Study protocol for comparing Screening, Brief Intervention, and Referral to Treatment (SBIRT) to referral as usual for depression in African American churches

Sidney H Hankerson, Rachel Shelton, Myrna Weissman, Kenneth B Wells, Jeanne Teresi, Janhavi Mallaiah, Amita Joshua, Olajide Williams, Sidney H Hankerson, Rachel Shelton, Myrna Weissman, Kenneth B Wells, Jeanne Teresi, Janhavi Mallaiah, Amita Joshua, Olajide Williams

Abstract

Background: Depression is a leading cause of disability worldwide. African American adults, compared to White adults, are half as likely to be screened for depression in primary care settings. Disparities in depression screening contribute to poor clinical outcomes, as African Americans with depression are more disabled and sicker longer compared to Whites. African American churches are trusted settings that provide access to supports for depression. Indeed, in the first study of its kind, the investigators found that 20% of adults in African American churches screened positive for depression using the Patient Health Questionnaire-9 (PHQ-9). However, no subjects with a positive screen (PHQ-9 ≥ 10) accepted a treatment referral when offered by research personnel. Community Health Workers, who are trusted paraprofessionals from the target community, may bridge the gap between depression screening and treatment. The investigators have trained and certified 112 Community Health Workers from 45 African American churches in New York City to deliver an evidence-based intervention called Screening, Brief Intervention, and Referral to Treatment (SBIRT). Thus, the aim of the current study is to test the impact of Community Health Worker-delivered depression screening in Black churches on engagement with clinical services.

Methods: Using a hybrid type 1 effectiveness-implementation design, we propose a 2-arm, mixed-methods cluster randomized controlled trial. Church study sites will be randomized to either SBIRT (intervention arm) or referral as usual (usual care arm). This trial will be conducted with 600 church members across 30 churches (300 intervention; 300 usual care). Our primary outcome is treatment engagement, defined as attending a depression-related clinical visit. Secondary outcomes will be changes in Mental Health-Related Quality of Life and depressive symptoms at 3 and 6 months post-screening. Lastly, we will conduct a concurrent, mixed-methods (qualitative-quantitative) process evaluation to assess contextual facilitators and barriers of screening and referral.

Discussion: This is the first randomized trial of a church-placed, community health worker-delivered intervention for depression in African American populations. This study may provide a novel and effective approach to increasing depression identification and treatment linkage in economically disadvantaged populations with high depression rates.

Trial registration: ClinicalTrials.gov NCT04524767 . Registered on 21 August 2020.

Keywords: African Americans; Brief Intervention; Cluster randomized controlled trial; Community-based participatory research; Depression; Health disparities; Hybrid type 1 effectiveness-implementation design; Patient Health Questionnaire-9; Screening; and Referral to Treatment.

Conflict of interest statement

The authors declare that they have no competing interests.

© 2022. The Author(s).

