Improving Recruitment, Retention, and Cultural Saliency of Health Promotion Efforts Targeting African American Men: A Scoping Review

Abstract

Background

When health promotion efforts intend to include African American men, they experience challenges with recruitment and retention, in addition to limited cultural saliency—interventions that do not align the cultural preferences and experiences of the target population produce less effective results.

Purpose

This scoping review provides an understanding of (a) how health promotion efforts among African American men are developed and implemented, in addition to the (b) main outcomes, (c) retention rates, and (d) methodological rigor of those efforts.

Methods

The following databases were used: PubMed, EMBASE (Ovid), PsycINFO (EBSCO), CINAHL (EBSCO), Web of Science (Clarivate), and ProQuest. Included studies were restricted to those: (a) conducted among African American men and (b) reported the effects of a health promotion intervention. Interventions using single-group pre–post study, post-test-only study, non-randomized controlled trial, and randomized controlled trial (RCT) study designs were included.

Results

The results indicate that varying degrees of customization in the design and implementation of health promotion efforts targeting African American can improve recruitment, retention, and health-related outcomes. Results draw attention to the need for community input when designing and implementing efforts targeting these men.

Conclusions

These results indicate that opportunities exist to innovate health promotion efforts among African American men, such as the intentional incorporation of the community’s values, perspectives, and preferences in the effort (i.e., cultural saliency) and explicitly indicating how the efforts were culturally tailored to improve saliency. Opportunities also exist to innovate health promotion efforts among African American men based on literature-derived best practices.

Efforts to promote health that are customized for African American men are an effective strategy to improve recruitment, retention, and health-related outcomes of these men.

Introduction

African American men have the lowest life expectancy of any ethnic-sex group in the United States [1, 2]. An African American man in the United States (US) is expected to live until 71.8 years of age—a life expectancy that is 4.7 years less than White non-Hispanic males and 7.3 years less than Hispanic males [1]. Significant contributors to this low life expectancy including heart disease, cancer, and stroke are largely preventable and have been widely targeted as part of efforts to reduce health disparities among the US general population [1].

The persistent health disparities experienced by African American men indicate that these efforts have produced limited results for these men or have been limited in their reach. Fewer than 10% of participants enrolled in clinical trials are African American men, and this population is significantly underrepresented in health promotion research [3–5]. In addition to recruitment and retention challenges, health promotion initiatives may be thwarted by limited attention to cultural sensitivity and tailoring. Efforts that do not align with the values, perspectives, and preferences of the target community often produce less effective health promotion results for these communities [6–8]. These challenges represent difficulties in the development, implementation, and assessment of health promotion efforts among African American men. To circumvent these challenges, culturally tailored and customized health promotion efforts for African American men that are informed by literature-derived and evidence-based best practices are needed.

Resnicow and colleagues describe two structures to ensure that recruitment and retention align with the values, perspectives, and preferences of the target community in health promotion efforts—surface structure and deep structure [9]. Surface structure refers to the apparent cultural fit of the effort and is expressed by the recruitment materials, language, and location of the effort [9]. This structure increases uptake (e.g., recruitment and retention) [9]. Deep structure refers to the health promotion efforts’ incorporation of the community’s values, perspectives, and preferences [9]. This structure increases the salience of the intervention to the lives and values of the target community. For African American men, this may include culturally tailoring the intervention and relying on peer-derived sources of support and delivery. Research conducted among African American men indicates that these men prefer relying on peers for health information [10–13] as evidenced by the popularity of barbershop-based health promotion interventions among these men [14–17].

To successfully produce lasting behavioral health change, and improve life expectancy and quality of life, efforts that focus exclusively on health promotion strategies among African American men may shed light on how to incorporate surface and deep structures into health promotion efforts and the success of these efforts [18, 19]. The health disparities experienced by African American men, coupled with the limited results of efforts to promote health among these men, highlight an urgent need for community-informed and evidenced-based culturally tailored and customized health promotion efforts for this population. Culturally tailored and customized approaches that are developed and implemented to address the needs and risks experienced by African American men are a high public health priority.

Our scoping review provides an understanding of (a) how health promotion efforts among African American men are developed and implemented, in addition to the (b) main outcomes, (c) retention rates, and (d) methodological rigor of those efforts. To our knowledge, this scoping review fills an important gap in the health promotion literature as it is the first to focus exclusively on health promotion interventions among African American men. Addressing this gap will allow for the provision of recommendations to those seeking to improve health among African American men.

