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

A pilot randomized clinical trial of a smartphone-based application to support at-home PSA screening and culturally tailored prostate cancer education for African American men: A study protocol

BACKGROUND

Prostate cancer is the most diagnosed cancer in Black/African American men (AA) and the second‑leading cause of cancer-related deaths. A prostate-specific antigen (PSA) blood test is an early detection screening tool for prostate cancer, but uptake of PSA screening remains low among AA men. Greater PSA screening rates among AA men, coupled with earlier treatment, may reduce disparities in prostate cancer outcomes, including mortality. The current pilot study will test the first-of-its-kind mobile health (mHealth) app to improve prostate cancer knowledge and increase PSA screening uptake among AA men using home-based screening methods.

METHODS

AA men aged 55 to 69 and are not up to date with PSA screening will be randomly assigned 1:1 to receive a prostate cancer screening app: Prevention Taskforce App (Taskforce App; control condition) or the Prostate Cancer Genius App (Genius App; intervention condition), which was developed specifically for AA men.

RESULTS

We will evaluate the preliminary efficacy of the apps via post-intervention group differences on the validated 18-item Prostate Cancer Knowledge Scale (primary outcome). We will also explore post-intervention group differences in perceived engagement, accessibility, and acceptability between the apps. Finally, we will derive preliminary estimates of PSA screening rates between study conditions and identify mechanisms of screening adherence.

DISCUSSION

mHealth apps offer promise to improve prostate cancer knowledge and screening rates among AA men. Demonstrating the preliminary efficacy of the Genius App will support future fully-powered mHealth interventions to address health disparities.

National Trends in PSA Cancer Screening With Parallel Investigation of Colorectal Cancer Screening: An Analysis of the CDC Behavioral Risk Factor Surveillance System From 2012 to 2022

INTRODUCTION/BACKGROUND

From 2012 to 2022 there have been numerous revisions in the United States Preventative Task Force guidelines for prostate cancer screening, including advising against PSA testing to allowing shared-decision making for men aged 55 to 69. We sought to observe trends in PSA testing rates in relation to the changing guidelines. Conversely, colorectal cancer screening recommendations remained consistent for patients aged 50-75 and we sought to use this as a comparison to observe the effect of differing guidelines.

METHODS

The Centers for Disease Control Behavioral Risk Factor Surveillance System is a national database of surveys on health-related behaviors and preventive medical services. We extracted responses from 2012 to 2022 regarding both prostate and colorectal cancer screening. Our primary variable of interest was prostate cancer screening while colorectal cancer screening served as a positive control.

RESULTS

Prostate cancer screening decreased among respondents from 70.1% in 2012 to 59.7% in 2022. However, there was a significant rebound in prostate cancer screening prevalence in 2022. In contrast, colorectal cancer screening rates steadily increased from 70.7% in 2012 to 78% in 2022. The annual percentage of men who had received prostate cancer screening was statistically different year to year.

CONCLUSIONS

Trends in the rate of screening for prostate and colorectal cancer appeared to adapt to the updated recommendations. However, further investigation regarding lower income levels, minority groups, and uninsured men are essential to address the social and racial disparities seen in prostate cancer screening. Efforts to promote shared-decision making may improve effective cancer screening.

Implementation Barriers and Recommendations for a Multisite Community Health Worker Intervention in Palliative Care for African American Oncology Patients: A Qualitative Study

