By Associate Professor Lina Ricciardelli FAPS, Professor David Mellor MAPS and Professor Marita McCabe FAPS, Centre for Mental Health and Wellbeing Research, Deakin University

In line with other Western countries, Australian men’s overall life expectancy and health has improved substantially over the last five decades (AIHW, 2011). However, men’s average life expectancy remains substantially lower than that of women’s. Males’ greater vulnerability to various disorders is apparent across cultures, and males are more vulnerable to disorders across the lifespan (White & Cash, 2004; Wilson, O'Leary, & Nathan, 1992). The following summary data demonstrate males’ greater vulnerability.

  • For every 100 girls that are conceived there are 140 boys conceived, but the birth ratio is 106 to 100 respectively; that is, nearly one third of boys die before birth (Wilson et al., 1992). 
  • More boys than girls die of birth disorders and diseases in infancy, especially during the first month (1,446 male versus 1,163 female deaths in Australia; ABS, 2010 ).
  • Boys show greater susceptibility to family stress, especially in the development of conduct disorders, and they continue to be more susceptible to both physical and psychological problems throughout the lifespan (Wilson et al., 1992). 
  • Among young Australians aged 12 to 24 years there are three male deaths to every one female death, with accidents and suicide accounting for most of this difference (Moon, Meyer, Grau, 2000). 
  • By the age of 65, females in Australia outnumber males by 25 per cent, and by the age of 85 females outnumber males by 50 per cent (ABS, 2006).

Among the main physical health problems that are leading causes of death and/or burden for men in Australia are heart disease, type 2 diabetes, stroke, chronic lower respiratory disease, adult onset hearing loss, blood and lymph cancer, lung cancer, prostate cancer and colorectal cancer (AIHW, 2011). 

Mental health problems are also becoming increasingly recognised in men of all ages, with the majority diagnosed among adolescents and young adults. However, only 12 per cent of adolescent boys and 35 per cent of adult men with mental health problems actually seek help (Slade et al., 2009). Mental health problems are often masked by other health risk behaviours that occur more frequently among men, which include alcohol and drug abuse, anger and aggression, speeding on roads and drink driving. The main mental health problems that are leading causes of death and/or burden for men in Australia include suicide and self-inflicted injuries, anxiety and depression, and dementia and Alzheimer’s disease (AIHW, 2011). 

In addition to the low prevalence of men seeking treatment from GPs and other health professionals, men are also less likely to have strong social networks that provide them with support for their physical and mental health problems. The consequences of not seeking treatment and poorer social networks is represented in the high prevalence of substance abuse and suicide, as well as aggression, violence and family breakdown among males (Slade et al., 2009). All these mental and social problems impact negatively on the lives of men, their partners, families and work.

Men at higher risk 

The main group of men who demonstrate poorer health in Australia are those living in remote areas. This is reflected in both their shorter life expectancies and their poorer self-assessed health status (AIHW, 2012). Males aged 45 to 65 years living in regional or remote areas are 1.2 times more likely to report high to very high levels of psychological distress and 1.4 times more likely to report depression than their urban counterparts (AIHW, 2008). In addition, alcohol consumption, cigarette smoking, drink driving accidents, depression and suicide are all significantly higher among men in rural communities compared to those residing in urban locations (Wilson, 2007). 

The poorer health status of rural residents when compared to their metropolitan counterparts may be exacerbated by the lack of availability of services within their community, and the transportation problems and/or associated costs of accessing health services located in another town or region (Berry et al., 2008; Heflinger & Christens, 2006). 

Aboriginal and Torres Strait Islander males

The other main group of Australian men who demonstrate poor health are Aboriginal and Torres Strait Islander males (AIHW, 2012). Recent reports from the Australian Bureau of Statistics indicate that the life expectancy for Aboriginal and Torres Strait Islander males is 11.5 years lower than that of non-Indigenous Australian men. Further, their mortality rates are at least two times higher than that of non-Indigenous Australians, and at least four to five times higher in young adult and middle-aged groups. The most significant conditions contributing to the burden of disease among Aboriginal and Torres Strait Islander males are cardiovascular disease, chronic respiratory disease, diabetes, lung cancer, kidney disease, obesity and poor mental health (AIHW, 2012). 

