Challenging Dogma - Fall 2008

Thursday, December 18, 2008

A Hypertension Intervention for Black Males – Missing the Target and Ultimately Missing the Point - Nicolette Barbour

A Look into the Health Belief Model That Shapes the Church/Health Fair Approach in the Black Community

African-Americans have long been disproportionately affected by health issues in America. From infant mortality to heart disease to homicide to the AIDS epidemic, high prevalence of disease among African-Americans has been astounding. Hypertension (high blood pressure) is one of many health concerns for African-Americans. According to Healthy People 2010 prevalence of hypertension among African-American adults was as high as 41% in 2000, up from 37% at baseline (1988-1994) (15). The prevalence of hypertension among black Americans was 1.5 times that of white Americans in 2000 and was the highest of all racial groups in the analysis (16, 5). There are also noteworthy gender differences among hypertensive African-Americans evident in the variation in hypertension prevalence, 41% for men and 44% for women (16). Hypertensive individuals are at an increased risk for heart disease and stroke which are two leading causes of death in the United States (1). Even more alarming is the unfortunate reality that of the top 10 causes of death, African-Americans have the highest mortality rate when compared to other racial groups for 8 of the top 10 causes of death ( 15, 11). Suffice to say, hypertension in the black community is a significant public health problem.
To address the serious health disparity of hypertension in the black community a number of interventions have been implemented. A popular intervention design is church health promotion programs and community health fairs. The church is especially regarded as a central institution in the black community, capable of mobilizing its members (7). These programs use social venues to provide information to attendants and increase awareness in the community (7, 6). Church programs and social/community events offer a forum for health professionals and community workers to offer free blood pressure screenings to members of the community in order to alert individuals of their risk of hypertension (6). This intervention uses the health belief model to increase individual’s perceived susceptibility and severity by providing attendants with vital information (18). Though these church and health fairs are widely utilized to address hypertension, the intervention proves to be substantially limited in targeting and impacting that of black males. The intervention may bring about awareness of the risks of hypertension for African-Americans but it is an ineffective outreach mechanism for black males, it completely neglects the realities of the unique social experience of black males, and it does not addresses the complexities of the patient-provider relationship that often serve as an obstacle to effective health care.
Ineffective Outreach to Black Males
African-American men have the highest mortality rates for cardiovascular disease, heart disease, and stroke when compared to black women, white men, and white women (15). Consequently effective interventions are needed for black men. Church and community health fairs are ineffective in targeting black males. By virtue of design these interventions are inadequate tools to provide effective outreach to black men. Though a large number of African-Americans attend church, a great deal more women then men make up these congregations (2,3). Assensoh and Assensoh found that in their study women were 23% more likely to attend church every week then men (3). A number of studies have confirmed the difference in church attendance of men and women. Therefore, programs implemented through the church as a main venue do not reach the larger number of African-American men that may be at risk or have hypertension.
Community fairs are also more frequented by women then men. One study noted as high as 78%, were women participants (averaged from two fairs) of the health fair (6). Another limitation of this intervention is that health fairs are commonly marketed as an opportunity for free screenings, clinic alternatives, and a way to “bring the professionals to you” (19). People often regard health fairs as a place to go when one has a health concern but limited resources to assess the concern. Black men often correlate sickness and being unhealthy with the presence of symptoms (13). Accordingly, if they feel healthy they will see no need to seek help. Since health fairs have been marketed as a means to seek help, African-American men may be less likely to attend. This is of extreme concern because high blood pressure is known as a “silent killer”, providing no real alarming symptoms when preventative measures would be most effective (13).
The Church and the community are support networks for their members. They serve as spiritual, physical, and political vehicles, ultimately promoting and supporting the well-being of its members (3). Yet black males report feeling a lower sense of tangible and instrumental social support then black women, and white men and women (12). Instead black males have cited mothers and sisters as their major support system (13). For this reason it is possible that black males connect less with larger social networks then their counterparts. Again, this point illustrates that church and community interventions are less appropriate and ineffective approaches when targeting black males.
Neglecting the Realities of the Unique Social Experience of Black Males
