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:

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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
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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
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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.
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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

The Ineffectiveness of Mammography Interventions in Reaching African-American Women in the U.S. – Kate Laporte

The Centers for Disease Control and Prevention (CDC) reported that breast cancer mortality in the U.S. declined by 2.2 percent per year from 1990 until 2004 (1). This is due primarily to widespread use of mammography and early detection of tumors, which leads to a better prognosis than late-presentation cases (2). However, racial disparities in breast cancer mortality have persisted even as the overall incidence rates have dropped. Incidence rates are lower for African-American women compared to white women, but African-American women have higher rates of mortality from the disease (3). African-American women have also been found to have a higher risk of underutilization of mammography, which is a factor in the increased mortality rates (4). Traditional public health approaches to increasing mammography use have focused on raising awareness about the risks of breast cancer and the benefits of mammography through education efforts. The National Breast and Cervical Cancer Early Detection Program of the CDC describes the purpose of their recruitment program as follows: to increase the number of women in priority populations receiving clinical screening services by raising awareness, addressing barriers, and motivating women to use these screening services (5). Intervention strategies to increase the uptake of mammography are focused on three aspects: educational efforts that increase women’s knowledge about breast cancer and mammography, training programs to help physicians increase uptake of mammography by their patients, and increasing access to mammography, typically through mobile mammography clinics and ensuring that women are informed about insurance coverage for mammograms (6). The interventions have failed to reach that goal, especially among African-American women. Researchers at the University of California at San Francisco included over one million women in a recent study of mammography utilization and found that African-American women had a 1.2 odds ratio of not obtaining a mammogram with comparison to white women (4). This study, published in 2006, found that large, advanced-stage tumors and lymph node–involved tumors were more likely to be diagnosed in African-American women than in white women. However, when rates of mammography screening were accounted for, the differences were attenuated or eliminated. Public health interventions to increase mammography use, based largely upon traditional behavioral change models, have had too narrow a focus to be effective in reaching African-American populations. The following arguments, based on the social context theory, the structural influence model and framing theory illuminate the weaknesses of this approach.
Considering the Social Environment
According to social context theory, there are three dimensions of the social environment that should be taken into consideration when modeling social change (7). These are the following: societal structures or shapers (factors external to individuals such as technology, race and social class), social processes (perceptions, attitudes, values) and social realities (common patterns of social behavior). The public health campaigns to promote mammography and evaluations of such programs have been based upon traditional behavioral models that do not include macro-level processes. They have been focused on changing individual women’s attitudes and beliefs toward their susceptibility to breast cancer and the value of mammography without including the larger societal influences that weigh in on behavior. One recent cross-sectional survey of African American women’s knowledge, attitudes and beliefs concerning breast cancer screening was based on the Health Belief Model (8). The Health Belief Model postulates that people will perform a health behavior if the perceived benefits of the behavior outweigh the perceived barriers (9). The researchers found that the women were aware of the value of the screening process and they identified breast cancer as one of the top health concerns for African-American women. This suggests that public health efforts and fund raisers targeted at increasing awareness had been successful. However, actual mammography utilization was drastically lower than recommended standards; less than half of the women reported having had a mammogram in the past year. The solution recommended by the researchers was increased educational campaigns targeted to African-American women. The broader societal forces that impact African American women were not accounted for in this narrow approach. Other evaluations have similar recommendations. According to social context theory, social realities (common patterns of social behavior) impact individual behavior. The folkways and norms that form common patterns of behavior in African-American communities have been reported to contribute to lower rates of mammography (10). For example, African American women have reported that cultural norms prioritize acute care over preventative health care. There is a tendency for women to neglect preventative care when other concerns are pressing. These others concerns were reported to include neighborhood violence, housing issues and substance abuse. None of these concerns are included as barriers to mammography in the traditional public health approach. Social context theory also emphasizes the affects of societal structures (e.g. race, socioeconomic status) on behavior. Since there is a disproportionate amount of African-American women are living in poverty and in unsafe neighborhoods, these societal structures are important determinants of whether a mammography is obtained. Thus, interventions to increase mammography use in this population must take into account the social context in which health behaviors take place. Another example of the impact of community-level beliefs is the integration of other women’s experiences with breast cancer into the folklore and norms of the community. One study found that the shared experiences of the community were found to impact women’s attitudes and beliefs concerning breast cancer screening (10). Negative experiences with mammography or breast cancer were found to impact how women viewed obtaining a mammogram, regardless of whether the information was correct or if it had happened to someone else. Recommendations to obtain mammograms were disregarded due to the integrated beliefs that it was associated with pain and cancer diagnosis. Traditional educational methods do not address community-level norms and beliefs and fail to capture the impact of these negative experiences on other women’s health behavior.
