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At the heart of general practice since 1960

January 2008: Improving disease outcomes in men

Why do men have worse disease outcomes?

How should healthcare for men be approached?

What are the key target areas?

Why do men have worse disease outcomes?

How should healthcare for men be approached?

What are the key target areas?

Men are notoriously reticent at seeking help for their health problems. fewer men visit their GP than women and those that do go less often. In 1990, for each visit men made to the GP, women made two (67 million visits compared with 143 million).1

In 1992 the CMO's annual report highlighted the fact that that fewer men contact health services than women. More recently, the General Household Survey and GP returns2 showed that attendance by girls and boys is similar until the teenage years, when attendance increases in young women but decreases in young men.

Women often have more reasons to visit their GP, including issues related to contraception, pregnancy, childbirth and children. However, the difference in behaviour between the sexes is thought to reflect the fact that women use their GP as a first port of call for medical advice, whereas men often seek advice elsewhere first.1 This difference remains up to the age of 55 years and then levels out, as men over this age are more likely to develop diseases that leave them no choice but to consult their GP.2

Men's health concerns

Men are at an increased risk of premature mortality across all major disease areas. There are three possible explanations.

• Men are biologically more vulnerable than women
• Men's lifestyles (such as higher rates of smoking and alcohol intake) create more life-limiting disease
• Men are more reluctant or unable to seek early medical attention.3

It appears that the health of men, in particular the ways in which men may be uniquely at risk, is still failing to receive adequate attention.

The Scoping Study on Men's Health, commissioned by the Department of Health,4 suggested that the four main concerns about men's health were:

• Access to health services
• Lack of awareness of health needs
• Lack of social networks
• Inability to express emotion.

Of these, access to health services appears to be the most important.

Since the early 1990s the Department of Health has produced some important documents that have had some impact on men's health. The Health of the Nation5 led to increased interest in health promotion and disease prevention in both sexes and provided a coherent structure for prevention. Morbidity and mortality are both greater in men than women in five key areas, which were specifically targeted for improvement:

• Heart disease – men must be encouraged to lead a healthier life and seek help quickly for chest pain
• Mental health – men are increasingly suffering from depression, anxiety and the resultant consequences, such as suicide, and need to be encouraged to admit to mental health problems
• Sexual health among young men and gay men, particularly the containment of HIV/AIDS
• Cancers – some cancers are specific to, or more common in, men
• Accidents – particularly in young men, who are more likely to suffer injuries from sporting and road traffic accidents and violence.

The subsequent green paper, Our Healthier Nation,6 set clear targets for improvement in four of these five key areas by the year 2010. These included targets to reduce mortality from:–

• Heart disease, stroke and related illness among people under 65 years by at least one-third
• Cancer among people under 65 by at least one-fifth
• Suicide and undetermined injury by at least one-sixth
• Accidents by at least one-fifth.

Progress has certainly been made in reducing cardiovascular disease mortality. However, research has shown that men remain at greater risk of developing certain conditions. The prevalence of CHD increases with age and men are more likely to develop CHD at any age than women. The latest statistics indicate that one in four men aged 75 years and over have CHD, compared with one in five women.7

The Stroke Association estimates that one in four men aged 45 will have a stroke if they live to 85, compared with one in five women.8 Risk factors for cardiovascular disease for both men and women include smoking, physical inactivity, a poor diet high in saturated fat and an increased waist circumference. However, distribution of body fat differs between the sexes. Men are more likely to develop central obesity, with the risk of metabolic syndrome, than women. Drinking to excess is also more common in men.

Recent research has shown that obesity has a direct and independent relationship with colorectal cancer9 and may increase the risk of aggressive prostate cancer.10

The IMPACT trial11 suggested that the stereotypical self-image of men and the stigma of depression appear to be major reasons why, compared with women of the same age, older men are less likely to recognise and report symptoms of depression and to receive referral or treatment. These findings are important as older men have significantly higher rates of completed suicide than older women.