Methods

This scoping review was designed and conducted in accordance with guidelines outlined in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) statement, a 22-item methodological approach to the production of scoping reviews [20, 21]. The lead author consulted research librarians at the authors’ institution to design the search strategy (e.g., search terms and databases). Search terms used are presented in Supplemental File 1. Information was identified by searching the following bibliographic databases: PubMed, EMBASE (Ovid), PsycINFO (EBSCO), CINAHL (EBSCO), and Web of Science (Clarivate). A post-hoc gray literature search was performed in ProQuest to identify potential interventions not reported in the peer-reviewed literature. The gray literature search was limited to books, dissertations, theses, and reports.

The protocol was informed by the PICOS (i.e., Population, Intervention, Comparison, Outcome, and Study Type) model [22]. Studies included in the scoping review were restricted to those reporting outcomes of health promotion interventions that sought to improve one or more physical or mental health indicators among African American men. Given the limited amount of health promotion efforts targeting this population that are documented in the literature [3–5], interventions and feasibility trials using single-group pre–post study, post-test-only study, non-randomized controlled trial, and randomized controlled trial (RCT) study designs were selected for inclusion. Comparison groups were not required for inclusion, and no date restrictions were applied to the search.

A priori inclusion and exclusion criteria were agreed upon by the authors. Studies were included if they (a) targeted adult African American men (age 18 or above), and (b) sought to improve one or more physical or mental health outcomes. Studies were excluded that (a) targeted African American men and women, (b) targeted African American men and men of other race/ethnicities, (c) targeted adults and children, and (d) did not report the outcomes of a health promotion intervention.

The protocol was registered with and published by the international prospective register of systematic reviews (i.e., PROSPERO) [23]. Registering the protocol in PROSPERO was made in an effort to promote transparency and avoid bias. Following registration in PROSPERO, the protocol was published in a leading journal of systematic and scoping reviews [24]. The original search was conducted in July 2020. Titles and abstracts were downloaded from each of the databases and uploaded to EndNote to remove duplicates. Once duplicates were removed, the remaining titles and abstracts were uploaded to Rayyan—a reference managing software that allows for the organization of articles and collaboration among investigators while conducting systematic and scoping reviews [25]. Two authors (G.M.W. and S.G.F.) independently screened all titles and abstracts against the a priori eligibility criteria to identify potential studies for inclusion. Disagreements between G.M.W. and S.G.F. were flagged by Rayyan and resolved by an independent third reviewer (D.A.A.). Through this process, 20 articles were identified as meeting the inclusion criteria.

The two reviewers (G.M.W. and S.G.F.) then read each article, extracted and managed the data for each of the included studies. The two reviewers read each of these articles and input data into a data extraction spreadsheet. While extracting the data from the original 20 articles, 4 additional articles that met the inclusion criteria were identified. These additional articles were included in the present scoping review and are noted. A PRISMA flow diagram of studies is shown in Fig. 1. The following headings for data extraction were used: targeted health outcome(s); theoretical orientations(s) of the intervention; intervention duration; study design; and main outcomes. Additionally, components of the intervention, setting of the intervention, and recruitment strategy were extracted to assess commonly used surface structures. Design of the intervention, culturally tailored/based, and delivery of the intervention were extracted to assess commonly used deep structures. Finally, recruitment and retention rates were also extracted. Data of interest that could not be found in the text were sought by emailing the corresponding author of the original article.

Fig. 1.

PRISMA 2009 flow diagram.

Results

The database searches identified 2,155 articles. The use of multiple databases yielded 1,048 duplicates. These duplicates were removed, thus resulting in 1,107 unique articles. The abstracts of each of the unique articles were blindly examined by both reviewers to assess exclusion. This preliminary assessment resulted in the further exclusion of 1,072 articles. Common reasons for the exclusion of articles based on this preliminary search included: (a) nonintervention studies (e.g., cross-sectional analyses), (2) interventions that included groups other than African American men, and (3) commentaries. This preliminary assessment yielded 35 unique articles that necessitated further examination (i.e., exclusion could not be determined by the abstract). Full-texts were acquired for each of these articles and again examined independently by each reviewer. Each article was then assessed for inclusion/exclusion. Discrepancies between the two reviewers were settled by a third blind reviewer. This process culminated in 20 studies included in the qualitative synthesis. An additional four studies were found through other sources [26–29]. The post-hoc gray literature search yielded 563 results. No results from this search met the inclusion criteria of the present review.

Description of the Design and Implementation of the Interventions

Nine interventions (37.5%) did not specify a guiding theoretical orientation. The most commonly identified theoretical orientation was Social Cognitive Theory (n = 9; 37.5%). The most common intervention design was a pre/post-test design (n = 14; 58.33%) [29–41]. Six interventions (25%) used a RCT design [14, 27, 42–45]. The remaining intervention designs were “quasi-experimental” (n = 2; 8.33%) [26, 46], serial cross-sectional (n = 1; 4.17%) [28], and post-test only (n = 1; 4.17%) [47]. See Table 1 for more information.