Communication and the Health Care System
The traditional approach has failed to examine the impact of the experiences of African American women with the health care system upon mammography use. Real or perceived negative experiences with the health care system can create a sense of fatalism regarding cancer (10). However, traditional individual-focused approaches to promoting mammography use have not considered the system-level factors of African American women’s experiences with the health care system. For instance, communication difficulties may play a part in discouraging women to obtain a mammography. One study that used focus groups to elicit the ideas and concerns of African-American women regarding mammography reported women’s fears about cancer that arose from a mistrust of the health care system due to negative encounters with health care providers. The negative encounters were largely concerned with communication, such as inadequate explanation of what a mammography entailed or what would be done with the results (10). Another study documented that African-Americans are less likely than whites to have their physicians discuss treatment plans and preventive health care during clinical encounters. This suggests that racial disparities may exist in the amount of information communicated to African-American women about screening mammograms (11). The structural influence model holds that social determinants (e.g. socioeconomic position) and mediating or moderating conditions (socio-demographics of age, gender, and race/ethnicity and social networks of social capital and resources) impact communication outcomes (12). Communication outcomes include information access, information processing and information utilization. A structural level approach to increasing mammography use would recognize that social determinants and mediating conditions influence communication of patients and providers. Race and poverty, in particular, can play mediating roles in the experiences of African-American women with their providers. Since a disproportionate amount of African-Americans are poor, they will encounter the health care system differently. Poverty has a negative impact on the behavior of health care providers and the availability of health services. Those who provide health care for minorities and people in low income areas, for example, are often less informed about preventive care services and are less likely to be board certified (13). This has not been accounted for in traditional provider training programs that have focused largely on increasing physician recommendation for mammography (6). Training that emphasizes increasing recommendations without regard to the other factors that are impacting communication is most likely ineffective. The structural influence model offers a more comprehensive view than the traditional approach of the interaction of African-American women with the health care system and the impact of that communication on mammogram use.
Framing the Issue
Much has been studied about the disparities in breast cancer mortality between African-American women and white women. The disparities have been documented for greater than thirty years (3). Interventions aimed at increasing mammography use have been focused on individual-level behavior and the problem of mammography utilization among African-American women has been thought of as an education and motivation problem. The social determinants of health have not entered the picture of breast cancer health disparities. Framing theory provides the means to readjust the paradigm concerning mammography use as one of a social and systems problem rather than an individual’s failure. A message can frame population health disparities as being caused by internal factors (within control of the individual), external factors (beyond the control of the individual), or some combination of the two (14). Instead of focusing on under utilization of mammography, the shift to a broader perspective of health disparities would take into consideration the underlying social determinants of health. The social determinants of race and the often correlating factor of income level serve little function as descriptions of study group participants. Their impact on women’s experiences with the health care system and the types of barriers faced by women in their everyday lives to preventative health care are critical factors in understanding why disparities have persisted. Investigation into the social determinants of health can lead to policy change that would address the fundamental underlying factors of disparities. Barriers inherent in the health care system such as communication difficulties could then be addressed on a widespread level. The social norms that discourage preventative health care could be addressed within African-American communities. Finally, agencies and organizations that aim to increase mammography uptake could take into account the real-life society-level concerns that African-American women face and design approaches that consider these concerns.
In conclusion, the traditional, educational, public health approach to mammography uptake has failed. Disparities in mammography utilization and related breast cancer mortality in African-American women in the U.S. have persisted despite millions of dollars of educational and awareness programs. Social science theory elucidates the limitations in the traditional approach. A comprehensive picture of the social context of health behavior and the role of the health care system in promoting mammography use offers new perspectives concerning the underlying determinants of health disparities. The new perspective gained can help frame this health disparity in a way that reflects social responsibility.
