A MALE GENDER - SPECIFIC HEALTH RISK
ASSESSMENT TOOL IN PRIMARY
CARE PRACTICE

A Scholarly Project for the Degree of MSN
MICHIGAN STATE UNIVERSITY

RUSSELL L. BEEMAN

1997

 

LIBRARY '
Michigan State
University

 

 

 

PLACE IN RETURN BOX to remove this checkout from your record.
To AVOID FINES return on or before date due.
MAY BE RECALLED with earlier due date if requested.

 

DATE DUE

DATE DUE

DATE DUE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6/01 cJCiRC/DateDuepSS-p. 1 5

 

 

 

 

 

 

 

 

A MALE GENDER-SPECIFIC HEALTH RISK ASSESSMENT TOOL
IN PRIMARY CARE PRACTICE

By

Russell L. Beeman

A SCHOLARLY PROJECT
Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

MASTER OF SCIENCE

College of Nursing

1 997

ABSTRACT

A MALE GEN DER-SPECIFIC HEALTH RISK ASSESSMENT TOOL
IN PRIMARY CARE PRACTICE

By

Russell L. Beeman

The purpose of this literature-based project was the development of a male gender-specific
health risk assessment tool based on Leininger's theory of Cultural Care Diversity and
Universality, and information collected from available literature. A secondary outcome of this
project was the identification of values and beliefs of men regarding their health care
utilization, motivation to seek health care, and barriers which influence their motivation and
utilization, as found in literature sources.

Males have many health needs. There are specific issues that affect a male’s health,
morbidity and mortality. By addressing these issues within a health risk assessment tool, the
nurse clinician can more effectively assist the male in achieving a healthier lifestyle, longer life
expectancy, decrease in the severity of disease processes, and promote health risk prevention
through appropriate client/patient education.

Little research has been conducted and few research-based articles exist in medicine and
nursing, regarding male-specific issues in men’s health care. There is a void in health care
provision for males. The missing link is holistic, individualized care provision.

Health care research has identified health factors that through education of and practice by
males, their risk of disease, injury, and death would be reduced dramatically. Life-style
changes, based on this research, can positively affect male morbidity and mortality. The male
gender-specific health risk assessment tool may provide the beginning in resolving men’s health

issues and assisting males to seek healthier lifestyles and health care management.

ACKNOWLEDGMENTS

As those know who have experienced Graduate Studies, it is an exciting but stress-
filled time of growth, perseverance, and change. Without the encouragement and support
from faculty, colleagues, patients, friends and family, I could not have arrived at this
point in my life and career. I am blessed and grateful to have had so many persons in
my life that have provided the necessary support and drive in my academic life.

I wish to thank my friend and partner of 17 long years, Thomas R. McCulloch,
JD, who has been a source of encouragement, support, insight, and wisdom. I also ask
forgiveness for the time spent on my career which became too much time away from
the relationship for it to continue. You were also a very good example within my study
of men’s health which gave me insight and fortitude to continue to pursue this project.

Without the guidance of my research and thesis committee, I would not have been
able to have completed this milestone. Thank you Louise Selanders, RN, EdD, my
chairperson, advisor, and longtime mentor, Mary Jo Arndt, RN, EdD, and Nuala Clark
Kavanagh, RN, MSN . Your collegiality and friendship will continue to be most
cherished. Also, your encouragement to pursue greater heights in my academic career
is most valued and appreciated.

I would also like to thank Dr. David Wade, Lisa McConnell, MS, RN, Lyn
O’Connor, RN, MSN, Dr. Jeanne Burton, Dr. Paul Coussens, and the others who

graciously gave their time to edit my manuscript. You are true selfless friends for

iii

whom I totally indebted and forever regard as priceless assets. Faithful friends are a
treasure indeed! Thank you from the bottom of my heart.

Last but not least, I am grateful for the wisdom, mentoring and support of Will H.
Courtenay, Ph.D. candidate, University of California at Berkeley, Dr. Donald Sabo,
Professor of Sociology, D’Youville College in Buffalo, NY, and Dr. Madeleine M.
Leininger, RN, Ph.D., Professor Emeritus, Wayne State University. Dr. Courtenay
has provided great support through his research on Men’s Health as well as his
permission to use the Health MEN tor tool he created for his organization, Men’s Health
Consulting, Berkeley, California. His friendship and sharing of vast research and
unpublished manuscripts have been most beneficial to my own study. Dr. Sabo has
been invaluable in his sharing of his experience in studying men’s health from a
sociological venue. Dr. Leininger has been my invaluable teacher and mentor in my
innovative study herein. Her instruction and practical input on her Cultural Care
Theory in nursing has provided me with a firm foundation not only for my research
project but also my nursing career and practice. In their teaching, guidance and advice,
I am forever grateful as well as for their friendship, time and direction while showing

me the scholarly way.

And to all those colleagues, friends and family unnamed here, you are ever in my

heart.

For all you have done,
For all you mean to me,

For all you are,
--- I give thanks!

iv

TABLE OF CONTENTS

LIST OF TABLES .......................................... vi

LIST OF FIGURES .......................................... vii

CHAPTER I

Statement of the Problem ....................................... 1
Problem Identification ...................................... 1
Background of the Problem ................................... 5
Purpose of the Project ...................................... 7
Advanced Practice Nursing and Primary Care ....................... 8

CHAPTER II

Review of Literature ......................................... 10
Women's Health Movement ................................. 10
Men's Movement ........................................ 12
Men's and Women's Movements: Parallels and Divergens ............. 13
Men's Health Status ....................................... 16
Men and the Health Care System .............................. 21
Men's Health Issues & Health Care Needs ........................ 25

CHAPTER III

Conceptual Framework ........................................ 30

CHAPTER IV

The Project ............................................... 37

CHAPTER V

Implications for Advanced Nursing Practice .......................... 52

APPENDICES ............................................. 59
Appendix A: Statistical Tables ............................... 60
Appendix B: Male Concerns & Issues ........................... 70
Appendix C: Conceptual Models .............................. 72

REFERENCES ............................................. 75

 

LIST OF TABLES
Statistical Tables .......................................... 60-69
Table 1 ~ Death Rates per 100,000, by Age and Sex: 1980-1991 .......... 61
Table 2 — Infant Mortality Rate for infant (under 1 year of age) deaths per 1,000
live births .................................... 62
Table 3 - Death rates by sex and Ten leading causes of death: 1989
(Age-adjusted Death rate per 100,000 population) .......... 63
Table 4 - Leading causes of death and numbers of deaths, according to sex, and
detailed race, selected years 1950—1992 ............... 64-66
Table 5 - Deaths by Age and Leading Cause: 1991 ................. 67-69

vi

 

LIST OF FIGURES

Conceptual Models ........................................ 72-74

Leininger’s Sunrise Model .................................. 73

Beeman’s Adaptation of Leininger’s Sunrise Model in relation to male studies . 74

vii

CHAPTER I

Statement of the Problem

E l l I 1 'fi .

Men do not live as long as women. In the United States, it is has been documented
that, on average, males live seven to eight years less than females (Allen & Whatley,
1986; Courtenay, 1996; Harrison, Chin & Ficarrotto, 1988; Kemper, McIntosh, &
Roberts, 1994, Sabo, 1995). Statistics clearly demonstrate higher mortality rates for
males of all ages than females of the same age groups (Harrison et al., pp. 274-277;
Sabo, 1995). This is true when accounting for the decrease in the male p0pulation
compared to the total population. From current health studies, men have higher death
rates than women for all 15 leading causes of death (males die 7-8 years younger).
They represent 50% of the workforce and yet account for 94% of all work-related
fatalities.

Males know less about health and take less responsibility for their health when
compared with females, and are less likely to see themselves as ill or susceptible to
disease or injury when they are more susceptible. With higher health risks, males do
less to reduce high blood pressure and smoke more than females. They also consume
more cholesterol in their diet, eat more meat and fat, and eat fewer fruits, vegetables
and less fiber. Males are well known to drive more recklessly and illegally, accounting

for 3 out of every 4 traffic fatalities (Courtenay, 1996).

2

According to Sabo (1995), public health nurses find more widows in their service
population than widowers. The general public is also aware that men generally do not
live as long as women. School nurses have observed that adolescent males are prone to
early death by suicide and automobile accidents. Public health educators are only
recently insisting on early detection and prevention of testicular and prostate cancer.
Health care planners in some urban settings know that the life expectancy and health
status of poor, inner-city African-American men are lower than the male populations of
Third World countries. When examining fatalities associated with the HIV/AIDS
epidemic, it is gay and bisexual men who are at highest risk for contagion from HIV
exposure and thus higher death rate, according to AIDS advocates and educators.

HIV /AIDS death rates may be assumed to be the same after transmission but
demographically, these gay and bisexual men have higher death rates because of very
high opportunistic disease incidence rate associated with their acquisition of HIV.
Actual statistic data supporting these Observances may be referred to in Appendix A.

American males usually come into contact with the health care system episodically,
whereas American women make 130 million more scheduled doctor visits per year than
men (Allen & Whatley, 1986). This may be true not because men may have more
money or better insurance plans but that women are simply more attuned to taking care
of themselves and readily seek attention for their physical/medical needs. Although in
the US. the female population is greater than the male population, the relative numbers
of females also increase in number with age progression. But even that does not

account for such a difference in medical visits. Women’s reproductive cycles may

3
“force” their attention to health care; e. g. , when a woman is pregnant, she is literally
responsible for another being’s development and health.

For men, however, just going to the doctor is not enough to improve a male’s
health (Allen & Whatley, 1986). Men hold attitudes about health, an entire catalog of
male myths according to Goldberg (1993). Their health attitudes not only keep them
from living longer, but also prevent them from fully enjoying the years they do
potentially have. Nurses and physicians in clinical settings often encounter male
patients who exhibit a “tough-guy” posture that feeds denial of the seriousness of an
illness. Not until males throw off the notion that they are supposed to be invulnerable,
to suffer through pain quietly and alone, will men make progress at breaking down the
seven-year difference between male and female life expectancy (Goldberg 1993). At
present, there are no statistical calculations that show this to be a statistically significant
difference since there have been no programs to educate the male population nor has
there been research to document any type of change in the improvement of the health of
the general male population in the United States.

Why do males seek health care differently than females? Most researchers have
focused on sociological issues in their investigations of the changing male and the
changing male-gender roles. Men usually come into contact with the health care system
episodically, usually for their own illness (Allen & Whatley, 1986):

Most males do not regularly engage with physicians regarding health concerns

where gender-identity issues may be the underlying source or etiology. When

they do, these males are interacting with a group which largely shares their

4

identity as men (since most men will seek out a male physician). The course
of the doctor-patient interaction focuses upon returning the male to normal

role functions, not on shaping, defining, re-defining or nurturing what those

functions are assumed to be (p. 6).

Although men have been used as primary subjects for research and studies, only
recently have researchers looked at male gender-specific issues (Fisher, 1997). With
this focus on men's studies and on men's health issues materializing periodically over
the past 20-30 years, it appears that the need for research on these issues is emerging.
In searching for male clinics and male gender-specific clinics in the United States, no
clinics were found which serve only male issues and male health concerns except for
specialty clinics, such as urology, sexual dysfunction, and psychiatry/psychological
clinics or clinics within a larger medical or health care setting. This is not true for
women. Females in the United States have many different specialty clinics and female
gender-specific specialty fields, such as the Obstetric/Gynecology medical specialty,
Women’s Health Clinics, women’s services which cover many areas from financial
guidance, psychological assistance, health education, female gender studies, domestic
violence, shelters for abused women from violence environments, cancer screening,
cancer risk counseling, governmental offices (e.g., Office of Research on Women’s
Health), birth control, eating disorder research, sexual dysfunction studies, and,
moreover, the recognition in medical and psycho-social research and journals of
Women’s Health and Women’s Issues as specific, researchable, delineated fields of

study, research and education.

MW

Male and female anatomy and physiology have been studied, but until recently
other areas, such as psychological, sociological, spiritual, cultural, and ethnic issues
have not been researched from a gender-specific perspective. For the past thirty years,
the women' s movement has strongly encouraged the scientific community to recognize
the need for women's health care, as well as the use of female subjects in health
research as gender—specific disease processes and other gender-related differences were
detected. Allen and Whatley (1986) proposed that the women's health movement
centered on (1) the fundamental issues of who controls a woman's body and her health,
(2) the need to control the area which directly affected women’s lives and which was
dominated by male health professionals, and (3) to create new meanings from women’ s
own experience. For men, it was more difficult. The medical experts who defined
men's health were, in fact, men. Thus, males encounter the health care system
differently than females. There is a lack of research and research literature which has
further addressed the subculture of males and their health care values, beliefs, and
needs. Gender-specific men's health issues and disease processes have not been
revisited with research-based data.

