Attitudes and Beliefs About Prostate Cancer and Screening Among Rural African American Men

Written By: Sam Savage

Published Date: December 14, 2007 Last Edited: December 14, 2007

By Oliver, JoAnn S

Abstract: Purpose. The research study purpose was to describe the personal attitudes and beliefs of rural African American men related to prostate cancer and screening. Procedure. Audio taped interviews were conducted with nine (9) African American men living in rural communities of West Central Alabama. Findings. Six common themes were found among the rural African American men participants. The themes identified were: (1) Disparity; (2) Lack of understanding; (3) Tradition; (4) Mistrust in the system; (5) Fear; and (6) Threat to manhood Conclusions. The results support the general significance of understanding the views of the target population and specifically its culture and offer opportunities for adapting health promotion to the population. Key Words: Prostate Cancer, Prostate Cancer Screening, African American Men, Rural, Qualitative Research

Prostate cancer is the most commonly diagnosed cancer, and the second leading cause of cancer death among men in the United States. The American Cancer Society [ACS] (2005) estimates that approximately 232,090 men will be diagnosed with prostate cancer and 30,350 will die of the disease in the year 2005. African American men are diagnosed with prostate cancer up to 65% more frequently than their Caucasian counterparts, and are more than twice as likely to die from it (ACS, 2005; Prostate Cancer Foundation, 2004). Reasons postulated for this health disparity is the lack of early diagnosis (prostate cancer screening) and treatment in African American men. One of the two major goals of Healthy People 2010 (United States Department of Health and Human Services [USDHHS], 2000) is to eliminate health disparities. To do so, a better understanding of the reasons that African American men do not avail themselves for prostate cancer screening is essential. The purpose of this study was to describe personal attitudes and beliefs of rural African American men related to prostate cancer and prostate cancer screening.

BACKGROUND

Prostate cancer screening is controversial relating to the lack of consensus surrounding screening recommendations (ACS, 2005; National Cancer Institute [NCI], 2005; Center for Disease Control and Prevention [CDC], 2003). Organizations such as NCI and the CDC do not advocate routine testing for prostate cancer at this time. However, the ACS, American Urological Association and the National Comprehensive Cancer Network recommend yearly prostate cancer screenings (ACS, 2005; Wilkinson, List, Sinner/Dai & Chodak, 2003). Most clinicians and researchers agree, however, that to significantly reduce prostate cancer mortality rates of at-risk male populations such as African American men and men with a family history of prostate cancer should be screened (ACS, 2005). African American men should be informed about the benefits of prostate cancer screening, including risks and benefits. Informed decisions can then be made concerning participation in prostate cancer screening.

Health Disparities.

Health disparity or health inequality is noted to be a difference in health status of one group of people compared to another (Smedley Stith, & Nelson, 2003). According to Woods et al. (2004) there is overwhelming evidence that African Americans and other minorities receive substandard health care compared to Caucasians across a range of health conditions and procedures when insurance status, income, age and severity of condition are comparable.

A major goal of Healthy People 2010 is to eliminate health disparities, specifically related to cancer in underserved populations. Cancer is one of the 28 focus areas identified to assist in the visualization of a healthy community (U.S. Department of Health and Human Services, 2000).

There is great diversity among rural African American communities, but compared to the United States population as a whole, most experience disparities in their health status. Whether it is related to physician access, transportation access, or other causes, undetected cancer and fewer visits to the physicians have been identified as being related to “differences” in the rural population (Mueller, Ortegra, Parker, Patil, Askenazi, 1999).

One in six American men will develop prostate cancer during his lifetime. African-American men have the highest risk of developing prostate cancer and are twice as likely to die from it as other men with the cancer (ACS, 2005). In the United States a man is 33% more likely to develop prostate cancer than an American woman is to get breast cancer (Prostate Cancer Foundation, 2005). Yet compared to breast cancer literature and cancer television and radio advertisements, media attention to prostate cancer screening is less prevalent. It is scarcely seen or heard in the arena of public awareness.