Background: Palliative care remains underutilized by African American patients with advanced cancer. Community health workers (CHWs) may help improve palliative care outcomes among this patient population. Objectives: To explore barriers to success of a proposed CHW intervention and synthesize design and implementation recommendations to both optimize our intervention and inform others working to alleviate palliative care disparities. Design: Semi-structured qualitative interviews. Setting/Subjects: Key informants were health care professionals across clinical, leadership, and community health fields. Participants were recruited through purposive sampling from Baltimore, Maryland; Birmingham, Alabama; and Salisbury, Maryland. Measurements: Interviewers used an interview guide grounded in established implementation science models. Data were analyzed through a combined abductive/deductive approach by independent coders. A framework methodology was used to facilitate thematic analysis. Results: In total, 25 professionals completed an interview. Key informants discussed multiple barriers, including at the patient level (lack of knowledge), clinician and facility level (decreased workflow efficiency), and health system level (limited funding). Recommendations related to the intervention's design included high quality preintervention CHW training and full integration of CHWs into the care team to "bridge" divides between outpatient, inpatient, and at-home settings. Intervention delivery recommendations included clearly defining care team roles and balancing flexibility and standardization in CHW support approaches. These recommendations were then used to adapt the planned intervention and its implementation process. Conclusions: Clinicians, cancer center leaders, and CHWs identified multilevel potential barriers to the intervention's success but also described recommendations that may mitigate these barriers. Key informant input represents an important step prior to initiating CHW-based interventions.

Effects of health education applying role play on decision making in acute myocardial infarction situation among older adults in community

Acute myocardial infarction is a silent killer for people worldwide, especially older adults who often experience atypical symptoms, causing late decision-making and a high mortality rate. The unrecognition of atypical symptoms, unconcerned about their risk, and not knowing how to deal with this critical situation are the barriers to a quick decision to visit the emergency department and delaying treatment, resulting in serious adverse outcomes. Therefore, specific and effective health education among older adults is needed. This double-blinded randomized controlled trial explored the effectiveness of health education by applying a role-play promoting decision-making ability program when expecting acute myocardial infarction occurrence among community-dwelling older adults. The participants were 96 community-dwelling older adults in central northeastern Thailand. We collected data between November 2021 and April 2022. The multi-stage sampling was applied to include participants. The intervention was the role-play promoting decision-making ability program and home visit. Outcomes were measured a week before attending and after finishing the intervention. T-tests, Mann-Whitney U test, Chi-square, and Wilcoxon Signed Rank test compared the outcomes between and within groups. Moreover, adjusted analysis was also demonstrated. Results revealed that participants who attended the program improved their knowledge, belief, and decision-making; only perceived susceptibility did not show improvement. Moreover, after demonstrating an adjusted analysis, the program participants had better knowledge about symptoms, perceived benefits, barriers, self-regulation, possible calling 1669, and first action. In conclusion, a role-play promoting decision-making ability program can promote knowledge, belief, and decision-making when expecting acute myocardial infarction occurrence among community-dwelling older adults. This study proved that role-play is one strategy to promote the program's effectiveness by inducing attention before giving older adults health information. Nurses and other healthcare professionals can implement this program as part of standard practice.Clinical Trial Registration Number: TCTR20210928004 on 28/09/2021.

Engaging disparities in prostate cancer: Piloting an interactive, virtual workshop to educate providers on shared decision-making for underserved populations

OBJECTIVE

Shared decision-making (SDM) is an approach to patient-centered care that is strongly recommended when counseling patients for screening and treatment of prostate cancer. However, providers report lack of comfort with SDM and particularly in disparate populations. We report our experience designing and piloting an online workshop to educate practicing urologists on SDM in diverse populations. Our objective was to create a valued interactive SDM workshop to help urologists learn to lead SDM discussions with men form underserved populations. Therefore, we tested the hypothesis that urologists would agree or strongly agree that we met our learning objectives on postcourse survey.

MATERIALS AND METHODS

With the support of the American Urologic Association, we developed a case-based workshop with interactive role-playing to demonstrate and teach integration of SDM into clinical care. Cases were centered around screening and treatment decisions for localized prostate cancer in diverse patients. Brief surveys were used to track success with learning objectives and urologists' satisfaction with the workshop.

RESULTS

The session included 14 participants from 6 countries. A postworkshop survey indicated that 100% of respondents (8 of 8) "strongly agreed" that the activity met learning objectives, and 100% rated the session as "good" (1), "very good" (1), or "excellent" (6). Participants' knowledge also improved on shared decision-making concepts and the knowledge was maintained one month after the workshop.

