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Abstract

Health communication researchers, public health workers, and health professionals must learn more about the health information-gathering behavior of low-income minority men at risk for prostate cancer in order to share information effectively with the population. In collaboration with the Milwaukee Health Department Men’s Health Referral Network, a total of 90 low-income adult men were recruited to complete a survey gauging information sources, seeking behavior, use of technology, as well as prostate cancer awareness and screening behavior. Results indicated participants primarily relied on health professionals, family, and friends for information about general issues of health as well as prostate cancer. The Internet was the least relied on source of information. A hierarchical regression indicated interpersonal information sources such as family or friends to be the only significant predictor enhancing prostate cancer awareness, controlling for other sources of information. Prostate screening behaviors were predicted by reliance on not only medical professionals but also the Internet. Practical implications of the study are discussed.

Keywords

health informatics African American prostate cancer information seeking digital divide

Prostate cancer is the second-leading cause of cancer death among men in the United States; in 2014, about 233,000 new cases will be diagnosed nationwide, and about 29,480 men will die from the disease (American Cancer Society, 2014). Despite the U.S. Preventive Services Task Force (2012) issuing a guideline recommending against routine prostate-specific antigen (PSA) blood tests, some provider groups advise prostate cancer screening, and Medicare and private insurers cover the cost. Against this contextual backdrop, health professionals are challenged not only to address the needs of men at risk for prostate cancer, especially African Americans who may be at highest risk for the disease (Centers for Disease Control and Prevention [CDC], 2013; U.S. Office of Minority Health, 2008), but also to help them understand the benefits and challenges of prostate cancer screening.

The principal public health approach—the approach taken by the CDC, for example—is to support informed decision making about prostate cancer screening. Decision-making support is communicated through educational materials, such as the American Cancer Society’s (2010) Testing for Prostate Cancer: “Should I Be Tested? Is It the Right Choice for Me?” and the CDC’s (2013) Take Time to Decide infographic, which are available online. Some evidence demonstrates Internet programs to be an effective way to share information about prostate cancer (Allen, Mohllajee, Shelton, Drake, & Mars, 2009; Dorfman et al., 2010). However, other studies point to limited Internet access and skills among low-income minority men at risk for prostate cancer (Fogel, Ribisi, Morgan, Humphreys, & Lyons, 2008; Wallington, 2008), reflecting both an Internet access- and Internet skill-based digital divide (Hargittai, 2002; Sarkar et al., 2011; Van Deursen & Van Dijk, 2011). Due to lack of computer access and/or limited online skills, the population may be excluded from public health initiatives aimed at providing support and information about prostate cancer.

To communicate information effectively with low-income minority men at risk for prostate cancer, health communication researchers, public health workers, and health care providers should learn more about the population’s information sources, technology use, and preferred medium for obtaining health information. Knowledge about the target group’s information-gathering practices can lead to interventions tailored to the group’s unique needs and preferences (Allen et al., 2009; Allen, Kennedy, Wilson-Glover, & Gilligan, 2007; Blocker et al., 2006; Fernández et al., 2009; Sanchez, Bowen, Hart, & Spigner, 2007). Fernandez et al. (2009), for example, demonstrated the effectiveness of an interpersonal intervention involving lay health workers to promote breast and cervical cancer screening among low-income Hispanic women. Equipped with quality health information, low-income minority men at risk for prostate cancer can make informed decisions about screening as well as lifestyle choices that may prevent or reduce the likelihood of a prostate cancer diagnosis.

Low-Income African American Men and Prostate Cancer

African American men maintain a disproportionate risk for prostate cancer and are more likely to die from the disease (CDC, 2013; U.S. Office of Minority Health, 2008). Per 100,000 men, the incidence of new prostate cancer cases each year among African American men (255.5) eclipses the average (168.0), and deaths from prostate cancer for African Americans (62.3) more than double the average (27.9; National Cancer Institute, 2004). Genetic variants may account for some of the disproportionate burden of prostate cancer among African American men (Haiman et al., 2007), but low socioeconomic status as well as decreased access to medical care, reduced health insurance coverage, and weak ties to primary care physicians continue to serve as barriers to screening and timely diagnosis of the disease (National Cancer Institute, 2004; Reynolds, 2008; Talcott et al., 2007).

