Gender Differences in Utilization of Preventive Care Services in the United States

Abstract

Background:

The utilization of preventive care services in the United States remains low, despite health-care costs being as high as $2.3 trillion. While gender disparities have been known to exist for utilization of overall health-care services, the same issue has not been probed for preventive care utilization.

Methods:

A retrospective, cross-sectional study using the 2008 Medical Expenditure Panel Survey (MEPS). Preventive care services common to both genders were included (blood pressure checkup, cholesterol checkup, sigmoidoscopy/colonoscopy, flu shot, and dental checkup). Guideline adherence was determined using clinically accepted guidelines such as Joint National Committee 7 and the American Cancer Society. Descriptive statistics were used to describe the population, and chi-square analysis was used to determine the within group differences between the two genders. A multivariate logistic regression was built to determine the likelihood of guideline adherence based on gender while adjusting for known demographic confounders such as age, race, and ethnicity.

Results:

There were 33,066 MEPS respondents for 2008. Of these, 4,291 to 30,629 met the inclusion criteria depending on the specific preventive care service being analyzed. Men were found to have significantly lower odds of using blood pressure check (odds ratio [OR] 0.35, 95% confidence interval [CI] 0.32–0.38), cholesterol check (OR 0.64, CI 0.60–0.69), dental check (OR 0.71, CI 0.68–0.75), and flu shots (OR 0.71, CI 0.67–0.76). While men had lower utilization for sigmoidoscopy/colonoscopy, the difference was nonsignificant.

Conclusions:

Preventive care utilization was found to be higher in women than in men. The gender disparity issue needs to be explored in greater detail to understand these differences.

Introduction

Health-care spending in the Unites States has been rising disproportionately over the last decade. It has been estimated that over $2.3 trillion was spent on health-care costs in 2008.¹ Among the different strategies to control spending, improved utilization of preventive services has been identified as a potential cost saver in the long run.^1,2 However, current utilization is considered very low, reflected by only 4 cents spent on preventive care for every dollar spent on overall health care.³ The existing literature has attempted to address the issue of underutilization of preventive care; however, very little is known about specific factors such as gender disparities and its influence on utilization.⁴ It has been found that women have greater share in heath-care utilization compared with men.² More recently, National Health and Interview Survey 2009 results showed that contact with health professionals in the last 6 months was higher among women than men.⁵ These findings suggest a need for investigating association of gender in context of preventive care services.

The existing literature addressing the issue of gender disparities mostly includes studies done outside of the United States.^6
–8 Those studies were successful in finding disparities; however, because of the largely different nature of the health-care system in the United States, the results may not apply to the U.S. population. In the United States, the few studies that have been done have hinted at gender differences existing in preventive care utilization; however, these studies were done on a community or state level, not at a national level.⁹ The current gap in the literature can be filled by conducting studies focusing on the U.S. population on a national level.

Based on the existing literature, we hypothesized that gender disparities exist in preventive care utilization in the U.S. population. The primary objective was therefore to identify the gender disparities in utilization of cost-effective preventive care services, namely blood pressure check-up, lipid screening, dental check-up, sigmoidoscopy/colonoscopy, and flu vaccination. Identifying such disparities will help in building future research to guide policy regarding preventive care services.

Materials and Methods

Study design and data source

The study followed a retrospective, cross-sectional design using the 2008 Medical Expenditure Panel Survey (MEPS). MEPS is a nationally representative panel survey conducted by the Agency for Healthcare Research and Quality (AHRQ) of the U.S. Department of Health and Human Services.¹⁰ Each year a panel of around 15,000 households is chosen. Respondents undergo five rounds of computer-assisted personal interview spanning two full calendar years during which all information regarding their demographics, medically related expenditures, sources of payment, access to health care, health status, prescribed medications, and medical conditions are recorded. The study was approved by the Institutional Review Board of University of Toledo.

Inclusion and exclusion criteria

For each of the preventive care services, the MEPS respondents were asked questions regarding utilization of various preventive care services. The specific questions asked by the interviewer pertaining to the preventive care services are listed in Table 1. Adherence to guideline recommendations was determined by suitable self-response to these questions, as noted in the MEPS database. Only those respondents who gave a valid response to the questions asked in the survey and were within the specified age limit for each guideline were included in the study (e.g., for appropriate utilization of blood pressure screening, only adults who were 18 years or older were included; for cholesterol checkup, adults aged 20 years and above were analyzed). Similar criteria were used for determining the population to be used for analysis. The nonvalid responses refer to those who did not know the responses to the question or refused to answer the questions, while non applicable were those who did not provide an answer as the questions were not relavent to them.

