Factors associated with men's use of prostate-specific antigen screening: evidence from Health Information National Trends Survey

Preventive Medicine 40 (2005) 461 – 468 www.elsevier.com/locate/ypmed

Factors associated with men’s use of prostate-specific antigen screening: evidence from Health Information National Trends Survey Lila J. Finney Rutten, Ph.D., M.P.H.a,*, Helen I. Meissner, Ph.D., Sc.M.b, Nancy Breen, Ph.D.c, Sally W. Vernon, Ph.D.d, Barbara K. Rimer, Dr.P.H.e a

Cancer Prevention Fellowship Program, Division of Cancer Prevention and Health Communication and Informatics Research Branch, Division of Cancer Control and Population Science, National Cancer Institute, Bethesda, MD 20892, 7361 USA b Applied Cancer Screening Research Branch, Division of Cancer Control and Population Science, National Cancer Institute, Bethesda, MD 20892, 7361 USA c Health Services and Economics Branch, Division of Cancer Control and Population Science, National Cancer Institute, Bethesda, MD 20892, 7361 USA d Division of Health Promotion and Behavioral Sciences, University of Texas-Houston School of Public Health, Houston, TX 77225, USA e Department of Health Behavior and Health Education and Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA Available online 3 September 2004

Abstract Background. Rapid uptake of prostate-specific antigen (PSA) testing has occurred in the United States despite inconclusive evidence regarding mortality benefit. Methods. We examined data (n = 927) from the 2003 Health Information National Trends Survey to assess prevalence of self-reported PSA use and its association with patients’ decision making. Results. Over half (55.2%) the sample reported ever having had a PSA test. Men aged 65–74 (OR = 2.53, 1.49–4.31), with some college (OR = 2.41, 1.22–4.77) or college degrees (OR = 5.01, 2.53–9.90) were more likely to have had PSA tests, while men without health insurance (OR = 0.32, 0.12–0.88) or a usual source of care (OR = 0.35, 0.22–0.54) were less likely. In a model including healthcare provider communication and information seeking, men who reported that providers involved them in decisions (OR = 1.76, 1.02–3.03) and recommended PSA (OR = 236.3, 70.5–791.4) were more likely to have had the tests. Men aged 65–74 (OR = 2.30, 1.33–4.00), with college degrees (OR = 2.91, 1.45–5.82), and greater information attention/seeking (OR = 1.23, 1.07–1.40) were more likely to report PSA recommendations, while those without usual care were less likely (OR = 0.37, 0.22–0.64). Men without usual care (OR = 0.38, 0.20–0.71) and Hispanic men (OR = 0.40, 0.19–0.85) were less likely to report that healthcare providers involved them in healthcare decisions. Conclusions. Results emphasize the relevance of patient decision making and the importance of healthcare providers in PSA testing. D 2004 The Institute For Cancer Prevention and Elsevier Inc. All rights reserved. Keywords: Prostate-specific antigen test; Prostate cancer screening; Informed decision making; Shared decision making; Communication

Introduction Prostate cancer poses a significant public health problem in the United States as the most common non-skin cancer

* Corresponding author. Cancer Prevention Fellowship Program, Division of Cancer Prevention and Health Communication and Informatics Research Branch, Division of Cancer Control and Population Science, National Cancer Institute, 6130 Executive Boulevard, 4051A MSC 7365, Bethesda, MD 20892-7361. Fax: +1 301 480 2198. E-mail address: [email protected] (L.J. Finney Rutten).

diagnosis and the second leading cause of cancer mortality among American men [1]. Interest in prostate cancer testing has increased since the early 1990s, with rapid uptake of prostate-specific antigen (PSA) testing for prostate cancer. Data from the 2000 National Health Interview Survey show that 41% of U.S. men aged 50 and older reported having had a PSA test within the last year [2]. PSA rates are similar to rates for colorectal cancer screening (home stool blood test within the past year or colorectal endoscopy within the past 5 years), for which a mortality benefit has been demonstrated [2]. Furthermore, given that some men may have