To promote early detection of the disease, the American Cancer Society (2014) recommends high-risk groups such as African American men receive information at age 45 about the benefits and limitations of prostate screening so that they can make informed decisions about testing “based on personal values and preferences” (p. 20). For men with a family history of prostate cancer, the American Cancer Society encourages information-sharing discussions with a provider at age 40. However, lack of established relationships with primary care physicians, distrust of physicians, and increased use of public clinics and emergency wards may preclude candid patient–provider conversations about prostate cancer testing (Talcott et al., 2007).

In the absence of ongoing contact with a trusted physician, low-income minority men at risk for prostate cancer also may not possess sufficient or accurate knowledge about the disease. Bloom, Stewart, Oakley-Girvans, Banks, and Chang (2006) reported that African American men with a family history of prostate cancer did not perceive their risk to be any higher than men with no family history, despite family history being the strongest known risk factor for prostate cancer—estimates of relative risk range from 1.7% to 8.7% when a man’s father or brother had been diagnosed with prostate cancer (Harvard Health Watch, 2003). Consedine et al. (2007) observed U.S.- and Jamaican-born African Americans demonstrated poorer knowledge of prostate cancer in a number of domains, compared to U.S.-born Whites and reported significantly more fear of screening processes. Fear of screening processes was negatively associated with screening behavior. Of men age 65 years and older, Fowke, Schlundt, Signorello, Ukoli, and Blot (2005) reported African American men were significantly less likely to report a PSA test in the past 12 months.

Attitudinal characteristics such as decreased efficacy beliefs also can serve as a barrier to prostate cancer prevention and detection and may affect quality of life. Maliski et al. (2004) reported low-income men with decreased perceptions of self-efficacy when interacting with a physician to be less satisfied with care, have reduced confidence in their doctor, and experience increased symptom distress. A community-based participatory educational outreach program provided among low-income African American improved prostate cancer knowledge and also increased screening decision-self efficacy (Wray, Vijaykumar, Jupka, Zellin, & Shahid, 2011). African American men diagnosed with prostate cancer with higher rates of self-efficacy for symptom control also report increased quality of life (Campbell et al., 2004).

Information Seeking and Digital Divide

Access to and use of technology dictate the effectiveness of health messages communicated through interactive media such as websites and e-mail. Digital divide research conducted by the Pew Research Center reveals key disparities in both Internet use and access across income and ethnicity (Zickuhr & Smith, 2012). In terms of Internet use, 62% of adults living in households with an income of <$30,000 a year use the Internet compared to 90% and 97% of adults living in households with incomes of $50,000 to $74,999 and >$75,000, respectively. Among people with a household annual income of <$30,000, a total of 41% have access to the Internet at home, compared to those with incomes between $50,000 and $74,999 (81%) and more than $75,000 (89%). Of non-Hispanic White individuals, 80% use the Internet, compared to 71% of African American and 68% of Hispanic individuals. African American (49%) and Hispanic (51%) people also are less likely to have access to the Internet than non-Hispanic Whites (66%).

Wyatt, Henwood, Hart, and Smith (2005) caution that the digital divide cannot be understood solely in terms of domestic Internet access:

Access involves much more than being in the vicinity of the right type of equipment: it also includes the gendered and generational social relations which form the context in which people’s daily interactions or non-interactions with the Internet take place. (p. 213)

A computer connection to the Internet is not the only marker of a digital divide between the “haves” and “have-nots”; instead, access to and use of the web are grounded in social contexts. Hargittai (2002) posits online skills to be a second-level digital divide, demarcating those who are able to search for content effectively (i.e., find the right content) and efficiently (i.e., in a limited timeframe) online from those who are not.

Rice and Katz (2003), using data from a national telephone survey of Americans, contend race to no longer be associated with the gap between users and nonusers of the Internet, despite associations between use income, and age. Kreps (2006) takes an opposing stance, arguing that vulnerable and underserved populations, including ethnic minority groups, continue to have “limited access to relevant communication channels that deliver key health information, especially information widely available on the Internet” (p. 766). He finds these populations to be cut off from relevant health information, thus increasing disparities in health care as well as associated morbidities and mortalities.

