Added: Doran Jefferies - Date: 05.02.2022 21:00 - Views: 22819 - Clicks: 7330
Prev Chronic Dis ; Data suggest that more men than women are dying of coronavirus disease COVID worldwide, but it is unclear why. A biopsychosocial approach is critical for understanding the disproportionate death rate among men. Biological, psychological, behavioral, and social factors may put men at disproportionate risk of death.
We propose a stepwise approach to clinical, public health, and policy interventions to reduce COVID—associated morbidity and mortality among men.
We also review what health professionals and policy makers can do, and are doing, to address the unique COVID—associated needs of men. According to the largest body of publicly available sex-disaggregated data from global government sources, although no apparent sex differences exist in the of confirmed cases, more men than women have died of COVID in 41 of 47 countries 2and the overall COVID case-fatality ratio is approximately 2. Another study from China, of critically ill patients, showed that men with comorbidities such as hypertension, cardiovascular disease, chronic kidney disease, and diabetes had the highest mortality 6 and US data showed similar patterns 4,7,8.
A multinational health research database using the TriNetX Network showed that among 14, male and female patients with confirmed COVID, men were older, were more likely to be hospitalized, and had a higher prevalence of hypertension, diabetes, coronary heart disease, obstructive pulmonary disease, nicotine dependence, and heart failure. Men also had higher all-cause mortality than women 8. Moreover, the cumulative probability of survival was ificantly lower among men after adjusting for age, comorbidities, and use of angiotensin-converting enzyme inhibitors ACEIs or angiotensin receptor blockers ARBs 9.
With the exception of Massachusetts, all states in the United States have reported higher mortality among men However, the United States has not been consistent in reporting sex-disaggregated data. In a recent analysis of 26 states, only half reported sex as a variable Exploring the differences in COVID morbidity and mortality across these sociodemographic strata are beyond the scope of this commentary, yet we recognize and note that race, ethnicity, sexual orientation, gender identity, and other factors are important and should call attention to particular populations during the COVID pandemic.Reassuring Studies: COVID-19 Vaccines do not cause female or male infertility
In this commentary, we discuss factors that may put men at a disproportionate risk of dying of COVID This approach facilitates efforts to identify strategies to intervene and improve the health of men during this public health crisis and beyond The sex gap in COVID—associated mortality is not easily explained by any single biological or social factor 3.
Recognizing the difference between sex and gender in health outcomes while discerning the influences one has on the other is important Differences in sex are biological. These include differences in reproductive organs and their functions, sexual hormones, and the gene expression of chromosomes. Gender is the performance of socially constructed roles, behaviors, and attributes considered socially acceptable for men and women. Although epidemiological data show a difference between men and women in the rates of mortality among those diagnosed with COVID, the mechanisms underlying sex differences in mortality are unclear 3,10, Because most health patterns are the result of a combination of biological, behavioral, and psychosocial factors, we must consider how sex-associated biological factors and gender-associated psychosocial and behavioral factors interact in determining health 14 and in explaining COVID—associated mortality 4,8, Men and women differ in both innate and adaptive immune responses, perhaps related in part to sex-specific inflammatory responses resulting from X-chromosomal inheritance.
The X chromosome contains a high density of immune-related genes; therefore, women generally mount stronger innate and adaptive immune responses than men 3. This differential regulation of immune responses in men and women is contributed by sex chromosome genes and sex hormones, including estrogen, progesterone, and androgens.
Sex-specific disease outcomes after viral infections are attributed to sex-dependent production of steroid hormones, different copy s of immune 19 male for women X-linked genes, and the presence of disease susceptibility genes 3. The internalization of the virus is potentiated by the cellular protease TMPRSS2 transmembrane protease, serine 2 in the host cell 17, The high burden of illness and high case-fatality ratio in patients with COVID may be driven in part by the strong affinity of the virus for ACE2, leading to virus entry and multisystem illness in pulmonary, gut, renal, cardiac, and central nervous systems Unravelling which cellular factors are used by SARS-CoV-2 for entry might provide insights into viral transmission and reveal therapeutic targets.
