Health Promotion Council of Southeastern PA Philadelphia Department

Health Promotion Council of Southeastern PA Philadelphia Department of Public Health Department of Family and Community Medicine Department of Medicine -Division of Genetic and Preventive Medicine Office to Advance Population Health SHAPE IT is a joint project with Thomas Jefferson University and Thomas Jefferson University Hospital, Health Promotion Council and The Philadelphia Department of Public Health. This project is funded, in part, under a contract with the Pennsylvania Department of Health. Basic data for use in this study were supplied by the Pennsylvania Department of Health, Harrisburg, Pennsylvania. The Department specially disclaims responsibility for any analyses, interpretations or conclusions.

Overview The Stroke Hypertension and Prostate Education Intervention Team (SHAPE-IT) is a 2. 5 year community-based intervention that fosters partnerships between community-based organizations, community members and health care providers to design and implement strategies to ultimately reduce disease and death from prostate cancer and stroke among African American men age 35 and older in North and West Philadelphia.

Background • Pennsylvania State Disparities Project - Reduce the incidence of stroke and mortality from prostate cancer • Philadelphia and Pittsburgh - 2. 5 years • Focus – AA men age 35+ - mortality from stroke and prostate cancer – RFP - Utilization of State Health Improvement Partnerships – Emphasis on Community Engagement and Planning in all project aspects Project Advisory Council

Project Goal and SHAPE-IT Aims • State - Reduce the incidence of stroke and mortality from prostate cancer Goal To reach men with education programs and encourage them to access providers for care. • Aims – Reach 25% of target population of 27, 000 African American men age 35+ – Use shared responsibility model of community health planning – Develop multiple strategies that are seen by target population as relevant – Direct these strategies towards 2 different health conditions that require different types of decision-making and behavior change

Community

Characteristics of Black Men Living in Target Areas • More likely to be unemployed, live in poverty and have less formal education • More likely to have regular source of care and have seen PCP in last year • Men aged 40 -49 twice as likely not to fill prescription due to cost • Men aged 40 -59 more likely to have a stroke • More likely to report extreme stress Philadelphia Health Management Corporation Household Health Survey, 2004

Assessment of Community and Individual Beliefs, Assets and Needs • 5 focus groups (57 participants) with men with and without hypertension, men with prostate cancer, men from the general population, and social support networks of men • 15 key informant interviews representing 11 disciplines (Family Medicine, Internal Medicine, Neurology, Health Educators, Cancer Patient Educator, ACS, Philadelphia Stroke Council, Stroke Educator, Drug and Alcohol Counselor, Registered Dietitian, Cancer Survivor and ACS volunteer).

Attitudes and Beliefs about Hypertension and Stroke “For many of my young (under 40) African American stroke patients the first time they find out they have hypertension is when they have a stroke. Or they know they have hypertension and it’s not controlled (can’t afford meds or are not taking). Major reasons for stroke are related to uncontrolled BP and cocaine use. ” “ Being Black in White America” (internal stress due to racism over time) “ Men need to know other treatment options. Need to promote that impotence can be treated with Viagra and other drugs, but if you have a heart attack or stroke then you can no longer take Viagra” “If meds make the patient tired then he may not take if he has multiple jobs…” “Patients may stop taking meds when the prescription runs out –may not realize that he needs to take them the rest of of his life. ” “I make changes when the doctor suggest it, but when I feel better I go back to the old ways”.

Barriers to Care and Treatment • Denial: “Men won’t see doctor unless they are in pain; they use home remedies first. ” “If it ain’t broke don’t fix it. ” “Depends on the consequences…will still smoke cause I know I won’t die then and there…if the doctor told me that the next cigarette would kill me, then I would stop. ” “Men will tell other men they need to see the doctor even if they don’t go themselves. ”

Barriers to Care and Treatment • Life Priorities – Time • Working/family responsibilities – can’t take off from work. Will go to the doctor when I have time. Need to pay the bills and take care of family. May have multiple jobs or searching for job. – Money • Insurance, co-pay, cost of prescriptions vs. food, rent, entertainment • Spend money on things that provide a visual perception of success. “You can’t see good health, like you can a car, jewelry and clothes (material possessions) or a trip to Disney World. Health is competing with bragging rights of how people spend money and time. ” – Don’t want to make lifestyle changes

Barriers to Care and Treatment • Lack of Education • “If you want to hide something from a Black man put it in a book. ” • “a lot of guys can’t read or write – need to educate verbally – don’t ask them to fill our papers. ” • “I was never a good reader so my wife was the one who spoke to the doctor and then explained it to me. ” • Men may be embarrassed at not understanding health related information. Doctors need to “talk in plain terms so it’s easy to understand. ”

Communication/Information Needs • Families, particularly men, may not discuss health until there is a crisis. • Mothers discuss health with daughters, but not with sons. If no male in household sons will learn about health issues from friends and information may be wrong. Need older male input. • Need person to person messages “Brothers talking to brothers… breaking it down” • Trust/credibility – believe someone who has been through it (testing/treatment) • Misconceptions are passed on also

Communication/Information Needs • Patient-Provider communication – Lack of time to discuss complex issues such as sexuality issues – Doctors may be intimidating or talk down to patients limiting patient willingness to ask questions – Need to develop on-going consistent relationship with doctor where “there’s some sharing going on”.