Table 1.

Overview of health promotion interventions among African American men

Study	Target outcome(s)	Theoretical orientation of intervention	Intervention duration	Study design	Outcome(s)
Crosby et al. [42]	Likelihood to contract STD; condom use	Unspecified	Single session (45– 50 min)	RCT	Lower likelihood to acquire STDs and more likely to report condom use among IG. Fewer sexual partners and acts of unprotected sex among IG. Higher proficiency for condom use among IG.
Dean et al. [46]	Physical activity	SEF, SCT, SDT, Social support	Eight weekly (90 min) sessions	Quasi-experimental	Increase in physical activity and decreases in weight and body fat percentage.
Drake et al. [26]	Prostate cancer screening	HBM, Ottawa Decision Support Framework	Single session (30 min to an hour)	Quasi-experimental	Increase in CaP knowledge and self-efficacy.
Dworkin et al. [30]	HIV medication adherence	Information, Motivation, and Behavioral Skills Model of Adherence	3 months	Pre/post-test	Improvements in pill adherence and health literacy.
Frencher et al. [31]	Prostate cancer screening decision	Unspecified	Single session	Pre/post-test	Increase in intention to screen and certainty in decision-making process.
Hendricks et al. [32]	Differences in diabetes- related subjective outcomes between monthly and 3-month follow-ups	Unspecified	Four (weekly) 2-hour classes	Pre/post-test	No significant differences between participants who received monthly and 3-month follow- ups. All participants improved knowledge, perceptions of general health, and HbA1c values.
Hess et al. [33]	Blood pressure	SCT	8 months	Pre/post-test	Decrease in blood pressure among IG. Increase in treatment and control among IG.
Hess et al. [33]	Blood pressure	SCT	14 months	Pre/post-test	Treatment and control increased.
Hightow-Weidman et al. [34]	Intention to use condoms, HIV-related knowledge, condom self-efficacy, attitudes toward engaging in safe sex	HBM, SCT, TPB	Participants asked to log onto website and spend 30 min on website weekly for 4 weeks	Pre/post-test	Increase in behavioral intentions to use condoms and engage in preparatory condom use behaviors among IG. Reduction in depression score among IG.
Hill et al. [27]	Hypertension	Unspecified	36 months	RCT	Decreases in systolic/diastolic blood pressure among IG. Higher proportion of men in IG than CG with controlled blood pressure. Left ventricular mass significant lower in IG than CG.
Hoffman et al. [35]	Oral health awareness	HBM	Three (2.5 hr) modules delivered over 2 days	Pre/post-test	Increase correct responses to questions about gingivitis, use of a hard toothbrush, and knowledge of ways to prevent gum disease. Decrease in endorsement of erroneous statements.
Hooker et al. [36]	Physical activity	SCT	Two weekly (90 min) sessions for 8 weeks	Pre/post-test	Positive changes in MVPA, PA, self-efficacy for PA, social support for PA from family and friends, self-regulation for planning, and goal setting.
Jones et al. [28]	HIV risk reduction	Diffusion of innovation theory	Four 2-hour sessions	Serial cross-sectional	Significant decreases in unprotected anal intercourse, unprotected insertive anal intercourse, unprotected receptive anal intercourse, and mean number of partners. Increase in condom use rate.
Klein et al. [37]	Risk reduction, disclosure practices, condom use	Unspecified	Six modules (total time 2 hr)	Pre/post-test	Decrease in risky sexual behavior and likelihood of lying about HIV status. Less concern about becoming HIV+.
Luque et al. [47]	Prostate cancer awareness	Unspecified	Single session	Post-test	Increase in knowledge of prostate cancer.
Operario et al. [29]	Reduction of HIV risk behavior	Information- Motivation-Behavior Model, AIDS Risk Reduction Model	Four weekly 1-hour sessions	Pre/post-test	Decrease in unprotected sexual encounters, number of sexual partners, and loneliness. Increase in social support and self-esteem.
Park et al. [38]	Barriers to tomato consumption	Unspecified	3 months (contact 2× weekly for first 2 weeks, then weekly for next 2.5 months)	Pre/post-test	Increase in lycopene intake and lycopene levels among IG. Decrease in barriers to adherence among IG.
Patel et al. [39]	Prostate cancer screening rates and behavior	Unspecified	Single session	Pre/post-test	Increase in knowledge and decrease in barriers. 55.77% of participants were screened 3-months post-intervention.
Tobin et al. [43]	HIV prevention	SCT, Information-Motivation-Behavior Model, Social Network Theory	Two sessions per week, Seven sessions total	RCT	Increased odds of 0 sex partners, condom use, and HIV negative/unknown status partners among IG.
Treadwell et al. [40]	Reduction of obesity and diabetes	Unspecified	6 weeks consisting of 12 hr of classroom education and 30 hr of exercise	Pre/post-test	Increase in knowledge about strategies for prevention and management of obesity and diabetes, increase in engagement in exercise, decrease in blood pressure, weight, and BMI. Increase in visits to primary care doctor.
Victor et al. [14]	Reduction of blood pressure	Behavioral Model of Healthcare Use, Community PROMISE	6 months followed by an additional 6 months	RCT	Greater decrease in blood pressure among IG compared to CG.
Wilson et al. [41]	HIV risk reduction	SCT	Single session (less than 2 hr)	Pre/post-test	Increase in attitudes and self-efficacy of condom use increased, and community empowerment. Decrease in sexual risk behavior.
Wilson et al. [44]	HIV prevention	SCT	Single session (less than 3 hr)	RCT	Greater likelihood of no condomless sex among IG.
Zhang et al. [45]	Physical activity	SCT, TRA	Three (90 min) sessions over three consecutive weeks	RCT	Increase in physical activity, reasoned action, subjective norms, and self-efficacy among IG.

