The Role of Racial Identity and Religious Beliefs in the Attitudes of African American Cancer Patients Toward and Intention To Enroll in Therapeutic Cancer Trials

Abstract

There is increasing evidence that societal inequities and cultural differences in attitudes toward cancer and its treatment drive health outcomes. Therapeutic clinical trials represent a promising treatment option for cancer patients, yet the percentage of African American patients who enroll in clinical trials is lower than the national average. This creates a racial imbalance that limits the extent to which research results from clinical trials can be generalized. Studies of African Americans report some attitudes toward trial participation are based on trust and fear. Enrollment of minority patients is necessary to collect group specific data, and adapt treatments as may be necessary. To that end, interventions aimed at shifting attitudes hol promise, but hinge upon a better understanding of the interplay between attitudes toward trial participation, cultural constructs, and enrollment.

The purpose of this dissertation was to examine interrelationships between two socio-cultural constructs, and four attitudinal barriers to clinical trial participation among African American cancer patients. Specifically, the study sought to (1) understand the relationship between attitudinal barriers to clinical trial participation and the subsequent intention to enroll; (2) understand the contribution of racial identity (racial centrality) and religious belief (specifically a belief in `God as healer') to intention to enroll. The study was guided by elements of the Theory of Planned Behavior and theories of racial identity and religiosity. Interviews were conducted with 111 African American cancer patients in a purposive sample from an urban, community-based teaching hospital in Washington, D.C.

Logistic regression analyses explored the predictive value of four attitudinal constructs in patients' intention to enroll. Three of the four attitudinal barriers were significant predictors of intention for this sample. The concern about ethical conduct of investigators was the only attitudinal barrier that remained statistically significant in the unadjusted model (OR =0.85, p=0.04). Racial identity and a belief in God as healer were not significant predictors of intention to enroll. Finally, a moderation analysis explored the effect of levels of racial centrality and religious belief on attitudes and on intention. A belief in God as healer significantly moderated the association between the concern about ethical conduct of investigators and intention to enroll in a therapeutic clinical trial. Among participants with a low belief in God as a healer, a lower level of concern about the ethical conduct of investigators predicted a greater intention to enroll than those with a higher level of concern about ethics. Racial centrality did not significantly moderate any of the attitudinal barriers.

The extant literature is scant in terms of addressing the role that socio-cultural constructs play in clinical trial decision-making for African American patients. In particular, implications of this study suggest that the historical legacy of research abuse and unethical treatment of African Americans in research continues to color attitudes towards clinical trials. This study provides a basis for further exploration of socio-cultural moderators among African Americans, an understanding of which may enable tailoring of interventions on these factors, which may improve intervention effects.