Men in the United States have been experiencing a silent health crisis for more than 50 years. Men’s life expectancy is shorter than women’s—women of all races now live 80.1 years, compared to men’s, who average 74.8 years. Men of color, in particular, are disproportionately affected by cardiovascular disease and type II diabetes, as well as many other chronic diseases. These men are also often reluctant to seek medical care unless they are very sick, and are twice as likely as women to report that they have no usual source of healthcare. Among men and women of different races and ethnicities in the U.S., black males also have the highest rate of cancer diagnoses and death, the highest death rate from heart disease and account for over two-thirds of deaths by homicide in the U.S.
Objective 1: Engage men at high-risk for diabetes and heart disease in behavioral change by enrolling them in Fit for Life (FFL), a 10-week personalized, mentored exercise program based at the YMCA.
Objective 2: Engage men in behavioral change by enrolling any man in the Community in the Fitness Brothers (FB) Program, a social support exercise promotion program.
Objective 3: Engage Black men with diabetes and/or high blood pressure and high cholesterol in navigated care within the CHA system to improve access to care and enhance care coordination through a Navigated Care Program (NC).
Preliminary evaluation results indicate the following changes in the health behaviors of program participants:
I. Physical Activity Participation in physical activity increased among program participants.• 42% had an increase in self-reported activity levels before and after participation.• 49% increased the number of times per week they exercise. • 86% intend to increase or continue their current level of exercise.
II. Diet/Nutrition Men’s Health League program participants improved diet over time. • 75% reported that they had developed healthier eating habits. • 40% reported having increased their daily consumption of fruits and vegetables.
III. Clinical Indicators Clinical indicators improved among Men’s Health League program participants. • 50% of all participants lost weight. • On average, participants showed a decrease of 21 points in their total cholesterol reading. • On average, participants showed a decrease of 28 points in their blood sugar reading.
IV. Access to Care Program participants reported greater access to health care. • For Navigated Care, 40% entered program with no medical home: at discharge, 100% had a primary care clinician. • For Fit for Life and the Men’s Health Team participants, the program saw a 13% increase in the percentage of men who reported having a primary care clinician.
The age-adjusted death rate for Cambridge males is 34% higher than for Cambridge females. Within the city’s male population, black males have a death rate that is 9% higher than that of white males, 78% higher than that of Hispanic males, and 327% higher than that of Asian males. The health department collected and analyzed local and state data on heart disease, cancer, stroke, and diabetes, which are among the top 10 leading causes of death for American males. In addition, the department examined data on HIV/AIDS, a leading cause of death nationwide for black and Hispanic men age 20 to 65. The data revealed that Cambridge males have higher death rates than females for heart disease and cancer, and higher infection rates for HIV/AIDS. While both sexes experience a similar rate of death from stroke and diabetes, Cambridge males are hospitalized for these two diseases at a higher rate than females. Among males of different races and ethnicities, black males had the highest death rate for cancer, the highest hospitalization rate for Diabetes and the highest infection rate for HIV/AIDS.
Some researchers have suggested that societal notions about male identity may be driving health disparities between the sexes. According to this theory, cultural beliefs about masculinity and manhood propel men to take actions that could harm their health and keep them from engaging in health-promoting behaviors and seeking medical care when necessary. Others propose a biological explanation for worse health outcomes. Still others assert that social determinants of health are a major factor, believing that the social conditions under which many men of color live make them sicker, and offer fewer opportunities for healthy living than those afforded other communities. Cambridge has had a focus on the health of men of color since 1993, stimulated by the findings of a community health assessment that was conducted in the early 1990’s which identified men’s health disparities as a major public health need in the area.
