Clinical Trial Protocol for a Randomized Trial of Community Health Worker-led Decision Coaching to Promote Shared Decision-making on Prostate Cancer Screening Among Black Male Patients and Their Providers

We propose a randomized controlled trial to evaluate the effectiveness of a community health worker-led decision-coaching program to facilitate shared decision-making for prostate cancer screening decisions by Black men at a primary care federally qualified health center.

Randomized trial of community health worker-led decision coaching to promote shared decision-making for prostate cancer screening among Black male patients and their providers

BACKGROUND

Black men are disproportionately affected by prostate cancer, the most common non-cutaneous malignancy among men in the USA. The United States Preventive Services Task Force (USPSTF) encourages prostate-specific antigen (PSA) testing decisions to be based on shared decision-making (SDM) clinician professional judgment, and patient preferences. However, evidence suggests that SDM is underutilized in clinical practice, especially among the most vulnerable patients. The purpose of this study is to evaluate the efficacy of a community health worker (CHW)-led decision-coaching program to facilitate SDM for prostate cancer screening among Black men in the primary care setting, with the ultimate aim of improving/optimizing decision quality.

METHODS

We proposed a CHW-led decision-coaching program to facilitate SDM for prostate cancer screening discussions in Black men at a primary care FQHC. This study enrolled Black men who were patients at the participating clinical site and up to 15 providers who cared for them. We estimated to recruit 228 participants, ages 40-69 to be randomized to either (1) a decision aid along with decision coaching on PSA screening from a CHW or (2) receiving a decision aid along with CHW-led interaction on modifying dietary and lifestyle to serve as an attention control. The independent randomization process was implemented within each provider and we controlled for age by dividing patients into two strata: 40-54 years and 55-69 years. This sample size sufficiently powered the detection differences in the primary study outcomes: knowledge, indicative of decision quality, and differences in PSA screening rates. Primary outcome measures for patients will be decision quality and decision regarding whether to undergo PSA screening. Primary outcome measures for providers will be acceptability and feasibility of the intervention. We will examine how decision coaching about prostate cancer screening impact patient-provider communication. These outcomes will be analyzed quantitatively through objective, validated scales and qualitatively through semi-structured, in-depth interviews, and thematic analysis of clinical encounters. Through a conceptual model combining elements of the Preventative Health Care Model (PHM) and Informed Decision-Making Model, we hypothesize that the prostate cancer screening decision coaching intervention will result in a preference-congruent decision and decisional satisfaction. We also hypothesize that this intervention will improve physician satisfaction with counseling patients about prostate cancer screening.

DISCUSSION

Decision coaching is an evidence-based approach to improve decision quality in many clinical contexts, but its efficacy is incompletely explored for PSA screening among Black men in primary care. Our proposal to evaluate a CHW-led decision-coaching program for PSA screening has high potential for scalability and public health impact. Our results will determine the efficacy, cost-effectiveness, and sustainability of a CHW intervention in a community clinic setting in order to inform subsequent widespread dissemination, a critical research area highlighted by USPSTF.

TRIAL REGISTRATION

The trial was registered prospectively with the National Institute of Health registry ( www.clinicaltrials.gov ), registration number NCT03726320 , on October 31, 2018.

A Framework for Using eHealth Interventions to Overcome Medical Mistrust Among Sexual Minority Men of Color Living with Chronic Conditions

The purpose of this paper is to present a stepwise, multi-construct, innovative framework that supports the use of eHealth technology to reach sexual minority populations of color to establish trustworthiness and build trust. The salience of eHealth interventions can be leveraged to minimize the existing paradigm of medical mistrust among sexual minority populations of color living with chronic illnesses. These interventions include virtual environments and avatar-led eHealth videos, which address psychosocial and structural-level challenges related to mistrust. Our proposed framework addresses how eHealth interventions enable technology adoption and usage, anonymity, co-presence, self-disclosure, and social support and establish trustworthiness and build trust.

Recruitment of racial/ethnic minority older adults through community sites for focus group discussions

Background

Despite a body of evidence on racial/ethnic minority enrollment and retention in research, literature specifically focused on recruiting racially/ethnically diverse older adults for social science studies is limited. There is a need for more rigorous research on methodological issues and the efficacy of recruitment methods. Cultural obstacles to recruitment of racial/ethnic minority older adults include language barriers, lack of cultural sensitivity of target communities on the part of researchers, and culturally inappropriate assessment tools.

Methods

Guided by the Consolidated Framework for Implementation Research (CFIR), this study critically appraised the recruitment of racial/ethnic minority older adults for focus groups. The initial approach involved using the physical and social infrastructure of the ElderSmile network, a community-based initiative to promote oral and general health and conduct health screenings in places where older adults gather, to recruit racial/ethnic minority adults for a social science component of an interdisciplinary initiative. The process involved planning a recruitment strategy, engaging the individuals involved in its implementation (opinion leaders in senior centers, program staff as implementation leaders, senior community-based colleagues as champions, and motivated center directors as change agents), executing the recruitment plan, and reflecting on the process of implementation.