A novel approach
Through use of the spatial interaction model, Mobley and colleagues describe a comprehensive approach to factors affecting mammography use (15). The model was applied to aggregate pooled information from several heterogeneous states in the U.S. The aim was to demonstrate that pooled data can provide misleading information regarding predictors of health care utilization. The model includes factors that impact mammography use at several different levels, including fundamental/macro factors, intermediate or community factors, interpersonal factors, and individual factors. It draws from different disciplines to create a more comprehensive picture of what impacts health behavior than individual beliefs and perceived risks (Health Belief Model). Each of the levels, from the outermost (fundamental/macro factors) to the innermost (individual factors) impedes on the next level until, ultimately, the cumulative effects weigh in on individual behavior. The model is described below:
Fundamental/Macro factors:
Distribution of wealth, educational opportunities, and political influence; social and economic policies, institutions, regulations, campaigns, topography, climate, water supply
Intermediate or Community:
Social context – neighborhood, workplace, and housing conditions; public infrastructure and investment; police, enforcement services, crime; health care system
Health care system: proximity and density of facilities, physicians; crowding, scheduling and convenience, personal physician, managed care climate, primary care physician shortage; international medical graduate enclave
Physical environment – community capacity and partnership; land use patterns, transportation systems, buildings, public resources, pollution
Interpersonal:
Stressors, social integration and support, psychosocial factors, behavioral settings, social relationships, living conditions, neighborhoods and communities, neighborhood watchfulness, driver courtesy, social or cultural cohesion, population health behaviors or norms
Individual/Population:
enabling/disabling: personal disability, personal resources, type of health coverage, new address, marital status, employment status
predisposing: age, sex, gender; race or ethnicity, educational attainment
need: beliefs, family history, perceived risk, health status
Accounting for social context
The terms that are highlighted were discussed in previous sections as potential mediating factors in African-American women’s mammography rates that were left unaddressed by the traditional approach. The traditional approach does not consider the social context in which African American women live, including social norms particular to their communities. Population health behaviors or norms are integrated into the interpersonal level in the spatial interaction model. Also, concerns that keep African American women from obtaining mammograms such as neighborhood violence and housing conditions are included at both the intermediate and interpersonal levels. The study based on this model found that factors at the intermediate level did, in fact, affect mammography rates differently across states. In particular, the researchers found that in five of the states, the proportion of the workforce who commuted more than sixty minutes each way to work was negatively associated with mammography use. These findings highlight the need to examine specific social contextual factors that traditionally seem unrelated to health care utilization.
Accounting for system level factors
The model also takes into account the characteristics of the health care system that can promote or inhibit mammography utilization. In particular, the availability of primary care physicians may have an impact on mammography use. Physician shortages tend to occur in poorer areas and this factor may have a disparate affect on African American women, since a disproportionate amount of African American women live in poverty. Crowding, scheduling, convenience and the availability of a personal physician may all play a role in determining whether African American women perceive their experiences with the health care system as positive or negative. These types of variables cannot be quantified at the individual level but require a systems perspective. However, valuable qualitative data from women’s experiences can be obtained through focus groups and open-ended questionnaires that can help illuminate the specific areas of concern. Here, the concerns that surfaced through focus groups are included in the model as mediating factors on mammography use.
Reframing the issue
The spatial interaction model includes race/ethnicity as an individual level factor. While this may seem to be akin to the traditional approach, the model accounts for the impact of race/ethnicity as a determinant of health care utilization through multilevel modeling. The macro-level, intermediate and interpersonal factors that are modeled are the same factors that affect people of different racial/ethnic groups differently. Thus, while including race or ethnicity as an individual risk factor, the spatial interaction model also investigates the higher level processes by which people of various races and ethnicities are affected. The authors reframe the issue of disparate mammography use as one of differences in place-specific resources. The issue of place-specific trends is tightly joined to racial health disparities due to the extremely high degree of racial geographic segregation in the US (16). The health disparities that affect one racial or ethnic group, such as African-American women, are reflective of the place-specific resources and conditions acting upon their lives.
Conclusion
The structural and social forces that drive racial inequalities are being recognized gradually in public health research as the underlying, foundational determinants of health disparities. Mammography utilization is particularly important for African American women, whose mortality rates remain high and frequently present with later stage disease than their white counterparts. Education and individual-level interventions have proven ineffective in reducing disparities over the last thirty years. Specific social contextual factors and broader structural determinants must be addressed if this gap in health care utilization is going to be eliminated.

