There is compelling evidence of several biomedical explanations for men’s apparently greater vulnerability to COVID-19 infection and mortality. But what about behaviour and attitudes?

The biological explanations include men’s weaker immune response and their higher expression of the ACE2 receptor which provides a route for the virus to penetrate cell walls in the lungs. Men’s health-related behaviours and beliefs could also help to explain why men appear to be more susceptible to infection and death. This article looks at the behaviours and beliefs that have recently been specifically linked with an increased risk of COVID-19 infection and death in men.

Smoking

Smoking is likely to be of particular significance because of the long-term damage it can cause to the lungs. In China, 46% of men smoke compared to 1% of women, according to WHO data. In Italy, 27% of men and 20% of women smoke. In the UK, the ‘sex gap’ is smaller: it is currently 17% of men and 13% of women.

However, in 2016/17, men in the UK were twice as likely as women to be admitted to hospital for conditions attributable to smoking (an estimated 6% vs 3% of all hospital admissions). This suggests that even though smoking rates have fallen in men in recent years and are now closer to the rates in women, the legacy of previously higher levels of male smoking could be relevant to the differential impact of COVID-19.

Drinking

There is evidence that alcohol consumption at hazardous levels can increase the risk of respiratory diseases. People with alcohol use disorder (AUD) are more likely to develop pneumonia, tuberculosis, respiratory syncytial virus infection, and acute respiratory distress syndrome. Increased susceptibility to these and other pulmonary infections is caused by impaired immune responses in people with AUD. In the UK, according to WHO data, the average man consumes almost five times as much alcohol as the average women. This potentially elevates the risk of severe COVID-19 disease in men.

Hand-washing

Men could be more exposed to COVID-19 because they are less likely to wash their hands. There are several studies looking at handwashing after using the toilet. A study of the handwashing practices of college students using restrooms in the USA found that 76% of women washed their hands compared to 57% of men and that 56% of women used soap compared to 29% of men.

A review of studies of handwashing practices in the community during and after the SARS outbreak in Hong Kong in 2003 found significant differences in compliance between men and women. During the H1N1 influenza outbreak in South Korea in 2009, female university students were more likely than male to wash their hands more frequently: 34% of male students washed their hands five times a day compared to 57% of female students.

A YouGov survey of 2,000 UK adults conducted on 19/20th March 2020 found that, in the past two weeks, most men and women had taken steps to protect themselves from COVID-19 by improving their personal hygiene (e.g. by washing their hands frequently or using a hand sanitiser). But fewer men than women had taken this step: 67% vs 74%.

Attitudes to the virus

A separate YouGov survey of over 2,000 adults in Great Britain conducted on 24/25th March concluded that men are more likely to downplay the severity of the virus. Nearly a quarter of men (24%) inaccurately believe coronavirus is ‘just like the flu’ compared with just 16% of women. Similarly, men are more likely to believe that coronavirus only affects older people and those with underlying health conditions at 14% versus 8% of women. They are also less inclined to believe official Government advice such as staying at home to stop the virus from spreading, with 10% saying this is false compared with 2% of women.

Delayed presentation

It has been reported in the media that men’s outcomes following COVID-19 infection could be worse because they are delaying seeking medical help. It has been suggested that men have been arriving in hospital in China with more advanced disease, for example. While there are no known published studies on this issue, it is widely believed that men generally use health services less effectively than women.

According to the WHO, there is good evidence that men with tuberculosis, a lung disease whose symptoms include a high temperature and a persistent cough, remain infectious in the community for longer than female patients because they are less likely to seek care.

Behaviour + biology

In conclusion, it is highly probable that men’s behaviours and beliefs, as well as their innate biology, are a factor in their susceptibility to COVID-19 infection and mortality. This in turn suggests that health services should adopt a response that takes account of these sex and gender differences, for example by developing male-targeted health information that improves men’s knowledge of the risks of COVID-19, prevention and the importance of timely help-seeking when appropriate. There should also be investment in research that aims to improve understanding of the biomedical and behavioural issues and to identify more effective interventions in the longer term.

Peter Baker
Men's Health Consultant
Director, Global Action on Men’s Health