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Dr. Brian Rivers

Dr. Brian Rivers

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Dr. Brian Rivers

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  1. Dr. Brian Rivers

  2. Brian M. Rivers, PhD, MPH Assistant Member Faculty Research, Health Outcomes and Behavior Moffitt Cancer Center A Evidenced-based Multi-level Framework for Addressing Prostate Cancer Disparities among African Americans 2

  3. BACKGROUND 3 Spring 2010 - National Institute for Minority Health and Health Disparities (NIMHD) & Agency for Health Care Quality and Research released a call for applications Response to Notice of Limited Competition Availability of Recovery Act Funds for NIMHD Competitive Revision Applications to Support Comparative Effectiveness Research (CER) for Elimination Disparities (CERED) Purposed to expand the scope of NIMHD-supported Centers of Excellence (P20) to establish a Core for the conduct CER

  4. Core-related Comparative Effectiveness Research Investments and Activities 4 • Research • Comparison of the effectiveness of community education, community-based multi-level interventions, community health advisors AND usual care • Human and Scientific Capital for CER • Integration of Research Training and Educational Core activities-will assist with the training of the CHWs • Data Infrastructure for CER • Strategies and linkages to enroll health disparity patients in Moffitt patient portal • Dissemination and Translation of CER findings

  5. Overview • Disparities in Prostate Cancer • Community Context • Study Concept and Design • Preliminary Findings • Next Steps

  6. African American Men and Prostate Cancer • Most frequently diagnosed cancer in U.S. men (ACS, 2013) • 2nd leading cause of cancer death in U.S. men (ACS, 2013) • Accounts for 37% of all cancer diagnosed in African American men (ACS, 2013) • African American men comprise the highest incidence (59%) and mortality (40%) for prostate cancer when compared to other racial and ethnic groups (ACS, 2013)

  7. Postulated Reasons for Disparity • Genetics • Biological Predisposition • Lifestyle • Behaviors • SES (Education and Income) • 24% of AA live below the federal poverty threshold vs. 8% of whites • 21% of AA are uninsured vs. 11% of whites • Highly correlated with cancer risk and outcomes across the continuum from prevention to palliative care • Patient-Provider Communication

  8. Contributing Factors • Late stage diagnosis • Cultural, historical, and social issues • Misconceptions • Fears • Attitudes • Low levels of Awareness and Knowledge

  9. Preventing Prostate Cancer • Known risk factors for developing prostate cancer: • Age • Race/Ethnicity • Family History of prostate cancer • No agreement on modifiable risk factors

  10. Prostate Cancer Diagnosis “DRE” “PSA”

  11. Screening Controversy • No Randomized Clinical Trail showing early detection of prostate cancer by DRE or PSA decreases morbidity or mortality • Adverse treatment outcomes: impotence, incontinence, strictures, bowel injury, and death

  12. Natural History of Prostate Cancer • Prostate cancer is biologically heterogeneous. • Some prostate cancers grow slowly and never cause symptoms. • Other prostate cancers are fast growing an metastasize quickly. • Other types grow at a modest pace.

  13. Are There Benefits From Screening and Early Treatment? • PSA screening detects cancer earlier • Treating PSA-detected cancer may be effective but we are uncertain • PSA may contribute to the declining death rate but we are uncertain

  14. Are There Harms From Screening and Early Treatment? • Three issues to consider: • False-positive screening tests. • Over-diagnosis (men who do not benefit from diagnosis). • Side effects of treatment.

  15. Organizational Recommendations • American Academy of Family Physicians • American Cancer Society • American College of Physicians/American Society of Internal Medicine • American College of Preventive Medicine • American Medical Association • American Urological Association • U.S. Preventive Services Task Force

  16. InformingPatients Do I know the likelihood of various outcomes? Do I know the potential benefits? Do I know the potential consequences of my decisions? Do I know the potential harms?

  17. Benefits of Decision Making • How the patient benefits: • Takes an active role in his health care. • Becomes better informed. • Chooses the option most consistent with his personal preferences. • How the clinician benefits: • Solves a clinical dilemma. • Informs and involves a patient in his care.

  18. Broad Categories of Factors that may influence receipt of optimal cancer care

  19. Structural Barriers • Health insurance status • Type of health insurance • Type of institution where care is received • Geographic region where care is received Shavers, V. L., and Brown, M. L. Racial and Ethnic Disparities in the Receipt of Cancer Treatment. Journal of Nat Cancer Inst, 2002, 94(5).