0091-7435/$ - see front matter D 2004 The Institute For Cancer Prevention and Elsevier Inc. All rights reserved. doi:10.1016/j.ypmed.2004.07.011

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PSA tests done without their active consent (e.g., as part of blood chemistry), self-reports of PSA use may underestimate actual testing prevalence [3–5]. Although PSA testing may play some role in recent declines in prostate cancer mortality, the data are not conclusive [1]. The U.S. Preventive Services Task Force recently reviewed the evidence on the relationship between PSA testing and prostate cancer mortality and concluded that there is insufficient evidence to support recommendations for routine screening of the general population [6–8]. Mortality data from ongoing randomized controlled trials, the U.S. National Cancer Institute’s Prostate, Lung, Colorectal and Ovarian Cancer Screening (PLCO) Trial, and the European Randomized Study of Screening for Prostate Cancer, will not be available for several years. Furthermore, it is not clear whether the benefits of screening outweigh potential risks [6,9–12]. Positive PSA tests require additional testing that may lead to more invasive diagnostic procedures. Radical prostatectomy and radiation treatments for prostate cancer may also produce complications such as erectile dysfunction and urinary incontinence [13]. Given the lack of definitive evidence of a mortality benefit for PSA screening, most professional organizations do not recommend routine PSA screening for all age-eligible men [14]. Rather, most organizations recommend that healthcare providers discuss testing and arrive at informed decisions with their male patients over age 50 [6,15–17]. Sociodemographic characteristics, such as age, race/ ethnicity, education, and income, have been associated with PSA use in previous research [2,18–22]. The prevalence of PSA use increases with age [2,18,20,21], education, and income [2,19]. Lower utilization rates have been documented among Hispanics, non-Hispanic Asians, and recent immigrants to the United States [2]. Not surprisingly, higher rates of PSA use are found among men with health insurance and a usual source of healthcare [2,19–21]. Provider recommendations for PSA testing also are associated with higher utilization rates [22]. The widespread use of PSA testing, coupled with controversies about PSA screening, have raised awareness about the need for men to understand the benefits and limitations of PSA tests. Thus, it is appropriate to examine patient decision making with regard to PSA test use [23]. Two complementary healthcare decision making models that have been proposed are shared decision making (SDM) and informed decision making (IDM). SDM occurs in clinical settings and is characterized by active provider involvement, mutual information sharing between the patient and provider, and expressions of patient preferences [24]. IDM occurs when patients understand their disease or condition and the particular test, regimen, or treatment under consideration. SDM and IDM are mutually supportive decision making processes wherein the patient (1) understands the risks and seriousness of a given health matter, (2) understands the risks, benefits, uncertainties, and alternatives to available preventive services, (3) has considered his or her values and

preferences regarding the preventive service, and (4) has participated in decision making about the service at a desired and comfortable level [23,24]. While SDM is limited to clinical settings, IDM may be cultivated both within and outside of the clinical setting. Moreover, IDM on the part of participants is required for SDM; thus, patients must be informed to share in the decision making process. SDM and IDM are particularly relevant to PSA test use because many professional organizations recommend that healthcare providers tailor decisions about PSA testing to individual patients by discussing the risks and benefits of the test and by taking patients’ risks, values, and preferences into account [6,15–17]. Within the SDM paradigm, men’s decisions about PSA testing are likely to be influenced by communication with healthcare providers including whether healthcare providers recommend PSA. IDM is not limited to the clinical setting, and does not require real-time communication between patients and heath care providers. However, if patients do not get the information from healthcare providers, IDM requires commitment beyond the physician’s office to help men understand what the PSA test is, as well as its potential benefits and limitations. The attention men pay to health information and health information seeking behavior is likely to influence the decision making process regarding PSA testing. The purpose of this report is to (1) examine PSA test use among subgroups defined by key demographic characteristics and (2) explore the association of PSA use with factors relevant to SDM and IDM. These include respondents’ perceptions of healthcare providers’ communication style and attention to health information and cancer information-seeking behavior.

