Terrance L. Albrecht, Ph.D.
KCI Associate Center Director, Population Sciences
Leader, KCI Population Studies and Disparities Research Program
Professor and Division Chief, Population Sciences
Wayne State University School of Medicine

Phase I: 2005—2010
◦ The NCI Community Network Program (CNP)
◦ Goal: Capacity Building with Pilot Studies, Training, Outreach
◦ Detroit CNP: Modeling the Sustainability of Community
Network Partnerships

Phase II: 2010—2015
◦ The NCI Community Network Program Center (CNPC)
◦ Detroit CNPC = “Southeast Michigan Partners Against Cancer
[SEMPAC]
◦ Goal: Community-Engaged Research (RCT; Pilots), Training
2005--2010
Aging Organization Partners
American Association of Retired Persons
Adult Well Being Services
Detroit Area Agency on Aging
Det. Parish Nurse Network
Luella Hannan Memorial Foundation
Healthier Black Elders/Institute of Gerontology
Neighborhood Service Organization
St. Aloysius Parish Detroit
Detroit Senior Citizens
Cancer-Related Organization Partners
Health-Related Organization Partners
American Cancer Society
Department of Health & Wellness Promotion
Michigan Society of Hematology and Oncology
Faith Access To Community Economic
Development
National Cancer Institute
Karmanos Cancer Institute
Greater Detroit Area Health Council
Sisters Network
MGM Casino Advisory Committee
Cancer Information Services
Michigan Department of Community Health
(Cancer group)
Myron Fraser - Community Advisory Committee
Oakland University
Pfizer
ProLiteracy
Voices of Detroit Initiative
Other
Henry Ford Hospital System (JFCC)
Detroit CNP to Reduce Cancer Disparities
Among Older, Underserved, African American
Adults U01 CA1536061; U01 CA1536061-S3
Baseline
Network
2006
Goal: Capacity Building
2008-2009

Challenge of Sustaining Network Relationships (Ties)
◦ Need to empirically explain retention of collaborative partnership ties
◦ Most studies of community networks assessed at one point in time;
sustainability entails longitudinal assessment
◦ Limited ability to model, visualize and understand change in
relationships over time with simple network sociograms

Research Questions
◦ What are the characteristics of collaborative network ties that sustain
over time?
 Strength of Reciprocated vs.
Unreciprocated ties
 Strength of Multiplex vs.

Uniplex ties
Manning, et al. Translational
Behavioral Medicine, 2014.
DATA: COLLABORATION MATRIX
Partner
representatives
completed once a
year for 4 years
(2005 – 2009).
KCI
1
X
X
X
X
X
3
1
Calculated Scores
On:
•
•
•
•
Multiplexity
Output degree
Input degree
Reciprocity
A = Sisters Network
B = Neighborhood Services Organization
C = KCI
D = Detroit Area Agency on Aging
A-B
A-C
A-D
B-A
B-C
B-D
C-A
C-B
C-D
D-A
D-B
D-C
2006
0
2
1
0
0
0
2
3
4
4
1
2
2007
0
3
2
2
3
0
1
2
3
4
1
1
2008
2
2
1
2
3
2
3
2
4
4
3
1
(Manning et al., 2012)
2009
3
1
2
0
1
0
2
3
3
4
1
1
QUESTION 1
 What are the characteristics of collaborative
network ties that sustain over time?
Reciprocated vs. Unreciprocated ties
Dark Lines =
Reciprocated Ties
OUTPUT DEGREE CENTRALIT Y
“POTENTIAL PROACTIVE INFLUENCE”
Non-SEMPAC
Output Degree Centrality
0.908
SEMPAC
0.808
0.708
0.608
“more potential
influence”
0.508
0.408
0.308
0.208
0.108
0.008
-3.00
SEMPAC group has
more outgoing
connections, and
they increase over
time
-2.00
-1.00
Time
0
INPUT DEGREE CENTRALIT Y
“FEWER MISSED COLLABORATIVE OPPORTUNITIES”
Non-SEMPAC
0.96
SEMPAC
0.86
Missed Opportunity
0.76
0.66
SEMPAC members
had fewer missed
opportunities from the
start, and continued to
have fewer missed
opportunities over
time.
0.56
Non-SEMPAC
members had more
missed opportunities,
and they increased
over time.
0.46
0.36
0.26
0.16
0.06
-3.00
-2.00
-1.00
Time
0
QUESTION 2
Multiplex vs. Uniplex ties
Are there discernable patterns in
reciprocated, multiplex partner
relationships over time?
 Indexed collaborative activity in each relationship
over 5 years: Resulting multiplexity pattern (array)
for each partner dyad
HEATMAP: MULTIPLEXIT Y OVER TIME
Submitted total
number of arrays
(n=930) to Cluster 3.0
to conduct
hierarchical clustering
analysis
Grouped partner
relationships with
similar arrays
Used Treeview to
generate “Heat Maps”
(similar to DNA micro
array analysis)
QUESTION 3
What explains the cluster patterns?
How did continuing network membership and
participation in collaborative events trigger
changes in structural markers?
How did collaborations among partner
organizations impact likelihood of continuing in
the CNP?
SUMMARY: MARKERS OF SUSTAINABILITY
 Network Level
 Sociograms – Graphical visualization of network
 Relationship Level
 Heat Maps – Clustered organization of relationships
 Increased activity clustered distinctly (2008, 2009)
 Individual Member Level
 SEMPAC partners: more central with more activity
 SEMPAC partners over time:
 Increased partnership ties
 activated by educational and research events
 fewer missed opportunities for collaborative
partnership
2005--2010
2010--2015
*
2005--2010
NCI Grant #U01CA1536061
U54Nanal Cancer Institute
NCI Grant #U54CA1536061
Sustaining Partners:



Regional Community Organizations
◦ Interfaith Health and Hope Coalition
◦ Detroit Area Agency on Aging
◦ Neighborhood Services Organization
◦ Adult Well Being Services
◦ Pro-Literacy Detroit, Inc.
◦ Michigan Center for Urban African American Aging Research
◦ Healthier Black Elders
◦ Area Agency on Aging 1-B
◦ The Senior Alliance, Area Agency on Aging
Non-Clinical Organizations
◦ Michigan Cancer Consortium
◦ Michigan Society of Hematology and Oncology
◦ American Cancer Society—Great Lakes Division
Clinics/Providers of Early Detection Services
◦ Michigan Breast and Cervical Cancer Control Program
◦ Henry Ford Health System

To reduce cancer disparities adversely affecting
older, underserved, African American adults in
southeast Michigan, through community-based
participatory research, training and outreach.

“Differences in health or health risks in which disadvantaged social
groups systematically experience worse health or greater health
risks than more advantaged groups”1
Interpersonal
(Patient and
Physician)
Multiple Causes:
Socioeconomic
Biological,
genetic,
medical
Health beliefs
and attitudes
BlackWhite
Treatment
Disparities
Environmental
1 Braveman, Ann Rev Public Health, 2009; Eggly et al., Health Expecs, 2013
Wayne, Macomb, Oakland Counties…
 67.5% of Michigan’s African American population
 42% of Michigan’s below poverty population
 40% of all invasive cancers statewide (2008-2010)
 713,777 Population (82% self-identify as Black/
African American
 36.7%
Poverty rate (median income: $26,098)
 27.0%
Single female parent households
 47.0%
Adult functional illiteracy rate
*datadrivendetroit.org, 2010
Age Adjusted Incidence Rates per 100,000 by Cancer Site, Race, and for Metro
Detroit SEER as compared with SEER-18 Registries, 2005-2010
Whites
Metro Detroit
African Americans
Metro Detroit
African Americans
SEER-18 Nationwide
Site
N
Rate
N
Rate
N
Rate
Prostate
14,363
166
5,772
256
47,890
230
Lung
15,253
80
4,589
87
32,582
70
Female Breast
13,156
128
4,046
125
35,033
121
Colon
6,438
33
2,300
44
19,490
42
Kidney
3,243
17
1,130
21
8,621
17
Endometrium
2,960
28
712
22
5,336
19
Cancer Type
Stage
African
American
White
Breast (female)
Advanced
37.9
26.9
Colorectal
Advanced
47.7
31
Prostate
Advanced
72.3
22.6
Lung
Advanced
204.3
178.2

Community Partner Collaborations for:
•
RESEARCH: A randomized controlled trial
•
TRAINING: Post doctoral fellows and junior faculty
•
OUTREACH: Education and engagement to increase
awareness about cancer risk, early detection/screening, the
importance of participating in clinical trials and biospecimen
donation for biobanking efforts
How Do Scientists and Community Partners Collaborate?
In the
Community…
In the
Clinic…

Breast: Blacks more likely to be significantly under dosed
in chemotherapy

Cervical: Blacks less likely to receive surgery

Colorectal: Blacks less likely to receive surgery or
radiation

Esophageal: Blacks less likely to see a surgeon; if see
surgeon less likely to receive surgery

Prostate: Blacks more likely to have “watchful waiting,”
less likely to have definitive therapy
Griggs, et al., 2006; Streyerberg et al., 2005; Shavers
et al., 2004a,b; SEER, 2005, Underwood et al., 2008;
Penner et al., 2012

Black patients usually have racially discordant visits
in oncology (<200 board certified African American
medical oncologists)

Racially discordant medical interactions:
•
•
•
•
•
•
Less active patient participation
Less patient-centered
Lower patient satisfaction
Lower patient trust
Shorter; less time on relationship-building
Less positive feelings
Siminoff et al 2006; Street et al 2007; Oliver et al 2001;
Eggly et al 2011; Penner et al 2013; ASCO, 2014

Addresses documented disparities in provision of
adjuvant/neoadjuvant chemotherapy to Black patients
with treatable breast, colorectal or lung cancers

