The sharp increase in the ethnic and cultural diversity of our nation, projected to continue into the foreseeable future, represents an unprecedented opportunity and challenge to the health care providers. Twenty-six million Latinos now live in the U.S.; this will increase to 40 million by the year 2000. One-third of the U.S. children are now African-American, Latinos, and Asians.² One in four Americans is non-Caucasian. In three decades, the non-white population will double, while the Caucasian population will remain the same.²

Medicaid recipients and non-insured poor people contain many ethnic minority groups. States are aggressively looking for ways to save costs in treating these patients, and part of the answer may lie in better knowledge of the health beliefs, customs and genetics of these groups. Furthermore, managed care will become the major provider for the Medicaid client. "Cultural Competence" will be part of the guidelines for the Health Care Financing Administration's (HCFA) evaluation of managed care contractors. HCFA and state Medicaid directors are now working with the National Committee for Quality Assurance (NCQA) to develop such guidelines.³

Caring for Medicaid and other low income patients is often expensive, due to their high incidence of disease; internal and external barriers; stressful environments; and unfamiliarity with the importance of prevention, early reporting of symptoms and compliance with therapy. However, a strategic plan with "Soft touch and High tech" includes trained community health workers to work directly with clients; culturally designed health education programs in key areas such as breast feeding, self breast examination, smoking cessation; and case management programs for adult on-set diabetes, hypertension, and cholesterol etc. A critically important high tech tool is an interactive computerized registry to track and monitor outcomes for immunizations; hypertension; diabetes; CHD; smoking cessation; and other patient outcomes with a variety of patient negative and positive behaviors, diseases and disorders.

With these latter components in place, Medicaid patients could be transformed into an attractive and highly manageable health care MARKET.

Health Plans that recommend that all clients with a given illness receive the same medicine may incur costly medical problems.

Research results in the field of pharmacogenetics have shown that a medicine that helps most Caucasians may not control the same condition in African-Americans. Further, the amount of a medicine that is safe and effective in most Caucasians may cause disturbing side effects among many African-Americans, Asians or Latinos. Scientific findings about genetic influences on the effects of medications reveal important dimensions to disease and treatments.

This new information calls for increased focus on sub-groups and individuals in order to provide effective, efficient treatment and seriously questions the trend to standardize pharmaceutical therapy.

As a new health system, THE COMMLNITY HEALTH OUTREACH INITIATIVE is designing a flexible protocol for medication to allow for the genetic differences - between as well as within racial and ethnic groups. This protocol involves some of the most popular medications and most prevalent diseases, including high blood pressure, depression and life threatening infections.

Medical science has long understood genetic influences in the cause of disease, making some families more prone to develop diabetes, high cholesterol and heart disease. Specific ethnic and racial groups are also more susceptible to specific illnesses on a hereditary basis (for example Sickle Cell disease in African-Americans and Tay-Sachs disease in Ashkenazi Jews). Therefore, it comes as no surprise to the scientific community that people with inherited differences respond somewhat differently to the same medicine. The most important differences involve metabolism rates (which affect how medicines are utilized and eliminated by the body), rates of improvement during treatment of an illness and side effects of medications.

One example of a condition that can have quite different underlying causes is high blood pressure; therefore, treatments should also be different. African-Americans tend to have high blood pressure thought to be caused by excess fluids or a reaction to salt in their food. When treated with a single medicine, they respond better to medicines called diuretics, which reduce body fluids. On the other hand, high blood pressure in Caucasians is more often caused by chemical imbalances. These patients do better on other medications (known as ACE inhibitors or beta blockers).

As stated above, results based on racial differences have been found to be associated with many of the most commonly used medications. However, we are in the very early stages of understanding this critical aspect of medical science.

Unfortunately, many providers of health care are acting without recognizing differences that demand more individualization, rather than standardization of pharmaceutical therapy.

