Report on the status of men's health in Georgia : a picture of men's health and well-being

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Contents

1

5 Introduction

3

Highlights

7 Chronic Diseases

Georgia's Aging Male Population

Cardiovascular Disease

Cancer

Diabetes

Arthritis

13 Injuries

Motor Vehicle Crashes

Homicide

Suicide

Falls

17 Health Behaviors

Smoking

Physical Activity & Weight

Colorectal Cancer Screening

Seat Belt Use

21 Infectious Diseases

Gonorrhea

HIV/AIDS

Tuberculosis

Influenza and Pneumonia

25 Substance Abuse

27 Health Care Utilization

28 Conclusion

29 Definitions

30 Data Sources

Acknowledgments

Georgia Department of Human Resources Division of Public Health Family Health Branch Chronic Disease Prevention and Health Promotion Branch Epidemiology Branch Prevention Services Branch Environmental Health and Injury Prevention Branch Graphic Designer

Gary B. Redding, Acting Commissioner Kathleen E. Toomey, M.D., M.P.H., Director
Rosalyn K. Bacon, M.P.H., Director James Brannon, M.S. M.Ed., Director
Paul Blake, M.D., M.P.H., Director Jack Kirby, Acting Director Mike Smith, Director Jimmy Clanton, Jr.

2000 Report on the Status of Men's Health in Georgia

4

Table 1 10 Leading Causes of Death in Georgia Males, by Age Group, 1994 - 1998

2000 Report on the Status of Men's Health in Georgia

Rate 1 2 3 4 5 6 7 8 9 10

15 -24 (N = 3,826)
Unintentional Injuries 1,712 Homicide

Number of Deaths in Each Age Group for the Time Period*

25 - 34 (N = 6,097)

35 - 44 (N = 10,320)

45 - 54 (N = 15,023)

55 - 64 (N = 21,638)

65 and over (N = 87,001)

Unintentional Injuries 1,528 HIV

HIV
2,056 Heart Disease

Heart Disease
4,329 Cancer

Heart Disease
7,086 Cancer

Heart Disease
28,773 Cancer

Total All Ages (N - 148,318)
Heart Disease
42,565 Cancer

809 Suicide
561 Cancer

1,460 Homicide
725 Suicide

1,704 Unintentional
Injuries 1,582
Cancer

3,544 Unintentional
Injuries 1,156
HIV

6,894 Stroke
995 COPD

21,957 Stroke
6,044 COPD

34,091 Unintentional
Injuries 9,561
Stroke

142 Heart Disease

669 Cancer

1,118 Suicide

829 Stoke

120

329

732

673

HIV

Heart Disease Liver Disease

Suicide

63
Congenital Anomalies
41 Pneumonia and
Influenza 28
Stroke

414 Pneumonia and
Influenza 79
Stroke
78 Diabetes

265 Pneumonia and
Influenza 178
Diabetes
162 Kidney Disease

532 Liver Disease
529 Diabetes
307 Homicide

850 Unintentional
Injuries 793
Diabetes
513 Liver Disease

5,707
Pneumonia and Influenza 3,816
Unintentional Injuries 2,017
Diabetes

8,121 COPD
6,927 Pneumonia and
Influenza 4,819 HIV

475
Pneumonia and Influenza 362 Suicide

1,609 Kidney Disease
1,243 Septicemia

4,713 Suicide
3,456 Homicide

23 Diabetes
17

54 Liver Disease
41

74 Congenital Anomalies
36

288 Pneumonia and
Influenza 278

331 Pneumonia and
Influenza 34,091

1,198 Alzheimer's
Disease 802

2,711 Diabetes
2,664

*Note: The "N" at the top of each column stands for number of total deaths in that age group, including the deaths that are not in the top ten causes.

2

Introduction
5
Introduction
American men are living longer today than ever before. A man's life expectancy has increased from 48 years in 1900 to nearly 74 years in 1997. Advances in public health have played a major role in increasing the overall life expectancy of men. However, even though men are living longer today than in the past, they currently die nearly seven years younger than women. Despite progress in increasing the overall life span of men, several important men's health issues continue as major problems today. Also, new health challenges have arisen, many related to aging because of men's longer life span.
Male health concerns vary in relationship to a man's age (Table 1). Among adolescent males and younger men, motor vehicle crash injuries, homicides, suicides, and infectious diseases, such as Tuberculosis, Human Immunodeficiency Virus (HIV), and Sexually Transmitted Diseases (STDs), are the major causes of death, disease, and disability. As men age, chronic diseases, such as heart disease, stroke, cancer, diabetes, and arthritis, as well as infectious diseases, such as pneumonia and influenza, and unintentional injuries (e.g., falls) become of greater concern. This document presents an overview of the current status of men's health in Georgia, with emphasis on prevalent issues. Information for this report was obtained primarily from the Division of Public Health (DPH), as well as from other Georgia Department of Human Resources (DHR) programs, and various national data sources. Comprehensive health data are not currently available for all racial and ethnic populations in Georgia. However, the Division of Public Health will be working with Georgia communities to monitor health trends in all populations, including the growing Hispanic/Latino population.
2000 Report on the Status of Men's Health in Georgia

Highlights
6
HIGHLIGHTS
Chronic health conditions are major causes of death and disability for Georgia men. These conditions occur most often in later life, at ages more commonly reached today because of men's increased life expectancy. Chronic conditions of particular concern are: cardiovascular disease, cancer, diabetes and arthritis.
Injury is one of the most significant causes of death among Georgia men aged 18 to 44 years. Unintentional injury, such as from motor vehicle crashes, is the most common type of injury that young men experience. Intentional injuries, such as homicides and suicides, are also major causes of death for young men. Homicide affects more young African American males, while suicide affects more young white males. Unintentional injury deaths from falling are more prevalent among elderly men, but occur occasionally in younger men, particularly among risk-takers or athletes.
Poor health behavior choices are significant factors in increasing a man's susceptibility for many chronic diseases, and some of these risky choices appear to be on the rise among Georgia men. Unhealthy behavior choices include: tobacco use, poor nutritional habits and physical inactivity. However, some good health behaviors such as seat belt use and colorectal cancer screening have been increasing among men.
Infectious diseases, such as gonorrhea, HIV, and tuberculosis, are major concerns for young men. These diseases also have a significant effect on the health of women. HIV is the leading cause of death for young men ages 35-44 and is a leading cause of mortality among males of all ages. Pneumonia and influenza are among the 10 leading causes of death for all age groups but are most significant among older men.
Substance Abuse is most common among young white men. An estimated one-fourth of young white men aged 18 to 24 have a substance abuse problem and would benefit from treatment.
Health Care Utilization is an important factor in men's health. National research suggests that men do not use health care services as often or as early as women. This disparity can be attributed in part to two factors: (1) fewer young men are covered by health insurance than young women, and (2) young women use health care with more regularity because of their need for gynecological care and obstetrical care.
2000 Report on the Status of Men's Health in Georgia