Research on prostate cancer and technology tends to lean in Krep’s (2006) direction. In the past 10 years, as an alternative to print-based media, the Internet has emerged as a pathway through which health messages can be communicated to men at risk for prostate cancer. Some studies find the web to be an effective means of sharing prostate cancer information. One feasibility study (Dorfman et al., 2010) conducted to assess older males’ Internet access and willingness to use a web-based decision aid determined the Internet to be a viable communication channel and source of information. Another computer-tailored intervention among African American men (Allen et al., 2009) in the form of a decision-aid tool resulted in increased prostate-cancer-related knowledge and decisional self-efficacy. The decision aid tool was only available at the research site; participants were not able to test its use independently using a computer outside of the study setting.

Despite studies pointing to the utility of the Internet for information and support about prostate cancer, African Americans tend to be less likely to go online to search for cancer-related information (Fogel, 2003, 2007; R. P. Smith et al., 2003) and underrepresented in Internet-based support groups (Henderson & Fogel, 2003; Im, Chee, Tsai, Lin, & Cheng, 2005; Monnier, Laken, & Carter, 2002). Fogel et al. (2008) attribute lack of online support group participation to issues of digital divide and inequity, preferences for interpersonal channels of support or culture-specific online support, and trust concerns. Wallington (2008), examining perceptions of the Internet as a patient education tool among African American men with prostate cancer, reported substantial variability in the use of the Internet for information and support, from nonuse to expert use. Internet use was influenced by prostate cancer diagnosis, poor patient–provider communication, and limited accessibility. Several men reported concerns about obtaining “bad information” on the web, and others indicated they could not afford or easily get to a computer to search for information.

Increasing cell phone ownership and use among minority men may be a trend through which differential Internet access issues can be resolved. African American and English-speaking Hispanic adults (87%) are slightly more likely than non-Hispanic Whites (80%) to own cell phones and tend to use cell phone capabilities such as calling and texting with more frequency and intensity. National trends also indicate more and more individuals access the Internet from cell phones, and one third of cell Internet users mostly use phones to go online (Duggan & Smith, 2013). Moreover, “cell-mostly Internet users,” individuals who primarly use their cell phones to go online, tend to be nonmajority, less-educated, and of relatively low income. The cell phone, therefore, may function as a bridge spanning digital divides related to race and socioeconomic status. Providing low-income minority men with health information via cell phone, through either text messaging or the mobile web, may help equip the population with decisional support around prostate cancer prevention and detection.

The current study was designed to learn more about the sources of information and preferred information mediums of low-income, primarily African American, men at risk for prostate cancer. The researchers also were interested in the relationship among information source, prostate cancer awareness, and screening behaviors. The more researchers and public health professionals know about the ways men at risk for prostate cancer seek information about the disease, the more the delivery and content of information can be tailored to communication modes and channels resonating with the population. The following research questions were proposed.

RQ1: On what sources of information do men at risk for prostate cancer rely?

RQ2: Through what medium would men at risk for prostate cancer feel most comfortable getting health information?

RQ3: How does source of information predict prostate cancer awareness?

RQ4: How does source of information predict prostate cancer screening?

Method

Procedures

After institutional review board approval was obtained at an urban, public university in the Midwest, the researchers commenced recruitment by attending monthly meetings of the Milwaukee Health Department Men’s Health Referral Network. The network brings together representatives from local and state health and social welfare organizations working to improve the health of men in the Milwaukee community. Each month, organizational partners report on men’s health-related activities and initiatives as well as share knowledge gains in the area of men’s health. When the goals of the current investigation were introduced, partners also made suggestions as to how and where recruitment should be conducted. The researchers spent three months refining recruitment plans in collaboration with the network.

Study recruitment occurred from January through March 2012 at three primary locations: a free prostate cancer-screening event at a community senior center, an employment services meeting at a local church, and a waiting area at a Milwaukee Health Department clinic. The study was advertised through a poster, flyers, and word of mouth at each location. Eligible study participants were men, age 40 years and older, who had a cell phone and who had been screened for prostate cancer or had questions about prostate cancer. Interested participants who met the eligibility criteria were given a consent form and a seven-page paper survey that took approximately 15 to 25 minutes to complete. The survey possessed a Flesch–Kincaid reading ease score of 57.6, representing a grade level of 7.8 (readability-score.com, http://www.readability-score.com/). Additionally, assistance was provided when participants had problems with reading the survey. Men completing the survey received either $20 cash or a $20 gift card to a pharmacy, depending on study location.

