Educating African American men about prostate cancer: the barbershop program.

Abstract: African American men have the world's highest rates of prostate cancer, with more than twice the mortality of Caucasian Americans. Traditional risk-reduction messages about this disease have not proved effective with African Americans, so two nurse educators forged a university-community coalition in upstate New York to address this public health problem. Working with local health professionals and other interested stakeholders, they developed a culturally competent prostate cancer education program utilizing a non-traditional setting--barbershops--to reach and engage black men. After recruiting six minority barbershop owners in Syracuse, the nurses provided a series of on-site educational sessions, targeting African American males ages 40 and above, to raise prostate cancer awareness and promote healthier behaviors in this population. Project findings and recommendations for educating minorities about health issues are presented.

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Prostate cancer has received a lot of attention in the past ten years, and research has underscored that African American men are especially vulnerable to this disease. But public awareness and health education programs targeted to this population have lagged far behind our medical knowledge, and traditional health messages designed for the general population have not been very effective in reaching minority men to improve prostate cancer outcomes. Mainstream health information often lacks ethnic familiarity and cultural relevance for African Americans, and is difficult for people with low literacy skills to read and understand. In addition, many minority males distrust the healthcare system, have limited access to it, and/or have fears and concerns about prostate cancer and male sexuality.

This case study describes how an innovative, culturally sensitive initiative in this area was designed and implemented through a university-community partnership in central New York State. The article outlines both the challenges and impacts of this program, demonstrating what can be accomplished with limited resources.

BACKGROUND AND SIGNIFICANCE

Prostate cancer is the second leading cause of cancer deaths among men in the United States. In 2004, it is expected that approximately 230,110 new cases of prostate cancer will be diagnosed and 29,900 men will die of the disease (CDC, 2004; ACS, 2004). The American Cancer Society has established a set of risk factors for prostate cancer which identify the at-risk population. Major factors include: age (50 yrs+), race (African American), diet (high fat/low fruits and vegetables), and heredity (father or brother with prostate cancer doubles a man's risk).

Particularly disturbing is the disproportionate representation of African Americans among the patient demographics. African American men have the world's highest incidence of prostate cancer and more than twice the mortality rate of Caucasian men, in part because they tend to be diagnosed at later, more advanced stages of the disease (Jemal, Thomas, Murray & Thun, 2002). Further, African Americans are typically younger, have significantly higher clinical stage, and have more symptoms of the disease when initially diagnosed (Merrill & Lyon, 2000). Researchers are seeking to determine why this group is at higher risk, investigating such factors as socioeconomic status, diet, occupation, and genetic and environmental factors (Chan et al., 2001; Latil et al., 2001; Luscombe et al., 2001; Michaud et al., 2001). For example, since a higher percentage of African American men are poor, less educated, uninsured or underinsured compared with white men, they typically have less access to health care so are less likely to receive information and routine care aimed at prevention, early diagnosis and effective treatment.

Education and early detection modalities such as digital rectal exams and PSA screening programs hold great promise to slow the prostate cancer mortality rate among African American men (Myers, 1999; American Urology Association, 2000), but prostate cancer screening is reported to be low among this group (Plowden, 1999; Steele, Miller, Maylahn, Uhler & Baker, 2000; Ashford et al., 2001). The reasons for this are unclear. Poor knowledge and awareness in the African American community may be one explanation (Wilkinson, List, Sinner, Dai, & Chodak, 2003; Barber et al., 1998; Weinrich, S.P., Boyd, Bradford, Mossa & Weinrich, M., 1998). Other reasons cited include psychological, cultural, resource and health provider barriers (Powe, 1996; Miller, et al. 2001; Nijs, Essink-Bot, DeKoning, Kirkels & Schroder, 2000).

