Provider Strategies for Retaining Low-Income Minority Cancer Patients to a Depression Treatment Intervention Trial: Lessons Learned

Purpose: Depression, one of the most common cancer symptoms, has a profound impact on treatment retention and adherence. As such, there is an increasing need to identify simple, effective, and feasible strategies for retaining cancer patients to depression treatment. This becomes especially important in the context of a large public sector care system, where there are not only patient barriers, but also organizational/institutional barriers to delivery. This study aimed to explore strategies used by intervention trial providers to increase retention to a clinical depression treatment trial (Alleviating Depression among Patients with Cancer [ADAPt-C]), among a cohort of low-income minority cancer patients. Specifically, this study identified viable provider strategies to decrease dropout and increase retention to the depression effectiveness treatment trial. 

Methods: Grounded theory qualitative methods were used to analyze data from fourteen providers representing the various care roles in a randomized clinical depression treatment trial intervention. Fourteen providers included: six social work therapists, three project recruiters, two patient navigators, one psychiatrist, one project manager, and one project assistant. From May to June, 2008, strategies were elicited through in-depth, semi-structured interviews. Sensitizing concepts from the literature and dropout barriers identified by patients (who were predominately female, Latino, foreign-born, unmarried, unemployed, moderately depressed, less advanced cancer stage diagnosis, and in follow-up cancer treatment) were used to guide interview prompts. Strength of this study involved the use of data triangulation to improve analytic accuracy and rigor. Provider participants received $10 gift card incentives.

Results: Of the 242 ADAPt-C patients enrolled in the ADAPt-C intervention, 152 satisfied criteria for adhering to treatment, while 90 patients met criteria for withdrawing or dropping out of treatment. Retention strategies clustered according to trial dropout barriers: 1) Depression treatment barrier strategies included patient satisfaction surveys, efforts to strengthen the therapeutic alliance (e.g., building rapport, early engagement, and active listening), and clinical motivation strategies (e.g., persistence, consistency, outcome-focused counseling, validation, family involvement, and strength identification); 2) Informational barrier strategies included education about the study and psycho-educational strategies; 3) Instrumental barrier strategies included transportation resources, consistent contact, reminder calls, phone communication, and flexibility; 4) Recruitment barrier strategies included birthday greetings and the importance of incentive types; 5) Cultural barrier strategies included patient-provider cultural and language matching; and 6) Systems’ barrier strategies included patient systems navigation strategies and the importance of provider-provider rapport and communication. The important cross-cutting thread which links all of these barrier strategies together involves the importance of mediated communication between providers and patients, and providers and patient systems.

Implications: This high rate of study adherence among a hard-to-reach population suggests that socio-culturally grounded strategies can be effective in facilitating depression treatment retention among low-income, minority patients in a public sector oncology care system. Findings indicate that identification of treatment barriers can help generate culturally sensitive strategies that not only inform patient level communication interventions, but also institutional and organizational level communication efforts. This study is important to future development of evidence-based sustainability interventions and real-world mental/ health care.