Figures

Fig. 1
Fig. 1
Randomization of churches
Fig. 2
Fig. 2
Safety assessment protocol

References

    1. Hankerson SH, Fenton MC, Geier TJ, Keyes KM, Weissman MM, Hasin DS. Racial differences in symptoms, comorbidity, and treatment for major depressive disorder among black and white adults. J Natl Med Assoc. 2011;103(7):576–584. doi: 10.1016/S0027-9684(15)30383-7.
    1. Williams DR, Gonzalez HM, Neighbors H, et al. Prevalence and distribution of major depressive disorder in African Americans, Caribbean blacks, and non-Hispanic whites: results from the National Survey of American Life. Arch Gen Psychiatry. 2007;64(3):305–315. doi: 10.1001/archpsyc.64.3.305.
    1. Hankerson SH, Suite D, Bailey RK. Treatment disparities among African American men with depression: implications for clinical practice. J Health Care Poor Underserved. 2015;26(1):21–34. doi: 10.1353/hpu.2015.0012.
    1. Alegria M, Chatterji P, Wells K, et al. Disparity in depression treatment among racial and ethnic minority populations in the United States. Psychiatr Serv. 2008;59(11):1264–1272. doi: 10.1176/ps.2008.59.11.1264.
    1. Gonzalez HM, Vega WA, Williams DR, Tarraf W, West BT, Neighbors HW. Depression care in the United States: too little for too few. Arch Gen Psychiatry. 2010;67(1):37–46. doi: 10.1001/archgenpsychiatry.2009.168.
    1. Akincigil A, Olfson M, Siegel M, Zurlo KA, Walkup JT, Crystal S. Racial and ethnic disparities in depression care in community-dwelling elderly in the United States. Am J Public Health. 2012;102(2):319–328. doi: 10.2105/AJPH.2011.300349.
    1. Nicolaidis C, Timmons V, Thomas MJ, Waters AS, Wahab S, Mejia A, Mitchell SR. “You don’t go tell White people nothing”: African American women’s perspectives on the influence of violence and race on depression and depression care. Am J Public Health. 2010;100(8):1470–1476. doi: 10.2105/AJPH.2009.161950.
    1. Hudson DL, Eaton J, Banks A, Sewell W, Neighbors H. "Down in the Sewers": perceptions of depression and depression care among African American men. Am J Mens Health. 2018;12(1):126–137. doi: 10.1177/1557988316654864.
    1. Kramer TL, Blevins D, Miller TL, Phillips MM, Davis V, Burris B. Ministers’ perceptions of depression: a model to understand and improve care. J Relig Health. 2007;46(1):123–139. doi: 10.1007/s10943-006-9090-1.
    1. Murphy E, Hankerson S. Beliefs about causes of major depression: clinical and treatment correlates among African Americans in an urban community. J Clin Psychol. 2018;74(4):594–607. doi: 10.1002/jclp.22523.
    1. Schraufnagel TJ, Wagner AW, Miranda J, Roy-Byrne PP. Treating minority patients with depression and anxiety: what does the evidence tell us? Gen Hosp Psychiatry. 2006;28(1):27–36. doi: 10.1016/j.genhosppsych.2005.07.002.
    1. Siu AL, Force USPST Screening for depression in children and adolescents: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2016;164(5):360–366. doi: 10.7326/M15-2957.
    1. Akincigil A, Matthews EB. National rates and patterns of depression screening in primary care: results from 2012 and 2013. Psychiatr Serv. 2017;68(7):660–666. doi: 10.1176/appi.ps.201600096.
    1. Ayalon L, Alvidrez J. The experience of Black consumers in the mental health system--identifying barriers to and facilitators of mental health treatment using the consumers' perspective. Issues Ment Health Nurs. 2007;28(12):1323–1340. doi: 10.1080/01612840701651454.
    1. Mojtabai R, Olfson M, Sampson NA, Jin R, Druss B, Wang PS, Wells KB, Pincus HA, Kessler RC. Barriers to mental health treatment: results from the National Comorbidity Survey Replication. Psychol Med. 2011;41(8):1751–1761. doi: 10.1017/S0033291710002291.
    1. Menke R, Flynn H. Relationships between stigma, depression, and treatment in white and African American primary care patients. J Nerv Ment Dis. 2009;197(6):407–411. doi: 10.1097/NMD.0b013e3181a6162e.