Despite efforts to heighten public awareness and to educate men in general about prostate cancer, not enough has been done to target African American men and their families (Powell, 1997; Cormier, Reid, Kwan, & Litwin, 2003). Leading experts and the American Cancer Society urge more education about prostate cancer in the African American community, and new innovative educational interventions and programming (Myers, 1999; Powell et al., 1999; ACS, 1998). Health initiatives that have been most successful with minorities are usually informed by cultural competence and health literacy issues. Cultural competence means being aware of and responsive to issues of culture, race, ethnicity; gender, age, socioeconomic status and sexual orientation. Low literacy skills in this population must also be taken into account.

A NEW PARTNERSHIP: THE PROSTATE CANCER EDUCATION COUNCIL OF CENTRAL NEW YORK

In upstate New York, the need to heighten public awareness about prostate cancer in the African American community was recognized, and a regional coalition was built to develop programs specifically targeted to this population. Under the leadership of Dr. Luvenia Cowart and Syracuse University's College of Nursing, the Prostate Cancer Education Council of Central New York was formed in 1999 to help reduce prostate cancer morbidity and mortality among African American males. Its mission is to educate these men about the disease and to promote prostate health through information about prevention, early detection and treatment options.

The New York State Department of Health's Office of Minority Health and the National Kidney Foundation of Central New York sponsored a planning grant to help launch the Council, which represents a partnership among academic, community, and healthcare professionals. Membership consists of over three dozen individuals who are committed to relieving the burden of prostate cancer among African Americans, including physicians, nurses, social workers, healthcare providers, community leaders, health policy analysts, educators, and prostate cancer survivors. The Council serves as a catalyst in the delivery of accessible, cost effective and culturally competent prostate health care for African American males across the life span.

Initially, the Council developed a Blueprint for Action to guide its program planning. This report identified strategies and interventions to promote professional and public awareness of prostate cancer in African American men, to produce and evaluate appropriate, culturally relevant educational materials, and to reduce barriers to early screening and detection of prostate cancer for these men. It also outlined ways to foster effective communication throughout the community, empower black men to feel comfortable seeking medical help, and assist with better communication among these men, their healthcare professionals and their families.

With Dr. Cowart serving as Executive Director, the Council has marshaled resources and developed several health-promotion programs to reduce prostate cancer incidence and deaths in African American men in our region. The Barbershop Education project, directed by Cowart and retired oncology nurse Betty Brown, is one of its most successful initiatives to date.

THE BARBERSHOP PROGRAM: CULTURALLY COMPETENT EDUCATION IN A NON-TRADITIONAL SETTING

OVERVIEW AND OBJECTIVES

In early 2000, planning commenced for a special project to promote public awareness about prostate cancer among African American men, and to educate those ages 40 and above concerning prostate cancer, its risk factors, and the importance of screening and early detection programs. The Barbershop Education Program for Prostate Cancer was derived from the following Blueprint for Action recommendation:

   Educational materials that provide African
   American men with culturally relevant information
   about symptom recognition, screening
   guidelines and disease prevention, must
   be developed and circulated widely within
   community settings frequented by the target
   population to decrease the knowledge deficit,
   and to allay fears about the prognosis of
   prostate cancer.

Council members discussed the importance of providing a culturally competent intervention. In particular, cultural concepts that must be considered when targeting African Americans include beliefs about health and illness, fears, questions regarding sexuality, distrust of the healthcare system, and the tendency to rely on folk treatments prior to entering into formal health care, together with a reliance on family, community and spiritual support. The setting was also critical. To be effective, the health education program needed to be delivered in a place where African American men frequently congregated and felt comfortable. Inner-city African American barbershops were suggested as an ideal location to access this population.

The program was to be administered by Council members Cowart (from the University) and Brown (from the healthcare community), both registered nurses and nurse educators with clinical experience. Both women are African American and have a strong background in health education, cultural competence, and prostate cancer care. Dr. Cowart, an assistant dean of her college, has extensive experience in leadership, healthcare and education administration, and program development. Ms. Brown has special expertise in oncology, a background in clinical instruction, and community leadership experience in health care. On behalf of the Council and Syracuse University, Cowart submitted a proposal for the Barbershop project to New York State's Office of Minority Health.