Despite the many differences among the cultures that make up our nation, we all have the same basic needs concerning our health: to be able to tell the story of our illness, receive competent care, be acknowledged and valued. Examples of our differences are endless, and serve only to point to the need for a common ground between practitioner and patient, a partnership in which any cultural health belief or treatment preference can be discussed. The major point of this topic is to stress the following points:

1. We are all members of an ethnic group. This orientation should help providers to feel empathy, instead of sympathy, when treating patients from other cultures.
2. The great diversity of our patient population demands a framework in which the practitioner can approach all patients regardless of cultural background as true partners in care.
3. By examining our differences, we come to the realization that our needs are the same.

The beliefs and attitudes of others are often apparent, while one's own are often transparent. Examining our beliefs and attitudes can help us honor the views of others and avoid a "we/them" mentality.

People from everywhere have a strong need to understand and explain their experiences, including sickness and health. Culturally shaped beliefs play a vital role in determining whether an explanation of illness or treatment makes sense. Indigenous systems of health beliefs, practices and medicines exist in all societies,^{4 5} and exert profound influences on patients' attitudes and behaviors. An example is the extensive use of traditional herbal medicines by African-Americans, Asian-Americans and Latino-Americans.⁶

Traditional healing is important among most minority groups, and a dual system of health care services is common among ethnic communities. For example, Western medicine is considered by the Chinese to be quick and effective in removing symptoms but is not considered to effect a permanent cure. In contrast, traditional Chinese medicine is perceived to have the power to remove the root cause of the problem.⁷ The Chinese therefore often use Western medicine for acute illness and severe disease but may rely on Chinese medicine for long term treatment. The growth and acceptance of Chinese acupuncture and the African herb Yohimbe to reverse impotence in the United States by doctors, patients and insurers exemplifies how our medical culture can grow stronger through assimilation of traditional practices.

Attitudes towards diet, exercise, smoking, drinking, and body image are imbedded in all cultures, and these attitudes affect health and interactions with providers in interesting and important ways. For example, in many communities, successful and prosperous individuals who have passed a certain age are not expected to be lean; and being overweight can be viewed as a sign of success and good health. This of course, contributes to the difficulty of controlling obesity, adult onset diabetes, and hypertension, since weight loss may be interpreted as a sign of illness.

In some cultures people tend to keep their illness to themselves, and they are therefore likely to come for treatment at later stages of disease. Some tend to minimize symptoms in an attempt to control their fears; and controlling feelings may be seen as a sign of refinement. Some ethnic groups have a fatalistic attitude towards illness, "It's my time, God is calling me." A fatalistic attitude impedes a direct confrontation with the consequences of unhealthy or at-risk behaviors, such as smoking.

The Harlem Park community of West Baltimore provides us with a typical examples of Medicaid clients. The preschool-aged children's immunization rate in 1994 was approximately 14%. We have found some families in the Harlem Park area who were not aware that they were covered by Medicaid/Managed Care. This is not surprising, because approximately 45% of adults cannot read, and approximately 32% of the Harlem Park families do not have telephones. Therefore, in order for "outsiders" (HMOs/Medicaid staff) to communicate with these families, significant efforts must be committed to door-to-door inquiry.

The typical AFDC Medicaid-recipient family has three children (between 5-15 years old), a mother, and a significant other/husband approximately 5-1 0% of the time. However, the man is usually not part of the Medicaid health plan.

In the Harlem Park community, only 13% of the residents own the house that they occupy, which corresponds to the current unemployment rate of 70%. With an unemployment rate so high and home ownership so low, most residents rent their dwellings. Subsequently, they will not answer "Outsiders" unannounced visitors, due to fears of rent and bill collectors. This barrier, as well as others, contributes to the low compliance for these community residents.

The typical resident of this community is impoverished, deprived, sensitive, and has a quiet profile. They need and deserve respect, support services, innovative education and training programs, decent and affordable housing, and comprehensive health care, with a strong focus on preventive health care. We believe that this community-based proposed program is needed, workable, and will play a major role in empowering the Harlem Park community, especially with regards to preventive and primary health care.