Improving services

The Scoping Study on Men's Health4 identified some important reasons why men delay seeking help:

• Problems making appointments and negotiating with receptionists
• Restricted opening times. The new proposals to extend opening hours for GPs should help
• An unwillingness to wait for appointments
• A perception that primary care is mainly for women and children and that sitting in the waiting room is uncomfortabl
• Concerns about confidentiality, especially within the gay community about the disclosure of HIV status
• Fear of shame that their problem may be trivial or judged to be of little consequence, or of having to admit they have a problem they need help to resolve
• Difficulty discussing sensitive issues, such as depression or erectile dysfunction.

Therefore, although much can be done in primary care, GPs need to think innovatively and provide health services for men in other locations, such as the workplace, sports grounds, pubs, clubs, transport cafes and places where men gather.

Men's health in primary care may be improved by a more systematic, protocol-driven approach towards the organisation of services specifically for men, including the development of well man clinics. Practical advice on setting up a men's health clinic is given in table 1, attached. Clinics should focus on conditions that target men exclusively or preferentially and integrate some or all of the following:

• The provision of detailed, accurate and current health information
• Health screening, systematically searching for diseases where early detection is important, for example diabetes, hypertension and hyperlipidaemia. All men over 40 should know their CVD risk
• Treatment monitoring and adjustment for chronic conditions
• Surveillance and monitoring of borderline abnormalities.

The benefits of providing a well man clinic extend beyond improving quality of care and patient treatment. It will also allow more effective use of commissioning group funds, team building and audit. This should lead to greater utilisation of collected data and increased sensitivity to local healthcare needs.

Initiatives outside surgeries and health centres are also very important. Services need to include drop-in clinics, school and workplace initiatives, housing projects, work with older men, especially in nursing homes, rehabilitation sessions, exercise and weight control groups and work with alcohol misuse services, particularly in deprived areas.

Health and lifestyle up to the age of 65 are likely to be major determinants of the quality of life after that age.

With increasing emphasis being put on individuals taking responsibility for their own health, it is hoped that men will continue to become more health conscious and present because they want to remain healthy and not succumb to premature illness or death. Effective health promotion campaigns, with input from the target group, combined with appropriate and accessible services, should help to increase service use.

Screening

The National Screening Committee provides an important resource for advice on appropriate screening for cancers, such as prostate, colon and lung, and sexually transmitted infections.

Screening should not be performed outside a national programme, but case finding is appropriate when symptoms or signs suggest an underlying disorder.

One of the key factors in screening for colorectal cancer is uptake. To date, colorectal screening programmes have had a low response rate compared with other, more established, programmes. In the UK pilot, participation was lower among men.12 Similarly, in an Australian pilot, only 43% of men who were invited to take part attended, compared with 47% of women.13

There remain many gaps in the data on preventative healthcare for men and physicians must therefore use available recommendations when developing any form of health improvement programme.

PCTs and commissioning groups need to tailor initiatives on men's health, after assessing the health needs of the local population, deciding on the range and location of health services and determining local targets and standards.

Improving disease outcomes in men Key points Table 1: Practical points when setting up a men's health clinic Providing health services for men outside the practice

Examples of screening for STIs and setting up a men's health clinic outside traditional settings are available online:

• Ma, R. Offer syphilis testing to at-risk groups. Practitioner 2007;251(1697):17 www.thepractitioner.co.uk

• Toynbee, M. How I set up a men's health session in our local pub. Pulse 23 August 2007 www.pulsetoday.co.uk

Useful weblinks

The Screening Specialist Library provides information on National Screening Programmes
www.library.nhs.uk/screening

Cancer Research UK provides publications for healthcare professionals on all types of cancer
publications.cancerresearchuk.org

Author

Professor Michael Kirby
MB BS MRCS FRCP
GP, Letchworth, Hertfordshire and Visiting Professor, Faculty of Health and Human Sciences, University
of Hertfordshire

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