    1. Sareen J, Jagdeo A, Cox BJ, et al. Perceived barriers to mental health service utilization in the United States, Ontario, and the Netherlands. Psychiatr Serv. 2007;58(3):357–364. doi: 10.1176/ps.2007.58.3.357.
    1. Warden D, Rush AJ, Wisniewski SR, Lesser IM, Thase ME, Balasubramani GK, Shores-Wilson K, Nierenberg AA, Trivedi MH. Income and attrition in the treatment of depression: a STAR*D report. Depress Anxiety. 2009;26(7):622–633. doi: 10.1002/da.20541.
    1. Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci. 2009;4(1):50. doi: 10.1186/1748-5908-4-50.
    1. Davis TW. General Social Survey. Association of Religion Data Archives Web site. 1994. . Accessed 14 Jan 2018.
    1. Campbell MK, Hudson MA, Resnicow K, Blakeney N, Paxton A, Baskin M. Church-based health promotion interventions: evidence and lessons learned. Annu Rev Public Health. 2007;28(1):213–234. doi: 10.1146/annurev.publhealth.28.021406.144016.
    1. Bowie JV, Wells AM, Juon H-S, Sydnor KD, Rodriguez EM. How old are African American women when they receive their first mammogram? Results from a church-based study. J Community Health. 2008;33(4):183–191. doi: 10.1007/s10900-008-9092-x.
    1. Matthews AK, Berrios N, Darnell JS, Calhoun E. A qualitative evaluation of a faith-based breast and cervical cancer screening intervention for African American women. Health Educ Behav. 2006;33(5):643–663. doi: 10.1177/1090198106288498.
    1. Holt CL, Wynn TA, Southward P, Litaker MS, Jeames S, Schulz E. Development of a spiritually based educational intervention to increase informed decision making for prostate cancer screening among church-attending African American men. J Health Commun. 2009;14(6):590–604. doi: 10.1080/10810730903120534.
    1. Tang TS, Nwankwo R, Whiten Y, Oney C. Training peers to deliver a church-based diabetes prevention program. Diabetes Educ. 2012;38(4):519–525. doi: 10.1177/0145721712447982.
    1. Austin SA, Claiborne N. Faith wellness collaboration: a community-based approach to address type II diabetes disparities in an African-American community. Soc Work Health Care. 2011;50(5):360–375. doi: 10.1080/00981389.2011.567128.
    1. Boltri JM, Davis-Smith YM, Seale JP, Shellenberger S, Okosun IS, Cornelius ME. Diabetes prevention in a faith-based setting: results of translational research. J Public Health Manag Pract. 2008;14(1):29–32. doi: 10.1097/01.PHH.0000303410.66485.91.
    1. Bauer AG, Berkley-Patton J, Bowe-Thompson C, Ruhland-Petty T, Berman M, Lister S, Christensen K. Do Black women's religious beliefs about body image influence their confidence in their ability to lose weight? Prev Chronic Dis. 2017;14:E98. doi: 10.5888/pcd14.170153.
    1. Derose KP, Williams MV, Florez KR, et al. Eat, pray, move: a pilot cluster randomized controlled trial of a multilevel church-based intervention to address obesity among African Americans and Latinos. Am J Health Promot. 2018;890117118813333(4):586–596. doi: 10.1177/0890117118813333.
    1. Cooper KC, King MA, Sarpong DF. Tipping the scales on obesity: church-based health promotion for African American women. J Christ Nurs. 2015;32(1):41–45. doi: 10.1097/CNJ.0000000000000132.
    1. Frank D, Grubbs L. A faith-based screening/education program for diabetes, CVD, and stroke in rural African Americans. ABNF J. 2008;19(3):96–101.
    1. Ralston PA, Young-Clark I, Coccia C. The development of health for hearts united: a longitudinal church-based intervention to reduce cardiovascular risk in mid-life and older African Americans. Ethn Dis. 2017;27(1):21–30. doi: 10.18865/ed.27.1.21.
    1. Tomlinson S. Evidence to support church-based health promotion programmes for African Canadians at risk for cardiovascular disease. J Immigr Minor Health. 2011;13(6):1175–1179. doi: 10.1007/s10903-011-9502-5.
    1. Hankerson SH, Watson KT, Lukachko A, Fullilove MT, Weissman M. Ministers’ perceptions of church-based programs to provide depression care for African Americans. J Urban Health. 2013;90(4):685–698. doi: 10.1007/s11524-013-9794-y.
