The primary goal of this cross-sectional community study was to examine the relative contribution of predisposing, enabling, need, and normative/attitudinal factors to routine health examination scheduling and receipt among African American men. Using the Andersen model28
and theory of reasoned action29
as frameworks for our investigation, we found that African American men in our sample were more likely to schedule and obtain a routine health examination when they had a usual source of care and were exposed to health-promoting male subjective norms. Routine health examination receipt was lower when African American men reported less trust in medical organizations and believed that “real men” should keep their concerns private and emotions out of view. Prior studies have reached similar conclusions when investigating such factors in isolation.34,48
However, none have simultaneously considered the role played by health care access, male norms, and attitudes linked to race-based incidents of medical maltreatment in quantitative investigations of African American men's preventive health services use. Our study addressed this important gap in men's health research and underscores the importance of augmenting general health care utilization models with health behavioral theories to improve our ability to detect the full range of psychosocial factors impacting African American men's decisions to use preventive services.
None of the predisposing factors produced a consistent impact on routine health examination scheduling. However, older men were more likely than younger men to obtain routine health examinations even after accounting for enabling, need, and attitudinal factors. This finding may be attributable to a greater investment in health monitoring among older men produced by normative aging. Initially, older African American men were also more likely to schedule routine health examinations, but this association was attenuated in the face of other study factors. We believe that this attenuation suggests that factors impacting intentions to obtain routine health examinations may be more similar among younger and older African American men. Admittedly, younger men are generally in better health and therefore may require less frequent routine health surveillance, yet when African American men's delayed presentation,57
and more abridged lifespan due to preventable conditions58
are considered, our finding that younger men had a reduced likelihood of scheduling and obtaining routine health examinations may appear less inconsequential. Hence, we join others mounting the growing adolescent and young, adult, male preventive health care agenda25,26,59
by suggesting the need to develop interventions designed to improve routine health examination uptake early in the African American male life course.
Consistent with prior evidence,60
African American men in the lowest education group had the lowest odds of scheduling a routine health examination, but only when enabling and need factors were excluded. Prior evidence indicates that lower education is associated with poorer health status and limited health care access.61
Thus, it is likely that the effect of education was absorbed by these factors. Education was not significantly associated with routine health examination receipt, and most of the ORs in our multivariate models were in an unexpected direction, indicating a higher likelihood of receipt among less-educated men. Although we are not certain and lack sufficient power to adequately test our hypothesis, we speculate that other factors (eg, mental health status) may be moderating the effects of education on routine health examination receipt. Future studies with larger sample sizes should explore this possibility. Even so, our findings imply that the positive influence of education on African American men's receipt of routine health examinations may be primarily felt through its tendency to increase intentions to obtain these services. Hence, less-educated African American men may need more buttressing of their behavioral intentions by policies that reduce structural barriers to health care and socioeconomic status attainment. Such a focus has been suggested by others62
and may be especially warranted since less-educated men formulate health care utilization intentions amidst a variety of competing downstream psychosocial priorities.
In line with existing studies documenting the positive impacts of marital status on men's health,63,64
we found that married African American men were more likely to report scheduling a routine health examination. However, this association did not hold up in models adjusting for the influence of our enabling or combined factors. Marriage has been shown to positively impact men's health insurance and usual source-of-care access.65
Although our attenuated finding may be attributable to suppression effects, it is equally plausible to presume that spousal encouragement to schedule routine health examinations may be of limited effectiveness when it is unmatched by health care access. This hypothesized limitation of spousal encouragement is further illustrated by the nonsignificant association between marital status and routine health examination receipt. Nonetheless, we encourage health care providers to direct some of their efforts to improve preventive services use among African American men towards engaging spouses or partners, who can offer supportive reminders to obtain periodic examinations and recommended screenings. Public health researchers might also undertake qualitative investigations, which might provide additional information about spousal or partner relationship dynamics around health care use that can inform future community-level interventions with African American men.
Usual source of care constitutes a significant facilitator of routine health examination scheduling and receipt among our sample, a well-documented finding in other populations.48
The strength of this association is even more notable since the number of men in our sample reporting a usual source of care is lower than the percentages (80%-82%) reported in data summaries from the US National Health Interview Survey.66
While our sample is relatively anomalous in terms of the roughly 70% to 80% of African American men estimated as having either private or public health care insurance during our study period,67
that alone was not a significant predictor of having scheduled a routine health examination in our study. This finding implies that although health insurance is an important determinant of routine health examination scheduling, its effect is likely mediated through having a usual source of care. Since our results imply that health insurance may not ensure access, policy makers will want to focus not only on improving coverage among African American men but should also work to bridge gaps in health services continuity. In the end, need factors did not play a role in routine health examination scheduling or receipt among our sample. Admittedly, this finding likely reflects the relatively healthy status of our younger sample. Future investigations among younger men should employ other indicators of health need that are less sensitive to the confounding effects of age.