Despite higher prostate cancer morbidity and mortality rates, African American men are less likely to participate in prostate cancer screenings. The reasons for this are unclear, and no qualitative studies were found to shed light on these reasons. Thus the purpose of the study is to describe the attitudes and beliefs about prostate cancer and prostate cancer screenings among rural African American men.

LITERATURE REVIEW

Prostate Cancer. The cost of prostate cancer is enormous. According to the ACS (2005) cancer costs to the economy were more than $189.8 billion for the year of 2004 (National Prostate Cancer Coalition, 2005). About 41,000 American men die of prostate cancer each year at a national cost of at least $1 billion (Gregg, 2002). According to the National Prostate Cancer Coalition (2005) prostate cancer screenings enable men to be diagnosed at earlier stages of the disease. Ultimately this could decrease mortality and improve opportunities for successful treatment and lessen cost.

Influences known to impact the risk of prostate cancer development in African American males are age, family history, diet and obesity. These factors combined with the lack of screening participation could contribute to the disparities of prostate cancer morbidity and mortality among African American males. A better understanding of the personal experiences, beliefs, and perceptions about prostate cancer and screening among African American men may be useful in developing targeted interventions for this at-risk population.

Prostate Cancer Screening.

Nationally there is a lack of consensus related to the efficacy of prostate cancer screening in the United States. Though the effectiveness of prostate cancer screening is unproven there are screening guidelines that recommend the communication of information on the limitations, as well as the benefits of prostate cancer screening (Weinrich, et al., 2004). The prostate-specific antigen blood test (PSA) and the digital rectal exam (DRE) are procedures used for screening and early detection of prostate cancer. According to ACS (2005) recommendations, the PSA and the DRE should be offered annually beginning at age 50 to men who have a life expectancy of at least 10 years. Men at high risk, such as African-American men, and men with a strong family history of one or more first-degree relatives diagnosed with prostate cancer, should begin testing by age 45 (ACS, 2005).

The earlier that prostate cancer is detected, the greater is the probability of a 5-year survival rate. If diagnosed during the early stages, prognosis of prostate cancer is optimistic. ACS (2005) has substantiated the fact that prostate cancer screenings have resulted in men being diagnosed early.

Weinrich, Yoon, and Weinrich (1998) found that even when free prostate cancer screenings were offered, African American men were less likely then Caucasian men to be screened for prostate cancer. Industry work sites in 11 counties in central South Carolina were recruited. One hundred-seventy-nine men participated in the research. Sixty-four percent of the sample population were African American (n =115). After completing a survey, a slide-tape show developed by the researchers was shown. The slide tape show involved a discussion of the prostate; the American Cancer Society screening guidelines for DRE and PSA; symptoms of prostate cancer; the importance of early detection, and a brief overview of treatment options including watchful waiting. Each participant received a voucher to take to his physician of choice for a free prostate cancer screening that included a DRE and PSA. The findings indicated that only 47% of the African American males availed themselves to the free screenings, compared to 71.9% of the White males (N=179).

Perceived benefits related to prostate cancer screening were examined in a study done by Tingen, Weinrich, Heydt, Boyd, and Weinrich (1998) utilizing a sample of 1522 men, 40-70 years of age. The perceived benefits were identified as being the personal belief and valuing of screening for early detection of prostate cancer. There were four possible educational interventions. The educational interventions included a.) the traditional approach which was education on prostate cancer; b.) the peer educator approach, which included the traditional method along with a male testimony of the importance of prostate cancer screening; c.) the client navigator approach, which included the traditional method and a social worker involvement in helping the participant through the “system” to participate in screening; and d.) the combination intervention which utilized all of the other approaches combined. Seventy-two percent (n=1,089) of the sample participants were African American. According to the researchers, the educational interventions were equally implemented among sample. However, only 64% of the African American men chose to participate and receive the free screening compared to 79% or the Caucasian men who participated in the free screening. Dale, Sartor, Davis, and Bennett (1999) conducted thirty- two focus groups to elicit attitudes towards prostate cancer. There were a total of 96 focus group participants. The ages of the participants rangedfrom 39 to 95 years. Twenty-eight percent of the men had a high school degree, and 33% had less than a high school education. Approximately half of the participants were Caucasian (49%) and half were African American (51%). There were 9 groups that consisted of all Caucasians, 10 groups that were all African American and 7 groups that were mixed with African American and Caucasians. Findings indicated that participants had negative impressions of the prostate examination, and did not believe in early detection. Time, out of pocket expenses, physical pain, social embarrassment, and uncertain values were identified as barriers to seeking care. Participants who had prostate examinations reported having the examination because of employer requirements.