Communication/Information Needs • Families, particularly men, may not discuss health until there is a crisis. • Mothers discuss health with daughters, but not with sons. If no male in household sons will learn about health issues from friends and information may be wrong. Need older male input. • Need person to person messages “Brothers talking to brothers… breaking it down” • Trust/credibility – believe someone who has been through it (testing/treatment) • Misconceptions are passed on also

Prostate Cancer • Men and women know little about prostate and prostate cancer (where prostate gland is, how it works, etc) • Some young men more worried about prostate cancer than about elevated blood pressure (over anxious) while other men who have witnessed a family member or friend with prostate cancer may deny symptoms • Prostate cancer feared more than stroke or heart attack • Confusion about screening criteria and what the PSA number mean

Prostate Cancer Risk Factors • Lack of circumcision • Heavy work/ construction/lifting straining • Tight clothing; too much pressure causes it to swell • Sex (too much; too little) • Age • Diet • Stress • Heredity • Hemorrhoids • Smoking • “Many men don’t know family history or believe that if it doesn’t run in family then they are not at risk.

Prevention of Prostate Cancer • Can’t prevent – early detection is best • Castor oil and tea • Vitamins (bottle says vitamins can reduce prostate cancer risk) • Fasting • Regular bowel movement • Rest • Exercise • Keep system clean; drink lots of water • Don’t smoke • Regular check-ups

Prostate Cancer Attitudes and Beliefs • Fatalism - cancer is a death sentence; therefore, why get screened • Some men not sure if checked for prostate or colon cancer • Denial- “What I don’t know won’t hurt me”. • Fear digital rectal exam • Fear erectile dysfunction • Fear of screening “Those not exposed to prostate cancer information have knowledge couched in superstition. Some men believe that if you have surgery then the cancer is exposed to air and will spread”. “Some men believe prostate cancer can be sexually transmitted to wife” “I don’t know if I’m at risk but cancer to me is scary and I pray to God I don’t have it. I think I’m at risk because I’m a black man…and you should get it checked at age 40. And my father and grandfather died from it…I would like to be tested but I fear doctors and I don’t want anything going in there…”

Barriers to Prostate Cancer Screening • Lack of insurance • Lack of knowledge • Digital rectal exam concerns • Male pride • Fear of screening outcome and treatment (impotence; incontinence) • Lack of family communication about health history “I was afraid of the outcome, a lot of men are too macho to get this thing done and feel that they will come out of the doctor’s office and be called gay. My son feels that this is his space and if anyone touches you there that they are violating him. I had to tell my son that there are certain procedures that doctors have to do that are good for you” “Backside territory is mine, raised not to let folks go there…” “It’s hard to let a man get behind me and ring the doorbell…” “Men fear treatment – see as mutilation/ castration. Black men are not aware of new treatments. They need to know their treatment options (at the time of screening)”.

Strategies • Intergenerational • Use “real people” who have survived, been screened, had treatment, etc; peer education • Interpersonal (man to man; friend to friend) • Use multiple strategies • Need consistent and sustainable programs/messages, not oneshot programs/messages (need to address throughout year – not just in September) • Hypertension, stroke and prostate should be addressed as part of a comprehensive program • Verbal communication best • Provide follow-up to screening • Focus on real messages, long term consequences • Promote taking personal responsibility for health • Theme: strong individuals, strong family, strong community = health • Tie community message to PCP messages

Community Action Plan Model Train the Trainer programs Recruit change agents such as: clergy, barbers, rehab staff, day care staff, probation officers Large Group Programs (Lectures/ Plays/ Videos/ Men’s Health Night Out / Health Fairs (1 session) ·Faith based ·Day care Centers ·Health Centers ·Fraternal Organizations Pre-intervention survey (telephone/survey) ·Knowledge, attitudes, beliefs, behaviors, access (insurance, PCP) Small Group Programs (2 sessions) ·Barbershops ·Faith based ·Halfway houses ·Daycare centers ·Fraternal organizations ·Support person/women ·Health Centers One-on-one counseling ·Health Centers ·Community sites Post Intervention Survey (telephone/survey; 2 months post program conducted with assistance from trained lay leaders ·Changes in knowledge, attitudes, beliefs, behaviors, access (insurance, PCP)

Project Targets • Total- 6, 750 – 18 month period - divided into two 9 month cycles; – 450 men per cycle; – providing the subset of 900 men - extensive assessment of the perceptions, beliefs and reactions to SHAPE-IT small group programs.

Small Interactive Groups Session I • 25 men per site • 450 men recruited during each of the two 9 -month periods (totaling 900 men) • Locations – 18 locations • • • 5 city health centers, 4 churches, 5 barbershops, 2 fraternal organizations, 2 recovery homes • 2 sessions; 2 hours each Blood Pressure Screens – What is High Blood Pressure/Stroke – Identify/Define Symptoms – Managing High Blood Pressure – Untreated High Blood Pressure Session II – Review of Session I – What is the Prostate and its function – Reasons to have the Prostate checked – Cause of Prostate Cancer – Diagnosis – Attitudes/Beliefs about Prostate Cancer/Screening – Talk to your Health Care Provider

Results to Date Total reached – 4620 • Small Groups – 545 • 340 to 2 small groups • 205 to 1 group • Follow up – on-going • Blood pressure - 255 (26% Hypertensive, 42% Pre Hypertension, 32% Normal • 1 on 1 Decision Counseling – 12 • Group Decision Counseling - 11

Results - Attitudes • After I talk with a doctor, the decision to be screened is up to me • Prostate cancer is a serious health concern for me • It is easy to talk with my partner about my health • High blood pressure is a serious health concern for me

Results - Knowledge • African American men are a increased risk for high blood pressure • Hypertension and high blood pressure are the same • African American men are at increased risk for prostate cancer • High blood pressure has no symptoms most of the time

Results - Knowledge • A stroke can be caused by a blockage in a blood vessel in the brain • It is important to detect prostate cancer in the early stages • People with high blood pressure only need to take blood pressure medicine when they think their pressure is high • People with high blood pressure can stop taking their medicine once their pressure is normal or controlled