As with all Australian men, one of the main factors contributing to the poor health among Aboriginal and Torres Strait Islander males is socioeconomic disadvantage. Aboriginal and Torres Strait Islander males on average report lower incomes, higher rates of unemployment, lower education attainment and live in more overcrowded households than other Australians. Associated with this socioeconomic disadvantage are higher levels of health risk behaviours, and these are known to be significant contributors to health problems among all populations. The main health risk behaviours among Aboriginal and Torres Strait Islander males are poor nutrition, physical inactivity, high body mass index, smoking and alcohol consumption. 

The other factor contributing to the health patterns of Aboriginal and Torres Strait Islander males is their location, as defined by the Australian Bureau of Statistics. Aboriginal and Torres Strait Islander males living in remote areas show higher rates of all-cause, cardiovascular, diabetes and renal mortality rates than Aboriginal and Torres Strait Islander males in outer regional and very remote areas. This may in part be due to those with chronic illnesses in very remote areas needing to relocate for better access to health care services. However, very remote areas may also provide more favourable social environments, stronger family support, more physical activity and healthier diets (Andreasyan & Hoy, 2010). Studies which specifically examine the different physical and social environments and how they impact on physical and emotional health are needed. 

There has been little research in the past that has focused on protective factors for Aboriginal and Torres Strait Islander men’s health, but studies have shown that focusing on positive factors is a way of promoting optimism and greater resilience among communities (e.g., Snyder et al., 2005). On the other hand, an over-emphasis on the negatives can lead to greater helplessness and pessimism. A current project is examining ways of promoting healthy eating and physical activity among Indigenous Australian men aged between 20 and 40 years in Melbourne, Mildura and Broome (Ricciardelli, Mellor, McCabe, & Mussap, 2010-2012). Over 100 Indigenous men have been interviewed to identify several protective socio-cultural factors that contribute to men’s attitudes and behaviours regarding individual health, physical activity, diet and body image. These include supportive families and friends, looking good and self-respect, employment, taking part in sport, and connecting with the land and culture. A focus on these positive factors will assist in developing more effective and culturally sensitive health promotion strategies for this population of Australian men.

Immigrant men in Australia

Interestingly, males born overseas generally demonstrate better health than the Australian-born population. They have lower mortality and hospitalisation rates, as well as lower rates of disability and risk factors for health problems, such as obesity and high blood pressure (Anikeeva et al., 2010). This is known as the ‘healthy migrant effect’, and is primarily attributable to the fact that individuals with poor health are unlikely to migrate or even be accepted for migration. For some migrants, this health advantage is maintained, and this is often attributed to the adherence to some of their cultural traditions, particularly diet. However, for many other migrants, this health advantage dissipates with increasing length of residence in Australia, as individuals’ lifestyles change, often adopting the host country's unhealthy behaviours. 

Other factors that can also contribute to declines in migrant men’s health include a lack of knowledge about the healthcare system of the host country, difficulties in communication with health practitioners, and cultural beliefs that present barriers to help-seeking or healthy behaviours. A decline in health has also been linked to negative consequences of immigration such as unemployment and low economic integration (see Ricciardelli et al., in press for a review). 

Lifestyle and health risk behaviours

One of the main factors that continues to disadvantage men is preventable lifestyle and health risk behaviours. These include diet, alcohol and other substances, and sedentary lifestyles. At all ages, men report eating more high calorie items and less fruit and vegetables than women. The most recent national data indicate that only five per cent of adult males meet the recommended daily guidelines for fruit and vegetables (AIHW, 2011).

Early adulthood is also one of the main health risk periods for men, as this is the age which includes the highest percentage of daily smokers and the highest number of men who consume alcohol at either risky or high risk levels. More needs to be done to moderate substance use among young males, as alcohol, smoking and other drug use have wide ranging effects on many health and social domains. This is also the age where lifestyle practices are set. Many of the common health problems in later life are conditions that result, in part, from unhealthy lifestyles that were adopted in youth and midlife (Whitman, Merluzzi, & White, 1999). 

Health continues to be compromised for many men during middle adulthood as physical activity levels decline and waist measurements that indicate a high risk of health problems increase. Physical activity levels reach the lowest level among men at the age of 75. This is another critical period for promoting positive health behaviours, particularly physical activity. Increases in physical activity can have wide ranging positive effects on physical health and wellbeing in later life (O’Halloran, in press).