Today, adult males do not usually seek health care unless they need sports, pre-
employment, or insurance—related physical examinations, or are acutely or chronically
ill, thus requiring intervention (Gerchufsky, 1995; Gongwer News Service, 1995;
Harrison, et al., 1992; Mishkind, et al., 1987; Sabo, 1995). The Ingham County

Health Department rural satellite clinics have statistically shown that adult men

6

traditionally do not access the health care system nearly as frequently as women
throughout the life span (Ingham County Health Department, 1993, 1994). Bozett and
Forrester (1988) state "as once had been the case for women, the total health care needs
of men are not being met"(p. 158). There is also a conspicuous separation between the
male expectations of their health care and the health care options available to them.
Current patterns of morbidity and mortality among men indicate an important
relationship between stereotypical male role behavior in contemporary American
society and men's health.
Wm
Sabo (1996) defines sex as referring to the biological aspects of a person's physical

and genetic identity, gender referring to the expectations and behaviors that individuals
learn about femininity and masculinity. Gendefldenfity would then be the person's
inner sense of themselves as being womanly, manly, feminine, or masculine as the
individual has experienced historical, societal, and/or cultural definitions of that
gender. Gender identity is seen as an outgrowth of an historically changing pattern of
relations between men and women and cultural definitions of masculinity and
femininity. In this context, gender identity is better understood as a process than as a
"thing" that people "have" (Messner and Sabo, 1990). Gender identities are learned
from others in varying social, cultural, and historical contexts and, as persons move
from one stage of life to another, decisions are made about accepting or rejecting a
wide array of cultural scripts for masculinity and femininity that supply direction, role

models, props, motivations, rewards and values (Sabo, 1994; West & Zimmerman,

7

1987). The scripting of masculinity contributes to men’s health and illness. Sabo
(1996) suggests that aspects of men's health and illness differ from those of women,
and implies there are gender differences that exist in relation to morbidity and
mortality; biological differences between the sexes may contribute to men's greater
susceptibility to certain forms of illness; elements of men's psychology, conformity to
masculine stereotypes, and cultural practices may have an impact on the shaping of
men's health and illness; and, there may be aspects of masculinity which are conducive
to health. Health care maintenance and provision by the medical profession has not
provided men nor women with appropriate gender-specific health care. The differences
between the two genders and their health provision focus on the male physician not
understanding female gender-specific health issues, and these same male physicians,
because of being males themselves and having cultural/ societal perceptions about their

own maleness and male roles, have not attempted to address male gender-specific health

concerns .

Wen

The purpose of this project is the development of a male gender-specific health risk
assessment tool based on Leininger's theory of Cultural Care Diversity and
Universality, and information collected from available literature. A secondary outcome
of this project is identification of values and beliefs of men regarding their health care

utilization, motivation to seek health care, and barriers which influence their motivation

and utilization, as found in literature sources.

8
I ”E .11. IE. C

Advanced practice nursing (APN) is defined as the deliberative diagnosis and
treatment of a wide range of human responses to actual or potential health problems and
issues (Calkin, 1984). Family Nurse Practitioners, as advanced practitioners, serve as
an individual’s case coordinator for the health care system, and serve many roles such
as client advocate, clinician, consultant, collaborator, counselor, educator, change
agent, role model, leader, mentor and researcher. Nurse Practitioners are gatekeepers
in the health care system, assuming responsibility and accountability for the
coordination, integration, and continuing management of the patient's total health care
and services. With working knowledge of the health care system and as an integral
component of primary care, APNs serve as guides through the complexities of this
system whether for health maintenance or for obtaining appropriate and effective
treatment.

Primary health care includes the initial contact of the patient with the health care
system and encompasses a full range of basic health services. Primary health care
should be readily accessible, patient oriented, of high quality, comprehensive,
individualized, and based on a firm foundation which integrates knowledge of the
nursing, medical, biological, physical, social psychological, and behavioral sciences
(Silver, 1977).

Nursing can provide the necessary expert leadership and knowledge in assisting in
health care for all Americans including men. From this project and the resulting male

gender-specific health risk assessment tool, the primary care advanced practice nurse

9

can better provide the essential primary health care assistance, wellness practices and
education to the male population from developing a better understanding of male

gender-specific health care issues and their impact on this population.

CHAPTER H

Review of Literature

Origins of the respective male and female movements have different sources based
on unique issues. The study of men's issues and men's health has relatively recent
beginnings. With different origins and foci than those of the women's health issues,
this chapter will examine the origins and issues of the men's movement, current
research literature regarding male and female health status, and the issues identified

towards understanding why men do not seek health care.

MW

Females historically have been viewed to be subservient, weaker, and less capable
of self-direction than males (Krjervik & Martinson, 1986). This may be true for recent
modern times (from the Victorian Age to present day) but is not true throughout time.
Reproductive anatomy and function, and gynecologic needs have been the traditional
foci of women’s health care (Yingling, 1996). In 1870, Napheys wrote a book
specifically for married or about to be married women, in which he identified three
phases in a woman’s life: maidenhood, matrimony, and maternity, and viewed a
woman’s physiological constitution as the determinant of the woman’s destiny. In a
1896 medical textbook, King wrote about women’s problems arising from “the sexual

excesses” prior to marriage which the woman was obligated to submit to, and that most

10

11

female complaints were associated with a sexual or reproductive disorder, a belief that
was central to women’s health care (Yingling, 1996). Culrninating in the 1960's and
1970's, in the United States, the women’s movement was emerging as a women’s
health care movement due to female activists calling attention to the neglect of medicine
in providing less than quality care to women.

Until recently (1960's-l970's), physicians had a lack of knowledge about and did
not acknowledge female values, beliefs, physiological processes and their associated
emotional and psychological presentations, and placed very little merit on the impact
these had on a woman’s health and functioning in society. Thus, the women’s health
movement developed out of the need for women to define and to learn enough about
their own bodies and health to be the defmers, thus creating new meanings of health
generated from women’s own experiences. From this foundation, women then acted
upon the need to exercise consumer pressure in having their decisions about health
needs accepted (Allen & Whatley, 1986). Allen and Whatley further present the
women’s movement as a causative factor in challenging the health care system(s) to
benefit both men and women.

Politically, the women’s health movement, as part of the larger women’s
movement, attempted to gain self-control within a male-dominated health care system
that directly affected women’s lives, creating new meanings from women’s own
experience (Allen & Whatley, 1986). Groups developed to learn and teach pelvic self-
examination, a developing dichotomy from this movement: development of women to

recognize and learn about their own bodies, and, the development of political and

12

assertive skills to play important and active roles in the decision—making process

involving their own health. From this, the women’s health movement has become a

powerful entity for the promotion and maintenance of female gender-specific ideology,

health care, and general well-being.

Sloane (1993) specifically identifies the following women’s health issues:

0

The quality of health care is currently lacking for women.

Women are subjects for new medical devices, surgical procedures, and drugs.
Frequent, unnecessary, and excessive surgical procedures are being
performed upon women/females.

There is an increase in “managed” pregnancies (i.e., caesarean sections).
Women’s mental health is/was perceived as psychosomatic or psychotic issues
by the medical community.

Women were seen as neurotic when medical treatment was requested.

The typical solution of the medical profession to women’s emotional problems

was to medicate; e.g., Valium.

The women's health movement arose from a central question of control over a

woman's body and her health. Women identified many specific complaints about the

health care system within the broader context of problems generated by men in defining

women’s health and disease (Allen & Whatley, 1986).
Menistment

The American “men’s movement” emerged in the early 1970’s with a very limited

population of male participants. The first national conference of the men’s movement

13

was held in the summer of 1973 in Louisville, Kentucky, with annual “men and
masculinity ” conferences since that time. Topics and issues of the movement were
largely sociological, psychological, and anthropological in nature. Joseph Pleck and
Jack Sawyer (1974) published their book, Men and Masculinity, highlighting how the
masculine role is learned, how it limits men, and how men could free themselves from
it (Pleck & Sawyer, 1974). Also during these beginnings of the men’s movement ,
Male Sexual Performance (1975) was published by Dr. Sam Julty. Setting the
groundwork for more distinct male studies literature, Dr. Julty (1979) published the
first work on men’s health and masculine psychosocial issues, Men ’s Bodies, Men ’5
Selves, where he provided information, advice and instructions on topics ranging from
stress, work roles, relationships with both men and women, physical health and
nutrition, emotional health, drug abuse and alcoholism, fathering, aging, and explicitly
sexual questions about performance, contraception, understanding the physiology of

both male and female genitalia, venereal disease, and rape and violence.

v ' 'v

There has not been any visible men’s health movement even as part of a larger
men’s movement (Allen & Whatley, 1986). The deve10pment of a men’s health
movement does not follow the pattern of development of the women’s health
movement. As the women’s health movement developed, women attempted to gain
control in a male dominated area which affected their lives, to create new meanings

from women’s own experiences , and to develop an understanding of their gender

14

identity (Allen & Whatley, 1986; Sabo, 1996; Yingling, 1996) Men and masculinity
theorists of the men’s movement continue to define maleness, male identity, and
masculinity. Identification of male health identity and men’s health issues continue to
be investigated, not necessarily by health care providers. One difficulty is that the
medical experts who define men’s health are themselves men. The medical models of
health and illness were also developed by males. Men do not suffer any comparable
definitional problem to that of women (Allen & Whatley, 1986). Bozett and Forrester
(1989) state the above supposition [with both provider and consumer being male, who
is better equipped to understand the needs of men than another man?] is founded on at
least two erroneous assumptions. One such assumption is that the physician is skilled at
getting behind the male facade to uncover problems or concerns that the patient is
unable or unwilling to share. Like most men, male physicians usually carry around an
armor of pretense, and it is as threatening for them to go beyond the superficial as it is
for their male patients.

Another assumption is that physicians provide health care, which they generally do
not. Prevention and the maintenance of health has not been the intent of most medical
education. Because of the highly specialized medical profession, men do not have one
Specialty provider to whom to go. “Although the man’s heart is attended to by a
cardiologist or his prostate by a urologist, what specialist does the man see who is
concerned about his stress level, occasional impotence, or other nonspecialist types of
problems?” (p. 159). Thus, health care maintenance and provision by the medical

profession has not provided men nor women with appropriate gender-specific health

15

care. The differences between the two genders and their health provision focus on the
male physician not understanding female gender-specific health issues, and these same
male physicians, because of being males themselves, have not attempted to address
male gender-specific health concerns for the above mentioned reasons.

The women' s movement and women' 3 health movement were highly stimulated in
their organizational development by gender-specific, research-based publications, such
as Our Bodies, Ourselves (Boston Women's Health Collective, 1971). Likewise, male
gender-specific publications have assisted in developing the men‘ s movement and men' 3
health movement. Men 's Bodies, Men 's Selves: The complete guide to the health and
well-being of men 's bodies, minds, and spirits (Julty, 1979), Men and Masculinity
(Pleck & Sawyer, 1974), early works by Marc Feigen-Fasteau (1974) and Warren
Farrell (1975) who made "connections between conformity to traditional masculinity
and men’ s emotional and physical health" (Sabo, 1996), and more recently, works by
Harry Brod (1987) The making of masculinities: The new men 's studies. Michael
Kimmel, Donald Sabo, Michael Messner, Will Courtenay, and others have most
recently called attention to male gender-specific issues in the American culture,
showing the need for redefinition of what it means to be a "male" , social and cultural
constructs which perpetuate and " reward the armoring and posturing of males in our
American Dream" (Kupers, 1993) , and the differentiation between gender and sex.
"Men' 5 health and illness can be explained as a gendered phenomenon in several

frameworks", and later, "gender influences the patterning of men's health risks, the

16

ways men perceive and use their bodies, and men’s psychosocial adjustments to illness

itself" (Sabo & Gordon, 1995, p. 6).

 

Mortality refers to the death rate in the population, and defined as "the death rate
which reflects the number of deaths per unit of population in any specific region, age
group, disease, or other classification" (Springhouse, 1994). Mortality rates give one
view of the ill health of a population. It must also be noted that the statistical tables
used in this project and presented in Appendix A are in the available format in which
they were found so the author will not be addressing race in the tables or presentation.
They are presented in the format which they were found.

Harrison, Chin and Ficarrotto (1988) investigating differences between male and
female mortality, distinguished two general perspectives, biogenic and psychosocial.
The biogenetic perspective attributes men’ s greater mortality to genetic factors while
the psychosocial perspective attributes men‘ s greater mortality in large part to lethal
aspects of the male role. Their study evaluated these two perspectives, and assessed the
consequences of male role behavior for life expectancy.

In the United States, male life expectancy is seven to eight years less than women
(Allen & Whatley, 1986; Courtenay, 1997; Harrison, Chin & Ficarrotto, 1988;
Kemper, McIntosh, & Roberts, 1994, Sabo, 1995). At all ages, male deaths have

outnumbered female deaths for the past 20 years (Stillion, 1995). Because women

l7

outlive men, the female population as a whole is older than the living male population.
Thus, health statistics usually use data which has been age-adjusted to account for this
difference when comparing females and males. All comparisons in this project are
based on age-adjusted death rates. Table 3 in Appendix A illustrates this sex
differential in death rates by the top 10 leading causes of death, age and sex. Most
recent trends show that differences between women's and men's mortality decreased in
the 1980's. Female life expectancy was 7.9 years greater than males in 1979 and 6.9
years in 1989 (National Center for Health Statistics, 1992). Some behavioral patterns
changes between the sexes (e.g. , increased smoking among women) have narrowed the
gap between men' s formerly higher mortality rates from lung cancer, chronic
obstructive pulmonary disease, and heart disease. It appears that both biologic and
sociocultural factors are involved with shaping patterns of men's and women's
mortality (Table 4, Appendix A). The tables in Appendix A are also separated by race
to demonstrate differences between and within races, cultures and localities. Again,
this author will not be looking at race or locality but at the male data in general.

