Faculty Bibliography

BACKGROUND:Black men are underrepresented in hypertension trials, even though this population has higher prevalence and more adverse sequelae from hypertension, compared to other groups. In this article we present recruitment and community engagement strategies for the Community-to-Clinic Linkage Implementation Program (CLIP), a cluster-randomized trial on hypertension prevention among Black men. METHODS:Using a 2-stage recruitment process: 1) we enrolled Black-owned barbershops from zip-codes with high hypertension prevalence; and 2) recruited Black male participants who fulfilled the eligibility criteria and were customers of the barbershops. Barbershop and participant recruitment was conducted by a partner community-based organization. RESULTS:The study met the recruitment goals for barbershop enrollment (N=22) and individual participants. Of eligible individuals (N=461), 430 enrolled in the study (93% consent rate, exceeding the original enrollment goal of N=420 participants). Throughout recruitment, the study team conducted 101 unique engagements (41 prior to recruitment, 60 during recruitment), totaling engagement with180 partners across all events, including individual and group meetings, attendance at community events, and educational presentations. In addition to a primary partner community organization, the study team collaborated with a Community Advisory Council, comprised of residents, and civic and community leaders, and with the local health department and varied other organizations. CONCLUSIONS:In CLIP, a high number of academic-community engagement encounters and close collaboration with community partners contributed to successful recruitment of Black men at risk for hypertension and with adverse social determinants. Our experience may serve as to inform investigators focused on recruiting underserved populations in hypertension research trials.

INTRODUCTION/BACKGROUND:Implicit bias can influence patient-clinician communication through clinician implicit bias (actual) or patients' perception of bias (perceived). Few curricula focus on skills to address implicit bias. We developed and evaluated a skills-based curriculum addressing implicit bias in clinical encounters. MATERIALS & METHODS/METHODS:A 60-minute session was delivered to 4 cohorts of learners (N = 458, ranging from first-year medical students to attendings) in academic medical settings. All had prior exposure to the topic of implicit bias. Instruction grounded in the Implicit Bias Recognition and Management framework described the impact of actual and perceived bias and patients' recommendations for restoring rapport once bias had impacted an encounter. Through audience response systems or role-plays with feedback, participants developed verbal procedures-personalized, verbatim statements to restore patient rapport when implicit bias has impacted an encounter. Learners submitted their verbal procedures online, which were then coded to identify helpful and unhelpful elements. Investigators coded verbal procedures and assigned point values for "helpful" and "unhelpful" elements resulting in scores from -1-6. RESULTS:Each approach yielded helpful elements. Overall, of submitted verbal procedures, 91.3 % were "helpful" and 8.6 % "unhelpful." Compared to audience response systems, verbal procedures developed through role-plays included significantly more "helpful" elements (2.21/1.29, p = 0.003 and 2.46/1.87 p = 0.009). CONCLUSIONS:Findings suggest learners can develop verbatim statements to restore rapport with patients in a single session if those learners have prior foundational knowledge about implicit bias and its relevance to healthcare disparities. PRACTICE IMPLICATIONS/CONCLUSIONS:Teaching verbal procedures could expand skill-building opportunities within implicit bias curricula.

BACKGROUND:Unmet structural and social needs create barriers to breast cancer screening and treatment. The impact of the intersection of these barriers on screening participation and timeliness of breast cancer care remains poorly understood. METHODS:People identifying as women participating in a breast cancer navigation program for screening or treatment were included. Patient navigators administered survey questions that addressed potential barriers to care access using the Health Leads Screening Toolkit. Odds ratios were calculated for unadjusted bivariate associations, and Cox proportional hazards were used to examine the relationship between barriers and time to treatment. RESULTS:A total of 2804 women (mean age, 53 years) enrolled in navigation for screening or cancer treatment participated in the survey about barriers to care. Of those, 435 (16%) reported unstable housing, 610 (23%) reported poor health literacy, and 164 (6%) reported feeling depressed. Limited transportation was significantly associated with unstable housing (odds ratio [OR] = 26.5, 95% confidence interval [CI] 19.9-35.4, p < 0.00001), poor health literacy (OR = 11.5, 95% CI 9.3-14.2, p < 0.0001), and depression (OR = 2.9, 95% CI 2.1-4.0, p < 0.00001). Individual barriers were not associated with a longer time to treatment, but an increasing number of barriers was associated with a longer time to treatment (Coef = 0.9, p < 0.05). CONCLUSIONS:Compounding structural and social barriers limit participation in breast cancer screening, and women with increasing unmet social needs face delays in treatment for breast cancer. Navigation programs may help women overcome barriers to care; however, understanding and targeting the intersectionality of unmet needs is essential for targeted interventions through breast cancer care navigation programs to be effective.