Results

While the recruitment phase of the study was delayed by 6 months to allow for ongoing recruitment and filling of focus group slots, the flexibility of the recruitment plan, the expertise of the research team members, the perseverance of the recruitment staff, and the cultivation of change agents ultimately resulted in meeting the study targets for enrollment in terms of both numbers of focus group discussions (n = 24) and numbers of participants (n = 194).

Conclusions

This study adds to the literature in two important ways. First, we leveraged the social and physical infrastructure of an existing program to recruit participants through community sites where older adults gather. Second, we used the CFIR to guide the appraisal of the recruitment process, which underscored important considerations for both reaching and engaging this underserved population. This was especially true in terms of understanding the disparate roles of the individuals involved in implementing and facilitating the recruitment plan.

A qualitative study to understand guideline-discordant use of imaging to stage incident prostate cancer

Background

Approximately half of veterans with low-risk prostate cancer receive guideline-discordant imaging. Our objective was to identify and describe (1) physician knowledge, attitudes, and practices related to the use of imaging to stage prostate cancer, (2) patient attitudes and behaviors related to use of imaging, and (3) to compare responses across three VA medical centers (VAMCs).

Methods

A qualitative approach was used to explore patient and provider knowledge and behaviors relating to the use of imaging. We conducted 39 semi-structured interviews total—including 22 interviews with patients with newly diagnosed with prostate cancer and 17 interviews with physicians caring for them—between September 2014 and July 2015 at three VAMCs representing a spectrum of inappropriate imaging rates. After core theoretical concepts were identified, the Theoretical Domains Framework (TDF) was selected to explore linkages between themes within the dataset and existing domains within the framework. Interviews were audio-recorded, transcribed verbatim, and then coded and analyzed using Nvivo software.

Results

Themes from patient interviews were categorized within four TDF domains. Patients reported little interest in staging as compared to disease treatment (goals), and many could not remember if they had imaging at all (knowledge). Patients tended to trust their doctor to make decisions about appropriate tests (beliefs about capabilities). Some patients expressed a minor concern for radiation exposure, but anxiety about cancer outcomes outweighed these fears (emotion). Themes from physician interviews were categorized within five TDF domains. Most physicians self-reported that they know and trust imaging guidelines (knowledge) yet some were still likely to follow their own intuition, whether due to clinical suspicion or years of experience (beliefs about capabilities). Additionally, physicians reported that medico-legal concerns, fear of missing associated diagnoses (beliefs about consequences), influence from colleagues who image frequently (social influences), and the facility where they practice influences rates of imaging (environmental context).

Conclusions

Interviews with patients and physicians suggest that physicians are the primary (and in some cases only) decision-makers regarding staging imaging for prostate cancer. This finding suggests a physician-targeted intervention may be the most effective strategy to improve guideline-concordant prostate cancer imaging.

Feasibility and acceptability of an audio computer-assisted self-interview version of the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) in primary care patients

BACKGROUND

This study explores the feasibility and acceptability of a computer self-administered approach to substance use screening from the perspective of primary care patients.

METHODS

Forty-eight patients from a large safety net hospital in New York City completed an audio computer-assisted self-interview (ACASI) version of the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) and a qualitative interview to assess feasibility and acceptability, comprehension, comfort with screening questions, and preferences for screening mode (interviewer or computer). Qualitative data analysis organized the participants' feedback into major themes.

RESULTS

Participants overwhelmingly reported being comfortable with the ACASI ASSIST. Mean administration time was 5.2 minutes (range: 1.6-14.8 minutes). The major themes from the qualitative interviews were (1) ACASI ASSIST is feasible and acceptable to patients, (2) Social stigma around substance use is a barrier to patient disclosure, and (3) ACASI screening should not preclude personal interaction with providers.

CONCLUSIONS

The ACASI ASSIST is an appropriate and feasible approach to substance use screening in primary care. Because of the highly sensitive nature of substance use, screening tools must explain the purpose of screening, assure patients that their privacy is protected, and inform patients of the opportunity to discuss their screening results with their provider.

Prevalence, patterns and predictors of substance use among Latino migrant men in a new receiving community

BACKGROUND

The purpose of this study was to evaluate the prevalence, patterns and predictors (individual, social, cultural, and environmental) of illicit drug use and binge drinking in a cohort of Latino migrant men (LMM) in a new receiving community.