Sample

A total of 90 men completed the survey, with ages ranging from 40 to 78 years (M = 52.7, SD = 8.8; see Table 1). The sample was composed of 76 African American men (91%), followed by White (n = 4, 5%), “Other” (n = 3, 4%), and Hispanic/Latino (n = 1, 1%). A majority of participants were single (n = 45, 55%), with the remaining individuals married (n = 16, 20%), divorced (n = 13, 16%), or separated (n = 7, 9%). Most of the men (n = 64, 77%) indicated a household income ranging from $0 to $25,000 annually, followed by $25,000 to $50,000 (n = 11, 13%), $50, 000 to $75,000 (n = 8, 8%), and $75,000+ (n = 1, 1%). When asked about health insurance status, 60% of the respondents (n = 45) did not have health insurance.

Table 1.

Demographic Information.

Variable	N	%
Age (years), M (SD)	90	52.7 (8.8)
Race/ethnicity
White	4	5
African American	76	91
Hispanic/Latino	1	1
Other	3	4
Relationship status
Single	45	55
Married	16	20
Divorced	13	16
Separated	7	9
Annual income, $
>25,000	64	77
25,000-50,000	11	13
50,000-75,000	8	8
<75,000	1	1
Health insurance
Yes	30	40
Cell phone user
Yes	78	89
Cell phone use
Never	0	0
Rarely	14	17
Monthly	2	2
2-3 Times a week	8	10
Daily	59	71
Own a smartphone	18	22
Internet use
Never	36	44
Rarely	8	10
Monthly	2	2
2-3 Times a week	13	16
Daily	23	28
Internet access at home	32	41
Prostate cancer
Diagnosed with prostate cancer	5	6
Received prostate cancer screening	45	58
Family history	17	20

In terms of technology use, most participants reported using a cell phone daily (n = 59, 71%), with just more than half of the sample (n = 43, 51%) using cell phones to make calls. Most (n = 64, 78%) reported their cell phones were not smartphones, and 58% (n = 45) reported never using the Internet on a cell phone. Use of cell phones to text message varied, with 23% (n = 18) texting very often, 14% (n = 11) fairly often, and 18% (n = 14) sometimes. Thirty-eight percent of the sample (n = 29) never used a cell phone to text message. A majority of the sample (n = 48, 59%) did not have web access at home, and 44% (n = 36) reported never using the Internet. Forty-four percent (n = 36) reported using the Internet daily or two-to-three times a week.

Measures

Sources of Information

Participants were asked to rate how often they used the following sources of information about (a) general issues of health and (b) prostate cancer: doctors/nurses, family, friends, church and other community resources, Internet, TV/movies/magazines, and other (adapted from Song, Cramer, McRoy, & May, 2013). A seven-point Likert-type scale (1 = never, 7 = always) was used to measure how frequently each source was consulted. Higher scores indicated increased reliance on a source for information.

Preferred Medium for Health Information

A series of three three-item measures were developed by the researchers to examine preferred medium for obtaining health information. Items in each measure were modified based on the medium (i.e., e-mail, text message, website). For example, to measure preferences for obtaining health information through e-mail (α = .92), participants rated their level of agreement with the following statements: “I feel comfortable using e-mail to receive health information,” “I am interested in getting health information through e-mail, if possible,” and “I am willing to learn how to get health information through e-mail.” Preferences for receiving health information through text message (α = .91) and websites were adapted accordingly. A five-point Likert-type scale measured level of agreement with each statement (1 = strongly disagree, 5 = strongly agree).

Prostate Cancer Awareness

Using an expanded version of Rimal’s (2001) one-item measure of motivation to think about disease, participants were asked to rate the extent to which they thought about prostate cancer, heard about prostate cancer, worried about prostate cancer, and searched for information about prostate cancer. The four-item measure (α = .78) included a five-point Likert-type frequency scale (1 = not at all, 5 = a great deal) for each item. Higher scores pointed to increased levels of prostate cancer awareness.

Prostate Cancer Screening and History

Participants responded “yes” or “no” to the questions about whether they had been screened for or diagnosed with prostate cancer, as well as whether a history of prostate cancer existed in the family. Of those responding, 58% reported prostate cancer screening (PSA or digital rectal examination), 6% had received a diagnosis of prostate cancer at some point in their lives, and 20% indicated a family history of the disease. Table 2 provides zero-order correlations, means, and standard deviations for all study variables.

Table 2.

Zero-Order Correlations, Means, and Standard Deviations.