Social determinants of health (SDoH), health care use, and cardiovascular disease (CVD) risk perception are understudied among men who identify as Black and Hispanic. In this study we sought to describe these factors among a cohort of urban-residing Black men, participants in a community-engaged trial on hypertension prevention. We focused on presenting intermediary SDoH, including material circumstances, health behaviors, and psychosocial factors, which allow for a more robust understanding of health inequities but are underexplored. We analyzed baseline trial data (N=430) and compared subgroups (44% of participants self-identified as having Hispanic ethnicity and a Black racial identity). Average age was 38 years, with mean blood pressure of 129/83 mmHg. Hispanic Black (HB) men reported higher unemployment (21.4% versus 11.1%, P=.02) and more housing instability (28.7% versus 18.6%, P=.01) than did non-Hispanic Black (NHB) men. Overall, HB men reported worse household conditions compared with NHB men. Approximately half of both groups reported high stress, 45% (HB) and 51% (NHB), respectively. Both groups had low perception of personal CVD risk and underutilized health care. Hispanic Black men were less likely to have a primary care provider than were NHB men (17.6% versus 29.3%, P<.001). Non-Hispanic Black men reported lower physical activity than did HB men (median, 2655 vs 2547 metabolic equivalent minutes/week, P=.03). Recognizing heterogeneity among Black populations, including in social drivers of CVD disparities, will allow for more precision in designing CVD health promotion interventions. Findings also suggest that perception of personal CVD risk and health care utilization may be important targets for CVD prevention in Black men.

Minoritized communities often experience worse health outcomes on the cancer continuum. Mainstream strategies may have limited reach and utility to populations experiencing inequities in real-world settings. Through the combined use of community-based participatory research (CBPR) and social marketing strategies, which highlight community-centered and culturally adapted processes, we provide an approach to inform future intervention research across various health topics that has been successful in engaging minoritized and understudied communities. We present two case studies that used participatory social marketing principles to culturally adapt evidence-based cancer screening programs for two communities in New York City. The first program is a campaign to increase screening and vaccination for hepatitis B among Korean and Chinese American immigrants. The second is a culturally adapted program to increase breast and cervical cancer screening among a multiracial and ethnic population of Muslim women. These case studies illustrate the benefits of integrating social marketing and CBPR approaches as a key strategy when developing public health campaigns to effectively reach and influence health behaviors in partnership with communities that have been socially marginalized and historically underserved.

Prostate-specific antigen (PSA)-based prostate cancer screening is a preference-sensitive decision for which experts recommend a shared decision making (SDM) approach. This study aimed to examine PSA screening SDM in primary care. Methods included qualitative analysis of audio-recorded patient-provider interactions supplemented by quantitative description. Participants included 5 clinic providers and 13 patients who were: (1) 40-69 years old, (2) Black, (3) male, and (4) attending clinic for routine primary care. Main measures were SDM element themes and "observing patient involvement in decision making" (OPTION) scoring. Some discussions addressed advantages, disadvantages, and/or scientific uncertainty of screening, however, few patients received all SDM elements. Nearly all providers recommended screening, however, only 3 patients were directly asked about screening preferences. Few patients were asked about prostate cancer knowledge (2), urological symptoms (3), or family history (6). Most providers discussed disadvantages (80%) and advantages (80%) of PSA screening. Average OPTION score was 25/100 (range 0-67) per provider. Our study found limited SDM during PSA screening consultations. The counseling that did take place utilized components of SDM but inconsistently and incompletely. We must improve SDM for PSA screening for diverse patient populations to promote health equity. This study highlights the need to improve SDM for PSA screening.

