Substantial time and effort are required to provide adequate and appropriate preventive healthcare services. One study estimated that 7.4 h per work day would be required for physicians to implement all of the preventive services recommended by the United States Preventive Services Task Force (USPSTF) for their patients [2]. Obviously, this is a time allotment that primary care physicians simply do not have, especially with their responsibility to provide care for both acute and chronic illnesses, in addition to preventive care that includes behavioral and psychosocial counseling [1].

Most primary care offices lack systems to ensure timely implementation and follow-up of preventive healthcare for all patients. This is not surprising, since adequate provision of preventive healthcare requires multiple steps that include:

This complex series of steps is further complicated by several factors including:

Unfortunately, considerable evidence exists from surveys of both patients and physicians demonstrating that physicians fall short of providing all of the necessary preventive care for their patients. In a population-based telephone survey of 13,275 adult patients and physicians in 12 metropolitan areas in the USA, only 54.9 % and 52.2 % reported receiving preventive healthcare and screening, respectively, determined by RAND’s Quality Assessment Tools system [4]. In a self-report survey of 3881 primary care physicians randomly sampled from the professional associations representing family medicine, internal medicine, pediatrics, and obstetrics/gynecology, the percentage of physicians who provided adequate clinical preventive service (defined as providing the service to more than 80 % of their patients who were indicated to receive them) varied from 60.2 to 87.2 % for screening, 26.6–44.7 % for immunizations, and 21.3–47.7 % for counseling [5].

A recent review performed by the Centers for Disease Control and Prevention (CDC) showed little improvement in the provision of preventive services up to the year 2010, with 62.7 % of adults aged 18 years and over being screened for tobacco abuse, 64.5 % of adults aged 50–75 years being screened for colorectal cancer, and just 28 % of adults aged 18–64 years receiving seasonal influenza vaccine [6]. Even when the initial preventive service is implemented appropriately, one study found that fewer than 75 % of patients receive adequate follow-up care [7]. From the findings of these and other related studies, deficiencies in the provision of preventive care are classified predominantly as underutilization, although overutilization (e.g., performing screening testicular examination in asymptomatic men) and inappropriate utilization (e.g., performing a digital rectal examination to assess for fecal occult blood in lieu of three take-home fecal occult blood test cards [8]) could also occur.

The various reasons as to why clinical preventive services are not implemented as well as those for why they should be are both numerous and complex. Physicians may not adhere to recommended clinical practice guidelines due to lack of awareness, lack of familiarity, disagreement with the recommendation, lack of self-efficacy (e.g., belief that they could effectively perform the recommended service), lack of outcome expectancy (e.g., belief that the performance of the recommended service will lead to the desired outcome), inertia of previous practice, and external barriers including lack of adequate time, resources, and reimbursement [9]. A physician’s level of experience may affect how much of the recommended guidelines he or she performs [10]. External barriers arising from the complexity of the healthcare delivery system, such as lack of continuity of care and breakdown in communication, may be bigger factors than the individual physician attributes [11]. The vagaries of each practice may be a particularly relevant issue in the USA, where preventive service delivery is dependent upon individual patient and physician interactions and not through centrally organized programs as seen in Europe and Japan, which increase the potential for variability in implementation and follow-up [12].

Common issues regarding preventive healthcare have been shown to be both unique to male patients as well as more amplified. A survey by Sandman et al. determined that [13]:

Other studies have also shown that men do not utilize preventive services as much as women. A recent review cited nine studies ranging in published year from 1989 to 2007 that showed men were less likely to endorse and engage in preventive services than women [14]. A Canadian study showed that men were less likely to be screened for colorectal cancer, diabetes, and hyperlipidemia compared to women [15].

Various adverse health outcomes that are more prevalent in men include [16, 17]:

More recent studies conducted in other countries in North America, Europe, and Asia confirm the poorer health outcomes among men [18–20]. The gender gap illustrated above is even greater among men aged below 30 years, men in minority groups, and men in lower socioeconomic class. Fortunately, this gender gap virtually disappears once men are aged 65 years or older.