The initiative has been guided by the community-based Men of Color Task Force composed of key stakeholders who make recommendations about programmatic directions and mobilize community participation in men’s health projects in the city. The primary success of this initiative has been establishing and institutionalizing the popular Hoops and Health event reaching about 1,000 black men annually. The event, which includes a mandatory health workshop, is designed to help youth and men of color learn about healthy behaviors, and to link them to health and social service resources throughout the city. Building on this history of community interest, and to gain a better understanding of gender, racial, and ethnic health disparities in Cambridge, the public health department examined disease and death data, surveyed Cambridge men about their health status, and asked men from culturally and racially diverse backgrounds to describe barriers to health and wellness in their communities. In 2007, the public health department surveyed 350 men in the greater Boston area, of whom 142 were Cambridge residents. Staff distributed questionnaires at local events and venues, including the 2007 Hoops n’ Health sports tournament, a Cambridge Health Alliance picnic, the Salvation Army meals program, two churches, and a gay pride event. The survey intentionally “oversampled” black and African-American men to better understand the health challenges facing this community. Among other finds, we discovered that a much smaller proportion of black respondents than white respondents reported currently having health insurance (75% vs. 91%). Following this, the Cambridge Public Health Department (CPHD) conducted a series of focus groups to help shape the men’s health programming. Two focus groups engaged men in designing the program now being proposed as a model in this application; the remaining four asked Ethiopian, Haitian, Spani
Agency Community RolesThe Cambridge Public Health Department has had the primary role in designing, staffing and implementing Men’s Health League activities. The program manager and care coordinator report directly to the department’s Director of Community Health Programs, and are supported by the Manger of Marketing and Health Promotion as well as epidemiology staff. Through a contractual agreement with the City of Cambridge, the public health department is part of a regional health system, The Cambridge Health Alliance, an integrated public healthcare system comprised of three community hospitals, over 25 primary care sites, the Cambridge Public Health Department, a managed Medicaid plan and the Institute for Community Health. Cambridge Health Alliance’s mission is to improve the health status of its communities through a commitment to quality, affordable, and accessible health care and public health initiatives. providing an extremely close connection with primary and ancillary care through the sharing of the electronic medical record. This unusual relationship between a local health department and a large health system has positioned us well to merge a community-wide health promotion intervention with clinical services at a hospital whose mission is to serve marginalized populations. The Public Health Department is also primarily responsible for data collection and program evaluation, working with the Institute for Community Health, a local organization focused on community-based participatory evaluation.
The ongoing collaboration on this national demonstration project has allowed the Cambridge Public Health Department to focus on broader public health goals while attending to the core functions and essential services we are required to deliver. The health department developed relationships with three local organizations to form the partnership which guided this effort to reduce health disparities in men of color. Each has a long history of serving the Cambridge community, and substantive relationships with a broad range of community leaders and residents. The Margaret Fuller Neighborhood House is a small community settlement house that has been recognized for over a century as a catalyst for community involvement, activities and support. The MFNH serves as the lead fiscal agency for the Men’s Health League, and provides a close connection with the African-American population through its outreach staff. Its Outreach Connections Project targets young men between the ages of 18 and 35 who are at serious risk (recently incarcerated, addicted to drugs or alcohol, unemployed, homeless, or in need of health care or education.
The street-worker leverages his long-standing relationships with local families to provide education, referral and case management support The Cambridge Family YMCA has served as the primary fitness facility for program activities. It is located close to the health department and the Margaret Fuller House, and offers an ideal setting to introduce program participants to opportunities for fitness, including a pool, weight room, martial arts classes and a brand new workout studio. The YMCA provides memberships for program participants, fitness trainers and has contributed to the design of the exercise components. An additional fitness facility, Bally’s Total Fitness, has now been added as a partner and hosts the Fitness Brothers components. The Men of Color Task Force is a group of community stakeholders whose mission is to improve the health of minority men by understanding and reducing barriers to health care and to provide health services and preventive care for Black and Latino men in Cambridge. Its primary success was in establishing and institutionalizing the popular Hoops and Health event reaching about 1,000 black men annually, and is now co-sponsored by the Men’s Health League. The Task Force also co-sponsors an annual Men’s Health Breakfast, which has become an annual signature event.
Costs and ExpendituresThe success of this program relies on engaging local partners to develop and implement wellness programs that engage and appeal to men of color. We established partnerships with a minority-serving community organization, a regional healthcare system and a local fitness center, as well as with The Men of Color Task Force, a group of community stakeholders with an interest in men’s health. Formal and informal leaders throughout the community were tapped to support and publicize the program, and men of color were hired as program staff. Grassroots health leadership was built by recruiting black men from the Cambridge, training them to be men’s health mentors and utilizing them in program activities. Men's Health Team members serves as liaisons to their community and to the specific community organizations to which they belong, and help with outreach, staff health fairs and mentoring program participants.
