Prostate cancer education in African American barbershops: Baseline client survey results and differences in decisional conflict and stage of decision making

Abstract

There have been very few studies to rigorously evaluate the potential of African-American barbers to educate men about prostate cancer (PCa) in the barbershop setting. This research brief presents baseline data from a cross-sectional survey identifying differences in decisional conflict and stage of decision making by screening status from an efficacy trial to educate African-American men about informed decision-making for prostate cancer screening. Those men who had already received the PSA test were more advanced in their stage of decision making and had less decisional conflict about the PSA test than those men who had never received a PSA test. Educational interventions to increase informed decision making with PCa screening must consider previous PSA test history as a mediating variable affecting decision self-efficacy.

Review articles have highlighted the promising role of barbershops and beauty salons for the delivery of health promotion and health education interventions (Linnan, D’Angelo, & Harrington, 2014; Luque, Ross, & Gwede, 2014). While many of the studies in these reviews addressed diabetes and hypertension, there were very few studies to rigorously evaluate the potential of barbershops to educate men about prostate cancer (PCa) and informed decision making for PCa screening. A recent study demonstrated that a culturally tailored decision aid delivered in barbershops led to significantly more men intending to have a prostate-specific antigen (PSA) test after a follow-up period of three months (Frencher et al., 2015). Another study using PCa screening events in medically underserved communities in Houston, Texas reported over half of the men had no prior history of screening (Ashorobi et al., 2015). This article describes baseline survey findings from an efficacy study conducted with African-American barbershop clients in two micropolitan areas in central and southeast Georgia.

Methods

This two-arm efficacy study aimed to test a community-based, barber-delivered PCa education intervention to increase informed decision making for PCa screening (i.e., knowing the benefits and potential harms of receiving a PSA test). In the intervention site, barbers delivered a targeted intervention toolkit to increase informed decision-making for PCa screening. The toolkit was comprised of brochures and posters with photos of local barbers, and a plastic anatomical model. Clients in the comparison site received educational brochures from the American Cancer Society. More details on the study design and the feasibility study leading up to the baseline survey administration has been described elsewhere (Luque, Roy, et al., 2014).

Barbershop clients between 40 and 70 years of age with no history of PCa were surveyed by male graduate students in 12 different barbershops (six shops per site, equal numbers of participants per barbershop). The 122 participants who completed the face-to-face survey received a stipend of $20, and individual barbers received a stipend of $25 for each completed survey. There were 18 refusals for a response rate of 87%. The 59-item survey (not including demographic questions) took approximately 15 minutes to complete. Questions asked participants about barbershop visit frequency, trust in their barber to give health-related advice, frequency of PCa discussions with their barber, health care provider recommendations about the PSA test, and knowledge about PCa. Questions also assessed men’s self-reported levels of decision self-efficacy, decisional conflict, control preferences, stage of decision making, and perceived risk related to PCa screening using established reliable scales and measures (Bunn & O’Connor, 1996; Degner, Sloan, & Venkatesh, 1997; O’Connor, 1995). Decisional conflict was determined by an existing 10-item Likert scale (α = 0.91 in this study; O’Connor, 1995) and stage of decision making was determined by one question with six response options to measure different stages of making a decision about the PSA test in the next 12 months, with higher values indicating greater certainty in making a decision about screening (whether to receive it or not). Pre-test/post-test changes in these psychosocial variables will be assessed with a six-month follow-up survey to test intervention efficacy. All participants provided written informed consent, and the study was approved by the university institutional review board.

Results

With the exception of one variable, bivariate analysis (see Table 1) revealed no statistically significant differences at the p ≤ 0.05 alpha level at baseline between intervention and comparison conditions on clients’ demographic, health, and study variables. The only difference detected was participants in the intervention arm had marginally higher levels of PCa baseline knowledge (p=0.05). Fifty-two (43%) participants had received a PSA test in their lifetime. Independent samples t-tests results between screened versus unscreened men identified significantly lower decisional conflict (34.9 vs. 32.5; p=0.01), with higher scores indicating less decisional conflict, and more advanced stage of decision making (5.3 vs. 2.7; p<0.001). Of the 71 participants who reported having spoken to their doctor about PSA test recommendations, 60 (85%) men indicated that their doctor recommended they have a PSA test, three (4%) men that they should not have the test, and eight (11%) men reported that their doctor did not make a recommendation.

Table 1.

Barbershop participant demographic, health, and study variables in Georgia in 2014–15.