Our research shows that a 16,000 (approximately) client population has the following people characteristics:

There are serious non-compliance problems with parents not taking their preschool-aged children, their older children, and themselves for regular health visits. This non-compliance rate is extremely high in spite of a $20 bonus incentive for adults and school-aged children who receive annual check-ups. Furthermore, there is a penalty of a $25 reduction in public assistance payments imposed on parents who either do not take their preschool-aged children for regular health visits, or send their children to school at least 80% of the time. Client behaviors suggest that there are very serious barriers that impoverished urban and rural residents have concerning HMOs that do not have support systems and clinics in their local communities. ^{8 9 10}

Few, "HMO/Managed Care" providers have community-based clinics, nor do they have significant numbers of physicians contracted with their plan who have offices located in impoverished communities. Studies have shown that the medically indigent are most likely to omit preventive health care because of the barriers they face when they attempt to obtain care. ^{11 12 13} Further, having to travel to unfamiliar communities to receive care from physicians who do not historically provide health care to impoverished community members are additional serious barriers that prevent this population of citizens from obtaining preventive care ^{14 15}

The physician-patient relationship is built through communication and the effective use of language. Along with clinical reasoning, observations, non-verbal cues, and the skillful use of language, endow the history with its clinical power and establish the medical interview as the provider's most powerful tool. ^{16 17 11 19}

However, in many large urban communities there are significant language and cultural barriers. ²⁰ Furthermore, it is through language that physicians and patients achieve true bonding that may be therapeutic in itself. ²¹

Familiarity with different cultures' expectations of their healers is valuable, too. Some believe physicians can only relieve symptoms rather than cure illness caused by religious figures. ²² Similarly, physicians also should become familiar with foreign-born patients' traditional healing practices and acknowledge that the Western ways of medicine aren't the only ways.

Cultural and language barriers impair the exchange of information from patient to physician. ^{23 24 25} Loss of the usual linguistic cues may disrupt how physicians assess and evaluate symptoms and result in misdiagnosis. ²⁶

Baltimore's Medicaid client population has more of a cultural barrier, than a language barrier. This is especially true for patients who are assigned to "other race" physicians who have little to no experience providing care to the poor urban African-American population. Major subcultural barriers are:

• 30% of these clients don't have telephones;
• approximately 40% do not read well; and

• approximately 70% have never had health insurance or access to health care, other than a hospital's emergency room.

Therefore, when "free" health care is "offered/provided", they don't believe it or cannot afford it because of all the other barriers stated above. The net result of these negative behaviors are the avoidance of routine preventive care and possibly entering the health care system with a more advanced stage of disease, poor compliance, inappropriate follow-up, and patient dissatisfaction. ^{27 28}

We are proposing an intervention with trained and knowledgeable "Community Health Coordinators" who will help guide Medicaid clients/patients across and through barriers, resulting in enhanced compliance. A major focus of this initiative is preventive and primary care, especially with preschool-aged children's immunizations, and annual physicals for parents, reducing the incidence of adult onset diabetes, hypertension, glaucoma, coronary heart disease, and stroke.

Finally, we propose with the utilization of our Interactive Voice Response (IVR) computerized data registry (ImmuneWatch) to track and monitor all of a health plan's pediatric immunizations. Children will be followed from birth through sixth grade for a health plans' total population membership.

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) is a private organization that yields enormous influence in the medical community. Hospitals lacking JCAHO accreditation are ineligible to receive Medicare funds. In an increasingly competitive medical marketplace, the details of JCAHO accreditation surveys are being used by corporate health care purchasers, insurance companies, and even consumers to determine whether their providers are capable of delivering top-quality care. Recently, Dr. Dennis S. O'Leary, president of JCAHO, said, "we are shifting the focus from structure and process to outcomes." Both hospitals and managed health plans are being told that they have to track the results of their interventions and treatments. What this means is that accreditation is going to transform the medical marketplace into an information marketplace. Quality information will determine quality health care. Accreditation will increasingly become the standard by which health care providers and health plans are measured and rewarded by patronage.