From conception, men are more prone to increased prenatal and neonatal mortality
than females. The chance of males dying during the prenatal stage of development
average are about 12 % more than females, and during the neonatal period of
development, the mortality rate is 130% greater than females (Sabo, 1996). Males
appear to be more susceptible to a number of disorders, including bacterial infections,

respiratory illness, digestive diseases and certain circulatory diseases of the aorta and

18

pulmonary artery. Table 2 in Appendix A provides a gender-specific comparison of
infant—neonatal mortality rates.

During the adolescent and young adult stages of the developmental continuum,
males continue to have higher mortality rates than females. This is believed to be
related to differences in developing gender lifestyles and beliefs (Courtenay, 1997;
Sabo, 1996; Sabo & Gordon, 1995; Stillion, 1995). Males of this group are prone to
higher mortality from their developing violent world of maleness. Suicide, accident,
and homicidal death rates are significantly higher in males than females. Tables 3-5 in
Appendix A demonstrate this difference (Sabo, 1996; Sabo & Gordon, 1995; Stillion,
1995; Woods, 1995).

For male age groups 45 years and older, chronic illnesses are the leading causes
for lowered life expectancy as compared to females. As seen in Tables 4 and 5, the
leading causes of male death are considerably higher incidence than females of their
respective age, race and ethnic origin.

It is also becoming clearer that there is a difference in the effects of stressors on
males and females. Biological effects of reproductive hormones, in interaction with
behavioral characteristics, influence the sex differences in coronary heart disease
mortality (Woods, 1995). Although no related statistics were found in the literature,
only the manifesting disease conditions can be seen in the health statistics, and

speculation of their etiology made from this data.

19

II 1.1. 'C . [E Eli! Ill

Morbidity refers to "the rate at which an illness or abnormality occurs, calculated
by dividing the entire number of people in a group by the number in that group who are
affected with the illness or abnormality; the rate at which an illness occurs in a
particular area or population" (Springhouse, 1994). Morbidity is a departure from
health and the restrictions or disabilities resulting from the condition (Cole, 1974).

Whereas females generally outlive males by 7 -8 years, females report higher
morbidity rates even after controlling for maternity (Sabo, 1996). In studying sex
differences in health, Waldron and Johnston (1976) present a striking paradox: men
have higher mortality but women have higher morbidity. Their reasons for this
paradox are that women report more symptoms, visit health care providers more often
and they will more often restrict their usual activities or spend a day in bed recuperating
because of illness (p. 23). Females experience acute illnesses, such as respiratory
conditions, infective and parasitic conditions, and digestive system disorder at higher
rates than males (Sabo, 1996; Dawson & Adams, 1987; Cypress, 1981; Givens, 1979).
Higher injury rates in males are partly a result of gender differences in socialization and
lifestyle, for example, learning to prove manhood through recklessness, involvement in
contact sports, and working in risky blue-collar occupations (Sabo, 1996). Females
generally are more likely than males to encounter chronic conditions such as anemia,
chronic enteritis and colitis, migraine headaches, arthritis, diabetes, and thyroid disease

(Sabo, 1996; Sabo & Gordon, 1995; Swanson & Forrest, 1984; Woods, 1995).

20

Males are more prone to the development of chronic illnesses such as coronary
artery disease, emphysema and gout. Although chronic conditions do not always lead
to death, they do limit the male’s activity or lead to disability (Sabo, 1996; Sabo &
Gordon, 1995; Swanson & Forrest, 1984). Cockerham (1995) asks, after noting
gender differences in morbidity, whether females really do experience more illness than
males, or if it could be that females are more sensitive to their bodily functions and
sensations than males or that men are not so prone as women to report symptoms and
seek appropriate health care. Cockerham ascertains that all the evidence highly
supports the conclusion that the overall differences in morbidity are real and, further,
that they result from a mixture of biological, psychological, and social influences.

Bozett and Forrester (1989) have identified that men die more frequently than do
women from five causes: malignant neoplasms of the respiratory system, chronic
obstructive pulmonary diseases (COPD), chronic ischemic heart disease, acute
myocardial infarction (MI), and cirrhosis of the liver. Since the late 1980's, human
immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS) have
also taken its toll on the US. male population. Bozett and Forrester (1989) cite four
external causes of death which also occur more often among men than among women:
homicide, suicide, motor vehicle accidents and other accidents, including occupational,
farm, environmental and mechanical. Coupled with the impact that stereotyped male
role behaviors have on male morbidity and mortality, there is a higher pr0portion of

men than women who suffer from limitation of physical activity because of chronic

21

conditions. Yet males take fewer days off from work, spend less time convalescing in

bed, and, see physicians less often than women.

WW

DeHoff and Forrest (1984) note that the usual pattern of United States medical
care, the system continues to contribute indirectly to the health problems of men. One
of the system barriers they cite to men's health care is that men have no one to go to
who "feels right ". Because the medical care in the United States has become
increasingly specialized, the re-incorporation of specialties into some form of general
medicine is a sign of the implicit recognition of the overlap in health care needs, the
need for general medical care, and the fostering of health. Males go to the general
practitioners to have addressed from the same person every health care need, from
cardiovascular, low back pain, headaches, declining sperm count, stress levels and so
on. But the man's own need to maintain his self image as a strong, knowledgeable, and
self-sufficient being in American society inhibits him from seeking help for these
problems, or even prevents him from consciously recognizing that he might need help.

While females have had direction and assistance in identification and control of
high maternal mortality and other overlooked women's health needs, the women's
health movement has brought attention to their gender-specific health care needs, and
the medical system drew its attention to those specific needs. Men, on the other hand,
have been overlooked as new medical specialties developed. Urology, often heavily

male-oriented in reproductive and prostate care management, also includes female

22

urology (DeHoff & Forrest, 1984). Urologists are specialists, not primary care health
care providers. Males have no specialty of their own to holistically care for their male
health needs in the current American primary care model.

A second barrier to men's health care is financial. Third-party payments for health
education, counseling, and preventive health care are not as available to males as those
for physical interventions of acute illness. Male physiology is different than female
physiology, and men do not have an equivalent of women's annual Pap test, which
legitimizes repeated contact with the health care system. Furthermore, with the Pap
test, women frequently receive patient teaching on breast self-examinations, blood
pressure monitoring, nutrition, weight, and cholesterol monitoring, and may be asked
about the need for assessment of other possible physical and emotional health problems.

A routine physical examination would then seem of particular value to males.
Currently, some health maintenance organizations encourage annual physicals, and
corporations may provide them for certain groups of employees. The average male
finds that his insurance policy does not include reimbursement for doctor visits without
a diagnosis or a declaration of pathology.

Another type of barrier identified by DeHoff and Forrest (1984) arises from sex
role stereotyping within the health care system itself; i.e., in professional roles which
are sex-typed, the relationship of the male patient to the provider is affected. Aware-
ness of sex role effects on such a relationship is a very recent phenomenon (p. 7).
This sex role stereotyping within the health professions exacerbates the problem of

responsibility for provision of men's reproductive health needs. Awkwardness by the

It

23
health care provider to assess, examine, discuss, and give quality patient education
hinders the male from provision of quality health care relative to his male sexual and
emotion health problems. Considerable prejudice against admission of sexual and
emotional problems still inhibits males from recognizing them, seeking counseling or
other mental health care, even when it is explicitly advised by the doctor, nurse
practitioner, nurse or physician assistant. This extends negatively to the teaching of

sexual, gender-specific, and reproductive materials in schools of medicine and nursing

(DeHoff & Forrest, 1984; Kimmel & Messner, 1992; Sabo, 1996; Sabo & Gordon,

1995; Woods, 1995).

Several sociologists and psychologists have cited such men's issues as maleness,
male identity, masculinities, and sex-role ideology as affecting the male response to

seeking health care assistance (Courtenay, 1995; Harrison, 1978, 1984; Harrison,

Chin & Ficarrotto, 1988; Jourard, 1971; Kimmel & Messner, 1992; Sabo, 1996;
Sabo & Gordon, 1995). Jourard (1971) states:
...the socially prescribed male role requires men to be non-communicative,
competitive and non-giving, and inexpressive, and to evaluate life success in
terms of external achievements rather than personal and interpersonal
fulfillment. All men are caught in a double bind. If a man fulfills the
prescribed role requirements, his basic needs go unmet; if these needs are

met, he may be considered, or consider himself, unmanly [in Harrison, Chin

& Ficarrotto, 1988] (Kimmel & Messner, p. 272).

 

24
Seeking health care assistance or admitting to illness by the male has been viewed as an
admission of weakness, vulnerability, unmanly behavior by the stereotypical definition
established by American society; thus, the male earns a decreased level of power

within the society and social structure. In addition, the requirements of the male work
role have also been implicated as a cause of men's greater mortality. Slobogin (1977)

suggests that stress and the competition to get ahead and to maintain a power role in his

community may result in greater vulnerability for men.

Health seems to be one of the most clear-cut areas in which the damaging impacts

of traditional masculinity are evident. While the concept of sex refers to the

physiologic attribute, the concept of gender represents the sociocultural expression of

sex (Kandrack et al. , 1991; Sabo, 1996). Sabo (1996) further delineates gender

identity as:
“. . . .a person's inner sense of themselves as being womanly, manly, feminine, or
masculine. Gender identity is seen as an outgrowth of an historically changing
pattern of relations between men and women and cultural definitions of masculinity
and femininity. In this context, gender identity is better understood as a process
than as a "thing " that people "have" (Messner and Sabo, 1990). Gender identities
are learned from others in varying social, cultural, and historical contexts and, as
we move from one stage of life to another, we make decisions about accepting or
rejecting a wide array of cultural scripts for masculinity and femininity that supply

direction, role models, props, motivations, rewards and values (Sabo, 1994;

25

West & Zimmerman, 1987). The scripting of masculinity contributes to men's

health and illness” ( p. 2-3).

Sabo suggests that aspects of men's health and illness differ from those of women, and
asks "why do gender differences exist in relation to morbidity and mortality? To what
extent do biological differences between the sexes contribute to men's greater
susceptibility to certain forms of illness? How do elements of men's psychology,
conformity to masculine stereotypes, and cultural practices shape men's health and
illness? What aspects of masculinity are conducive to health?" (p. 2).

Men's issues only recently are being addressed and documented, and are becoming
very extensiye and definitive in their identification of psychosocial needs, roles, values
and meanings of the American male in general. Only a few of such issues have been
addressed here, but from this general overview, one can only begin to understand the

thrust these issues have on the male and his identity, wellness, health, and participatory

role in American society.

Whitest:

Swanson and Forrest (1984) suggest that men have unique biological and social .

health care needs, including:

0 Permission to have health concerns, and to talk about them openly.

0 Support for considering life-style and male role influences on their physical

health risks and mental well-being.

26

Professional attention to factors in men's lives which are likely to cause illness
or influence the expression of it, such as occupation, leisure patterns, sexual

and nonsexual personal relationships.

Information about their bodies-«how they function, what is normal, what

constitutes illness, what to do about it, what exercise and proper nutrition can

contribute.

Instruction in self-care techniques, particularly testicular and genital self-
examination.

Physical examination and medical history-taking which include the sexual-
reproductive system and its functioning as integral parts of the individual's
life, in sickness and in health, at all ages.

Treatment for problems of couples-«interpersonal emotional maladjustments,
infertility, conception control, sexual dissatisfaction, sexually-transmissible
diseases of which the man may have no symptoms, yet which continually

reinfect a partner with resulting distress to both.

Help in fathering, being included as an interested parent in the care of their

children, both male and female.
Help for single parents, of either sex, who are the main caretakers of a child

of the opposite sex, in how to deal with the child's sexual needs and concerns.
Recognition that, in times of rapid social change, including changes in sex
roles, a sense of confusion and uncertainty is normal, and can be the

beginning of healthy adaptation to changing circumstances.

 

pal

prc

illl

HICI

27

o A health care system that adjusts to time and location constraints imposed by
men's occupation, or which cooperates with workplace demands to make it
possible for the man to obtain health care.

0 Financially reasonable ways of obtaining all of the above (pp. 8-9).

Summary

Males have a life expectancy that is 7-8 years less than females, and are more
prone to more chronic and terminal illnesses than females. Further, they seek medical
attention much less frequently than females at any given age.

Males have perceptions of maleness, manhood, and masculinity. Males have had a
patriarchal position/place and role in societies. Because of this, males have perpetuated
and protected these roles of power, self-identity, strength and health which has also
protected and prevented males from analyzing, redeterrnining, negotiating and assisting
in resolution of their own roles, meanings, and beliefs in society.

Being male equates strength, strength maintains one’s power. As one looks at
men’s health issues, illness or lack of wellness equates weakness, vulnerability in the
male’s position in his family, clan, peers, tribe, subculture, and culture. Thus, by
ignoring health risk factors, risky lifestyles, mental health/well-being, self-care and
health maintenance, the male protects his own concept, self-image, perceives himself as
strong, healthy and virile. The male will drive unsafely, drink alcohol excessively,

fight and enact other acts of violence, and refuse to wear seatbelts while drivmg or

28

wearing condoms during sexual intercourse to, as he and his peer group(s) perceive,
exhibit his masculinity, his maleness, strength, and his “rights” as a virile male
member of his subculture, culture and society. To further perpetuate this risky health
behavior, males seek medical attention from male physicians who, in turn, maintain
similar societal male role identities, behaviors and perceptions.

