Due to disparities in the use of genetic services, there has been growing interest in examining beliefs and attitudes related to genetic testing for breast and/or ovarian cancer risk among women of African descent. However, to date, few studies have addressed critical cultural variations among this minority group and their influence on such beliefs and attitudes.
We assessed ethnic, racial and cultural identity and examined their relationships with perceived benefits and barriers related to genetic testing for cancer risk in a sample of 160 women of African descent (49% self-identified African American, 39% Black-West Indian/Caribbean, 12% Black-Other) who met genetic risk criteria and were participating in a larger longitudinal study including the opportunity for free genetic counseling and testing in New York City. All participants completed the following previously validated measures: (a) the multi-group ethnic identity measure (including ethnic search and affirmation subscales) and other-group orientation for ethnic identity, (b) centrality to assess racial identity, and (c) Africentrism to measure cultural identity. Perceived benefits and barriers related to genetic testing included: (1) pros/advantages (including family-related pros), (2) cons/disadvantages (including family-related cons, stigma and confidentiality concerns), and (3) concerns about abuses of genetic testing.
In multivariate analyses, several ethnic identity elements showed significant, largely positive relationships to perceived benefits about genetic testing for breast and/or ovarian cancer risk, the exception being ethnic search, which was positively associated with cons/disadvantages, in general, and family-related cons/disadvantages. Racial identity (centrality) showed a significant association with confidentiality concerns. Cultural identity (Africentrism) was not related to perceived benefits and/or barriers.
Ethnic and racial identity may influence perceived benefits and barriers related to genetic testing for breast and/or ovarian cancer risk among at-risk women of African descent. Genetic counseling services may want to take into account these factors in the creation of culturally-appropriate services which best meet the needs of this heterogenous population.
Breast cancer; Cultural identity; Ethnic identity; Genetic testing; Racial identity
This feasibility study developed and pilot tested an intervention to: (1) increase knowledge about prostate cancer (CaP) screening; and (2) promote self-efficacy to participate in the informed decision-making (IDM) process.
African-American (AA) men are a priority audience for CaP screening interventions to promote IDM, and faith-based settings have been shown to be an effective venue to reach this population. Therefore we used predominantly AA churches to develop and test our intervention.
Participants (N=73) were recruited and the intervention was administered by an AA health educator.
We developed and pre-tested a CaP screening IDM intervention based on the Ottawa Decision Support Framework and the Health Belief Model. The intervention included a tool called the ‘Road Map’ that depicts the potential consequences of a decision to undergo, or to forgo screening. A quasi-experimental design was used to test the intervention.
Main Outcome Measures
The main outcome measures were change in knowledge and self-efficacy post intervention.
CaP knowledge (p<0.0001) and self-efficacy (p=0.025) significantly increased.
A church-based intervention delivered by anAA health educator is a promising strategy for promoting IDM among AA men.
prostate cancer screening; informed decision-making; faith-based intervention; disparities; African-American
News stories reporting race-specific health information commonly emphasize disparities between racial groups. But recent research suggests this focus on disparities has unintended effects on African American audiences, generating negative emotions and less interest in preventive behaviors (Nicholson RA, Kreuter MW, Lapka C et al. Unintended effects of emphasizing disparities in cancer communication to African-Americans. Cancer Epidemiol Biomarkers Prev 2008; 17: 2946–52). They found that black adults are more interested in cancer screening after reading about the progress African Americans have made in fighting cancer than after reading stories emphasizing disparities between blacks and whites. This study builds on past findings by (i) examining how health journalists judge the newsworthiness of stories that report race-specific health information by emphasizing disparities versus progress and (ii) determining whether these judgments can be changed by informing journalists of audience reactions to disparity versus progress framing. In a double-blind-randomized experiment, 175 health journalists read either a disparity- or progress-framed story on colon cancer, preceded by either an inoculation about audience effects of such framing or an unrelated (i.e. control) information stimuli. Journalists rated the disparity-frame story more favorably than the progress-frame story in every category of news values. However, the inoculation significantly increased positive reactions to the progress-frame story. Informing journalists of audience reactions to race-specific health information could influence how health news stories are framed.
