Monaem, Sliwka, Smith, and Trezise (2010) identified and discussed the various “pathways” to despair and depression in 25- to 44-year-old males in Australia. The European Commission (2011) also found higher rates of suicide in countries where depression and drug use were reportedly higher.
Brun et al. (2009) acknowledge that mental health outcomes likely result from a confluence of both physical (including genetic defects) and social factors. Research has consistently shown that males are far less likely to share and discuss their feelings as compared with their female counterparts (Baraff, 1991; Hale et al., 2010). This often is due to the perception of lost masculinity if they share their feelings and emotions with others (Addis & Mahalik, 2003; McGrath, 2002; Shain, 2007). What we suggest is that this is likely a learned behavior versus a biological trait.
Whether real or perceived, the inability to appropriately express emotion and feelings often predisposes a person to depression, which ultimately, can lead to suicide (Ferguson, Woodward, & Horwood, 2000). Baraff (1991) notes that suppression of emotions affect health both psychologically and physically. For example, aggressive actions may be a form of acting out one’s emotionality, which clearly contributes to risky behaviors such as unintentional injuries (Carpenter & Addis, 2000). Encouraging development of emotional intelligence in males and reversing the normative enculturation of emotional repression has been highlighted by others (Kindlon & Thompson, 2000, chap. 2) and will be discussed further in this review.
Occupational Health
The inherent danger of jobs that are exclusively, or very much dominated by, males places many men at risk for morbidity and mortality (Kposowa, 2001; Marmot, 1999). For example, exposure to toxins and smoke at work has been implicated in certain cancers and chronic obstructive pulmonary disorder among men (Menville et al., 2010). Men account for 90% of unintentional injuries (accidents) in the workplace (Courtenay, 2000) and these are the leading cause of infirmary and disability in working-aged men (Coggon, Harris, Brown, Rice, & Palmer, 2010; Roberts, 2010).
Whether men are firefighters, construction workers, coal miners, military personnel, or any other traditionally male-dominated profession, they occupy some of the most hazardous occupations in the world (Coggon et al., 2010; Menville et al., 2010; Roberts, 2010). The U.S. Bureau of Labor Statistics (http://www.bls.gov/) lists loggers, fishermen, pilots and navigators, structural metal workers, roofers, electricians, farmers, construction workers, laborers, and truck drivers as 10 of the most hazardous occupations, of which, all are dominated by men. Additionally, occupations such as coal mining are one of the most dangerous work settings and it is almost entirely composed of men.
A man’s self-esteem is intricately woven into his ability to work and provide for himself and others. Occupation provides for oneself and his family, it provides a social outlet, and it often helps a man define himself. One of the first questions men will ask of each other is “so, what do you do?” With such inherent value in occupation and work status for men, it is no wonder that health often falters when a man can no longer work due to being laid off or because of disability (Kposowa, 2001). The type of job also relates to masculinity; for example, men who are nurses may be viewed as less masculine than a coal miner (Addis & Mahalik, 2003; Roth & Coleman, 2008). Consistent with this article’s thesis, why are men disproportionately employed in such dangerous jobs? Is it that the physical demands of the job require men to perform them due to perceptions of greater physical strength versus females, or is it something more socially engrained that men are “supposed” to do more dangerous things including employment?
“Normatively Content”? Social Determination of Health Inequity
Sociocultural ramifications
It appears that the social determinants of health (e.g., gender scripting of employment) are an underlying premise to many of the health inequities experienced by men. At least, they are more of a predictor variable of health outcomes than once thought. Furthermore, these issues are relatively absent from any comprehensive discussion at a policy level. Alarmingly, this lack of discussion from an academic and activist position prevents these issues from becoming a popular topic of debate. This, in turn, is influenced by the seemingly normalization of poorer health outcomes experienced by men when compared with women. It appears that males are naturally meant to live sicker and die sooner.
Although much is unknown, there has been some research regarding social influences on male health outcomes. What is known is that how males are socialized into their respective culture often determines several psychosocial, health-related variables (Addis & Mahalik, 2003; Katz, 2011; Williams, 2003), but this can vary among cultures. For example, in societies and cultures where traditional masculine norms are valued (e.g., strength, sturdiness, stoicism, competitiveness, independence, and aggression), anyone deviating from the norm often is met by resistance (Addis & Mahalik, 2003). Ironically, males who do conform to the social norms of masculine values often fare no better. Demonstrating one’s masculinity often can lead to risk-taking, aggressive behavior, violence, and can even guide how a male may not seek preventative health care (Katz, 2011; Williams, 2003). Homicide and rates of incarceration also plague the male sex more so than females with astoundingly high rates highlighted by data from the U.S. penal system (Bureau of Justice Statistics, 2010, http://bjs.ojp.usdoj.gov/). Social health for males may be viewed as an inherent risk or as an opportunity to advance quality of life.
