Randomized trial of a question prompt list to increase patient active participation during interactions with black patients and their oncologists

ObjectiveCommunication during racially-discordant interactions is often of poor quality and may contribute to racial treatment disparities. We evaluated an intervention designed to increase patient active participation and other communication-related outcomes during interactions between Black patients and non-Black oncologists.MethodsParticipants were 18 non-Black medical oncologists and 114 Black patients at two cancer hospitals in Detroit, Michigan, USA. Before a clinic visit to discuss treatment, patients were randomly assigned to usual care or to one of two question prompt list (QPL) formats: booklet (QPL-Only), or booklet and communication coach (QPL-plus-Coach). Patient-oncologist interactions were video recorded. Patients reported perceptions of the intervention, oncologist communication, role in treatment decisions, and trust in the oncologist. Observers assessed interaction length, patient active participation, and oncologist communication.ResultsThe intervention was viewed positively and did not increase interaction length. The QPL-only format increased patient active participation; the QPL-plus-Coach format decreased patient perceptions of oncologist communication. No other significant effects were found.ConclusionThis QPL booklet is acceptable and increases patient active participation in racially-discordant oncology interactions. Future research should investigate whether adding physician-focused interventions might improve other outcomes.Practice implicationsThis QPL booklet is acceptable and can improve patient active participation in racially-discordant oncology interactions.     

Physician overestimation of patient literacy: a potential source of health care disparities

OBJECTIVE: To investigate physician overestimation of patient literacy level in a primary care setting. METHODS: The study sample consisted of 12 non-academic primary care physicians and 100 patients from a U.S. Department of Veterans Affairs Hospital in Houston, Texas. Patient literacy level was measured on a 1-4 scale using the Rapid Estimate of Adult Literacy in Medicine (REALM). Physicians rated each patient's literacy level on a corresponding scale. Chi-square was used to test for association of patient race/ethnicity and gender with: (1) patient REALM level and (2) discrepancy between patient REALM level and physician rating of patient literacy level. RESULTS: Patient REALM level was not statistically significantly associated with patient race/ethnicity or gender. Physicians overestimated the REALM level for 54% of African American, 11% of white non-Hispanic, and 36% of other race/ethnicity patients (p<.01). CONCLUSION: Physicians commonly overestimate patients' literacy levels, and this apparently occurs more often with minority patients, and particularly with African Americans, than with white non-Hispanic patients. This discordance in estimation of patient's literacy level may be a source of disparities in health care.     

Asking questions: The effect of a brief intervention in community health centers on patient activation

Objective

To evaluate the impact of a patient activation intervention (PAI) focused on building question formulation skills that was delivered to patients in community health centers prior to their physician visit.

Methods

Level of patient activation and patient preferred role were examined using the patient activation measure (PAM) and the patient preference for control (PPC) measure.

Results

More of the 252 patients evaluated were at lower levels of activation (PAM levels 1 or 2) than U.S. population norms before the intervention. Paired-samples t-test revealed a statistically significant increase from pre-intervention to post-visit PAM scores. One-third of participants moved from lower levels of activation to higher levels (PAM levels 3 or 4) post-intervention. Patients preferring a more passive role had lower initial PAM scores and greater increases in their post-intervention PAM scores than did those who preferred a more active role.

Conclusion

Patients exposed to the PAI demonstrated significant improvement on a measure of activation. The PAI may be useful in helping patients prepare for more effective encounters with their physicians.

Practice implications

The PAI was feasible to deliver in the health center setting and may be a useful method for activating low-income, racial/ethnic minority patient populations.     

Class, race, ethnicity and information needs in post-treatment cancer patients

Objective

Health information-seeking behaviors (HISBs) are associated with active participation in cancer care decisions which, in turn, may positively impact health outcomes. The goal of this study was to develop a taxonomy of topics for which post-treatment cancer patients sought information, and to explore HISB patterns by sociodemographic factors and cancer type.

Methods

We examined how health information seeking is associated with social determinants in a survey of 521 post-treatment cancer patients.

Results

Four major topics of interest were found: disease/treatment, self-care management, health services, and work/finance. Assessment of the relationship between social determinants and these four topics showed associations for (1) HISBs on disease/treatment topics decreased with age and increased with education; (2) HISBs on self-care management increased with education and varied by cancer type; (3) HISBs on health services increased with education; and (4) HISBs on work/finance decreased with age and wealth, but increased with debt.