    1. Chatters LM, Taylor RJ, Woodward AT, Bohnert ASB, Peterson TL, Perron BE. Differences between African Americans and non-hispanic whites utilization of clergy for counseling with serious personal problems. Race Soc Probl. 2017;9(2):139–149. doi: 10.1007/s12552-017-9207-z.
    1. Hankerson SH, Weissman MM. Church-based health programs for mental disorders among African Americans: a review. Psychiatr Serv. 2012;63(3):243–249. doi: 10.1176/appi.ps.201100216.
    1. Curran GM, Bauer M, Mittman B, Pyne JM, Stetler C. Effectiveness-implementation hybrid designs: combining elements of clinical effectiveness and implementation research to enhance public health impact. Med Care. 2012;50(3):217–226. doi: 10.1097/MLR.0b013e3182408812.
    1. Community District Needs. Department of City Planning. . Published 2012. Accessed 16 Jan 2013.
    1. Babor TF, McRee BG, Kassebaum PA, Grimaldi PL, Ahmed K, Bray J. Screening, Brief Intervention, and Referral to Treatment (SBIRT) Subst Abus. 2007;28(3):7–30. doi: 10.1300/J465v28n03_03.
    1. Administration SAaMHS . White Paper on Screening, Brief Intervention and Referral to Treatment (SBIRT) in Behavioral Healthcare Substance Abuse and Mental Health Services Administration. 2011.
    1. Gilbody S, Richards D, Brealey S, Hewitt C. Screening for depression in medical settings with the Patient Health Questionnaire (PHQ): a diagnostic meta-analysis. J Gen Intern Med. 2007;22(11):1596–1602. doi: 10.1007/s11606-007-0333-y.
    1. McMillan D, Gilbody S, Richards D. Defining successful treatment outcome in depression using the PHQ-9: a comparison of methods. J Affect Disord. 2010;127(1-3):122–129. doi: 10.1016/j.jad.2010.04.030.
    1. Manea L, Gilbody S, McMillan D. Optimal cut-off score for diagnosing depression with the Patient Health Questionnaire (PHQ-9): a meta-analysis. CMAJ. 2012;184(3):E191–E196. doi: 10.1503/cmaj.110829.
    1. Reese A, Thorpe R, Bell C, Bowie J, LaVeist T. The effect of religious service attendance on race differences in depression: findings from the EHDIC-SWB Study. J Urban Health. 2012;89(3):510–518. doi: 10.1007/s11524-011-9659-1.
    1. Monahan PO, Shacham E, Reece M, Kroenke K, Ong’or WO, Omollo O, Yebei VN, Ojwang C. Validity/reliability of PHQ-9 and PHQ-2 depression scales among adults living with HIV/AIDS in western Kenya. J Gen Intern Med. 2009;24(2):189–197. doi: 10.1007/s11606-008-0846-z.
    1. Chen S, Chiu H, Xu B, Ma Y, Jin T, Wu M, Conwell Y. Reliability and validity of the PHQ-9 for screening late-life depression in Chinese primary care. Int J Geriatr Psychiatry. 2010;25(11):1127–1133. doi: 10.1002/gps.2442.
    1. Miller WR. In: Motivational interviewing: helping people change. 3. Rollnick S, editor. New York, NY: Guilford Press; 2013.
    1. Hettema J, Steele J, Miller WR. Motivational interviewing. Annu Rev Clin Psychol. 2005;1:21. doi: 10.1146/annurev.clinpsy.1.102803.143833.
    1. Brody AE. Motivational interviewing with a depressed adolescent. J Clin Psychol. 2009;65(11):1168–1179. doi: 10.1002/jclp.20636.
    1. Friedman ES, Wisniewski SR, Gilmer W, Nierenberg AA, Rush AJ, Fava M, Zisook S, Balasubramani GK, Trivedi MH. Sociodemographic, clinical, and treatment characteristics associated with worsened depression during treatment with citalopram: results of the NIMH STAR(*)D trial. Depress Anxiety. 2009;26(7):612–621. doi: 10.1002/da.20568.
    1. Kroenke K, Spitzer RL. The PHQ-9: a new depression diagnostic and severity measure. Psychiatric Annals. 2002;32(9):1–7. doi: 10.3928/0048-5713-20020901-06.
    1. Vidair HB, Boccia AS, Johnson JG, Verdeli H, Wickramaratne P, Klink KA, Softness AM, Dominguez-Rafer C, Younge RG, Weissman MM. Depressed parents’ treatment needs and children’s problems in an urban family medicine practice. Psychiatr Serv. 2011;62(3):317–321. doi: 10.1176/ps.62.3.pss6203_0317.