It is well known that the incidence of prostate cancer increases dramatically with age (ACS, 2005). The incidence of prostate cancer in African American males’ exceeds that of Caucasians. The risk of developing prostate cancer for Caucasian males with no family history of the disease begins at age 50, while risk for African American men begins at age 40 (ACS, 2005). The fact that African American men delay or avoid screening coupled with health disparity has been identified as a possible reason for differences in prostate cancer diagnosis and mortality in African American men (Parchment, 2004).

Woods, et al. (2004) used a mixed methods longitudinal cohort study (baseline and 6-month follow-up) to explore general and screening related health behaviors concerning prostate cancer. Phase I consisted of a formative qualitative data collection around beliefs about prostate cancer prevention issues. Interviews were conducted with “key informants”, 15 black men, 7 physicians and 2 nurses. Two focus groups (n = 22) from the target community were conducted to validate key informant’s findings. Phase II consisted of 277 participants who completed the questionnaire. Mean age of the sample was 53 years with 4% under age 40. Five themes emerged on how culture influences attitudes, beliefs and practices regarding decision making about prostate cancer prevention. Themes identified consisted of lack of knowledge, communication, social support, quality of care and sexuality.

Jernigan et al. (2001) conducted focus groups with older African American men and women to identify and examine psychosocial factors that influence screening behaviors. A total of 26 males and 19 females participated in the focus groups. Findings indicated that their perceptions of cancer screening were positive. According to the researchers’ findings, participants identified getting older as a more motivating factor for receiving cancer screening test. Men tended to express distrust of the medical system and perceived cancer as a death sentence. Males reported presence of symptoms as the reason for initial test for cancer. Men were less likely to initiate tests for cancer on their own and relied on close females for encouragement.

Health Disparities

Many studies identified the lack of cultural sensitivity on the part of healthcare providers when approaching issues such as prostate cancer with minorities. (Parchment, 2004; Baldwin, 2003; Plowden, 2003).

Weinrich, Weinrich, Boyd and Atkinson (1998) identified the need for qualitative studies to document perceptions of individuals undergoing prostate cancer screening. The authors discussed the need for a study of barriers related to participation, especially in African American men. Parchment (2004) stated, “Insufficient information may be an obstacle to obtaining screening among Black men” (p. 117).

Rural

Literature suggests that there are differences in cancer staging among rural populations. Rural population’s cancers tend to be diagnosed at a more advanced stage (Gosschalk & Carozza, 2004). In a study by Higginbotham, Moulder, and Currier (2001), African Americans living in rural areas were particularly at risk of late stage cancer diagnosis. casey, Thiede, and Kinger (2001) documented that rural dwellers are reported to have less access to and or less utilization of early cancer detection programs. Mueller, Ortega, Parker, Patil and Askenazi (1999) identified the need for more research involving rural minorities not only due to factors such as shortages of professionals, geography and distance but also factors such as socioeconomic and cultural barriers that could consequently result in even more health disparities, such as with prostate cancer morbidity and mortality. Although the literature does highlight the need for prostate cancer screening among African American men, no studies were found that addressed the concerns and beliefs of rural African American men about prostate cancer and prostate cancer screening. The purpose of this qualitative research study was to describe the personal attitudes and beliefs of rural African American men related to prostate cancer and screening.