CONCLUSION

We successfully created and piloted an interactive online workshop to improve urologists' comfort using shared decision-making in caring for diverse patient populations. The course met its objectives and participant feedback for the course was positive. Sharing this process and framework for development of this intervention may inform future workshops that can be applied to medical students, residents, and providers.

Patient Communication Preferences for Prostate Cancer Screening Discussions: A Scoping Review

PURPOSE

Prostate cancer screening guidelines have changed as new evidence showing an equivocal mortality benefit led many organizations to relax recommendations for this screening and instead suggest shared decision making. Presently, it is unknown how successfully these conversations happen. Our objective was to understand men's communication preferences when they discuss prostate cancer screening.

METHODS

In this scoping review, we searched 4 electronic databases (Medline, Embase, PsycINFO, and CINAHL) and the gray literature. Additional studies were obtained from reference lists of included studies and relevant review articles. We included qualitative studies reporting patient perspectives relevant to the research question and published in English. Two independent researchers screened titles and abstracts based on these criteria, conducted a full-text review for final inclusion, evaluated the remaining articles for validity, extracted data, and used thematic analysis to build a thematic framework. A subgroup analysis was performed for Black men as many studies elicited their perspectives.

RESULTS

Analyses were based on 29 studies. We identified 4 main themes that men described as critical for successful prostate cancer screening risk discussions with their primary care clinician: using everyday language, receiving a sufficient quantity of information, spending enough time, and having a trusting and respectful relationship. Three additional themes emerged that prohibited men from having any discussions at all: having already decided to pursue prostate cancer screening, being passive in medical encounters, and perceiving threat to one's well-being. Black men faced racism, which impacted medical interactions.

CONCLUSIONS

Our findings point to strategies to support men's communication preferences and address preconceptions surrounding prostate cancer screening. More studies are needed in certain underrepresented populations given the propensity for disparity in health outcomes.

Disparities in Diagnosis, Treatment Access, and Time to Treatment Among Hispanic Men With Metastatic Prostate Cancer

PURPOSE

Reporting racial/ethnic disparities in aggregate obscures within-group heterogeneity. We sought to identify disparities in diagnosis and treatment in Hispanic subpopulations with metastatic prostate cancer (mPCa).

METHODS

We disaggregated men with prostate adenocarcinoma from the National Cancer Database from 2004 to 2017 by racial subgroup and Hispanic background. We assessed (1) presenting with mPCa, (2) receiving any treatment, and (3) receiving delayed treatment beyond 90 days. Logistic regression and adjusted odds ratios (aOR) were reported.

RESULTS

Hispanic men had greater odds of presenting with mPCa (aOR, 1.54; 95% CI, 1.50 to 1.58; P < .001) compared with non-Hispanic White (NHW) men. All Hispanic racial subgroups were more likely to present with mPCa, with the highest risk in Hispanic Black (HB) men (aOR, 1.68; 95% CI, 1.46 to 1.93; P < .01). Men from all Hispanic backgrounds had higher odds of presenting with mPCa, especially Mexican men (aOR, 1.99; 95% CI, 1.86 to 2.12; P < .01). Hispanic men were less likely to receive any treatment (aOR, 0.60; 95% CI, 0.53 to 0.67; P < .001), and this effect was particularly strong for Hispanic White patients (aOR, 0.58; 95% CI, 0.52 to 0.66; P < .001) and Dominican men (aOR, 0.52; 95% CI, 0.28 to 0.98; P = .044). Hispanic men were more likely to experience treatment delays compared with NHW men (aOR, 1.38; 95% CI, 1.26 to 1.52; P < .001) and in particular HB (aOR, 1.83; 95% CI, 1.22 to 2.75; P = .002) and South/Central American men (aOR, 1.48; 95% CI, 1.07 to 2.04; P = .018).

CONCLUSION

Differences exist in stage at presentation, treatment receipt, and delays in treatment on disaggregation by racial subgroup and Hispanic heritage. We need to study the potential mechanisms of the observed variations to help develop targeted interventions.

