African American men face a disproportionately high risk of developing and dying from prostate cancer. To address this disparity, various prostate cancer intervention programs have been implemented, including the use of online decision aids (DAs) and culturally tailored interventions.
The Role of Decision Aids
The prostate-specific antigen (PSA) test, a common screening modality for prostate cancer, remains controversial due to high false-positive rates, overdiagnosis of indolent cancers, and overtreatment. Medical organizations recommend that men, especially those at high risk like African American men, be fully informed about the potential risks and benefits of screening before making a decision, a process known as shared decision-making (SDM).
Decision aids (DAs) can provide men with easy-to-understand and unbiased information to help them understand the potential benefits, risks, and limitations of prostate cancer screening. Studies show that DAs can effectively increase patients' knowledge, promote confidence in decision-making, and decrease decisional conflict.
PCSPrep: A Decision Aid for African American Men
To address the specific needs of African American men, an online prostate cancer decision aid called Prostate Cancer Screening Preparation (PCSPrep) was developed. PCSPrep aims to provide men with the knowledge and skills to participate in a shared decision about prostate cancer screening with their providers.
A pilot study of PCSPrep among men recruited from community settings showed that it significantly improved men's knowledge about prostate cancer and reduced conflict about decision-making.
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Evaluating PCSPrep in Primary Care Settings
A study was conducted to evaluate the impact of PCSPrep on African American patients in primary care settings. The study involved African American men aged 45-70 years with no prior history of prostate cancer. Participants used the DA on an iPad before their routine visit and completed surveys before and after using the DA.
Study Design and Participants
Five primary care sites affiliated with an academic medical center in Atlanta, GA, participated in the study. Eligible patients were identified through electronic medical records and scheduling systems. Participants were asked to arrive 90 minutes before their appointment to provide consent, use the DA, and complete data collection activities.
Outcomes and Measures
The study assessed several primary outcomes, including:
- Prostate cancer knowledge
- Confidence in ability to make informed decisions
- Decisional conflict
- Satisfaction with the decision
- Preparedness for decision-making
- Perceptions about shared decision-making
Data was collected using validated scales and questionnaires, including the Prostate Cancer Knowledge Scale, Decision Self-Efficacy Scale, Decisional Conflict Scale, and Shared Decision-Making Questionnaire.
Study Results
The study found that use of the DA was associated with:
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- Increased knowledge about prostate cancer (55.3% vs 71.2%, p < 0.001)
- Reduced decisional conflict (33.4 vs 23.6, p=0.002)
- Decreased preference to be screened (88% vs 69%, p=0.01)
Most participants (89%) reported that the decision aid prepared them well/very well for SDM with their provider. Following the clinical visit, mean scores on perceived involvement in SDM was 68.5.
These findings suggest that PCSPrep can help prepare men to engage in SDM when administered in primary care clinics. After using the tool, men had significantly greater knowledge about prostate cancer screening, experienced reduced decisional conflict, and had a decreased preference to undergo screening.
The observed increase in knowledge after use of PCSPrep is generally consistent with recent reviews of prostate cancer DAs and with other DA studies conducted among African American men. Taken together, DAs consistently demonstrate significant improvements in prostate cancer knowledge.
Cultural Beliefs and Stigma in Sub-Saharan Africa
In sub-Saharan Africa (SSA), prostate cancer poses a growing burden, with projections indicating a near doubling of deaths by 2040. Cultural beliefs and stigmas surrounding prostate cancer can deter men from seeking timely medical care until the disease has advanced.
A systematic review explored the intersection of cultural influences on prostate cancer care in SSA, identifying barriers and facilitators to improving health outcomes for sub-Saharan African men. The review included 34 studies that revealed diverse cultural perceptions influencing attitudes to prostate cancer, such as associating it with spiritual causes or issues of masculinity, leading to stigma and delays in seeking medical care.
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Key Findings on Cultural Perceptions
- Men perceive prostate cancer screening negatively due to fears of discomfort, social stigma, fatalism, and misconceptions about the causes and outcomes of the disease.
- Effective strategies for improving awareness about prostate cancer include community engagement, media outreach, healthcare provider education, and enhancing accessibility to screening services, particularly in rural areas.
- The review highlighted the significant impact of cultural beliefs on prostate cancer care-seeking behaviors in SSA and uncovers widespread misconceptions and stigmas that impede timely diagnosis and treatment.
The Need for Culturally Tailored Interventions
There is an urgent need for culturally tailored interventions to increase awareness, correct misconceptions, and diminish the stigma associated with prostate cancer in the region. African American men already face low clinical trial participation, and African men in SSA are further excluded due to limited research diversity and structural and cultural barriers.
Addressing Disparities Through Targeted Interventions
To address the personal factors of black men that have been linked to CaP disparity, numerous community-based intervention programmes have been developed to enhance black men’s CaP awareness, knowledge, and early behaviours. [7, 13-16] Although some of these intervention programmes demonstrated effectiveness during the active phase of implementation, the successes have been short term.
According to Green and Glasgow, most health interventions fail in targeted communities because they are impractical [17, 18]. Another reason for the failure of intervention programmes is that most are not guided by comprehensive, valid, and culturally appropriate behavioural theories. The lack of theory-based interventions greatly impacts the sustainability of prostate health intervention programmes for black men.
Based on over 10 years of research, the Florida Prostate Cancer Health Disparity Research (CaPHDR) group developed a Personal Integrative Model of Prostate Cancer Disparity (PIPCaD) for black men [4-6, 19-23]. The PIPCaD model hypothesises that a potential source of CaP disparity in black men is their personal behavioural factors such as lack of CaP risk reduction behaviours, and early CaP detection behaviours.