Methods Data source Data for this investigation are from the 2003 Health Information National Trends Survey (HINTS). HINTS collects nationally representative data every 2 years on the American public’s need for, access to, and use of cancerrelevant information (see URL for complete copy of document: http://cancercontrol.cancer.gov/hints/). The conceptual framework that guided the development of HINTS proposes that health behaviors are influenced by a two-stage process of consumer-oriented health communication [25]. During health awareness building, the first stage in this process, exposure to formal (e.g., physicians and other healthcare professionals), informal (e.g., friends and family), and mass communication sources (e.g., TV, newspapers) generates attention to public health concerns. The extent to which communication sources influence health awareness may depend, in part, on personal characteristics such as age, race, and education. A perceived need for information flows from the awareness building to a second

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stage, information seeking. This two-stage process influences the attitudes, beliefs, and knowledge that shape subsequent health behaviors. Survey items HINTS reflects the conceptual framework described above. Survey items assess factors relevant to SDM and IDM. HINTS data provide a unique opportunity to examine factors associated with PSA test use in previous research as well as factors relevant to SDM and IDM in a large, national population-based survey. Available covariates include sociodemographic characteristics (age, race, ethnicity, education, income), access to healthcare (insurance, usual source of care), attention to health information, cancer information seeking, and perceptions of healthcare providers’ communication behavior. PSA test use Male respondents in the HINTS sample with no prior history of prostate cancer were asked if they had ever heard of the PSA test and whether they ever had a PSA test. Men who said they had never heard of the PSA test (n = 231) were not asked questions about PSA use. We included these men in our analyses and counted them as not having had the test. Just over half (55%) of the men in the sample reported that they ever had one or more PSA tests. Most of these men (80%) reported having had the test within the past year. Thus, we used the ever/never had PSA survey item as our primary outcome variable because it best captures variability in men’s use of PSA tests. Sociodemographic characteristics Following Office of Management and Budget standards [26], ethnicity and race were assessed as separate survey items. The ethnicity item asked respondents to indicate whether they were Hispanic; the race item asked them to identify their race. When respondents identified more than one race category, we used the first one they selected as their primary affiliation. Responses to the ethnicity and race questions were combined to create the following four categories: (1) non-Hispanic Whites, (2) non-Hispanic Blacks, (3) Hispanics, and (4) non-Hispanic others. Access to healthcare Health insurance status was assessed by asking respondents if they had any kind of healthcare coverage, including health insurance, prepaid plans, such as HMOs, or government plans such as Medicare. For usual source of care, respondents were asked if they had a particular doctor, nurse, or other health professional that they see most often. Perceptions of provider communication behavior Respondents who had heard of the PSA test and who responded on a previous question that they had talked with a health professional in the past year were asked if a doctor,