    1. Sheehan DV, Lecrubier Y, Sheehan KH, et al. The Mini-International Neuropsychiatric Interview (M.I.N.I.): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. J Clin Psychiatry. 1998;59(Suppl 20):22–33.
    1. Wells KB, Jones L, Chung B, Dixon EL, Tang L, Gilmore J, Sherbourne C, Ngo VK, Ong MK, Stockdale S, Ramos E, Belin TR, Miranda J. Community-partnered cluster-randomized comparative effectiveness trial of community engagement and planning or resources for services to address depression disparities. J Gen Intern Med. 2013;28(10):1268–1278. doi: 10.1007/s11606-013-2484-3.
    1. Ong MK, Jones L, Aoki W, Belin TR, Bromley E, Chung B, Dixon E, Johnson MD, Jones F, Koegel P, Khodyakov D, Landry CM, Lizaola E, Mtume N, Ngo VK, Perlman J, Pulido E, Sauer V, Sherbourne CD, Tang L, Vidaurri E, Whittington Y, Williams P, Lucas-Wright A, Zhang L, Southard M, Miranda J, Wells K. A community-partnered, participatory, cluster-randomized study of depression care quality improvement: three-year outcomes. Psychiatr Serv. 2017;68(12):1262–1270. doi: 10.1176/appi.ps.201600488.
    1. Miranda J, Ong MK, Jones L, Chung B, Dixon EL, Tang L, Gilmore J, Sherbourne C, Ngo VK, Stockdale S, Ramos E, Belin TR, Wells KB. Community-partnered evaluation of depression services for clients of community-based agencies in under-resourced communities in Los Angeles. J Gen Intern Med. 2013;28(10):1279–1287. doi: 10.1007/s11606-013-2480-7.
    1. Springgate B, Tang L, Ong M, Aoki W, Chung B, Dixon E, Johnson MD, Jones F, Landry C, Lizaola E, Mtume N, Ngo VK, Pulido E, Sherbourne C, Wright AL, Whittington Y, Williams P, Zhang L, Miranda J, Belin T, Gilmore J, Jones L, Wells KB. Comparative effectiveness of coalitions versus technical assistance for depression quality improvement in persons with multiple chronic conditions. Ethn Dis. 2018;28(Suppl 2):325–338. doi: 10.18865/ed.28.S2.325.
    1. Chang ET, Wells KB, Gilmore J, Tang L, Morgan AU, Sanders S, Chung B. Comorbid depression and substance abuse among safety-net clients in Los Angeles: a community participatory study. Psychiatr Serv. 2015;66(3):285–294. doi: 10.1176/appi.ps.201300318.
    1. Chung B, Ong M, Ettner SL, Jones F, Gilmore J, McCreary M, Sherbourne C, Ngo V, Koegel P, Tang L, Dixon E, Miranda J, Belin TR, Wells KB. 12-month outcomes of community engagement versus technical assistance to implement depression collaborative care: a partnered, cluster, randomized, comparative effectiveness trial. Ann Intern Med. 2014;161(10 Suppl):S23–S34. doi: 10.7326/M13-3011.
    1. Ware J, Jr, Kosinski M, Keller SD. A 12-Item Short-Form Health Survey: construction of scales and preliminary tests of reliability and validity. Med Care. 1996;34(3):220–233. doi: 10.1097/00005650-199603000-00003.
    1. Rush AJ, Trivedi MH, Ibrahim HM, Carmody TJ, Arnow B, Klein DN, Markowitz JC, Ninan PT, Kornstein S, Manber R, Thase ME, Kocsis JH, Keller MB. The 16-Item Quick Inventory of Depressive Symptomatology (QIDS), clinician rating (QIDS-C), and self-report (QIDS-SR): a psychometric evaluation in patients with chronic major depression. Biol Psychiatry. 2003;54(5):573–583. doi: 10.1016/S0006-3223(02)01866-8.
    1. Kroenke K, Yu Z, Wu J, Kean J, Monahan PO. Operating characteristics of PROMIS four-item depression and anxiety scales in primary care patients with chronic pain. Pain Med. 2014;15(11):1892–1901. doi: 10.1111/pme.12537.
    1. Tagai EK, Scheirer MA, Santos SLZ, Haider M, Bowie J, Slade J, Whitehead TL, Wang MQ, Holt CL. Assessing capacity of faith-based organizations for health promotion activities. Health Promot Pract. 2017;1524839917737510(5):714–723. doi: 10.1177/1524839917737510.
    1. Boyatzis RE. Transforming qualitative information: Thematic analysis and code development. Incorporated: Sage Publications; 1998.