METHODS

An interview method was used to complete this qualitative study. A convenience sample of nine (9) African American men was recruited to participate in individual semi-structured interviews. These African American men resided in rural communities in West Central Alabama. Community contacts and the use of the snowballing technique were sources for participant recruitment. Nine African American men agreed to participate in a semi-structured interview. Sample inclusion criteria required that the men be at least 40 years of age, English speaking, and have no personal history of prostate cancer. Participants were recruited via fellow community organization members, friends and family contacts. Participants informed others of the opportunity to participate in the study. If they were interested they provided a phone number to be given to the researcher or were given the researcher’s phone number and a contact was made. Once the potential participant was contacted, the researcher provided details of the study and an opportunity for participation.

Participants ranged in age from 43-72 years. Seven of the nine participants were married. Six of the nine participants were employed, three of which were employed in professional occupations, three in non-professional occupations. Two of the participants were retired and one disabled. Education of the participants varied with three of the participants having an associate degree or higher. Two reported having some college and one reported having at least a high school diploma. Three of the participants reported having less than a high school diploma. Six of the participants reported incomes equal to or greater than $30,000 annually. All of the participants reported having some form of health insurance. Only four of the nine participants reported being previously screened for prostate cancer, all of whom reported having both the PSA and DRE.

Approval to conduct research involving human subjects was obtained from the Georgia State University Institutional Review Board. Written informed consent was obtained from each participant, and the interviews were held in a convenient, quiet room conducive to maintaining confidentiality. Prior to beginning the interview each participant chose a pseudonym to be used. Participants received assurance that all data would be kept confidential, and information regarding their right to withdraw from the study at any time until conclusion of data analysis. Each participant was provided a signed copy of the consent, which also included the IRB and researcher’s contact information. As a token of appreciation, upon completion of the interview participants was given $5.00 for their participation in the study.

Data Collection

Audio taped semi-structured interviews lasting approximately one (1) hour were conducted in a mutually agreeable quiet place, such as participants’ homes, offices or the researcher’s office. Data from the audiotapes were transcribed verbatim. Questions most often asked of the respondents were the following:

* Tell me what you have heard or what people have told you about prostate cancer?

* Tell me what you have heard or what people have told you about screening for prostate cancer?

* Have you ever had prostate cancer screening?

* What kinds of things would encourage you to have a prostate cancer screening?

* What are some things that would keep you from having a prostate cancer screening?

* What nas your doctor or nurse told you about prostate cancer screening?

The questions were based on literature found concerning prostate cancer and African American men. Experienced PhD researchers and prostate cancer experts viewed the interview questions and demographic form and provided suggestions. The interview guide and the demographic data form were pilot tested with three African American men. As a result some wording was changed on the interview guide for clarity. Also income categories were added to the demographic form. Field notes supplemented participant responses and enabled the researcher to capture the emotional details of the interview.

DATA ANALYSIS

Data were analyzed using content analysis of the transcribed interviews. Content analysis (Weber, 1990) is a systematic technique used to categorize data. Each transcript was read in order to obtain a sense of the whole. The researcher then reread the entire document to develop an understanding and to gain further familiarity. The text was then searched for major themes and subcategories. Once identified, each theme and subcategory was coded with a descriptive subheading and was noted on file. Each transcript was scrutinized in the same manner, and any new theme or subcategory was coded and added to the file. The process continued until all nine transcripts had been scrutinized in this manner. The data under each subheading was then analyzed. Key paragraphs, relevant sentences, phrases and words were extracted from the text to exemplify the message of the participant. Themes were identified. Multiple steps of analysis conducted with experienced researchers and key participants were used to assist in assuring that data was not overinterpreted or underinterpreted (Weber, 1990). Select participants were asked to review their transcribed data to verify content, demographic data etc. Findings

Data analysis revealed several themes. Disparity, lack of understanding, traditions, mistrust of the system, fear, and threat to manhood were identified as central to the attitudes and beliefs among these rural African American men. Each of these themes is presented with data to illustrate the interpretation.