Hegemonic masculinity

Another significant contributor to men’s health is socialisation and developmental processes that underpin ‘hegemonic masculinity’. This is a dominant theoretical construction of masculinity, which has been identified as determining and maintaining men’s health practices and other health risk behaviours (Gough, 2007). In most Western cultures men learn to be emotionally and physically strong, independent and prone to risk taking. As a result they are more likely to engage in unhealthy practices, and less likely to admit to pain or seek medical advice, which subsequently leads to delays in receiving treatment and often serious health consequences such as advanced cancer or heart disease. 

Several researchers have specifically described masculinity as being inherently paradoxical and contradictory (see Ricciardelli & Williams, 2011 for a review). Many of the risk-taking behaviours engaged in by males are utilised to display their power and strength, but in the longer term these lead to powerlessness and poor health outcomes. This view is best reflected in men’s use and abuse of alcohol and other drugs. As summarised by Peralta (2007): “Heavy alcohol use demonstrates bodily power and superiority. Ironically, however, heavy and prolonged alcohol use in fact weakens one’s body” (p. 747). 

The same paradox is also evident in men’s help-seeking behaviour. Men are often reluctant to seek medical advice in order to maintain a position of power or not be labelled as weak. As with substance use, many men may be primarily engaging in other health risk behaviours and avoiding help-seeking behaviours in order to affirm and legitimise their masculinity. It has been frequently shown that men do not seek help as much as women because of their greater independence and self-reliance. Similarly, rather than seeking help, men have been shown to respond to mental health and physical symptoms through a number of strategies: denial; a ‘toughen up’ attitude that assumes they just need to ‘shake it off’; and by convincing themselves that they can manage their symptoms alone. However, this becomes a ‘double jeopardy’ as a rigid identification with many traditional masculine gender norms is associated with both an increased likelihood of depressive symptoms and more negative attitudes towards seeking psychological help, and in the longer term this further increases their vulnerability to poorer health. 

Other researchers have highlighted how masculinity may place men at risk of heart disease and poor adjustment to heart disease through direct and indirect associations with poor social supports and low health care. Several correlational studies have shown that negative masculinity, depicted by characteristics such as aggressiveness and showing off, is related to impaired social networks and poor health behaviour. In one study, Mahalik, Burns and Syzdek (2007) found a negative relationship between total scores on the Conformity to Traditional Masculine Norms Inventory and health-promoting behaviour in a sample of adult men aged between 18 and 78 years. Specifically, men reported greater frequency of health-promoting behaviours when they conformed less to traditional masculine norms. 

The ‘double jeopardy’ and the ‘paradox of masculinity’ as it applies to men’s health risk behaviours have been well summarised by Courtenay (2000): 

By dismissing their health needs and taking risks, men legitimise themselves as the “stronger” sex. In this way, men’s use of unhealthy beliefs and behaviours helps to sustain and reproduce social inequality and the social structures that, in turn, reinforce and reward men’s poor health habits. … Naming and confronting men’s poor health status and unhealthy beliefs and behaviours may well improve their physical wellbeing, but it will necessarily undermine men’s privileged position and threaten their power and authority in relation to women. (p. 1,397)

Among the many challenges for health professionals is the need to promote the view that there is more than one way to be masculine (de Visser & Smith, 2007) and that a healthy masculinity is one that “connects men in healthy relationships with other men, family, and intimate partners” (Capraro, 2000, p. 313). More recently, a “possible masculinity” has been proposed (Davies, Shen-Miller, & Isacco, 2010), which “encompasses what men need to become healthy, responsible, tolerant, civil, and nurturing in their families and communities” by identifying the “attitudes, characteristics, behaviors, skills, and coping strategies that are required for men to lead positive, healthy lives” (p. 348). 

It’s not all toughness and high risk behaviours

While many men identify and pursue the ideal of ‘hegemonic masculinity’ and engage in high levels of unhealthy behaviours, many others are focused on their health and engage in health-promoting behaviours. Overall, men engage in higher levels of sport and physical activity than women, with 42 per cent of adult men being sufficiently active to ensure health benefits (AIHW, 2011). Many men are more focused on seeking information before seeking help, and are more likely to rely on their partners or friends for help than professionals (Smith et al., 2008). Conversely, other men report feelings of embarrassment, lack of confidence and high levels of anxiety about seeing GPs and other health professionals (Jeffries & Grogan, 2012). As concluded by Jeffries and Grogan (2012) “ the reasons for lack of self-referral are, in fact, more complex and the ways men understand and talk about their healthcare behaviours is subject to variation and contradiction” (p. 911). We now need a better understanding of this variation and the factors that facilitate and moderate health-promoting behaviours among men. 

