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"Community Health Strategies to Improve the Life Options of Young Men of Color,"

by Jorielle R. Brown September/October 2005 issue of Poverty & Race

Minority men (Hispanic/Latino and non-Hispanic who are African- American/Black, American Indian/Alaskan Native, Asian-American, Native Hawaiian/Other Pacific Islander) constitute approximately 30% of the United States male population. Yet this cohort is disproportionately burdened by disease, as evidenced by minority men having a significantly lower life expectancy than all women and white men. Diseases such as hypertension, diabetes, obesity and HIV are particularly high among young minority men ages 25–34. These conditions are known to lead to disability and preventable deaths from various cancers, cardiovascular disease and AIDS. Therefore, they warrant particular attention with regard to young minority males.

On an individual as well as an institutional basis, the health of young men of color has been neglected. Unfortunately, this neglect results in limited research, and therefore an incomplete understanding of effective strategies, optimal prevention and intervention programs, best practices, and estimations of models efficacious for promoting and providing health services for minority men. However, a promising area for the reversal of this trend is the furthering of community health strategies. Community health strategies are defined as promoting community involvement in and ownership of health problems and solutions to improve and strengthen the well-being of community members and their quality of community life. Because young men of color are vital members of the community, the improvement of life options for them will heavily rely on community health strategies. For example, community-based health promotion can facilitate outreach and access to publicly supported health care programs and access to primary and secondary prevention efforts targeted toward young minority men. Further, adopting a community health perspective requires tailoring the strategies to the community’s needs, such as integrating physical and mental health, accessing healthcare professionals who reflect community members’ demographics, and addressing areas where young minority men are over-represented (e.g., prison, homelessness).

In addressing the health of young men of color, we must consider their issues and health in the context of their experience in the larger society. Improving the life options of young men of color requires a paradigm shift from the present reactive stance which neglects this category of individuals to a proactive posture more holistic in nature. To lead and assist in this paradigm shift will likely require institutional level changes, such as the establishment of an Office of Men’s Health in the U.S. Department of Health and Human Services, as there is now an Office of Women’s Health.

The Issues

Access to community-based health promotion and treatment services: Men are less likely than women to engage in attention to their health. For instance, women are twice as likely as men to visit a doctor’s office for preventive services and annual examinations. In fact, research indicates that, in particular, many black males do not seek routine medical intervention, and these findings hold true for other racial/ethnic minorities.

The demographics and social circumstances (e.g., limited education, low income, poor employment) of this cohort create barriers to accessing treatment and prevention services. Such barriers may include lack of a telephone or transportation, work schedule inflexibility, limited knowledge of how the healthcare systems function, lack of financial resources, limited healthcare facility hours, or medical mistrust. Without a systematic approach to addressing these and other issues, young minority men are at increased risk of poor health.

Key to community-based health promotion is the development of materials and methods to disseminate information on public health to minority men. This involves creating innovative and practical tools, resources, links and approaches to engaging in health promotion. These materials must be gender-, culture- and age-appropriate. However, due to the dearth of data on young men of color, particularly subgroups of Asian Americans and Hispanic/Latinos, the first essential component in the development of materials is determining the needs and resources present in the community. Such information can be obtained through comprehensive needs assessments. For men of color, it will be particularly relevant to assess cultural and contextual issues, because studies suggest that beliefs about masculinity and cultural norms may lead minority men to either take actions that harm themselves or refrain from engaging in health-protective behaviors. Direct community involvement in designing assessment/evaluation tools is therefore essential to obtaining accurate information on which to base both the promotion materials and the mechanisms for distribution. Primary health, substance use, mental health, social and environmental health are examples of topic areas to be included in a needs assessment.

Another key to increasing access to community health promotion and treatment for young minority men is the need to remove the barriers that limit well-being, as noted above. Often these barriers are not adequately considered, yet they are important matters, since minority men are often reliant on community health services. Frequently, community health treatment facilities serve the uninsured and the underinsured. Minority men are over-represented in these categories due to over-representation among those who are incarcerated, homeless, unemployed or institutionalized. These conditions marginalize them in the labor force and limit insurance options, often restricting them to use of community health treatment. Thus, community health promotion and treatment is a key component to improvements in the health of young minority men.

The implementation of school-based community health promotion has proven beneficial for adolescent minority males. Evidence suggests that school-based health clinics in high schools can facilitate collaboration with key constituent groups, expand the delivery of healthcare services and improve the health status of students they serve. Areas for increased attention are the feasibility, acceptability and effectiveness of clinics serving younger minority children.

For young men of color, community-based health promotion should focus on both healthy minority males and those at risk. Health promotion needs to reach minority men before they are symptomatic, and at a time when changing health behaviors can prevent illness, disability and death. This will likely require a partnership with educational entities in order to raise health awareness in the early stages of adolescence and encourage lifestyle changes.