The specific objectives for the proposed project were outlined as follows:

* Promote public awareness of prostate cancer among African American men.

* Increase knowledge about prostate cancer screening (PSA test, digital rectal exam) and the importance of early detection programs.

* Provide information about the risk factors associated with prostate cancer.

* Formulate and evaluate clear, simple and concise educational messages for culturally competent and relevant literature about prostate cancer, and direct public service messages to diverse channels, primarily radio but also television and print media.

* Develop a public awareness campaign in collaboration with existing community activities, and customize programs for African Americans.

* Empower African American men in their relationships with their families and medical providers so that they are comfortable seeking health care, asking questions and making health-related decisions (e.g., provide appropriate referral information).

PLANNING AND IMPLEMENTATION

When this grant was awarded in 2000, administrative planning began. The six largest African American barbershops in Syracuse were identified as possible sites, and Ms. Brown, the project coordinator, made initial telephone contact with the owners, explaining the purpose and nature of the project. Dr. Cowart continued to direct the activities of the Council, soliciting members' participation and additional suggestions for implementation. Both women were involved in public relations and networking for the project. Cowart and Brown also began further refining the educational curricula they had developed for the proposal, with special attention to cultural relevance. They planned short, informal sessions with direct, to-the-point messages, and decided to use a short video on prostate cancer provided by an African American radiologist who is a Prostate Cancer Education Council member. This video was targeted specifically to African American men, and the physician had obtained it from a national black medical association.

The barbershop owners were then invited to participate in the intervention by letter and a follow-up phone call. To introduce them to the program, Cowart and Brown conducted orientation sessions on site at each shop (an attempt to organize group orientation sessions proved unsuccessful). Individual sessions allowed flexibility in scheduling and a personalized introduction. During the orientation, owners were given a simple overview of the program's goals and objectives, anticipated outcomes, and what would be expected of them. Specifically, they were asked to commit to the goals and objectives of the project; provide space for a display of posters, brochures, and other materials; adhere to established hours of operation; maintain contact with the project coordinator; attend a post focus group; and complete a written evaluation form. All six owners agreed to participate and were trained by the nurse educators to invite their customers to accept educational literature. The training focused on the serious problem of prostate cancer among the African American men, the importance of screening and early detection, and the benefits of the program to both customers and the owners themselves.

A search for culturally appropriate patient educational materials on prostate cancer did not turn up anything useful, so after the initial sessions in 2001, the team decided to produce its own brochure. With a Vision Fund grant from Syracuse University, the women hired two undergraduate nursing students to conduct some research on the disease, then trained them concerning cultural competence, prostate cancer and "best practices" for community outreach with African Americans. Together Cowart, Brown and the students designed a culturally sensitive, easy-to-read pamphlet targeted to African American men. Exploiting the cultural connection between males and automobiles, they chose a simple, attention-getting traffic light for the cover graphic, with bold masculine colors (red, amber, and blue-green against a black background) and an easy-to-read text message: "STOP LOOK MOVE ... to save your life." Medical content was checked for accuracy by Council physicians, while the nurse educators and other Council members made sure the entire piece reflected their culture, from photos of minority men to a testimonial from an African American prostate cancer survivor (interviewed by the students over the telephone) to the very title itself. This brochure, "Prostate Cancer: It's a Matter of Color," has received broad regional recognition and is now available nationally.

Before the barbershop education sessions began, the project team publicized the program in appropriate African American venues. Planned activities were announced to the community through churches, newspapers (including an inner-city minority publication), and community events. Council members also talked about the program in their professional and cultural networks, alerting patients, friends and colleagues.

The target population for the intervention consisted of African American men, ages 40 and above, who are customers in the six local barbershops in Greater Syracuse. However, we have actually served a more diverse ethnic group patronizing these barbershops, including men of African, West Indian, Bahamian, Haitian, and Jamaican heritages. Participants freely agreed to attend the sessions and to accept the information offered.