Conclusion

These results demonstrate one pathway through which social determinants may drive communication inequalities, which may result in increased disparities in health outcomes.

Practice implications

Further exploration of the relationship between social determinants and information-seeking among post-treatment cancer patients may contribute to the development of strategies to reduce health disparities.     

Communicating with diverse patients: How patient and clinician factors affect disparities

Objective

Patient-clinician communication (PCC) may generate or reduce healthcare disparities. This paper is based on the 2017 International Conference on Communication in Healthcare keynote address and reviews PCC literature as a research area for the National Institute on Minority Health and Health Disparities (NIMHD).

Identifying patient information needs about cancer clinical trials using a Question Prompt List

Objective

Question Prompt Lists (QPLs) have demonstrated significant promise in facilitating communication in general, surgical and palliative oncology settings yet have not been tested in the oncology clinical trial setting. We aimed to develop a targeted QPL for Clinical Trials (QPL-CT).

Methods

Breast, lung, and genitourinary cancer patients who either had (trial experienced) or had not (trial naive) participated in a clinical trial joined focus groups to help develop and explore the acceptability of a QPL-CT. Clinicians also participated in separated focus groups. Focus groups were audio-recorded and transcribed. We explored patients’ trial information needs and views about the utility of the QPL-CT.

Results

Patients focused on four trial information needs: understanding foundational information, conflict of interest issues and financial implications of trial participation. Of note, experienced patients need to personalize foundational information.

Conclusion

Patient information needs varied considerably and were influenced by trial experience. Patients valued the QPL-CT as an aid to gathering new trial information and ensuring that their information needs were met.

Practice implications

Physicians need to carefully elicit patient information needs and tailor trial information to meet these needs. The QPL-CT, may be of great benefit during clinical trial discussions.     

Fatalism and educational disparities in beliefs about the curability of advanced cancer

Objective

Understanding socioeconomic disparities in the care of patients with incurable cancer is a high priority. We hypothesized that patients without a high school education are more likely to believe that they could be cured and we explored the role of fatalism.

Communicating with providers about racial healthcare disparities: The role of providers’ prior beliefs on their receptivity to different narrative frames

Objective

Evaluate narratives aimed at motivating providers with different pre-existing beliefs to address racial healthcare disparities.

The association between parent-reported provider communication quality and child obesity status: Variation by parent obesity and child race/ethnicity

ObjectiveTo examine the association between healthcare provider communication quality and child obesity status, and the role of parent obesity and child race/ethnicity regarding this association.MethodsWe conducted a cross-sectional secondary data analysis with the 2011–2013 Medical Expenditures Panel Survey of parents with children ages 6–12 (n = 5390). We used multivariable logistic regression to examine the association of parent-reported healthcare provider communication quality (explaining well, listening carefully, showing respect, and spending enough time) with child obesity status, and effect modification by parent obesity and child race/ethnicity.ResultsParents of obese children were more likely to report that their child’s healthcare provider listened carefully (OR = 1.41, p = 0.002) and spent enough time (OR = 1.33, p = 0.022) than parents of non-obese children. Non-obese parents of obese children experienced better communication in the domains of listening carefully (p < 0.001) and spending enough time (p = 0.007). Parents of obese non-Hispanic Asian children and non-Hispanic Black children were more likely to report that providers explained things well (p = 0.043) and listened carefully (p = 0.012), respectively.ConclusionParents of obese children experienced better communication if parents were non-obese or children were non-Hispanic Black or Asian.Practice implicationsHealthcare providers should ensure effective communication with obese parents of obese children.     

Teaching clinical communication: A mainstream activity or just a minority sport?

This plenary presentation from the EACH International Conference on Communication in Healthcare in Oslo 2008, takes an honest look at the present state of communication teaching and considers how to take the next steps to move communication into the very centre of medical education.Although clinical communication teaching has become increasingly accepted as a formal component of the medical curriculum, there is still a problem to be faced. Communication still often appears in medical education to be a peripheral element rather than a mainstream activity truly perceived by schools and learners as central to all clinical interactions.This presentation explores why clinical communication often appears to be a minority sport in medical education, considers how to overcome this via integration throughout the curriculum, looks at five specific examples of integration in action, presents a new UK consensus statement which helps integrate communication into the mainstream, and finally explores the progression to maturity in communication curricula.     