SEF social ecological framework; SCT social cognitive theory; SDT self-determination theory; HBM health belief model; TPB theory of planned behavior; TRA theory of reasoned action; IG intervention group; CG control group; STD sexually transmitted disease; BMI body mass index; RCT randomized controlled trial.

Surface and Deep Level Customizing to Culture on Implementation of Interventions

Surface structure

There was a wide variation in attention to surface and deep structures in the design and implementation of the interventions. Most interventions sought to increase knowledge, motivation, and skills related to the target health outcome(s). Some of the interventions incorporated technology, such as FitBit devices [46], SMS text messaging [46], DVDs [31, 47], and websites [30]. Most of the interventions occurred in the community (n = 11; 45.83%; e.g., barbershops, community centers, and city-managed wellness centers) [14, 26, 29, 31–33, 36, 40, 46, 47], with the remaining occurring in academic or medical settings (n = 7; 29.17%; e.g., STD clinic, community college, research clinic, medical school) [27, 35, 39, 42, 43, 44, 45] and online (n = 3; 12.5%; e.g., phone application and website) [30, 34, 37]. One intervention occurred in both a community setting and a medical school [41]. Two interventions did not specify a location [28, 38]. All interventions made efforts to recruit participants from the targeted community. It is noteworthy that the methods for recruitment varied across all the interventions and that each intervention employed a variety of methods. Methods included passive and population-specific, directed methods. Passive methods included word of mouth [30, 35, 36, 46] and the posting of flyers [26, 29, 30, 34–36, 39, 40, 45, 46]. Population-specific, directed methods included recruitment at barbershops [14, 31, 33, 41, 44, 47], announcements made by pastors and postings in church bulletins [26, 32], and other venues frequented by the population [28, 29, 37, 38, 42, 43, 45]. It should be noted that the number of participants recruited as a result of each method was not reported. Additionally, the content of the method (e.g., including an image of an African American man on the flyer) was not described.

Deep structure

Most interventions (n = 17; 70.83%) explicitly specified that the intervention was developed with some sort of community input. The incorporation of community input suggests that most interventions were sensitive to the community’s needs and may have been culturally tailored/based, though the extent to which they were culturally tailored/based or customized was often unclear. Examples of community input include preliminary qualitative research among African American men [26, 28, 29, 31, 34, 36, 37, 39–42, 44–46], relying on a community advisory board comprised of African American men [35, 37, 39, 41, 43, 44], and exploratory needs assessments conducted among African American men [35, 37]. Seven interventions (29.17%) did not explicitly indicate that the intervention was developed with some sort of community input [14, 27, 30, 32, 33, 38]. Although the delivery of the interventions differed, eight of the interventions (33.33%) were completely peer-delivered (i.e., delivered solely by African American men from the community) [26, 29, 39, 40, 42–44, 46]. See Table 2 for more information.

Table 2.

Surface and deep structures of health promotion interventions among African American men