Normative content has several sociocultural implications. The notion of social justice is appropriate to the present discussion in terms of male health and health outcomes. Defined, social justice pertains to the development and maintenance of equality, solidarity, and human rights and dignity of all people. Moreover, the egalitarian nature of this term aims to define the rights and values of human beings as well as promote the dignity of the human condition (Turnock, 2009). With this said, social justice principles in the context of male health, aim to provide a mechanism to improve overall health, health outcomes, and other leading health indicators by way of primary, secondary, and tertiary prevention; fair and equitable access; and treatment, follow-up, and promotion of health-related principles. Early death rates and high morbidity are preventable; Wilkins (2010) notes, “they [deaths] are happening for no other reason than that we are not very good at addressing male-specific needs” (p. 201). Addressing these needs at the policy level likely will yield the greatest results.
Arguably, the strongest health risk factor in males may not be any particular infection, illness, or disease process, but inaction and normative content. Society must continue to realize that the strength of a nation is not necessarily the individual health of one citizen, but rather, the collective health of its citizenry. Male health is not simply an individual issue, but one that warrants social action. Culture, social expectations, and the daily experiences (including barriers) may stack against males being proactive in their health. For example, weakness, femininity, stigma, and many other “challenges” to one’s masculinity often go hand in hand with health care and health-seeking behaviors. If culture promotes males to “tough it out,” then why are we surprised that the majority live sicker and experience less quality of life (Brett & Burt, 2001; Porche, 2010)? Form follows function; therefore, if society reinforces that males should be functional parts and simply wait to be “fixed” if (when) they break down, how can we expect positive health outcomes? Achieving such a feat stems from providing equitable opportunities, which include the systematic deconstruction of the encultured gender-scripted roles for men in society. These expected social norms contribute to health disparities seen between the sexes.
The impact of normative contentment on society has far-reaching implications. Take for example an article in 1969 that detailed, “Selective Service statistics reveal a significant incidence of handicapping conditions in males, aged 18-26, suggesting that if the entire male population of draft age were examined, approximately one-third would be disqualified for military service” (Douglass, 1969). These statistics are no better, if not worse, today. Gender-based inequities need to be better understood to bridge the disparate gap between males and females not simply for the health of males, but for the holistic health and well-being of communities at large and even national security (Bonhomme, 2007).
Economic Issues
Lending a blind eye to male health issues has severe economic consequences. Lost work productivity, years of potential life lost, and opportunities with families bear a huge burden on Federal, State, and local governments. Men who are sick and/or unable to work cost the U.S. government approximately $142 billion dollars annually. Lost tax revenue and payments into Social Security also are greatly affected by premature morbidity and mortality in males (Brott et al., 2011). If males are infirm or deceased, there is an additional financial strain on their families and widows. In fact, loss of a spouse is implicated in widows living below the poverty line in 50% of cases (USDHHS, 2001). Moreover, $156 billion in direct medical payments and lost work productivity as well as $181 billion in diminished quality of life are put on the government and ultimately the taxpayers (Brott et al., 2011).
Normative content also has likely led to underfunding of male health initiatives. For example, it is estimated that 33,720 men die of prostate cancer annually. Comparably, 39,520 women die of breast cancer, a difference of 5,800 lives (American Cancer Society, 2011). However, in 2011 the National Institutes of Health (2011) allocated $778 million for breast cancer and $95 million for cervical cancer compared with $337 million for prostate and testicular cancer. Even less funding is provided for testicular cancer, even though it is the deadliest form of cancer in males aged 15 to 35 years (Jemal et al., 2009; see Table 2). The latter is even more impactful given that 15 to 35 includes productive work years from males including military service. Therefore, to assure socially just principles, public health must prevent male health disparities and inequities from flying under the radar. To improve the health of all communities, we must realize (as John F. Kennedy once noted) that “a rising tide lifts all boats.” Social policy reform that is inclusive of males and their unique issues will allow for the tide to take its due course.
Mortality and Relative Costs Associated With Male and Female Cancers in the United States.
Per 100,000 persons.
Addressing Normative Content and Enculturation: A Logic Model for Male Health Advocacy
Increasing public awareness of issues affecting males in the United States and abroad is a strong first step; however, demonstrating progress through measurable goals and objectives will lead to actual change. Perhaps one of the greatest challenges to the former is breaking through long-held beliefs and traditional masculine hegemony that men are expected to “suck it up” in terms of health and die sooner than women. The issue of normative contentment in society may be a newer term or concept, but understanding how this concept limits positive health outcomes for males is critical.