Table 1.

Medical Expenditure Panel Survey Questionnaire and Criteria for Determining Guideline Adherence

Services	MEPS question ^a	Adherence to guideline recommendations (age group, frequency)
Blood pressure	About how long has it been since (person) had (person)'s blood pressure checked by a doctor, nurse or other health professional?	Anyone >18 years, annually
Lipid screening	About how long has it been since (person) had (person)'s blood cholesterol checked by a doctor or other health professional?	Adults >20 years, every 5 years
Sigmoidoscopy/colonoscopy	A sigmoidoscopy or colonoscopy is when a tube is inserted in the rectum to view the bowel for signs of cancer or other health problems. (Have/Has) (person) ever had this exam?	Age >50 years, sigmoidoscopy every 5 years, colonoscopy every 10 years
Flu shots	About how long has it been since (person) had a flu vaccination (shot or nasal spray)?	Everyone, annually
Dental	On average, how often (do/does) (person) receive a dental checkup?	Everyone, twice a year

MEPS, medical expenditure panel survey.

Dependent and independent variables

Guideline adherence was determined according to clinically accepted and widely used guidelines, for each preventive care service. For blood pressure check-up, Joint National Committee-7 guidelines were used. The guidelines state that adults above the age of 18 years should get their blood pressure checked every 2 years, while patients with elevated blood pressure should get theirs checked at least once every year.¹¹ For lipid screening, guidelines set by the National Cholesterol Education Program, which stated that all adults over the age of 20 should have their lipid panel checked at least once every 5 years, were considered.¹² For dental checkup, guidelines set by the American Dental Association, which state a routine dental checkup should be done twice a year, were considered.¹³ Flu shot utilization was determined by the recommendations of the Centers for Disease Control and Prevention Advisory Committee on Influenza Practices, which states that a flu shot should be received every year.¹⁴ According to the American Cancer Society, every adult above the age of 50 years should get a colonoscopy done every 10 years, while a sigmoidoscopy should be done every 5 years.¹⁵ In MEPS, respondents get to answer their utilization of both the sigmoidoscopy and colonoscopy through just one question. Hence a conservative estimate of 5 years, instead of 10 years, was chosen to represent appropriate utilization for both and avoid overestimation of the results.

The adherence of the respondents to the various preventive care guidelines was the dependent variable, while gender was the primary independent variable. Age, income, race, ethnicity, type of insurance, and perceived health status were the other independent variables. Age was classified as under 18 years, 18–54 years, 55–64 years, and above 65 years. The level annual income was broken down into four categories: below $20,000, $20,000 to $34,999, $35,000 to $54,999, and above $55,000. Race was classified as white, black, Asian, and other, while ethnicity was classified as Hispanic, non-Hispanic black, non-Hispanic Asian, and other. The type of insurance was identified as public, private, and uninsured.

Statistical analysis

Descriptive statistics were used to describe the study population. A chi-square test determined the within group difference in utilization among the independent variables. A multivariate logistic regression was built to predict the odds of utilization for each preventive care services (blood pressure checkup, lipid screening, dental checkup, sigmoidoscopy/colonoscopy, and flu vaccination), using gender as the primary predictor, while controlling for the other demographic variables. As MEPS involves a complex survey design, AHRQ formulates sampling weights, to be used for providing nationally representative estimates and to avoid nonresponse bias. These weights were used for calculations and all the analyses were done using the SAS version 9.2 (SAS Institute).

Results

A total of 33,066 people responded to the MEPS survey in 2008. Of these, 21,132 met the inclusion criteria for blood pressure checkup, 30,629 met the inclusion criteria for dental checkup, 21,207 met the inclusion criteria for flu shots, 19,498 met the inclusion criteria for lipid screening, and 4291 met the inclusion criteria for sigmoidoscopy/colonoscopy screenings. All demographic characteristics are described in Table 2. Further analysis was done to break down all the study variables based on gander (Supplementary Table S1; Supplementary Data are available online at www.liebertonline.com/jwh).

Table 2.