METHODS

A cohort of LMM in New Orleans (n=125) was assembled in 2007 using respondent driven sampling and interviewed quarterly for 18 months regarding past month substance use and other potential covariates. Baseline frequencies were weighted using RDSAT and longitudinal analyses included generalized estimating equations (GEE) and the Cochran-Armitage test for trends.

RESULTS

At baseline, substance use behaviors were: drug use 15.0% (range 7.3-25.0%) and binge drinking 58.3% (range 43.6-74.6%). All three of these behaviors decreased over follow-up (P<0.01). Baseline alcohol dependence and drug problem were 11.8% (range 5.6-24.3%) and 0.08% (range 0.00-2.7%) and both remained the same over time. Baseline rate of chlamydia was 9% (range 0.00-22.4%); all men tested negative for gonorrhea, HIV, and syphilis. For both binge drinking and drug use, having sex with a female sex worker was associated with increased risk, whereas belonging to a club or organization was associated with less risk. Additional factors associated with increased drug use were: having a friend in New Orleans upon arrival, symptoms of depression, and working in construction. An additional factor associated with less binge drinking was having family in New Orleans upon arrival.

CONCLUSION

Among LMM, substance use is influenced by social and environmental factors. Interventions increase community connectedness may help decrease usage.

Knowledge and beliefs about reproductive anatomy and physiology among Mexican-Origin women in the USA: implications for effective oral contraceptive use

Inherent in many reproductive health and family planning programmes is the problematic assumption that the body, its processes and modifications to it are universally experienced in the same way. This paper addresses contraceptive knowledge and beliefs among Mexican-origin women, based upon data gathered by the qualitative component of the Border Contraceptive Access Study. Open-ended interviews explored the perceived mechanism of action of the pill, side-effects, non-contraceptive benefits, and general knowledge of contraception. Findings revealed complex connections between traditional and scientific information. The use of medical terms (e.g. 'hormone') illustrated attempts to integrate new information with existing knowledge and belief systems. Conclusions address concerns that existing information and services may not be sufficient if population-specific knowledge and beliefs are not assessed and addressed. Findings can contribute to the development of effective education, screening and reproductive health services.

HIV risk and prevention among Hispanic immigrants in New York: the salience of diversity

The importance of identifying differences in HIV risk between Hispanic subgroups is the focus of this article. Data are drawn from two New York?based HIV-related studies: among Puerto Rican drug users and among new immigrants from Central America, the Dominican Republic, and Mexico. Results indicated that intercultural individuals (i.e., those involved in both Puerto Rican and mainland cultures) were less risky in terms of injection- and sex-related risk behaviors and that geographic and other contextual factors, along with cultural norms, influence risk behaviors for immigrants. Both studies indicate the need to differentiate subgroup factors affecting HIV risk and prevention behaviors to develop appropriate and effective community-based interventions. The study's limitations are noted.

HIV risk behaviors, knowledge, and prevention service experiences among African American and other offenders

African Americans are at the intersection of the AIDS epidemic and burgeoning prison and offender populations, yet little is known about offenders' HIV knowledge and risk behaviors or ability to access effective services. We present findings from an exploratory study based on 300 interviews with New York City offenders conducted in 2001-2002. The data indicate relatively high rates of HIV infection and HIV risk behaviors among African American and other offenders. There were no clear patterns of risk behaviors by race/ethnicity. Although overall HIV knowledge level is high, important gaps in HIV knowledge remain and there is widespread skepticism among offenders about government information about HIV/AIDS. In the corrections setting, there is inconsistent access to HIV prevention and education services, and an emphasis on more passive learning materials. To reduce HIV infection rates, there is a need to expand peer-led and culturally- and gender-specific interventions, and to improve access to correctional facilities for community-based HIV service providers. HIV interventions must also be expanded for offenders on probation and parole. Mandatory HIV education and harm reduction approaches should be considered.

Research challenges to the study of HIV/AIDS among migrant and immigrant Hispanic populations in the United States

Migrant populations have been found to be at risk of HIV/AIDS. The growth in immigrant and migrant Hispanic populations in the United States increases the need to enhance understanding of influences on their HIV-risk behaviors. Four challenges to conducting research among these populations were identified: (1) the need to use multilevel theoretical frameworks; (2) the need to differentiate between Hispanic subgroups; (3) challenges to recruitment and data collection; and (4) ethical issues. This article describes how two studies of Hispanic immigrants and migrants in the New York area addressed these challenges. One study focused on new immigrants from Mexico, the Dominican Republic, El Salvador, Honduras and Guatemala, and a second study focused on Puerto Rican drug users. Both studies incorporated qualitative and quantitative methods to study these hard-to-reach populations. Continued study of the sociocultural and contextual factors affecting HIV risk for mobile populations, and addressing the research challenges, is crucial to developing effective intervention programs.