Research literature on male issues have been very limited, especially when directed
at maleness, male identity, male roles, and ideologies for male risk behaviors. In the
existing literature, gender bias exists. Gender bias exists for both males and females.
Gender bias exists for different reasons. From a male perspective, little has been done
in the literature.

This author believes that males have been inadvertently ignored in the development
of a men’s health arena or specialty with an accompanying lack of research-based
studies and publications. Nursing and medical disciplines must begin to study the male
as being different from females: physiologically, biologically, psycho-socially, as well
as their societal/cultural identities and roles. Males in American society have illnesses
and diseases that, for the most part, can be prevented or even resolved before becoming
chronic or life threatening. Etiologies of these disease processes are centered around
maleness, masculinity, male identity, male roles in society, perceptions and ideologies
Slipported, taught and perpetuated by the culture and society itself. Health care
professions must join with the sociologists and psychologists who are making StfideS in

understanding the male at all ages. Only then can there be a change towards quality

29

health care provision, healthier lifestyles and lower mortality rates of males, through

change and new knowledge.

[Iii

1453.31
his
legal
legal
Phil:

ism

CHAPTER III

Conceptual Framework

For this study, Leininger’s culture care theory will be utilized as the conceptual
model. A conceptual model is a framework that is used to assist in understanding
observed phenomenon. The conceptual model seeks to define concepts, observations,
and interrelationships that are used by practitioners and researchers to direct inquiries
and interventions.

In the sociocultural model, health and illness are understood primarily in light of
cultural values and practices, social conditions, and human emotion and perception
(Sabo & Gordon, 1995). Leininger's (1988b, 1991a) cultural care theory becomes an
important tool as the theory identifies the need for cultural care accommodation and
negotiation which refer to the process of finding ways to adapt health care services and
negotiate for beneficial outcomes which are congruent with the cultural lifeways of the
people. To accomplish this, life histories and ethnographic interviewing assist in
discovering how persons integrate past health care beliefs and practices in their present
setting (Wenger, 1992). Also, diversity of the community should alert the nurse and
other health care professionals against assuming characteristics of the male's culture
within the community. This will require nurses to have a transcultural nursing
knowledge to assist in planning for male culturally congruent care. Although access is

a major concern, utilization will determine if access to health care has been achieved.

30

31

Culture is a major determining factor in health care utilization. “No human activity

exists that is not mediated through culture” (Kandrack, 1991).

W

Cultural care theory is an open and dynamic theory that attempts to explain health
and well-being of individuals, families, and communities through the study of the world
view of cultural care in different cultural and social structures and environmental
contexts. Discovery of broad or specific nursing phenomena is accomplished through
inductive reasoning and discovery research processes (Leininger, 1991b). Leininger's
Sunrise Model is the conceptual model of her theory. This is found in Appendix C.

Health care expressions, patterns, and practices of individuals, families, groups,
and communities are influenced by these different cultural and social structures. This is
of particular interest in this project because of the need to investigate meanings and
expressions of what a male subculture and the men themselves regard as "male", male-
specific. As Leininger defined health, the theorist viewed caring as essential for health.
Leininger (1991b) defines caring as "a humanistic mode of being with others to assist
them in times of need or to help them maintain their well-being or health" (p. 29).

The goal of the Cultural Care Theory is to identify differences and similarities of
care of a culture or subculture in order to acknowledge and to provide culturally
congruent care to the individual, family, community, and! or society. Nurses can
provide culturally congruent care through preservation, accommodation, and

repatterning of the culture’s differences and similarities (Leininger, 1991b). Culturally

32

congruent care will also be influenced by one's generic or folk practices, nursing, and
the professional system (Leininger, 1991b).

Culturally congruent care cannot occur if the nurse is not transculturally prepared
to be sensitive and knowledgeable about different cultural values and lifeways, and their
importance to the individual being cared for. Cultural Care Theory assists the nurse
researcher to envision a cultural world of different life forces or influences on human
conditions, which in turn helps the researcher to discover human care in its fullest way
(Leininger, 1991b). Moreover, the desired outcome of Cultural Care Theory is to
improve care to people, respective of their perceptions, values, beliefs, and perceived
meanings.

Conceptualization of the theory and its three modes (cultural care preservation-
maintenance, cultural care accommodation-negotiation, and cultural care repatterning-
restructuring) is illustrated in Leininger's Sunrise Model (Appendix C). It is a holistic
conceptualization to assist the researcher in systematically investigating the theory‘ 3
different components such as world view, social structure factors, cultural values and
beliefs, and folk/professional health systems, and to illustrate how these components
interface with each other in a gestaltic perspective.

C | l D E . .

Conceptual definitions are used to provide a broad conceptual focus and to guide

the investigator in discovering how people know, define and experience the concepts or

phenomena which the researcher is investigating. According to Leininger, the

33
following key definitions are important in understanding her theory and its utilization in
an investigation.

Caring refers to actions or activities of an individual with intentions to provide
support to another individual during times of needs, and to maintain one's healthy state
of being (1991b).

Health refers to "beliefs, values, and action-patterns that are culturally known and
are used to preserve and maintain personal or group well-being, and to perform daily
role activities" (1985).

Emir. refers to the beliefs, practices, perceptions, and communication of
individuals or groups to a particular phenomena; i.e. , responses originating within the
individual or the group toward a particular phenomena. From the peOple, from the
person; folk medicinal practices are examples of emic (1985, 1994).

Elle, on the other hand, refers to beliefs, practices, perceptions, and
communication patterns pertaining to more than one group, cultures or individuals.
Professional beliefs and practices are etic beliefs and practices directed toward an
individual(s) (1985).

Ethnohealth refers to the "emic cognitive beliefs and actions used to preserve or
maintain personal or group well-being, and to perform daily role activities" (1985).

Ethnncaring refers to the emic cognitive, assistive, facilitative, or enabling acts or

decisions that are valued and practiced to help individuals, families, or groups (1978).

iii
In

fate

34

W refers to the subjectively and objectively learned and transmitted
values, beliefs, and patterned lifeways that support, assist, facilitate, or enable another
individual or group to maintain their well being, health, to improve their human
condition and lifeway, or to deal with illness, handicaps, or death ( 1991).

WWW refers to those cognitively based assistive,
supportive, facilitative, or enabling acts or decisions that are tailor-made to fit with
individual, group, or institutional cultural values, beliefs, and lifeways in order to
provide or support meaningful, beneficial, and satisfying health care, or well-being
services (1991b). Culturally congruent care can be influenced by one's folk practices,
nursing, and the professional system (1991b), and cannot occur if the nurse is not
transculturally prepared to be sensitive to and knowledgeable about different cultural
values and lifeways.

W is delineated by Leininger as assistive,
supportive, or enabling professional actions and decisions that help clients of a
particular culture to preserve or maintain a state of health, or to recover from illness
and to face death. WWW refers to those assistive,
supportive, or enabling professional actions and decisions that help clients of a
particular culture to adapt or negotiate for a beneficial or satisfying health status or to
face death. WW refers to those assistive,
supportive, or enabling professional actions and decisions that help clients change their
lifeways for new or different patterns that are culturally meaningful and satisfying or

that support beneficial and healthy life patterns (1988a).

mill

35

WW, according to Leininger (1984), is defined as "a humanistic
and scientific area of formal study and practice in nursing which is focused upon the
comparative study of cultures with regard to differences and similarities in care, health,
and illness patterns based upon cultural values, beliefs, and practices of different
cultures in the world, and the use of this knowledge to provide culturally-specific and
or universal nursing care to people" (p. 42).

Cultural Care theory and ethnonursing research provide nurses with a tool for
learning, knowing, and discovering the epistemics of care. Culturally based nursing
care is essential to nursing and to clients if cultural conflicts and noncompliance within
the health care system are to be prevented, and health promotion attained. When folk
and professional care is used in combination, culturally congruent care is provided.
This is essential for one's well-being and health. Without the knowledge of folk care
expressions and the provision of culturally congruent care, male clients will be labeled
as non-compliant or lack the responsibility in meeting their health needs. "The total
health care needs of men are not being met” (Bozett & Forrester, 1988) but in
implementing Leininger's Cultural Care theory, Sunrise Model, and ethnonursing
techniques, more complete assessment, discovery, understanding, and care may be
accomplished to provide more culturally appropriate (culture congruent care), direct
and specialized health care.

I . . , I] 11 'l' .
Leininger’s Sunrise Model will be altered pictorially (Appendix C, p. 72) to be

more specific to this project, and presented to illustrate how the Sunrise Model shall be

36

used so one understands the importance of asking men to identify their values and
beliefs which in turn may affect their health care beliefs, practices, and utilization. In
better understanding the individual male’s identity issues, perceptions, values and
beliefs that assist or act as barriers for the male from seeking health care. By this
identification and analysis, a male gender-specific health assessment/health appraisal
tool can be developed for use to clinically assist the male and the health care

professional in the male’s health care.

Summary

Cultural Care theory may be a philosophical route in exploring men’s health issues
and assessment. By being culturally astute to the levels of the theory and Sunrise
Model, especially the seven (7) Cultural and Social Dimensions, identification of
specific male beliefs and health needs may be determined and approached with
workable modifications, interventions, and solutions. As sociologists and psychologists
have discovered, males have an array of beliefs and reasons for approaching life and
their health issues, which are both similar and different to those of females in the same
culture. Some are based on socially- and culturally-defined male roles, teachings and
traditions. It is here that Leininger’s Cultural Care Theory and Sunrise Model can be
helpful in gleaning pertinent, valuable information from the male client. This is further
complimented by additional investigation of the remaining cultural and social

dimensions in the Sunrise Model.

h!

at]

pH

tdl

DPI

hea

CHAPTER IV

The Project

Mm

It has been shown that little research has been conducted and few research-based
articles exist in medicine and nursing, regarding male specific issues in men's health
care. With use of the available literature and Leininger’s Cultural Care Theory, this

chapter will focus on the development and presentation of a male gender-specific health

risk assessment tool for primary care practice.

WWW

Males have many health needs. There are specific issues that affect a male’s
health, morbidity and mortality. By addressing these issues within a health risk
assessment tool, the nurse clinician may be able to more effectively assist the male in
achieving a healthier lifestyle, longer life expectancy, decrease in the severity of disease
processes, and promote health risk prevention through appropriate client/patient

education.

This health risk assessment tool is designed to elicit responses through asking
Open-ended questions that allow the male client to “tell his own story” regarding his

health and lifestyle, shedding light on issues which would concern his well-being and

37

38

toward recognition of health risks and current health problems. Also, there are specific
data-seeking questions to generate specific information from the male.

In using Leininger’s model, the questions have been developed around the specific
cultural and social dimension components; i.e., technological factors, religious and
philosophical factors, kinship and social factors, cultural values and lifeways, political
and legal factors, economic factors, and educational factors which Leininger presents as
influencing care expressions, patterns and practices (Leininger, 1995). Specialized
questions of this nature elicit important information regarding the individual male
client’s life patterns which may effect his current and future health status and well-
being. From the data gathered in using such a tool, the nurse clinician and other health
care providers then diagnose, evaluate, educate and assist in the management of the

male’s health and his health risk patterns.

13 . 1 E l . E l I l
Courtenay, in sixteen (16) years of research on men, masculinities, and men’s

health, delineates the leading causes of male deaths. The list also summarizes
government health statistics. From this data, common areas appeared as prime
contributing agents to these diseases and/or causes of death in males. They include:

v diet

> exercise

> self-care and preventive care

> tobacco, alcohol, and drug use

iii

C0
die
the:
tho:
and

199

39

> stress
v sexual practices
v social support systems
> safety issues
> lifestyle behaviors

Medical research has identified these factors that through education of and practice
by males, their risk of disease, injury, and death would be reduced dramatically. Life-
style changes, based on this research, can positively affect male morbidity and
mortality, and reclaim the 7-8 year mortality difference between males and females.
Male attitudes and ideology regarding maleness, manhood, and masculinity must also
be included in this analysis. These issues have been identified in the literature.

It is generally known that diet is very important to a healthy state. The intake of
specific foods, quantities, and preparation of these foods as well as obesity, lack of
exercise, and uncontrolled stress, have been shown to increase heart and coronary
artery disease, risk of many types of cancer, and hypertension. According to
Courtenay (1996c), men, as compared to women, consume more cholesterol in their
diet, eat more meat and fat, fewer fresh fruits and vegetables, and less fiber, raising
their health risks, especially for cancer. In general, men’s diets are less healthy than
those of women’s diets where males of all ages ingest more foods high in saturated fat
and dietary cholesterol, and are less likely to limit fat or red meat in their diets (Gilroy,

1991; Rakowski, 1986). Males use salt on their food significantly more often, are less

4o
likely to limit sugar, sweet foods and caffeine in their daily diets, and less likely to eat
breakfast daily than females (Courtenay, 1997a, 1997b).

The number of American adults, as well as children, that are overweight continues
to increase yearly. Currently, those who weigh at least 20% above ideal body weight
are defined by the Department of Health and Human Services as being significantly
overweight (Department of Health and Human Services, 1993). According to DHHS
statistics, more than one-third of the adults in the United States are categorized as
overweight by this definition with the majority of this number being males (Department
of Health and Human Services, 1993).

Regular exercise that increases heart, respiratory, and metabolic rates have been
proven to increase health status by increasing metabolism, burning stored fat,
increasing endurance, strengthening the cardiovascular system, expending calories, and
increasing circulation. From Courtenay’s studies (1996c, 1996d), it was found that
men are less physically active from age 35 to 54, further raising their risk of heart
disease, the leading cause of death among men.