REFERENCES:
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The Un-fulfilled Goals Of National Diabetes Education Program Towards Limiting Racial Disparities In Diabetes Prevention- Monica Gupta

Introduction to Diabetes and NDEP

In the last twenty years, diabetes has rapidly become global problem for all races and all types of people. There are approximately 117 million people who are suffering from and living with diabetes making it a world wide epidemic (1). Of this, 8% of the American population has diabetes (2). Although the cause of diabetes is still unknown, certain environmental and behavioral factors have been linked to diabetes. The general population’s increase of obesity is though to be a principal explanation behind the cause of rising prevalence. While non-Hispanic white Americans, age 20 or older, have a prevalence of 8.7%, racial minorities have higher prevalence’s, with 13.3% among non-Hispanic blacks and 12.8% among American Indians. The prevalence of Hispanic/Latinos populations is not known, but with Mexican Americans there is about a 9.5% prevalence among adults 20 years of age or older. The prevalence among other minorities is unknown but there are signs that groups such as Asian Americans and Pacific Islanders have twice the risk of developing diabetes when compared to non-Hispanic whites(2).

Albeit its origins are still medically unknown, there are many ways to control and limit the effects of diabetes on individuals. To help spread the knowledge, there is the federally funded National Diabetes Education Program (3). This organizations works to continue to promote public awareness and educate people about diabetes symptoms, facts, treatment, and general lifestyle changes that can be made to help reduce the risk of illness (21). One of the fundamental purposes is to reduce racial health disparities in groups that are heavily burdened by diabetes. However, even with its good intentions, the program lacks cultural integration and chooses to ignore social outlets that would help spread the public health message much more effectively. If there were changes made, and money and time directed to a more wide spread reach, there ability to change communities would become promising.

Argument 1: Not as culturally friendly as intended.

NDEP is part of a large national movement to educate the public on who may be at risk for diabetes and about the threat to their health. This means addressing people of all races, whose origins span all the 195 countries (4). Therefore, NDEP has made a strong effort to connect itself with as many multi-racial organizations possible, such as Association of American Indian Physicians, Black Women’s Health Imperative, and National Alliance of Hispanic Health (3). However, even with these partnerships, there are inherent problems. One of the initial issues is that this organization hopes to encourage awareness among Asian Americans and Pacific Islander, and yet there is no sufficient data about their prevalence (5). What is reported are estimates based on incomplete data. If the goal is to promote change, there is a primary necessity to have done the surveillance and find out how much of the each groups are affected. Increased research is needed on minorities so that NDEP may build better programs for the groups in question (22). There is a barrier to health care services that women and men of color face on a daily bases and to help emphasize the importance of risk of diabetes among minorities to health care workers, the data is needed to share with them as well (6). Without a strong base on the problems and issues of where diabetes stems from in minorities, it will be difficult to make behavioral changes in individuals, much less groups.

While many ethnic minorities are under-educated, there is also significantly large group who are very educated and take censuses and statistics into consideration before making behavioral changes (5). The program tries to grasp for attention with its facts and statistics, however it is incomplete. It is imperative that the data is gathered and reported so that minorities may have an accurate view of how their environmental and behavioral factors affect their risk of developing diabetes. Many minorities are also mistrustful of the health care system and need more support to make changes in their lives (24). They are biased and have fear for the health care system which has not always been kind to them and their needs, may it be here in the US or in other countries. This data will help gather information on not only who to target, but what practices are best for each of the different groups and help bring a strong, more cohesive prevention plan into action

The website does try to include many minority groups by translating a handful of its most important brochures’ in to various languages such as Spanish, Tagalog, Hindi, Chinese, and a dozen more so that they may be read by all people (8). However, information that is provided is not adjusted accordingly. They are straight translations from the English version, which does not adjust for the different cultural understandings that is necessary when translation for medical purposes (9). Cross-cultural testing requires translations that adapt to different communities mentalities and linguistics. The multiple language versions are not fitted for their target population, which is an important step in translation that has been skipped (9). Factors such as educational background have not been taken into consideration, and can lead to brochures that are unhelpful to the population being targeted (10). It is evident that the website was created to help physicians assist their patients with brochures in their native language; however these ill translated texts could instead further hamper the care patients receive (24). This translation issue is a failure that undermines the programs goals to reduce racial barriers to better health care.

Argument 2: Lack of knowledge of history of woman and ethnic food

Along with the lack of data and sufficient translations, NDEP fails to help reach out to the many racial communities by failing to be sensitive to the history of the various groups and how it now affects the way people act towards their health. Although these minorities currently reside in the United States and therefore have some differences in health outcomes than from their counterparts in their native countries, there are a lot of traditions that do not change (23). NDEP fails to educate caregivers about the difference’s that will be seen depending on if they woman is a Hmong from China, a Black refugee, an illegal Hispanic, Catholic, Hindu, or Muslim. The mental status of each of these women will differ and therefore require different types of interventions, even within each group (11). Their health care outlook is affected by their ability to seek help and their responsibilities to primarily care for their family and then themselves (12). NDEP needs to provide more information so that these women, who may not be internet savvy and unable to find additional information online, are able to receive the information from caregivers and community outreach programs that depend on NDEP for adequate information.