Study	Surface-level structures			Deep-level structures
	Components of intervention	Setting of intervention	Recruitment strategy	Design of intervention	Culturally tailored/based	Delivery of interventiona
Crosby et al. [42]	Information, motivation, and behavioral skills on condom use	STD clinic	Recruited from public STD clinic following diagnosis	Qualitative research among AA men	Yes	Black male lay health advisor
Dean et al. [46]	Sessions to foster self-efficacy, motivation, enjoyment of physical activity; FitBit; SMS texts with reminders, information, and motivation; Access to physical centers	Personal training facility	Word of mouth, flyers, emails to partner organizations	Qualitative research among AA men	Yes	Black male certified personal trainer
Drake et al. [26]	Benefits and harm of CaP screen, facts about CaP, decision tree	Faith-based organization	Announcements made by pastors, flyers in church bulletin	Qualitative research among AA men	Yes	African American male health educator
Dworkin et al. [30]	Motivation, behavioral skills, education for treatment adherence	Phone application	Flyers, word of mouth	Unspecified	Unspecified	Black avatar
Frencher et al. [31]	Culturally tailored DVD decision support instrument	Barbershops	Targeting of men at barbershops who appeared to qualify	Focus group data	Yes	Predominately African American cast
Hendricks et al. [32]	Skills training class to take charge of diabetes	Community center	Diabetes educators, AA churches, PSAs	Unspecified	Yes	Unspecified LCSW, nurse practitioner
Hess et al. [33]	Blood pressure report cards, role model stories	Barbershops	Men attending barbershop	Unspecified	Unspecified	Black research assistant and premedical student supervised by Black nurse
Hess et al. [33]	Blood pressure report cards, role model stories	Barbershops	Men attending barbershop	Unspecified	Unspecified	Barbers
Hightow-Weidman et al. [34]	Live chat, interactive quizzes, health journals, decision support instruments	Website	Flyers, HIV clinic providers, community outreach, internet, word of mouth	Focus groups and semi-structured interviews with AA men	Yes	Website containing images/graphics of Black men
Hill et al. [27]	Individualized treatment, free medication, visits by nurse practitioner and community health worker, referral to community resources	Outpatient research center, home visits	Unspecified	Unspecified	Unspecified	Unspecified nurse practitioner, community health worker, and physician
Hoffman et al. [35]	Oral health didactics, demonstrations, and discussions on barriers and facilitators	Centrally located community college	Presentations by CAB, word of mouth, flyers, referrals	Input from CAB, community health assessment	Yes	Dentists and public health practitioners
Hooker et al. [36]	Benefits of PA, overcoming barriers, goal setting, self- monitoring	City-managed wellness center	Local media, AA faculty listservs, flyers and announcements, senior residential facilities, wellness centers, word of mouth	Interview data with AA men	Yes	Two trained facilitators (non-Black)
Jones et al. [28]	Local and state HIV/AIDS and STD, facts and myths about HIV/AIDS, characteristics of effective risk reduction conversations, roleplaying	Unspecified	Local nightclubs frequented by target population	Key informant interviews	Yes	Local prevention specialists (all but one were Black)
Klein et al. [37]	Content addressing community, goals, stress and social support, harm reduction, communication, and building healthy relationships	Computer/tablet delivered	Social media, snowball sampling, client base, venue-based outreach	Needs assessment, focus groups, prototyping, community panel	Yes	Computer/tablet delivered with clips of Black men
Luque et al. [47]	Brochure, poster, DVD, prostate model, talking points card about CaP, list of community resources	Barbershop	Sample from barbershops	Learner verification	Yes	Barber-led
Operario et al. [29]	Risk reduction counseling, assessment of risk, demonstrations, testing, exploration of interpersonal dynamics, exploration of motivation, role-play	Office of community- based organization	Flyers and outreach at venues and public spaces were target population congregates, referrals	In-depth interviews, focus groups, participant observation	Yes	African American counselors
Park et al. [38]	Information session, telephone coaching, newsletter, given tomato food products, prescription to eat tomato products	Unspecified	Occurred at urology clinic	Unspecified	Yes	Unspecified
Patel et al. [39]	CaP educational brochure	Lobby of health center	Flyers	CAB, focus group data	Yes	Black male lay community educators
Tobin et al. [43]	Self-care, relationship hygiene, community care, role-play	Research clinic	Bars, clubs, cafes, restaurants, college campus, newspapers, referrals, internet	Advisory board	Yes	Black male facilitators
Treadwell et al. [40]	Diabetes-related educational sessions, exercise time, identification of providers and community resources	Various community settings	Flyers	Focus group data, key informant interviews	Yes	Black male CHWs
Victor et al. [14]	Poster, role model stories, follow-up with pharmacist	Barbershop	Following blood pressure screenings at barbershops	Unspecified	Unspecified	Barber-encouraged, pharmacist delivered
Wilson et al. [41]	Session to foster skill building, understanding of HIV prevention, motivation, social support and provide feedback.	Barbershop, medical school	Barber recruited	Barber observations, focus group data, risk assessments, individual interviews, steering committee	Yes	Barber delivered
Wilson et al. [44]	Messages, role-play activities, self-evaluation to (a) promote attitudes, self-efficacy, and perceived norms to reduce risk behavior, (b) increase condom-related communication, and (c) develop personal responsibility	Medical school, university	Recruited from barbershops	Steering committee	Yes	Black men from area
Zhang et al. [45]	Sessions to increase attitude, self-efficacy, skills, interactive exercises, discussions, videos, role-playing, assignments	University research center	Newspapers, organizations, flyers, face-to-face at social events	Focus group data	Unspecified	Trained facilitators

^aRace, gender, and profession are given when possible.