	1	2	3	4	5	6	7	8	9
1. PC awareness	1.00
Information source
2. Medical professionals	.27*	1.00
3. Family and friends	.41**	.61**	1.00
4. Internet	.29**	.47**	.51**	1.00
5. TV and other media	.31**	.32**	.50**	.54**	1.00
6. PC diagnosis	−.06	−.36**	−.27*	−.04	−.08	1.00
7. Income	.01	.18	.01	.27*	−.01	.13	1.00
8. PC Screening	−.22	−.45**	−.23*	−.06	−.13	.08	−.13	1.00
9. Location	.09	.91	.08	−.07	.08	−.15	−.11	−.23*	1.00
M	2.55	3.58	3.04	2.35	2.87	1.94	1.34	1.42	0.34
SD	0.89	2.12	1.84	1.69	1.70	0.23	0.69	0.50	0.48

Note. PC = prostate cancer; Location = recruitment location.

p < .05. **p < .01. ***p < .001 (two-tailed).

Data Analysis

For descriptive analyses, the means and standard deviations were computed for numerical variables; number and percentage were computed for categorical variables. Before conducting the regression analysis, multicollinearity was checked. Correlation analyses using Pearson’s r were employed with all the variables. There were no correlation coefficients bigger than .7, suggesting no issues in multicollinearity (shown later). For the hierarchical regression, two models were tested. In Model 1, four health information sources were inserted and then known controlling variables were additionally inserted in Model 2. Controlling variables included income, prostate cancer diagnosis, and recruitment location. Recruitment location was added to the model because one location was sponsoring a free, community-based prostate cancer-screening event at the time of recruitment. We supposed that participants at a prostate cancer–screening event might demonstrate greater awareness about prostate cancer than counterparts recruited at other locations. Logistic regression was conducted to predict participation in prostate cancer screening.

Results

The first research question explored the sources of information on which low-income men at risk for prostate cancer rely. Results indicated the target population primarily relied on health professionals for information about general issues of health (M = 3.93, SD = 1.87) as well as prostate cancer specifically (M = 3.58; SD = 2.12; see Table 3). Family and friends followed health professionals as frequently consulted sources of information for both areas. The Internet was the least relied on source of information for general health as well as prostate cancer. Paired t tests revealed significant differences in the frequency with which the sample relied on sources for information based on content area (general health and prostate cancer). The men in the study reported seeking general health information from all sources more frequently than information focused specifically on prostate cancer. Especially, differences observed in family and friends were quite noticeable (t = 3.82). Family and friends were consulted to a significantly lesser extent about prostate cancer information compared to general health issues.

Table 3.

Sources of Information for General Health and Prostate Canncer, Paired t Tests.

	General health		Prostate cancer
Source	M	SD	M	SD	t	df	p
Medical professionals	3.93	1.87	3.58	2.12	2.16	85	.034^*
Family/friends	3.64	1.57	3.04	1.84	3.82	83	.000^***
Internet	2.65	1.84	2.35	1.69	3.21	82	.002^**
TV/movies/magazines	2.95	1.60	2.87	1.70	0.75	83	.457

p < .05. **p < .01. ***p < .001 (two-tailed).

Research Question 2 consisted of a simple inquiry as to the medium through which low-income men preferred to receive health information. Comparing means between the three variables revealed the sample preferred receiving health information via e-mail (M = 3.47, SD = 1.32), followed by text message (M = 3.33, SD = 1.30), and website (M = 2.74, SD = .96).

To test Research Question 3, hierarchical regression was conducted (see Table 4). In Model 1, four different sources of prostate cancer information were entered. The results indicated interpersonal sources of information such as family and friends to be the only significant predictor (β = .39, p < .01) enhancing prostate cancer awareness controlling for other sources of information including medical professionals, the Internet, and other media. In Model 2, income, prostate cancer diagnosis, and recruitment location were added. Controlling for those three added variables, the effect of using family and friends remained intact (β = .40, p < .01). R² for Model 2 was .22 while adjusted R² was .15.

Table 4.

Regression Analysis Results for Prostate Cancer Awareness and Screening.