One of the key features to reducing diabetes is with weight loss and prevention of obesity. Along with exercise, the NDEP promotes eating well which relies on many changes for patients such as decreasing sugar intake, decreasing carbohydrates, and increasing fruits and vegetables (7). The list and information is a positive starting point, however, it completely fails to consider the ethnic differences in food choices. Because of the heavy dependency on self-management among diabetes interventions, it is essential that all the information is provided so there are options on how to change to manage the disease (13.) The recipe and meal planner provided by NDEP lacks ethnic specific plans. It offers very generic advice with recipes that are not adjusted for minorities whose main meals are very different from an ‘American’ meal and who are not familiar with the options given. Groups may become fearful of what is recommended if they believe that the caregivers are forcing them to choice between a way of life and tradition and a living longer (24, 25). What is needed is, at the very least, links to sites that do offer more information. If patients do not have this information, they are more likely to fail making changes and unable to save themselves from future problems.

Argument 3: Do not use media to full potential

Minority children in America are at a higher risk of becoming obese and this extra weight could put them at an increased risk of developing diabetes. The change in weight is mainly due to the decrease of exercise, and the increase of sedentary activates such as watching television (15). Both the adults and children of minorities spend more time in front of the television than non-Hispanic white’s do, putting them at risk to be more prone to behavioral factors that affect their health. They are also highly influenced to make unhealthy choices based on the norms shown through the regular programming and advertisements (16.) One resource NDEP has not used is the media, targeting specific minorities according to different broadcasting stations. There are stations such as Zee TV, TvAsia, CTV, TV Japan, and Telemundo which are watched by thousands of minorities’ nation wide and where there is an automatic large community that can be communicated with ease. Some of these people are also part of a hard to reach community that lack health insurance and are not well connected with a primary physician who would help care for the diabetes (26). Many of these channels are watched so that the audience may continue to have a connection with their culture, and therefore watch many different types of shows. The media is a strong influence for all types of SES, where norms are represented through news, soap operas, shows, and advertisements (16). It instead could be used to help promote health lifestyle and bring awareness through well made advertisements, documentaries, and enjoyable programs that bring diabetes to greater attention (17). With the help of social marketing, the media can support positive health outcomes and change the prevalence for the future (26).

Along with using media and creating PSA’s for international channels, there is a need to present information efficiently. Currently NDEP’s method of choice is to be sent out the same material repeat, and ‘blasting’ the target population with paper and emails (18). However, this has been shown to not be helpful in the long run, and instead the over exposure can lead to indifference to the topic (19). This was observed among a younger, new generation of homosexual men, who have become immune to the threat of HIV and AID’s, thanks to the past twenty years of injecting fear into their minds. Their new attitude is very much que sera sera and they are indifferent to HIV. While the facts are important, it is also important to not preach, instead somehow draw attention to the benefits of changing behavior in general (20). Changes need to be made to increase the effectiveness of each outreach program and spend more time tailoring them specifically to the type of technology being used. The NDEP site is currently also difficult to get around, and has room for improvement. Programs which are heavily depended on websites should be easier to maneuver around than this one is. This website is not user friendly and takes to much time and knowledge to search for and download relevant information in various languages and for different groups (18). While it is on the agenda for future plans, for now it is difficult for minorities to initial get on the internet, and then to maneuver the website is beyond some of their capabilities. In the future, if technology is going to be used as the primary location for interventions, the communities being targeted should be taken into greater consideration.

Alterations to NDEP:

Even with all of the problems that plague NDEP’s website, the ability to fix it self is possible. As mentioned earlier, there are a couple of options to start off with. One of the easier routes is to add information to the site, and to make it easier to search for. The first change has to be to the “Recipe and Meal Planner Guide” (7). The plan needs to include other ethnicities recipes, and adjust their staples of different types of carbohydrates, meats, vegetables, and drinks into consideration. A link to American Association of Physicians of Indian Origins website is a must (14). AAPI has a very detailed diabetics guide to food that is not only specifically made for patients of Indian origin, but it is also specific to the many different regions and cultures of India who have different daily traditions for food and cooking. It will add to the database so diabetics have more than seven meal options. It has everything from breakfast, lunch, and dinner, but also snacks and restaurant food. It evaluates the different choices, the nutritional pros and cons, and gives advice on how to change each and every meal so that people now have incredibly specific information that fits their needs. The snack replacements for traditional Indian snacks and sweets show how high in carbohydrates and calories these mini meals are. This very detailed and lengthy AAPI Nutrition book is a must that needs to be distributed by doctors or diabetes organizations to patients of South Asian descent. It clarifies misconceptions that stem from hundreds of years of cooking with the inability to find healthier ingredients. These are adjustments that few nutritionists would know to recommend; hence making patients visit’s frustrating.