Understanding the Role of Urology Practice Organization and Racial Composition in Prostate Cancer Treatment Disparities

PURPOSE

Black men have a higher risk of prostate cancer diagnosis and mortality but are less likely to receive definitive treatment. The impact of structural aspects on treatment is unknown but may lead to actionable insights to mitigate disparities. We sought to examine the associations between urology practice organization and racial composition and treatment patterns for Medicare beneficiaries with incident prostate cancer.

METHODS

Using a 20% sample of national Medicare data, we identified beneficiaries diagnosed with prostate cancer between January 2010 and December 2015 and followed them through 2016. We linked urologists to their practices with tax identification numbers. We then linked patients to practices on the basis of their primary urologist. We grouped practices into quartiles on the basis of their proportion of Black patients. We used multilevel mixed-effects models to identify treatment associations.

RESULTS

We identified 54,443 patients with incident prostate cancer associated with 4,194 practices. Most patients were White (87%), and 9% were Black. We found wide variation in racial practice composition and practice segregation. Patients in practices with the highest proportion of Black patients had the lowest socioeconomic status (43.1%), highest comorbidity (9.9% with comorbidity score ≥ 3), and earlier age at prostate cancer diagnosis (33.5% age 66-69 years; P < .01). Black patients had lower odds of definitive therapy (adjusted odds ratio, 0.87; 95% CI, 0.81 to 0.93) and underwent less treatment than White patients in every practice context. Black patients in practices with higher proportions of Black patients had higher treatment rates than Black patients in practices with lower proportions. Black patients had lower predicted probability of treatment (66%) than White patients (69%; P < .05).

CONCLUSION

Despite Medicare coverage, we found less definitive treatment among Black beneficiaries consistent with ongoing prostate cancer treatment disparities. Our findings are reflective of the adverse effects of practice segregation and structural racism, highlighting the need for multilevel interventions.

Effectiveness of a Community Health Worker-Led Intervention on Knowledge, Perception, and Prostate Cancer Screening among Men in Rural Kenya

Background

Globally, an increase in mortality from prostate cancer (PC) remains a big challenge with disparities existing with a slight preponderance among men in low and middle-income countries. Prostate cancer is a leading cause of mortality among men in sub-Saharan Africa. In Kenya, despite the majority of men presenting with advanced prostate cancer for treatment, knowledge and screening for prostate cancer is low. The study aimed to examine the effectiveness of a community health worker-led education intervention on knowledge, perception, and PC screening.

Methods

This was a quasiexperimental study among Kenyan men aged 40-69 years. The intervention site was Gatundu North subcounty and the control site was Kiambu subcounty in Kiambu County. Stratified random sampling was applied to select 288 respondents per arm of the study. We used a pretested interviewer-administered questionnaire to collect data at baseline and 6 months postintervention. Pearson's chi-square test was used for data analysis.

Results

Awareness of prostate cancer significantly increased postintervention (P < 0.05). The proportion of respondents who had good knowledge of prostate cancer increased significantly from 49% to 76.4%(P < 0.05) in the intervention arm. The proportion of respondents with a high perception of self-vulnerability increased significantly from 26% to 42.1% (P < 0.05). The proportion of men who had undergone PC screening significantly increased from 4.5% to 20.4% (P < 0.05) in the intervention arm. In postintervention, there was a statistically significant difference in the proportion of men screened for prostate cancer in the intervention and control arm (P < 0.05).

Conclusion

Health education by community health workers during household visits increased awareness and knowledge, perception, and uptake of PC screening. Utilization of community health worker delivered education is an effective strategy that requires to be adopted to enhance screening.

Decision coaching for people making healthcare decisions

BACKGROUND

Decision coaching is non-directive support delivered by a healthcare provider to help patients prepare to actively participate in making a health decision. 'Healthcare providers' are considered to be all people who are engaged in actions whose primary intent is to protect and improve health (e.g. nurses, doctors, pharmacists, social workers, health support workers such as peer health workers). Little is known about the effectiveness of decision coaching.