As follows with interventions utilizing the Health Belief Model, church and community health fair interventions fail to address the social and cultural context of African-American men and their perception of health. The reality of Blacks in America is one plagued with health disparities. Differential quality and access to care is exacerbated by the wide gap in socio-economic status and the lack of healthcare for all Americans (9). Nonetheless, studies show that “racial differences in blood pressure can persist despite adequate access to care” (1). Thus the root of health disparities must be addressed by exploring the social and cultural context in order to truly reduce the prevalence of hypertension among African-American men. The large divide in social experiences of whites and blacks is the aftermath of hundreds of years of segregation, slavery, and racial discrimination. America has never truly dealt with or healed from these issues. Because America never dealt with the consequences of the actions of slavery, segregation, and racial discrimination African-Americans unique past has manifested physically, mentally, and possibly genetically (11). This part of history is analogous to a child being raped and to deal with the issue the family moves to another city and acts like it never happened. Thus, with such a troubling history and trying current social environment, how do black males voice their concerns when the world around them does not relate to, or has little knowledge of their unique social experience. According to Abraham Maslow’s Hierarchy of Needs it is difficult to address health concerns when lower level needs such as physiological and safety needs cannot be met in such an environment (17).
Today, it is likely that discrimination is unconsciously committed based on stereotypes and social norms (5). African-Americans perceive grave differences in their social experience in America illustrated by a number of common themes such as extensive use of nontraditional support systems; general mistrust of European Americans; African Americans' being undervalued as human beings and members of American society; effective use of improvisation; uneven playing field as a result of persistent discrimination; preservation of a unique ethnic identity; socioeconomic status as a major influence and predictor of behaviors (14). Understanding and consideration of these influences must be taken into account in order to remove the adverse social differences in experience and effectively reduce high blood pressure among black men. Black men appreciate validation and acknowledgment of their unique social experience when seeking care and find it easier to achieve successful outcomes in such an environment (13). This intervention in no way addresses the unique social experience of black males and thus fails to effectively intervene on behalf of black men.
Another major social and cultural issue that is not addressed by the church and community health fair intervention is the tendency of black men to view seeking help as a sign of weakness (13). Black men find it hard to be vulnerable. They are taught at a young age not to cry and not to complain. Also an increase in single mothers raising black male children may add to this issue (5). In an effort to raise a tough boy mothers may not engage in emotional dialog and men may not know how to express themselves. This type of upbringing is apart of black males cultural context and may result in an inability to express concerns and share feelings. If they indeed need care, such obstacles may delay the act of seeking care.
Complexities of the Patient-Provider Relationship
“There are ethnic nuances in communication between doctor and patient. These ethnic nuances have a large effect on what is said to the patient and what is heard” (11). The church and community health fair model fails to tackle the issue of patient physician communication barriers. How the interaction between patient and physician plays out is a key indicator of whether or not the patient will return (13). Miscommunication can adversely affect the diagnosis and/or the treatment regime (10). Too little communication could also cause problems. For black men communication and expressions of care are highly valued. Too little information, not looking the patient in the eyes, and not taking the time to explain the treatment to the patient can lead to noncompliance and resentment of the profession or the professional (13).
Some external issues that physicians face may also affect patient-physician communication. Unfortunately many doctors have limited time with patients and cannot appear caring and approachable if they feel rushed to get the next patient (20). Due to a number of factors doctors are less able to make lasting connections with patients and advise patients on preventive measures that can be taken to reduce high blood pressure. Physicians have to schedule a large number of patients per day to maintain the pay bills. This may lead to heavy appointment days and less time per patient. There are also less primary care physicians in the United States compared to other developed nation (20). This may also aggravate the issue of time per patient due to a large number of patients per physician (20). Additionally the large number of uninsured patients in America may not be able to go to a physician, and could cause there not to be a physician patient relationship at all for some individuals. These issues lead to a decline in effective communication and poor patient care.
Cultural issues also complicate the patient physician relationship. Communication problems between white physicians and minority patients seem to be a risk factor of health disparities (10). Particularly with hypertension, black men have a hard time incorporating diet and exercise into their lives (13). Without the understanding of the doctor and further dialog as to the complexities of their (black men) lives and economic situations, adherence to and effectiveness of a treatment may prove increasingly difficult.
Conclusion
Though the church and community health fair intervention is effective in bringing about awareness of hypertension and the heightened risk of African-Americans to get the disease, it effectively misses Black males as a target. Black males are at higher risk to die from CVD, heart disease and stroke and need to be targeted with interventions that address their specific issues and concerns. Due to their low attendance rates in churches and at heath fairs, this intervention is by design ineffective. The intervention also follows the Health Belief Model and has no means of accounting for the unique social experience of Black males and the communication barriers between physicians and patients when seeking and receiving health care. The intervention’s inability to address these issues proves that it not only misses its target, it also misses the point.