To understand why society lacks even the most marginal of protests pertaining to the aforementioned health and well-being inequities seen between the sexes, first it is important to understand how attitudes and perceptions can become normative. According to expectancy theory (Figure 2), a person decides to act/behave in a certain way based on motivational influences, such as sociocultural expectations (Oliver, 1974). Moreover, the theory of planned behavior (Figure 2; Ajzen, 1991) applies to the former in that attitudes, subjective norms, and perceived behavioral control shape an individual’s behavior.
Comparison of expectancy theory and the theory of planned behavior in terms of influencing male health outcomes.
Rodin, Silberstein, and Striegel-Moore (1984) introduced the concept of “normative discontent” pertaining to women’s preoccupation with thinness and beauty according to Western standards. They suggest that stigmatization of overweight and obesity presents a strong motivational force for women to attain an ideal of attractiveness and beauty. This has enacted a cultural shift in women and girls where they are expected to be concerned, if not preoccupied, with how they look. In essence, it became a normal expectation for females to be discontent with their bodies and body image (Rodin et al., 1984). Our discussion suggests that society also has become “normatively content” with the health inequities seen between the sexes and therefore men are expected to live sicker and die sooner.
Social health is an important avenue by which to enact change in the normative content of males. Males learn from others, but particularly from other males. Expectancy theory and the theory of planned behavior (Figure 2) can be used to help men realize that they can be strong, masculine, productive citizens without having to give up their quality of life, health, and years of life. For example, a potential application of the theory of planned behavior might consider young males and testicular self-examinations (TSEs). Taking into consideration negative behavioral beliefs (i.e., lack of perceived vulnerability to the disease and/or low perceived severity of the disease) and negative normative beliefs (i.e., negative peer group feedback on performing TSE or discussing testicular cancer risks with peers) surrounding TSE performance, as well as low perceived behavioral control (i.e., lack of knowledge on how to perform TSE), men may have little to no intention to perform self-examination. What the proposed logic model can do is to consider the negative inputs and restructure them to be positive. For example, hosting group/peer discussions and creating exposure to testicular health information in an open forum to eliminate stigma of public discussion of TSE may help persuade men to consider the severity of testicular cancer and their potential risk. That, coupled with teaching men how to do a TSE could turn the negatives to positives and spur community and individual programs and interventions (see the “activities” section of the model). Potentially, this could lead to greater participation in TSEs, which breeds short-, medium-, and long-term health benefits from absolute and relative risk reduction. Increasing informed decision-making skills for possible future health events using the TPB and a logic model may help attenuate negative health outcomes. Ultimately, the “Y” chromosome need not be viewed as an inherent risk factor, but, rather, a closer exploration as to how male health has fallen by the wayside resulting from normative contentment is warranted.
We present a logic model (Figure 3) that can be used to better conceptualize processes needed to improve male health in light of normative contentment. As with most logic models, inputs, outputs, and outcomes are framed by the individual processes and programs aligned to affect advocacy and policy. The model helps to account for assumptions made about male health, analyzes external influences and factors, and proposes activities that encourage participation so as to plan and achieve short-, medium-, and long-term goals, ultimately advancing male health outcomes (see previous application example).
Logic model for male health advocacy.
Positive (e.g., males’ propensity to be competitive) and negative (e.g., males being less likely to express emotionality) sociocultural variables are accounted for in the model so program planners and policy advocates can fully take these into account. For example, Rovito, Gordon, Bass, and DuCette’s (2011) statements that men prefer to receive health promotional messages in private instead of a public setting, particularly regarding more sensitive health topics such as testicular cancer and topics influencing masculinity, can be classified as a negative sociocultural variable due to the fact that men feel embarrassed, ashamed, or weak to speak to said issues with unfamiliar audiences. On the other hand, Rovito and Leone (in press) discovered that men may be more apt to share and disclose information even on sensitive health topics if they discuss them with close family or among a tight-knit cultural or religious group (e.g., men’s church groups). The notion of “family ties” or “camaraderie” can be seen as a positive sociocultural variable when researchers are determining how best to reach a particular group of men with specific health information.
Next, activities are planned with target male audiences in mind using clear goals and measurable and achievable objectives. For example, making programs and policies more relevant to males versus simply calling for health improvement is likely to be more effective. Planning health screenings at sporting events is more likely to appeal to males rather than telling them to come to a clinic for a checkup. For example, the Men’s Health Network has provided various health screenings at National Football League games on an annual basis to achieve greater community outreach. These critical planning steps likely will improve short-term goals and objectives such as attendance at sponsored events or behavioral compliance with health initiatives (e.g., smoking cessation, dieting). From short-term goals, the planning focus can shift beyond awareness and compliance to actual behavior change that positively affects health outcomes in males.