  20. Provider Recommendations • Influenced by • Clinical Stage • Presence of Certain Prognostic Indicators • Co-morbidity • Pain assessment • Physician perception/biases Shavers, V. L., and Brown, M. L. Racial and Ethnic Disparities in the Receipt of Cancer Treatment. Journal of Nat Cancer Inst, 2002, 94(5).

  21. Patient Decision Making • Influenced by • Socioeconomic status • Patient preferences/decision-making • Cost/Co-payment • Transportation • Time required for treatment • Family/other support Shavers, V. L., and Brown, M. L. Racial and Ethnic Disparities in the Receipt of Cancer Treatment. Journal of Nat Cancer Inst, 2002, 94(5).

  22. BARRIERS TO HEALTHCARE 31 AA continue to experience a 60% higher incidence and are 2x more likely to die from prostate cancer. Socio-cultural factors-patient-access to care, provider communication, level of prostate cancer knowledge, attitudes and perceptions of care, SES, etc. Screening and early detection likely to assist; however, there’s a lack of scientific evidence Patients are encouraged to participate in Informed Decision Making (IDM) process Extent of patient-provider interaction (Time spent ~ 7 minutes) serves a barrier to securing adequate healthcare among racial and ethnic groups. Mistrust, fear, discrimination, and racism-all been cited as factors of concern for AA when interfacing with healthcare system

  23. Although differences have been noted in patterns of cancer prevention, detection, and treatment, many of these differences are not the result of clinical profiles. • More recently, recommendations to address these differences have focused on addressing the influence of nonclinical factors on the receipt of cancer care as a means of reducing/eliminating disparities in health.

  24. Impact of Knowledge • Men, in particular African American men, have a low level of prostate cancer knowledge. • Diefenbach et al, 1996; Steele, 2000; Fitzpatrick et al, 1998; Agho & Lewis, 2001. • Low levels of prostate cancer knowledge among African Americans have been correlated with their ability to recognize cancer symptoms, access to cancer screening services, late stage presentation, lack of participation in screening activities and delays in seeking care after diagnosis. • Targonski et al, 1991; Smith et al, 1997; Richardson et al, 2004; ACS, 2009; Clarke-Tasker, 2005; Forrester-Anderson, 2005; Weinrich, 2003

  25. Multi-level Intervention Framework Interdependence Model of Social Influence and Interpersonal Communication Agents of Social Influence -LHA Social Norms -Cultural norms Relationship Characteristics -Referent Power -Mutuality Communication Larger Systems -Policy and Org Target’s Health-Related Outcomes -IDM -Intentions to be screened Targets of Social Influence -AA male Sociodemographic Factors -Patient level

  26. What is community-based participatory research (CBPR)? • “a collaborative approach to research that equitably involves all partners in the research process and recognizes the unique strengths that each brings” W.K. Kellogg Foundation (2001)

  27. Community Based Participatory Framework

  28. RESEARCH SUB-PROJECT 38 • Goal: To examine the effectiveness of IDM for prostate cancer screening among African American (AA) men in usual medical care setting compared with a community based educational approach. • Multi-level Community-based educational approach- • Community Health Workers • Community settings – Barbershops, Churches, Health Fairs • Empirically tested and evaluated enhanced patient decision aid • Emerging Technology for standardized messaging *congruent with funding mechanism, each of the above components have been rigorously tested and yielded effectiveness

  29. SPECIFIC AIMS 39 Evaluate the effectiveness of the enhanced PtDA, Is the PSA Test Right for You, in the delivery of culturally, linguistically, and literacy-relevant topics on IDM to AA men. [PHASE I] Evaluate a training program for CHWs to disseminate educational messages on IDM for prostate cancer screening to AA men utilizing methods grounded in CBPR. [PHASE II] Compare the effectiveness of a community based education program guided by CHWs and an enhanced PtDA with usual care in clinical settings in the dissemination of IDM to AA men. [PHASE III]

  30. RESEARCH QUESTIONS 40 • Does the CHWs delivery model positively impact the knowledge of AA men related to prostate cancer? • Is IDM for prostate cancer screening more effective when delivered in community based programs VS. usual care? • How effective is the CHWs and an enhanced PtDA in the dissemination of IDM as compared to usual care? • Hypothesis: “Usual Care” clinical processes are less effective than CHWs using PtDA video iPADs in the delivery of culturally, linguistically and literacy-relevant prostate cancer screening IDM topics to African American men.

