Survey on the use of health services by adult men: prevalence rates and associated factors1

Objective estimate the prevalence and identify factors associated with the use of health services by men between 20 and 59 years of age. Method population-based, cross-sectional domestic survey undertaken with 421 adult men, selected through systematic random sampling. The data were collected through a structured instrument and analyzed using descriptive and inferential statistics with multiple logistic regression. Results the prevalence rate of health service use during the three months before the interviews was 42.8%, being higher among unemployed men with a religious creed who used private hospitals more frequently, had been hospitalized in the previous 12 months and referred some disease. Conclusion the prevalence of health service use by adult men does not differ from other studies and was considered high. It shows to be related with the need for curative care, based on the associated factors found.


Introduction
In knowledge production about man's health, studies have evolved towards solving the reduction on the health of the male in relation to the female population, reflecting on inequalities in health and appointing the importance of a broadened perspective on the differences between men and women regarding the morbidity and mortality profile (1) .
A review on man's health indicates hypotheses to explain these differences: biological and genetic singularities of the sexes; social inequalities; gender differences; frailties in professional health care for men; little demand and use of health services by men (2) . These hypotheses support the characteristics of a background marked by unfavorable health conditions for men (2) .
The use of health services is a complex behavior with multifaceted determinations, according to differences in locations, socioeconomic situation, morbidity profiles, quality of life and knowledge about health (3) . In a study about factors associated with health service use, important variations are revealed according to age, sex, income, education, skin color and even differences inherent in the type of care model that is adopted (4)(5) . In that context, health surveys can provide important information on the characteristics of the population, which are necessary to formulate practices and public policies, considering that health services particularly avail themselves of the users' problems to elaborate their actions (6) .
The groups of men who use health services are not homogeneous and, therefore, international recommendations appoint the need for studies that demonstrate these differences in the profiles, so as to support alternative approaches to man's health (7) .
Studies on the use of health services are undertaken to identify what factors are associated and what determines the population, in this case adult men's use of the services. Knowledge on these factors can equip professionals and managers to plan, operate and assess care strategies, programs and models (8) , with a view to promoting the supply of and access to the services, entailing improvements in the health profile of the male population.
In that sense, the objective in this study was to estimate the prevalence and identify the factors associated with the use of health services by adult men, according to socioeconomic, demographic, health and service usage characteristics.
The prevalence of health service use during the three months before the research was 42.8% (n=180) and was higher for the public services (57.8%). The most used service type was the primary health care service (46.3%), the most used type of attendance was the doctor's appointment (82.7%) and disease was the most prevalent reason to visit the service (55.3%).
During the previous 12 months, 11.7% of the men had been hospitalized. Most men (77.0%) showed a positive self-perceived health, although 42.8% reported some morbidity.
In Table 1, it is observed that, in the univariate analysis, "occupational status" and "work" were associated with health service use in the three months preceding the research.    Arruda GO, Marcon SS.
Although the literature appoints that women use health services more often, mainly due to gynecological, genital-urinary and obstetric causes and greater perceived health risks (9) , it is highlighted that health service use has increased in general, thanks to the expanded coverage of the Unified Health System (SUS), greater access to private health insurances and health information (3) . were contacted, including elderly people (5) . As health services tend to be used more among the elderly (8) , their participation tends to increase the prevalence, even when a shorter period is considered.
As regards the services men use more, during the three months before the research, it was verified in a study undertaken in the city of Pelotas that the prevalence of primary health service use among men and women corresponded to 49.5%, without significant differences between the sexes (6) . Therefore, the prevalence found in this study is not distant from that found in the other research. In view of the logic of the high population coverage, expanded access and service organization based on integral health care, the relevance of primary health care services is highlighted as the services the male population uses most (3) .
The higher proportional use of this service, however, should not be the sole parameter to verify the actual access to public services nor the attendance to the male population's health needs as, according to the literature, it is common for men to enter the health system through specialized care services, due to the worsening of a disease, deriving from a delay to seek care (1) . In a study developed in Ribeirão Preto, SP, the duplication of services was found, that is, the simultaneous use of primary health care and emergency services for the same end (diagnosis, treatment or rehabilitation), pointing towards the absence of problem-solving care and dissatisfaction among the users (14) .
Aiming for integral care, therefore, the need emerges to create conditions to produce care at all levels, but mainly in Primary Care, in which the teams frequently face a lack of time for planning, structural shortages in the services and professional limitations in the interventions (15) .
The literature appoints that the doctor's appointment is the main type of care demanded. Some studies exclusively focus on the usage pattern of this type of care (4,6,9) . Concerning men's demand for doctor's appointments, in a review on the health situation of the male population in Canada, 80% of the men refuse to consult the doctor and only give in when convinced by their wife or partner (16) . Nevertheless, the higher proportional use of medical consultations is not only due to men's demand for this type of care but is also the services' main response to the population's health problems, of rationality mainly centered on a curative care model that only privileges the consumption of the service offered, secularizing and abolishing other care possibilities.
