Education is an essential component of the national blueprint to eliminate cancer health disparities. Evidenced-based tools exist that can help men learn about the issues surrounding prostate cancer screening. However, many of these tools have not been evaluated for use with the subpopulations with the greatest educational needs. The purpose of this exploratory study was to examine the applicability of an evidenced-based video intervention—The PSA for Prostate Cancer: Is it right for me?—for use with African-American men with different levels of health literacy in the Greater Florida Panhandle. Results from this exploratory study suggest that the video intervention is useful for African-American men with different levels of health literacy in two counties in the Greater Florida Panhandle Region.
We first evaluated the impact of the video intervention on knowledge about issues surrounding prostate cancer screening with the PSA blood test. We found that CaP knowledge scores for the entire sample were significantly higher at posttest than at pretest. CaP knowledge scores increased for 77.6% of participants, remained the same for 14.3%, and decreased for 8.2%. This trend in short term increases in knowledge is consistent with results from other studies where the video intervention was tested.29,31–33
Some researchers have shown that knowledge gained from the intervention can endure from 2 weeks to 1 year. However, we were unable to confirm how long the knowledge gains witnessed in our sample lasted because our posttest was administered immediately following the video’s viewing.
We also explored the impact of the video intervention on PSA screening knowledge among men across different levels of health literacy. We were not surprised to find that there were positive associations between literacy level and CaP knowledge at baseline. That is, men with functional health literacy had the highest levels of CaP knowledge at pretest; men with marginal literacy had the second highest levels of CaP knowledge; and men with inadequate health literacy had the lowest levels of knowledge. Other researchers have found similar associations between health literacy and health-related knowledge with other populations in different health contexts.34,35
However, we were encouraged to discover that the video helped men in all three literacy groups learn something new. Most encouraging was the finding that men with the lowest level of health literacy had the highest gain in knowledge. Pretest-posttest knowledge differences for men with inadequate, marginal and functional health literacy were +2.05, +1.50, and +1.27, respectively.
To the best of our knowledge, this is the first instance of this video being tested with a focus on participant’s ability to comprehend messages according to health literacy status. Although health literacy has long been recognized as a key barrier to health education,36–38
cancer educators have been slow to incorporate this construct into cancer education research studies. Common reasons cited for not measuring health literacy in studies is that literacy is a sensitive topic and negative emotions (shame or embarrassment) may prevent individuals from revealing their literacy skill levels to others. Ryan et al.39
found that nearly all (98%) of the potential participants approached were willing to have their health literacy levels assessed in clinical settings. In the current study, all of the men we approached agreed to have their health literacy assessed in a community setting. Trust is critical to having an individual agree to complete a literacy assessment in any situation. There are several ways to build the trust needed to facilitate participant willingness to complete a literacy assessment. Ryan and colleagues capitalized on the trust built over time in patient-provider relationships. In our study, we established trust by including recruiters who were part of an existing community-academic partnership and by having racial concordance between our interviewers and interviewees. More research is needed to determine other situations that facilitate or inhibit the trust needed to conduct health literacy assessments in different settings.
To determine which specific CaP knowledge details the video helped participants learn, we examined changes in the proportions of correct and incorrect responses for each knowledge question at pretest and posttest. Consistent with other studies, a large portion of men in our sample had difficulty with the specific item “Prostate cancer is the MOST COMMON cause of problems with urination.
” In a sample of 1,152 veterans 50 years of age and older, Partin and colleagues31
found that slightly less than a third (32%) of participants were able to answer this question correctly after viewing the video. In our sample, only 36.8% of men were able to answer this question correctly post video viewing. More troubling was the finding that half of the men in our sample answered this question correctly at baseline but incorrectly on the posttest.
After reviewing the video again, our team discovered a clip where prostate cancer complications are listed and “difficulty urinating” is listed first with “pain,” “weight loss,” and “death” following, respectively. Perhaps, men watching this video interpret the placement of “difficulty urinating” at the top of this list to mean that prostate cancer is the MOST COMMON cause of problems with urination. We do not believe this finding invalidates the utility of the video but it does indicate that problems may arise if the video is shown without a period of facilitated discussion. Recognizing that facilitated discussion may not always be possible after the video is shown, we suggest that the developers of this video conduct additional research with men to find more effective ways to state this important piece of information in future versions.
In addition to the study findings mentioned above, there are several limitations to this research that must be acknowledged. The first limitation is that a convenience sampling strategy was employed. The use of this type of sampling scheme limits the external validity of our findings to men whose characteristics are similar to those of this study’s population. While convenience sampling was appropriate for our exploratory investigation to assess the usefulness of the intervention with African-American men in a small geographic area, future research should be conducted with larger samples of African-American men using a random sampling strategy. The quasi-experimental, one group pretest-posttest group design is suboptimal and does not allow us to rule out known threats to internal validity (i.e. instrumentation and testing). PSA screening was assessed but not verified through individual chart reviews. The absence of an additional follow up period limited our ability to determine any effects of the intervention on long term behaviors—talking with a physician or undergoing future PSA testing. We believe these are important outcomes and future studies should seek to evaluate how the intervention influences these behaviors. Finally, the results of this study are based on self report. Thus, problems that are inherent in studies relying on self-reported data collection (e.g., recall bias, social desirability) also apply here.
Using evidenced-based interventions with different populations is an efficient use of limited resources and an effective way to accelerate the nation’s health disparities research agenda. Our findings regarding the intervention’s effect on men’s CaP screening knowledge and participant’s positive evaluations of the information presented in the video suggest that this intervention is useful for African-American men with different levels of health literacy. The next step of this research is to conduct longitudinal studies with larger samples of African-American men to determine the intervention’s long term effects on knowledge, intentions to be screened and actual CaP screening behavior.