Premises:
◦ Patients’/Physicians’ pre-existing characteristics and
race-related attitudes (MD bias/PT mistrust) affect
communication in clinic visits when treatment discussed
◦ Communication affects MD-PT perceptions of each other
and of treatment, in turn, affects actual treatment African
American patients receive
Theoretical Model
Before Interaction
During Interaction
Patient
Characteristics/
attitudes
Quality of
Communication
and
Information
Exchange
Physician
Characteristics/
attitudes
After Interaction
Patient
Treatment-Related
Attitudes and Beliefs
Patient
Treatment Decision
Physician
Treatment-Related
Attitudes and
Beliefs
Physician
Treatment Decision
INTERVENTION

To collaborate with our community partners to develop and
pilot test a patient-oriented, theory driven, scientifically
sound and practical intervention to improve the quality of
communication and information exchange during clinical
interactions in which African American patients discuss
treatment with their oncologists
◦ Intervention: A Question Prompt List (QPL)
◦ For patient use during interaction with oncologist
◦ QPL is a series of questions to encourage patients to participate
actively in visit by asking questions, stating concerns, etc.
◦ This aim achieved (see Eggly, et al., J. Cancer Education 2013)

To test the effectiveness of the intervention developed in
Aim 1 through a three-arm randomized controlled trial
with African American patients with stage I, II, or III
breast cancer or stage II or III colorectal or lung cancer.
◦ Hypothesis: Providing African American patients with QPL
alone or QPL with a communication coach (discusses
questions in the QPL and how to ask them) vs. standard of
care, will significantly improve:
 Appropriateness of MD-PT treatment decisions (receipt, dosing,
delay to treatment)
 Quality of MD-PT communication during visit and treatment
related attitudes and beliefs following visits
Step 1: Investigators create initial draft
Step 2: Consult with Research Advisory
Committee-RAC (Residents of
Southeast Michigan)
Step 3: Consult with medical
oncologists
Step 4: Qualitative interviews with
patients and families
Step 5: Consult with RAC and
medical oncologists for final draft
Eggly et al., 2013
GROUP 1:
STANDARD OF
CARE
No Intervention
GROUP 2:
QUESTION
PROMPT LIST
GROUP 3:
QUESTION
PROMPT LIST
+
COMMUNICATION
COACH
1.
2.
3.
4.
5.
MDs & African American PTs recruited, consented at
two cancer centers in urban Detroit (one NCIdesignated, comprehensive center, one community
center)
PTs baseline questionnaire: SES, personal history,
employment, attitudes and beliefs about medical care
Randomization to one of three arms
MD’s baseline questionnaire: professional history,
racial bias
One week later, MD-PT visit occurs
•
•
•
6.
Visit is video recorded
PTs report perceptions of MD, treatment
MDs asked parallel questions about treatment, PTs
One week later, PTs telephone interview
 Report perceptions of MD, treatment, intervention


Length of Interaction
Level of Patient Active Participation
◦ Frequency of patients’ questions, concerns, assertions

Patient-Centeredness
◦ Rate physicians’ supportiveness, informativeness

Shared Decision Making Processes
◦ Rate physician SDM behaviors

Oncologist-Patient Agreement
◦ Assess how well patients and physicians remember and
agree about content of discussion






Nao Hagiwara Ph.D. (now at Virginia Commonwealth University)
Rifky Tkatch, Ph.D. (WSU/KCI)
Mark Manning, Ph.D. (WSU/KCI)
Tara Eaton, Ph.D. (WSU/KCI)
Jamie Mitchell, Ph.D. (WSU/KCI)
Lauren Hamel, Ph.D. (WSU/KCI)
Trainees
(2010-2013)
SEMPAC
Training
Budget
Other Grant
Funding
Generated
N=6
$198,245
$593,213
(4) Postdoctoral
Fellows;
(2) Asst. Professors
Federal, WSU,
Local Foundation
Grants
Total
Leveraged
Training
Funds
$791,458





Key reason for community-engaged research: to create
partnerships for protecting community health and
reducing disparities
Sustainability of partnerships if related to quality of
partner inter-relationships evolving across time
Sustained partnerships engender community trust and
active participation in the research
Community-engaged approaches help improve clinicbased intervention trials
Community engaged research improves training of new
investigators (mentoring and leveraging)














Terrance L. Albrecht Ph.D., Principal Investigator (WSU/KCI)
Robert Chapman, M.D., Co-Principal Investigator (JFCI/HFHS)
Lisa Berry-Bobovski, M.A. (KCI/WSU)
John F. Dovidio Ph.D. (Yale University)
Susan Eggly Ph.D. (WSU/KCI)
Carie Francis, B.A. MPA (WSU/KCI)
Shirish Gadgeel, M.D. (WSU/KCI)
Richard Gonzalez Ph.D. (University of Michigan)
Elisabeth Heath, M.D. (KCI/WSU)
Peter Lichtenberg, Ph.D. (WSU/KCI)
Louis A. Penner, Ph.D. (WSU/KCI)
Anthony Shields, M.D., Ph.D. (WSU/KCI)
Hayley Thompson, Ph.D. (WSU/KCI)
Michelle van Ryn Ph.D. (Mayo Clinic)