Although biological factors clearly help to explain the sex difference in COVID mortality, psychosocial and behavioral factors also play a part. In addition to sex differences in immune responses, hormones, and genes, there are also psychological, social, and behavioral components that influence COVID progression 1, Compared with women, men tend to engage in more high-risk behaviors that generate potential for contracting COVID 1,4.
Polls taken early in the first wave of COVID cases in the United States show sex differences in the perceived severity of the pandemic In addition, compared with women in many countries, including the United States, men tend to have higher rates of behaviors that are linked with COVID infection and mortality, including higher rates of tobacco use and alcohol consumption 1,4,21, Men also tend to have lower rates than women of handwashing, social distancing, wearing masks, and effectively and proactively seeking medical help 1,4,21,25, It is particularly important to focus on men who respond to threats like COVID with aggression and anger.
These socially constructed behaviors reduce the perception of susceptibility and severity, which then translates into a decrease in the practice of preventive measures, such as handwashing, and protests against pandemic-related restrictions. Other factors may intersect with sex and gender, such as age and geography For example, a US study of associations between perceived risk and worry with age and gender found that although older men perceived their risks of COVID to be higher than those of younger men, older men made the fewest behavior changes across age and gender groups Another study highlighted the importance of considering place or geography.
In urban areas with high percentages of Black residents with low socioeconomic status, some problematic narratives have emerged that blame the men and women who live in these areas for their high rates of COVID rather than the policies or structures that create these conditions In addition to these psychological and behavioral factors, differences in occupational risk exist between men and women. In the United States, a larger of women than men are deemed essential workers primarily because of the large share of women employed as social workers and in health care Nevertheless, the low-skilled or low-paid occupations that are considered essential workers eg, food processing, transportation, delivery, warehousing, construction, manufacturingwhere men out women, seem to be associated with a greater risk of mortality In summary, a range of biological, psychological, and behavioral factors can explain why men have higher rates of COVID—associated morbidity and mortality than women.
Although it is critical to identify the factors associated with increased risk for men of COVID mortality, it is equally important to determine how to reduce the risk of men dying of COVID 1,4. Educational efforts to increase compliance with public health recommendations may be more effective in changing the behavior of men if these efforts incorporate some of the principles from health communications research that consider how health behavior is gendered 33, Building on principles of the self-determination theory, we suggest that messages to engage men seek ways to motivate them to consciously choose to engage in healthier behaviors, not because of shame, pressure, or coercion but because they are intrinsically motivated to do so For example, some men may be motivated to engage in behaviors to reduce their risk of contracting or potentially transmitting COVID not by focusing on their risk but by focusing on the high rates of morbidity or mortality of their racial or ethnic group, communities, neighborhood, or family.
As a result, a federally qualified health center in Baton Rouge, Louisiana, for example, is conducting outreach to men with underlying conditions and their partners to ensure that they are aware of their susceptibility to COVID Increasing access and eliminating barriers to community-wide testing are additional ways to improve COVID outcomes. Testing or screening use may be influenced by exposure to decision education and the influence of screening-related primary care practice factors Federally qualified health centers offering primary care services are key community institutions that have increased COVID testing — with no out-of-pocket costs to patients in many areas.
These kinds of programs allow men to have access to testing without cost barriers that may otherwise deter them from accessing testing. The community-wide testing also offers an opportunity for men to be tested before returning to work as states begin to reopen and more services barber shops, gyms, restaurants are offered in communities. These initiatives help to normalize testing and reduce the stigma of getting tested, although they may not reduce the stigma of receiving a positive test result.
Given the rates of cardiometabolic risk factors and underlying or preexisting conditions such as obesity or comorbid chronic diseases eg, diabetes, heart disease, cancer among men, a focus on men with underlying conditions that increase their risk of COVID mortality is critical 34, Although the greater severity of complications attributable to COVID among men is not well understood, preliminary findings of a higher incidence of mortality attributable to underlying comorbid conditions suggest that clinicians tailor current treatment options with this in mind.
The study, which used data from 9 high-volume cardiac catheterization laboratories, showed that total STEMI activations decreased from more than per month mean, We need to reassure patients that although routine and elective care might be curtailed by the pandemic, new symptoms of myocardial infarction and stroke still need to be immediately addressed.