Although prior research shows that substantial proportions of African Americans hold conspiracy beliefs, little is known about the subgroups of African Americans most likely to endorse such beliefs. We examined the relationship of African Americans' sociodemographic characteristics to their conspiracy beliefs about HIV/AIDS and birth control. Anonymous telephone surveys were conducted with a targeted random-digit-dial sample of 500 African Americans (15-44 years) in the contiguous United States. Respondents reported agreement with statements capturing beliefs in HIV/AIDS conspiracies (one scale) and birth control conspiracies (two scales). Sociodemographic variables included gender, age, education, employment, income, number of people income supports, number of living children, marital/cohabitation status, religiosity and black identity. Multivariate analyses indicated that stronger HIV/AIDS conspiracy beliefs were significantly associated with male gender, black identity and lower income. Male gender and lower education were significantly related to black genocide conspiracy beliefs, and male gender and high religiosity were significantly related to contraceptive safety conspiracy beliefs. The set of sociodemographic characteristics explained a moderately small amount of the variance in conspiracy beliefs regarding HIV/AIDS (R2 range=0.07-0.12) and birth control (R2 range=0.05-0.09). Findings suggest that conspiracy beliefs are not isolated to specific segments of the African-American population.
Radio stations that target African American audiences ("black radio") reach a national African American audience daily, making black radio an ideal medium for health promotion and disparities reduction in the African American community. Black radio can be used to communicate public health messages and to recruit African Americans into public health research.
Racial attitude characteristics of African Americans may have important implications for patient-therapist matching in substance abuse treatment. The Black Racial Identity Attitude Scale (BRIAS) is a questionnaire used to measure racial identity attitudes. This study tested the stability and internal consistency of the BRIAS in an African-American substance-abusing population. This is the first known test of the BRIAS in a clinical population. African-American veterans (n = 53) were administered the BRIAS to test for stability over time and internal consistency. Initial analysis of the instrument revealed that a majority of items were not stable over time. Using the initial results, we removed 26 problematic items. Three modified scales remained, each having marginal test-retest reliability. Two of the modified scales had moderately adequate internal consistency, and the third was minimally adequate. We found that the BRIAS did not demonstrate sufficient internal consistency or stability in this population to adequately identify the constructs of the Nigrescence Racial Identity Development theory of William Cross, Jr. There is a growing recognition of the need to explore the extent of racial, ethnic, and cultural factors in substance abuse behavior and treatment; therefore, we recommend that further attention be directed toward developing an instrument to reliably and accurately measure identity constructs among African-American clinical subjects.
In the current article, the authors examine the potential role of mind-body interventions for preventing or reducing health disparities in a specific group—African American women. The authors first discuss how health disparities affect this group, including empirical evidence regarding the influence of biopsychosocial processes (e.g., psychological stress and social context) on disparate health outcomes. They also detail how African American women's unique stress experiences as a result of distinct sociohistorical and cultural experiences related to race and gender potentially widen exposure to stressors and influence stress responses and coping behaviors. Using two independent, but related, frameworks (Superwoman Schema [SWS] and the Strong Black Woman Script [SBW-S]), they discuss how, for African American women, stress is affected by “strength” (vis-à-vis resilience, fortitude, and self-sufficiency) and the emergent health-compromising behaviors related to strength (e.g., emotional suppression, extraordinary caregiving, and self-care postponement). The authors then describe the potential utility of three mind-body interventions—mindfulness-based stress reduction (MBSR), loving-kindness meditation (LKM), and NTU psychotherapy—for specifically targeting the stress-, strength-, and contextually related factors that are thought to influence disparate outcomes for African American women. Self-awareness, self-care, inter- and intrapersonal restorative healing and a redefinition of inner strength may manifest through developing a mindfulness practice to decrease stress-related responses; using LKM to cultivate compassion and forgiveness for self and others; and the balance of independence and interdependence as a grounding NTU principle for redefining strength. The authors conclude with a discussion of potential benefits for integrating key aspects of the interventions with recommendations for future research.
mind-body; CAM; African American women; stress; health disparities; strength; MBSR; loving-kindness; NTU
African-American women have the highest breast cancer death rates of all racial/ethnic groups in the US. Reasons for these disparities are multi-factorial, but include lower mammogram utilization among this population. Cultural attitudes and beliefs, such as fear and fatalism, have not been fully explored as potential barriers to mammography among African-American women.
To explore the reasons for fear associated with breast cancer screening among low-income African-American women.
