Following their report
Men’s Health Across 17 European Countries, commissioned by the EMHF,
Alan White and
Keith Cash review their findings and look to the future.
We have known for some time that men have a shorter life expectancy than women. In fact it is now so well known that it has, perhaps, ceased to be a surprise or even a cause for concern. However, a new report on the state of men’s health across the 15 countries of the EU, as well as Norway and Switzerland brings home the depth and scale of the problem. The awareness that across the 17 countries of this study there are 190,500,000 men and of these 50% will be dead before they are 75 as compared to 25% of women is an opportunity to reflect on this figure and to ask ourselves several questions. First, should this fact be taken so complacently? Second, what are the causes of this inequality? Third, what are the implications for the health of men and fourth, what can be done about the situation?
This study commissioned by the European Men’s Health Forum has brought together key international data on a wide range of disease conditions as well as lifestyle and demographic data for men across Western Europe and has highlighted that men’s health varies considerably between countries and between different ages. By also focusing on the statistics for men in comparison to women the report has demonstrated that men are at a universal disadvantage across all the major disease states such that there can now be no doubt that health is gendered and that, as such, health policy, health strategy and health care provision must reflect the differing needs of men and women.
The cause of death between countries varies considerably suggesting that there are specific health concerns that each country should focus on. For instance 11% of male deaths in Belgium are due to lung cancer as compared to 4% in Sweden. Austria saw 47.6% of their men die of cardio-vascular disease as compared to 27.7% of men from France. Prostate cancer was the cause of 5.3% of deaths in Sweden as compared to 2.2% in Greece, with nearly 3% of male deaths in Portugal the result of cancer of the stomach but only 1% of male deaths in Denmark.
When the ratios of male to female deaths are compared across all the major disease states it is only over the age of 75 that the female rate exceeds that of men and for all the major cancers the male incidence rate was higher.
There are large differences between the life expectancy of men across Europe ranging from 73.0 years for men in Ireland to 77.5 years in Sweden but no country comes close to the life expectancy of women, with France having the largest gap (7.5 years) between the two genders. In 8 of the countries under study, men are not expected to reach in 2020 the level women were enjoying in 1980.
Ischaemic heart disease
When compared to women it can be seen that overall death rates due to ischaemic heart disease are much higher for men across all the countries. The figures between the men and the women also suggest that there is a much smaller difference in death rates for women between countries as opposed to the relatively large differences for men. In the age group 45–54 there is an over 14-fold difference between the men and women in Finland.
Cancers of the digestive system
Cancers of the stomach, colon, rectum, rectosigmoid junction and anus primarily affect men over the age of 65. Men having similar median death rates for all the countries to women in the younger age brackets but there are marked differences above the age of 55 where men appear to be much more at risk of dying of these cancers than women.
Accidents and deaths due to external causes
The median death rates for men and women due to accidents and external causes of death show two trends: one is in relation to the increased risk of younger and older men, but also the excess of male mortality over women until the 75+ age group where the rate of death of women exceeds that of men.
These charts show the pattern with respect to deaths, when the age standardised rates for incidence are examined similar trends emerge. For example there is an increase in the number of women smoking but incidence for lung cancer still shows a substantially greater rate of new cases of cancer in men than in women, with a 12-fold difference between men and women in the United Kingdom.
The rate of incidence for cancer of the stomach again shows an almost two-fold difference between men and women across all the countries. The difference between men and women is not so great, but it still exists across all the countries in relation to the incidence of cancer of the colon and rectum.
Suicide and self inflicted injury
There are substantial national differences in suicide rates, ranging from 0.6% of total deaths in Greece to 3.9% in Finland. Substantial increases in death rate from suicide and self harm are seen in the over 65 year age group in the majority of countries. Men show a consistently higher rate of suicide than females.
Chronic liver disease and cirrhosis
There is a wide variation in the number of deaths related to chronic liver disease and cirrhosis between the countries in the study but overall the death rate is declining. Again men show a consistently higher death rate than women
Diabetes mellitus
Diabetes is a growing public health issue, as it is associated with coronary heart disease, blindness, hypertension and sexual dysfunction. Although the incidence is increasing the death rate is decreasing but there are wide variations in the death rate between the countries of the study. Men show consistently higher death rates due to diabetes than women.
Mental disorders
Men appear to have more disorders related to substance misuse than females, who have more neuro-psychiatric and depressive disorders. Men generally have a higher death rate associated with mental illness until reaching the 75+ age group when there are more female than male deaths. There seems to be little comparative European data on mental health.
Sexually transmitted disease
There has been a general and substantial reduction in the degree of sexually transmitted diseases but there is now a growing concern that this trend is being reversed.
HIV/AIDS
Overall the incidence rates for AIDS have gone down in all countries except Portugal but what is emerging is that though the number of AIDS cases in the homosexual male population are declining transmission by heterosexual contact is increasing with the main impact being on the 25 to 44 age group. The death rates for AIDS for men have declined substantially in all countries except for Portugal. The incidence of HIV seemed to be in decline until the late 1990s but now seems to be on the increase again.