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nurse, or other health professional had advised them to have a PSA test within the past 12 months. Men who reported that they had not seen a health professional in the past year (n = 145) were not asked this question and were classified as not having PSA recommended in the past 12 months. The patient’s perspective of the quality of patient– provider communication was assessed using HINTS items taken from the Consumer Assessment of Health Plans Study (CAHPS) [27]. Respondents rated their general perceptions about the quality of their communication with healthcare providers over the past 12 months without specific reference to any particular patient–provider encounter or to any specific preventive health behavior such as PSA testing. Thus, these measures provide a global assessment of respondents’ perceptions of healthcare providers’ communication behaviors. Respondents were asked to indicate how often doctors or other healthcare providers engaged in the following activities: (1) listened carefully to you, (2) explained things in a way you could understand, (3) showed respect for what you had to say, (4) spent enough time with you, and (5) involved you in decisions about your healthcare. Responses were on the following 4-point scale: always, usually, sometimes, never. We reversed scores on each item so that higher scores indicated greater endorsement of the healthcare provider behavior. To capture whether SDM/IDM occurred in the clinical setting, we limited our analyses to the two items that assessed respondents’ perceptions of whether healthcare providers explained things in an understandable manner and involved them in healthcare decisions. Health information attending and seeking Attention to health information was assessed with a series of items that asked respondents to rate how much (a lot, some, a little, not at all) they pay attention to information about health or medical topics from the following sources: TV, radio, newspapers, magazines, and the internet. Scores were reversed, and responses were dichotomized as follows: 1 = a little and not at all and 2 = a lot and some. Respondents also were asked whether they had ever looked for information about cancer from any source. We summed dichotomous responses to these items to create a composite health information attention/seeking variable with scores ranging from 6 to 12; higher scores indicated that respondents paid more attention to health information and more actively sought cancer information. This composite captures factors conceptually relevant to IDM. Data collection, response rates, and sample Data were collected from October 2002 through April 2003. The survey was administered by trained interviewers to a representative sample of U.S. households drawn from all telephone exchanges in the U.S. Exchanges with high numbers of Blacks and Hispanics were oversampled. One adult aged 18 or older within each household was selected

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for the extended interview during a household screening. Complete interviews were conducted with 6,149 adults [25]. The final response rate for the household screener was 55%, and the final response rate for extended interview was 62.8%. Further details about the sample and sampling design are published elsewhere [25]. The questionnaire is available at http://cancercontrol.cancer.gov/hints/. Men who reported a history of prostate cancer (n = 63) or who did not complete the interview (n = 33) were not asked about PSA testing and were, therefore, excluded from all analyses. A total of 927 men aged 50 and older with no prior history of prostate cancer completed interviews. All responses to survey items classified as ‘‘refused’’ and ‘‘don’t know’’ were counted as missing. Respondents with missing values for relevant variables were excluded from analyses, resulting in sample sizes ranging from 718 to 927. Data analysis To account for the multistage sample design of HINTS, we used SUDAAN to calculate population estimates and confidence intervals (CIs). Cross-tabulations and chisquare tests of PSA test use and variables measuring sociodemographics, healthcare access, and perceptions of healthcare providers’ communication behaviors were conducted. Point-biserial correlation was used to assess the association between PSA test use and respondents’ health information attention/seeking. Initially, we conducted two logistic regression models. Model 1 assessed the extent to which PSA test use is associated with sociodemographic and healthcare access variables including age, race/ ethnicity, education, health insurance, and usual source of care. Preliminary analyses revealed a high correlation between education and income (r = 0.54, p b 0.0001). We decided that education was more conceptually relevant to SDM and IDM than income; thus, income was excluded from multivariate analyses to avoid problems with multicollinearity. To examine the association of patients’ perceptions of provider communication behavior (explain, involve, recommended PSA) and information attention/seeking with PSA testing while controlling for sociodemographic and healthcare access variables, these variables were added to the logistic regression in model 2. The 4-point scales that assessed whether the provider explained and involved the patient were treated as continuous in this model. The observed linear association of the explained and the involved variables with the outcome variable (PSA testing) and the nonsignificant difference in the nested logistic models entering these variables as categorical and continuous confirmed the appropriateness of treating these variables as continuous. We conducted two additional logistic regression models to identify correlates of respondents’ reports of receiving recommendations for PSA testing and perceptions of involvement in healthcare decisions.