The 'natural' body, God and contraceptive use in the southeastern United States

Data collected among African-American and Caucasian women and men in the southeastern USA indicate that participants' perceptions of nature, God's will and the human body influence reproductive health and decision-making. Attitudes about the health care system, pharmaceutical companies and government programmes for fertility regulation reinforce these views and may negatively affect willingness to use contraceptive methods consistently and correctly.

Integrating qualitative and quantitative methods: comparing HIV-related risk behaviors among Puerto Rican drug users in Puerto Rico and New York

A dual site project was conducted to assess determinants of injection and sex-related risk behaviors among Puerto Rican drug users. The project focused on injection drug users and crack smokers, and was conducted in East Harlem, NY and Bayamón, PR in 1996-2000. Qualitative methods included ethnographic mapping, focus groups, in-depth interviews, and observations. A survey component (East Harlem, n = 800; Bayamón, n = 400) was also conducted. Procedures to ensure integration of methodologies and comparability of data were developed. This paper describes the qualitative and survey methods used, and presents the comparative HIV risk behaviors. The integration of the two methodologies served multiple functions: each component identified issues to be addressed in the other, enhanced cross-site comparability of data, and assisted in interpretation of findings. The survey data showed high levels of risk behaviors in both communities, with significantly higher levels of risk reported in Bayamón. Conducting studies of similar ethnic groups in different communities provides opportunities to examine diverse sources of influence on risk behaviors. The integration of qualitative and quantitative methods can enhance comparability and understanding of findings, particularly when there are differences in behaviors between communities.

Impact of the September 11th attacks in New York City on drug users: a preliminary assessment

An exploratory assessment of the impact of the September 11th attacks in New York City on drug users, including their perceptions of changes in drug use, drug availability, police activities, and access to services, was undertaken. Methods included focus groups with drug users and acquired immunodeficiency syndrome (AIDS) outreach worker supervisors and surveys of service providers. Results indicated that, while there was some immediate concern about the potential impact on drug availability, there was no perceived scarcity, although some drug users did report a decrease in drug purity. Responses included increased use of drugs and increased demand for drug treatment. The wide range of responses indicates that continued monitoring of the impact may be needed to assess long-term effects.

Dominican, Mexican, and Puerto Rican prostitutes: drug use and sexual behaviors

Although Hispanics are overrepresented in AIDS cases in the United States, little information is available to help understand differences in drug and sex risk behaviors in Hispanic subgroups, needed to develop appropriate prevention programs. This study reports on HIV-related risk behaviors in three groups of Hispanic prostitutes recruited in the United States: Dominican (77), recruited in Washington Heights, NY, Mexican (151), recruited in El Paso, 7X; and Puerto Rican (48), recruited in East Harlem, NY Ethnographic interviews were conducted with a subsample of subjects to examine cultural meaning of risk behaviors; structured interviews were conducted with subjects to describe demographic characteristics and summarize levels of risk behaviors. Results indicated that the labels Hispanic and prostitute obfuscated important differences related to geographic and cultural factors. To be effective for diverse Hispanic groups, HIV prevention efforts and interventions must be based on knowledge of these differences.

HIV risk behaviors among Dominican brothel and street prostitutes in New York City

Latina women are overrepresented among AIDS cases in the United States. To assist in developing appropriate prevention and intervention programs, information regarding HIV risk behaviors is needed on the many diverse Latina subgroups. This study examined sociodemographic characteristics and HIV risk behaviors of Dominican female prostitutes, comparing those who worked primarily in brothels with those who were street workers. A total of 77 Dominican prostitutes (54 brothel; 23 street) were recruited in New York City to participate in a structured interview and were offered HIV testing. Ethnographic interviews were conducted with a subscale. Results indicated that there were many significant differences in demographics and risk behaviors between the two groups, and those working in brothels engaged in lower levels of risk behaviors. In addition, those working in brothels had closer ties to the Dominican and Spanish cultures. Implications for AIDS prevention efforts are discussed.

HIV-related concerns and behaviors among Hispanic women

Hispanic women whose sexual partners have other sexual partners may be at risk for HIV. A structured interview was administered to 106 Dominican and Puerto Rican women who reported that they knew or suspected that their partner had other partners. A subsample participated in qualitative interviews. The study assessed concern about HIV and predictors of condom use. The majority of women reported that they worried about getting HIV and almost half had been HIV-tested. Most of the women discussed HIV/AIDS concerns with their partners, and one-third reported some condom use. Predictors of condom use were: born in the Dominican Republic/Puerto Rico, having talked with their partner about being tested, and belief that he used condoms with others. Although the women were concerned about HIV, condom use was infrequent. Results suggested methods to address this discrepancy: introducing condoms early in the relationship, developing women-controlled methods, and directly influencing men's behavior.