These few demographical characteristics point to the uniqueness of the need for our proposed program:

• A significant % of the population requires help with reading correspondence describing Medicaid support for comprehensive health care at local HMOs/MCOs;

• With no community-based clinics, clients/patients must leave their community to obtain care;
• "Community Health Coordinators" selected from and trained in the community by UHI staff, will not be viewed as "outsiders" and/or "strangers" to Medicaid clients; and
• This is an ideal way of utilizing community human resources to help "disease management" within the community.
• The electronic, interactive, tracking and monitoring REGISTRY will provide multiple health outcomes continuously.

There are specific community sources of recruitment for potential program enrollees: the Harlem Park Community Association; the Harlem Park Middle School PTA; and Head Minister of Unity United Church (a community church) and City Councilman. All three persons work daily with children from the Harlem Park-Sandtown community. For this reason we felt that they would be in an ideal position to help select men and women who are outstanding and responsible candidates for our training program. There should be a combined data bank yielding approximately 400 candidates to draw from.

We will use of the Diagnostic Interview Survey of N.I.M.H., the Maryland State Department of Education's (MSDE) GED Testing Service, and the Baltimore City and Maryland State Criminal Justice database to determine the current psychological, academic, and criminal status of prospective enrollees and their eligibility for the program.

After eligibility is determined, further, ongoing educational and psychological counseling assessments will aid in determining placement into pre-GED and post-GED groups. We then can assess an initial skill level in reading, writing, computational/computer skills, problem-solving skills, psychological measures of self-esteem, internal and external loss of control, organic brain damage screen, and the need for psychotherapy, when needed.

Selected trainees will be educated and trained in the following categories:

1. Personal Communication Skills: Proper dress codes, proper oral delivery, politeness and courtesy, making doctors appointments for clients, assisting clients in preparing for appointments, and providing transportation for clients to doctors office and/or hospital.
2. Health Education and Emergency Medical Techniques: Coronary pulmonary Resuscitation (CPR), pulse, blood pressure, temperature, acute vs. chronic diseases, health surveys and survey questionnaires, knowledge, attitude and behavioral (KAB) surveys.
3. Technical Office Skills: Basic word processing and computer skills, data entry/retrieval, taxing, copying.
4. Information on the State of Maryland Medical Care Programs: Medicaid, Medicare, Primary Care, Preventive Health and Capitation. Health services: hospital, residential treatment services, nursing facility services, physicians services, free-standing clinic services, nursing services, Health Maintenance Organization (HMO) services, dental services, home health services, medical day care services, and Maryland Healthy Kids Program.

UHI's project coordinators will obtain a list of all Baltimore "Managed Care"/Medicaid residents. All persons with telephones will be contacted by UHI staff to introduce UHI and the program to the clients; explain the goals/objectives of the program; and to solicit their support and cooperation. Those clients without telephones will be contacted by mail, followed with a personal visit by the Community Health Coordinator. Persons who have moved and cannot be easily contacted will be contacted by inquiring throughout their old neighborhoods. Further attempts will be made to obtain telephone numbers from neighbors, friends and/or relatives that could be used for emergencies to contact those clients without telephones and/or fixed addresses (for example, homeless).

Once we have located and identified the population (from the managed-care file) by our community workers, we will revisit this population and conduct a short survey questionnaire to obtain basic information on knowledge, attitudes, and behaviors (KAB) on seeking health care, responding to pain, daily practices regarding social habits like alcohol and drug consumption, and the amounts and types of exercise done and foods consumed daily. A randomly-picked sample of 2-5% of the total population will be selected and administered the KAB survey questionnaire. After the survey has been conducted and results tabulated, we should know a great deal about what barriers caused or prevented certain behaviors; for example, after breast self-examination revealed a lump, the patient failed to seek a mammogram. The reason could be that she was too busy or did not have baby-sitting services, both of which were more important than a mammogram due to her lack of education on the importance of mammography.