Retention Rates

Retention rates were presented immediately post-intervention, 1-month post-intervention, 3-months post-intervention, 6-months post-intervention, 12-months post-intervention, 24-months post-intervention, and 36-months post-intervention. When data were available, multiple retention rates for a particular study are presented. Retention rates for the intervention groups ranged from 52.94% [26] to 100% [26, 31, 32, 38, 47], though rates varied by differences in the duration of follow-up. See Table 3 for more information.

Table 3.

Recruitment and retention rates of health promotion interventions among African American men

Study	Initial # of participants in intervention group	Final # of participants in intervention group	Retention rate of intervention group	Initial # of participants in control group	Final # of participants in control group	Retention rate of control group
Crosby et al. [42]	141	105	74.46%c	127	92	72.44%c
Dean et al. [46]	40	34	85%a	–	–	–
Drake et al. [26]	73	73	100%a	–	–	–
Dworkin et al. [30]	43	32	74.42%a	–	–	–
Frencher et al. [31]	60	60	100%a	60	60	100%a
Hendricks et al. [32]	15	15	100%c	15	15	100%d
Hess et al. [33]	50	36	72%a	44	27	61.36%a
Hess et al. [33]	321	308	95.95%a	–	–	–
Hightow-Weidman et al. [34]	25	22	88%b	25	23	92%b
	25	21	84%c	25	18	72%c
Hill et al. [27]	157	142	90.44%e	152	122	80.26%e
	157	134	85.35%f	152	118	77.63%f
	157	125	79.62%g	152	106	69.73%g
Hoffman et al. [35]	52	45	86.54%a	–	–	–
Hooker et al. [36]	27	25	92.59%a	–	–	–
Jones et al. [28]	–	–	–h	–	–	–
Klein et al. [37]	106	72	67.92%d	120	68	68%d
Luque et al. [47]	40	40	100%b	–	–	–
Operario et al. [29]	68	36	52.94%c	–	–	–
Park et al. [38]	22	20	100%b	15	14	93.33%b
	22	20	100%c	15	14	93.33%c
Patel et al. [39]	104	104	100%c	–	–	–
Tobin et al. [43]	75	73	97.33%c	72	71	98.61%c
Treadwell et al. [40]	42	Unspecified	Unspecified	–	–	–
Victor et al. [14]	139	132	94.96%d	180	171	95%d
Wilson et al. [41]	78	71	91.02%c	–	–	–
Wilson et al. [44]	436	352	80.73%d	424	305	71.93%d
Zhang et al. [45]	295	274	92.88%a	300	279	93%a
	295	255	86.44%d	300	250	83.33%d
	295	255	86.44%e	300	248	82.67%e

^aImmediately post-intervention follow-up.

^b1-month post-intervention follow-up.

^c3-months post-intervention follow-up.

^d6-months post-intervention follow-up.

^e12-months post-intervention follow-up.

^f24-months post-intervention follow-up.

^g36-months post-intervention follow-up.

^hno retention rates, serial cross-sectional design.

Outcomes

The interventions were designed to target a variety of outcomes. Nine interventions (37.5%) were designed to promote positive sexual practices [28–30, 34, 37, 41–44]. Examples included HIV medication adherence, intention to use condoms, and disclosure practices. Other outcomes included those targeting improvements in blood pressure (n = 4; 16.67%) [14, 27, 33], prostate cancer screening (n = 4; 16.67%) [26, 31, 39, 47], physical activity (n = 3; 12.5%) [36, 45, 46], obesity/diabetes (n = 2; 8.33%) [32, 40], healthy eating (n = 1; 4.17%) [38], and oral health (n = 1; 4.17%) [35]. All of the interventions in this review had a favorable impact on a health indicator of the African American male participants. The outcomes of each of the interventions are presented in Table 1. The interventions assessed were further divided into those that resulted in changes of at least one objective health outcome (e.g., likelihood to acquire an STD, physical activity; n = 18) [14, 27–30, 32, 33, 36, 38–46] and those that resulted solely in changes of health-related intention, knowledge, and/or perceptions (i.e., no changes in objective health outcomes; e.g., CaP knowledge and self-efficacy, intention to screen; n = 6) [26, 31, 34, 35, 37, 47].