Cardiovascular Disease
Chronic Diseases

7

Figure 1 - Male Age Distribution in Georgia 1910 Compared to 1998

45%

40%

40%

35%

34%

30% 28%

25%

24%

21%

20%

16%

15%

15%

11%

10%

5%

0%

0-9

10-19

20-44

45-64

Age Group

1910 1998
8% 3%
>64

Figure 2 - Leading Causes of Death Among Georgia Males, 1994-1998

Other 19%
Diabetes 2%
HIV 3%

CVD 34%

Pneumonia Influenza
3%
COPD 5%

Injuries 11%
CVD = cardiovascular disease COPD = chronic obstructive pulmonary disease HIV = human immunodeficiency virus

Cancer 23%

Georgia's Aging Male Population
Georgia's male population has been steadily attaining longer life spans in increasing numbers during the last nine decades. In the time span between 1910 and 1998, the percentage of men in Georgia 20 years of age and older has increased, while the percentage of men younger than 20 years of age has decreased (Figure 1). In 1910 only 3% of Georgia's male population was over 64 years of age, compared to 8% in 1998. As the percentage of elderly Georgia men increases, the chronic diseases related to aging become a greater health concern. Thus, information regarding age-related disease can provide men with some insight into the prevention and/or control of these problems.
Cardiovascular Disease
Cardiovascular disease (CVD) is the leading cause of death among men in Georgia, accounting for about 12,000 male deaths per year or 34% of all male deaths (Figure 2). The two most common forms of CVD, heart attack and stroke together, account for more deaths in every Georgia county than any other cause of death. CVD is also a major cause of costly hospitalizations and disability expenses. In 1997 a total of 133,000 hospitalizations for CVD (involving both male and female admissions) occurred in Georgia. Hospital charges during that time totaled $1.8 billion. According to the American Heart Association, CVD is a leading cause of disability in the nation.
CVD death rates differ according to age, sex, and race. CVD death rates are higher in men than in women. African Americans have higher death rates than whites. In Georgia the racial disparity in CVD deaths is particularly striking. In 1997 the risk of dying from CVD was 25% higher for African

2000 Report on the Status of Men's Health in Georgia

Cardiovascular Disease

8

American males than white males. A racial disparity also exists in the percentage of premature CVD deaths (before age 65) in Georgia. The percent of premature deaths from CVD among African American males is 60% higher than the percent of premature deaths among white males (Figure 3). These differences have not changed much over the past two decades. The reasons for higher CVD death rates among African Americans are not well understood, but could be related to the higher percentage of African Americans with high blood pressure or, in some cases, to lifestyle factors caused by poverty, such as poor diet or decreased access to health care.
Prevention and Control of CVD Individuals can reduce their risk of heart attack or stroke. Risk reduction behavior choices include: avoiding tobacco products; practicing regular moderate physical activity most days for at least 30 minutes a day; maintaining a normal body weight; and consuming a balanced, nutritious diet that is low in fat and includes five or more servings a day of fruits and vegetables combined. Adherence to these health behaviors can help reduce high blood cholesterol and high blood pressure. These healthy behaviors also can reduce an individual's risk for diabetes. Having diabetes is another risk factor for CVD. Regular medical care, including blood pressure and blood cholesterol checks along with other important preventive care screenings, can provide men with appropriate guidance toward maintaining healthier lifestyles and, if necessary, appropriate medication to reduce the risk of CVD.

Figure 3 - Premature Cardiovascular Disease Deaths (under age 65) for Georgia Males by Race, 1997

50% 45% 40% 35% 30% 25% 20% 15% 10%
5% 0%

44.1% Black

27.0% White

2000 Report on the Status of Men's Health in Georgia

Cancer

9

Deaths per 100,000

Figure 4 - Cancer Death Rates for Georgia Males (1994-98) Compared to U.S. (1993-97)

120
100.6 100
84.3 80

Georgia US

60

43.4

40

36.4 27.3

23.7

20

11.8 12.2 10.6 10.5

0 Lung & Bronchus

Prostate

Colorectal Pancreas

Leukemia

Age-adjusted to 1970 U.S. population

Figure 5 - Total Male Cancer Death Rates in Georgia by Race, 1994-1998

Deaths per 100,000

250 205
200
150
100
50
0 Black

161 White

Age-adjusted to 1970 U.S. population

Deaths per 100,000

Figure 6 - Top Causes of Male Cancer Deaths in Georgia by Race, 1994-1998

120

100

96

82

80

59.8 60

White Black

40

24.5

20

22.8

17.4

8.6 12.9

8 8.5

0 Lung & Prostate Colorectal Pancreas Leukemia Bronchus

Age-adjusted to 1970 U.S. population

Cancer
Among Georgia males, cancer is the second leading cause of death, responsible for 23% of all male deaths (Figure 2). In the year 2000 an estimated 7,490 Georgia males are expected to die from cancer and more than 17,760 new cancer cases will be diagnosed in males.
The five leading causes of cancer deaths among males in the U.S. and Georgia are lung, prostate, colorectal, pancreas and leukemia. Lung cancer is the leading cause of cancer death among males in the U.S. and Georgia (Figure 4). Both the lung and prostate cancer death rates for males are 19% higher in Georgia than in the U.S. The colorectal rate is 12% lower in Georgia than in the U.S. Deaths from colorectal cancer in Georgia have been declining since 1990. In both Georgia and the U.S., the rate of lung cancer death is more than twice that of prostate cancer, even though prostate cancer is the second leading cause of male cancer deaths (SEER Cancer Statistics Review, 1973-1997).
Overall, African American males in Georgia are more likely than white males to die from cancer (205/100,000 vs. 161/100,000) (Figure 5). African American males are more likely to die of lung, prostate, and colorectal cancers than white males (Figure 6). Racial disparity is particularly apparent in the prostate cancer mortality rates. African American males are more than twice as likely to die from prostate cancer than white males.
Prevention and Control of Cancer Many cancers can be prevented. Approximately twothirds of cancer deaths are linked to modifiable risk factors. Smoking tobacco alone accounts for 87% of all lung cancer cases. Georgia males can reduce their risk of developing cancer (1) by not using tobacco; (2) by being more physically active; (3) by eating a