Sample Distribution expressed as Percentages

Demographic characteristic	Blood pressure check	Dental check	Flu shot	Cholesterol check	Sigmoidoscopy/colonoscopy
Gender
Men	48.11	49.00	48.18	47.89	47.11
Women	51.89	51.00	51.82	52.11	52.89
Age, years
<18	NA^a	24.76	0.18	NA	NA
18–54	63.07	49.28	65.20	63.37	11.40
55–64	12.89	10.83	14.43	15.29	34.80
>65	24.04	15.13	20.19	21.34	53.80
Race
White	81.59	80.22	81.59	81.88	86.83
Black	11.52	12.40	11.45	11.21	8.77
Asian	4.34	4.31	4.42	4.38	2.41
Other race	2.55	3.07	2.54	2.53	1.99
Ethnicity
Hispanic	13.60	15.76	13.72	13.44	5.73
Black non-Hispanic	11.27	12.04	11.2	10.99	8.63
Asian non-Hispanic	4.32	4.27	4.39	4.36	2.40
Other	70.81	67.93	70.69	71.21	83.24
Insurance
Private	68.64	NA	68.54	69.19	72.11
Public	16.37	NA	16.40	16.05	24.21
Uninsured	14.99	NA	15.06	14.76	3.68
Dental insurance
Yes	NA	42.62	NA	NA	NA
No	NA	57.38	NA	NA	NA
Income category, $
<20,000	40.47	55.21	40.70	38.11	35.03
20,000–34,999	20.75	15.72	20.74	21.51	20.58
35,000-54,999	18.16	13.64	18.09	18.90	19.72
>55,000	20.62	15.43	20.47	21.48	24.67
Perceived health status
Missing	0.02	0.02	0.02	0.02	0.00
Excellent	25.76	33.04	26.05	25.18	18.47
Very good	33.02	32.24	32.94	33.07	32.08
Good	27.63	24.02	27.51	28.04	30.73
Fair	10.12	8.05	10.05	10.20	13.53
Poor	3.45	2.63	3.43	3.49	5.19

NA, not applicable.

Women were found to utilize more preventive care services than men in almost all the cases (Fig. 1). Chi-square analysis (Table 3) showed that significant disparities in gender were found to exist in the study population for all the preventive care services (p<0.01), except for sigmoidoscopy/colonoscopy screenings (p=0.1864). Utilization rates for various preventive care services ranged from 52% to 57% compared with 43% to 48% in men. Even for sigmoidoscopy/colonoscopy screenings, a trend of higher utilization was seen amongst women, although the difference was not significant. Overall adherence to guideline recommendations for routine blood pressure checkup, lipid screening, and sigmoidoscopy/colonoscopy screenings was comparable to national statistics and was in the range of 78% to 89%, with adherence being the highest for routine blood pressure checks. Compared with this, the adherence to the guidelines for routine dental checks and annual flu shots was found to be low and stood at 41% and 35%, respectively.

FIG. 1.

Gender-wise and national estimates of average rate of adherence to preventive care services.

Table 3.

Chi-Square Analysis of Adherence to Preventive Care Guidelines and Gender

Preventive care service	Men (%)	Women (%)	p value (χ²)
Blood pressure check	45.18	54.82	<.0001
Dental check	45.38	54.62	<.0001
Flu shot	42.55	57.45	<.0001
Cholesterol check	46.04	53.96	0.0022
Sigmoidoscopy/colonoscopy	47.62	52.38	0.1864

After controlling for all predisposing factors (race, ethnicity, income category, type of insurance, age, and perceived health status) known to influence the utilization of preventive care services, gender was seen to predict appropriate utilization, except in the case of sigmoidoscopy/colonoscopy screenings. Women were found to have higher odds of utilizing preventive care services than men for each service in which disparities were significant (Table 3). It was found that men were less likely to be adherent to the guideline recommendations for blood pressure checkup compared with women (OR 0.35, CI 0.32–0.38). Also they were less likely to be adherent to annual flu shots (OR 0.71, CI 0.67–0.76), routine dental checkups (OR 0.71, CI 0.68–0.75), and routine lipid screenings (OR 0.64, CI 0.60–0.69) than women (Tables 4 and 5).

Table 4.