The risk reduction behaviours include lifestyle factors such as healthy eating and exercise. Early detection behaviours include informed screening decision. The personal factors are in turn impacted by cognitive-behavioural factors (such as knowledge and health beliefs), cultural beliefs and values, and socio-demographic factors.
In line with our long-term goal of improving prostate health in minority, rural, and under-served communities, the W.O.R.D video focuses on explaining the risk factors for CaP, how to reduce the risk for CaP, and informed decision making about CaP screening.
The W.O.R.D video addressed the limitations of previous CaP intervention programmes for black men using two innovative strategies. The first strategy was the use of a theoretical framework, the PIPCaD model, to plan and develop a video. The PIPCaD model provided information on the behavioural factors to target the CaP education intervention, including: attitude, perceived severity, perceived susceptibility, cues to action, knowledge, and perceived behavioural control.
The second strategy is the use of the Health Communication Process Model [24] to ensure the successful development of the programme. The intervention is based on the six stages of continuous process of planning and improvement proposed by the Health Communication Process Model. The stages are: (1) planning and strategy selection, (2) selecting channels and materials for the intervention, (3) developing materials and pre-testing, (4) implementation of intervention, (5) assessing effectiveness of intervention, and (6) feedback to refine the programme.
Video has been found to be one of the most effective channels for educating black men [25, 26]. It has also been used as a critical medium to promote diverse health issues. In a review of 175 studies (mostly conducted in the US), Eiser and Eiser [27] concluded that video is an effective communication tool for health interventions if it is grounded in behavioural theory and engages the audience.
The setting for the W.O.R.D video was a barbershop. The barbershop was selected for the setting because it is accessed by black men of diverse educational backgrounds and socio-economic classes [28-30].
The modifiable variables targeted for the intervention message were: (1) perceived behavioural control; (2) perceived susceptibility to CaP; (3) perceived severity of CaP; and (4) cues to action.
The storyline for the script was that Quincy (a black man in his mid-40s) becomes aware of the importance of CaP prevention and having a consultation with a physician for informed decision on screening, and finally decides to discuss it with his doctor after a lively conversation with his friends at a barbershop.
Participants were recruited at health forums and community outreach events, including the African American Men’s Summit in Orlando, the Men’s Health Expo in Gainesville, and the University of Florida mobile health clinics in Gainesville.
The study participants were mostly US-born black men, between 50 and 59 years, married, urban residents, who had full-time employment, with an education level of high school diploma, and earned less than US$20,000.
The mean pre-test knowledge score was 63.6%, and the mean post-test knowledge score after intervention exposure was 74.0%.
Patient Navigation Programs
Patient navigation is an evidence-based intervention that can help reduce racial/ethnic disparities in cancer care. Launched in 1995 in Harlem, New York, patient navigation was developed by Dr. Harold Freeman to reduce health disparities among low-income African American women with an abnormal breast screening.
Since its first use, researchers and healthcare professionals have broadened the practice across the cancer continuum to include cancer prevention, detection, diagnosis, treatment, and survivorship. Navigation has been shown to eliminate disparities in delays in diagnostic resolution and treatment initiation and adherence, improve patient-centered communication, care coordination, and clinical outcomes.
The National Cancer Institute (NCI) implemented the Patient Navigation Research Program to address the need for standardization of navigation programs across health systems and defines patient navigation as support and guidance offered to vulnerable persons with abnormal screening or a cancer diagnosis, with the goal of overcoming barriers to timely and effective diagnosis and treatment.
Notably, navigators are well-positioned to provide and improve cancer care within the context of cultural humility given their role as liaison between patients and providers. Cultural humility takes a learning-oriented approach (curiosity and self-reflection over mastery) to working with people from diverse cultural backgrounds and emphasizes recognition of patients’ cultural perspectives as equally valid, and critical reflection on how systemic issues and power dynamics impact health care.
Patient navigation programs can enact cultural humility through navigator training that emphasizes cultural sensitivity, openness, and appreciation of diverse perspectives of the patient population, and challenges within the healthcare system that disadvantage certain groups, including racism and implicit bias.
Navigation programs can also be culturally tailored, in which navigators are racially and linguistically matched to patients, as peers from one’s racial/ethnic group, age group, and/or gender that serve as sources of credible information.
A scoping review examined navigation programs among African American men facing PCa from screening through survivorship, to uncover specific components and processes of navigation, including cultural humility to meet the unique needs of this underserved population, and how navigation is used to address disparities in quality of care.
The review explored the following programmatic characteristics: (a) types of navigators-nurse, lay, peer, etc.; (b) navigators’ background and training; (c) managing navigators-who and how; (d) navigation activities/protocol; and (e) impact and outcomes measured.
The review included studies that described or investigated navigation programs/interventions for PCa from screening through survivorship and included at least 30% African American/Black men.
The most common navigation activities reported were care coordination, education/information provision, and comfort/emotional support. Navigation improved screening uptake, PCa management, and access to supportive services.
Navigation programs in PCa care are beneficial; however, few studies were identified despite disease burden and disparities among African American/Black men.
Prostate Cancer and African-American Men: What You Need to Know | SERO
Table 1: Summary of Key Findings
| Intervention Type | Target Population | Key Outcomes | Cultural Considerations |
|---|---|---|---|
| Decision Aids (PCSPrep) | African American men aged 45-70 | Increased knowledge, reduced decisional conflict, decreased preference for screening | Tailored content for African American men, emphasis on individual preferences and values |
| Community-Based Video Intervention (W.O.R.D) | Black men in Florida | Increased knowledge, improved screening intention, reduced decisional conflict | Barbershop setting, culturally relevant actors and storyline, PIPCaD model |
| Patient Navigation Programs | African American men facing PCa | Improved screening uptake, PCa management, access to supportive services | Culturally tailored navigators, emphasis on cultural humility and addressing systemic issues |