2000 Report on the Status of Men's Health in Georgia

Diabetes

10
nutritious and balanced diet that is high in fiber, low in fat, and includes at least five daily servings of fruits and vegetables combined; and (4) by reducing their skin's exposure to the sun. Regular medical care, including age-appropriate cancer screening, can result in early detection of many cancers to ensure appropriate, timely treatment.
Diabetes
Diabetes is one of the most common chronic diseases. It is the seventh leading cause of death among Georgia males and is responsible for nearly 500 deaths among men in the state each year (Table 1 on page 2). Diabetes is also a major cause of related illnesses and disabilities and often is a contributing factor in deaths from other causes. For every death in Georgia where diabetes is the primary cause, there are approximately 2.5 deaths with diabetes listed on the death certificate as a contributing cause of death.
Among Georgia's male population, 3.5% (approximately 91,000) know they have diabetes. For every two people who know they have diabetes, a third person has it but is not aware of the problem. Early symptoms may be mild or absent. When lack of awareness is considered, the number of men with diabetes is estimated to be about 138,000 or 5% of the male population in Georgia.
Diabetes is approximately twice as prevalent among African American men as among white men (Figure 7). The risk for developing diabetes increases with age. In fact, the majority of men with diabetes are 55 years of age and older. More than one-fifth of African American men over age 54 know they have diabetes.

Percent with Diabetes

Figure 7 - Percent of Men with Diabetes by Age and Race, Georgia 1993-1997

25%

20%

White

Black

15%

2 1.4%

10%

8.2%

5% 0.7% 1.3%

2.9% 1.9%

0%

18-34

35-54

55 +

Age Group

2000 Report on the Status of Men's Health in Georgia

Arthritis

Percent Reporting Arthritis

Percent with Arthritis

Figure 8 - Percent of Georgia Men Who Report Having Arthritis by Race , 1998

35% 30%
25% 20%
20%
15%
10% 5%
0% Black

32% White

Figure 9 - Percent of Men with Arthritis by

Age Group in Georgia, 1998

60%

50%

50%

40% 30%

31%

20% 10%

14%

0% 18-34 Years

35-54 Years

Age Group

55+ Years

11
Prevention and Control of Diabetes To significantly reduce the risk of developing Type 2 diabetes (Type 2 is responsible for 90-95% of all diabetes and typically begins in adulthood), it is important to maintain a normal body weight and to participate regularly in moderate physical activity. Among people who have diabetes, it is important to maintain blood glucose levels as close to normal range as possible. This can be accomplished by (1) following medically recommended nutritional modifications (daily diet recommendations), (2) by exercising regularly according to provided medical guidelines, and (3) by properly using prescribed medications and careful monitoring of blood glucose levels at regularly prescribed intervals. By following the health care provider's recommendations, a person with diabetes can possibly avoid serious difficulties, such as heart disease, stroke, blindness, kidney disease and other complications. Treatment for controlling blood glucose levels varies with each individual, and all prescribed treatment should be explained clearly by the patient's health care provider or case worker.
Arthritis
Arthritis is the nation's leading cause of disability and may cause difficulty in one or more daily activities. Arthritis is more common among older people, so the number of people suffering from arthritis will continue to increase in accordance with the increasing number of older people in the state. In Georgia, approximately 750,000 men, representing 29% of the men 18 years and older, have arthritis or a related condition. White men are more likely to report symptoms of arthritis than African American men (Figure 8). The prevalence of arthritis in adult men increases from 14% among men 18 to 34 years of age to 50% among men 55 years of age and older (Figure 9).

2000 Report on the Status of Men's Health in Georgia

Arthritis
12
Prevention and Control of Arthritis Maintaining normal body weight and being physically active can help prevent the development of osteoarthritis. Osteoarthritis is the degenerative form of arthritis that is most common among all the many types of arthritis and normally associated with aging. When arthritis develops, pain can be reduced and function maintained through good medical management. Appropriate medical care involves diagnosing the specific type of arthritis and developing a medical management plan that includes suitable exercise and medications.
2000 Report on the Status of Men's Health in Georgia

Injuries

Motor Vehicle Crashes

Deaths per 100,000

Figure 10 - Injury Death Rates by Race and Sex, Georgia 1993-1997

140.0

120.0 98.2
100.0

80.0

60.0

40.0

36.5

124.5 89.7
43.1

20.0

0.0 Male Female

White Male

Black Male

Other Male

Age-adjusted to the 2000 U.S. standard population

Figure 11 - Leading Causes of Male Injury Deaths in Georgia by Race, 1993-1997

Deaths per 100,000

45

40

38.6

35

34.3 29.7

30

24.7

25

20

15 10

12.9

13.0

7.9 6.7 10.0

5

0

Motor Vehicle

Suicide Homicide

White Black Other
8.0 6.5
Falls

Age-adjusted to the 2000 U.S. standard population

13
From 1993 through 1997, injuries caused 15,755 deaths among Georgia males. More than twice as many males as females died from injuries (6,680 female deaths). African American males are more likely to die from an injury than any other race (Figure 10). Sixty-two percent of all injury deaths in the state are unintentional, with motor vehicle-related injuries accounting for more than half of this category. Other causes of unintentional injury deaths include falls, drowning, fire, and poisoning (e.g., drug overdoses). While chronic diseases are the primary health burden affecting older men, unintentional injuries are the leading cause of death for young men through age 34.
Georgia's top four causes of male injury deaths are motor vehicle crashes, suicides, homicides and falls (Figure 11).
Motor Vehicle Crashes
In 1997 male drivers in Georgia accounted for 49.5% (approximately one-half)) of all licensed drivers, but were involved in 59% of all crashes and 72% of all fatal crashes. From 1993 to 1997, a total of 5,094 Georgia males died from injuries sustained in a motor vehicle crash, an average of over 1,000 deaths per year. Of the Georgia males who died, 62% were between the ages of 15 to 44, and 70% were white. However, the risk of a motor vehicle-related death is 15% higher for an African American male than for a white male.
Prevention and Control of Motor Vehicle Crashes Injury and death due to motor vehicle crashes can be significantly reduced through: (1) use of seat belts and safety seats for children; (2) enforcement of motor vehicle-related traffic laws, especially regarding speeding or driving under the influence of alcohol or

