标题：Community-Based, Preclinical Patient Navigation for Colorectal Cancer Screening Among Older Black Men Recruited From Barbershops: The MISTER B Trial
摘要：Objectives. To test the effectiveness of a preclinical, telephone-based patient navigation intervention to encourage colorectal cancer (CRC) screening among older Black men. Methods. We conducted a 3-parallel-arm, randomized trial among 731 self-identified Black men recruited at barbershops between 2010 and 2013 in New York City. Participants had to be aged 50 years or older, not be up-to-date on CRC screening, have uncontrolled high blood pressure, and have a working telephone. We randomized participants to 1 of 3 groups: (1) patient navigation by a community health worker for CRC screening (PN), (2) motivational interviewing for blood pressure control by a trained counselor (MINT), or (3) both interventions (PLUS). We assessed CRC screening completion at 6-month follow-up. Results. Intent-to-treat analysis revealed that participants in the navigation interventions were significantly more likely than those in the MINT-only group to be screened for CRC during the 6-month study period (17.5% of participants in PN, 17.8% in PLUS, 8.4% in MINT; P < .01). Conclusions. Telephone-based preclinical patient navigation has the potential to be effective for older Black men. Our results indicate the importance of community-based health interventions for improving health among minority men. Black men suffer disproportionately from the effects of chronic diseases compared with other demographic groups. In the United States, Black men have the highest incidence of colorectal cancer (CRC) and the highest CRC mortality, 1–3 yet Blacks have signficiantly lower screening rates than Whites nationally. 4 One explanation for the disproportionate CRC mortality may be that Black men are less likely than are White men to be diagnosed at an early stage of the disease, leading to decreased survival rates. 2 Lower rates of early-stage diagnosis may be attributable in part to lack of timely screening, because CRC screening leads to identification and, often, curative excision of precancerous polyps and early cancers. Even in New York City, where disparities in overall CRC screening have been largely reduced, racial differences in age at screening, early-stage diagnosis, and CRC mortality persist. 3,5,6 Thus, for Black men, a focus on timely CRC screening is particularly important. Several approaches have been shown to increase CRC screening rates. 7,8 One such intervention is patient navigation (PN), defined as “assistance offered to patients, survivors, families, and caregivers to help them access and chart a course through the healthcare system” and overcome barriers to health care. 9 (p71) PN has demonstrated efficacy in increasing CRC screening rates when delivered in practice-based settings, 9–15 particularly among minority groups. Several of these studies have implemented PN for patients who have already received a doctor’s recommendation for screening, 10–12,15 potentially missing individuals who are least likely to be screened. However, the effectiveness of PN programs for Black men has not been tested in nonclinical, community-based settings. In contrast with the traditional navigation model, in which patients are navigated from the primary care doctor’s office to the colonoscopy suite, a model of navigation from community settings may be of particular importance for Black men. 13 Black men are less likely to receive regular health care or to have a personal doctor than are Whites, 16 because of barriers including cost, lower rates of insurance coverage, lack of trust, experiences of discrimination in health care, and multilevel societal racism. 16–21 Physician-level factors further complicate these complex patient- and system-level factors. A recent study showed that being Black, having a lower income, or having a lower education level was associated with being less likely to receive a recommendation for CRC screening from a physician. 22 Thus, a traditional PN model is likely not to reach those men who may need navigation the most. In this context, the translation of evidence-based navigation approaches to community-based settings is necessary for reducing disparities in CRC mortality in Black men. Our past research suggests that nonclinical places such as barbershops may be a promising setting for reaching Black men, regardless of their education, income, or health care–seeking behavior. 23 Prior research has demonstrated the efficacy of barbershop interventions for addressing cardiovascular disease in Black men, 24,25 but no CRC screening interventions have been tested in the barbershop setting. The Multi-Intervention Study to Improve CRC Screening and to Enhance Risk Reduction in Black Men (MISTER B) aimed to determine whether a PN intervention to encourage CRC screening would improve screening rates among middle-aged and older Black men recruited from barbershops in New York City.