We join other studies citing the significance of male role norms in men's health behavior18,43
and extend those examining the contribution of medical mistrust to health services use35,36
to a community-based sample of African American men. Corroborating previous findings,43,68
we found that traditional male role norms around disclosure negatively impacted African American men's routine health examination receipt. African American men's decisions to obtain routine health examinations may be negatively influenced by concerns over disclosing vulnerability because of distal (eg, the Tuskegee study) and proximal (eg, racial discrimination) experiences that heighten anticipation of medical maltreatment and threaten sense of masculine control.
However, our findings also offer important preliminary insights about how subjective male norms might work to positively inspire African American men to take preventive health action even, while they express a strong endorsement of traditional masculine role norms. We did not observe a significant bivariate or multivariate relationship between traditional male norms around disclosure and routine health examination scheduling. It could be that the inclusion of other aspects of masculinity that were not measured in the current study (eg, conformity to masculine role norms and male role-specific barriers to health help seeking) might help to clarify the relationships between this factor and African American men's preventive health care intentions. Health value also did not emerge as a significant correlate of African American men's routine health examination scheduling. For African American men, health value beliefs may be more important correlates of health behaviors with a higher degree of autonomy and that depend less on health care system engagement (eg, dietary behavior or physical activity).
To our knowledge, this investigation is one of few empirical studies linking medical mistrust to African American men's routine health examination obtainment. Since we included 2 indicators of routine health examination obtainment, we also add to this knowledge base a better understanding of when medical mistrust might enter the preventive health care decision-making process for African American men. Specifically, our findings imply that African American men's intentions to seek routine health examinations may be less altered by medical mistrust than lack of health care access. On the other hand, whether African American men show up for routine health examinations may be more contingent on how much trust they have in medical organizations. The more pronounced association between medical mistrust and routine health examination receipt may also be a consequence of problems in the processes of obtaining care after appointments have been scheduled, which was unaccounted for in our models. Cultural competence training in medical education may want to emphasize patient-centered care delivery with African American men as a strategy to increase their preventive health services use since this interactional style has been associated with lower levels of mistrust among this population38
and may mitigate male role-related concerns about disclosing vulnerability.
Our study has some notable limitations. Given the descriptive and cross-sectional nature of this study, we cannot clearly establish causal relationships with our data. Future studies should employ longitudinal methods and more complex sampling designs. We also used recruitment methods that did not allow us to draw a nationally representative sample of African American men, which limits our ability to make generalizable inferences. However, during the data collection period, between 34% to 40% of African American men in the United States were married,69
the unemployment rate among this group was between 8.4% and 13.4%,70
and 20% to 21% reported completing some college.69
These data suggest that our sample is demographically similar to the US population of African American men. We assessed routine health examination scheduling with a single-item question and used the CES-D as a sole indicator of mental health status. Future studies will want to use additional data sources (eg, appointment records) to assess routine health examination scheduling and evaluate other dimensions of mental health status. Our data were also obtained by self-report, a manner which increases the possibility for bias responding. However, since we present estimates adjusted for social desirability using a well-established measure51
in our multivariate logistic regression models, reporting bias effects are less probable. Our relatively small sample size may have also limited our ability to detect effects in some of our models.
Despite these limitations, our study moves the literature beyond simple documentation of gender and race differences in health services use towards a more comprehensive understanding of specific psychosocial aspects of race and gender influencing preventive health care utilization among a population of men at greatest risk for disparities. To our knowledge, our study is one of few existing investigations that address a broad range of psychosocial factors associated with African American men's routine health examination receipt and scheduling. Our use of barbershops as a primary recruitment site increased the probability of reaching a cross-section of African American men who may have not been reached by traditional sampling approaches. This study also provides information that can be used in interventions designed to reduce disparities in African-American men's health care utilization. Situated within current debates about the value of routine health examinations1-3 71
and documented patterns of men's preventive health care avoidance,7,8,72
our findings suggest that improving preventive health care engagement among African American men will require a simultaneous focus on increasing health care access, mitigating concerns about racially biased medical treatment, assuaging concerns about disclosing vulnerability, and leveraging health promoting male social networks.