Barriers to seeking help

One way to improve the use of health services by men is to focus on the services themselves. Malcher (2005) has suggested that many services are not male-friendly, being often staffed by women, decorated by women for women, and primarily aimed at women and/or children. Health care providers, even males, are not trained in how to engage men and to communicate about health issues. 

These arguments help us to further understand why many men do not utilise health services or engage in positive health behaviours, and provide some suggestions as to how the situation may be changed. One solution would be to provide health education to men that addresses the negative consequences of embracing the attitudes associated with the masculine identity (Malcher, 2005). Since these attitudes are likely to be inculcated through early socialisation processes, this education would need to be provided in early childhood perhaps with booster campaigns aimed at critical transition periods such as adolescence and early adulthood. Male-targeted health promotion campaigns might be one way of doing this. For adults, other initiatives such as the Men's Shed movement could be used to encourage men to discuss health and health behaviours, and the advantages of seeking professional help for preventative as well as (delayed) treatment of health problems. 

At the service level, steps could be taken to make health centres more male friendly, and to enhance the training of health professionals, both male and female, on how to communicate with and engage men in more than a brief consultation about a specific health issue (Davies et al., 2010; Roberston & White, 2011).

Conclusions

A quiet crisis is underway in men’s health. Men are more vulnerable to various disorders at all ages across the lifespan, engage in more health risk behaviours but less help-seeking, and are less likely to have strong and supportive social networks. Many men are simply not interested in their health, so why would they pursue health checks, health services and positive health behaviours? Our increased recognition and understanding of these serious challenges needs to lead to more effective solutions. One step forward is to acknowledge men’s functional view of health which entails that they do not see the need to act until something goes wrong. Even when things do go wrong, men may take a ‘do-it-yourself’ approach rather than seek the help of health professionals. New health promotion strategies are needed that tap into men’s self-reliance and independence, as these may encourage men to be more active in seeking professional health (Jeffries & Grogan, 2012). In addition, a greater focus on the gendered nature of health attitudes and behaviours needs to be featured in current models of health psychology and behaviour change, and facilitated within the public health agenda (Roberston & White, 2011). n