Socioeconomic and geographic disparities in health information seeking and internet use in puerto rico

Background

Geographically isolated Hispanic populations, such as those living in Puerto Rico, may face unique barriers to health information access. However, little is known about health information access and health information-seeking behaviors of this population.

Objective

To examine differences in health and cancer information seeking among survey respondents who ever used the Internet and those who did not, and to explore sociodemographic and geographic trends.

Methods

Data for our analyses were from a special implementation of the Health Information National Trends Survey conducted in Puerto Rico in 2009. We collected data through random digit dialing, computer-assisted telephone interviews (N = 639). The sample was drawn from the eight geographic regions of the Puerto Rico Department of Health. To account for complex survey design and perform weighted analyses to obtain population estimates, we analyzed the data using SUDAAN. Frequencies, cross-tabulation with chi-square, and logistic regression analyses were conducted. Geographic information system maps were developed to examine geographic distributions of Internet use and information seeking.

Results

Of 639 participants, 142 (weighted percentage 32.7%) indicated that they had ever gone online to access the Internet or World Wide Web; this proportion was substantially lower than that of US mainland Hispanics who reported using the Internet (49%). While 101 of 142 (weighted percentage 59.6%) respondents who used the Web had ever sought health information, only 118 of 497 (weighted percentage 20.0%) of those who did not use the Web had sought health information. The pattern was similar for cancer information: 76 of 142 respondents (weighted percentage 47.2%) who used the Web had ever sought cancer information compared with 105 of 497 (weighted percentage 18.8%) of those who had not used the Web. These results were slightly lower but generally consistent with US mainland Hispanics’ health (50.9%) and cancer (26.4%) information seeking. Results of separate logistic regression models controlling for sociodemographic characteristics demonstrated that, compared with individuals who did not seek health or cancer information, those who did were over 5 times as likely to have used the Internet (odds ratio 5.11, P < .001). Those who sought cancer information were over twice as likely to have used the Internet (odds ratio 2.5, P < .05). The frequency of Internet use and health and cancer information seeking was higher in the San Juan metro region than in more rural areas.

Conclusions

Our results contribute to the evidence base for health and cancer communication planning for Puerto Rico, and suggest that health education and outreach efforts should explore the use of available and trusted methods of dissemination such as radio and television, as well as community-based health care providers and organizations, to supplement and encourage use of the Internet as a source of health information.     

Tested communication strategies for providing information to patients in medical consultations: A scoping review and quality assessment of the literature

ObjectivesTo systematize the scientific knowledge of empirically tested strategies for verbally providing medical information in patient-physician consultations.MethodsA scoping review searching for terms related to physician, information, oral communication, and controlled study. Four pairs of reviewers screened articles. For each selected study, we assessed the quality and summarized aspects on participants, study, intervention, and outcomes. Information provision strategies were inductively classified by types and main categories.ResultsAfter screening 9422 articles, 39 were included. The methodological quality was moderate. We identified four differently used categories of strategies for providing information: cognitive aid (n = 13), persuasive (n = 8), relationship- (n = 3), and objectivity-oriented strategies (n = 4); plus, one “mixed” category (n = 11). Strategies were rarely theoretically derived.ConclusionsCurrent research of tested strategies for verbally providing medical information is marked by great heterogeneity in methods and outcomes, and lack of theory-driven approaches. The list of strategies could be used to analyse real life communication.Practice implicationsFindings may aid the harmonization of future efforts to develop empirically-based information provision strategies to be used in clinical and teaching settings.     

Discrimination and racial disparities in health: evidence and needed research

This paper provides a review and critique of empirical research on perceived discrimination and health. The patterns of racial disparities in health suggest that there are multiple ways by which racism can affect health. Perceived discrimination is one such pathway and the paper reviews the published research on discrimination and health that appeared in PubMed between 2005 and 2007. This recent research continues to document an inverse association between discrimination and health. This pattern is now evident in a wider range of contexts and for a broader array of outcomes. Advancing our understanding of the relationship between perceived discrimination and health will require more attention to situating discrimination within the context of other health-relevant aspects of racism, measuring it comprehensively and accurately, assessing its stressful dimensions, and identifying the mechanisms that link discrimination to health.     