We conducted four focus groups ( = 29) among a sample of African-American women at an urban academic medical center. We used trained race-concordant interviewers with experience discussing preventive health behaviors. Each interview/focus group was audio-taped, transcribed verbatim and imported into Atlas.ti software. Coding was conducted using an iterative process, and each transcription was independently coded by members of the research team.
Several major themes arose in our exploration of fear and other psychosocial barriers to mammogram utilization, including negative health care experiences, fear of the health care system, denial and repression, psychosocial issues, delays in seeking health care, poor health outcomes and fatalism. We constructed a conceptual model for understanding these themes.
Fear of breast cancer screening among low-income African-American women is multi-faceted, and reflects shared experiences within the health care system as well as the psychosocial context in which women live. This study identifies a prominent role for clinicians, particularly primary care physicians, and the health care system to address these barriers to mammogram utilization within this population.
breast cancer; mammography; African-Americans; barriers to healthcare
Recent reports suggest that providers’ implicit attitudes about race contribute to racial and ethnic health care disparities. However, little is known about physicians’ implicit racial attitudes. This study measured implicit and explicit attitudes about race using the Race Attitude Implicit Association Test (IAT) for a large sample of test takers (N = 404,277), including a sub-sample of medical doctors (MDs) (n = 2,535). Medical doctors, like the entire sample, showed an implicit preference for White Americans relative to Black Americans. We examined these effects among White, African American, Hispanic, and Asian MDs and by physician gender. Strength of implicit bias exceeded self-report among all test takers except African American MDs. African American MDs, on average, did not show an implicit preference for either Blacks or Whites, and women showed less implicit bias than men. Future research should explore whether, and under what conditions, MDs’ implicit attitudes about race affect the quality of medical care.
Racial and ethnic health care disparities; implicit and explicit attitudes about race; physician racial bias; physicians; gender; race; ethnicity
The purpose of this study was to examine African Americans’ lay beliefs and attributions toward suicide. The Attitudes Toward Suicide Scale, Life Ownership Orientation Questionnaire, Stigma Questionnaire, and Suicide Ideation Questionnaire were administered to 251 undergraduate college students. Beliefs about stigma associated with suicide were comparable across ethnic groups. However, African American college students were significantly less likely than European American college students were to attribute suicide to interpersonal problems and to report that the individual or government is responsible for life. African American students were significantly more likely to report that God is responsible for life. These findings have important implications for suicide risk and also for developing culturally appropriate interventions.
lay theory; suicide; beliefs; attributions; African American
The under-representation of racial/ethnic minorities among medical research participants has recently resulted in mandates for their inclusion by the National Institutes of Health (NIH). Therefore, there is a need to determine how history, attitudes, cultural beliefs, social issues, and investigator behavior affect minority enrollment in medical research studies. From January 1998 to March 1999, 179 African-American and white residents of the Detroit Primary Metropolitan Statistical Area (PMSA) participated in a mail and telephone survey designed to examine impediments to African-American participation in medical research studies. Chi-square tests were performed to assess differences between the study groups using the Survey Data Analysis Program (SUDAAN). Eighty-one percent of African Americans and 28% of whites had knowledge of the Tuskegee Study (p = <0.001). Knowledge of the Tuskegee Study resulted in less trust of researchers for 51% of African-Americans and 17% of whites (p = 0.02). Forty-six percent of African-Americans and 34% of whites indicated that their knowledge of the study would affect future research participation decisions (p = 0.25). Of these, 49% of African-Americans and 17% of whites would not be willing to participate in future medical research studies (p = 0.05). This study confirms the need for medical researchers to confront the issue of the Tuskegee Study and its continuing impact on African-Americans' trust of medical research studies.
This study identifies unique psychosocial characteristics among African American men that put the men at risk for non-adherence to colorectal cancer (CRC) screening (colonoscopy, sigmoidoscopy and FOBT). Subgroups sharing similar psychosocial characteristics may be targeted with specific intervention strategies aimed at increasing participation in screening, which could lead to increased early detection and decreased morbidity and mortality.
The male, African American veterans in our sample (n=260) had a mean age = 57.3 (SD=7.3). Our study employs latent class analysis (LCA), a quantitative-based, audience segmentation method to identify homogeneous subgroups of African American men with similar psychosocial characteristics related to CRC screening, potentially in need of different health information and intervention strategies. Latent class regression was used to examine the relationships among latent class structure and demographic characteristics.
