Nursing assignment 99

Prostate cancer (CaP) is the most commonly diagnosed cancer and the second leading cause of cancer-related death in men (National Cancer Institute, 2017). African American (AA) men are the highest risk race for this cancer, with the largest number of deaths and shortest survival rates (DeSantis et al., 2016). AA men have a median age of diagnosis of 63 years compared to 66 years for European American (EA) men (Noone et al., 2018). Approximately one in six AA men are diagnosed with CaP in their lifetime, and their white counterparts, one in eight. Disparities for AA men exist across all areas of prostate health, including screening, diagnosis, treatment, and recovery (Kinlock et al., 2016; Moses et al., 201; Mullins et al., 2010). However, this paper will focus on CaP screening, arguably the foundation of prostate health.

Currently, CaP screening has yet to reach a consensus with recommendations varying widely across organizations (Lin, Petitti, & Burda, 2018; Van, 2019). The reason for this is that prostate specific antigen (PSA) testing, which used to be the gold standard for CaP screening, has been found to have low sensitivity and specificity. There is also no clear evidence for determining what threshold warrants prostate biopsy. Concerns about the current CaP screening and prevention methods are warranted, especially when the risks and benefits are weighed. Harms of overdiagnosis and overtreatment can include side effects such as erectile dysfunction, urinary incontinence, bowel urgency and fecal incontinence as well as psychological stress and anxiety. Nevertheless, the increased risk of disease incidence for AA men has led several organizations to believe that an individualized screening approach should be utilized. For example, the American Cancer Society advises early screening (45 years old) for high risk men, which includes AA men with a first-degree relative diagnosed with CaP before age 65 (American Cancer Society, 2019). It is crucial for providers to be aware of the controversies surrounding CaP screening and the increased risk for African Americans.

There is ongoing research regarding the cause of the known health disparity for AA men. Many researchers believe that the abnormal rates are not solely a result of genetics but influenced by socioeconomic barriers. In the United States, African Americans suffer loss of income, education, access to healthcare, and proper nutrition due to lower socioeconomic status (SES) (American Psychological Association, 2020). Although this is difficult to prove, some studies have attempted to show the connection between SES, education and health. A qualitative study researching both AA men and EA men shows that a lower level of education, rather than race, is associated with less knowledge about the prostate gland, CaP symptoms, CaP screening, and fear of CaP (Winterich et al., 2009). Ogunsanya et al. (2017) found that AA men who lived in less rural areas, had higher levels of education, or majored in healthcare or natural sciences demonstrated higher levels of CaP knowledge. These studies help guide healthcare professionals on how best to care for this vulnerable population and address the disparity gap for CaP screening. Considering lack of knowledge prevents many in the AA community from caring for their prostate health, nurse practitioners must find innovative strategies involving CaP education to reach this high-risk population.

Innovative Strategies

Input from the African American Community

One way that healthcare can improve CaP education in the AA community is by producing culturally-relevant teaching material. Jackson et al. (2015) completed a mixed-methods, multiple-phase study titled “Innovative and Community-Guided Evaluation and Dissemination of a Prostate Cancer Education Program for African-American Men and Women” with the goal of evaluating current CaP education material and utilizing input from the AA community to make updates. The first phase included 32 AA men and women who were mailed copies of the program materials and asked to complete a feedback survey with 25 open- and close-ended questions. After surveys were returned, the researchers worked with two consulting CaP experts and a graphic designer to apply the recommendations. The education program was updated and then pilot-tested at a community forum for another round of suggestions. Once the material had been fully revised and a final version created, the researchers presented the CaP education program during a statewide videoconference in South Carolina. Twenty-eight AA men and women attended the videoconference. This third phase included a pre- and post-test design to evaluate the effectiveness of the educational program in increasing CaP knowledge.

The results from the surveys showed a general increase in knowledge about CaP. Information about CaP diagnosis and risk factors showed the most significant increases. Moreover, there was an overall positive response to the videoconference educational program. Not only did the majority of participants feel that the program itself was excellent, but they reported that they would encourage others to find out more about CaP and discuss CaP screening with their providers. While this study has limited generalizability due to its small sample size, it also presents a number of unique strengths. The first two phases of the study retrieved input from the AA community directly and applied these suggestions to the CaP educational program, ensuring that the material is individualized to their target audience. The study also allowed women to participate, taking a broader family approach to CaP education.

Prostate Cancer Education Outside of Clinics

Another study done by Sandiford & D’Errico (2016) called “Facilitating Shared Decision Making About Prostate Cancer Screening Among African American Men” highlights the need for more CaP education outside of healthcare appointments. This study chose the setting of two AA churches in Southern California to perform their research. In this pre- and post-test design, a convenience sample of 50 African Americans participated in a 30-minute program which included a lecture with a PowerPoint presentation and Prostate Cancer Screening Decision Aid, time allotted for questions and answers, and video featuring testimonies from two AA CaP survivors. The pre-test included demographic information, a CaP health history, and evaluation of CaP knowledge. The post-test survey included the same questions given in the pre-test about CaP knowledge to determine the effectiveness of the presentation. Upon completion of the post-test survey, PSA screening was offered on-site for free and additional take-home resources were provided to participants.