As a way to engage all community men of color in The League, we developed the Fitness Brothers program, which utilizes social support to motivate teams of men to exercise in a 10-week competition. Group workouts taught by a personal trainer and three health promotion workshops conducted by the LHD are included in this intervention. Fit for Life is a more intensive program targeting men at high-risk for diabetes and heart disease. These men receive a free YMCA membership, six personal training sessions and are matched with a mentor from the Men’s Health Team. In addition, we have implemented a community-wide campaign for men’s health by providing health education and screening events in churches, community centers and worksites, and utilizing well-known men of color to provide motivation and inspiration to men of color wanting to improve their health. Activities include Hoops ‘n Health, an annual basketball tournament and health fair that attracts over 1000 participants; a yearly Men’s Health Breakfast; cooking workshops/demonstrations and a variety of faith-based activities for men. In an effort to stimulate local organizations to develop their own men’s health programming, a Men’s Health League replication manual has been created, and competitive mini-grants have been awarded to community-based groups for this purpose.
The first six months were devoted to recruiting and hiring staff; conducting focus groups to inform the design and branding of the initiative; engaging local leadership; and developing a training curriculum and evaluation design. A logic model was developed, outcome indicators selected and evaluation instruments designed and tested. In-kind management consultation was provided by senior staff at the Cambridge Public Health Department, and program materials were designed and produced by the department’s Manager for Marketing and Health Promotion, using social marketing concepts to “pitch” improved health behaviors. Organizations, businesses, civic associations, and a broad spectrum of stakeholders engaged with the Men’s Health League to highlight health in a way that speaks to their constituents. Local leaders, including politicians and ministers, applied to participate as both mentors and participants. The local chapter of the NAACP highlighted the Men’s Health League at its annual Martin Luther King breakfast, and the Department of Public Works incorporated men’s health activities into its staff training schedule. When possible, activities were co-sponsored by community-based organizations, to assist with recruitment, and to build organizational capacity to carry on the work independently. In year three of the program’s operations, the Men’s Health League issued mini-grants to small, grassroots agencies interested in developing men’s health activities on site, and offered health promotion activities in an additional fitness facility, and piloted the Fitness Brothers model in the local high school. The federal Office of Minority Health provided three years of funding.
ImplementationSpecific steps to implementation: * Recruit and hire staff that reflect the target population * Conduct focus groups with target population to determine need and approach • Design program components, with input from target population • Develop supporting materials, including intake and evaluation documents • Develop marketing and outreach plan, and conduct outreach activities, including face-to-face conversations with local leaders, print and electronic media • Develop personal relationships with clinicians committed to health disparities • Become trained in and certified to utilize the electronic medical system • Recruit and orient participants • Build, maintain and evaluate relationships with program partners• Write and produce replication manual for print and electronic distribution.
Although the first six months of the project was devoted to planning and start-up, most of these tasks were iterative, requiring attention throughout the program's history. Substantial effort was devoted to ongoing quality improvement of program interventions, marketing materials and approach, client recruitment and engagement. We made adjustments as we received and integrated feedback.
To develop a community network called the Men’s Health League (MHL) to reduce disparities and improve health outcomes specifically related to heart disease/stroke and diabetes risk for men of color. The Institute for Community Health worked closely with the program partnership (Margaret Fuller House, the Cambridge Health Alliance and the Cambridge YMCA) to implement the evaluation plan. The evaluation is participatory in nature and involves the program participants in all stages of logic model development, instrument development, data collection, analysis and in generating recommendations around program findings. Engage men in behavioral change by enrolling 100 men in Fit for Life (FFL), a 10-week personalized, mentored exercise based at the YMCA.Process Measures: List your expectations (e.g. number of meetings held by a specific date, number of partners contacted by a specific date) (150 word limit) number of Fit for Life sessions held each year number of men enrolled in Fit for Life each session.The Institute for Community Health (ICH), the evaluator worked with the partnership (Margaret Fuller House, the Cambridge Health Alliance (CHA) and the Cambridge YMCA in a participatory manner to collect the data.