Outreach and enrollment in publicly supported healthcare programs: For young men of color over the age of 18 and reliant on publicly supported healthcare programs, the expansion of Medicaid in the late 1980s did little to improve their insurance status. Instead, the eligibility requirements for many publicly supported programs exclude those over the age of 18.

Among non-elderly men, 46% of Latinos and 28% of African Americans lack health insurance. Men of color are less likely than white men to have job-based insurance, and only 6 to 8% of Latino and African-American men have Medicaid. Regardless of insurance status, men of color are less likely to receive timely preventive services and are more likely to suffer the consequences of delayed medical treatment, such as limb amputations and radical cancer surgery.

In the United States, care of the uninsured relies significantly on a patchwork system of safety-net providers, including community health centers (CHCs). President Bush recognized the importance of CHCs in his first budget and proposed to double the number by calendar year 2006. While this expansion is much needed, a substantial increase in their budgets is also pivotal. Data suggest that while CHCs are providing primary care services to their uninsured patients, they are often unable to provide much needed diagnostic, specialty and behavioral health services, thus limiting the quality of care offered. Since CHCs are the primary providers of care for young minority men, increased financial assistance to CHCs is mandatory in order to offer the quality of care provided to insured patients.

Access to both primary and secondary prevention, including personal health responsibility and early intervention for treatment: The goal of primary prevention for this group is to target generally healthy young minority males, while the aim of secondary prevention is to address those men with risk factors for particular diseases or illness. The susceptibility to illness and rates of morbidity in this cohort suggest a need for significant levels of primary and secondary prevention for children and adolescents. While prevention efforts would be expected in the educational system, a large number of younger minority males reside in inner cities where educational systems are often ill-equipped to provide needed services. Further, because young adult males are not considered a priority population, little attention is paid to primary or secondary prevention efforts for this group, especially for young men of color.

Targeted outreach is essential due to the lack of emphasis men place on their health. Yet studies suggest that when health education and awareness are provided in a comfortable and engaging environment, minority men prioritize their health. Thus, campaigns that promote health and wellness, such as outreach, health screenings, gender-specific clinics and other such initiatives are needed.

Integration of physical promotion and behavioral health (mental health and substance abuse) delivery: Mental health and physical health are mutually inclusive issues. Yet there continues to be a stigma associated with mental health. For young minority males, this may be particularly true, because in their communities the perception of mental distress may be intertwined with issues of masculinity. This may lead to denial of emotional problems or adoption of coping styles maladaptive to functioning. Unfortunately, rates of mental illness and substance abuse serve as significant barriers to improved emotional well-being for young men of color. Men generally are less likely than women to recognize, acknowledge and seek treatment for depression. Further, loved ones and physicians may not detect symptoms in men because the presentation is manifested differently. The lack of research in this area limits our understanding of depression in young men of color. With respect to alcohol and drug abuse, rates for males are typically higher than those for females. African-American men are at greater risk for alcohol-related social and health problems, and this increases the risk of diseases such as hypertension, diabetes, heart disease, and certain types of cancers and malignant neoplasms.

In contrast to females, who are more likely to use relational opportunities (e.g., family, friends, support groups) to manage stress, society has taught men to harbor their issues, which often exacerbates the problem. Moreover, seeking help from the healthcare system may be misconstrued as a sign of weakness. On the other hand, for males, the integration of physical activity as a coping mechanism or intervention for improved mental well-being is a viable and untapped resource.

Discrimination, poor education, limited job opportunities and poverty are realities for many young men of color. Behavioral responses, such as depression, substance abuse and risky sexual behavior are not uncommon. Diagnostically, clinical and non-clinical levels of mental illness are characterized in part by a diminished interest in usual activities. For adolescent and young adult minority males, this may be reflected in a reduction of physical activity, a more normative behavior for this cohort. However, participation in physical activity has been associated with a positive mood, greater self-esteem, and greater physical and psychological well-being. Additionally, participation in physical activity and team sports activities may provide adolescents with a social network that can support and protect them from depression.

Access to health care professionals and services (including mental health) that reflect the cultural, racial and gender composition of the community: As discussed above, access to care is one challenge for young minority males; compounding the challenge is the shortage of healthcare professionals who reflect their culture, race and gender. In 2003, of the approximately 646,000 male physicians, 2% were Black, 3.3% were Hispanic, 8% were Asian and less than 1% were Native American/Alaskan Native. Yet research indicates that there is greater satisfaction and adherence to treatment when the patient and provider are of the same race. Unfortunately, in most states, the “diversity ratio”—the degree to which a state’s physician composition reflects its demographic composition—indicates the need for a substantial increase in the number of minority healthcare professionals.