Disparity. Some of the men verbalized feelings of disparity when accessing health care. They expressed a need to feel like “somebody” instead of “something” when being spoken to concerning their health care

“I think the older White person (physician) to me tends to be, they can create an uncomfortable zone. I think the older White gentlemen have created that uncomfortable zone over the years and it has been difficult for them to practice and talk to Blacks over the years.” (Jack, age 53)

“Over the years, they (the physician) don’t act in a not so much demeaning way I guess, but not as caring, not as a relationship with that person (your physician) should be, you know, you go in to see the doctor, next, next. ..it is not a relationship.” (Patrick, age 49)

Lack of Understanding. Many of the men knew very little about the symptoms of prostate cancer or what is involved in prostate cancer screening. At times it seemed somewhat embarrassing for some of the individuals that they did not know what symptoms were associated with prostate cancer or what was involved in being screened for prostate cancer. Several participants stated “lack of knowledge” as being a major problem for African American men in general related to prostate cancer and screening.

“…I think right now we suffer from not really knowing what to ask. So it is kind of funny we don’t ask anything.” (Tom, age 56)

“I guess it is one of the things. I should know but I don’t know” (John, age 50)

” I really don’t know other than I am assuming that they test you certain ways but…” (Jerry, age 66)

One participant (to describe his thoughts about prostate cancer screening) used a unique descriptor.

“.. .you know if you go to the doctor you can catch the problem, like you know your automobile may have a little small problem. You fix that small problem it will take care of the big ones a lot of the times. (Jim, age 43)

Traditions. Past family health practices influenced the health patterns of many of the respondents. The men spoke frankly about both their family traditions and the influences that currently affect how they approach their own health today.

“…any African American man I know, myself and others, that was always the same. You didn’t go to no doctor unless you were sick or you felt bad. It wasn’t a common practice to just go to the doctor for a checkup or physical unless you were going on a job or you had to have one or something like that. It was just a fact.” (James, 48)

“…but the old home remedies that my grandmother and great grandmother used to have, that was what we mostly count on because at the time we didn’t have the money. ..and transportation, so you kind of had to depend on home remedies” (Jack, age 53)

“That is the way my family did. They didn’t believe in that many doctors.” (Sam, age 48)

Mistrust in the system. Participants spoke of mistrust of the health care providers and the health care system. Several of the participants identified particular reasons for not personally trusting the provider or the system, including referencing the Tuskegee Syphilis Study.

“Well it was proven in Tuskegee that blacks were used as guinea pigs, you know for syphilis or whatever…” (Jim, age 43)

“…I don’t think they give you a thorough exam and, they won’t tell you everything that is actually wrong with you, you know.” (John, age 50)

Fear. Expression of fear and concern were common among participants as they expressed why they had not participated in prostate cancer screening. One participant who had been screened stated reasons why others might not participate in screening. Several participants discussed their fears and their sincere desire to understand what actually occurs during a prostate cancer screening.

“Because they were afraid that there would be something wrong with them…” (Wilson, age 72)

“Some people are afraid to go find out their problems””The Big C” or Cancer was considered a death sentence and people tend to still think that way.” (John, age 50)

“Because of fear, a Black man, he’s proud and when it comes to things like you know examining, he kind, of backs away from it. Because I guess it’s, how Would you phrase that? A myth that they have heard or something like that.” (Tom, age 56)

“… My fear was mostly that it would be painful.” (Jerry, age 66)

Threat to Manhood. When discussing the prostate cancer-screening exam, many of the participants expressed their ideas related to why some men do not participate. One reason they linked to lack of participation in prostate cancer screening was a threat to manhood. Most of the men verbalized an obvious dislike for the digital rectal exam, and one gentleman actually compared it to women getting their pap smears, but stated it was also an obvious difference because it sometimes seemed as if you (men) were being violated.