The principal author can be contacted at lina.ricciardelli@deakin.edu.au

References

  • ABS (2006). Population by Age and Sex, Australia. Retrieved July 18, 2012, from http://www.abs.gov.au/ausstats/abs@.nsf/mf/3235.0.55.001
  • ABS (2010). Causes of Death, Australia, Retrieved July 18, 2012, from http://www.abs.gov.au/ausstats/abs@.nsf/Products/F161A09A03397ED9CA2579C6000F73D5?opendocument
  • AIHW (2008). Rural, regional and remote health: Indicators of health status and determinants of health. Rural health series, number 9. Retrieved March 11, 2009 from http://www.aihw.gov.au/publications/index.cfm/title/10519
  • AIHW (2011). The health of Australia's males. Cat. no. PHE 141. Canberra: AIHW.
  • AIHW (2012). The health of Australia's males: a focus on five population groups. Cat. no. PHE 160. Canberra: AIHW. Retrieved 2 July, 2012 from http://www.aihw.gov.au/publication-detail/?id=10737421980
  • Andreasyan, K., & Hoy, W.E. (2010). Recent patterns in chronic disease mortality in remote living Indigenous Australians. BMC Public Health, 10, 10-483.
  • Anikeeva, O., Peng, B., Hiller, J.E., Ryan, P., Roder, D., & Han, G. (2010). The health status of migrants in Australia: A review. Asia-Pacific Journal of Public Health, 22, 159-193.
  • Berry, H. L., Kelly, B. J., Hanigan, I. C., Coates, J. H., McMichael, A. J., Welsh, J. A., et al. (2008). Rural mental health impacts of climate change. Garnaut Climate Change Review. Retrieved March 11, 2009 from http://www.garnautreview.org.au/CA25734E0016A131/WebObj/03-DMentalhealth/$File/03-D%20Mental%20health.pdf
  • Capraro, R.L. (2000). Why college men drink: Alcohol, adventure, and the paradox of masculinity. Journal of American College of Health, 48, 307-315.
  • Courtenay, W. (2000). Constructions of masculinity and their influence on men’s well-being: A theory of gender and health. Social Science and Medicine, 50, 1385-1401.
  • De Visser, R. O., & Smith, J. A. (2007). Alcohol consumption and masculine identity among young men. Psychology and Health, 22, 595-614.
  • Gough, B. (2007). Real men don’t diet: An analysis of contemporary newspaper representations of men, food and health. Social Science and Medicine, 64, 326-337.
  • Heflinger, C. A., & Christens, B. (2006). Rural behavioral health services for children and adolescents: An ecological and community psychology analysis. Journal of Community Psychology, 34, 379-400.
  • Jeffries, M. & Grogan, S. (2012). ‘Oh, I’m just, you know, a little bit weak because I’m going to the doctor's’: Young men's talk of self-referral to primary healthcare services. Psychology and Health, 27, 898-915
  • Mahalik, J. R., Burns, S. M., & Syzdek, M. (2007). Masculinity and perceived normative health behaviors as predictors of men’s health behaviors. Social Science and Medicine, 64, 2201-2209.
  • Malcher, G.O. (2005). Men’s health, GPs, and ’GPs4Men’. Australian Family Physician, 34, 21-23.
  • Moon, L, Meyer, P., & Grau, J. (2000). Australia's young people 1999: Their health and wellbeing. Cat. no. PHE 19. Canberra: AIHW
  • O’Halloran, P. (in press). Physical activity: An evidence based examination of why, how much and how to increase it. In Caltabiano, M. L. and Ricciardelli, L.A. (Eds), Applied topics in health psychology. Oxford, UK: Wiley-Blackwell.
  • Peralta, R.L. (2007). College alcohol use and the embodiment of hegemonic masculinity among European American men. Sex Roles, 56, 741-756.
  • Ricciardelli, L. A., Mellor, D., McCabe, M. P., & Mussap, A. J. (2010- 2012). Promoting fit bodies, healthy eating and physical activity among Indigenous Australian men: Preliminary findings. Unpublished reports of Australian Research Council Grant. Deakin University, Melbourne, Australia.
  • Ricciardelli, L. A., Mellor, D., McCabe, M. P., Mussap, A., & Kolar, C. (in press). Culture and health: An Australian perspective. In Caltabiano, M. L. and Ricciardelli, L.A. (Eds), Applied topics in health psychology. Oxford, UK: Wiley-Blackwell.
  • Ricciardelli, L.A., & Williams, R.J. (2011). The role of masculinity and femininity in the development and maintenance of health risk behaviors. In C. Blazina and D. S. Shen-Miller (Eds), An international psychology of men: Theoretical advances, case studies, and clinical innovation (pp.57-98). New York: Routledge.
  • Robertson, A. & White, A. (2011). Tackling men’s health: A research, policy and practice perspective. Public Health, 125, 399-400.
  • Slade, T., Johnston, A., Teesson, M., Whiteford, H., Burgess, P., Pirkis, J., & Saw, S. (2009). The mental health of Australians 2: Report on the 2007 National Survey of Mental Health and Wellbeing. Canberra: Department of Health and Ageing.
  • Smith, J. A., Braunack-Mayer, A., Wittert, G., & Warin, M. (2008). "It's sort of like being a detective": Understanding how Australian men self-monitor their health prior to seeking help. BMC Health Services Research, 8:56 doi:10.1186/1472-6963-8-56.
  • Snyder, R. et al. (2005). Handbook of positive psychology. New York: Oxford University Press.
  • Wilson, G. T., O'Leary, K. D., & Nathan, P. (1992). Abnormal psychology. Englewood Cliffs, NJ: Prentice Hall.
  • Wilson, R. L. (2007). Out back and out-of-whack: issues related to the experience of early psychosis in the New England region, New South Wales, Australia. Rural and Remote Health, 7, 715. Available from: http://www.rrh.org.au
  • White, A., & Cash, K. (2004). The state of men’s health in Western Europe. Journal of Men’s Health and Gender, 1, 60-66.
  • Whitman, T. L., Merluzzi, T.V., & White, R.D. (1999). Life-span perspectives on health and illness. New Jersey: Lawrence Erlbaum.

InPsych August 2012