There were four psychosocial risk classes across the three screening tests. A significant subset of men had psychosocial characteristics indicative of willingness to be screened for each test (Colonscopy=21.8%, Sigmoidoscopy=31.5%, FOBT=10.8%), although they were currently non-adherent. Men who received a past screening test, had greater than a high school education, or were married were more likely to be represented in a latent class indicative of being prepared for getting colonoscopy or sigmoidoscopy. Socio-demographic variables were unrelated to FOBT latent class structure.
Segmenting our sample of male African American veterans based on psychosocial risk characteristics can inform the development of more precisely targeted interventions for African American men who are non-adherent for CRC screening.
Colorectal cancer screening; Latent Class Analysis; Black men
One of the major health disparities in the African-American population is the high incidence of underdiagnosed cardiovascular disease prior to onset of symptoms. Cardiovascular diseases are one of the chief causes of decreased longevity, reduced quality of life, and poor treatment outcomes among African Americans. The Church-Based Heart Health Project, a pilot initiative of Kaiser Permanente (KP) Ohio's Center of Excellence for Health Disparities and Cultural Competency for African American Health, was implemented in 2004 as an innovative and proactive response to confront this cardiovascular health disparity in greater Cleveland's African-American population. The goal of this program was to reduce individual participants' risks for cardiac events (that is, heart attack, heart disease, or cardiac death) by 1) providing individual risk assessment and interpretation and 2) cataloging the generalized health status of urban churchgoing African Americans in greater Cleveland. We describe the cardiovascular risk factors present in a random population of urban churchgoing African Americans participating in sponsored health screenings at their church. A convenience sample of 144 African-American adults participated in this study. Twenty-five percent (37) were men and 75% (107) were women, and participants' mean age was 54.2 years. Ninety percent were not members of KP Ohio. Cardiovascular risk factors measured included body mass index, lipid levels (cholesterol, high-density lipoprotein, low-density lipoprotein, triglycerides), blood pressure, brief health history, Framingham Coronary Heart Disease Prediction Score, and National Heart, Lung, and Blood Institute prediction score for ten-year risk. A large portion of the population was found to have at least one risk factor for coronary heart disease (CHD).
An adequate blood supply depends on volunteer non-remunerated blood donors. African Americans have lower blood donation rates than whites. To improve African American blood donation rates, the motivators and barriers to African Americans must be explored. To study the differences in motivators and barriers to blood donation between donor and non-donor African American college students.
African Americans college students at two Historically Black Colleges and Universities completed a 41-item, self-administered questionnaire, which assessed participant’s donation frequency, motivators and barriers toward donation, and knowledge and beliefs towards blood donation.
364 primarily female college students (96% African Americans, 93% female) completed the questionnaire. 49% reported prior blood donation experience (donors) and 51% were non-donors. The primary motivator for donors and non-donors was convenience (89% donor, 82% non-donor). Donors were more likely than non-donors to disagree with statements regarding blood donation as being too painful (82% donor, 44% non-donor), resulting in feeling faint, dizzy, or nauseated (61% donor, 29% non-donor). Donors more often agreed that the blood supply is safe (77% donor, 58% non-donor), less often concerned about receiving a transfusion (61% donor, 73% non-donor), and more often aware of local blood shortages (50% donor, 35% non-donor).
African Americans female college students are willing to donate blood given convenience and support from their university. Educational campaigns to increase knowledge regarding the safety of the blood donation process and the ongoing needs of an adequate blood supply might be effective methods to increase blood donation.
More than 60% of African American adults do not meet recommendations for moderate physical activity. We sought to discover the extent to which health attitudes and beliefs are associated with leisure-time physical activity in this population.
African American adults were asked about their health attitudes and beliefs during a national survey.
Participants were 807 African American men and women aged 18 years and older. Random-digit dialing was employed, sampling telephone numbers by geographical region, area code, and population size.
Main Outcome Measures
Participants were asked six health belief questions on the importance of exercise and body weight in health. Logistic regression was used to determine which of these factors were associated with physical activity participation.
