Department of Public Health Sciences, 2462University of Chicago, 5841 S Maryland Ave, Chicago, IL, USA.
Department of Public Health Sciences, 12235University of Miami Miller School of Medicine, Miami, FL, USA.
Cancer Control. 2023 Jan-Dec;30:10732748231162479. doi: 10.1177/10732748231162479.
Despite the importance of advance care planning (ACP), a process that optimizes future medical treatment and end-of-life care, for at-risk populations, rates of patient-provider ACP conversations are extremely low among Black women with breast cancer. Community health workers (CHWs) are well-positioned to support patients in engaging in ACP conversations with their providers; yet research on integrating CHWs to promote ACP is scant. The current study examined multilevel facilitators and barriers to successful ACP conversations among Black women from the perspective of providers and CHWs who serve this community.
Providers and CHWs were recruited from an academic medical center in a large urban city. Retrospective qualitative data on barriers and facilitators to ACP conversations, as well as CHWs' training needs, were collected from two focus groups (N = 5 providers, N = 5 CHWs) and one individual interview (N = 1 provider), and transcribed and coded for themes.
All providers reported working primarily with Black patients, and identified stigma and time constraints as major barriers to ACP discussions; they also identified the structural barriers and injustices that their patients face during medical care. CHWs reported having a trusted relationship with their patients and flexibility in their care that would allow for ongoing ACP conversations, discussing their ability to serve as a bridge between the patient and provider. However, CHWs discussed that they lacked the tools and skills to have ACP conversations, largely because existing formal trainings in ACP are cost prohibitive.
Competing priorities of the provider to discuss/treat the patient's disease and medical mistrust were major barriers to successful ACP conversations among Black women with breast cancer, leading to ACP completion occurring late in treatment. CHWs are uniquely qualified to overcome multilevel barriers to ACP and establish trusting relationships with patients in order to facilitate earlier and ongoing communication between patients and providers.
尽管预先医疗照护计划（ACP）对于高危人群的未来医疗和临终关怀至关重要，但在患有乳腺癌的黑人女性中，患者与医护人员进行 ACP 对话的比率极低。社区卫生工作者（CHW）非常适合支持患者与医护人员进行 ACP 对话；然而，关于整合 CHW 以促进 ACP 的研究却很少。本研究从为该社区服务的医护人员和 CHW 的角度，探讨了成功进行 ACP 对话的多层次促进因素和障碍。
从一家大型城市学术医疗中心招募了医护人员和 CHW。通过两个焦点小组（N=5 名医护人员，N=5 名 CHW）和一个单独访谈（N=1 名医护人员），收集了关于 ACP 对话的障碍和促进因素以及 CHW 培训需求的回顾性定性数据，并对其进行了转录和编码以提取主题。
所有医护人员均报告主要与黑人患者合作，并指出污名化和时间限制是 ACP 讨论的主要障碍；他们还指出了患者在医疗过程中面临的结构性障碍和不公正待遇。CHW 报告与患者建立了信任关系，并且在照顾患者方面具有灵活性，这使得可以进行持续的 ACP 对话，讨论他们作为患者与医护人员之间的桥梁的能力。然而，CHW 表示，他们缺乏进行 ACP 对话的工具和技能，主要是因为现有的 ACP 正式培训费用过高。
医护人员讨论/治疗患者疾病和医疗不信任的优先事项相互竞争，是黑人女性乳腺癌患者 ACP 对话成功的主要障碍，导致 ACP 在治疗后期才完成。CHW 具有独特的资格来克服 ACP 的多层次障碍，并与患者建立信任关系，以便促进患者与医护人员之间的早期和持续沟通。