Methodological Rigor

The Cochrane Risk of Bias Tool was used to assess methodological rigor [48]. Risk of bias for the following indices was assessed: random sequence generation, allocation concealment, blinding of participants, blinding of personnel, blinding of outcome assessment, incomplete outcome data, and selective reporting was assessed. According to the Cochrane Risk of Bias Tool, studies were assessed to be “high risk” or “low risk” in each of these seven indices. If a study did not present adequate information to ascertain its level of risk for the index, it was assumed to be “high risk” in that index. All but five of the interventions had one or more indices with a high risk of bias. The interventions with a low risk of bias across all the indices represent five of the six RCTs [27, 42, 43, 44, 45]. See Table 4 for more information.

Table 4.

Risk of bias tool

	Random sequence generation	Allocation concealment	Blinding of participants	Blinding of personnel	Blinding of outcome assessment	Incomplete outcome data	Selective reporting
Crosby et al. [42]	Low	Low	Low	Low	Low	Low	Low
Dean et al. [46]	High	High	High	Low	High	Low	Low
Drake et al. [26]	High	High	High	Low	High	Low	Low
Dworkin et al. [30]	High	High	High	Low	High	High	Low
Frencher et al. [31]	High	High	Low	Low	Low	Low	Low
Hendricks et al. [32]	High	High	Low	Low	Low	Low	Low
Hess et al. [33]	High	High	Low	Low	Low	Low	Low
Hess et al. [33]	High	High	High	Low	Low	Low	Low
Hightow-Weidman et al. [34]	High	High	Low	Low	Low	Low	Low
Hill et al. [27]	Low	Low	Low	Low	Low	Low	Low
Hoffman et al. [35]	High	High	High	Low	High	Low	Low
Hooker et al. [36]	High	High	High	Low	High	Low	Low
Jones et al. [28]	High	High	Low	Low	Low	High	Low
Klein et al. [37]	High	High	Low	Low	Low	High	Low
Luque et al. [47]	High	High	High	Low	High	Low	Low
Operario et al. [29]	High	High	High	Low	High	High	Low
Park et al. [38]	High	High	Low	Low	Low	Low	Low
Patel et al. [39]	High	High	High	Low	High	Low	Low
Tobin et al. [43]	Low	Low	Low	Low	Low	Low	Low
Treadwell et al. [40]	High	High	High	Low	High	High	Low
Victor et al. [14]	High	High	Low	Low	Low	Low	Low
Wilson et al. [41]	High	High	High	Low	High	Low	Low
Wilson et al. [44]	Low	Low	Low	Low	Low	Low	Low
Zhang et al. [45]	Low	Low	Low	Low	Low	Low	Low

Risk was deemed “High” if insufficient information was given.

Discussion

Little has been done to achieve the National Institutes of Health (NIH) Revitalization Act of 1993 that mandated the proportional inclusion of minorities in health research [49]. African American men continue to be an underrepresented group in health promotion efforts. It is alarming that this review found that only 24 health promotion interventions, including six RCTs, designed to promote health among African American men have been reported. The low amount of efforts targeting these men often stem from challenges with recruitment. When these men are successfully recruited, other challenges arise such as ensuring these health promotion efforts are culturally salient. These challenges highlight an urgency for those developing and implementing health promotion efforts targeting African American men to attend to surface and deep structures. Attention to these structures can improve recruitment, retention, and saliency [9]. This scoping review is the first to focus exclusively on health promotion efforts among African American men. The data extracted from these studies may inform the development and implementation of efforts that intentionally attend to surface and deep structures or customize the effort to the culture of African American men.

The studies reviewed provide some evidence that those who developed and implemented the efforts attended to surface and deep structures, though it is unclear whether this attention was deliberate. It is also unclear to what degree certain elements of the structures were incorporated in the intervention. For example, aligning the intervention with the values, perspectives, and preferences of the African American men, elements of deep structure used to create a culturally tailored/based intervention or customized to cultural perspective, was often inferred by the participatory design of the interventions (e.g., designs that included advisory boards, preliminary qualitative research), though explicit mention of how and to what degree the interventions were adapted was often omitted. The omission of this information reveals an important future direction in the reporting of health promotion interventions among these men given that cultural tailoring of health promotion interventions has been found to improve recruitment and retention [50, 51]. The inference of alignment, though the lack of information regarding the specifics of this alignment is reflected in Table 2. Overall, this intentional or unintentional attention to surface and deep structures or customization to cultural perspectives may be a result of the researchers’ specific interests in designing and implementing health promotion efforts for African American men.

The results of these efforts indicate that there are benefits to attending to these structures as evidenced by the retention rates and outcomes. Data examining retention rates of African American men in health promotion research are scarce, though it is well known that retention among these men poses a significant concern [52]. The Cochrane Handbook for Systematic Reviews of Interventions provides guidance on acceptable retention rates—a high risk of attrition bias occurs if 20% of participants in short-term and 30% of participants in long-term follow-up designs are not retained [48]. It is noteworthy that based on this guidance all but five of the efforts reviewed would be considered at low risk of attrition bias. Additionally, it is well-documented that health promotion efforts often produce limited results among racial/ethnic minority groups. All of the interventions in this review had a favorable impact on a health indicator of the African American male participants. The impact of these interventions, coupled with their high rate of participant retention, provide support for the development and implementation of community-informed strategies that align with the values, perspectives, and preferences of African American men.