BACKGROUND:Colorectal cancer (CRC) is the second most lethal cancer in the United States (U.S.) with the highest incidence and mortality rates among African Americans (AAs) compared to other racial groups. Despite these disparities, AAs are the least likely to undergo CRC screening, have precancerous colorectal polyps removed, and have CRC detected at stages early enough for curative excision. In addition, compelling evidence links inflammatory dietary patterns to increased CRC and cardiovascular disease risk. Studies show that AA churches can successfully engage in health promotion activities including those related to cancer control. The current study seeks to leverage church-placed Community Health Workers (CHWs) to increase CRC screening and reduce CRC risk. DESIGN AND METHODS/METHODS:We aim to (1) increase guideline concordant CRC screening uptake using church-placed CHWs trained in screening with a validated instrument, Brief Intervention using Motivational Interviewing, and Referral to Treatment (SBIRT); and (2) reduce dietary risk factors (inflammatory dietary patterns) linked to CRC. The latter will be addressed by culturally adapting an existing, web-based lifestyle program called Alive!. Using a Hybrid Type 1 Implementation-Effectiveness cluster randomized design, we will randomize 22 AA churches into either the dual intervention arm (CHW-led SBIRT intervention plus Alive!) or a usual care arm comprised of CRC prevention educational pamphlets and a list of CRC screening sites. We will recruit 440 subjects and evaluate the effects of both arms on screening uptake (colonoscopy, fecal DNA) (primary outcome) and dietary inflammation score (secondary outcome) at 6-month follow-up, and Life Simple7 (LS7)-a cardiovascular disease (CVD) risk score-at 6 months and 1 year (secondary outcome). Finally, guided by a racism-conscious adaptation of the Consolidated Framework for Implementation Research (CFIR), we will conduct a mixed-methods process evaluation with key stakeholders to understand multi-level influences on CRC screening and CVD risk behaviors. DISCUSSION/CONCLUSIONS:Church-placed CHWs are trusted influential connectors between communities and health systems. Studies have shown that these CHWs can successfully implement health prevention protocols in churches, including those related to cancer control, making them potentially important community mediators of CRC screening uptake and CRC/CVD risk reduction. TRIAL REGISTRATION/BACKGROUND:, 2023.

PURPOSE/UNASSIGNED:Although the majority of US adults obtain health information on the internet, the quality of information about prostate cancer is highly variable. Black adults are underrepresented in online content about prostate cancer despite a higher incidence of and mortality from the disease. The goal of this study was to explore the perspectives of Black patients with prostate cancer on the importance of racial representation in online content and other factors influencing trust. MATERIALS AND METHODS/UNASSIGNED:We conducted 7 virtual focus groups with Black patients with prostate cancer in 2022 and 2023. Participants completed an intake questionnaire with demographics followed by a group discussion, including feedback on purposefully selected online content. Transcripts were independently analyzed by 2 investigators experienced in qualitative research using a constant comparative method. RESULTS/UNASSIGNED:Most participants use online sources to look for prostate cancer information. Racial representation is an important factor affecting trust in the content. A lack of Black representation has consequences, including misperceptions about a lower risk of prostate cancer and discouraging further information-seeking. Other key themes affecting trust in online content included the importance of a reputable source of information, professional website structure, and soliciting money. CONCLUSIONS/UNASSIGNED:Underrepresentation of Black adults in prostate cancer content has the potential to worsen health disparities. Optimal online communications should include racially diverse representation and evidence-based information in a professional format from reputable sources without financial conflict.