The percent of respondents participating in some form of physical activity during the past month was 87.1% in men and 82.9% in women. Factors associated with previous month physical activity in men were perceived personal importance of exercise (p<0.001) and necessity of exercise for health (p=0.018). In women, perceived personal importance of exercise (p<0.001), necessity of exercise for health (p= 0.006), and having enough activity space (p=0.017) were associated with physical activity participation.
Though the direction of causation is unknown, having the attitude that it is important to exercise or be physically active for health predicts physical activity participation in both African American men and women. Creating a sense of importance of physical activity to relieve stress and foster good health may stimulate physical activity participation in African American adults.
physical activity; African American; attitudes; beliefs; survey
PURPOSE: Prostate cancer provides the most dramatic evidence of cancer disparities based on race and ethnicity among U.S. men. African-American men still hold a commanding lead in both prostate cancer incidence and mortality, particularly among those of low socioeconomic status (SES) and the medically underserved. Therefore, the need for early intervention persists. The purpose of this exploratory pilot study was to: a) assess the knowledge of a cohort of low-SES African-American men regarding prostate health/prostate cancer, and b) uncover myths/misinformation as barriers to prostate health decisions and behaviors. PROCEDURES: Asymptomatic African-American men participated in focus groups to candidly discuss: a) health concerns, b) prostate health, c) prostate cancer screening, diagnosis and treatment, and d) factors influencing prostate health decisions/behaviors. FINDINGS: Participants revealed sociocultural and psychological barriers: myths and lack of accurate/adequate knowledge about prostate health and cancer, fear, denial and apathy. CONCLUSIONS: These findings suggest factors that may explain the reluctance and limited participation in prostate health and prostate cancer services among medically underserved, socioeconomically disadvantaged, African-American men. Lack of knowledge, which affects all barriers to care, is amenable to change. Therefore, improvements in prostate cancer outcomes are achievable through culturally and linguistically appropriate health education tailored to their specific needs.
Based on the latest available data, African Americans are faced with persistent, or worsening, wide and deep, race-based health disparities compared to the white or general population as we enter the new millennium. These disparities are a 382-year continuum. There have been two periods of health reform specifically addressing the correction of race-based health disparities. The first period (1865-1872) was linked to Freedmen's Bureau legislation and the second (1965-1975) was a part of the Black Civil Rights Movement. Both had dramatic and positive effects on black health status and outcome, but were discontinued too soon to correct the "slave health deficit." Although African-American health status and outcome is slowly improving, black health has generally stagnated or deteriorated compared to whites since 1980. There is a compelling need for a third period of health reform accompanied by a cultural competence movement to address and correct persistent, often worsening, race-based health disparities.
African-American women are disproportionately affected by HIV, accounting for 60% of all cases among women in the United States. Although their race is not a precursor for HIV, the socioeconomic and cultural disparities associated with being African American may increase their risk of infection. Prior research has shown that interventions designed to reduce HIV infection among African-American women must address the life demands and social problems they encounter. The present study used a qualitative exploratory design to elicit information about strategies to prevent HIV transmission among young, low-income African-American women.
Twenty five low income African American women, ages 18–29, participated in five focus groups of five women each conducted at a housing project in Houston, Texas, a large demographically diverse metropolitan area that is regarded as one of the HIV/AIDS epicenters in the United States. Each group was audiotaped, transcribed, and analyzed using theme and domain analysis.
The participants revealed that they had most frequently placed themselves at risk for HIV infection through drugs and drinking and they also reported drug and alcohol use as important barriers to practicing safer sex. The women also reported that the need for money and having sex for money to buy food or drugs had placed them at risk for HIV transmission. About one-third of the participants stated that a barrier to their practicing safe sex was their belief that there was no risk based on their being in a monogamous relationship and feeling no need to use protection, but later learning that their mate was unfaithful. Other reasons given were lack of concern, being unprepared, partner's refusal to use a condom, and lack of money to buy condoms. Finally, the women stated that they were motivated to practice safe sex because of fear of contracting sexually transmitted diseases and HIV, desire not to become pregnant, and personal experience with someone who had contracted HIV.
This study offers a foundation for further research that may be used to create culturally relevant HIV prevention programs for African-American women.
African Americans; women; HIV; AIDS; Risk behaviors; Intervention.
