Men and COVID-19: A Biopsychosocial Approach to Understanding Sex Differences in Mortality and Recommendations for Practice and Policy Interventions

Derek M. Griffith, PhD; Garima Sharma, MD; Christopher S. Holliday, PhD, MPH; Okechuku K. Enyia, MPH; Matthew Valliere, MPA; Andrea R. Semlow, MS, MPH; Elizabeth C. Stewart, DrPH, MSPH; Roger Scott Blumenthal, MD

Disclosures

Prev Chronic Dis. 2020;17(7):e63 

In This Article

Intervention Strategies to Reduce Men's COVID-19 Mortality Risk

To reduce virus transmission and increase screening for the virus and thereby reduce men's risk of COVID-19 mortality, we propose 5 strategies: 1) health education, community engagement, and public health outreach; 2) health promotion and preventive care; 3) sex-disaggregated data in clinical practice and policy; 4) rehabilitation and health care delivery infrastructure; and 5) health policy and legislative interventions (Figure).

Figure.

Intervention strategies to reduce men's COVID-19 mortality risk.

Health Education, Community Engagement, and Public Health Outreach

Educational efforts to increase compliance with public health recommendations may be more effective in changing the behavior of men if these efforts incorporate some of the principles from health communications research that consider how health behavior is gendered.[33,34] Building on research examining psychosocial barriers to men's health-promoting behaviours,[34,35] we note the importance of exploring how men's priorities, values, and goals are affecting their choices to follow or ignore COVID-19–related transmission prevention messages and pay attention to or ignore potential symptoms that may be present in their bodies. Building on principles of the self-determination theory, we suggest that messages to engage men seek ways to motivate them to consciously choose to engage in healthier behaviors, not because of shame, pressure, or coercion but because they are intrinsically motivated to do so.[36] For example, some men may be motivated to engage in behaviors to reduce their risk of contracting or potentially transmitting COVID-19 not by focusing on their risk but by focusing on the high rates of morbidity or mortality of their racial or ethnic group, communities, neighborhood, or family. Being motivated by one's own reasons to follow COVID-19–related transmission prevention messages is critical when men are faced with pressures to go back to work, the desire to spend leisure time with friends and family, and the inconvenience and fatigue of wearing face masks and gloves or maintaining physical distance from others.

Although the health education of men is useful, the health education of men's partners and their families about men's health risks is also critical. One US study of communication strategies examined the influence of men's partners and found that communicating with a man's loved one, combined with a reminder system implemented by providers, was associated with increases in preventive health care screenings.[37] As a result, a federally qualified health center in Baton Rouge, Louisiana, for example, is conducting outreach to men with underlying conditions and their partners to ensure that they are aware of their susceptibility to COVID-19.

Increasing access and eliminating barriers to community-wide testing are additional ways to improve COVID-19 outcomes. Testing or screening use may be influenced by exposure to decision education and the influence of screening-related primary care practice factors.[38] Federally qualified health centers offering primary care services are key community institutions that have increased COVID-19 testing — with no out-of-pocket costs to patients in many areas. These kinds of programs allow men to have access to testing without cost barriers that may otherwise deter them from accessing testing. The community-wide testing also offers an opportunity for men to be tested before returning to work as states begin to reopen and more services (barber shops, gyms, restaurants) are offered in communities. These initiatives help to normalize testing and reduce the stigma of getting tested, although they may not reduce the stigma of receiving a positive test result.

Health Promotion and Preventive Care

Given the rates of cardiometabolic risk factors and underlying or preexisting conditions such as obesity or comorbid chronic diseases (eg, diabetes, heart disease, cancer) among men, a focus on men with underlying conditions that increase their risk of COVID-19 mortality is critical.[34,37] Although the greater severity of complications attributable to COVID-19 among men is not well understood, preliminary findings of a higher incidence of mortality attributable to underlying comorbid conditions suggest that clinicians tailor current treatment options with this in mind. A model that examined activations for ST-segment elevation myocardial infarction (STEMI), the time from coronary artery occlusion to coronary blood flow restoration, showed a significant drop of 38% from roughly the year before the outbreak (January 2019) to the first month of it (March 2020).[25] The study, which used data from 9 high-volume cardiac catheterization laboratories, showed that total STEMI activations decreased from more than 180 per month (mean, 23.6 per center) to only 138 activations per month (mean, 15.3 per center) Thus, patients might be staying at home for fear of contracting the virus even though they need urgent care. We need to reassure patients that although routine and elective care might be curtailed by the pandemic, new symptoms of myocardial infarction and stroke still need to be immediately addressed.