2000 Report on the Status of Men's Health in Georgia

Suicide

14

drugs; and (3) safety-related environmental changes (e.g., using visible road signs, planning adequately for future traffic increases, engineering better roadways, improving poor road conditions, and orchestrating better traffic light flow).
Suicide
From 1993 through 1997, 3,518 males in Georgia died as a result of suicide, an average of about 700 deaths per year. Fifty-seven percent of these deaths were among men ages 15 to 44 (Figure 12). Georgia's suicide death rate is about five times higher for males than for females. Also, suicide occurs twice as often among white men as among African American men (Figure 13). In Georgia, approximately three out of four (73%) suicide deaths involved a firearm. The large number of deaths and the potential preventability of suicides have caused this problem to be labeled a high public health priority. In 2000 Governor Barnes and the Georgia Legislature set aside $250,000 to develop a state plan to prevent suicide.
Prevention and Control of Suicides Providing adequate help lines or other crisis services can prevent some suicides. Appropriate clinical care for individuals suffering from mental health problems, substance abuse or poor physical health can also reduce the incidence of suicide. Training parents, teachers and other caregivers how to recognize the warning signs of deepening depression or irrational behavior, and then how to seek appropriate help, can assist in reaching potential suicide victims early to prevent the act. To further reduce the risk of suicide, it is important to prevent at-risk individuals from having easy access to lethal weapons, such as firearms or sedatives. Finally, treatment should be provided for those who have attempted suicide to prevent future attempts.

Deaths per 100,000

Figure 12 - Total Number of Male Suicide Deaths* by Age Group, Georgia 1993-1997

1200

Wh it e

1 ,091

1000

Black

800

O ther

787

Number

600

417

400

303

200

0

20 7 0

5-14

160 10
15-24

9 25-44

Age Group

592

67 6
45-64

45 1
65+

*Three deaths of unknown age are not included.

Figure 13 - Suicide Death Rates by Race/Sex, Georgia 1993-1997

30

24.7

25

22.0

20

15

13.0

14.1

10
5.1 5

7.9

1.6

2.9

6.6 5.3 4.1

0
WWMM WF

BM BBF

OOMM OF

M F

WW B O

Age-adjusted to the 2000 U.S. standard population

2000 Report on the Status of Men's Health in Georgia

Number

Homicide

Figure 14 - Total Number of Male Homicide Deaths by Age Group, Georgia 1993-1997

1000

White

893

900

800

Black
704

700

Other

600

500

400

300

200

150

100

24

30 1

16 28 1

0

402 7

219 212

13

12

58 49 0

Under 5 5-14

15-24

25-44

45-64

65+

Age Group

*Two deaths of unknown age are not included.

Figure 15 - Homicide Death Rates by Race/Sex, Georgia 1993-1997

45 38.6
40

35

30 23.1
25

20

15.2

15

10 6.7

5

2.9

9.9 10 5.5

5 4.8

7.7

0 WM WF BM BF OM OF M F W B O

Age-adjusted to the 2000 U.S. standard population

15
Homicide
From 1993 to 1997, 2,821 males in Georgia died from a homicide, an average of more than 500 deaths per year. Seventy-seven percent of male homicide victims were between the ages of 15 to 44, and 68% of male homicide victims were African American (Figure 14). The risk of homicide death for males is three times higher than for females. African American males are almost six times more likely to die from homicide than white males (Figure 15).
Prevention and Control of Homicides Homicides can be reduced through interventions that provide both behavioral and environmental changes. In Best Practices of Youth Violence Prevention: A Sourcebook for Community Action, several interventions are recommended to prevent youth violence. One recommendation involves engaging families and communities in the development and implementation of violence prevention strategies. Other recommended youth strategies include the use of: (1) mentoring programs; (2) school-based programs, employing behavior modification methods to promote social skills; and (3) home-visiting programs.
Some communities have been successful in reducing violence through local policing programs, assisted collaboratively by supportive community organizations. Modification of dangerous physical environments (through improved lighting or removal of abandoned buildings) can provide safer surroundings. Reducing illegal acquisition and use of firearms by criminals and juvenile offenders can be effective in reducing homicides.

Deaths per 100,000

2000 Report on the Status of Men's Health in Georgia

Falls

16

Falls
While younger men are more likely to die from motor vehicle crashes, suicides, and homicides than older men, older men are more likely to die from falls (Figure 16). From 1993 through 1997, 800 males in Georgia died from injuries sustained in a fall, an average of 160 deaths per year. Of these, 58% were aged 65 years and older, and 77% were white. The risk of death from a fall is 84% higher for males than for females.

Prevention and Control of Falls Some falls can be prevented through participation in regular physical activity and stretching or strength exercises to improve coordination, agility and strength at any age. Other falls, related to unsafe environmental conditions (particularly in the home), can be prevented by improving lighting in a darkened area, installing railings to help with balance and protection, removing loose rugs, and covering slippery surfaces with material providing traction. Careful attention to or supervision of medication use may also prevent some falls that are caused by dizziness or disorientation related to overdoses, underdoses, or improper drug combinations.

Figure 16 - Total Number of Male Deaths from Falls by Age Group, Georgia 1993-1997
450 398
400