Self-care and preventive care activities include those preventative self-care
practices such as regular health monitoring (physical and dental exams at least yearly),
yearly prostate exam (rectal digital examination) with PSA monitoring after age 40,
testicular self-exams at least monthly, administering and attaining physician-prescribed
medications appropriately, self-examining of skin for unusual discoloring or formation,
wearing sun screen while outside in the sun, adequate restful sleep and rest, taking time

away from work and activities to recover from illnesses, and monitoring of blood

 

 

41

pressure and cholesterol levels at least yearly. Contrary to popular opinion, males are
not as physically active as females. To emphasize this, the Centers for Disease Control
(1993) suggest that equal numbers of men and women engage in little or no physical
activity but men appear to be more likely than women to engage in more vigorous
exercise and sports (p. 576-9). Health-related risk-taking behavior among men of all
ages is the major contributor to their lack of healthy self care actions (Courtenay,
1997a).

Recreational drug use refers to smoking or chewing tobacco, abusive alcohol
practices, and illicit drug use such as narcotics, barbiturates, and misuse of
prescription-type drugs. Smoking tobacco increases respiratory dysfunction, increases
the risk of cancer, COPD (asthma, emphysema, bronchitis) and arteriosclerotic heart
disease/coronary heart disease as much as twice that for women (Waldron, 1976).
Alcohol and illicit drugs have serious ramifications on normal brain, liver, kidney and
other major organ function. These effects are compounded when used in conjunction
with driving motor vehicles, operating machinery, and other tasks that require mental
alertness and high—level thought processes. Injury is a leading cause of death for 1- to
44~year old males. Verbugge ( 1985) reports that men ages 17 to 44 years incur up to
60% more injuries than women. For those males in the 15-24 age group, three of
every four deaths are male, and unintentional injuries claim over 1% times more lives
than the next leading cause of death (Appendix A, Table 5). Transculturally

comparisons show that sex differences in tobacco, alcohol, and recreational drug use

42
are highly influenced by cultural factors, such as socialization pressures, peer pressure,
gender peer pressure, and learned behavioral expectations.

Gender differences in psychological aspects and behavior have influence on the
male’s health status (Courtenay, 1996a, b, c). Males present higher scores on
appraisals for stress, hostility, temperament, and mistrust of others (W aldron, 1995).
Waldron (1995) relates these behaviors to higher incidences of ischemic heart disease in
males, resulting in gender differences in mortality.

According to Waldron (1995), “more males than females are employed, and males’
jobs are more physically hazardous on the average. Males’ greater exposure to
occupational hazards contributes to their higher rates of lung cancer and accident
mortality. Evidence for the United States suggests that males’ greater exposure to
occupational hazards is responsible for roughly 5 % to 10% of the gender difference in
mortality” (pp. 24-25).

Death rates are about three times greater for males than for females in regards to
motor vehicle accidents. This can be attributed in part to men driving more but, more
hportant, men drive less safely (W aldron & Johnston, 1976). For accidents other than
motor vehicle accidents, female death rates are less than half the rates for males with
about half of the male accidents being work—related accidents. It is evident, therefore,
that statistically men’s higher accident fatalities are “a result of behaviors which are
encouraged in boys and men: driving, working at sometimes hazardous jobs, using
811115, being adventurous and acting unafraid” (p. 19). Also, American culture and

society “teach” that males are expected to be brave, not to cry, and as a result, males

43
are generally less able to respond to a risky situation by admitting fear and backing out.
As a result of these attitudes, males are more likely to be involved in fatal auto
accidents, accidental drownings, suicide, homicide, etc. (p. 20).

Males begin sexual activity much earlier than women, and are more likely to be
active sexually, practicing high-risk sex activities, have more than one sexual partner in
a year, have multiple sexual partners overall, and not be monogamous in their
adulthood (Courtenay, 1997a). Courtenay (1997a) also presents that only one in four
men always uses a condom, and less than one third of men at high risk for STDs always
use condoms (p. 10).

Social support systems are much smaller social networks for males than females.
Males appear to have fewer, less intimate friendships than do females (Courtenay,
1997a). Further, male social networks are not as multifaceted and supportive as female
social networlm, so when the male has times of stress, he is less likely to mobilize
varied social supports than females. Statistically, this results in higher risk for death.
Courtenay (1997a) states that men with lowest levels of social relationships are 2 to 3
times more likely to die , even after controlling for health conditions and other issues
(p. 13). Marriage is a social support system that highly effects health. “Being married
predicts survival, and all the current scientific evidence indicates that this correlation
and the health risks linked with being unmarried are greater for men than women”
(Courtenay, 1997a). Unmarried, single, divorced, and separated men are at higher risk
for poorer health habits and behaviors. This group of men have been shown to drink

alcohol and smoke more, eat fewer fresh fruits and vegetables, at a greater risk for

Iii

CO]

at.
this

in

44

contracting sexually-transmitted diseases (STDs), utilize medical services less often,
more likely to commit suicide, and are less likely to have had their blood pressure and
other health monitoring checked (Courtenay, 1997a).

While some of the health issues are NOT gender specific issues but, these in
combination with others, truly affect a male’s health. This is illustrated by Courtenay’s
(1997a) studies on health behaviors:

“The behaviors examined [here] frequently co-occur in healthy or
unhealthy clusters. The interaction of these behaviors often compounds men’s
health risks. For example, when combined with alcohol use, tobacco use
activates cell division and tumor growth, increasing the already high risk of
cancer up to 15 times. Similarly, unbelted drivers also drive dangerously
which compounds the risk of injury. Rather than representing a collection of
discrete and isolated activities, these behaviors may represent organized
constellations of behavior or a risk behavior syndrome. This review reveals
that such a syndrome would be far more common among men than among
women. However, little is currently known about constellations of health-
related behaviors practiced by individuals, and even less is known about the
psychosocial mechanisms that mediate these behaviors” (p. 15).

This has been a presentation of male gender-specific health issues. It is this
author’s opinion that to begin addressing quality health care for males, inclusion of
these in a male health-risk assessment tool, as well as reiteration in the health screening

portion of the professional health encounter, are of utmost importance. These health

45

risk behaviors may be the etiologies of many disease processes and conditions which

have increased male mortality.

;; r: 1::

.“4

fig"

(..J
L_J

 

46

 

 

 

 

MaliflealthflskAssessmcm
Name: Age: Birth date:
Address: City: Zip Code:
Height: Weight: Last Dr. Appointment: Last physical:

Medications you take:

 

 

 

 

W: Please complete the following questions to the best of your knowledge. By
answering these questions as fully as possible, your answers will help your health care provider in
providing quality care to you, and will assist in developing healthier lifestyle patterns which will help to
decrease the severity of any health problems you may have now but will also help to prevent those that
can be prevented in the future. Your health is your responsibility but with our assistance. No one can

   
  

 

rativel wa .

   

DIET

do it for you but we are here to help. We ask that you help us also to help you in a mutually and

Ieat the following foods. (Please check all the foods you eat on a routine basis, giving the amounts of
each category and how often you eat them.)

 

TYPE of FOOD

0/

How much of this food I eat?

How many times a day?

Comments

 

Fresh Fruits and
Vegetables

 

Beans, whole grain
breads or cereals

 

Baked, broiled, boiled,
poached or stewed foods

 

Fried foods, chips, etc.

 

Chicken, fish, turkey

 

Low fat milk &
cheeses

 

Enact. margarine,
salad dressing

 

Salty foods, add salt
to food

 

 

Susar. candy,
desserts, soft drinks

 

 

 

 

 

 

47
W

Do you participate in physical activity or exercise outside of work?

 

Describe your exercise routine. Also tell how often you exercise and they type of activity.

 

 

 

 

Do you: Yes No How much? How often?
(V) (V) COMMENTS also

 

Drink alcohol?

 

Use recreational drugs or steroids?

 

Smoke or chew tobacco?

 

Use marijuana, cocaine, heroine,
or other recreational drugs?

 

take prescription medicine only as
directed by a physician?

 

do a testicular exam on yourself?

 

get a physical exam?

 

get a dental exam?

 

get a rectal exam (to check your
prostate gland)?

 

get your blood pressure checked?

 

get your cholesterol checked?

 

sleep 7 or 8 hours and wake
feeling rested?

 

stay home and in bed to recover
when you are ill?

 

wear a seatbelt?

 

obey traffic rules and speed limits
when driving?

 

have a gun for protection?

 

get into fights when angry?

 

wear a condom when having sex?

 

How many sexual partners do you
have?

 

 

 

 

 

 

48

I am in a 7long-te7rm, exclusive relationship.
Cl Stronglyagee7 CI Somewhat agpee7 7D Somewhat disagree [:1 Strongly Disaggee El Not Applicable

I have a close friend or family member that I talk to about things that are bothering me.

_It’_s important for me E work out my personal problems on my7own.777
D summarise D SQMMF agree El Somewhat disasrse D Strongly Disagree D Nor Applicablgk

 

I find it easy to express my feelings to others.
.El Strongly agree El Somewhat agree Cl Somewhat disagree [I] Strongly Disagree D Not Applicable

I go to all my scheduled physical and mental health appointments.
7E1 Strongly agree El Somewhat agree [3 Somewhat disagree E] Strongly Disagree El Not Applicable

1 consult a physician or health care provider right away when I have unfamiliar physical

symptoms. 7 _ A, 1.
El Strongly agree El Somewhat agree Cl Somewhat disagree El Strongly Disagree D Not Applicable

I would consult a mental health professional if I ever felt sad or depressed for longer
than :71 month.

71] Strgngly agree _ Cl Somewhat agree [:1 Somewhat disagree E] Strongly Disagfee Cl Not Applicable

1 find that it is easy to relax. 77 W , _-
Cl Strongly agree El Somewhat agree [I Somewhat disagree 7D Strongly Disagree El Not Applicable

1 get angry and annoyed when I am caught in traffic.
.7D7Strongly agree [3 Somewhat agree 7C1 Somewhat disagree Cl Strongly Disagree [I Not Applicable

I get irritated and mad when waiting in lines. 7
-0 Strongly agree [I] Somewhat agree El Somewhat disagree [3 Strongly Disagree Cl Not Applicable

Things build up inside until I lose my temper.
U Strongly agree Cl Somewhat agree Cl Somewhat disagree Cl Strongly Disagree [I Not Applicable

Idrink alcohol to relievem my stress. ,,
7D Stropglypgree D7789mewhatag1ee77El Somewhat disagreed E] Strongly Disagree E] Not Applicable

I believe a man should be able to handl7e his problems 9117 his own

El Strongly agree C] Somewhat agree U Somewhat disagree D Strongly Disagree [:1 Not Applicable

I believeit is important for a man to be physically strong- .
D §tr9ngly agree Cl Somewnagm; 77173 Somewhat usages D Strongly Disagree U Not Applicable

 

49

I believe a man should always try to control his emotions.
Cl Strongly agree Cl Somewhat agree Cl Somewhat disagree El Strongly Disagree Cl Not Applicable

I believe risking danger is unavoidable for a man.
713 7S7t7rr71171gly agree El Somewhat agree 7E] Somewhat disagree 1] Strongly Disagree [3 Not Applicable

I believe a man should not admit being sick to others unless he really has to.
Cl Strongly agree El Somewhat agree Cl Somewhat disagree Cl Strongly Disagree Cl Not Applicable

I am7s7atisfied with my health.
‘Cl Stpongly agree [I] Somewhat agree7 El Somewhat disagree El Strongly Disagree El Not Applicable

I believe I am healthy. 7 7 _ _
Cl Strongly agree Cl Somewhat agree Cl Somewhat disagree [I] Strongly Disagree El Not Applicable

What changes, if any, would you like to make in your life or lifestyle?

 

 

 

 

Describe your ideal health care provider. What do you expect from your health care

provider?

 

 

 

 

Other comments or concerns you may want to talk about or at least let us know about?

 

50
Implementation

This male health risk assessment tool is developed for use in numerous clinical
settings by the health care provider (doctor, nurse practitioner, nurse clinician, or
physician assistant). Designed to be completed by the male client prior to his first
appointment, unanswered questions or those with unclear or high risk answers are to be
addressed by the nurse clinician or nurse practitioner during the physical exam visit.
Emphasis is placed on the health care professional/provider to deve10p a trust-relationship
between the provider and the male client, and to assist the male client in understanding
his role in his own health care management.

To best gather data from the questions, it is suggested that the questionnaire be
mailed to the male client one or two weeks prior to his scheduled health history and
physical exam appointment. The male client completes the questionnaire, and brings the
completed questionnaire with him to the appointment. The clinician goes over the
responses with the male client at the beginning of the visit. At future clinical visits, more
data may be attained, especially in highly sensitive areas of the tool such as drug use and
sexual life styles. This health risk assessment tool process encourages the male to
truthfully provide basic male gender-specific information, and the health care
professionals to elicit appropriate information needed at that clinical visit (prioritization
of care needs), to develop a trusting client-clinician relationship, and to schedule the male
client for consistent, consecutive office visits where more issues may be addressed. This
male gender-specific health risk assessment tool is ongoing and presents a more

complete overview of the specific male client’s perceptions of his own world that effects

51

his health and health behaviors, care expressions, patterns and practices. In presenting
this holistic view of the male client, the nurse practitioner or advanced practice nurse is
able to understand this client’s abilities to be more health conscious, and can more

precisely diagnose, treat, manage, and educate the client in a more timely manner.