Results of Logistic Regression Analysis for Blood Pressure Check, Cholesterol Check, and Sigmoidoscopy/Colonoscopy Guideline Adherence

	OR (95% CI) ^a
Variables	Blood pressure check	Cholesterol check	Sigmoidoscopy/colonoscopy
Age, years
18–54	Reference
55–64	1.50 (1.29–1.74)	0.11 (0.10–0.13)	0.94 (0.70–1.27)
>65	1.98 (1.73–2.27)	0.48 (0.39–0.59)	0.89 (0.66–1.19)
Gender
Female	Reference
Male	0.35 (0.32–0.38)	0.64 (0.60–0.69)	1.10 (0.98–1.31)
Race
White	Reference
Black	1.29 (0.71–2.34)	0.77 (0.46–1.30)	>999.99 (0.01–999.99)
Asian	0.55 (0.11–2.72)	1.24 (0.25–6.17)	<0.01 (0.01–999.99)
Other race	1.11 (0.87–1.43)	1.02 (0.83–1.24)	1.40 (0.74–2.66)
Ethnicity
Hispanic	Reference
Black non-Hispanic	1.28 (0.70–2.33)	1.36 (0.81–2.30)	<0.01 (0.01–999.99)
Asian non-Hispanic	1.72 (0.35–8.58)	0.71 (0.14–3.54)	>999.99 (0.01–999.99)
Other	1.72 (1.55–1.90)	0.72 (0.66–0.79)	0.54 (0.40–0.74)
Income category
<20,000	Reference
20,000–34,999	1.16 (1.04–1.30)	1.26 (1.15–1.39)	1.00 (0.80–1.26)
35,000–54,999	1.42 (1.23–1.63)	1.69 (1.51–1.90)	1.14 (0.88–1.48)
>55,000	1.85 (1.60–2.14)	2.77 (2.45–3.13)	1.27 (0.98–1.66)
Insurance
Private	Reference
Public	0.89 (0.77–1.02)	0.73 (0.65–0.82)	0.81 (0.65–1.00)
Uninsured	0.27 (0.24–0.30)	0.41 (0.37–0.45)	0.57 (0.39–0.83)
Perceived health status
Excellent	Reference
Missing	0.20 (0.01–3.19)	0.18 (0.01–2.72)	NA
Very good	0.23 (0.16–0.34)	0.21 (0.15–0.28)	1.09 (0.72–1.67)
Good	0.31 (0.21–0.44)	0.27 (0.20–0.36)	1.02 (0.69–1.51)
Fair	0.32 (0.22–0.46)	0.33 (0.25–0.45)	0.96 (0.65–1.41)
Poor	0.53 (0.36–0.79)	0.50 (0.37–0.68)	1.03 (0.68–1.55)

OR, odds ratio; 95% CI, 95% confidence interval.

Table 5.

Results of Logistic Regression for Dental Check and Flu Shot Guideline Adherence

	OR (95% CI)
Variables	Dental check	Flu shot
Age, years
<18	Reference
18–54	0.36 (0.34–0.39)	1.58 (0.67–3.75)
55–64	0.50 (0.45–0.56)	4.32 (1.82–10.28)
>65	0.57 (0.52–0.62)	9.40 (3.96–22.31)
Gender
Female	Reference
Male	0.71 (0.68–0.75)	0.71 (0.67–0.76)
Race
White	Reference
Black	0.93 (0.68–1.28)	1.55 (0.99–2.43)
Asian	3.07 (1.19–7.89)	1.28 (0.32–5.21)
Other	0.98 (0.86–1.11)	1.05 (0.87–1.25)
Ethnicity
Hispanic	Reference
Black non-Hispanic	1.21 (0.89–1.66)	0.63 (0.40–0.99)
Asian non-Hispanic	0.48 (0.18–1.23)	1.17 (0.29–4.75)
Other	1.70 (1.6–1.81)	1.35 (1.24–1.47)
Income category, $
<20,000	Reference
20,000–34,999	1.25 (1.15–1.35)	1.16 (1.07–1.27)
35,000–54,999	1.97 (1.81–2.14)	1.25 (1.13–1.38)
>55,000	2.68 (2.46–2.92)	1.59 (1.45–1.75)
Insurance
Private	Reference
Public	NA	1.01 (0.92–1.1)
Uninsured	NA	0.42 (0.38–0.47)
Dental insurance
Yes	Reference
No	0.48 (0.46–0.51)	NA
Perceived health status
Excellent	Reference
Missing	0.68 (0.07–6.26)	0.77 (0.08–7.61)
Very Good	2.32 (1.91–2.81)	0.44 (0.37–0.53)
Good	2.01 (1.73–2.54)	0.49 (0.42–0.59)
Fair	1.85 (1.52–2.24)	0.56 (0.47–0.66)
Poor	1.43 (1.16–1.75)	0.72 (0.60–0.86)