350

White

Number

300

Black

250

Other

200

150

129

100 50

1 31

3

1 0

3 17

0

80 45 0

0

53 0

Under 5 5-14 15-24 25-44 45-64 Age Group

66
0 65+

2000 Report on the Status of Men's Health in Georgia

Tobacco Use
Health Behaviors

Figure 17 - Smoking-Related Mortality by Sex Georgia 1996

100% 90% 80% 70% 60% 50% 40% 30% 20% 10%
0%

Men

Women

33%

28%

40%

67%

72%

60%

CVD

Lung Cancer

COPD

Figure 18 - Percent of Adult Cigarette Smokers by Sex, Georgia 1984-1998

40% 30% 20% 10%

37%
25% 21%

29% 30% Men

26%

26%

21%

22%

18%

19%

16%

Women

28% 24% 25%

21%

20%

17% 16%

0% 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98
Year

17
Tobacco Use
Tobacco use is the leading cause of preventable death in Georgia, causing approximately 17% of all deaths in the state. Over half of the tobacco-related deaths involve adult males. Tobacco use is known to be a causative factor in cancers of the lungs, larynx, esophagus, mouth, and bladder. Tobacco use also increases the likelihood of developing chronic obstructive pulmonary disease (COPD) and cardiovascular disease (CVD). In 1996, 72% of smoking-related lung cancer deaths, 67% of smokingrelated CVD deaths, and 60% of smoking-related COPD deaths were adult males (Figure 17).
According to BRFSS (Behavior Risk Factor Surveillance System), approximately 28% of Georgia males, ages 18 and older, smoked cigarettes in 1998. The prevalence of smoking males declined between 1984 and 1992. Since 1992, however, the prevalence has increased about 4% per year (Figure 18).
Smokeless tobacco (spit tobacco) products are not a safe alternative to cigarettes. These products are a major cause of cancers of the oral cavity and are used more frequently by males than females. In 1997 the prevalence of smokeless tobacco use in Georgia was 25% among adult males compared to only 4% among adult females. Twenty-two percent of high school males in Georgia use spit tobacco regularly.
Cigar smoking increased significantly during the 1990s, particularly among adult males. In 1998 one out of every five males reported being a current cigar smoker. One-third of the current cigar users reported smoking a cigar at least once a week, and 8% of current cigar users reported smoking a cigar every day.

2000 Report on the Status of Men's Health in Georgia

Physical Activity and Weight

18

Tobacco use in Georgia is a problem that is not limited to just adult and high school populations. It is also a growing problem in Georgia's middle school population, grades 6-8. In 1999 middle school males reported a 59% lifetime prevalence of tobacco use, 21% current tobacco use, and 14% current cigarette use. Many of these young adolescents are addicted or will soon become addicted to tobacco, and thus potentially will be exposed to many long-term, preventable health problems.
Physical Activity and Weight
Physical inactivity and being overweight are factors that can increase a person's risk for cardiovascular disease, diabetes, arthritis, and other chronic health conditions. According to BRFSS, the percentage of men who are overweight or obese has increased steadily from 47% in 1984 to 62% in 1998 (Figure 19). Overweight is defined as a BMI (Body Mass Index - definition on page 27) of between 25.0 and 29.9. Obesity is defined as a BMI of 30.0 or over.

Figure 19 - Men Reporting No Regular Activity & Being Overweight or Obese, Georgia 1984-1998

80% 60% 40%

No Regular Physical Activity

74%

65% 61%

62%

68% 67% 64% 62%

68%

68% 62%

47% 47%

57%

59%

61% 60%

55% 54%

53% 55%

47% 50%

56%

65%

58%

Being Overweight or Obese

20%

0% 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98
Year

More than half of Georgia men are not physically active on a regular basis. From 1984 through 1998, estimates of the percentage of men in Georgia with no regular physical activity have ranged from 56% to 74%. Regular physical activity can reduce the risk for heart disease, high blood pressure, stroke, diabetes, colon cancer, and osteoporosis. Recommended amounts of physical activity also can reduce symptoms of anxiety and/or depression and help maintain a healthy body weight. CDC recommends that regular physical activity should be at least of moderate in intensity (e.g., walking at a brisk pace, dancing, swimming, climbing stairs) and maintained for 30 minutes a day, most days of the week. It is effective to do the 30 minutes a day in 10 minute intervals throughout the day.
2000 Report on the Status of Men's Health in Georgia

Colorectal Cancer Screening

Figure 20 - Percent of Georgians, aged 50+, Who've Had Colorectal Cancer Screening 1993-1997

60% 50% 40% 30%

46% 35%

53% 40%

52% 45%

20%

Men

Women

10%

0%

1993

1995

1997

Year

19
Colorectal Cancer Screening
As previously noted, colorectal cancer is the third leading cause of cancer-related deaths among Georgia men, and the rate is higher for African American men than white men. Research suggests that the declining colorectal mortality rate is related in part to the increased use of screening tests.
The American Cancer Society Screening Guidelines recommend that, beginning at age 50, average-risk adults should have one of the following: A fecal occult blood test (FOBT) and a flexible
sigmoidoscopy (if normal, repeat FOBT annually, and flexible sigmoidoscopy every 5 years); A colonoscopy (if normal, repeat every 10 years); or A double-contrast barium enema (if normal, repeat every 5 to 10 years).
In 1997, 52% of Georgia males, 50 or older, reported ever having had colorectal cancer screening (Figure 20). Although the percentage of men being screened has been hovering around 50% between 1993 and 1997, the data reflect continuing under-utilization of cancer screening mechanisms, especially when compared to screenings for other cancers such as breast and cervical cancers in women. Men, however, are currently more likely than women to seek colorectal screenings (Figure 20).

2000 Report on the Status of Men's Health in Georgia

Seat Belt Use
20
Seat Belt Use
Many factors contribute to motor vehicle crashes, such as bad weather, heavy traffic, and reckless or impaired driving. The risk of being injured and/or killed in a motor vehicle crash, however, can be reduced through defensive driving techniques and safety awareness. Seat belt use is one of the most effective safety means of decreasing the risk of injury or death. Fortunately, surveys show that overall seat belt use is on the rise and that seat belt use specifically among Georgia males has been increasing. However, Georgia men, whether they are in the driver's or passenger's seat, are still less likely to wear a seat belt than a woman (Figure 21).

Figure 21 - Seat Belt Use Among Men and Women Georgia 1999

90% 80% 70% 60% 50% 40% 30% 20% 10%
0%

84% 71%

Men Women

80%

70%

Driver Belt Use

Passenger Belt Use

2000 Report on the Status of Men's Health in Georgia

Total Cases

Gonorrhea HIV/AIDS
Infectious Diseases

Rates (Cases per 100,000)

Figure 22 - Male Gonorrhea Cases and Rates

by Age Group, Georgia 1998

6000

1000

5000

887

Cases

Rates 800

4000 600

3000

4887

2000

336

346

400

1000

1913

0
10-19

2223
20-29 30-39 Age Group

200 94 1288
0
>=40

Figure 23 - Male AIDS Cases by Mode of HIV Transmission, Georgia, 1981-1999

Other/Not reported
Heterosexual contact
MSM and IDU

10% 7% 7%

IDU**

17%

MSM*

59%

0% 10% 20% 30%
*Men having Sex with Men (MSM)