	PC awareness				PC screening
	Model 1		Model 2		Model 1		Model 2
	β	p	β	p	e ^B	p	e ^B	p
Step 1: Information source
Medical professionals	.05	.73	.09	.54	0.48	.00***	0.46	.00***
Family and friends	.39	.01**	.40	.01**	1.16	.54	1.13	.61
Internet	.02	.86	.02	.90	1.52	.07	1.65	.05*
TV and other media	.04	.75	.03	.85	0.77	.23	0.73	.17
Step 2: Control variable
PC diagnosed			.11	.36			0.29	.39
Income			−.03	.81			0.68	.42
Location			.04	.73			0.30	.06
R ²	.21		.22		.24		.24
ΔR²	.22		.15

Note. PC = prostate cancer; β = standardized coefficients, beta from regression equation. For PC screening, logistic regression was conducted. R² in the logistical regression indicate Cox–Snell R². Location indicates recruitment location.

p < .05. **p < .01. ***p < .001.

Logistic regression was conducted to test Research Question 4, investigating factors contributing to prostate cancer screening. Model 1 reported that individuals who received prostate cancer information from physicians were most likely to have been screened for prostate cancer (e^B = .48, p < .001), controlling for other information sources. Interestingly, interpersonal sources of information were not significant predictors (e^B = 1.16, ns). In Model 2, prostate cancer diagnosis, income, and recruitment location were again added. Regardless of prostate cancer diagnosis, income, and recruitment location, individuals relying on health care professionals for prostate cancer information were more likely to have been screened (e^B = .46, p < .001). Using the Internet to seek out prostate cancer information was also a significant predictor of prostate cancer screening (e^B = 1.65, p < .05), whereas interpersonal sources of information were not significant (e^B = 1.13, ns).

Discussion

The purpose of this exploratory study was to investigate the health information–seeking behaviors of low-income, primarily African American men at risk for prostate cancer. Identifying relationships between information-seeking variables and associated outcomes (i.e., awareness, screening behavior) is a crucial first step in providing the target population with decisional support through the most effective and used communication channels.

The findings suggest the study sample to be largely oriented toward interpersonal sources of health information. Participants primarily communicated with health professionals for information about general issues of health as well as prostate cancer, a preference pattern consistently observed among cancer patients (Rutten, Arora, Bakos, Aziz, & Rowland, 2005). Family and friends followed health professionals as sources often consulted for information about general health issues and prostate cancer. Consistent with previous research, family members in particular tend to serve as important sources of both instrumental and informational support for an individual with a health need or who faces a health-related decision (Shaw, Scott, & Ferrante, 2013). Reflecting research on the variable use of the Internet among African American men at risk for prostate cancer (Wallington, 2008), the Internet was the least relied on source of information for general health as well as prostate cancer. A hierarchical regression indicated interpersonal information sources such as family or friends to be the only significant predictor enhancing prostate cancer awareness, controlling for other sources of information including medical professionals, Internet, and other media.

Although the study sample relied on information from family and friends, a significant difference was observed based on information topic. A substantial gap was detected between consulting family and friends about general health information and prostate cancer information—results suggesting that when it comes to prostate cancer, the men in the study are more reluctant to talk about the disease with people close to them. Past research demonstrates a prostate cancer diagnosis can trigger feelings of shame and embarrassment, likely due to perceptions of the disease as a problem of sexual and urologic functioning (Ford, Vernan, Havstad, Thomas, & Davis, 2006; Forrester-Anderson, 2005; Weinrich, Griener, Reis-Starr, Yoon, & Weinrich, 1998; Weinrich, Weinrich, Mettlin, Reynolds, & Wofford, 1998). Embarrassment has been cited also as a barrier to prostate cancer screening (Shelton, Weinrich, & Reynolds, 1999). Men who experience cognitive and psychological discomfort about attending a prostate cancer screening or a prostate cancer diagnosis may subsequently avoid the information provided by and advice of family and friends.

Moreover, an interesting trend was observed related to prostate cancer screening: Men who relied on medical professionals for information were more likely to have had a screening, but other interpersonal sources such as friends and family did not predict screening behavior. Results indicate that the physician remains an important source of advice and guidance: Patient–physician discussions about PSA testing, for example, correlate with increased screening behavior among African American men (Ross, Power, Taylor, & Howard, 2008). Men at risk for prostate cancer may be comparatively hesitant to turn to family and friends for information about prostate cancer. The information provided by close personal relations may not be adequate to compel health-related behavior, such as prostate cancer screening. Reliance on the Internet as a source of information, however, did predict screening behavior. For those who can access and use the Internet, the Internet serves as a powerful tool in providing information about screening.