The data extracted for this scoping review also indicate that opportunities exist to further innovate health promotion efforts among African American men, in addition to improving the science and understanding of health promotion efforts among these men. There are several literature-derived best practices and opportunities when promoting health among African American men that may be capitalized upon to improve the health and our understanding of health of these men. These best practices and opportunities indicate that there is a need for (a) a greater focus on comprehensive approaches (i.e., approaches that target multiple and diverse indicators of health) to health promotion among African American men, (b) interventions that leverage informal networks of social support, (c) more interventions to promote health among African American men, particularly rigorous intervention designs (e.g., RCTs), and (d) the inclusion of explicit information on how efforts were designed to align with the values, perspectives, and preferences of African American men in the reporting of these interventions.

There is support derived from the results of the present review and the literature base for these best practices and opportunities. Qualitative research among African American men resoundingly indicates that these men have a comprehensive understanding of health that integrates physical, psychological, and social functioning [10, 53, 54]. This has led some experts to conclude that many health promotion efforts among African American men are too narrowly focused (e.g., focusing on one indicator of health) [55]. All of the interventions included in this review focused on a narrow aspect of health; thus there are existing opportunities for the design and implementation of comprehensive health promotion interventions [56], particularly among African American men. Additionally, research among African American men shows that these men prefer informal sources of support (e.g., peers) when addressing health-related concerns [10–13, 57–59]. This may explain why successful health promotion interventions for African American men have been conducted in the barbershop. Eight of the interventions reviewed relied on peer-to-peer models. These models, which are sustainable, scalable, and cost-effective, have the potential to ameliorate health disparities among African American men [60]. Finally, the interventions reviewed highlight a lack of interventions to promote health among African American men, including those with rigorous designs (e.g., RCTs), in addition to a lack of details on cultural tailoring efforts. There is a need for more rigorous designs and designs that explicitly indicate how the effort incorporated the community’s values, perspectives, and preferences. Such practices would make great strides to improving health promotion efforts among African American men and reducing health disparities.

The results of this scoping review should be viewed in conjunction with its strengths and limitations. The methodological rigor of this scoping review is strong. The search strategy was developed with the aid of librarians at the authors’ institution and was registered a priori with PROSPERO (i.e., the international prospective register of systematic reviews) and the protocol was published in the leading journal for systematic and scoping review protocols [23, 24]. Additionally, the inclusion and exclusion of potential articles were assessed by three blind reviewers. The data were then synthesized by four authors—all of whom have experience in designing and implementing health promotion interventions among African American men. Despite the methodological strengths of this review, there are some noteworthy limitations. First, the inclusion criteria were restricted to interventions conducted only among African American men. There is the potential that critical information from interventions that included men of other races/ethnicities was overlooked. Additionally, the present review did not systematically assess the impact (e.g., through meta-analyses) of the included interventions on the health of African American men. Thus, there is a future opportunity to assess the impact of these interventions when additional, methodologically rigorous health promotion efforts among African American men are conducted and reported. Finally, the review is likely limited by publication bias—only studies that report significant results are typically published and no gray literature papers met the criteria for inclusion.

The dire state of health among African American men represents an urgent public health concern—a concern that can be mitigated by the design and implementation of effective health promotion efforts that are informed by literature-derived and evidence-based best practices. This scoping review is the first to collate, summarize, and synthesize data assessing the design, implementation, and outcomes of health promotion efforts conducted among these men. The results of the present review highlight the need for attention to surface and in particular deep structures through community input when designing and implementing health promotion efforts targeting African American men. Such attention has the potential to improve recruitment and retention of these men, in addition to cultural saliency of the effort—avoidable limitations of many health promotion efforts among these men. Addressing these limitations will likely have the impact of mitigating the health inequities experienced by African American men.

Funding Disclosure

Dr. Guillermo M. Wippold was funded by the National Institute on Minority Health and Health Disparities of the National Institutes of Health under award number K23MD016123. Dr. Demetrius Abshire was funded by the National Institute on Minority Health and Health Disparities of the National Institutes of Health under award number K23MD013899. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Compliance with Ethical Standards

Conflict of Interest: The authors declare that they have no conflict of interest.

Statement of human rights: For this type of study formal consent is not required.

Statement on the welfare of animals: This article does not contain any studies with human participants or animals performed by any of the authors.

Informed consent: Informed consent was not needed for the present systematic review.