40% 50% 60%
**Illicit Drug Use

70%

21
Gonorrhea
Among males, gonorrhea is the most frequently reported infectious disease in Georgia, with 10,525 case reports in 1998. Currently, gonorrhea cases appear to be on the rise, even though there previously had been a gradual decline in the number of reported gonorrhea cases over a several-year span. In 1998 both the number of gonorrhea cases and the prevalence rates were highest in persons 20 to 29 years old (Figure 22).
Prevention and Control Abstinence from sex, use of condoms during any sexual encounter, and avoiding sex with an infected partner can prevent gonorrhea and other sexually transmitted diseases (STDs). Most infections in males produce obvious or uncomfortable symptoms that cause men to seek treatment early enough to prevent serious complications. Usually, however, the treatment is too late to prevent some partners from being exposed to the disease. Because persons with gonorrhea are frequently co-infected with chlamydia, treatment for both infections is recommended. Persons infected with gonorrhea or any other STD should tell their sex partners to seek treatment as well.
HIV/AIDS
Males account for 84% of all persons reported with Acquired Immune Deficiency Syndrome (AIDS) in Georgia, and as of December 1999, there were 7,889 males living with AIDS in the state. The most common mode of HIV transmission among the 17,929 adolescent and adult males reported from 1981 to 1999 was through men who have sex with men (MSM). Fifty-nine percent of AIDS cases in Georgia resulted from MSM, 24% resulted from injected drug usage (dirty needles), and 7% resulted from

2000 Report on the Status of Men's Health in Georgia

Tuberculosis

22

heterosexual contact (Figure 23). The other cases were from unreported causes. Many of the infections in this category could have been transferred through blood transfusions or through an infected pregnant woman passing the infection to her baby.
In recent years, a growing number of AIDS cases have been reported among minorities, particularly African Americans. The percent of male African American AIDS cases has increased from 50% in 1990 to 79% in 1999 (Figure 24).
Prevention and Control Abstinence from sex, use of condoms during any sexual encounter, and avoiding unprotected sex with an infected partner can prevent most HIV transmissions. Injection drug users should use needles and syringes that are new or appropriately cleaned to prevent HIV. On average, an AIDS diagnosis occurs about 8 to 10 years after a person becomes infected with HIV. Because effective HIV treatment is now available, persons who think they could have been exposed to HIV should voluntarily seek HIV testing as soon as possible, then follow-up with any necessary counseling or recommended courses of action.
Tuberculosis
Tuberculosis in Georgia predominantly affects males. In 1999, 66% of reported TB cases and 74% of TB cases co-infected with HIV were reported among Georgia men. In the 1999 report, over 60% of the TB cases were among African Americans. Between 1993 and 1999, however, the proportion of TB cases among African American men has been declining, and the proportion of TB cases among Hispanic men has been increasing (Figure 25).

Figure 24 - Percentages of Male AIDS Cases by Race/Ethnicity in Year Diagnosed, Georgia 1987-99

90%

White Black Hispanic Other 79.0%

80%

70% 60% 50%

62.0%

50.0%

40%

30% 35.0%

20%
10% 2.3% 0% 0.1%

19.0% 2.1%
0.4%

87 88 89 90 91 92 93 94 95 96 97 98 99

Year

Figure 25 - Percentage of Men's TB Cases by Race/Ethnicity, Georgia 1993-1999

80%
70% 73%
60%
50%

Black

White

71% 62%

61%

Hispanic 66%
58%

Asian 60%

40%

30% 20% 10% 0%

22%

23%

25%

28%

21%

23%

22%

3%
2% 1993

5%
1% 1994

7%
5% 1995

6% 7%

5% 1996

6% 1997

13%

11%

6%

6%

1998 1999

Year

2000 Report on the Status of Men's Health in Georgia

Tuberculosis
23
In the mid-80s Georgia witnessed a resurgence in the incidence of tuberculosis. This problematic increase has been connected to several different factors, including: (1) the dramatic increase in the number of persons contracting AIDS, making them also susceptible to TB; (2) the arrival of immigrants from countries where TB is endemic; (3) the transmission of TB within poor health environments such as prisons and shelters; and (4) decreased funding for TB control within the public health infrastructure. Since 1991, however, TB cases have been declining in Georgia. The decreasing number of new TB cases is believed to be the result of successful public health strategies, such as directly observed therapy for TB patients. The direct observation method ensures that proper medications are taken and ensures other treatment strategies are completed. This procedure has resulted in higher rates of treatment completion, regular and consistent evaluations of any contacts who might have been exposed to the disease, and then preventive treatment of the infected contacts.
Prevention and Control Finding all cases of active TB and ensuring completion of therapy is the primary mechanism for controlling TB. Non-completion of TB therapy leads to treatment failure, relapse, the development of drugresistant TB strains, and further transmission of tuberculosis. TB patients should receive directly observed therapy because results show that, through this procedure, a patient is more likely to complete the therapy. Anyone in contact with a person known to have TB should have a tuberculin skin test. If a positive skin test is reported, the contact then should receive preventive treatment for tuberculosis.
2000 Report on the Status of Men's Health in Georgia

Pneumonia and Influenza

24
Pneumonia and Influenza
Pneumonia and influenza (P&I) are listed together as one of the top 10 causes of death in males of all ages (Table 1 on page 2). In Georgia, among men ages 65 and older, P&I resulted in 3,816 deaths from 1994 to 1998, making P&I the fifth leading cause of death for that age group.
Influenza or "the flu" is a viral respiratory disease that can lead to pneumonia. The percentage of Georgia men over age 64 who reported having had a yearly influenza vaccine has increased from 39% in 1993 to 62% in 1998 (Figure 26).
Pneumonia can have many causes. A vaccine, however, can prevent one of the most deadly kinds, pneumococcal pneumonia. The percentage of Georgia men over age 64 who reported ever having had a pneumococcal pneumonia vaccine increased from 24% in 1993 to 49% in 1998 (Figure 26).
Prevention and Control Influenza vaccine is now recommended for everyone 50 years of age or older and for anyone with a chronic medical condition, such as diabetes. Although the vaccine does not prevent all cases of influenza, it usually prevents complications from influenza such as life-threatening pneumonia. Everyone age 65 or older and anyone with a chronic medical condition should have a pneumococcal pneumonia vaccine. Unlike the flu shot, this vaccine usually is given just once in a lifetime. It is especially important for men whose lungs have been damaged by smoking to get these vaccines, because men with weakened lungs are more likely to develop severe influenza and pneumonia.