At this time, the Institute staff would design a culturally sensitive and relevant education intervention program just for this specific population of citizens to reduce and/or completely remove these barriers. Thus, this type of patient would become more knowledgeable and more likely to act and prevent major harm to him/herself, and would help others in the process.

We will design educational preventive intervention components for each of the "at-risk" groups shown in Table 2. We believe that an effective intervention program for people with a disorder such as adult onset diabetes (NIDDM) would be of great value, resulting in both financial savings and life savings. In 1992, direct medical cost in the United States for NIDDM alone was $85 billion.

We have developed a computerized Interactive Voice Response (IVR) system specifically for the seamless tracking of childhood immunizations across public and private sectors. Birth registry information from delivering mothers are input into the IVR computer database which can then be used to update and retrieve individual immunization records simply by touch tone phone. This unique system provides selected access to health care providers, Women/Infants/Children (WIC) agents, school nurses and other authorized users as easily as using an Automated Teller Machine (ATM). Therefore, we can immunize, track, and monitor all of Managed Health Care Plan's babies from birth until they are 12 years old, regardless of where the baby is born.

Finally, with our IVR System, we can monitor unlimited clients regarding medical outcomes compliance, weight control, nutrition, exercise, blood sugar control, and all other important information regarding health care. It can serve as a reminder to the physician to perform certain activities regarding that patient, such as counseling and/or performing a specific service or procedure.

In order to determine if the proposed Community Health Coordinators Program has met its goals, process, and outcome evaluation data will be collected, as well as a cost-effectiveness analysis.

During the first year of implementation, progress regarding the completion of start-up activities will be monitored monthly. During the first year, a sample of participating physicians plus Community Health Coordinators will be queried monthly during the first quarter, and quarterly thereafter, in order to determine the quality of performance, the level of physicians participation in the program, and satisfaction with the preventive and primary care service.

The ultimate outcome measure of this program is the following: a) outcomes for hypertension, blood sugar and cholesterol controls, % mammograms provided, home lead paint sources (water paints, furnace leakage), and b) rate of immunization of children before school age. Maryland regulations for school admission require that children be fully immunized for school entry, therefore, school-aged immunization completion has been "reported" to be satisfactory for years.

However, the critical test of the program will be immunization rates at 24 months and all compliance with the demands of Waiver 1115. In cooperation with the Maryland Department of Health and Mental Hygiene, surveillance of immunization rates at 24 months in participating jurisdictions will be used to determine the effectiveness of the program. In the past, this surveillance has consisted of retrospective reviews of immunization records of children entering school, public health clinic reviews, and private hospital reviews. Subsequent program implementation years will be compared with that baseline. Finally, health education and yearly physicals by school-aged children and their parents will be other major factors in determining the efficacy of the program.

Routine surveillance of diseases preventable by immunizations will also be used to determine program effectiveness, since the rates of measles etc. should decrease with universal immunization.

Based upon the increase in immunization rates and reductions in preventable disease incidents in the members of the AFDC family. The costs of the program can be compared with the costs of medical care for these preventable incidents.

1. Breast Feeding: Time to Teach What We Preach

If we are to reach the Health People 2000 goals, we must promote breast-feeding. The strongest defense against major infections for the newbom comes from colostrum, the substance produced in the first few days after birth. It provides the first immunization (VMCEF, 1992). Breast-feeding offers advantages to both babies and mothers in many ways, and the overwhelming health benefits of human milk are well-documented. These include:

• prevention of gastrointestinal and respiratory illness and infections ²⁹
• reduction of the incidence of allergy ³⁰
• stimulation of the infant's own immune system development from IgA in human milk ³¹
• better response to medicines with higher aby levels than formula fed babies ³²

