Download Barriers to Care and Treatment

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
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