Abstract What are the health risks of stress? What are the health benefits of stress management? How can poverty-related stressors and racial discrimination create synergistic effects? Learn why there is a crucial need for stress management services, especially for indigent and underserved populations, and how public health education can play a role in providing these services. Find out how to design a stress management program that emphasizes the balance between physical, mental, emotional, social, and spiritual health and where to obtain the skills and resources necessary to teach such a program. Discover what barriers healthcare providers face in referring patients for stress management services, and how to help them overcome these barriers. Learn how to customize discussion topics, adapt printed materials, increase attendance and adherence, and overcome monetary and transportation barriers to address the specific needs of an indigent population. In addition, learn how to culturally tailor a stress management program for an urban African American population in the South by overcoming perceptual barriers (there may be fewer problems than you’d think), employing storytelling techniques, incorporating spiritual beliefs, and utilizing extended family and community support. How can you measure the success of such a program? Learn how to identify assessment tools to measure reductions in perceived stress, increases in coping skills, and improvements in health outcomes. Finally, reflect on the future directions for stress management and the need to clarify the role of public health in mind/body medicine.

Health Risks of Chronic Stress Increased susceptibility to: Anxiety & depression Autoimmune & inflammatory diseases –Allergies, asthma, Chronic Fatigue Syndrome, & Rheumatoid Arthritis Cardiovascular heart disease & risk factors –Hypertension & hypercholesterolemia Chronic pain conditions –Headaches, back aches, arthritis, & fibromyalgia Dermatologic problems –eczema, psoriasis Diabetes Gastrointestinal problems –Irritable Bowel Syndrome & ulcers Immunosuppression –Cold, flu, dental caries, cancer, herpes outbreaks, HIV Reproductive system problems –Menstrual irregularities & decreased fertility

Health Benefits of Stress Management Decreased anxiety and depression Enhanced sense of well-being Empowerment Better management of chronic disease Better pain tolerance Immune system functioning improved Enhanced insulin control Prevention of Disease and Successful Aging ? ?

Synergistic Effects of Poverty and Racism Low SES African Americans experience higher rates of stressors such as unemployment than low SES whites. Low SES African Americans are more vulnerable than middle SES African Americans to the impact of life events and economic problems. African Americans are also vulnerable to acculturative stressors such as threats to racial identity, culture-specific values, and patterns of living. The combination of poverty and discrimination may have a synergistic effect on stress.

Barriers to Stress Management Referrals Smoking, nutrition, and exercise believed to be more important than stress Lack of training in stress management Lack of confidence in teaching relaxation techniques Lack of referral sources

How to Overcome Provider Barriers Education on stress research Identification of referral source(s) Case study Screening tool Training in relaxation techniques

Address Specific Indigent Population Needs Customize discussion topics Adapt printed materials Utilize strategies to increase attendance and adherence Address monetary and transportation barriers

Customize Discussion Topics Time management & getting along with your boss may not be relevant to participants who are unemployed or on disability. Taking care of yourself may be more important for caregivers and those with chronic illness. Expressing emotions may be more important for those who have experienced abuse, neglect, or significant loss.

Adapt Printed Materials Print materials should be adapted for the literacy levels of class participants. Screening materials should have a limited number of choices per item and a limited number of total items. Print materials should be read out loud or alternatives to print should be available for those unable to read. Icons should reflect the ethnicity, gender, and lifestyle of participants, when possible.

Working with an indigent population means participants have more immediate priorities than attending classes. Weekly reminder phone calls help maintain attendance. Increase Attendance

Increase Adherence Provide notebooks to organize class materials Assign easy-to-do homework and discuss it in class Organize class topics so each week is new, different, and interesting Throw a graduation party at the end –This can be especially meaningful to those who haven’t graduated from school

Address Monetary Barriers Offer all necessary class materials for free or at minimal cost Reduce the need for childcare by allowing children to come to class (as long as they’re not disruptive)

Address Transportation Barriers Screen for transportation barriers and offer information on alternatives Provide public transportation tokens when possible

Tailor to the Culture of Your Audience Overcome perceptual barriers Use storytelling, visual images, analogies, & metaphors Incorporate spiritual beliefs Utilize extended family and community support

Overcome Perceptual Barriers Q: Are indigent African American patients really going to want to meditate, or is this too white/new age-y/yuppie for them? A: They have fewer pre-conceived notions than most of the middle-SES white staff do.

Storytelling Tell it in a story –Rather than saying, “Experts have found..., tell research findings in the form of a story (it’s more interesting this way anyway!) Use visual images, analogies, and metaphors –Relaxation = Armor, Coping = Sword –Cognitive restructuring - they can’t push your buttons if you take away the buttons to push

Incorporate Spiritual Beliefs Ask about spiritual and religious beliefs and practices Reinforce practice of meditation as a form of prayer Discuss taking care of yourself as a spiritual duty

Utilize Extended Family and Community Support Encourage participants to bring family members & friends to class Provide referrals to community services when appropriate Encourage participants to share what they’ve learned with others –churches and social groups

Measuring Success Perceived Stress Scale Quality of life measures Intensity of health problems Frequency of health problems Pictures!