“You Have to be Part of the Process”: A Qualitative Analysis of Older African American Men's Engagement in Primary Care Decision-Making and Communication

Background: Older African American men’s (AAM) perceptions of patient- provider communication are a strong predictor of patient satisfaction with care; trust in physicians, and participation in informed decision-making. Older AAM face a disproportionate burden of disparate health outcomes and concerns exist about whether primary care providers are promoting shared understanding, power, and responsibility with AAM during medical visits. Objectives: The current study sought to qualitatively assess older AAMs experiences with the patient-provider communication and care during primary care medical visits. We also elicited older AAM’s preferences for actively participating during medical visits by using specific communicative behaviors such as question asking. Methods: Participants were drawn from an existing community-based research registry of African American older adults in Southeast Michigan. The final sample consisted of 30 AAM age 50 and older who could speak English and had seen a health provider for a non-emergency medical visit in the prior 12 months. Three graduate students conducted and recorded a single semi-structured phone interview lasting up to one hour with each participant; participants received a $20 incentive. The qualitative interview protocol was informed by extant literature and comprised of open-ended prompts on therapeutic alliance, preferences for decision-making, self-efficacy, patient satisfaction, and companion participation during primary care medical visits. Phone interviews were transcribed, uploaded to a secure web-based analysis platform, and systematically coded for content. Coding yielded categories that were further revised and reduced to reliably capture the type, function, and context of patient care and communication experiences.  Analytic tools such as 3-D code clouds, interactive descriptor graphs, and code count tables corroborated the researchers’ interpretation of data patterns. Findings: Participants were 30 AAM, with a mean age was 76.4 and 60% were married. Emergent themes included the perception of rushed and inattentive care related to low socioeconomic status, inadequate information exchange about medical testing and follow-up care, welcoming the help of highly engaged companions, and proactively preparing for medical visits. Participants also expressed that physicians should be more accountable for building rapport, improving communication, and developing trusting relationships with older AAM patients. By far, the most prevalent and rich discussions centered on participants’ willingness to be assertive, confident, and persistent about engaging with health providers regarding agenda-setting for their care. Sub-categories included feeling comfortable seeking second opinions, advocating for specific courses of treatment that aligned with values, beliefs, or lifestyle, trusting physicians’ expertise while not being afraid to question recommendations, and being highly comfortable seeking additional health information from the Internet and trusted non-medical sources. Discussion and Implications: These findings reinforce that older AAM may not consistently receive patient-centered care and communication, particularly those with low socioeconomic status. However, the confidence and assertiveness expressed by participants contradicts a common narrative that AAM are less engaged in or informed about their health care. Social work researchers and practitioners should continue to explore the role of older age and socioeconomic status in shaping AAMs self-efficacy for active participation in medical encounters, and advocate for more inclusive patient-centered care for older AAM.