Results Bivariate analyses Sociodemographic and healthcare access characteristics for the total sample as well as frequencies and percentages for respondents who reported ever (n = 515) and never (n = 379) having had PSA tests are shown in Table 1. Most men were aged 50–64 and were white. Compared with respondents who ever had PSA, a greater proportion of respondents who never had PSA tests were Hispanic, had annual incomes of $25,000 or less, had less than a high school education, did not have health insurance, and did not have a usual source of care (Table 1). The majority of the sample reported having health insurance (93%) and a usual source of care (76%). Respondents who reported that their healthcare providers involved them in decisions about their healthcare were more likely to have had PSA tests (r = 0.13, p b 0.001). There was a statistically significant association between having a PSA test and reporting that it was recommended by a healthcare professional [m2 (1) = 603.2, p b 0.0001]. Among respondents who ever had PSA tests, 76% reported a healthcare provider had recommended the test, while among respondents who never had a PSA test only 2% reported that a healthcare provider had recommended the test. Finally, health information attention/seeking was more likely among men who ever had a PSA test than among those who never had PSA tests (r = 0.23, p b 0.0001). Multivariate analyses Table 2 summarizes the odds ratios (ORs) and 95% confidence intervals (CIs) resulting from two separate logistic regression analyses. In model 1, age, education, health insurance, and usual source of care were significantly associated with ever having PSA tests. Compared with respondents aged 50–64, respondents aged 65–74 were more likely to have ever had a PSA test. Respondents who attended college were more likely than respondents with less than a high school education to have ever had a PSA test. Respondents with no health insurance and those with no usual source of care were less likely than those with insurance and with a usual source of care to have had PSA tests. Although the magnitude of the odds ratios and pattern of results for sociodemographic and healthcare access variables observed in model 2 were similar to model 1, all these variables, except age, became nonsignificant in model 2. As Table 2 shows, respondents who reported that their healthcare providers involved them in decisions about their healthcare, and especially those who said that a healthcare provider had recommended PSA testing, were more likely to have ever had PSA tests. We computed an additional logistic regression model to examine the association of provider PSA test recommenda-

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Table 1 Distribution and weighted percents for characteristics of men aged 50 and older (N = 927)a—HINTS 2003 Variables Sociodemographic Age 50–64 65–74 75+ Race/ethnicity White, non-Hispanic Black, non-Hispanic Hispanic Non-Hispanic other Income V25,000 N25,000 to b50,000 z50,000 Education bHigh school High school graduate Some college College graduate Health care access Insurance Yes No Usual source of care Yes No

Men aged 50+b (N = 927)

Ever had PSAc (N = 515, 55.2%)

Never had PSAc (N = 379, 44.8%)

N

%

N

%

N

%

563 229 135

61.6 25.1 13.3

286 155 74

49.7 67.9 57.6

263 64 52

50.3 32.1 42.4

724 84 63 32

79.5 9.2 7.0 4.3

426 44 18 12

58.7 52.0 26.4 34.2

274 37 41 20

41.3 48.0 73.6 65.8

233 261 356

27.8 31.0 41.2

88 146 234

37.4 57.5 63.5

135 105 114

62.6 42.5 36.5

128 263 203 332

20.6 29.8 21.7 27.9

41 122 114 238

38.9 48.9 57.0 72.3

81 128 80 89

61.1 51.1 43.0 27.7

857 69

92.6 7.4

501 14

58.3 17.9

325 54

41.7 82.2

706 219

76.2 23.8

439 74

61.9 32.8

239 140

38.1 67.2

a

All m2 for crosstabs of ever/never had PSA with sociodemographic and health care access variables significant at p b 0.01. Percentages were calculated as percent of total sample size (927) for each subcategory. Thus, percentages sum to 100 by column; not all categories sum to N = 927 due to missing values and not all percentages sum to 100 due to rounding.

b

tions with sociodemographic, healthcare access, perceived provider communication behavior, and information attention/seeking (Table 3). Compared with their referent groups, men aged 65–74, with college degrees, and those who reported greater information attention/seeking were more likely to report that their healthcare providers had recommended PSA. Compared with those who reported having a usual source of care, men without a usual source of care were less likely to report that their providers had recommended PSA tests. We also performed a logistic regression analysis examining correlates of involvement in decision making (Table 3). Responses on the 4-point scale assessing whether respondents were involved in decision making were dichotomized for use as the outcome variable in the logistic model as follows: 0 = never and sometimes and 1 = usually and always. Less involvement in decision making was observed among Hispanic men and those with no usual source of care.