Prostate cancer
Prostate cancer is becoming more common than lung cancer amongst men and is now the second most important cause of deaths through malignancy in men resulting in over 3% of all male deaths in these countries. Sweden has the highest proportion of total male deaths due to prostate cancer, while Greece has the lowest. Deaths from prostate cancer occur primarily in the over 65 age bracket but there are still a significant number of deaths in the younger age groups.
Testicular cancer
Although there is not a large death rate from testicular cancer it has great relevance to men as it is a cancer of young men with an almost 100% survival rate if it is caught early enough. The death rate for testicular cancer is decreasing across all the countries in this study with Switzerland having the highest death certification rates and Spain the lowest. However though the death rate is decreasing there is a rising incidence of testicular cancer.
Opening up the debate
This study did not focus on why men were more susceptible to all the major diseases and had such a high degree of premature death but it is to this investigation, once the messages of this study have been dwelt on, that we must turn our attention. We need to open the debate and engage in more discussion and research into the reasons why men are so much more likely to suffer premature death.
There are three possible reasons that would seem to warrant the most urgent consideration:
1. Men are more vulnerable to the diseases.
2.Men’s lifestyles, for example alcohol consumption and smoking, lay them more open to risk,
3.Men are delaying seeking help
The vulnerability of men
A key finding from the report is that men seem to be at greater risk of developing nearly all the major diseases that can affect both sexes. There is a complex sociological argument on the difference between sex and gender with the term sex relating to the biological status of the individual and gender being the way a man or women is affected by social determinants.
The study seems to suggest that it is necessary to look both at the biological entity of man as well as the role masculinity has to play within the health of men. The role of men’s ‘nature’ as well as ‘nurture’ has to be explored. We have a well rehearsed argument with regard to cardiovascular disease but we need to further this debate to see if, as Kramer states, men are more ‘fragile’ than women or if being a man is in itself a ‘disease’.
Men’s lifestyles
Certainly for some illnesses the destructive nature of men’s addictive and risky behaviour are evident: the number of men who develop lung cancer reflects the high level of male smoking, the greater mortality from liver disease and cirrhosis results from alcohol, and more men are overweight than women and have a tendency to deposit fat around their abdomen leading them to the greater risk of developing cardiovascular disease and diabetes to name but three obvious examples. There are also links to smoking and diet that help explain men’s increased risk of cancer of the stomach. Indeed the figures for mortality due to mental health disorders highlight a greater vulnerability to addictive disorders.
With 60% of deaths in the age group 1–24 being from external causes young men’s risk taking can also be seen as an element of men’s lifestyle that has a negative impact on their health, for instance deaths as a result of road traffic accidents and accidents at work. Further research is needed to determine why the men from the different countries had such differing health outcomes and whether this is due to variations in lifestyle and legislation.
Delayed help seeking
This would also appear to be a key factor in men’s greater death rate and ties in with the socially imposed model of the man as a person who is independent, in control and strong. If there is an increased risk to men, and the higher incident rates certainly suggest this to be the case, then any delay in responding to symptoms or avoiding routine medical check ups will add to the possibility of an early death. We must focus now on determining what aspects of men’s health beliefs and behaviour militate against help seeking to find ways to ensure that men gain early and effective care. This involves the investigation of men’s decision making processes with regard to their health.
Coupled with this is the need to investigate men’s actual usage of health services across Europe. If the supposition is that men have a problem with seeking help and guidance and this delay has a negative impact on their health then we need to have data on this. Comparative studies need to be undertaken both between men and women and between men from the different countries.
– The findings of the report suggest that public health strategies in European countries need to address the respective health needs of both men and women rather than rely on a ‘one policy fits all’ approach.
– Health policy should be formulated that is gender sensitive and should target men as a specific population group.
– Gender must become ‘mainstream’ and influence the provision and delivery of health services.
– Research must ensure that gender is considered as a possible variable and included where appropriate
. – Health indicators should be collected that are disaggregated for both gender and country to enable a more sensitive understanding of health needs; this is especially true for data on morbidity.
– There is a need to foster collaboration and coordination between European countries to facilitate the dissemination and implementation of example of good practice.
Conclusion
– Even though health is improving for many conditions there are still marked inequalities that exist, both between countries and between men and women.
– There are clear gender-related differences in population health needs.
– National public health strategies should address these needs by promoting gender sensitive policies.
– This report provides an essential corner stone from which to launch additional research projects.
Dr Alan White is Principal Lecturer, School of Health & Community Care, Leeds Metropolitan University.
Professor Keith Cash is based at the School of Health & Community Care, Leeds Metropolitan University.
Together they are the authors of the EMHF's Men’s Health Across 17 European Countries.
This article first appeared in Eurohealth
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Men’s Health Across 17 European Countries
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