Here, two practical implications emerge. First, health care professionals’ investment in the lives of minority men cannot be emphasized enough. Our current data reveal interpersonal sources of information to be consulted at considerably greater frequency than online, audiovisual, and print mediums. Among personal contacts, health care professionals are relied on more than family and friends. A study conducted by Moore et al. (2012) indicates interpersonal treatment and patient–physician communication perceived as good to increase levels of patient satisfaction among African American men. Watkins and Jefferson (2013), moreover, note that low-income African American men are exposed to more psychological stressors and experience higher levels of distress than other groups. Health care professionals must strive to make sense of the “intrapersonal and environmental adversities that affect [African American men] and predispose them to distress, because this oftentimes limits their ability to make use of health resources” (p. 329). Sensitivity to sources of distress can help health care professionals find solutions that are confidential, convenient, and supportive in the prevention of prostate cancer. Cultural competency training for physicians also may be paramount in providing “information about screening, treatment, and survivorship [that is] clear and culturally relevant” (Moore et al., 2012; see also Allen et al., 2007)

A second practical implication is the necessity of providing tailored messages to low-income African American men using interpersonal channels. The authors believe that such tailored information can be most efficiently delivered through interpersonal interaction due to the sample’s reliance on interpersonal sources to obtain health information. The greatest impact on promoting prostate cancer awareness and screening behavior was provided by interpersonal communication.

Although interpersonal interventions through health professionals or community workers may be one way to provide more information to men at risk for prostate cancer, the solution likely is not cost-effective, and associated outcomes would be difficult to measure. As an alternative, our study demonstrates that certain types of media can provide tailored information in an effective format—e-mail and text messaging are preferred by the target population rather than going online. Especially, use of text messaging to share health information with the target population seems to be one way of providing tailored messages, in readable chunks (160 characters per message), using a portable device that is becoming increasingly more popular among the demographic (Lenhart, 2010). Considerably more participants in our study sample had access to and made regular use of a cell phone compared to the Internet. Moreover, participants reported a preference for receiving health information in text-based formats (e-mail and text messaging) compared to viewing a website.

The authors believe that text messaging may be one way to traverse first- and second-level digital divides (Hargittai, 2002) among low-income minority groups, specifically when sharing information about prostate cancer with men who may be at risk for the disease. First-level access issues are resolved with text messages, as information is sent through a mobile provider rather than a wireless or broadband connection. Cell phone plans and prepaid services tend to be less expensive than smartphone data packages, not to mention the increased costs associated with Internet access at home. Moreover, African and Latino Americans are using text messaging at rates faster than other ethnic groups, including Whites (Lenhart, 2010). Second-level skills, such as the ability to search for information effectively within a reasonable timeframe, are addressed by providing the user with content-specific information in easy-to-grasp chunks. In this way, when learning about prostate cancer, the user avoids having to sift through websites with large amounts of often hard-to-understand content (most health materials are written at a 10th-grade level although most adults read at an 8th-grade level; Safeer & Keenan, 2005). Instead, targeted health information can be reviewed with minimal effort or skill.

Text messaging may be an effective media for prostate cancer-related education interventions targeting low-income at-risk men because the target population (a) reports sufficient access to cell phones, (b) possesses the skills to use text messaging, and (c) indicates a fairly strong preference for text messaging to learn about prostate cancer compared to other media. In addition, (d) text messaging functions as a particularly efficient media for tailoring and communicating information about confidential health topics such as prostate cancer. We suggest future interventions should consider incorporating text messaging as a potential medium to deliver health information. Such interventions may take several different forms. Text messaging could be used to facilitate provider–patient communication. Because health professionals exerted the strongest influence on prostate cancer screening behavior among the sample, text messaging may serve as an accessible medium for low-income minority men to obtain information from health professionals. Text messages from health professionals could be sent to remind individuals about upcoming screenings, physician visits, or other prostate cancer–related events. Text messages also could incorporate automated question-answering services. Although the iPhone’s Siri (voice-based agent) provides highly tailored information in an interpersonal, easy-to-use format, such functionality can be costly. Automated question-answering services (text-based agent) can provide similar benefits to Siri and other voice-based agents at reasonable cost.