Discussion Patterns of PSA test use in our sample are similar to those observed in other national samples [2]. Over half the

men reported that they ever had one or more PSA tests. Consistent with previous research [2,18–22], age, education, health insurance, and usual source of care were associated with PSA test use. Men aged 65–74, with at least some college education, with health insurance, and a usual source of care were more likely to report having a PSA test. Lower use of services such as Pap, mammography, and colorectal screening has also been documented among ethnic minority, low income, and uninsured groups [2,28–37]. Men who reported that their healthcare providers involved them in decisions about their healthcare and recommended PSA tests were more likely to have had the tests. These results call attention to patient involvement in healthcare decisions and confirm the key role of healthcare providers in men’s decisions about PSA testing [22–24]. Providers’ recommendations consistently have been shown to be one of the strongest predictors of adherence to recommendations for mammography [38–47] and colorectal screening [34–37]. In our sample, men aged 65–74, with a usual source of care, with a college degree and men who attend to and seek out health information were more likely to report that they received recommendations for PSA testing from their healthcare providers. Men with higher levels of education who pay more attention to health

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Table 2 Logistic regression models of ever had PSA with sociodemographic and health care access variables (n = 869)a and information attention/seeking and perceptions of providers’ communication behavior (n = 711)b—HINTS 2003 Variables Sociodemographic Age 50–64 65–74 75 plus Race/ethnicity White, non-Hispanic Black, non-Hispanic Hispanic Other, non-Hispanic Education bHS HS Some college College graduate Health care access Health Insurance Yes No Usual source of care Yes No Information Attention/seekingc Perceived provider Communication behavior Explained clearlyc Involved in decisionsc Recommend PSA Yes No

Model 1

Model 2

OR

95% CI

1.00 2.53 1.50

1.49–4.31 0.84–2.68

1.00 2.60 2.12

1.19–5.66 0.74–6.13

1.00 0.94 0.51 0.38

0.47–1.87 0.21–1.24 0.14–1.03

1.00 0.57 0.65 0.26

0.17–1.86 0.07–5.76 0.06–1.18

1.00 1.78 2.41 5.01

0.94–3.40 1.22–4.77 2.53–9.90

1.00 1.59 2.19 4.47

0.39–6.48 0.42–11.32 0.99–20.29

1.00 0.32

OR

0.12–0.88

1.00 0.18

0.22–0.54

1.00 0.64

95% CI

0.01–2.68

ment in healthcare decisions. Healthcare providers may also be more likely to involve patients in discussions about PSA testing if mechanisms are in place to reimburse providers for providing patient counseling. Hispanic men were less likely to report being involved by healthcare providers in decisions about healthcare than white non-Hispanic men. Previous research has shown the importance of language and cultural competence skills in health communication with Spanishspeaking patients [48]. Cultural differences and language barriers likely contribute to the lower involvement of Hispanic men in healthcare decisions. Limitations The HINTS instrument assessed patients’ perceptions of provider communication in general. The data do not allow us to discern whether specific discussion of PSA testing influenced men’s decisions about PSA testing. More direct Table 3 Logistic regression models examining associates of provider recommendation of PSA (n = 722)a and involvement in decision making (n = 746)b— HINTS 2003 Variables

1.00 0.35 –

– – – –

–

– – – –

1.02

0.65 1.76 236.30 1.00

0.29–1.38 0.83–1.25

0.38–1.12 1.02–3.03 70.5–791.4

a

Model 1: F(11) = 11.32, p b 0.0001. Model 2: F(15) = 10.31, p b 0.0001. c Scores on the information attention/seeking variable and the explained and involved variables were continuous. ORs are interpreted as the relative amount by which the odds of the outcome increase (OR N 1.0) or decrease (OR b 1.0) when the predictor variable increases by 1.0 units. b

information and more actively seek out cancer information may be more likely to initiate discussions of PSA testing with their healthcare providers. Healthcare providers may also be more engaged with patients who have higher levels of education or patients who pay greater attention to and seek out health information. Although HINTS 2003 data cannot show the direction of influence regarding initiation of discussions, they emphasize the importance of provider recommendations and patient information seeking in shaping healthcare decisions. Men with a usual source of healthcare were more likely to report being involved with healthcare providers in decisions about their health. Among these men, there may be greater opportunity for continuity of care and the development of patient–provider relationships that foster patient involve-