Three rounds of the program have been delivered to date, starting in 2001 and continuing every year. The two RNs present all educational sessions in the barbershop settings. Most of the time, they are joined by a male Prostate Cancer Council member: to date our male volunteers have included several physicians (a urologist, internist, oncologist, and radiologist), a school principal, and a prostate cancer survivor, all African American and often known to some of the shop customers. Sessions are held on Saturday mornings and run four to five hours contingent upon the flow of customers during the scheduled period. Cowart and Brown provide the posters, brochures, and all other educational materials.

The program format consists of both one-to-one and small group sessions, which are generally brief, conversational, and informal. The nurses show a 10-minute video that contains culturally sensitive messages about prostate cancer, with familiar African American faces and culturally identifiable music. Initially they brought their own video equipment but soon discovered that all the barbershops had televisions with VCR set-ups, so it was only necessary to bring the video to later sessions. After the video, the healthcare team answers any questions the men have and provides additional information. Copies of the special prostate cancer brochure ("It's a Matter of Color") are displayed prominently and offered to every contact. Referral information addresses both insured and uninsured participants.

PROGRAM IMPACT AND OUTCOMES

We found that the African American men we talked to were very appreciative of the barbershop education sessions. They were both responsive to our health messages about prostate cancer and accepting of the information presented. Unfortunately, due to limited resources and time constraints, we have not been able thus far to link the referrals we provided to specific physician offices or healthcare agencies to determine the number of participants who actually sought screening as a result of the barbershop program. However, while we have no outcome measures of this kind (i.e., behavior modification) to date, our preliminary data show some promising results, and we learned some interesting facts about our participants and our program.

First, we estimate that we contacted approximately 550-600 men in the first three years of this program. The Barbershop Project has been well received and well publicized in our region, and we have been invited back to conduct the educational sessions at regular intervals. In addition, this project has received much media attention, from special reports and television coverage to articles in area magazines and newspapers, including the inner-city minority paper PRIDE. The Prostate Cancer Education Council has also received the Chancellor's Award for Public and Community Service from Syracuse University in recognition of its public service and programmatic efforts to reduce prostate cancer incidence and mortality in African Americans.

More specific feedback from barbershop owners and Council members has been useful and informative as well. We first had to adjust our proposed evaluation process: though the post-intervention focus group session with owners and Council members was scheduled as planned, owners were not able to attend due to changes in their work schedules or other conflicts. So we talked to them in person regarding their perceptions about the success of the educational program. All owners had very positive responses. Our findings concerning program participants over three rounds, which include the barbershop owners' feedback, are summarized below:

* African American men are interested in and willing to talk about prostate cancer.

* Prostate cancer educational programs are needed in the Greater Syracuse community.

* Most African American men we met are not knowledgeable about prostate cancer.

* Barbershops are an especially good place to find and educate African American men.

* African American men who have prostate cancer typically do not self-identify, so they suffer quietly and alone.

* African American men want to help other African American men learn about this disease.

* African American men learn about prostate cancer screening and testing most often from healthcare providers in industry, i.e., health offices in their workplace; and least often from primary care physicians and other mainstream healthcare providers.

* African American men appreciate the knowledge, caring, and caregiving provided on their behalf, and they encourage the continuation of educational programming.

* Educational programming about prostate cancer fosters reflection concerning friends and family members who now suffer from the disease or who have had the disease in the past.

* Most participants had not been tested for prostate cancer. With new knowledge, however, most of them expressed an interest in the screening process and early detection programs.

Our Barbershop team returns to each shop periodically between scheduled educational sessions to restock the prostate cancer literature and talk with owners about the program, addressing any questions they may have and continuing the dialogue about this disease among African American men. Interestingly, the barbers (both owners and the men they employ) have become advocates for the program and resources for helping to educate their customers. This community outreach effort goes on informally between our scheduled interventions.

DISCUSSION AND RECOMMENDATIONS

With three full rounds of this project behind us, we now have enough experience with the Barbershop Education Program to assess the key factors contributing to its success in Central New York, and to outline the challenges such initiatives present. This section describes what we learned in this project and provides some recommendations for applying that knowledge to other health education programs targeting minority populations.