    1. Fleiss JL, Levin B, Paik MC. Statistical Methods for Rates and Proportions, Third Edition. New Jersey: Wiley; 2003.
    1. Hsieh JH. Sample size tables for logistic regression. Stat Med. 1989;8(7):795–803. doi: 10.1002/sim.4780080704.
    1. Whittemore A. Sample size for logistic regression with small response probability. J Am Stat Assoc. 1981;76(373):27–32. doi: 10.1080/01621459.1981.10477597.
    1. Diggle P, Liang K-Y, Zeger S, editors. Analysis of Longitudinal Data. New York: Oxford University Press; 1994.
    1. Stanley B, Brown GK, Karlin B, Kemp JE, VonBergen HA. Safety plan treatment manual to reduce suicide risk: Veteran version. Washington DC: United States Department of Veteran Affairs, 12. 2008.
    1. Stanley B, Brown GK. Safety planning intervention: a brief intervention to mitigate suicide risk. Cogn Behav Pract. 2012;19(2):256–264. doi: 10.1016/j.cbpra.2011.01.001.
    1. Shelton RC, Cooper BR, Stirman SW. The sustainability of evidence-based interventions and practices in public health and health care. Annu Rev Public Health. 2018;39(1):55–76. doi: 10.1146/annurev-publhealth-040617-014731.
    1. Greenberg PE, Fournier AA, Sisitsky T, Pike CT, Kessler RC. The economic burden of adults with major depressive disorder in the United States (2005 and 2010) J Clin Psychiatry. 2015;76(2):155–162. doi: 10.4088/JCP.14m09298.
    1. Gilbody S, Sheldon T, House A. Screening and case-finding instruments for depression: a meta-analysis. CMAJ. 2008;178(8):997–1003. doi: 10.1503/cmaj.070281.
    1. Lincoln CE, Mamiya LH. The Black Church in the African American Experience. Durham and London: Duke University Press; 1990.
    1. Lukachko A, Myer I, Hankerson S. Religiosity and Mental Health Service Utilization Among African-Americans. J Nerv Ment Dis. 2015;203(8):578–582. doi: 10.1097/NMD.0000000000000334.
    1. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16(9):606–613. doi: 10.1046/j.1525-1497.2001.016009606.x.
    1. Hankerson SH, Lee YA, Brawley DK, Braswell K, Wickramaratne PJ, Weissman MM. Screening for Depression in African-American Churches. Am J Prev Med. 2015;49(4):526–533. doi: 10.1016/j.amepre.2015.03.039.
    1. Williams L, Gorman R, Hankerson S. Implementing a mental health ministry committee in faith-based organizations: the promoting emotional wellness and spirituality program. Soc Work Health Care. 2014;53(4):414–434. doi: 10.1080/00981389.2014.880391.
    1. Wennerstrom A, Haywood C, Wallace M, Sugarman M, Walker A, Bonner T, Sutton Y, Keller BL, Lewis M, Springgate B, Theall K. Creating safe spaces: a community health worker-academic partnered approach to addressing intimate partner violence. Ethn Dis. 2018;28(Suppl 2):317–324. doi: 10.18865/ed.28.S2.317.
    1. Wennerstrom A, Johnson L, Gibson K, Batta SE, Springgate BF. Community health workers leading the charge on workforce development: lessons from New Orleans. J Community Health. 2014;39(6):1140–1149. doi: 10.1007/s10900-014-9869-z.
    1. Ravenell J, Leighton-Herrmann E, Abel-Bey A, DeSorbo A, Teresi J, Valdez L, Gordillo M, Gerin W, Hecht M, Ramirez M, Noble J, Cohn E, Jean-Louis G, Spruill T, Waddy S, Ogedegbe G, Williams O. Tailored approaches to stroke health education (TASHE): study protocol for a randomized controlled trial. Trials. 2015;16(1):176. doi: 10.1186/s13063-015-0703-4.
    1. Kitchener BA, Jorm AF. Mental Health First Aid: an international programme for early intervention. Early Interv Psychiatry. 2008;2(1):55–61. doi: 10.1111/j.1751-7893.2007.00056.x.
    1. Ravenell J, Thompson H, Cole H, Plumhoff J, Cobb G, Afolabi L, Boutin-Foster C, Wells M, Scott M, Ogedegbe G. A novel community-based study to address disparities in hypertension and colorectal cancer: a study protocol for a randomized control trial. Trials. 2013;14(1):287. doi: 10.1186/1745-6215-14-287.

Source: PubMed

Sponsors and Collaborators

Medical Conditions

Drug Interventions

3
Subscribe