Figure 26 - Percentage of Georgia Men Over Age 64 Who've Had Influenza* or Pnuemococcal** Vaccine

70% 60% 50% 40% 30% 20% 10%
0%

Pneumococcal

39% 24%

41% 38%

Influe nza 56%
45%

62% 49%

93

95

97

98

* Men who've had influenza vaccine in the past 12 months. ** Men who've ever had a pneumococcal pneumonia vaccine.

2000 Report on the Status of Men's Health in Georgia

Substance Abuse

25

Figure 27 - Substance Abuse Prevalence Estimates Among Men by Age Group, Georgia 1998

30%

26.6%

White & Other*

25%

20%

15%

10%

4.9%

5%

2.6%

19.3%

Black

12.5%

14.6%

9.1%

6.9%

7.3% 3.4%

0%

15-17

18-24

25-34

35-44

44+

Age Group

* Asians and Hispanics

Figure 28 - Percentage of Binge Drinking* Among Men by Age Group, Georgia 1997

40% 36.9% 35% 30%

32.6%

32.8%

25%

21.8%

20.2%

20%

15%

10% 4.9%
5%

0%

18-24

25-34

35-44

45-64

55-64

65+

* 5 or more drinks on at least one occasion in the past 30 days

Recent studies of substance abuse treatment needs show that whites more than African Americans, males more than females, and young men more than older men have a severe enough substance abuse problem (alcohol or illicit drug use) to require treatment services. The problem is greatest among young white men aged 18 to 24. In fact, an estimated one-fourth of all white men in this age group has a substance abuse problem (Figure 27). Although estimated substance abuse is relatively low for adolescent males aged 15 to 17, the fact that it increases dramatically for men aged 18 to 24 suggests that the behaviors probably begin in adolescence.
Binge drinking, defined as five or more drinks on at least one occasion within the past 30 days, is most problematic among young men. Almost 37% of young men aged 18 to 24 report that they binge drink. The percentage of men who report that they binge drink decreases with age (Figure 28).
Prevention and Treatment Substance abuse can be prevented through the implementation of multifaceted strategies targeted at individuals, families, schools, and communities. All health promotions should emphasize the importance of healthy lifestyle behavior choices across a man's entire life span. Georgia males can prevent the disease of substance abuse/addiction by abstaining from the illegal use of drugs and practicing low-risk drinking behavior. The Prevention Research Institute defines low-risk drinking behavior as consuming 02 servings of alcohol per day, depending on individual risk factors assessed by age, lean weight, health conditions, and hereditary factors. Males with a family history of alcoholism or addiction and/or a high tolerance to alcohol are at particularly highrisk for developing the disease of addiction.

2000 Report on the Status of Men's Health in Georgia

Substance Abuse
26
Successful treatment for substance abuse/addiction requires community services that (1) provide early screening of high-risk/problem drinking or drug-using behaviors; (2) assessment to determine severity of the problem; and (3) referral to medically-supervised detoxification and professional individualized treatment. Treatment may include residential or outpatient services that utilize group therapy, individual counseling,12-Step programs, and/or medications. Treatment should address underlying mental illness or other health conditions.
2000 Report on the Status of Men's Health in Georgia

Health Insurance Coverage Use of Services
Health Care Utilization

27

Health Insurance Coverage
About one-fifth of all men in Georgia (19%) aged 18 to 64 were without health insurance in 1998. Younger men are more likely to be without health insurance than older men. In 1998, 38% of men aged 18 to 24 were without health insurance, compared to 19% of men aged 25 to 44 and 12% of men aged 45 to 64 (Figure 29). Only 30% of women aged 18 to 24 have no health insurance. As men and women age, the gap in health insurance coverage narrows.
Use of Services
The Commonwealth Fund Men's and Women's Health Care Survey Findings indicate that younger men aged 18 to 29 years of age were less likely than women of the same age to have a regular physician (33% vs. 53%) or to have visited a physician in the past year (7% vs. 33%). A woman's need for regular gynecological and/or obstetrical care offers some explanation for this discrepancy. This health care discrepancy, however, is a major public health

problem. Men of all ages, even very young men, should be informed repeatedly of their need for regular preventive health care and important health status screenings, such as blood pressure and cholesterol measurements. Men should have better counseling and support regarding good health practices, with emphasis on the advantages of nutritious foods, moderate physical activity, and the elimination of tobacco products. Better choices in these particular health behaviors can offer men some protection from several chronic diseases, particularly CVD and cancer.
According to the Commonwealth Fund survey, men typically delay seeking medical help. Up to 24% of men will wait as long as possible when sick or in pain before seeking medical care, and 38% will wait at least a few days to get medical help. Men's delays in seeking medical care and their lack of health insurance increase their risk for chronic diseases as they age. Easier access to health care (e.g., at work sites), especially preventive care, could reduce some male risk factors for health problems.

Percent Covered

Figure 29 - Health Insurance Coverage Among Men by Age Group, Georgia 1998

Private
90%

80%

76%

70% 60% 58%

Public
81%

Uninsured
69%

50% 40%

38%

30% 20%
8% 10%

19% 7%

13% 12%

18% 19%

0% 18-24

25-44

45-64

Age Group

Total

2000 Report on the Status of Men's Health in Georgia

Conclusion

28

Men's health behaviors and overall health status have improved in some categories over the last decade. For example, death rates from colon and prostate cancer have declined in the 1990s. In other areas, however, there is reason for concern. After nearly three decades, cardiovascular death rates have stabilized in the 1990s, and the prevalence of diabetes and its complications are rising. Also, although men are living longer today, they continue to die nearly seven years younger than women. This gender disparity has several possible causes. Among the many suggested causes are (1) men's health behaviors, (2) men's poor health care access and utilization, and (3) male pressures resulting from gender expectations. In the Commonwealth Fund Men's and Women's Health Care Survey Findings, one of five (20%) adult men said that they were "not at all" or "not very" comfortable discussing their feelings with a doctor. This reluctance could influence the discussion of some problems or symptoms and adversely affect the health care men receive.
Complex men's health challenges in Georgia will require statewide collaborative strategies to develop solutions. Although the challenges are numerous and have existed for some time, men's health still is considered a "new" public health issue. As a result, initiatives to address men's health are emerging, but still relatively rare. Many areas of men's health, in Georgia and in the nation, require attention to the development or enhancement of services, programs, and policies.
In 2000 the Georgia Legislature created a Commission on Men's Health through House Bill 1235. The Commission is charged with finding effective solutions to current men's health issues. This Commission is working to develop strategies, public policy recommendations, and programs that are