FOCUS, STRUCTURE AND STRATEGIES

First, if we are to eliminate health disparities and provide effective health care to all Americans, it is imperative that interventions for African Americans and other minorities be culturally competent and relevant. Many people in these groups (especially men) may not be comfortable with the mainstream healthcare system, may lack adequate insurance and healthcare resources, and/or may have low literacy skills which impair their ability to read and understand traditional health information. Establishing credibility and trust is vitally important, and requires shaping the program to fit their needs, perceptions, sensitivities, and concerns.

Our team was careful to adapt the educational format and material to African American men, providing a relatively simple presentation in a relaxed, informal style. When we could not find culturally sensitive material on prostate cancer for these men, we developed our own "ethnic," easy-to-read brochure; in addition, we made sure our referral information was dear, useful, and included contacts for those without health insurance. Our project team participants--nurse educators, Council volunteers, and barbers--are all African American. We chose a setting that was natural and "non-threatening" for our target population and brought the program to them without asking that they alter their normal routines. Using a video that was short, engaging, focused on African American men, and that contained culturally familiar music also worked very well: the video attracted the attention of men coming into the barbershops, raised their curiosity about prostate health, and provided some basic facts in an accessible manner. They were then better prepared to accept additional counseling and to ask questions about prostate cancer.

Community networking and positive publicity also proved helpful in reaching African American men and inspiring confidence in the program. Initially Council members played a key role in publicizing the barbershop project, and word of mouth continues to bring men of color to the scheduled sessions. But shortly after the "pilot" round (2001), the regional media began reporting on the program: articles and features appeared in newspapers, magazines, radio and television broadcasts, with some messages targeted specifically to the black community (e.g., Syracuse's minority paper PRIDE). Project team members also visited minority churches and other faith-based organizations to present information on prostate cancer and the barbershop initiative. Public support by church and community leaders helped gain acceptance among African Americans for messages about prostate cancer as well as credibility for our program.

A final structural issue entails how we approached and involved the barbershop owners. While it was not difficult to convince them of the significance and benefits of the program, most of them were concerned about possible disruptions to their business. The shops are small and owners wondered whether there would be enough space to display posters and brochures, as well as present educational sessions to individuals or small groups. They needed to be reassured that the program would pose no inconvenience to them, their employees, or their customers. We also were not successful in organizing a group orientation or a post intervention focus group. Minority owners have varying schedules, and are not used to attending public meetings in a different location. Written evaluations did not work well either. However, when we shifted our strategy from "group scheduling" and survey forms to one-on-one talks with owners at their shops, they gave us remarkable cooperation and good feedback. Being sensitive and responsive to their needs and perspectives helped us gain their trust and build positive relationships. These barbers now welcome us cordially, and fully support our prostate cancer education activities.

Moreover, we focused on strengths that barbershop owners could bring to the program. One-on-one and small group interactions with customers are natural for them, so talking about prostate cancer issues with men who patronize their shops takes only a modest amount of training and experience. Although we initially trained only the owners, the four to seven other barbers (employees) in each shop became informed and involved advocates by watching the video, listening to the educational sessions and participating in the conversations. Since many barbershop customers are men over 40, this topic is of special interest to patrons, and the barbers feel they are providing an important service to their African American community. In effect, we tapped into the supportive culture of camraderie already operating in these barbershops. The natural social environment of the barbershop fostered a comfort level and relaxed interactions about a challenging topic, helping to dispel fears about cancer and distrust of healthcare providers.

RESOURCE ISSUES

Organizational resources were critical in launching this program: notably, support from Syracuse University (SU), and grants from the State's Office of Minority Health and the local chapter of the National Kidney Foundation. The grants provided funds to establish the Prostate Cancer Education Council and initiate the Barbershop project, paying Ms. Brown to coordinate the start-up phase. There is currently no funding to sustain the program, however: barbershop team members continue to deliver the education sessions as unpaid volunteers. We note that it is usually easier to win support to develop new programs than to find funds to maintain them, even if they prove successful. But grants were very helpful in forming the Council and developing the barbershop concept, and we continue to seek funding to sustain and extend this work.