Males seeing beyond the “norm” and being discontent with poor health outcomes ultimately guides the long-term vision of our logic model. Male health advocates and policy makers are encouraged to use logic models such as the one we present to inform planning initiatives as well as long-term sociocultural change. Our logic model aims to address upstream determinants and influence policy as it pertains to creating a more focused and concentrated effort in achieving a true public health that is equally representative of males and females.
Future Directions
As noted in Healthy People 2020, male health initiatives need to engage multiple sectors to strengthen policies and improve practice-based and evidence-based directives (USDHHS, n.d.). Assessing and responding to the unique needs of males cannot wait another decade as morbidity and mortality rates persist at the expense of males, their families, and the economy. Culturally, we must advocate for gender equity in all areas of health care and programming affecting the health of the nation; good health is not a privilege controlled by health providers and medical conglomerations, but a human right.
We need to celebrate advancements in the areas of maternal and child health, reproductive rights, and other women’s programs; however, we need to assure that 50% of the population does not go by the wayside simply because human health has become genderized. As previously stated, the creation of the Office of Women’s Health, as well as the introduction, and subsequent passage of, legislation such as the Milkulski Amendment, suggest that there is a complete lack of any comprehensive discussion on the creation of an Office of Men’s Health and similar policies, thus indicating some form of gender bias in even the most powerful of political offices in our nation. This is indicative of a “normalization” of the idea that one sex (females) should have more attention than the other (males) with regard to health and wellness promotion.
Although there is some federal policy, along with Healthy People 2020, aiming to improve the health of all citizens of the United States by targeting and eliminating disparities (USDHHS, n.d.), in terms of specific advocacy for men, efforts are anemic compared with female-specific legislation. Only in legislation through the Indian Health Service (http://www.ihs.gov/) do gender-specific, male health initiatives receive attention. The establishment of an Office of Men’s Health similar to rights and programs stipulated in the male health policy through the Indian Health Service (http://www.ihs.gov/) is needed. In achieving the former, the Men’s Health Caucus of the American Public Health Association set forth a National Policy Agenda for 2011-2012 calling for immediate attention and action (Bond et al., 2011). The establishment of a Congressional Men’s Health Caucus also has opened an important door toward legislative action. We encourage continued discussion, planning, and action, including the use of logic models as the one presented in this article, to forge a new emphasis on population health, males notwithstanding.
Despite many successes recently seen in the advancement of a national men’s health agenda, continuous monitoring and public advocacy also must compliment the establishment of policy and organizations. For example, in the fall of 2011, the U.S. Preventive Services Task Force (2011) changed prostate-specific antigen testing from an “I” rating (no recommendation) to a “D” rating (do not screen). In addition to prostate screenings, testicular screenings also currently have a “D” rating. Essentially, this rating means that many men will have less of an opportunity to secure preventative screenings along with consultation with their doctor than if the rating were left at an “I.”
Complacency in the face of social and health care disparities is almost as detrimental to social justice as the actual disparity. If we are to improve the health of all people and attend to the goals of public policy, such as Healthy People 2020, we need to assure that population health does not subscribe to being normatively content with obvious gender/sex disparities and health outcomes. Male health needs to be viewed from a different lens. Bonhomme (2007) notes, “Just as you cannot effectively weed half a garden, in failing to address the health challenges facing both genders, you cannot do a thorough job of addressing the health needs of either gender” (p. 335).
Conclusions
It is vital to create a culture that promotes good health for all people through healthy development across the lifespan. Morbidity and mortality rates in males in the United States and abroad are striking and unacceptable. Shedding light on how government policies as well as public attention have grown to accept poorer male health outcomes is a task that needs to be carefully dissected and attended in public health, health education, health promotion, and community involvement.
This article presented how society has become “normatively content” with disparate male health outcomes across the lifespan and what it means to families and communities. Social and political action is warranted and suggestions were provided to guide the reader. A logic model detailing how program planners, policy makers and advocates, and legislators can use a comprehensive conceptualization process to attend to male health disparities was presented and discussed.
Perhaps to understand normative content in terms of male health, consider a quote from famed British industrialist Geoffrey Vickers who stated, “. . . the history of public health is one of blending knowledge with social values to shape responses to problems that require collective action after they have crossed the boundary from the acceptable to the unacceptable [italics added]” (Turnock, 2009, pp. 10-11). It is time to recognize and act on the fact that poor health outcomes in males have crossed into the realm of the unacceptable.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.