Deaf adults at higher risk for severe illness: COVID-19 information preference and perceived health consequences

ObjectivesThis study explores deaf and hard of hearing (DHH) individuals’ preferred sources of information for COVID-19 and their perceptions of developing severe illness from COVID-19 given underlying medical conditions.MethodsA national online bilingual American Sign Language/English survey was conducted from April 17 to May 1, 2020. Weighted sample of 474 DHH adults living in the United States. Multivariate logistic regression analyses were conducted to examine independent associations of sociodemographic variables and health indicators with perceived COVID-19 health consequences.ResultsAbout 44% of the medical condition sample used the Internet (English-based text) first for COVID-19 information, followed by TV (24%). Only 1% selected healthcare provider as the go-to source; the remainder got information from family or friends. Perceived health consequences increased with age (adjusted OR = 1.04; CI 95% = 1.02, 1.06). At-risk respondents who self-identified as persons of color were nearly three times more likely to believe that their health will be severely affected by COVID-19 compared to respondents who self-identified as white (adjusted OR = 2.94; CI 95% = 1.20, 7.18).ConclusionsPerception of COVID-19 health consequences vary among DHH adults at higher risk for severe illness.Practice implicationsInformation delivery methods must be flexible and comprehensive to meet the diverse community’s needs, especially during the COVID-19 pandemic.     

The influence of information structuring and health literacy on recall and satisfaction in a simulated discharge communication

Objective

We investigated the effects of information structuring and its potential interaction with pre-existing medical knowledge on recall in a simulated discharge communication.

Understanding the potential of state-based public health genomics programs to mitigate disparities in access to clinical genetic services

PurposeState health agencies (SHAs) have developed public health genomics (PHG) programs that play an instrumental role in advancing precision public health, but there is limited research on their approaches. This study examines how PHG programs attempt to mitigate or forestall health disparities and inequities in the utilization of genomic medicine.MethodsWe compared PHG programs in three states: Connecticut, Michigan, and Utah. We analyzed 85 in-depth interviews with SHA internal and external collaborators and program documents. We employed a qualitative coding process to capture themes relating to health disparities and inequities.ResultsEach SHA implemented population-level approaches to identify individuals who carry genetic variants that increase risk of hereditary cancers. However, each SHA developed a unique strategy—which we label public health action repertoires—to reach specific subgroups who faced barriers in accessing genetic services. These strategies varied across states given demographics of the state population, state-level partnerships, and availability of healthcare services.ConclusionOur findings illustrate the imperative of tailoring PHG programs to local demographic characteristics and existing community resources. Furthermore, our study highlights how integrating genomics into precision public health will require multilevel, multisector collaboration to optimize efficacy and equity.     

Crossing borders, crossing cultures: barriers to communication about cancer prevention and treatment along the U.S./Mexico border

OBJECTIVE: To describe cultural barriers to cancer prevention and treatment efforts among Latinos living along the U.S./Mexico border. METHODS: In-depth interviews with 8 Mexican immigrants who are residents of a Texas colonia were conducted to understand the roles of culture and poverty in their experiences with cancer. Questions were asked about participants' cancer experiences, religiosity, medical establishment barriers, and cultural identity. Narrative and thematic analysis was used to highlight dialectical tensions inherent in the stories. RESULTS: The participants' narratives illustrate how poverty and Latino cultural beliefs create barriers to effective cancer prevention and treatment based on: (1) metaphysical beliefs about how they developed cancer and religious beliefs about how it was cured; (2) gender identity and treatment in the U.S. medical system and; (3) national/cultural identity and treatment in the U.S. medical system. CONCLUSION: Structural and cultural barriers interact in complex ways as low-income Latino/a patients and their families attempt to receive cancer care on the U.S./Mexico border. The manner in which these patients negotiate the tensions may reinforce barriers and inability to access health care and should be specifically addressed. PRACTICE IMPLICATIONS: Immigrant populations worldwide are especially vulnerable to health care disparities. Effective cancer prevention and treatment messages must be constructed to help patients and families reconcile cultural and economic tensions in ways that allow them maintain their identities but still receive the necessary health care.