For men who are at increased risk because of a history of a chronic condition or disease, clinicians should actively assess risks; optimize antihypertensive and statin therapies where indicated; provide behavioral and pharmacotherapy for tobacco use cessation cigarettes and vaping ; educate on healthy diets rich in vegetables, legumes, grains, fruits and nuts; and make exercise recommendations In addition to providing information, clinicians should encourage men to participate in behavioral interventions that target psychosocial factors eg, self-efficacy, motivation that can facilitate lifestyle change and maintenance of behavior changes over time These important interventions should continue during a pandemic through virtual visits and telemedicine platforms.
Several professional organizations have made COVID—specific clinical and operational guidelines in their specialties; these include patient education information on occupational risk mitigations and recognizing s and symptoms of COVID infection, hand hygiene and surface decontamination, and protecting family members 40, While deing clinical trials to address COVID—related conditions, clinicians and researchers need to consistently consider sex as a biological variable and the behaviors and social stressors associated with gender that might affect drug efficacy, treatment options, and adverse outcomes 3, There is a long history of not analyzing and reporting sex differences and underrepresenting women in cardiovascular clinical trials and in the treatment of infectious diseases 10and COVID is proving no different in many countries 4, from the randomized, controlled Adaptive COVID Treatment Trial, which tested remdesivir as a therapeutic agent for the treatment of COVID, showed a 4-day difference in time to recovery between the treatment group and the control group, but the study did not provide explicit information on sex-based efficacy or adverse reactions Only by investigating sex differences consistently, critically, and reflectively can we fulfill the requirements of scientific rigor, excellence, and maximum impact.
Strategies aimed at preventing complications associated with COVID are essential for safe and effective return to personal, professional, and societal obligations. Urgent needs also exist to provide post—acute care rehabilitation services for patients recovering from COVID and to train a new workforce to care for these patients Strong evidence suggests that interventions engaging community health workers improve health outcomes for patients, including men, across multiple chronic conditions.
As care extenders, community health workers provide a culturally and linguistically appropriate clinical—community linkage for difficult-to-reach patients, such as men. They can provide direct outreach to men with comorbidities that make them more susceptible to COVID and its complications. Given the high rates of pre-existing chronic conditions among men 1the Center for Medicare and Medicaid Services may need to expand access to telehealth services for men to receive care where they are to allow them to remain in isolation and prevent spread of the virus; however, most assisted living and long-term care facilities do not have computer access for residents for this purpose.
This patient-centered care delivery model could be a particularly useful strategy to increase access to preventive medicine for men who are from medically underrepresented groups or groups with lower socioeconomic status In addition to various practice initiatives to reduce virus transmission and mortality, we must also consider the potential policy efforts to address the COVID epidemic in the United States. Because men are dying of COVID disproportionately, policy makers need to explicitly consider gender but not conflate gender with women 1.
To do so, local, state, and national policy makers should ensure that legislation includes language that promotes data collection, disaggregation, and dissemination by race, ethnicity, and sex 1,4, Finally, it is essential for policy makers to adopt 19 male for women equity-based approach that considers the heterogeneity among men 1, Men who are marginalized or disadvantaged because of their race, ethnicity, sexual orientation, incarceration, homelessness, or other factor are particularly vulnerable to COVID and policies should explore which groups of men are overrepresented among essential workers, at risk because of preexisting health conditions, or most in need because of other socioeconomic factors.
A biopsychosocial approach takes into not only the range of factors that determine risk but also the range of places where we might intervene within a population health framework that considers both biomedical and public health points of intervention to reduce mortality from COVID We must ensure that COVID screening, testing, and quarantine of all confirmed and potential cases; contact tracing; financing; and development of vaccines and clinical trials for novel therapeutic targets do not vary by sex or other socially meaningful markers of difference in our society.
Moreover, we need to dramatically increase our investment in the prevention and control of chronic diseases such as hypertension, diabetes, cardiovascular diseases, chronic renal disorders, and mental health disorders that may help us to reduce COVID mortality among men. Drs Griffith and Sharma served as co-first authors and contributed equally to this work. No copyrighted materials were used in the preparation or writing of this article. Corresponding Author: Derek M. : Derek. The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.
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Men and COVID A Biopsychosocial Approach to Understanding Sex Differences in Mortality and Recommendations for Practice and Policy Interventions