	All (n=122)	Intervention (n=61)	Control (n=61)	P valuea
Demographic characteristics
Age [years; mean (SD)]	51.7 (7.9)	52.1 (8.3)	51.3 (7.7)	0.56
Some college or above (%)	50.8	54.1	47.5	0.47
Married (%)	53.3	55.7	50.8	0.59
Median income range	$40K–$49K	$40K–$49K	$40K–$49K	0.89
Health characteristics
Have health insurance (%)	87.7	83.6	91.8	0.17
Have a regular provider (%)	89.3	88.5	90.2	0.77
Barber discussed PCa > 2 times (%)	8.2	6.6	9.8	0.51
Ever had a PSA (%)	42.6	37.7	47.5	0.27
Family History of PCa (%)	18.2	24.6	11.7	0.07
Study variablesb
Decision self-efficacy [mean (SD)]	51.5 (4.9)	51.5 (4.7)	51.6 (5.2)	0.89
Decisional conflict [mean (SD)]	33.5 (5.2)	34.1 (5.2)	33.0 (5.1)	0.24
Control preferences [mean (SD)]	2.7 (1.2)	2.8 (1.2)	2.5 (1.2)	0.26
Stage of decision making [mean (SD)]	3.8 (1.9)	3.7 (1.9)	4.0 (1.9)	0.39
Perceived risk of PCa [mean (SD)]	3.2 (1.3)	3.3 (1.4)	3.1 (1.2)	0.29
PCa Knowledge [mean (SD)]	10.2 (1.6)	10.5 (1.3)	9.9 (1.8)	0.05*

^aBivariate analyses were conducted using independent samples t-test and Chi-square test to establish if baseline differences existed between study arms.

^*p ≤ .05

^bDecision self-efficacy is an 11-item scale with a maximum value of 55, with higher scores indicating high self-efficacy for making a decision about screening. Decisional conflict is a 10-item scale with a maximum value of 50, with higher scores indicating less decisional conflict about the PSA test. Control preferences is a single item based on a 5-point Likert scale with higher values indicating that a doctor should make medical decisions rather than the individual. Stage of decision making is a single item based on a 6-point Likert scale with higher values indicating greater certainty for making a decision about the PSA test. Perceived risk of PCa is a single item based on a 5-point Likert scale with higher values indicating higher perceived risk. PCa knowledge is measured by a 13 question True/False test with higher scores indicating a higher number of correct answers.

Recommendations

Those men who had already received the PSA test were more advanced in their stage of decision making and had less decisional conflict about the PSA test than those men who had never received screening. Educational interventions to increase informed decision making for PCa screening must take into account previous PSA test history and stage of decision making as mediating variables affecting outcome variables such as decision self-efficacy or intention to receive a PSA test. A study conducted in Philadelphia reported men who had a physician’s recommendation were 14 times more likely to have received a PSA test (Halbert et al., 2015). In the barber training, intervention arm barbers were trained to advise their clients to talk to their doctor about the “pros” and “cons” of PCa screening. However, another study reported that doctors who discussed harms and benefits with patients were actually less likely to support screening (Volk et al., 2013).

Since the main outcome variable of the efficacy study is decision self-efficacy, the outcomes analysis will test for differences between men who talked with their doctor or received a screening recommendation and those men who did not, following conversations with their barbers. Men who had received the PSA test were more advanced in their stage of decision making and had less decisional conflict about the test. A significant barrier to screening is fear of negative side effects from follow-up biopsies after a positive PSA test; therefore, one theory to explain the finding about decisional conflict is that having a discussion with their doctor might have allayed some of these fears (Hunter, Vines, & Carlisle, 2015). What remains unknown is whether a barbershop-based PCa educational intervention targeted to African Americans would have any measurable effect on men’s decision self-efficacy. Preliminary findings examining differences in decision self-efficacy between intervention and control groups point to a possible null effect. Decision self-efficacy is a nuanced concept and challenging to disseminate in community settings by peer educators. A simple message instructing men to “get the test” is more easily communicated. Cancer screening education studies typically focus on more concrete outcomes such as self-report of receiving a screening test, oftentimes verified by medical record. Because of the controversy about population based screening using the PSA test, decision-based metrics are used to measure study outcomes. Despite the shortcomings regarding PCa screening, providing community-based education has the potential to empower patients to engage with their primary care providers on important decisions regarding their health care and reduce men’s anxiety regarding the PSA test.

There were several limitations to the study. First, since the participant survey was based on self-report, there was no independent verification of medical records for PSA test receipt. Second, the study employed convenience sampling to recruit and identify barbershops; therefore, the findings might not be generalizable to other African-American barbershops in rural Georgia. The strengths of the study included the barbershop-based recruitment of rural African-American men and the rapport developed using the face-to-face survey method to improve data quality and response rate. Future studies should investigate the use of health coach teams involving health educators, barbers, and healthcare providers to provide African-American men with individualized educational information based on their family history and other potential risk factors about the benefits or shortcomings of PCa screening and possible follow-up diagnostic tests.