Part II

Counter-Proposal to the Church/Community Health Fair
In light of the limitations of the health fair intervention derived from the health belief model, I propose a more integrated approach to address hypertension among black males. I propose an intervention that recruits black men to be the arbiters of the program. The program is modeled after the City Year program. Its focus would be to positively affect the health of those working for the program as well as the men the program targets. Within this program young black men would facilitate outreach events in their communities.
Like City Year, these men would commit a year to work on behalf of the program. They would be expected to learn about health issues that affect black men. Their own personal health would be assessed and they would be expected to lead a healthy lifestyle while in the program. Their responsibility would consist in going out into the community and talking to other black men about living a healthier life. They would also provide forums to address social and policy issues that affect black men’s health. The main objectives of the program would be effective outreach to black men, educating men about the social context and its effect on health, and active pursuit of eliminating health disparities. The program provides a voice for black men and a constructive use of resources and time.
A More Effective Outreach
The health fairs relied on men to come to them. For these men to hear the information, they had to go to church or a community health fair. This intervention would address the main flaw of the health fair intervention by truly reaching out to the men in the community. Who better to address black men’s health and issues than black men themselves. With this intervention the black men recruited by the program would go directly to places more frequented by other black men, such as their homes, the barbershop, college/school programs, or even on the streets, in addition to churches (26).
Black men have been known to be hard to reach in any one social institution (21,22). Accordingly, this program allows the intervention to diversify and use different methods to reach more people. Using the black men recruited by the program as a small focus group or cohort to get a better idea as to how to motivate and reach out to black males, more effective outreach methods tailored to that community could be created and implemented. The Program would have wide appeal because it would be implemented on a national as well as a local level. The same would foster strong relationships with influential organizations in the black community enlisting the support of black Greek letter fraternal organizations, the NAACP, local promotions companies, and black celebrities. By using this model, Black male youth have a constructive way to spend their time, they are given financially incentives, become engaged in their community, and help other black men in the community at the same time.
Addressing the Realities of the Unique Social Experience of Black Males
Addressing the realities of the consequences of discrimination, slavery, and racism in this country is a daunting task. Nonetheless, in order to begin to eliminate health disparities these issues must be addressed (5). The first step to closing the gap in health disparities is to understand the social and cultural context in which such disparities arise. Thus the history taught in school should not only address the events of the past but also the impact that those events have had and how that translates to our social environment today. The intervention proposed will be able to address this lack in education by having the men in the program talk to area schools. They could hold school summits and assemblies to talk about different pertinent social issues. This type of semi-informal forum will allow the stigma on speaking about race to dissipate.
In addition to these types of events the national level of the program will provide black men with a political voice that could place health disparities on the national agenda. The more exposure the program gets, the easier it is to get the issue on the national agenda (25). By using agenda setting to address these issues, the social norm of health disparities based on race may no longer be tolerated by society as a whole (25). By giving these men a voice in their community they will not internalize their feelings and have better tools and more knowledge to address their issues productively. Such an outlet could have profound effects on society.
Dealing with the Complexities of the Patient-Provider Relationship
Traditionally cultural competency or cultural sensitivity classes have been the answer to patient provider communication problems. However I believe that, in addition to this approach, this intervention can help to improve this relationship it two ways. First, the men involved in the program can provide forums to speak directly to the physician in the area. The men would be able to relay different concerns to the physician and the physicians would be able to learn in a real way how they can improve appropriateness of care for the men of that community. The second way is more indirect in nature. Race and ethnicity have stood out as major variables in the quality of care patients receive. Unfortunately as America grows more culturally diverse, the diversity among American’s physician’s has not grown to equal the patients they will serve (24). The program would give the young men involved exposure to the medical industry. This exposure may spark the interest of these men to go into the medical field. The intervention could then serve as a pipeline to careers in medicine. For future physicians learning how to deliver culturally competent care could be enhanced by learning medicine with students and from faculty who are themselves emblematic of society’s diversity (23). By increasing the diversity among physicians to mirror the diversity of the surrounding community (in addition to cultural competency classes) the medical workforce will be better equip to serve their patients and thus improve the overall quality of care.
Conclusion
Like any social science intervention there are limitations to this design. One intervention cannot abolish widespread social problems in our society. Also one intervention cannot end an era of political correctness that may impede some of the effects outlined above. I do not claim a cure for social problems. However, I do believe that reforms, policies, and interventions in this vein can positively impact health disparities. The intervention proposed unlike the Church/Community health fair intervention has a more comprehensive approach to addressing hypertension in black men. The proposed intervention accounts for social, cultural, and well as local issues. The intervention actively seeks out the target audience in the community and uses people from that audience to also deliver the message, thus actively engaging the community to participate in health awareness. The intervention also addresses cultural barriers in communication and barriers that cause disparities. This intervention is a superior option when compared to the health fair intervention because it goes beyond the individual level of awareness and addresses the barriers to implementation of better health behaviors.