We created a logic model for FFL and developed instruments based on the model to collect mixed methods data including a) pre- and post-test demographic information, information on self-rated health/perceptions of health, exercise and nutrition and qualitative questions measuring program satisfaction (only post), b) pre- and post-clinical screening data on blood pressure, glucose, cholesterol, body fat, and body mass index, and c) in-depth interviews to understand program impact with a sample of men. Pre- and post-test data was gathered by CHA staff trained by ICH in IRB and data procedures. Pre and post clinical data was gathered by specially trained outreach workers or public health nurses. Qualitative data was gathered by a trained man of color from the CHA.Pre- and post-test data was gathered at two time points, once at pre-program participation, prior to the start of the first session, and again at the end of the 10 weeks, during the last session.
Clinical data was similarly gathered. Qualitative data was gathered at the end of 10 weeks through individually scheduled interviews with participantsFindings were shared at multiple levels. Nationally, we have presented findings at the a) American Public Health Association Meeting (2009), b) the Society for Public Health Education Meeting (2009) and the c) National Partnership for Action to End Health Disparities leadership summit (2009). Regionally we have presented at the New England Regional Minority Health Committee conference (2009). Locally, we have presented to several key stakeholders including the Men of Color Task Force, a local advisory group involved in promoting the health of men of color. ICH also presented evaluation data at partnership meetings which included partners and program participants. Finally, the program staff participated in several recommendations generation meetings based on data collected, facilitated by ICH.
As a result, several programmatic changes were instituted to address recruitment, retention and other programmatic issues for example increased trainer support for FFL participants and more frequent fitness training sessions of shorter durationWe achieved several outcomes (Sample consists of N=22 participants with both pre- and post-test information): changes in pre- to post-current physical activity level (short- to mid-term), pre- to post-mindfulness around healthy eating (short- to mi- term) and pre to post increased knowledge about risk factors for cardiovascular disease among men of color (short term). These pre- to post-changes are all statistically significant. Of the 22 men from whom we gathered pre and post test data, 100% said they would participate in FFL again. Finally qualitative data shows that over 90% of FFL parti
The commitment of program partners has increased over time, and as organizational relationships have deepened and matured. The relationship of the LHD with the small, settlement house that is our primary partner in particular, has emerged as critical for both organizations, and has led to a variety of new collaborative initiatives. The resulting mutual gain in capacity will certainly be sustained over time. New partners have seen how integrating the MHL model into their current offerings attracts new members and is therefore an effective marketing tool for them. Many local athletic facilities and personal trainers have volunteered staff time and space with this in mind. As this program enters its third year of pilot funding, the question of sustainability is increasingly on our agenda. We are hopeful of continued federal and state funding for our efforts, and are implementing several additional strategies towards sustaining this successful intervention. All partners have expressed their commitment to sustaining program activities and integrating them into its ongoing menu of services. We believe the success of the Men’s Health League lies in its ability to raise the profile of men’s health in communities of color and spawn a range of new health promotion activities. Substantial effort has been made to build capacity in other organizations to implement health promotion programming for men of color.
A program replication manual was developed and will be available to any interested institution to guide them through the implementation process. We have included health education materials targeting men, evaluation documents, and detailed curriculum for health education sessions. We have also implemented a mini-grant program to seed small health promotion initiatives in local community-based organizations. Fifteen applications were received from a diverse group of agencies including churches, fitness clubs, sports teams and municipal departments. Six grants were funded, and technical assistance will be provided to ensure success and to integrate funded activities into overall Men’s Health League activities. We have also begun to integrate program activities into schools and youth centers, modifying components for a younger cohort. The Fitness Posse, an iteration of Fitness Brothers which incorporates both boys and girls in a team competition, will kick off this spring in the local high school, targeting teens enrolled in special education classes. A local boxing program for high-risk teens involved in the judicial system has begun to incorporate health education workshops that were designed for Fitness Brothers as part of their regular program. The members of the Men’s Health Team, who have received three years of leadership education and support, will serve as ongoing carriers of important health information to their neighborhoods. These men are committed to improving their own health and that of others, and will continue to serve as models and motivators of good health practices.