Higher rates of attrition in health research have been reported for African Americans (AAs). However, little is known about which AAs are more prone to drop out and why. One potential predictor that has not been explored is Ethnic Identity (EI). This study examined the association between EI and loss-to-follow-up among AAs enrolled in a health promotion intervention to increase fruit and vegetable intake.
Five hundred and sixty AA adults from two integrated health care delivery systems in Atlanta and Detroit were enrolled into a randomized intervention trial. At baseline, all participants were classified into six EI core groups: Afrocentric, Black American, Bicultural, Multicultural, Assimilated, and High Cultural Mistrust. We examined loss-to-follow-up rates by these EI type.
Overall, 92 participants (16%) were lost to follow up. Loss-to-follow-up rates were higher among those classified as Afrocentric (24%) than those without an Afrocentric identity (13%). After adjustment for covariates, Afrocentric participants were 1.9 times (CI: 1.1 – 3.6) more likely to be lost to follow up than participants without this identity type.
Assessing EI of AAs in research studies may help identify groups at risk for dropout and/or non-response.
Ethnic identity; African American; tailored health communication
Compared to published norms, African Americans endorse significantly more items intended to assess pathological anxiety about contamination on self-report instruments for obsessive-compulsive disorder. The current study suggests this is not due to greater psychopathology in African Americans, but rather to differences in normal attitudes about cleanliness that also influence responses to items intended to assess anxiety pathology. Contamination items from OCD scales including the Padua Inventory (Behav Res Ther. 26:2 (1988) 169) were supplemented with cleanliness attitude items and administered to Black and White participants (N=1483). An exploratory factor analysis suggested a three-factor solution: one factor that encompassed pathological anxiety, and two that expressed attitudes about cleanliness, grooming, and domestic animals. African Americans scored significantly higher on all three factors. A confirmatory factor analysis demonstrated that the difference between Black and White participants on the pathological anxiety factor was eliminated when differences on the attitude factors were controlled statistically.
factor analysis; assessment; obsessive-compulsive disorder; ethnic differences; contamination; anxiety; attitudes
To explore colorectal cancer (CRC) screening knowledge, attitudes, barriers, and preferences among urban African Americans as a prelude to the development of culturally appropriate interventions to improve screening for this group.
Qualitative focus group study with assessment of CRC screening preferences.
Community health center serving low-income African Americans.
Fifty-five self-identified African Americans over 40 years of age.
MEASUREMENTS AND MAIN RESULTS
Transcripts were analyzed using an iterative coding process with consensus and triangulation on final thematic findings. Six major themes were identified: (1) Hope—a positive attitude toward screening, (2) Mistrust—distrust that the system or providers put patients first, (3) Fear—fear of cancer, the system, and of CRC screening procedures, (4) Fatalism—the belief that screening and treatment may be futile and surgery causes spread of cancer, (5) Accuracy—a preference for the most thorough and accurate test for CRC, and (6) Knowledge—lack of CRC knowledge and a desire for more information. The Fear and Knowledge themes were most frequently noted in transcript theme counts. The Hope and Accuracy themes were crucial moderators of the influence of all barriers. The largest number of participants preferred either colonoscopy (33%) or home fecal occult blood testing (26%).
Low-income African Americans are optimistic and hopeful about early CRC detection and believe that thorough and accurate CRC screening is valuable. Lack of CRC knowledge and fear are major barriers to screening for this population along with mistrust, and fatalism.
colorectal cancer; screening; African American; minority; qualitative
Several studies document disparities in access to care and quality of care for depression for African Americans. Research suggests that patient attitudes and clinician communication behaviors may contribute to these disparities. Evidence links patient-centered care to improvements in mental health outcomes; therefore, quality improvement interventions that enhance this dimension of care are promising strategies to improve treatment and outcomes of depression among African Americans. This paper describes the design of the BRIDGE (Blacks Receiving Interventions for Depression and Gaining Empowerment) Study. The goal of the study is to compare the effectiveness of two interventions for African-American patients with depression--a standard quality improvement program and a patient-centered quality improvement program. The main hypothesis is that patients in the patient-centered group will have a greater reduction in their depression symptoms, higher rates of depression remission, and greater improvements in mental health functioning at six, twelve, and eighteen months than patients in the standard group. The study also examines patient ratings of care and receipt of guideline-concordant treatment for depression.