designed to educate Georgia's men about better health procedures and practices.
Public Health in Georgia should play a critical role in the expansion of men's health activities by continuing to monitor the status of men's health. Through this process, Georgia can identify and share information regarding emerging trends and problems. Public Health also should work with state and local level health care providers, consumer groups, and other stakeholders to advocate for policies that can improve the lives of Georgia men. Policies should be promoted to offer better environments for health in the state, such as improved air quality (from less automobile emissions), healthier work sites (e.g., offering health status monitoring and counseling, physical activity opportunities, and healthier snacks in vending machines), more physical activity in school programs, and more safe walking and biking paths throughout Georgia. In addition, Public Health should work with policy makers, health care providers, physicians, community groups, consumers, and other stakeholders to develop or enhance men's health programs and services so that health care is more specifically tailored to the social, economic, and cultural needs of Georgia's men. The state's public health system should continue to offer leadership and guidance in shaping the future of men's health in Georgia (e.g., by providing assistance to the Men's Health Commission in the development of men's health guidelines to educate and counsel men about preventive health measures or better health practices).
For further information, contact Sean Johnson with the Men's Health Initiative in the Family Health Branch at 404-657-2743.

2000 Report on the Status of Men's Health in Georgia

Definitions
29
Age-Adjusted: A rate that is adjusted to account for differences in the age distributions of the
populations being compared.
AIDS: Acquired Immune Deficiency Syndrome is a severe immunological disorder caused by the
Human Immunodeficiency Virus (HIV). AIDS causes the body's immune responses to react poorly, resulting in increased susceptibility to infections and certain cancers. An HIV-infected person may not show symptoms of AIDS for 8-10 years after being infected with the virus.
AIDS reporting: AIDS is a notifiable disease. The data in this document are based on year of
diagnosis rather than year of report. Therefore, the case numbers may increase over time as cases from recent years are reported to Department of Human Resources (DHR). HIV, the virus that causes AIDS, is not currently a notifiable disease.
Behavioral Risk Factor Surveillance Survey (BRFSS): A state-based surveillance system
administered by the Division of Public Health (DPH) in collaboration with the Centers for Disease Control and Prevention (CDC) to gather information about knowledge, attitudes, and behaviors related to health. Every month in Georgia, a random sample of adults is selected for a telephone interview.
Body Mass Index (BMI): A measure of body size, which is the ratio of weight (in kilograms) to
height (in meters squared). Overweight is defined as a BMI between 25 and 29.9, and obesity is defined as a BMI of 30 or over. A BMI of under 18.5 can be cause for concern also--indicating mild to severe starvation as the number decreases. These definitions are the same for men and women.
Barium Enema: Radioactive liquid placed in the intestine to allow X-ray examination.
Colonoscopy and Sigmoidoscopy: Using tubular instruments ("scopes") to visually examine
inside the entire colon or the sigmoid region of the colon (S-shaped section of the colon between the descending region and the rectum).
Colorectal Cancer: Cancers that develop in the colon (large intestine) or rectum.
Fecal Occult Blood Test (FOBT): A test for blood in a person's stools, possibly indicating cancer
or some other problem. The word occult means "hidden from view," so closer testing of the stool sample is usually required to detect blood.
Homicide: Death intentionally caused by a person other than the victim. Prevalence: The percent of a population that has a disease or a risk factor at a specific time. Risk Factor: A habit, characteristic, or finding during clinical examination that is associated with an
increased chance of having or developing a condition or disease.
Suicide: A person's intentionally causing his or her own death.
2000 Report on the Status of Men's Health in Georgia

Data Sources
30
Georgia Department of Human Resources (DHR), Division of Public Health
AIDS Surveillance Database
Georgia Behavioral Risk Factor Surveillance System (BRFSS)
Georgia Sexually Transmitted Disease Surveillance Database
Report of Verified Case of Tuberculosis
Vital Statistics 1993-1998
U.S. Census Bureau. General Population Characteristics Age by Race and Sex: 1910 to 1980.
Georgia Epidemiology Report, Vol. 14, No. 4. Georgia Department of Human Resources, Division of Public Health, Epidemiology Branch, 1998.
Governor's Office of Highway Safety: Statewide Use of Occupant Restraints 1999. Atlanta, GA: Governor's Office of Highway Safety, 1999.
Landis SH, Steiner CB, Bayakly AR, McNamara C, Powell KE. Georgia Cancer Data Report 2000. Georgia Department of Human Resources, Division of Public Health, Cancer Control Section, and the American Cancer Society, Southeast Division. Atlanta, GA: Cancer Control Section and the American Cancer Society, Southeast Division, May 2000. Publication number DPH00.27HW.
McGinnis JJ, Wilson WH, Powell KE, Martin LM, Lytle HM, Martin EA. The Georgia Arthritis Report, 2000. Arthritis Foundation, Georgia Chapter. Georgia Department of Human Resources, Division of Public Health, Epidemiology Section, May 2000. Publication number DPH00.14H.
National Cancer Institute. SEER Cancer Statistics Review, 1973-1997. Bethesda, MD: NCI, 2000.
Powell KE, Thomas SM, Martin LM, and Fox PM. 1999 Georgia Diabetes Report. Georgia Department of Human Resources, Division of Public Health, Cardiovascular Health Section, March 2000. Publication number DPH00.15HW.
Rowe AK, Powell KE, and Hall V. The 1999 Georgia State of the Heart Report. Georgia Department of Human Resources, Division of Public Health, Cardiovascular Health Section and the American Heart Association, Southeast Affiliate, February 1999. Publication number DPH99.3HW.
Sandman D, Simantov C, and An C. Out of Touch: American Men and the Health Care System, Commonwealth Fund Men's and Women's Health Care Survey Findings. The Commonwealth Fund 1998 Survey of Men's and Women's Health, March 2000.
Schmertmann ML, Yeager DM, Powell, KE, and Davidson SC. The 1999 Georgia Injury Profile. Georgia Department of Human Resources, Division of Public Health, Office of Injury Prevention and Epidemiology Section, December 1999. Publication number DPH00.10H.
Thorton TN, Craft CA, Dahlberg LL, Lynch BS, Baer K. Best Practices of Youth Violence Prevention: A Sourcebook for Community Action. Atlanta: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, 2000.
2000 Report on the Status of Men's Health in Georgia