  31. Study Overview PHASE I (Months 0-6) PHASE II (Months 0-6) PHASE III (Months 6-18) Qualitative Methods Train-the-Trainer Modules Quantitative Methods Focus Groups (2) with AA men (N=16-20 ) Community Health Worker Training Workshop (Potential topics) -Understanding prostate cancer -Understanding prostate cancer screening: benefits, risks, limitations, alternatives and uncertainties Quasi-Experimental Design: ## AA men -## usual care -## CHW + Enhanced Patient Decision Aid Baseline Assessment: -Demographics -Outcome Measures Follow-up Assessment: -Outcome Measures (2 weeks post intervention) & (6 months post intervention) Analysis Integrate Information obtained from focus groups Focus Groups (2) with African American from the target community (N=10-14) Augment the patient Decision Aid (Convert the DVD to digital interfaces (podcast) Evaluation of Training Workshop Pre- and Post-test Design Pre-testing iterations of the enhanced patient Decision Aid -Understandability -Cultural/Linguistic relevancy -Appeal, self efficacy, usability

  32. Phase IAim 1. To evaluate the effectiveness of the enhanced PtDA in the delivery of culturally, linguistically and literacy-relevant topics on IDM to AA men

  33. Formative Research Inform the adaptation of the PtDA Conduct pre-testing iterations of the enhanced PtDA Consult with medical and technological experts METHODS Focus Groups Pre-testing Iteration Learner Verification

  34. Who Participated? • 18 Black men • AGE: 41 to 65 years (average=48.5) • REGION: 33.3% (6) from St. Pete, 66.7% (12) from Tampa • MARITAL STATUS: 72.2% (13) married, 16.7% (3) divorced, 11.1% (2) never married • EDUCATION: 61.1% (11) high school; 22.2% (4) bachelors; 11.1% (2) some college/associates; 5.6% (1) <high school • SCREENING: 38.9% (7) previously screened for prostate cancer Comparative Effectiveness Research for Eliminating Disparities (CERED)

  35. Key Themes • Sources of Health Information • Trustworthiness • Sharing of Information in the Community • Important Issues about Prostate Cancer • Current Knowledge about Prostate Cancer • Barriers and Benefits to Prostate Cancer Screening • Cultural Issues • Informed Decision Making Comparative Effectiveness Research for Eliminating Disparities (CERED)

  36. Sources of Health Information: • Multiple reported sources of health information/prostate cancer information: • physicians/health care providers • internet, television programs • friends/peers with previous experience • trusted friends/family members (e.g., wife) Comparative Effectiveness Research for Eliminating Disparities (CERED)

  37. Trustworthiness of Information: • Information should come from a person who is trusted due to their relationship (e.g., wife, friend, family member) or their skills or training (doctor) • However, there were mixed results regarding trusting doctors – some stated that with their advanced studies and training, they should know what they’re talking about, but other stated that you still have to double-check information Comparative Effectiveness Research for Eliminating Disparities (CERED)

  38. Knowledge about Prostate Cancer: • Although all of the participants had heard of prostate cancer, very few had any knowledge of prostate cancer • Some had heard about screening and treatment but did not know much about what this meant or included • Some knew that prostate cancer was more prevalent among Black men and older men Comparative Effectiveness Research for Eliminating Disparities (CERED)

  39. Cultural Issues: • Socio-cultural norms and beliefs must be addressed with Black men • not going to the doctor • homophobia • cultural relevance/understanding of spokespersons/peer educators • “I just think…you have culture and other factors that are not dealt with in this video. I think culture is a big one.” • “My understanding is culturally there are various things that can affect prostate.” Comparative Effectiveness Research for Eliminating Disparities (CERED)

  40. Informed Decision Making: • Many participants identified need to make own decision regarding screening due to multiple lifestyle and personal factors that vary from person to person • Concern about the uncertainty of outcomes (i.e., quality of life) associated with prostate cancer screening and treatment, as well as costs • Recommendation that wife and family members be involved in decision-making process Comparative Effectiveness Research for Eliminating Disparities (CERED)