In terms of factors admittedly associated with the use of health services, it should be highlighted that the literature has appointed the importance of the relation between advanced age and increased frequency of health service use, due to the new care demands, more frequent hospitalization and longer/more expensive interventions, as consequences of aging associated with illness (8,17) . These findings underline the premise that the age range should be considered, like in this study, as an adjustment factor to estimate explanatory models for the use of health services. Nevertheless, it is highlighted that, in the preliminary univariate analysis (without theoretical adjustments), the age range showed no statistically significant association, possibly due to the fact that, among men between 20 and 59 years of age, the proportion of health service use did not vary among the age ranges, as opposed to what could have been observed if elderly men were included in the study. In addition, the interval between 50 and 59 years, which showed a greater difference when compared to the reference category (20 to 29 years), was not the most frequent in the total sample, leading to the conclusion that the sample size of the age subgroups may have influenced the non-identification of an association between age and health service use.
The greater use of health services by unemployed individuals, as verified in this study, was also identified in the population covered by the family health strategy in Porto Alegre, RS (3) . In another study, developed in ten Brazilian metropolitan regions, an association was found between unemployment and worse health conditions among adult men between 15 and 64 years of age (18) . The work relations result in health inequalities, demanding the implementation of effective policies and institutional changes to promote equity (18) . Hence, Rev. Latino-Am. Enfermagem 2016;24:e2685 besides overcoming barriers, increasing the service supply and adapting the health institutions' profile to the users who work, attention to unemployed individuals is urgent, especially in the adult male population (18) , for which work indicates the exercise of manhood.
Having a religious creed was associated with greater health service use among the investigated men.
Hence, adhering to or following a religion influences, sometimes positively, the health conditions and the adoption of healthy behaviors. A study involving 345 adult Latin individuals living in Texas showed that the proportions of alcohol abuse and smoking were significantly higher among people who indicated having no religion at all (19) . In another study involving 1,076 North Americans, it was shown that having a religion predisposes to greater health service use for preventive ends, mainly because they participate in preventive activities in the religious community, and also because they talk about behaviors and tests with peers who follow the same religion (20) .
Paradoxically, an association was found between the occupational status "unemployed" and the management type "private" and health service use.
Nevertheless, this can be justified as follows: 35% of the unemployed men informed having a health insurance, some of whom informed they were registered as dependent in their partner or children's insurance so that, even without an income, they had access to health insurance services; 30% of the people who indicated they were unemployed were between 20 and 29 years old, that is, young men, who were not even professionally active yet, with studying as their main activity, and therefore dependent on the family for expenses in general and health expenses in particular.
Even in case of unemployment, private health services can be used when other family members pay for them.
The most frequent type of health system gained significance in the multiple analysis, like hospitalization in the previous years and reference to some disease.
When the use per management type is verified, a greater demand for health services is observed for individuals who use private health services, despite the increased demand for public services in the general population.
One aspect that was not mentioned in this study refers to the use of public services by insured people/people with a health insurance as a secondary option, mainly in function of some services charged in the private sphere, like vaccination, or delivered exclusively in the public sector, like medication distribution (21) . These two types of services frequently attract men to the public health system (22) .
Concerning hospitalization, the prevalence of this event was much higher than in a Brazilian study using PNAD data, in which the prevalence of hospitalization amounted to 7.0 and 7.1% (18) in 2003 and 2008, respectively, and also higher than in a study in the South of Brazil (9) . hospitalized within one year before the interview (6,9) . This finding may be related to the fact that the individuals who were hospitalized are sicker than people who were not hospitalized and, therefore, have a greater demand for health services (9) . In addition, adult men tend to self-perception lost significance in the multiple analysis applied in this study, like in another study (6) .
In addition, the prevalence of referred morbidity remained within the limits evidenced in a Brazilian study in the age groups between 25 and 49 years (33.9%) and between 50 and 64 years (62.0%) (26) .
It was verified that the referred morbidity was associated with greater use of health services among adult men. This finding was in line with the literature, mainly concerning chronic illnesses (9,10,27) . This appoints that men are seeking monitoring, which is positive as, Arruda GO, Marcon SS.
sometimes, they are known for the difficulty to socialize their health problems and, after conquering this barrier, the health professionals have the opportunity to establish a therapeutic bond. On the other hand, it may indicate that they only seek professional support when they are ill. This is a source of concern, especially for young men, who should spontaneously seek health promotion and preventive care orientations as well, beyond mere medical and curative care.
Having a health insurance was not identified as an associated factor, in turn, although the literature appoints that this resources allows men to use health services more frequently, as evidenced in a study among Asian and American men (28) . Even when they live in an area covered by the family health strategy, adult men can choose to use health insurance services (6) for reasons like the delay to get care, the lack of professionals and inputs, the predominance of women, children and elderly people at the primary care services, lack of valuation of preventive practices and fear because they cannot choose the professional who will attend them (22) . Therefore, having a reference professional can play a determinant role in the demand for and use of the health services (6) . In a populationbased study, for example, it was observed that the probability of having a prostate exam increased by 98% among patients who indicated having a reference professional (4) . The findings on the association between unemployment and use of private or health insurance plans stand out, based on which it can be inferred that the access to these types of services derives from family dependence, especially when considering that most of the men who self-declared they were unemployed were between 20 and 29 years of age. Thus, in the current family configuration patterns, young people commonly stay longer at their parents' home and depend on them, also for health expenses. Another issue that should be considered is that, although many consider they are family heads and unemployed, another person can serve as a family provider and pay for the family's needs.
In view of the associations found, mainly factors like hospitalization in the previous 12 months, negative self-perceived health and reference to some morbidity, health service use among adult men seems to be related with the need for curative care. Therefore, it is fundamental that, from the formulation to the implementation of man's health policies and programs, the associations found in this study are taken into account.