It is important to note that not all gender differences are statistically disadvantageous to men. For example, more men have been found to exercise three or more days per week than women (51 % vs. 39 %, respectively) [17]. Provision of smoking cessation counseling (30 % men vs. 31 % women), diet (44 % vs. 49 %), exercise (46 % vs. 52 %), alcohol and illicit drug abuse (22 % vs. 24 %), safety (6 % vs. 9 %), and sexually transmitted infections (STIs) (14 % vs. 17 %) is unacceptably low for both men and women [17].

Some studies have looked at social and behavioral determinants that may lead to underutilization of preventive healthcare services by men. Frequently cited determinants include lack of knowledge, fear of finding a disease, lack of time, low perceived risk, and negative perceptions about the screening procedure such as pain, discomfort, and embarrassment [21, 22]. A feature unique to men is their concept of masculinity and how it negatively impacts health-seeking behavior. Men have reported that they may regard seeking healthcare as showing vulnerability, lacking self-reliance, and being feminine [23, 24]. In particular, screening procedures involving the rectum such as colonoscopy and the digital rectal examination are regarded as threats to their masculinity.

Several conclusions may be drawn from the data trends regarding provision of preventive services to men. Many, if not most, primary care physicians’ offices fall short of providing appropriate preventive care to all of their patients. Second, data supports the difficulty of organizing appropriate preventive care for all patients in primary care physicians’ offices; the barriers include lack of adequate time during an office visit, complexity of the recommendations, complexity of the healthcare delivery system, and physician beliefs and behaviors. Third, men have health behavior characteristics that place them at an increased risk for morbidity and mortality from a variety of conditions, and their greater lack of adequate preventive care compounds the situation. Lastly, organizing preventive care for men in the physician’s practice will entail organizing the care for all patients in the practice.

Recent evidence from the literature supports a set of preventive services tailored to an individual’s age, gender, and risk factors, rather than a one-size-fits-all battery of examinations and screening tests [25, 26]. With this in mind, one of the challenges toward implementing appropriate preventive care is the seemingly constant changes in guidelines. Fortunately the USPSTF, considered by many primary healthcare professionals to be the most authoritative of the guidelines for preventive services, has a Web site that is frequently updated with the most current evidence-based recommendations [25]. Other organizations that have Web sites that are regularly updated for provision of preventive services include the American Academy of Family Physicians (AAFP) [27] and the National Guideline Clearinghouse (NGC) [28]. A particularly useful Web site for vaccination recommendation updates is that of the CDC, which highlights the updated immunization guidelines from the Advisory Committee on Immunization Practices (ACIP) [29].

Many studies have been performed with the outcome goal of finding ways to improve the rate of providing preventive healthcare in the ambulatory care setting. Extrapolation of data from these study findings to design an effective strategy for other physician practices has been difficult to interpret. One reason is that the complexity of each practice creates unique barriers that defy straightforward implementation of tools, even if they showed efficacy in other settings [30, 31]. Another reason is that many successful studies rely on external assistance through funding during the course of the research project, and once the study ends and the funded external assistance is removed, the implemented systems tend to disappear [32].

Nevertheless, several excellent reviews have arrived at similar conclusions in terms of effective interventions in the delivery of preventive healthcare services [33–36]. Patient and physician reminder systems have been shown to be effective tools. While these reminders do not need to be electronic, computer-generated prompting and reminding has the advantage of both efficiency and responsiveness [37, 38]. The availability of a complete electronic health record (EHR) system has the additional benefit of a lower incidence of missing clinical information relevant to patient care [39]. However, overall results are mixed on the performance of EHR on improving preventive healthcare outcomes. EHRs may better capture services not captured by medical claims in patients intermittently covered by health insurance [40].

EHRs with clinical decision support system (CDSS) have led to modest improvements in actual provision of preventive care, such as screening for abdominal aortic aneurysm [41]. EHRs that combined point-of-care recommendations, disease registry capabilities, and continuous performance feedback for physicians have led to modest increases in completion of a variety of preventive care services [42]. However, while a systematic review of electronic CDSS in primary care practices noted small improvements in processes of care, the authors noted that “there is wide variation and interpretation in CDSS implementation, and most studies can truly speak only to the effectiveness of a particular CDSS product used in a particular setting” [43, 44]. Use of the copy-and-paste practice in EHRs may lead to documentation of activities that did not occur, such as lifestyle counseling in diabetics, leading to spuriously low effectiveness of preventive care services [45].