University support was also crucial in forging the academic-community alliance that led to the Council. SU has provided leadership (e.g., faculty and administrative expertise, proposal writing) and other resources, including technology, space for Council meetings and activities, and a special grant to develop the culturally sensitive brochure. Its reputation for teaching, research, and service also enhanced the project's credibility, increasing the likelihood of grant funding from external sponsors and helping to attract community professionals as partners.

EXPERTISE, COMMITMENT, AND BUILDING TRUST

The Barbershop Program was developed and is being sustained through a remarkable collaboration among the nurse educators, other Council members, and local barbers, along with assistance from community leaders and the media. The primary challenge was to win credibility and support from the African American community; the key was to involve diverse stakeholders.

The Prostate Cancer Council, whose members are mostly but not all African American, provided the idea for the barbershops as well as substantial advice and input for developing the program. Besides the nurse educators, contributors included physicians in various specialties, other healthcare professionals, social workers, Syracuse University faculty and administrators, community leaders and educators, and prostate cancer survivors. Together they brought medical expertise, healthcare and provider experience, knowledge of minority issues, personal patient experience, networking opportunities, practical ideas and fresh perspectives to the conceptual planning and implementation phases, which strengthened the pilot session and helped ensure the program's acceptance among African Americans. In addition, six male Council members have served as the third member of the intervention team during the barbershop sessions, volunteering several hours on a Saturday to talk with minority men about prostate cancer issues. We believe that this strong commitment from busy physicians and other professionals has been a significant factor in the success of this ongoing health education and promotion effort.

Leadership for the program was another important element. Nurse educators Cowart and Brown have special expertise in public health education, prostate cancer, minority health issues and cultural competence, as well as a dedication to reducing health disparities in minority populations. Cowart's academic background, administrative and program development skills (including grant writing) complement Brown's experience in clinical instruction and community health care. Together this team had many professional contacts in several health-related fields, and their ability to network effectively, raise awareness of the prostate cancer epidemic among African American men, and persuade others to support this project was crucial to its success.

Their clinical experience and interpersonal skills also served the project well. The nurses first had to convince barbershop owners to participate in the program, which all agreed to do after their initial concerns were addressed. Of primary importance in establishing trust with the owners were a sincere desire to help African American men, mutual respect, a non-judgmental attitude, and a lack of preconceived notions: the nurses accepted both barbers and customers wherever they were in their health status, from the fearful who had not had a physical in years to those who had seen their doctor the previous week. Then they trained the barber owners and delivered the intervention to their minority customers, which required health education skills and sensitivity to cultural issues. Both women have developed good personal relationships with the owners and other barbers, who soon began to share their personal health histories and seek health advice from the nurses. Such trust ensures the owners' continuing participation and has fostered wider outreach to the target population. Cowart and Brown have also become well known in the African American community and are now viewed as health advocates for men of color.

Finally, the program has won loyal support from the barber participants, whose ethnicity and "people skills" with their customers have bolstered trust and confidence in the intervention. In the first round in 2001, the project team directed the education process and the barbers mainly observed, but now they proactively engage their customers on issues concerning prostate cancer. The nurse educators noticed that most owners, who tend to be older (and married), were up-to-date with their physicals and were more comfortable discussing prostate cancer; they took a more active role from the outset. In contrast, younger barbers displayed more fear and apprehension, particularly about the digital rectal examination. Both owners and their employees have become invested partners in the program, however: they now promote it, assist in the scheduled sessions, and provide information between the project team's visits, thereby extending its impact much farther into the African American community.