There is also a list of meal planning for various other Asian groups, such as Chinese, Khmer, Korean, and Vietnamese, which can be found on the King County, Washington Public Health website (27). This site has the different Asian regions split by culture, and offers meal planning and recipes, written and translated in the language of each group. This, like the AAPI guide, is useful to individuals from specific regions as well as could be beneficial to all diabetics who are put onto new diets and who might need help learning to cook for meals 365 days a year. The seven recipes currently offered by NDEP is a ridiculously small list that needs to be updated immediately with the information presented. And none of this involves new work of developing the material. The information is ready to be distributed. However, NDEP does need to put it directly on their site, with easy access. NDEP should make an effort to make these meal planners and others like it one of the central points on their homepage so that the risk of diabetes due to obesity and high glucose levels may decrease. If people are not able to find the information through their doctors or online, there is no use of it even existing. Nutrition is an essential for diabetes control, and any education program should recognize advice on meals should not be hidden deep into the website, but easy to find and pleasing to the eye, as well as the stomach.

Along with meal planner, which is change that can be made with out great difficulty, there is the bigger problem of the lack of sufficient data on minorities and diabetes. This is a surveillance and reporting problem that may be beyond NDEP’s reach, however they should encourage the CDC and Department of Health and Health Services to start the collecting the information. Any data that is collected will be helpful compared to what is currently available (22). Data on prevalence, age of incidence, gender differences, and obesity rates among minorities who have diabetes is needed. Much of this information can come from records that physicians already have. Although this requires a large scale reporting, it is necessary. This could be done through the physicians and hospitals, but it could also be done through the patients themselves. NDEP officials could use the community centers such as churches, temples, local minority organizations to compile the data.

Once this initial information is available, the CDC and NDEP will be able to provide it on their websites, to doctors and other caregivers as a solid mathematical evidence of risk to different individuals. Of course, further information would be beneficial, to compare the different SES, cultural differences among minority groups, and what other underlying factors may affect different types of groups’ risk (5-11). There are a lot of possibilities, and while many hours of work and money need to be invested in this project, it is feasible, It will help educate and save thousands of people who are currently sitting in a gray zone, where they know they are at risk, but not really how much or why.

If these two previous issues are resolved, and NDEP has made progress towards achieving some sort of racial equality on diabetes education, the next big step could be to help with outreach through the multinational radio and television channels. Some of mentioned programs are based in the US and some are not. More advertisement needs to be made, based on who is at risk and what steps should be taken to help individuals and families with diabetes (17). Advertisements will have actors based on the race/ethnicity being targeted, speaking the various languages spoken, with representation in traditional and western clothes, as well of the multiple religions that may come from each country. A PSA message on Telemundo would have to target native Mexicans new to America, Mexican Americans born in America, Indigenous Mexicans in America, Catholics, and the rest of the diverse Latin Americans that watch those programs. The same goes with other channels such as TV Japan. It would target older Japanese who may be very traditional, all the way to young Japanese who may be much more western but still watch TV Japan. This could result in many different variations of the same message, but it is will help bring out the message that Diabetes is problem for the community and people need to acknowledge and address the disease.

Program Overview:

Even though diabetes is a chronic disease that affects millions of people worldwide, in the United States there are not enough high quality preventions being done for minorities. Health disparities will continue to be a problem due to not enough data being collected on the affected groups, the lack to knowledge of different cultures and their preferences due to different backgrounds, and the inability for public health to use all of the resources present. For diabetes to be controlled any time in the future there needs to be mass culturally sensitive public health measures put into place that go beyond the doctor’s office. People need to be educated about the risk from childhood and encouraged to have healthier lifestyles that can not only help prevent diabetes, but various other aliments as well. While there is a lot of work that needs to be done, large steps have been taken with the start of organizations such as the NDEP. The CDC is on the right track to change the faces of diabetes. The alterations that have been discussed are all steps in the right directions to help reduce health disparities as well as help educate minorities. If now only the issues of lack of health care and financial woes could be removed, great changes could happen.

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