“There again I think it goes back to that manhood type thing for the most part we are uncomfortable discussing, talking about and deny it…” (Sam, age 48)

“Don’t like it. It is just that simple. It is just that simple, don’t like it, dread It, uncomfortable and I think it suggests that a man is being invaded in a way that he shouldn’t be…O.K. I ask some friends that when they go to the doctor and they are taking the ‘sissy’ test.” (Patrick, age 49)

“I know I kind of had exams before but that type exam, I kind of felt a little funny.. .1 guess it was just a man thing… Some men just don’t want nobody to go in behind them. ” (Tom, age 56)

In general, these participants were open to discussing prostate cancer screening, a topic they find to be quite sensitive. Although the need for prostate cancer screening was recognized, only a few participants had partaken in the screening.

DISCUSSION

Similar to previous findings in the literature participants expressed a desire to feel equal to the health care provider “man to man” or “woman to man”. The stories of these participants demonstrated that more education and discussion in terms that are understandable to the patient are needed. The constraints of the current managed care environment prevent health promotion interventions, which provides knowledge and allows for an explanation of the participants attitudes. Woods, Montgomery, Belliard, Ramirez-Johnson, and Wilson (2004) found in their study with African American men, physicians and health care providers did not discuss prostate health information in ways that could be understood by their patients. Therefore it is not only important to provide information, but that information should be communicated in a manner that is understood by the population it is intended to benefit.

The men in this study varied in their knowledge about prostate cancer screening. Some were familiar with it while others had little knowledge. Previous studies have found that African-American men have less knowledge and more misconceptions about prostate cancer than White men. (Wilkinson, List, Sinner, Dai, & Chodak, 2003).

There is a need to look at many alternatives for prostate cancer screening education for African American men in rural communities. The literature and the reports from some of these participants suggest that the DRE is seen as a problematic part of the prostate cancer-screening exam. Some participants viewed the exam as being associated with homosexuality and reported specifically not wanting the DRE exam. New approaches to promoting prostate cancer screening must address the attitudes and fears expressed by African American men in rural communities.

STUDY LIMITATIONS

The findings of this study were limited to African American males from one geographical location in rural areas surrounding West Central Alabama. The sample size was small, but saturation of content was reached before data collection stopped. The researcher used a convenience sample utilizing the snowball method.

CONCLUSIONS AND IMPLICATIONS

Some rural African American men continue to distrust the health care system in light of historical events of the past such as the Tuskegee Syphilis Study. Perceptions and beliefs that rural African American men have about prostate cancer screening are contributing factors to prostate cancer screening participation. Health care providers must make an effort to develop a trusting relationship with the rural African American male population and communities involved in providing cancer screening and health care.

The stories of these African American men documented that knowledge alone is insufficient to motivate men to participate in screening. Fear, threat to their manhood and distrust of health care providers kept them from screening activities that could save their lives.

A greater understanding of the personal experiences, beliefs, and perceptions about prostate cancer and prostate cancer screening among African American men can be influential in providing guidance to researchers and health care providers in adapting educational materials and activities to better guide African American men related to prostate cancer and screening for early prostate cancer detection. REFERENCES

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Acknowledgements: This study was funded by Sigma Theta Tau International Epsilon Alpha Chapter ofthe Byrdine F. Lewis School of Nursing at Georgia State University. Many thanks to Dr. Peg Lyons, Associate Professor Emeritus, Capstone College of Nursing, University of Alabama; Dr. Cecelia Grindel, Professor, Byrdine F. Lewis, School of Nursing at Georgia State University and Dr. Ptlene Minick, Associate Professor, Byrdine F. Lewis, School of Nursing at Georgia State University.

JOANN S. OLIVER, MSN, RN, CRNP

JoAnn S. Oliver, MSN, RNC, CRNP, was a doctoral student in the Byrdine F. Lewis School of Nursing at Georgia State University in Atlanta, Georgia, and a nursing Instructor in the Capstone College of Nursing at The University of Alabama, Box 870358, Tuscaloosa, Alabama 35487-0358. Ms. Oliver may be reached at: E-mail: joliver@bama. ua.edu.

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