2. Immunizations

Thirty-seven to fifty-seven percent (37%-57%) of 2-year old children in this country are adequately immunized. However, the immunization rates for poor rural and poor urban children are much worse. In September 1995, 5,000 first graders in Baltimore public schools were sent back home on the first day of school because they were not properly immunized. The immunization rate in Harlem Park/Sandtown-Winchester community for first through third graders is less than 50%, in spite of the fact that major HMOs are suppose to provide preventive and primary care to most of the residents. Further, the measles vaccine has not fully protected adolescents from reinfection. ³³

3. Nutrition

Maintaining a high quality life requires proper nutrition at all stages of growth and development.  This ranges from colostrum received at birth from mothers who breast-feed to foods containing high fiber that are important to our diets even at the senior citizen age. Proper nutrition includes limiting animal fat intake and avoiding large amounts of simple sugars (glucose & sucrose) that have a high calorie content and no fiber. High fiber containing foods (apples, bananas, whole grain cereals, vegetables, beans, peas and lentils) combined with proper exercise allows people to ³⁴ live longer with high quality lifestyles. Further, recent research results have shown that "fiber, independent of fat intake, is an important dietary component for the prevention of coronary disease."

4. Exercise for Fitness

Although rigorous exercise is beneficial, Americans do not have to workout strenuously in a gym or jog for an hour each day to reduce their risk of heart disease, obesity, diabetes and osteoporosis, according to experts from The American College of Sports Medicine (ACSM). In fact, too much exercise such as overtraining can be harmful.

Moderate activity, such as walking briskly, cycling, swimming, golfing (pulling a cart or carrying clubs), general housework or mowing the lawn, provides enough exercise to adequately tone muscles, increase respiratory capacity and prevent or reduce risks for heart disease. ³⁵ Physically fit individuals have lower mortality rates because their incidence of heart disease, cancer and other causes of death is lower than less fit individuals. ³⁶

5.Exercise for Weight Reduction

Exercise for the purpose of weight reduction, especially in obese individuals will provide at least three major benefits. One will be the reduction in risk for adult onset diabetes, the second is a reduction in the risk for coronary heart disease; and the third is just feeling better, physically and mentally.

Between 1980 and 1991, there was an eight percent (8%) increase in the prevalence of obesity in the U.S.³⁷ As part of the Healthy People 2000, National Health Promotion and Disease Prevention Objectives, a national health status objective was set to reduce obesity to a prevalence of no more than 20% by the year 2000. However, things are getting worse. In 1991, 58.1% of U.S. adults reported virtually no recreational exercise.³⁸ Exercise is the answer.

6. Exercise (Tai chi) to Reduce Risk for Falling by Senior Citizens

Frailty, defined as a reduction in physiological reserves and behavioral capacities, can affect individuals throughout life. However, the consequences of frailty are particularly devastating for older persons.³⁹ Substantial evidence exists that proves older people can become stronger, improve their balance, and increase their gait speed.⁴⁰ At the same time falls constitute a major impediment to independence among older citizens. Falls are attributable to multifactorial events, such as intrinsic changes in their physiological systems⁴¹, and extrinsic factors, including medication and environmental hazards.⁴² The ancient Chinese exercise, Tai Chi, has been shown to reduce falls in frail senior citizen by 50% after three months of training.

7. Asthma Management

Asthma is a chronic medical condition that accounts for substantial morbidity and mortality in the general population. Hospitalization discharge rates for asthma in persons aged 5-34 years in 1992 was 17.9 per 10,000. The annual age-adjusted death rate Increased 4O% during that time. ⁴³

Asthma is a persistent inflammatory disease of the airways that manifests itself by wheezing and chronic coughing. Treatment includes drugs that target the inflammatory components (corticosteroids/cromolyn) and symptoms (beta-agonists/theophylline). ⁴⁴