As an extension of the current investigation, a two-part pilot investigation examined the viability of deploying automated question-answering text-messaging system as an alternative to Internet searching in order to provide information about prostate cancer screening for low-income African American men (McRoy, Cramer, & Song, 2014). The study consisted of (a) a controlled observational study of both web searching and question answering using the text messaging system and (b) a community-based mobile health intervention involving interaction with a health provider, where participants could text questions to a community health nurse. Most participants in the controlled observational study indicated the text messaging system answered their questions, was easy to use, and was a favorable tool for information seeking. Moreover, participants showed interest in using the system in the future. The community-based study also demonstrated the potential for text message question answering via health care provider to be helpful for the target population in accessing health information. Participants’ questions spanned several topics: smoking cessation, the role of drinking water in weight loss, how often one can donate blood, and the values that correspond to a healthy blood pressure.

Limitations and Future Directions

A limitation of the study was eligibility criteria requiring study participants to have a cell phone. The cell phone requirement was specified because we planned to recruit from the survey sample a smaller group of men to participate in an experiment using their cell phones (see McRoy et al., 2014). The authors recognize the eligibility criteria potentially biases study results by overestimating the population’s use of technology by only including cell phone users. Future research should eliminate any technological component to eligibility criteria in order to obtain a more realistic sense of the population’s use of technology. Pew survey research (Smith, 2014), however, reports high levels of cell phone ownership among low-income African American adults (90%; <$30,000) as well as older African American adults (89%, 50-64 years; 77%, 65+ years). Overall demographic trends indicate no significant differences between Whites and African Americans in cell phone use.

The omission of a measure of educational achievement in the survey constituted an unfortunate oversight. Digital divide research demonstrates disparities in Internet use and access across education (Zickuhr & Smith, 2012). Although education was not measured explicitly, the researchers inferred during data collection that participants possessed low levels of educational attainment. Many participants experienced problems reading the questionnaire, while some required some help with completion. Future research should promptly address the omission in the current research by examining the relationship between educational achievement and technology use among low-income minority men at risk for prostate cancer.

Our sample constituted a large portion of unpartnered participants due to being single, divorced, or separated (80%). Research indicates that partnership status significantly affects quality of life for low-income men with prostate cancer; specifically, unpartnered patients experience reduced mental well-being and higher symptom distress when compared to partnered patients (Gore, Krupski, Kwan, Maliski, & Litwin, 2005). A spouse may serve as a “built-in support system for coping with psychosocial and physical obstacles that confront the patient with prostate cancer” (Gore et al., 2005, p. 191). Such findings lead the researchers to surmise a majority of the sample in the current investigation lack “built-in” support. As a result, the potential for reduced health-related quality of life with a prostate cancer diagnosis is high for the sample population. In the absence of a partner, men at risk for prostate cancer should be encouraged to seek social support mechanisms in the prevention of prostate cancer. The physician is an important interpersonal source of support, in addition to relatives and friends. Again, if the presence of a family member causes embarrassment or discomfort, support groups in the community should be identified to increase psychosocial support. The authors believe that more studies are warranted to replicate this study.

Conclusion

Consulting sources of information about prostate cancer constitutes a communicative act: Messages are sent, received, encoded, and decoded for the purpose of learning more about the disease. Health communication professionals must continue to research the health information behaviors of low-income minority men at risk for prostate cancer in order to determine the interpersonal and interactive communication channels best suited to meet their health care needs.

Footnotes

Acknowledgements

The authors thank the study participants and Milwaukee Health Department Men’s Health Referral Network who assisted with data collection and offered insights and feedback on the study design.

Authors’ Note

Research materials related to the study are available from the corresponding author.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was part of the Public Health Impact Initiative of the University of Wisconsin–Milwaukee Zilber School of Public Health, funded by the U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, and National Center for Chronic Disease Prevention and Health Promotion (Grant No. 101X228).

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Information Gathering and Technology Use Among Low-Income Minority Men at Risk for Prostate Cancer

Abstract

Keywords

Low-Income African American Men and Prostate Cancer

Information Seeking and Digital Divide

Method

Procedures

Sample

Measures

Sources of Information

Preferred Medium for Health Information

Prostate Cancer Awareness

Prostate Cancer Screening and History

Data Analysis

Results

Discussion

Limitations and Future Directions

Conclusion

Footnotes

Acknowledgements

Authors’ Note

Declaration of Conflicting Interests

Funding

References