CHAPTER V

Implications for Advanced Nursing Practice In Primary Care

With the development of a male gender-specific health risk assessment tool, the
purpose of this chapter is to evaluate the tool, speculate on the impact of such a tool upon

primary health care provision for males, and to present areas for fi1rther research.

Exalnationnflthcldol

This study and developed tool are not to divide care provision or clinical practice
into individual male, female, child, adult, etc. realms or specialties but for individualizing
care by taking into consideration the male’s issues which in turn affects the male’s health
and well-being. Each male is unique with his own individual issues, beliefs, health care
beliefs, and his own culturally-based taboos, values and beliefs. It is then necessary to
move from the clinical path model to a holistic, individualized care model. This tool
attempts to begin that process, and it cannot be regarded as an “end-all” in male health
care provision. It is only the beginning step in providing quality, individualized holistic
health care to the male population.

Another factor of the tool is the formation of a collaborative relationship between the
care provider and the client in his (the male’s) care provision, and the need to intensify

that collaborative relationship which is based on trust. Trust is a key element to a male in

52

53

developing any type of relationship (Courtenay, 1997a, 1997c; Stallion, 1995). Males
have fewer friends, a smaller social network and less supportive support systems than
females (Courtenay, 1997a, 1997c). Trust must be developed first in order to develop a
working, nurturing collaborative client-health care provider relationship and care
management setting. Trust development is one thing but provider knowledge of male
issues is premiere.

Development of an appropriate health risk assessment tool takes time and many
changes respective to the type of health care practice’s goals, objectives, and capabilities.
In developing this tool, it is advantageous to be comprehensive but as general as possible
to develop a health status baseline of the client while establishing a need for the
individual health care practices to change or modify the tool toward their knowledge base,
type of health care practice, effectiveness in client health care management and necessary
information that needs collecting. Evaluation of the tool, then, will be determined by that
individual health care practice organization while using the assessment tool. In this way,
appropriate information is gathered relative to the clinic or health care provider’s abilities
to diagnose, treat, educate and manage the individual males client’s health and well-

bIiillg. This is true for any health risk assessment tool that is developed and marketed;

it, the health risk assessment tool must be adaptable to fit the needs of the clinic and its

staff to best manage their client’s health and well-being-

TO begin using the developed tool, it will also be necessary to educate the health

. . . . . S in
Care professionals and other allied health staff in lookrng upon the nnssmg prece

' ' continuum of
male health care provision because there seems to be an rllusron of the

Cu
or:

pro?

spec
pres:

[hill

 

54

care in men’s health within the health care system. The continuum of care needs to be
looked upon from an individualistic point, not from a general perspective. Educating
physicians, physician assistants, nurse practitioners, and staff nurses to male issues is of
utmost importance in using this tool and providing care to the male. Education to the
fact that males have different health beliefs and etiologies of those beliefs which are
rooted in societal and cultural patterning is necessary. This education must come prior
to using this tool, which may be a drawback of this tool. The remedy is achievable;
short course or workshop presentations to health care staff is an answer. Dr. Will
Courtenay, founder and director of Men’s Health Consulting in Berkeley, California, is
one known lecturer and workshop facilitator for on-site male issues education and
professional training.

Another possible solution may lie within the development of a secondary tool
specifically for the health care provider. This secondary tool would include the
presented tool with an overlay which presents a very brief background and synopsis of
the identified male issue being highlighted in the client tool, and would be used to
educate the provider on that male issue. This approach again is only a begirming for
the health care professional in understanding and in developing a knowledge base for
male identity, male issues, and male health issues. Again the male gender-specific
health risk assessment process is just a beginning step to the understanding and
provision of quality individualist, holistic health care to males of all ages.

Broader validity and reliability of the health risk assessment tool will be further

evaluated within actual practice and implementation of the tool. The goal of the project

i2:

Iii

acre:
in
ates .
hall.
is re
the b

reliabj

[0 Cree

 

55
was to develop a prototype male gender-specific health risk assessment tool which in
future research and use, the validity and reliability would be tested.

Validity looks at the issue of truth in determining whether the instrument measures
what it is supposed to measure. Face validity determines through visual examination of
the extent to which an instrument measures the domain of interest. It is an opinion, not
necessarily a valid assessment. This tool has face value in that it is a compilation of
questions based on the literature. As the research literature has validity in itself, the
questions within this tool have face validity. This face value is based on the content
validity which is established through review of the literature and examines the degree to
which the data collection instrument measures the theoretical concepts (T albot, 1995).
This tool will need to be reviewed by a panel of experts, both professional and lay, to
attain the level of true content validity. The tool in itself has shown to provide the
necessary assessment information for treatment of the male client but can improve as it
is used in clinical practice for varied populations and subcultures of males of different
ages and localities. Currently, the tool can be used, changed or altered for use by any
health care system. Upon use by a health care system, that system should then test for
the reliability and validity of the deve10ped tool according to the specifications which
the tool was altered to include. Again, it is not the intent of this project to test for
reliability and validity at this time.

Lastly, this project and male gender-specific health risk assessment tool were done

to create a foundation for further research in the same topic arena. It is this author’s

 

56

intent to continue this research and to further develop te health risk assessment tool in

future doctoral studies.

 

Because of the holistic approach in nursing practice, the Advanced Practice Nurse
(APN) already has an excellent nursing background upon which male issues and men’s
health issues can be added. As a Primary Care Practitioner, the APN is in a unique
situation of care provision to apply Leininger’s Theory in assessing the client more
holistically. Using Leininger’s theory and model, knowledge of men’s issues
compliment the assessment process and identification of the male client’s issues and
behaviors which affect his health status. This tool and project are an attempt to move
from a generalist view to a holistic view and approach to care provision of the male. It
is emphasized that the male be viewed as an individual with his own unique collection
of health issues. Implementation of Leininger’s Cultural Care Theory into the APN’s
assessment skills will assist in treating the individual male ethnically/culturally but yet
more specific.

The APN as educator can be important in teaching other health care providers
about men’s health issues and how such knowledge is critical to the assessment,
diagnosis, treatment and rehabilitation of the male in his disease status. In turn, the
APN is in a vital position to assisting the male in identifying, understanding and
managing his issues, beliefs and values toward a healthier lifestyle and promotion of

future wellness.

57
I l‘ . E B I

As mentioned, there is a need for development of a holistic individualized primary
care model which assesses and provides appropriate care and treatment of the individual
male client respective of his unique collection of male issues, health behaviors, health
conditions, and culturally based beliefs. Nursing research in developing this expanded
concept of Leininger’s Cultural Care theory and Sunrise Model toward this holistic,
individualized care model is proposed.

A concentrated collaborative, interdisciplinary research effort focused specifically
on analysis of male issues, male identity, male culture! subculture, male societal roles,
male gender-specific health issues and concerns is another area to be considered in
future research. This research “team” would be comprised of advanced practice
nurses, sociologists, psychologists, and other health professionals with the joint
responsibility of collaborative research on males and masculinity in our society.
Research-based literature regarding male gender-specific issues is currently lacking, as
presented throughout this project.

Bozett and Forrester (1989) presented the concept of a new specialty nurse
practitioner, i.e. , the Men’s Health Nurse Practitioner (MHNP). This MHNP arena
might present itself with the skills and knowledge of the Adult Nurse Practitioner
specialty but would expand its knowledge base and skills to include at least the issues
presented herein this project. Other research possibilities in this area include:

---A MHNP curriculum has been proposed by Bozett and Forrester (1988)

«research to substantiate the need for this specialty and a curriculum for MHNP

 

58
511mm

Males have specific issues which are culturally and societally based and may be
etiologies of male health beliefs and behaviors which in turn effect their mortality. The
developed male gender-specific health risk assessment tool is only a beginning in
assessing the male for health status and identifying male health issues. Throughout this
project presentation, it has been reiterated that there has been sporadic research on
males, maleness, male issues, male identity, male health and health issues that are
gender specific in nature. There is even less researched-based literature on the subject,
and this creates a need for further research.

Advanced Practice Nurses in primary care roles have the unique opportunity to be
leaders in men’s health research as well as holistic, individualistic health care provision
to male clients. By learning more about Leininger’s Cultural Care theory, its
application, and male health issues, APNs can provide the appropriate, specialized care
which has not been previously implemented in the health and well-being of males.

Men’s health as a health care specialization is absolutely a needed area in the
health care arena. In developing this Specialty practice, males may have the
Opportunity to reclaim the 7 -8 years of life that their own behavior has stolen from

them (Courtenay, 1997 a).

APPENDICES

Appendix A: Statistical Tables

60

Table 1.

 

 

 

 

 

AGE 1980 1990 1991

Under 1: Male 1,428.5 1,037.5 1,007.2
Female 1,141.7 831.2 790.5

14: Male 72.6 48.7 48.9
Female 54.7 39.4 44.5

5-14: Male 36.7 29.1 28.8
Female 24.2 18.8 19.0

15-24: Male 172.3 156.1 160.8
Female 57.5 50.8 52.2

25-34: Male 196. 1 205 .6 201 . 1
Female 75.9 73.4 73.6

35-44: Male 299.2 306.1 311.3
Female 159.3 138.1 135.8

45-54: Male 767.3 600.9 598.2
Female 412.9 332.6 325.6

55-64: Male 1,815.1 1,507.5 1,503.6
Female 934.3 877.5 854.7

65-74: Male 4,105.2 3,358.5 3,307.3
Female 2,144.7 2,002.1 1,971.7

7584: Male 8,816.7 7,950.2 7,663.1
Female 5,440.1 4,941.7 4,862.2

Over 85: Male 18,801.1 17,521.6 17,150.9
Female 14,727 .9 13,727 .5 13.3284

Adapted from: National Center for Health Statistics (1992)

61

 

Table 2.

Year

1950
1960
1970

1980

 

1989

 

LU '

 

Adapted from: National Center for Health Statistics (1992).

62

AllRages White Black

Bath Bath Bath

_U! '1.!.' ' ' 7H,! '11.!.' ’.' 11! ‘t.!
29.2 32.8 25.5 26.8 30.2 23.1 43.9 48.3 39.4
26.0 29.3 22.6 22.9 26.0 19.6 44.3 49.1 39.4
20.0 22.4 17.5 17.8 20.0 15.4 32.6 36.2 ----
12.6 13.9 11.2 11.0 12.3 9.6 21.4 23.3 19.4
9.8 10.8 8.8 8.2 9.2 7.2 17.7 19.0 16.3

 

Table 3. .4}! .l 1 1
(Ag -adju

 

 

 
   

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Cause of Death
Diseases of the Heart 155.9 210.2 112.3 1.87
Malignant Neoplasms 133.0 162.4 111.7 1.45
Accidents and Adverse Effects 33.8 49.5 18.9 2.62
Cerebrovascular Disease 28.0 30.4 26.2 1.16
Chronic Obstructive Pulmonary Disease 13.7 26.4 14.7 1.80
Pneumonia 11.3 17.9 10.7 1.67
Chronic Liver Disease/Cirrhosis 8.9 12.8 5.5 2.33
Diabetes 11.5 2.0 11.0 1.09
Suicide 11.3 18.6 4.5 4.13
Homicide and Legal Intervention 9.4 14.7 4.1 m 359
Adaptedfrom :7 ,,7 , 1. .H ,n- - 7,, r . ,2 1 ,, 4," 9- __ ..e u

63

 

Hamiltlimud

CFCDN-NHNAU

& H arm.