Asthma is a very expensive chronic illness. The total cost in 1990 is estimated to be $6.2 billion. Managing patients effectively includes preventing emergency visits, hospitalization, and death while maintaining an optimal quality of life.⁴⁵

8. Diabetes Management

An estimated 14 million Americans have Type 11 diabetes (adult onset diabetes). Half of them don't know it - and what they don't know could kill them. African-Americans, Native Americans and Latino Americans lead in the prevalence and incidence of this silent epidemic. The less prevalent Type I diabetes (approximately IO%) occurs primarily in children (between 4-18 years old). Both types are characterized by high blood sugar levels, and they both cause the same crippling and fatal long-term complications: eye and nerve damage, kidney failure, heart disease and stroke. However, the similarities end here. In type-I the pancreas stops making insulin and instead insulin must be injected in daily. In Type -II, the pancreases continues to make insulin, but something blocks the insulin from removing the glucose from the blood and carrying it to the liver and other tissues. With weight reduction, proper diet and exercise, a person can live a normal and high quality life. ⁴⁶

9. Hypertension Management

Hypertensive emergency and accelerative hypertension are the most severe forms of uncontrolled hypertension and are now seen predominantly in poor, minority populations.⁴⁷ Hypertension is currently the most consistently powerful predictor of stroke; it is a factor in nearly 70% of strokes.⁴⁸

Exercise, proper nutrition, weight control and blood pressure control can prevent stroke and coronary heart disease. Health education programs for at-risk populations will save millions of lives and dollars. There are a number of safe and effective alternative therapeutic interventions that allow citizens to discontinue taking anti-hypertensive pharmacological drugs.^{49 50}

10. Cholesterol Management

Hypercholesterolemia is a major risk factor for coronary heart disease.⁵¹ This disorder can result from excessive consumption of saturated animal fats.⁵² However, numerous well-controlled studies have shown that treating mild-to-moderate hypertensive persons can result in hypokalemia and hypercholesterolemia.⁵³ There are numerous pharmacological treatments to reduce blood cholesterol level,⁵⁴ and there is at least one alternative medical intervention with walnuts to reduce serum cholesterol.⁵⁵

A well-managed program that includes proper diet, exercise, relaxation and weight control will allow most hypercholesterolemia persons to live a normal and high quality life.

11. Breast Examination and Screening (Self and Mammography)

Self breast examinations and mammography screening are the best methods of detecting early breast cancers. Health education programs are important.

12. Testicular Self Examination

Teen males and young men who have a high risk for testicular cancer (due to family history of testicular cancer or personal history of undescended testicles) are encouraged to examine their testes once a month. Testicular cancer is very rare and highly curable when detected early.

The best time to do the exam is after a warm bath or shower when the scrotal skin is relaxed.

• Stand and place the right leg on an elevated surface. A tub side or toilet seat works fine.
• Explore the surface of the right testicle by gently rolling it between the thumb and the fingers of both hands. Feel for any hard lumps or nodules. The testicle should feel round and smooth.
• Notice any enlargement of the testicle or a change in its consistency. It is normal for one testicle to be slightly larger than the other. Any major size differences should be reported to a health professional.
• REPEAT, lifting the left leg and examining the left testicle.

Call your health professional for an immediate appointment if you notice any of the following:

• unusual lumps or nodules in testes
• unexplained pain or swelling
• penile discharge, or sore on your penis

13. Educational Interventions for Sexually Transmitted Diseases (STDs)

Nearly all at-risk behaviors that lead to sexually transmitted diseases (STDs), including AIDS are closely associated with alcohol and/or other drug use/abuse (AOD). Therefore, our approach to providing education and counseling regarding sexually transmitted diseases are combined with a component on alcohol and other drugs.

14. Smoking Cessation Program

This excess appears to be directly linked to smoking rates found among African-American men. The answer lies in direct health education on the facts and need to STOP smoking. Community institutions must be included in this effort along with primary providers who serve the community.

15.Interactive Computerized Immunization and Information Registry

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