Sociodemographic Age 50–64 65–74 75 plus Race/ethnicity Non-Hispanic white Non-Hispanic black Hispanic Non-Hispanic other Education bHS HS Some college College graduate Health care access Health insurance Yes No Usual source of care Yes No Information Attention/seekingc Perceived provider Communication behavior Explained clearlyc Involved in decisionsc a

Recommended PSA

Involved in decisions

OR

95% CI

OR

95% CI

1.00 2.30 1.46

1.33–4.00 0.77–2.76

1.00 0.72 0.94

0.45–1.17 0.47–1.88

1.00 1.19 0.51 0.39

0.54–2.61 0.22–1.19 0.12–1.22

1.00 2.29 0.40 0.99

0.66–7.79 0.19–0.85 0.25–4.00

1.00 1.51 1.64 2.91

0.77–2.96 0.83–3.22 1.45–5.82

1.00 0.58 0.56 1.04

0.32–1.05 0.24–1.28 0.58–1.87

1.00 0.45

0.14–1.46

1.00 0.32

0.10–1.07

1.00 0.37

0.22–0.64

1.00 0.38

0.20–0.71

1.23

1.07–1.40

1.08

0.94–1.25

0.91 1.16

0.63–1.31 0.86–1.57

– –

– –

Recommended PSA: F(14) = 5.56, p b 0.0001. Involved in decisions: F(12) = 14.85, p b 0.0001. c Scores on the information attention/seeking variable and the explained and involved variables were continuous. ORs are interpreted as the relative amount by which the odds of the outcome increase (OR N 1.0) or decrease (OR b1.0) when the predictor variable increases by 1.0 units. b

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assessment of patients’ perceptions of healthcare providers’ communication about PSA testing would provide a better measure of the extent to which the communication between providers and patients is consistent with SDM/IDM on this issue. The data also do not provide information about the proportion of men who may have chosen not to have PSA tests after discussion with their healthcare providers. Previous research suggests that IDM and SDM result in lower uptake of PSA testing [49,50]. Our measure of information attention/seeking was not specific to PSA testing. More direct assessment of men’s attention to health information and information seeking relevant to PSA testing would provide greater insight into processes of SDM/IDM and PSA testing. Self-report of PSA test use is another potential limitation of this study. Some overreporting of screening use for Pap, mammography, colorectal screening, and digital rectal exams has been documented [51–53]. However, recent evidence suggests that men underreport PSA testing for reasons specific to the nature of the test [3–5]. Chan et al. [3] demonstrated that one-third of the patients interviewed in two outpatient clinic settings were unaware that they had PSA tests done during their visits. Thus, our decision to count men who never heard of PSA testing among those who never had a PSA test may have resulted in the misclassification of respondents who had the test without knowing it, which may lead to underestimation of the percentage of respondents who had the test.

Conclusions The lack of sufficient evidence to support recommendations for population-wide prostate cancer screening and documented deficits in patients’ knowledge of PSA testing [54,55] underscores the value of both SDM and IDM in supporting men’s decisions about PSA testing. Healthcare providers have a critical role in informing patients and involving them in decisions about PSA testing. Inconsistencies in healthcare providers’ willingness, ability, and available time to share information about PSA testing with their patients will almost certainly impede the processes of SDM [54,56]. Therefore, it is not realistic to expect healthcare providers and SDM to bear the entire burden of informing all age-eligible men about prostate cancer and PSA testing. Thus, IDM about PSA testing should be widely promoted both within and beyond clinical settings as part of public health programs and campaigns to increase public awareness about the benefits and limitations of PSA testing.

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