Discussion

A trend of greater utilization of preventive care services was seen among women when compared with men. The higher utilization of general health-care services has been well documented for women and the same was seen for preventive care services. This higher utilization is often said to be as a result of reproductive health-care needs and increased prevalence of chronic illness.¹⁶ The lower preventive care utilization seen in men reinforces the commonly held view that they are less likely to visit a doctor and thereby utilize these health-care services poorly.^9,17 Recent national estimates from The National Health Interview Survey of 2009 in the U.S. population showed that 25% of men had no office visits to the doctor in the past 12 months compared with 12% of women.¹⁸ The low interaction of men with a health-care provider might lower their probability of seeking or being administered preventive care services, which was seen in our study population as well. In this study, blood pressure and cholesterol check services were found to be utilized more in women than men. This higher utilization by women is a positive sign, as past reports have found that only 57% of women might be aware that cardiovascular disease is the biggest cause for mortality among women.¹⁹ The overall trend of lower utilization of cholesterol checkup though is a cause of concern and needs to be encouraged in both sexes, especially in women. This is because high-density lipoprotein cholesterol is a stronger predictor of heart disease in women than in men.²⁰ Identifying any abnormalities through a cholesterol checkup will help in early detection and timely initiation of therapy and avoid potential long-term complications.

For the preventive care services dental checkup and flu shot in past year, even though women were found to have a higher utilization, the overall utilization was very low. For dental checkup, our results were comparable to previous studies that have assessed use of this service by men and women.²¹ Studies done in other countries have shown that presence of dental insurance and having dental checkups are related.^22,23 The gender difference found in this study existed even after controlling for dental insurance status. The low utilization of flu shots among both men and women was similar to what other studies and reports have found.^24,25 Cutting across genders, the very low utilization of flu shots is an issue that should draw the attention of policymakers because the cost of a severe influenza epidemic is estimated to be greater than $87 billion.²⁶ The only preventive care services for which no gender disparity was found was sigmoidoscopy/colonoscopy. Present statistics in this country neither show nor refute the presence of gender disparity for these services. In a study done in United Kingdom, however, it was found that colorectal screening rates were higher in men compared with women, but these differences could be explained by socioeconomic differences.²⁷

There are several possible explanations for the difference in health and utilization behaviors. The female hormone estrogen has been suggested to play a role in differences in health between the two genders.²⁸ Additionally, the lack of help-seeking behavior in men may be due to their perceptions of “masculinity” and affects early treatment and prevention.²⁹ Further, women traditionally have had a greater role and responsibility in managing family's health, and they have higher likelihood of using health-care services.²⁸ While there might be several factors ranging from biological, social, and psychological at play, it has been shown in the literature that women generally report a poorer quality of life compared with men.³⁰ The lower perceived quality of life may play a role in the way men and women utilize the preventive care services. It was seen that for all preventive care services that were analyzed, except for dental care services, poorer self-reported health status had equal or a higher likelihood of utilizing the preventive care services compared with respondents with better health. However, gender disparities persisted even after controlling for the self-reported health status. Poorer quality of life has been found to be linked to increased health-care utilization such as emergency room and hospital visits, particularly among the elderly.³¹ Recent national level data reported by Tang et al.³² have also shown that women continue to have disproportionately higher number of emergency room visits compared with men.

The association between lower health status and higher utilization of preventive care services seen in this study was surprising because higher utilization of preventive care services has been shown to lower adverse outcomes in several chronic conditions.^33,34 The current health-care reform has recognized the importance of preventive care services and does not require consumers to pay anything for these services.³⁵ Our findings show that the current status of preventive care utilization by women, though higher than by men, remains low overall and needs to be improved to lower the chances of acute care utilization. The results of this study can help direct further research towards finding avenues to optimize preventive care services by making efforts to eliminate disparities.

Limitations

Because all responses in MEPS are self-reported, the data will suffer from recall bias from the respondents, particularly when asked to recall the last time they utilized events, which could be as long as 5 years back for some of these services like cholesterol checks and sigmoidoscopy/colonoscopy. Another limitation due to the nature of the MEPS database was that adherence to sigmoidoscopy and colonoscopy screenings could not be analyzed separately. As they have different guideline recommendations, this limited our ability to accurately represent disparities for these services.

Conclusion

As with other health-care services, women in this study were found to have higher utilization of preventive care services. While overall utilization was of concern for specific services, issues in women's health care need to be further explored to determine why they have higher health care utilization despite better utilization of preventive care when compared with men.

Footnotes

Disclosure Statement

No competing financial interests exist.

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