NU

[thIrtI

    

 

Deaths per 100010 resident population

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

All cusses 840.5 760.9 714.3 585.8 520.2 504.5
Natural causes 766.6 695.2 636.9 519.7 465.1 452.3
Diseases of heart 307.2 286.2 253.6 202.0 152.0 144.3
lschemichemdiseuse ---- 149.8 102.6 95.7
Cerebrovascular dim 88.6 79.7 66.3 40.8 27.7 26.2
Malignant neoplasms 125.3 125.8 129.8 132.8 135.0 133.1
Respiratory system 12.8 19.2 28.4 36.4 41.4 40.8
Colo-rectal 19.0 17.7 16.8 15.5 13.6 13.1
Prostate 13.4 13.1 13.3 14.4 16.7 16.6
Breast 22.2 22.3 23.1 22.7 23.1 21.9
Chronic obstructive pininonuy diseases 4.4 8.2 13.2 15.9 19.7 19.9
Pneumonia and influenza 26.2 28.0 22.1 12.9 14.0 12.7
Chronic liver disease and cirrhosis 8.5 10.5 14.7 12.2 8.6 8.0
Diabetes mellitus 14.3 13.6 14.1 10.1 11.7 11.9
Nephritis/mphrotic syndrome/nephrosis - - - - - - - - - - - - 4.5 4.3 4.3
septicemia ---- ---- ---- 2.6 4.1 4.0
mmmimyvimmfection ---- ---- ---- ---- 9.3 12-6
Exterml causes 73.9 65.7 77.4 66.1 55.1 52.1
Unintentional injuries 57.5 49.9 53.7 42.3 32.5 29.4
Motor vehicle crashes 23.3 22.5 27.4 22.9 18.5 15.8
Suicide 11.0 10.6 11.8 11.4 11.5 11.1
Homicide and legal intervention 5.4 5.2 9.1 10.8 10.2 10.5
Drug-induced causes - - - - - - - - - - - - 3.0 3.6 4.3
Alcohol-W “use; - - - - - - - - - - - - 8.4 7.2 6-8
White male Deaths per “IMHO resident population
A“ was 963.1 917.7 893.4 745.3 644.3 620.9
Neutral causes 860.1 825.8 788.6 651.2 567.6 548.8
Diseases of heart 381.1 375.4 347.6 277.5 202.0 190-3
ISCIKlmc m disease _ , _ - - - - - - - - . 2180 145-3 1348
Cerebrovascular diseases 87.0 80.3 68.8 41.9 27.7 26.3
Malignant neoplasms 130.9 141.6 154.3 160.5 160.3 152.3
Minion! system 21,6 34.6 49.9 58.0 59.0 5 .
Colo-rectal 19,8 18.9 18.9 18.3 16.5 15.7
Prosmte 13.1 12.4 12.3 13.2 15.3 15.1
. . . 24.0 26.7 27.4 26.8
Chrome obstructive pulmonary diseases 6.0 13.8 15 8
Pneumonia and influenza 27.1 31.0 26.0 16.2 17.5 “.1
Chronic liver disease and cirrhosis 11.6 14.4 18.8 15.7 11.5 ”.6
Diabetes mellitus 11.3 11-6 ‘2-7 3‘3 1411.135 4'3
glintis/ncphrotic syndrome/nephrosis - - - - 7 " '7' 2:8 4:2 379
mm“ ' ' ’ ' - . -- 15.0 18.1
H . . . . d on . . - _ - . . - . - . .
Ex ten1:.In111‘7171‘77175112811111100:ficreticy Virus infec 10370 9179 104.8 9471 :21 z 51,
Unintentional in'urics 80.9 70.5 76.2 62.3 - 22.2
. J 34 0 40.1 34.8 26.3 .
SmMotor vehicle crashes 1:2? 17.5 18 2 18 9 20.1 19.5
cm: . ' ‘ ' 9.3
Homicide and legal intervention 3.9 3.9 73 “g; 3.2 5.5
Drug-induced causes ' ' ' ' ' ' ° . : : - , 10:3 9.9 9-9
Alcohol-Induced' causes "" ""

 

 

 

 

 

 

CFCDN.&HWMU

Ya”.
{In

 

   

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Black male Deaths per 1111,1110 resident population
1111 causes 1,373.1 1,246.1 1,318.6 1,112.8 1,061.3 1,026.9
Natural causes 1,209.2 1,093.4 1,095.4 942.6 915.2 886.7
Diseases ofheart 415.5 381.2 375.9 327.3 275.9 264.1
1schernichesrtdisesse 196.0 147.1 138.2
Cerebrovascular diseases 146.2 141.2 122.5 77.5 56.1 52.0
Malignant neoplasms 126.1 158.5 198.0 229.9 248.1 238.1
Respiratory system 16.9 36.6 60.8 82.0 91.0 86.7
Colo—rectal 13.8 15.0 17.3 19.2 21.6 20.5
Prostate 16.9 22.2 25.4 29.1 35.3 35.8
Chronic obstructivepulmonarydiseases ---- ---- ---- 20.9 26.5 24.8
Pneumonia and influenza 63.8 70.2 53.8 28.0 28.7 25.0
Chronic liver disease and cirrhosis 8.8 14.8 33.1 30.6 20.0 17.2
Diabetes mellitus 11.5 16.2 21.2 17.7 23.6 24.2
Nephritislnephmtic syndrome/nephrosis - - . - - - . . - - - - 14.2 12.9 12.5
Septicemia 8.0 11.6 11.4
Humanimmunodeficiencyvirusinfection -.-. nu ---- 44.2 61.8
Emmi causes 163.9 152.7 223.2 170.2 146.0 140.2
Unintentional injuries 105.7 100.0 119.5 82.0 62.4 56.7
Motor vehicle crashes 39.8 38.2 50.1 32.9 28.9 25.0
Suicide 7.0 7.8 9.9 11.1 12.4 12.4
Homicide and legal intervention 51.1 44.9 82.1 71.9 68.7 68.1
Drug-Mm --.- ---- ---- 5.8 8.4 10-6
Alcohol-inducedcauses 32.4 26.6 22.3

White female Deaths per 11111110 resident population
A“ cause: 645.0 555.0 501.7 411.1 369.9 359.9
”mm! causes 607.7 522.7 463.8 380.0 344.2 335.8
Diseases of heart 223.6 197.1 167.8 134.6 103.1 98.1
Ischemichesrtdisease 97.4 68.6 64.1
Cerebrovascular diseases 79.7 68.7 56.2 35.2 23.8 22.5
Malignant neoplasms 119.4 109.5 107.6 107.7 111.2 110.3
Respiratory system 4.6 5.1 10.1 18.2 26.5 27.4
Colo-rectal 19.0 17.0 15.3 13.3 10.9 10.5
Breast 22.5 22.4 23.4 22.8 22.9 215:
Chronic obstructive pulmonary diseases 2.8 3.3 5.3 9.2 15% 9.7
Pneumonia and influenza 18.9 19.0 15.0 9" 13'8 46
Chronic liver disease and cirrhosis 5.8 6.6 8-7 7'0 9'5 9'6
Diabetes meilitus 16,4 13.7 12.8 g; 3-0 3'0
gghritis/nephrotic syndrome/nephrosis "" 1:3 3.1 3.1
ncem1a "" "H --.- 1.1 L6
Human immunodeficiency virus infection ' ' ' ' ' ' - - . ' - 7 25.7 24-0
External causes 37'3 32'3 3;: 3:: 17.6 16.1
Unintentional injuries 30.6 25.5 14-4 ”'3 11.0 9.6
Motor vehicle crashes 10-6 “'1 ' 5'7 4.8 4.6
Suicide 53 5'3 3% 32 2.8 2.8
Homicide and legal intervention 1-4 1-5 _ .' 2:6 25 2,7
Rims-induced causes ' ’ ' ' ' ' ' ' :_ _ 3,5 2.8 2-6

 

 

65

 

E .5:

 

Black female

Deaths per 100,000 resident population

 

 

Alcohol-induced causes

 

 

 

 

 

 

 

All causes 1,115.7 916.9 814.4 631.1 581.6 568.4
Natural causes 1,054.8 867.3 757.9 588.4 545.1 533.3
Diseases of heart 349.5 292.6 251.7 201.1 168.1 162.4
ischemicheartdisease ---- ---- 116.1 88.8 84.9
Cerebrovascular diseases 155.6 139.5 107.9 61.7 42.7 39.9
Malignant neoplasm 131.9 127.8 123.5 129.7 137.2 136.6
Respiratory system 4.1 5.5 10.9 19.5 27.5 28.5
Colo-rectal 15.0 15.4 16.1 15.3 15.5 14.8
Breast 19.3 21.3 21.5 23.3 27.5 27.0
Chronicobstructive pulmonarydiseases ---- ---- ---- 6.3 10.7 11.2
Pneumonia and influenza 50.4 43.9 29.2 12.7 13.7 12.2
Chronic liver disease and cirrhosis 5.7 8.9 17.8 14.4 8.7 6.9
Diabetes mellitus 22.7 27.3 30.9 22.1 25.4 25.8
Nephritis/nephrotic syndrome/nephrosis - - - - - - - - - - - - 10.3 9.4 8.7
Septiccmia ---- ---- ~--- 5.4 8.0 8.1
Human immunodeficiency virus infection - - ~ - - - - - - - - - - - - - 9-9 14-3
Exterml causes 51.9 49.6 56.5 42.7 36.6 35.0
Unintentional injuries 38.5 35.9 35.3 25.1 20.4 19.3
Motor vehicle crashes 10.3 10.0 13.8 8.4 9.3 8.7
Suicide 1.7 1.9 2.9 2.4 2.4 2.1
Homicide and legal intervention 11.7 11.8 15.0 13.7 13.0 13.0
Dmgfinduceduuses ---- ---- ---- 2.7 34 3-6
. . . . - - - - 10.6 7.7 6.3

 

 

Source: Health, United States, 1994, Table 31.

66

 

 

ill

3..“

 

 

 

DEATH RATE PER 100,000 PER

 
     

 

100,000 POPULATION
AGE and LEADING CAUSE OF l TOTAL MALE FEMALE
DEATH
ALL AGES l
All races 860.3 912.1 811.0
White 886.2 926.2 847.7
Black 864.9 998.7 744.5
lsadinuaussutslsath;
Heart Disease 285.9 292.6 279.5
Malignant neoplasms (cancer) 204.1 221.5 187.5
Cerebrovascular disease (stroke) 56.9 46.1 67.2
Chronic obstructive pulmonary disease 35.9 41.1 31.2
Accidents 35.4 48.6 22.9
Motor-vehicle 17.3 24.4 10.5
Pneumonia 30.9 29.4 32.2
Diabetes 19.4 17.2 21.6
Suicide 12.2 20. 1 (NA)
HIV infection 11.7 21.2 (NA)
Homicide & legal intervention 10.5 16.9 (NA)
1 to 4 years old
All causes 47-4 52°O 42'7
Leadin causes of death:
Accicfents 17.5 22.; 1::
Motor-vehicle 5 g 6' O 5 . 4
Congenital anomalies 3'5 3'7 3'2
Malignant neoplasms (cancer) .8 3'0 2. 6
Homicide & legal intervention 3'2 2'3 21
Heart disease 1'4' 116 1.1
Pneumonia & influenza '

 

 

 

 

 

 

67

 

FEMALE ‘

 

AGE and LEADING CAUSE OF TOTAL MALE
DEATH
5 to 14 years old ll
All causes 23.6 28.7 18.3
W:
Accidents 10.2 13.6 6.7
Malignant neoplasms (cancer) 3.1 3.5 2.6
Congenital anomalies 1.4 1.4 1.3
Homicide & legal intervention 1.4 1.8 1.0
Heart disease 0.8 0.8 0.7
Pneumonia & influenza 0.4 0.4 0.4
15 to 24 years old
All causes 100.1 148.0 50.0
W:
Accidents 42.0 62.0 21 .0
Motor-vehicle 32.0 45.5 18.0
Homicide & legal intervention 22.4 37.2 6.9
Suicide 13.1 21.9 3.8
Malignant neoplasms (cancer) 5.0 5-3 4-1
Heart disease 2.7 3.4 2.0
HIV infection 1.7 2.4 0.9
25 to 44 years old
All causes 179.9 255.2 105.3
leadinuaussutslsath:
Accidents 32.3 50.3 1;:
Motor-vehicle 18 -4 :13 29' 2
Malignant neoplasms (cancer) 27-1 47'] 60
HIV infection 26.5 28.1 10.5
Heart disease 19'3 23'9 6.3
Homicide & legal intervention 15.1 - 5 9
Suicide 14.9 24. l .

 

 

 

 

 

68

 

 

 

 

 

 

 

 

 

AGE and LEADING CAUSE OF 5 TOTAL MALE FEMALE '1

L” , _ DETH _ L. ___ __ L .

45to64years old ' 11

All causes 788.9 1,011.2 582.6 1
Malignant neoplasms (cancer) 286.9 320.9 255.4
Heart disease 225.4 330.1 128.3

Cerebrovascular disease (stroke) 30.9 34.6 27.5 .1
Accidents 29.3 43.3 16.3
Motor-vehicle 14.2 19.8 8.9
Chronic obstructive pulmonary disease 27.3 30.6 24.3
Chronic liver disease/cirrhosis 22.5 32.5 13.2
Diabetes 21.5 22.8 20.3

65 years old and older R}
All causes 4,924.0 5,719.9 4,387.0
Wm:

Heart disease 1,881.0 2,131.3 1,712.0
Malignant neoplasms (cancer) 1.1 17.3 1,469.3 879.7
Cerebrovascular disease (stroke) 394.1 366.6 412.7
Chronic obstructive pulmonary disease 240.6 334.7 177.2
Pneumonia & influenza 217.2 240.1 201.7
Diabetes 115.0 114.1 115.7
Accidents 83.3 102.9 70.0
Motor-vehicle 22.2 30.9 16.3

Source: US National Center for Health Statistics, Vital Statistics of the United States, annual, 1991,
No. 127; and unpublished data.

69

Appendix B: Male Concerns & Issues

Men have unique biological and social health care needs, including:
Permission to have health concerns, and to talk about them openly.

Support for considering life-style and male role influences on their physical health
risks and mental well-being.

Professional attention to factors in men's lives which are likely to cause illness or
influence the expression of it, such as occupation, leisure patterns, sexual and
nonsexual personal relationships.

Information about their bodies---how they function, what is normal, what

constitutes illness, what to do about it, what exercise and proper nutrition can
contribute.

Instruction in self-care techniques, particularly testicular and genital self-
examination.

Physical examination and medical history-taking which include the sexual-
reproductive system and its functioning as integral parts of the individual's life, in
sickness and in health, at all ages.

Treatment for problems of couples---interpersonal emotional maladjustments,
infertility, conception control, sexual dissatisfaction, sexually-transmissible
diseases of which the man may have no symptoms, yet which continually reinfect a
partner with resulting distress to both.

Help in fathering, being included as an interested parent in the care of their
children, both male and female.

Help for single parents, of either sex, who are the main caretakers of a child of the
opposite sex, in how to deal with the child's sexual needs and concerns.

Recognition that, in times of rapid social change, including changes in sex roles, a
sense of confusion and uncertainty is normal, and can be the beginning of healthy
adaptation to changing circumstances.