The outcome of the study showed an 8% increase in knowledge, from 69% correct responses pre-test to 77% post-test. Participant knowledge improved in their awareness of personal risks, confidence and ability to talk about CaP with their providers, intention to discuss CaP with their providers within six months, and general CaP knowledge. The majority of participants indicated they desired to participate in PSA screening that was offered on-site, further proving the success of the educational material. However, the researchers identified a few weaknesses in the study. It is likely that the high CaP knowledge scores at baseline were due to the high college education level of the participants and high number of men reporting previous CaP screening. Additionally, the religious affiliation of the participants may have led to a higher interest in the educational program because of beliefs that there is a moral responsibility from God to care for one’s body. Nevertheless, this study provides a unique approach to CaP education by encouraging teaching settings that are more comfortable and familiar for the AA community.

Empowering African American Community Members

All barbershop participants responded positively about the contents of the educational material provided. Participants reported an increase in their knowledge about CaP, likelihood of discussing CaP with their healthcare provider and following their advice, and likelihood that they would advise others to do the same. Although this study would be stronger with a pre- and post-test design and a larger sample size, there are a number of mentionable strengths. The informal nature of the study’s setting allows for a more casual environment for learning to take place. The participants of the study were also previous barbershop customers, which may indicate that they had already developed rapport with the trained barbers. While it is important for healthcare providers to discuss CaP screening with their high-risk AA patients during appointments, there is great benefit in empowering AA community members to educate one another as well.

The Support of African American Women

The researchers of this study transcribed the recordings of the nine sessions and assiduously evaluated the information received. Three major themes emerged as a result of their analysis. The first is that the women lacked knowledge about CaP screening, but they want to be educated along with their partners. The second theme that arose from the research is that women play a central role in supporting their partners, informationally, emotionally, and logistically, in their health. Finally, the women exposed a number of barriers that prevent their partners from visiting the doctor, such as fear, financial concerns, and beliefs about their manhood. A systematic review by James et al. (2017) reinforces that men experience a number of psychological and emotional obstacles specifically in relation to CaP screening. Even though no specific intervention was performed in this study and the sample size is small, the information obtained can guide future research on the impact and importance of female partners on CaP screening in the AA community.

Conclusion

Summary of Articles

The importance of education in empowering the AA community is key to their ability to make informed decisions regarding CaP. Although there may be inconsistencies across organizations of how and when to screen for CaP, it is clear that special attention must be paid to the AA community due to their increased risk and existing health disparity. From the articles presented, there are a number of innovate strategies that can be utilized to reach this population. Jackson et al. (2015) demonstrates how the AA community can have a direct influence on CaP educational material. Other articles, such as those by Sandiford & D’Errico (2016) and Luque et al. (2011), collaborated with local communities to bring CaP education to AA churches and barbershops. While these articles predominantly highlight education towards men, some arising research by Allen et al. (2018) focuses on women’s desire to be involved in the informed decision-making process alongside their male partners. These studies can help guide nurse practitioners on how best to educate their AA patients about CaP screening.

Response of Nurse Practitioners

These four articles provide unique ideas as to how advanced practice nurses (APNs) can be involved in diminishing the health disparity gap for AA men. First of all, Sandiford & D’Errico (2016) and Luque et al. (2011) demonstrate the value of collaborating with local communities to educate the general public about CaP and how to do so in a culturally sensitive manner. APNs can support these efforts by partnering with community leaders to form similar projects locally. As demonstrated in the study “Barbers Against Prostate Cancer”, the community members themselves can be trained to deliver the information to the public. APNs can function as educators, equipping others to provide accurate information to about CaP to African Americans. Furthermore, both Allen et al. (2018) and Jackson et al. (2015) agree that a more family-based approach to CaP education should be attempted. APNs can support these studies by encouraging both men and women to be involved in the informed decision-making process regarding CaP screening. Whether through educating more AA women about prostate health or advising spouses to attend appointments, APNs must recognize that AA couples are individually affected by CaP and that spouses can be an asset in supporting their husbands.

Moreover, there are some simple, easily applicable ways that APNs can utilize the findings from the mentioned studies to improve their practice. In all four studies, participants were asked about or encouraged to discuss CaP options with their healthcare providers (Allen et al., 2018; Jackson et al., 2015; Luque et al., 2011; Sandiford & D’Errico, 2016). For this reason, it is crucial that APNs are prepared to have these follow-up conversations with their patients. They should feel confident in their understanding of the controversies surrounding CaP screening, the risks and benefits related to screening, and continue to stay current on the CaP screening recommendations. APNs must be willing to join their AA patients and their spouses in the process, being patient with the time and effort that comes with reaching an individualized, collaborative decision about their prostate health. As APNs educate their AA patients both within the family practice setting and in their local communities, the health disparity gap for CaP screening may decrease.

References

Allen, J. D., Akinyemi, I. C., Reich, A., Fleary, S., Tendulkar, S., & Lamour, N. (2018). African American women's involvement in promoting informed decision-making for prostate cancer screening among their partners/spouses.  American journal of men's health,  12(4), 884–893. https://doi.org/10.1177/1557988317742257

Mullins, C. D., Onukwugha, E., Bikov, K., Seal, B., & Hussain, A. (2010). Health disparities in staging of SEER-medicare prostate cancer patients in the United States. Urology, 76(3), 566-572. https://doi.org/10.1016/j.urology.2009.10061

National Cancer Institute. (2017). SEER cancer stat facts: Prostate cancer. Retrieved on April 5, 2020 from https://seer. cancer.gov/statfacts/html/prost.html