OVERALL EVALUATION

Our experiential and qualitative findings indicate that the Barbershop Program has been very successful thus far. It has raised awareness of this public health problem among African Americans and others in our geographic area, provided effective health education and counseling for men of color, deterred fears and myths about prostate cancer, and spread knowledge to the minority community. We have both anecdotal evidence (e.g., from barbers) and individual testimonies that affirm improved health practices among African American men, especially their following up with PSA screenings and healthcare visits. Most of our barbershop patrons clearly did not know much about prostate cancer before the intervention; many of them told us afterward how much they appreciate the program and how important they think it is. Such an impact reflects an emerging but significant cultural shift in awareness, knowledge and attitude--the beginning of informed healthcare decision-making and personal responsibility--that can truly make a difference in our battle against prostate cancer and other diseases in this population.

RECOMMENDATIONS AND CONCLUSION

Based on this Barbershop program and similar community-based initiatives, the project leaders and the Prostate Cancer Education Council of Central New York have developed the following recommendations for educating African American men about prostate cancer. These recommendations can also be applied to more general healthcare issues for minority populations.

* Forge partnerships with academic institutions, healthcare professionals, community organizations, corporations and other parties interested in minority health issues. Seek funding to develop and maintain long-term programming, and target stakeholders who have a commitment to the minority community.

* Provide educational programs in a familiar community setting that is frequented by the target population: e.g., barbershops, faith-based and community organizations, African American fraternities and professional organizations, sports venues.

* Build trust and create a comfortable interactive environment with minority participants. Mutual respect, sincerity, and a non-judgment attitude are crucial to successful programs.

* Use informal teaching methodologies, e.g., casual conversations, simple and clear educational messages in videos; and incorporate ethnically familiar faces.

* Schedule one-to-one meetings with minority participants, rather than group meetings, and use flexible program formats. Barbershop owners were more responsive to individual contact for orientation instructions, and our sessions fit in with their unstructured routine.

* Plan programs for African American men to train other men. Peer-to-peer formats in churches, community agencies, barbershops and sports events have proved successful.

* Plan prostate cancer programs in places of employment that have a large African American population. African American men are eager to learn about preventative health, but culturally competent healthcare must be offered by healthcare providers. Men reported learning about prostate cancer, its risk factors and screening from employment health offices during their annual physical examination. Few men reported learning about prostate cancer from their primary healthcare provider.

* Develop culturally competent literature to impart knowledge about prostate cancer to African American men. Familiar faces and simple educational messages are crucial for motivating them to accept and participate in educational programming for prostate cancer.

* Use minority male-female educator teams to work with African American men or other minorities. African American men respond well to education provided by minority nurse educators. Educators must create feelings of comfort and trust as well as promote credibility. Male and female partnerships make excellent educational teams for prostate cancer.

More effective health education and health promotion programs for minority males are sorely needed, and non-traditional settings offer a better prospect for success than mainstream venues for these men. We recommend developing culturally sensitive interventions and implementing them in environments where the target group feels comfortable and is likely to congregate. African American barbershops provided a natural, familiar setting for our minority men, as well as interested male advocates--the barbers who helped build trust and extend the program's outreach beyond the scheduled sessions. Our experience shows that with commitment and the support of the local community, this model can work well for minority populations.

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Luvenia W. Cowart, Ed.D., R.N.

Betty Brown, R.N.

Diana J. Biro, Ph.D.

Luvenia W. Cowart, Ed.D., R.N. is the Assistant Dean of Student Affairs and Special Projects in the College of Human Services and Health Professions at Syracuse University. She is also the Executive Director of the Prostate Cancer Education Council of Central New York. Betty Brown, R.N. was a Senior Staff Nurse of Radiation Oncology at the SUNY Upstate Medical University (ret.). She is also the Project Coordinator of the Prostate Cancer Education Council of Central New York. Diana J. Biro, Ph.D. is a Research Development and Writing Consultant for the College of Human Services and Health Professions at Syracuse University. Address all correspondence to Luvenia W. Cowart, Ed.D., R.N., 340 Sims Hall, Syracuse University, Syracuse, NY 13244, PHONE: [phone], FAX: [phone], E-MAIL: [e-mail]