Abstract and Introduction
Abstract
Background:
The worldwide incidence of prostate cancer is higher among American
black men than any other male group. In the United States, lack of
participation in screening for prostate cancer by black men is
influenced by several cultural factors, including knowledge, health
beliefs, barriers, and relationships with primary healthcare providers.
Methods:
We used the qualitative and paralleling descriptive quantitative
findings of a mixed-method longitudinal study exploring prostate cancer
screening behaviors among 277 black men.
Results:
Five themes were identified as critical elements affecting men's
screening for prostate cancer: lack of knowledge, communication, social
support, quality of care, and sexuality. These themes were associated
with a sense of disconnectedness by black men from the healthcare
system and contributed to nonparticipation in prostate cancer early
detection activities.
Conclusions: Lack of
discussion about the decision to screen for prostate cancer and general
lack of culturally appropriate communication with healthcare providers
has engendered distrust, created fear, fostered disconnect, and
increased the likelihood of nonparticipation in prostate cancer
screening among black men.
Introduction
Prostate cancer
is the leading cancer diagnosed among men in the United States. Black
men in America continue to have the highest incidence rate of prostate
cancer in the world -- 180.6 per 100,000 population.[1]
Between 1996 and 2000 in the United States, the age-adjusted death rate
of prostate cancer among black men (73.0 per 100,000 population) was
more than double that of non-Hispanic white men (30.2 per 100,000
population).[2,3] The causes of higher rates of prostate
cancer among black men are largely unknown. However, higher mortality
is associated with late detection.
Screening is the most common
method for early detection of disease in asymptomatic populations. One
problem with early detection in prostate cancer prevention is a lack of
consensus regarding screening and early detection guidelines among
medical professional groups.[4] Current guidelines of the American Cancer Society (ACS)[5]
recommend that men at high-risk (eg, family history, black) should
begin early detection with the prostate-spe-cific antigen (PSA) blood
test and the digital rectal examination (DRE) at 45 years of age.
Furthermore,ACS guidelines suggest that the decision for high-risk men
to be tested should be made within the doctor/patient relationship. The
US Prevention Services Task Force recently concluded that there was
insufficient evidence for or against routine screening for prostate
cancer using PSA or DRE.[6] According to the Task Force,
however, good evidence exists that PSA screening can detect early-stage
prostate cancer, but it is unclear how early detection improves health
outcomes.[7] The National Cancer Institute (NCI) has
concluded that there is insufficient evidence that prostate cancer
mortality can be reduced by early detection and screening methods.[8]
It is not clear however, that studies on which these recommendations
are based included sufficient numbers of black men, despite the fact
that they have the highest disease burden of all ethnic and racial
groups.
This confusion is complicated by the fact that men are less likely than women to seek assistance when health problems arise.[9]
Furthermore, compared with women or with any other group of men, black
men are less likely to seek care and participate in health-related
activities. Such health activities are preventive and self-care
practices, which places them at high risk for nonparticipation in
prostate cancer early detection and screening.[10]
Researchers attribute the lack of participation in prostate cancer
prevention activities to economic limitations, low level of education,
poor access to health care, lack of awareness about studies, past
negative experiences, physicians' attitudes, and cultural and religious
beliefs/atti-tudes.[11,12] In addition, some researchers
have identified sexual dysfunction as a sensitive issue for black men,
which discourages their involvement in prostate cancer screening and
early detection activities.[13,14]
Braithwaite[10]
discusses the concept of "stoicism" as a possible explanation of why
black men are disconnected from the American healthcare system and are
reluctant to participate in health-related activities. The theory of
stoicism suggest that black men become "indifferent to pain or
discomfort and do not seek healthcare services until absolutely
necessary, and then most often in the emergency room."[10]
Additional factors that contribute to their nonparticipation in
screening include lack of adequate health insurance, traditional
attitudes about male gender roles, fear of a poor prognosis, and
distrust of the medical community. Difficulty in obtaining information
about black health behavior is compounded by limited participation by
this population in all forms of research.
Historically,
researchers have studied the impact of culture on health-seeking
behaviors among many ethnic groups such as Asian, Native Americans, and
Latinos to better understand the role of culture in health-related
behav-[15-17] In contrast, little is known about the effect of culture in health-seeking behaviors and disconnectedness among black men.[18-21] One problem has been a focus on blacks as a race rather than as an ethnic group with unique cultural traits.[22]
The National Institutes of Health (NIH) 2000 enrollment of non-Hispanic
black men and women in extramural research was 11.3%; male
participation was [23-25] The syphilis experiments
conducted at Tuskegee, Alabama, have left a legacy of distrust and
profound fear among blacks for research participation.[26-28] Distrust and fear are strong deterrents for black men to engage the healthcare system.
A goal of Healthy People 2010 is to eliminate racial health disparities.[29] Black men suffer a disproportionately higher burden of disease than any other ethnic and racial group.[3,30] Black men in particular have been labeled an "endangered species"[10]
due to health, sociopolitical, and psychological issues affecting this
group. To achieve the Healthy People 2010 goals of decreasing health
disparities, innovative strategies must be used to overcome this
barrier of distrust and create mechanisms to engage, support, and
reinforce black men to make healthy choices.[31]
This
study explores how culture and communication with healthcare providers
influence black men's knowledge, health beliefs, and practices
regarding prostate cancer screening. We utilized a mixed-method
research approach to investigate these issues in a cohort of 277 black
men and 94 primary care providers. In this article, we present the
qualitative results of the black participants in our study.
Quantitative data are used to show that the qualitative findings were
verified in the subsequent survey work.