A total of 36 primary care clinicians and 132 of their African-American patients with major depressive disorder were recruited into a cluster randomized trial. The study uses intent-to-treat analyses to compare the effectiveness of standard quality improvement interventions (academic detailing about depression guidelines for clinicians and disease-oriented care management for their patients) and patient-centered quality improvement interventions (communication skills training to enhance participatory decision-making for clinicians and care management focused on explanatory models, socio-cultural barriers, and treatment preferences for their patients) for improving outcomes over 12 months of follow-up.
The BRIDGE Study includes clinicians and African-American patients in under-resourced community-based practices who have not been well-represented in clinical trials to improve depression care. The patient-centered and culturally targeted approach to depression care is a relatively new one that has not been tested in most previous studies. The study will provide evidence about whether patient-centered accommodations improve quality of care and outcomes to a greater extent than standard quality improvement strategies for African Americans with depression.
We report the first multisite, multicomponent community intervention trial to focus on cancer prevention in African Americans. The project explored the potential of historically black medical schools to deliver health information to their local communities and used a community-based participatory research approach. The intervention consisted of culturally sensitive messages at appropriate educational levels delivered over an 18-month period and tested in predominantly black census tracts in Nashville, TN and Atlanta, GA. Chattanooga, TN and Decatur, GA served as comparison cities. Results were evaluated by pre- and postintervention random-digit dial telephone surveys. The intervention cities showed an increase in reported contact with or knowledge of the project. There was little or no effect on knowledge or attitudes in the intervention cities. Compared to Chattanooga, Nashville showed an increase in percentage of women receiving Pap smears. Compared to Decatur, Atlanta showed an increase in percentage of age-appropriate populations receiving digital rectal exams, colorectal cancer screenings and mammograms. The results of this community intervention trial demonstrated modest success and are encouraging for future efforts of longer duration.
Cultural beliefs and values are thought to account for differences between African Americans and Whites in the use of advance directives and beliefs about hospice care. However, little data clarifies which beliefs and values explain these differences.
We surveyed 205 older adults (≥ age 65) who received primary care in the Duke University Health System. The survey included five scales: Hospice Beliefs and Attitudes, Preferences for Care, Spirituality, Healthcare System Distrust, and Beliefs about Dying and Advance Care Planning. Compared to Whites, African Americans were less likely to have completed an advance directive (35.5% vs. 67.4%, P<.001) and had less favorable beliefs about hospice care (Hospice Beliefs and Attitudes Scale score, P<.001). African Americans were more likely to express discomfort discussing death, want aggressive care at the end of life, have spiritual beliefs which conflict with the goals of palliative care, and distrust the healthcare system. In multivariate analyses, none of these factors alone completely explained racial differences in either possession of an advance directive or beliefs about hospice care. However, when all of these factors were combined, race was no longer a significant predictor of either of the two outcomes.
Our findings suggest that ethnicity is a marker of common cultural beliefs and values which in combination influence decision-making at the end of life. This study has implications for the design of healthcare delivery models and programs which provide culturally-sensitive end-of-life care to a growing population of ethnically diverse older adults.
race; end-of-life care; hospice; advance directives
To examine sociocultural factors that influence an informed decision about colorectal cancer (CRC) screening among African American men and women.
A medical center, a National Cancer Institute-designated comprehensive cancer center, and various social organizations and barbershops in a midwestern city of the United States.
A purposive sample of African American women (n = 65) and African American men (n = 64) aged 50 years and older.
Participants completed a self-administered survey.
Main Research Variables
Cultural identity, CRC beliefs, family support, and informed decision.
Family support was positively related to CRC beliefs among participants, and CRC beliefs were positively related to an informed decision. However, among men, family support positively related to an informed decision about CRC screening. In addition, t-test results indicated that the men and women were significantly different. Family support predicted CRC beliefs among men (p < 0.01) and women (p < 0.01). CRC beliefs predicted CRC screening informed decisions among men (p < 0.01) and women (p < 0.05). However, the accounted variance was dissimilar, suggesting a difference in the impact of the predictors among the men and women.
Family support has a significant impact on CRC beliefs about CRC screening among African Americans. However, how men and women relate to the variables differs.
Implications for Nursing
To improve CRC screening rates, informed decision-making interventions for African Americans should differ for men and women and address family support, CRC beliefs, and elements of cultural identity.