The lack of access to healthcare and mental health services mirroring the demographics of young minority men presents many barriers to quality care. Adolescence and young adulthood are periods of self-actualization and growing independence. During these phases, language barriers and poor communication can be impediments to receiving treatment and are related to patient dissatisfaction. In fact, about three in ten Latinos say they have had problems communicating with health providers. For young men of color, limited English proficiency and/or low levels of education likely lead to limited medical literacy, thus hindering possible improvements in their health.

Additionally, medical mistrust is common among minorities. Particularly for young men of color, this may be a learned behavior from historical precedence (such as the role of Tuskegee Syphilis Study). Disclosure of mental and physical health problems and the role of gender are often culturally-specific, thus complicating the patient-provider relationship. An increase in minority healthcare professionals may assist in reversing this negative cycle of ineffective care for young men of color.

The Sullivan Commission in 2003 reported the alarming decrease in rates of minorities in medical, dental and nursing schools. Its report made recommendations on how to diversify our nation’s healthcare workforce. These recommendations (e.g., science and math initiatives in high schools) are in the early stages of implementation, yet they show promise.

Additionally, the Institute for Diversity in Health Management, established in 1994, has surmised that even those minorities present in the health care system are not in positions of power. It found that minority workers hold more than 20% of healthcare positions, but less than 1% of top hospital management positions. In response, the Robert Wood Johnson Foundation provided grant support to the Institute designed to create a database to link minority candidates to executive-level health management job openings. In addition, the Institute has several campaigns focusing on increasing the number of minority healthcare professionals.

Access to quality physical and behavioral medical and health services within the criminal justice and juvenile justice systems and foster care system: In 2004, among males age 25 to 29, 12.6% of blacks and 3.6% of Hispanics, compared to about 1.7% of whites, were in prison or jail. Considering the recent trend of more stringent criminal legislation (e.g., zero tolerance, abandoning rehabilitation programs), the incarceration rates for young men of color likely will increase. Their disproportionate representation among the incarcerated population subjects minority men to the disproportionate levels of infectious diseases. Clearly, there is need for adequate healthcare services for those in prison. Unfortunately, there is no federal or state structure to assure such services. Very few states have an office that oversees healthcare in adult correctional facilities, and no federal mandates exist for juvenile justice facilities. Congress should require that federal, state and local correctional systems (criminal and juvenile justice) adhere to nationally recognized standards of delivery and provide resources to these systems.

Within the foster care system, children of color make up the majority of youth—approximately 42% are African-American and 36% are Hispanic. As a group, children in foster care suffer high rates of serious physical or psychological problems, compared with other children from the same socioeconomic backgrounds. Studies indicate that 50-60% have moderate to severe mental health problems. Given their overwhelming and complex needs, foster children require and use health services more than other children.

Foster children receive the same minimum health benefits as children in the Temporary Assistance for Needy Families program. However, these services are not meeting the needs of foster children. Of concern is the constant mobility of foster children, particularly young minority males, who tend to be the most difficult to place. Additionally, healthcare providers often resist serving foster children, due to low payment schedules and stigma. The lack of an infrastructure which systematically attends to the healthcare of foster children impedes improvement in this area. Recommendations include foster care nurses for the healthcare of foster children and increased education and training for foster parents and healthcare providers. Pediatricians and child welfare agencies should work together to ensure that children in foster care receive the full range of preventive and therapeutic services. It also is essential to comply with legal mandates to expeditiously formulate permanency plans for minority males, many of whom remain in foster care interminably.

Conclusion

Government entities, researchers, health professionals and activists currently have prioritized the issue of health disparities in America. However, the health of men, and more specifically young minority males, continues to be overlooked. Young men of color are disproportionately impacted by both physical and mental illnesses. Yet this cohort has limited access to healthcare, and research on effective ways to address this problem is woefully inadequate. Implementing community health strategies is one solution to improving the health of young minority males. However, community health strategies require a stable infrastructure to assist and monitor the development and support of effective strategies. Thus, a federal Office of Men’s Health should be established.

Congress established the Office of Women’s Health in 1991, and there has been marked improvement in the health status of women since then. Legislation now before the House and Senate to create an Office of Men’s Health would provide accountability, funding, resources and leadership for improving the health of men generally, and young minority men specifically. Improving the health of young minority men is undoubtedly a considerable undertaking. However, continuing to neglect this population will limit the life options of young men of color, at an untold cost to the society as a whole.

Jorielle R. Brown is a Public Health Advisor in the Co-occuring and Homeless Activities Branch in the Substance Abuse and Mental Health Services Administration. jorielle.brown@samhsa.hhs.gov
 

Notes:

This article is adapted from a longer, as yet unpublished paper prepared by Dr. Brown for the Dellums Commission of the Joint Center's Health Policy Institute; contact gchristopher@jointcenter.org for the publication plans.

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