References:

1. Bosworth H. et al.. Racial Differences in Blood Pressure Control: Potential Explanatory Factors. The American Journal of Medicine (2006) 119, 70.e9-70.e15
2. Reese L. and Brown R. Source The Effects of Religious Messages on Racial Identity and System Blame among African Americans. The Journal of Politics, Vol. 57, No. 1 (Feb., 1995), pp. 24-43
3. Alex-Assensoh Y. and Assensoh A.. Inner-City Contexts, Church Attendance, and African-American Political Participation. The Journal of Politics, Vol. 63, No. 3 (Aug., 2001), pp. 886-901
4. Felix AK, Levine D, Burstin HR. African American church participation
and health care practices. Journal of General Internal Medicine 2003;
18(11):908-913.
5. Williams D. et al. . Racial Residential Segregation: A Fundamental Cause of Racial Disparities in Health. Public Health Reports. (2001) vol. 119 pp 404-416
6. Jennings-Sanders A. Using health Fairs to Examine Health Promotion Behaviors of Older African-Americans. The ABNF Journal. 2003 pp13-16
7. Markens S. et al.. Role of Black Churches in Health Promotion Programs:Lessons From the Los Angeles Mammography Promotion in Churches Program. American Journal of Public Health. May 2002, Vol 92, No. 5
8. Bell C. et al.. Understanding the role of mediating risk factors and proxy
effects in the association between socio-economic status and
untreated hypertension. Social Science & Medicine 59 (2004) 275–283
9. Kington and Smith. Socioeconomic Status and Racial and Ethnic Differences in Functional Status Associated with Chronic Diseases. American Journal of Public Health. May 1997, Vol. 87, No. 5
10. Balsa A..Testing for Statistical Discrimination in Health Care. HSR 40:1 (2005)
11. Joel E. Dimsdale, MD.. Stalked by the Past: The Influence of Ethnicity on Health. Psychosomatic Medicine 62:161–170 (2000)
12. SAAB P. et al.. Influence of Ethnicity and Gender on Cardiovascular Responses to Active Coping and Inhibitory-Passive Coping Challenges Psychosomatic Medicine 59:434-446 (1997)
13. Rose L. et al.. The contexts of adherence for African Americans with high blood pressure. Journal of Advanced Nursing, 2000, 32(3), 587±594
14. Ard JD et al. Perceptions of African-American culture and implications for clinical trial design. Ethnicity & Disease. 15(2):292-9, 2005
15. Healthy People 2010
http://www.cdc.gov/nchs/ppt/hpdata2010/focusareas/fa12_bookcharts.ppt
16. Center for Disease Control and Prevention
http://www.cdc.gov/bloodpressure/facts.htm
17. Wikipedia. Maslow’s Hierarchy of Needs. Wikimedia Foundation Inc. http://en.wikipedia.org/wiki/Maslow%27s_hierarchy_of_needs.
18. Rosenstock I.. Historical Origins of the Health Belief Model. Health Education Monographs. (1974) Vol. 2 no. 4
19. Rotary International Foundation http://www.rotary.org/en/MediaAndNews/News/Pages/080428_news_denver_russianhealthdelegates.aspx
20. Kowalczyk L. . Hospital doctors shut doors to new patients. The Boston Globe. November 12, 2006.
21. Becker DM.et al. Impact of a community-based multiple risk factor intervention on cardiovascular risk in black families with a history of premature coronary disease. Circulation. 111(10):1298-304, 2005 Mar 15.
22. Chalapati W. and Chumworathayi B. Can a home-visit invitation increase Pap smear screening in Samliem, Khon Kaen, Thailand?. Asian Pacific Journal of Cancer Prevention: Apjcp. 8(1):119-23, 2007 Jan-Mar.
23. Pilcher ES. et al. Development and assessment of a cultural competency curriculum. Journal of Dental Education. 72(9):1020-8, 2008 Sep.
24. Data is from Minorities in Medical Education: Facts and Figures 2005
25. Agenda-Setting Theory (http://en.wikipedia.org/wiki/Agenda-setting_theory)
26. Barbershops as Hypertension Detection, Referral, and Follow-Up hyper.ahajournals.org/cgi/content/full/49/5/1040

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1 Comments:

  • At December 19, 2008 at 7:34 AM , Blogger Lynne said...

    Thank you for your thoughtful (and referenced!) ideas on outreaching to Black men. I agree with your concerns about the unacceptably high health disparities that affect the Black community, and that we need to continue to assess the effectiveness of current approaches/interventions, while always searching for innovative ways to address the heavy burden of disparities in this population.

    A comment about church-based interventions -- you are correct in that the majority of this population is women. However, we have found that an effective way to reach men, to get men to come in for screenings and to take other health-enhancing actions, is through the important women in their lives. This is why statistics show that married men have longer life spans than unmarried men... or perhaps it just seems that way! :-)

    Another example of reaching a specific type of men -- offering free flea dips for dogs at pet/hunting stores, and free prostate exams for the dogs' owners, as they're waiting for their dogs to be dipped!

    Cheers,
    Lynne

     

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