OBJECTIVES

To determine the effects of decision coaching (I) for people facing healthcare decisions for themselves or a family member (P) compared to (C) usual care or evidence-based intervention only, on outcomes (O) related to preparation for decision making, decisional needs and potential adverse effects.

SEARCH METHODS

We searched the Cochrane Library (Wiley), Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (Ovid), Embase (Ovid), PsycINFO (Ovid), CINAHL (Ebsco), Nursing and Allied Health Source (ProQuest), and Web of Science from database inception to June 2021.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) where the intervention was provided to adults or children preparing to make a treatment or screening healthcare decision for themselves or a family member. Decision coaching was defined as: a) delivered individually by a healthcare provider who is trained or using a protocol; and b) providing non-directive support and preparing an adult or child to participate in a healthcare decision. Comparisons included usual care or an alternate intervention. There were no language restrictions.

DATA COLLECTION AND ANALYSIS

Two authors independently screened citations, assessed risk of bias, and extracted data on characteristics of the intervention(s) and outcomes. Any disagreements were resolved by discussion to reach consensus. We used the standardised mean difference (SMD) with 95% confidence intervals (CI) as the measures of treatment effect and, where possible, synthesised results using a random-effects model. If more than one study measured the same outcome using different tools, we used a random-effects model to calculate the standardised mean difference (SMD) and 95% CI. We presented outcomes in summary of findings tables and applied GRADE methods to rate the certainty of the evidence.

MAIN RESULTS

Out of 12,984 citations screened, we included 28 studies of decision coaching interventions alone or in combination with evidence-based information, involving 5509 adult participants (aged 18 to 85 years; 64% female, 52% white, 33% African-American/Black; 68% post-secondary education). The studies evaluated decision coaching used for a range of healthcare decisions (e.g. treatment decisions for cancer, menopause, mental illness, advancing kidney disease; screening decisions for cancer, genetic testing). Four of the 28 studies included three comparator arms.  For decision coaching compared with usual care (n = 4 studies), we are uncertain if decision coaching compared with usual care improves any outcomes (i.e. preparation for decision making, decision self-confidence, knowledge, decision regret, anxiety) as the certainty of the evidence was very low.  For decision coaching compared with evidence-based information only (n = 4 studies), there is low certainty-evidence that participants exposed to decision coaching may have little or no change in knowledge (SMD -0.23, 95% CI: -0.50 to 0.04; 3 studies, 406 participants). There is low certainty-evidence that participants exposed to decision coaching may have little or no change in anxiety, compared with evidence-based information. We are uncertain if decision coaching compared with evidence-based information improves other outcomes (i.e. decision self-confidence, feeling uninformed) as the certainty of the evidence was very low. For decision coaching plus evidence-based information compared with usual care (n = 17 studies), there is low certainty-evidence that participants may have improved knowledge (SMD 9.3, 95% CI: 6.6 to 12.1; 5 studies, 1073 participants). We are uncertain if decision coaching plus evidence-based information compared with usual care improves other outcomes (i.e. preparation for decision making, decision self-confidence, feeling uninformed, unclear values, feeling unsupported, decision regret, anxiety) as the certainty of the evidence was very low. For decision coaching plus evidence-based information compared with evidence-based information only (n = 7 studies), we are uncertain if decision coaching plus evidence-based information compared with evidence-based information only improves any outcomes (i.e. feeling uninformed, unclear values, feeling unsupported, knowledge, anxiety) as the certainty of the evidence was very low.

AUTHORS' CONCLUSIONS

Decision coaching may improve participants' knowledge when used with evidence-based information. Our findings do not indicate any significant adverse effects (e.g. decision regret, anxiety) with the use of decision coaching. It is not possible to establish strong conclusions for other outcomes. It is unclear if decision coaching always needs to be paired with evidence-informed information. Further research is needed to establish the effectiveness of decision coaching for a broader range of outcomes.