For men who are at increased risk because of a history of a chronic condition or disease, clinicians should actively assess risks; optimize antihypertensive and statin therapies where indicated; provide behavioral and pharmacotherapy for tobacco use cessation (cigarettes and vaping); educate on healthy diets rich in vegetables, legumes, grains, fruits and nuts; and make exercise recommendations.[39] In addition to providing information, clinicians should encourage men to participate in behavioral interventions that target psychosocial factors (eg, self-efficacy, motivation) that can facilitate lifestyle change and maintenance of behavior changes over time.[34] These important interventions should continue during a pandemic through virtual visits and telemedicine platforms. Several professional organizations have made COVID-19–specific clinical and operational guidelines in their specialties; these include patient education information on occupational risk mitigations and recognizing signs and symptoms of COVID-19 infection, hand hygiene and surface decontamination, and protecting family members.[40,41]

Sex-disaggregated Data in Clinical Practice and Policy

While designing clinical trials to address COVID-19–related conditions, clinicians and researchers need to consistently consider sex as a biological variable and the behaviors and social stressors associated with gender that might affect drug efficacy, treatment options, and adverse outcomes.[3,13] There is a long history of not analyzing and reporting sex differences and underrepresenting women in cardiovascular clinical trials and in the treatment of infectious diseases,[10] and COVID-19 is proving no different in many countries.[4,15] Results from the randomized, controlled Adaptive COVID-19 Treatment Trial, which tested remdesivir as a therapeutic agent for the treatment of COVID-19, showed a 4-day difference in time to recovery between the treatment group and the control group, but the study did not provide explicit information on sex-based efficacy or adverse reactions.[42] An immunologic sex difference may exist in the mitigation of COVID-19, yet 86% of participants enrolled in clinical trials of immunotherapies (eg, tocilizumab) are men.[43] Only by investigating sex differences consistently, critically, and reflectively can we fulfill the requirements of scientific rigor, excellence, and maximum impact.

Rehabilitation and Health Care Delivery Infrastructure

Strategies aimed at preventing complications associated with COVID-19 are essential for safe and effective return to personal, professional, and societal obligations. Urgent needs also exist to provide post–acute care rehabilitation services for patients recovering from COVID-19 and to train a new workforce to care for these patients.[44] Strong evidence suggests that interventions engaging community health workers improve health outcomes for patients, including men, across multiple chronic conditions. As care extenders, community health workers provide a culturally and linguistically appropriate clinical–community linkage for difficult-to-reach patients, such as men. They can provide direct outreach to men with comorbidities that make them more susceptible to COVID-19 and its complications.

Given the high rates of pre-existing chronic conditions among men,[1] the Center for Medicare and Medicaid Services may need to expand access to telehealth services for men to receive care where they are to allow them to remain in isolation and prevent spread of the virus; however, most assisted living and long-term care facilities do not have computer access for residents for this purpose. This patient-centered care delivery model could be a particularly useful strategy to increase access to preventive medicine for men who are from medically underrepresented groups or groups with lower socioeconomic status.[45]

Health Policy and Legislative Interventions

In addition to various practice initiatives to reduce virus transmission and mortality, we must also consider the potential policy efforts to address the COVID-19 epidemic in the United States. Because men are dying of COVID-19 disproportionately, policy makers need to explicitly consider gender but not conflate gender with women.[1] To do so, local, state, and national policy makers should ensure that legislation includes language that promotes data collection, disaggregation, and dissemination by race, ethnicity, and sex.[1,4,15] Collecting and disseminating data by sex may help to make a vital economic case for considering men's health explicitly in the COVID-19 pandemic; however, men's health policy needs to be located in a framework that embraces gender equity and that does not treat men's health and women's health as though they are competing interests or priorities.[1] Finally, it is essential for policy makers to adopt an equity-based approach that considers the heterogeneity among men.[1,12] Men who are marginalized or disadvantaged because of their race, ethnicity, sexual orientation, incarceration, homelessness, or other factor are particularly vulnerable to COVID-19 and policies should explore which groups of men are overrepresented among essential workers, at risk because of preexisting health conditions, or most in need because of other socioeconomic factors.

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