A health care system that adjusts to time and location constraints imposed by
men's occupation, or which cooperates with workplace demands to make it
possible for the man to obtain health care.

Financially reasonable ways of obtaining all of the above.
(From: Swanson & Forrest, 1984, pp. 8-9)

71

Appendix C: Conceptual Models

Cultural Care
Worldview

  
    

     
 

Cultural & Social Structure Dimensions

‘----.-~
'- ‘Q
a s

"' Cultural , x‘

I ’ ’ t WU“ ‘ J
' Kinship 8: ‘ Lileways, ’ Political s ‘
. I Legal ,
‘ ‘ FEIO'S ‘. 0' Factor; ’ a
\ Environmental Context ,’
\ Language 11. Ethnonistory ,'
’ Religious 11. ‘~
I Philosophical ‘. Mi ,’ Economic
1 Factors Factors
.' ‘ ‘ ~ Hintluences \\ ’
,‘ \ Care Expressions, . ’ . .
- "sf! Patterns a Practices , 3S , , ’
.' IMM'OOW I t: Educational
1 MO“ ‘7’ ‘4' Factors
' -_ Health (Well-Being) 1 ’

Individuals. Families, Groups. Communities. 11. institutions
in
Diverse Health Systems

’ I ' ‘ \ I \
I \I \/ \
I I \ ’ \ \
I I ‘ I \ l
l I ‘ p \ l
l Generic u ‘ Nursing 1 ' Protessional '
' or Folk ' ' . Care ' I Systems '
I
‘1 Systems ' , ‘1 , ,
\ s I \ I I
\ 4 i I
\ ’ \ ’ \ ’
\ ‘ I I \ ‘ I ' \ ‘ I I
Nursing Care Decisions 3. Actions

Culture Cars Preservation [Maintenance
Cultural Care Aocomodation I Negotiation

Cultural Care Repattemlng I Restructuring
H i
L '"numfl Culture Congnlent (Nursing) Care

Frum(. ‘uhum (‘ an: Dl'wrsl'ty and Universality: A 7 been for Nursing by M. Leininger, l99l. New
York: National League for Nursing. Reprinrui by permission.

 

73

silo filo .”fl" .Jir Div 1 r. llo "Li 1"

 

' ‘ ’ ‘ I ‘
I ‘ ’ ‘
' \I ‘
0' ' “ U ‘ U
' n ' Will ,
: W , s m H .
I “M H. . a. . ‘0 W ;
w t
\ ‘ , ' ’
‘ s! mda u ,
. g of .. ’
“ "“ U ’ “ "
~~ " “ oooooo 'l ‘ ..... '

 

74

REFERENCES

Allen, D. G., & Whatley, M. (1986). Nursing and men's health: Some critical

considerations. WW 2110). 3-13.
Bozett, F. W., & Forrester, D. A. (1988). A proposal for a men's health nurse

practitioner. WWW. 21(3). 158-161.
Brink. P. 1.. & Wood. M. J. (1988). W
W (3rd ed.). Boston: Jones and Bartlett Publishers.

Calkin, J. D. (1984). A model for advanced nursing practice. W

Adminimfifln 151(1). 27-

Centers for Disease Control (1993). Prevalence of sedentary lifestyle---Behavioral risk

factor surveillance system, United States, 1991. W

Kellen. 42(29), 576-9.
Cockerham, W. C. (1995). W Englewood Cliffs, NJ: Prentice-Hall.

Cole, P. (1974). Morbidity in the United States. In C. Erhardt & J. Berlin (Eds),

WM (pp. 66-104). Cambridge, MA:

Harvard University Press.

Collado, C. (1992). Primary health care: A continuing challenge. W

Care. 13(8), 408-413.

Courtenay, W. H. (1996a). African American men’s health: With emphasis on males

15 to 24 years old [On-line]. Available at: http://www.menshealth.org/afroam.html

75

76
Courtenay, W. H. (1996b). Alcohol and other drugs [On-line]. Available at:
http://www.menshealth.org/drugs.html
Courtenay, W. H. (1997). Consultation to managed care & health maintenance

organizations [On-line]. Available at: http://www.menshealth.org/managed.html
Courtenay. W. H. (1997a. in revieW). W
W Manuscript submitted

for publication.
Courtenay. W. H. (1997b. in reviCW). WWW—Gall
traction. Manuscript submitted for publication.

Courtenay, W. H. (1996c). Current health facts about men [On-line]. Available at:

http://www.menshealth.org/

Courtenay, W. H. (19970, in review). W
W. Manuscript submitted for publication.

Courtenay, W. H. (l996d). Leading causes of death & other health facts about college-
age men [Online]. Available at: www.menshealth.org/deathcollege.html

Courtenay, W. H. (1996c). Health Mentor: Health risk assessment for men. Berkeley,

CA: Men’s Health Consulting.

Courtenay, W. H. (1996f). Men’s leading causes of death [On-line]. Available at:

http://www. menshealth.org/death.hmll

Courtenay, W. H. (1997d, in review). WWW

.Manuscript submitted

 

for publication.

 

77
Courtenay, W. H. (1996g). Why men die younger than women [On-line]. Available
at: http://www.menshealth.org/behavior.html
Craig, S. (Ed.). (1992). WWW. Newbury Park, CA: Sage

Publications .

 

Cypress, B. (1981).

WWW DHHS Publication No (PHS) 82- 1717.
Series 13, No. 56. Hyattsville, MD: National Center for Health Statistics,

December, 1981.
Dawson, D.A., & Adams, RF. (1987). W

111' temew saggy; 11.5,, 1286, Vital Health Statistics Series, Series 10, No. 164.
DHHS Publication No. (PHS) 87-1592, Public Health Service. Washington, DC:
US. Government Printing Office.

DeHoff, J. B. & Forrest, K. A. (1984). Men’s health. In J. M. Swanson & K. A.

Forrest (Eds), Wealth, (pp. 3-10). New York: Springer
Publishing Company.

Department of Health and Human Services (1993). Vita] and Mann statistics Health
WWW-1299; DHHS publication no.

(PHS) 93-1513. Hyattsville, MD: Public Health Service.

Farrell. W. (1975). W New York: Random

House.

Feigen—Fasteau, M. (1974). W New York: McGraw-Hill.

 

78

Fisher, N. M. (1997). Gender bias in health care. WW, 22(6), 208-
213.

Gerchufsky, M. (1995). Impotence: The problem men don't talk about. Adymfor
WES. 3 (3), 12-16.

Gilroy, D. (Ed.) (1991). W. Emmaus, PA: Rodale Press.

Givens. 1- (1979). WWW
DHHS Publication No. (PHS) 80-1551, Series 10, No. 130. Hyattsville, MD:
Office of Health Research Statistics.

Goeppinger, J. (1993). Health promotion for rural populations: Partnership
interventions. Comm, 16(1), 1-10.

Goldberg. K- (1993). W
W. Fort Worth, TX: The Summit Group.

Gongwer News Service (1995). "Task force report: Black males distrust health care
System.” WWW. Report no.
123, Volume 34.

Harrison, J ., Chin, J ., & Ficarrotto, T. (1988). Warning: Masculinity may be
dangerous to your health. In M. S. Kimmel & M. A. Messner (Eds), Mew
(2nd ed.), (pp. 271-285). New York: Macmillan Publishing Company.

Ingham County Health Department (1993). Satellite clinic statistics 1993. Lansing,

MI: Ingham County Health Department.

Julty, S. (1979). W New York: Dell Publishing.

79

Kandrack, M., Grant, K. R., & Segall, A. (1991). Gender differences in health related

behaviour: Some unanswered questions. Wine, 32(5), 579-
90.

Kemper, D. W., McIntosh, K. E., & Roberts, T. M. (1994). MW

W (11th ed.). Boise, ID: Healthwise, Inc.
Kimmel, M. S. (Ed.), (1987). Ural 941'

 

masculinity. Newbury Park, CA: Sage Publications.

Kimmel, M. S., & Messner, M. A., (Eds), Menlmygs (2nd ed.). New York:
Macmillan Publishing Company.

Krjervik, D., & Martinson, I. (1986). WWW
anchrisjs, Philadelphia: W.B. Saunders.

Kupers, T. A. (1993). W New York: Guilford Press.

Ieininger. M. M. (1970). W New
York: Wiley & Sons.

Leininger, M. M. (1984). Transcultural nursing: an essential knowledge and practice
field for today. W, December 1984, 41—45.

Leininger, M. M. (1985). Southern rural black and white American lifeways with
focus on care and health phenomena. In M. M. Leininger (Ed.), graham
W (pp. 195-216). Philadelphia: Saunders.

Leininger, M. M. (1988a). Leininger's theory of nursing: cultural care diversity and

universality. W. 1(4). 152-160.

80
Leininger, M. M. (1988b). History, issues, and trends in the discovery and uses of
care in nursing. In M. M. Leininger (Ed.), WW
WW1]; (pp. 11-28). Detroit: Wayne State University Press.

Leininger, M. M. (1990a). Ethnomethods: The philosophic and epistemic bases to

explicate transcultural nursing knowledge. WWW. 1(2),
40-51.

Leininger, M. M. (1990b). The significance of cultural concepts in nursing. 191111131
W8. 2(1), 52-59.

Leininger, M. M. (1991a). Ethnonursing: A research method with enablers to study
the theory of culture care. In M. M. Leininger (Ed.), W
W (pp. 73-117). Detroit: Wayne State University
Press.

Leininger, M. M. (1991b). The theory of culture care diversity and universality. In
M- M- Leininger (Ed.). WW
nursing (pp. 5—68). Detroit: Wayne State University Press.

Leininger, M. M. (1994).

 

Columbus, OH: Greyden Press.
Leininger, M. M. (1995). fljransculmral nursm' g; 9911131213, theories, research 1%;
12111911135, (2nd ed.). NY: McGraw-Hill.

Messner. M. A.. & SabO. D. (1990)- W

W Champaign, IL: Human Kinetics Publishers.

81

Messner, M. A., & Sabo, D. (1994). WWW
masculinim Freedom, CA: Crossing Press.

Michigan Primary Care Association (1989). A blueprint for primary health care:
Communities building a healthy foundation. BMW.

Mills, M. E. (1989). Clinical nurse specialist organizational value and role support._
We. 3(4), 186-87.

Mishkind, M. E., Rodin, J ., Silberstein, L. R., & Stn'egel-Moore, R. H. (1987). The
embodiment of masculinity: Cultural, psychological, and behavioral dimensions.
In M. S. Kimmel. (Ed.). (1987). W
W, pp. 37-52. Newbury Park, CA: Sage Publications.

National Institute for Occupational Safety and Health (1996). W
Wan [On-line]. Available at:
http://www.cdc.gov/niosh/mi.hmil

Pleck, J ., & Sawyer, J. (1974). Masculinity, Englewood Cliffs, N.J.:

Prentice-Hall.

Rakowski, W. (1986). Personal health practices, health status, and expected control
over future health. MW, 11(3), 189-203.

Sabo, D. (1996). Caring for Men. In Cookfair, J ., (Ed.), W
cgmmunig. Chicago: Mosby—Year Book.

Sabo, D.. & Gordon. D. F. (1995). WWW
thL Thousand Oaks, CA: Sage Publications.

Sloane, E. (1993). HEW, (3rd ed.). Albany, NY: Delmar.

82

Speetor.R. 13- (1991). W.Bw ed). Norwalk.
CT: Appleton & Lange.

Springhouse Corporation (1994). Definiiigns (The Nurses' Reference Library).
Springhouse, PA: Springhouse Corporation.

Stillion, J. (1995). Premature death among males: Extending the bottom line of men's
health. In D. Sabo & D. F. Gordon (Eds), Menihealihandjflnessfiendfl,
Wm (pp. 46-67). Thousand Oaks, CA: Sage Publications.

Swanson, J. M., & Forrest, K. A. (1984). WWI-h. New York:
Springer Publishing Company.

Talbot, L. A. (1995). W. St. Louis, MO:
Mosby-Year Book, Inc.

United States Census Bureau (1990). 1W. Washington, DC:
Government Printing Office.

United States Department of Health and Human Services (May, 1995). Healmflniigd
W. Hyattsville, MD: National Center for Health Statistics.

Verbugge, L. M. (1985). Gender and health: An update on hypotheses and evidence.
WM. 26. 156-82.

Verbugge, L. M., & Wingard, D. L. (1987). Sex differentials in health and mortality.
Wm. 12(2). 10345-

Waldron, I. (1976). Why do women live longer than men?, Part 1. mm
Stress, 2(1), 2-13.

Waldron, 1., & Johnson, 8. (1976). Why do women live longer than men?, Part II.
IonmalofHumauStress. 2(2). 19-30.

83

Wenger, A. F. Z. (1992). Transcultural nursing and health care issues in urban and

rural contexts. Iournamflransculmramursing. 51(2). 4-10.
Wingard, D. L. (1984). The sex differential in morbidity, mortality, and lifestyle.

Ammalfigdmtmhlieflealth. 5. 433-58.
world Health Assembly (May 19. 1989). W

W” Geneva: Author.
Yingling, M. J. (1996). Caring for women. In Cookfair, J ., (Ed.), Wm:

communim. Chicago: Mosby-Year Book.

MK H115 AN STATE UNIVERSITY LIBRARIE

1 ill Hill NH

31293 02374 9751

   

Mi