Abstract
This study was conducted to identify the salient behavioral beliefs of young Black men toward prostate cancer screening, and to identify the issues surrounding their comfortability with prostate examinations. A total of 20 Black men, aged between 18 and 40 years, participated in three focus group sessions between June 2013 and July 2013 in Austin, Texas. Participants were asked open-ended questions about: (a) the advantages and disadvantages of screening to identify salient behavioral beliefs about screening and (b) issues that would make prostate examinations comfortable or uncomfortable to identify comfortability factors. Focus group discussions were tape-recorded, transcribed, and content analyzed to identify emerging themes of salient beliefs and comfortability. Also, nine salient behavioral beliefs toward prostate cancer screening were identified, and eight factors were linked to comfortability with prostate examinations. Given the increase of prostate cancer disparity as a public health issue, understanding the beliefs of Black men of prescreening age (18-40 years) may be crucial to the effectiveness of future interventions to improve screening when recommended at later ages.
Keywords
Introduction
Prostate cancer is the most commonly diagnosed cancer and the second leading cause of cancer death among Black men. Death rates from prostate cancer among Black American men are the highest in the world (Howlader et al., 2013; Leigh, 2004). Compared with men of other racial and ethnic groups, Black men are at least 56% more likely to develop prostate cancer, and mortality from prostate cancer is twice as likely in men of Black origin (Parchment, 2004; Weinrich, 2006). According to the American Cancer Society (ACS), the survival rate for prostate cancer when diagnosed and treated early is nearly 100%—making it one of the highest of all cancers, yet Black men are still at increased risk of dying from it.
A major factor thought to be responsible for this disparity in morbidity and mortality is that ethnic minority men are less likely to get preventive care, such as prostate cancer screening when recommended. Several studies report that even after adjusting for socioeconomic status, comorbidities, and access to care, Black men are less likely to undergo prostate cancer screening (Berglund, Nilsson, & Nordin, 2005; Consedine, Morgenstern, Kudadjie-Gyamfi, Magai, & Neugut, 2006; Gilligan, Wang, Levin, Kantoff, & Avorn, 2004; Niederdeppe & Levy, 2007; Odedina et al., 2009; Patel et al., 2010; Sanchez, Bowen, Hart, & Spigner, 2007). Perceived discomfort associated with digital rectal examinations (DREs) has been identified as one of the most significant factors associated with screening participation, especially among Black men (Macias, Sarabia, & Sklar, 2000; Odedina et al., 2004; Ramalho, Wilson, Brenny, & Mamedio, 2008; Webb, Kronheim, Williams, & Hartman, 2006).
Procedures used for early detection, and screening for prostate cancer, are the prostate-specific antigen (PSA) blood test and the DRE (Brawley & Kramer, 2005; Chomyszyn-Gajewska, Cabala, & Virtanen, 2012). Prostate cancer screening remains a controversial topic (Clarke-Tasker & Wade, 2002; Sirovich, Schwartz, & Woloshin, 2003; Smith, Brooks, Cokkinides, Saslow, & Brawley, 2013). The ACS, American Urological Association (Carter et al., 2013), the U.S. Preventive Health Services Task Force, and the National Medical Association have differing views regarding screening guidelines, age to undergo screening, and the most effective screening method. For example, the U.S. Preventive Health Services Task Force suggests that the risks associated with prostate cancer screening outweighs its benefits and recommends against PSA screening in men of any age or racial group (Chou et al., 2011; Moyer, 2012). Conversely, the ACS recommends that information related to limitations and advantages of prostate cancer screening be communicated to those intending to get screened for prostate cancer, and recommends a universal approach to the use of DRE and PSA for prostate cancer screening. For at-risk groups like Black men, the ACS suggests that screening could begin as early as 45 years for all men or 40 years for Black men with positive family histories of prostate cancer.
Nonetheless, early detection of prostate cancer has been reported to increase chances of survival (Brawer, 2000; Carter et al., 2013; Hayes & Barry, 2014; Moyer, 2012). Thus, Black men, who have been reported to be the most at-risk population, should be educated about screening early on so that they are better equipped to make future decisions about prostate cancer screening. Further evidence suggests that education about health-enhancing behaviors, like screening, in early adult years will enhance young Black men’s ability to make informed decisions about screening in later years (Miller, 2014; Odedina, Scrivens, et al., 2011); yet nearly all studies examining issues regarding prostate cancer screening in Black men have focused on men older than 40 years (ages range from 40 to 79 years; Dean et al., 2014; Gonzalez, Consedine, McKiernan, & Spencer, 2008; Odedina, Campbell, LaRose-Pierre, Scrivens, & Hill, 2008; Odedina, Dagne, et al., 2011; Odedina, Scrivens, et al., 2011). Perhaps, a focus on men of prescreening ages (younger than 40 years) will facilitate efforts to improve screening rates when recommended at the age of 40 (for high risk) or 45 years. This process likely would be more effective if physicians’ recommendations are based on messages that are tailored to the needs and expectations of Black men, and lend understanding to their options regarding prostate cancer screening and treatment (Smith et al., 2013).
Several studies have reported that low participation in prostate cancer screening remains a significant burden in the Black male population despite decades of research highlighting the importance of screening in preventing morbidity and mortality from prostate cancer (DePrimo, Shinghal, Vidanes, & Brooks, 2001; Loeb & Schaeffer, 2009; Woods, Montgomery, Herring, Gardner, & Stokols, 2006). Reasons given for low participation in prostate cancer screening among older Black men include fear of invasion of their privacy and bodies, and masculinity, as expressed by toughness and manliness (Blocker et al., 2006; Cheatham, Barksdale, & Rodgers, 2008; Dube, Fuller, Rosen, Fagan, & O’Donnell, 2005; Wade, 2009; Winterich et al., 2009). These reasons were elicited in men older than 40 years, and it is unknown whether these beliefs are similar or different among younger Black men. Therefore, the purpose of this study was to identify the salient behavioral beliefs of young Black men toward prostate cancer screening and to identify the issues surrounding comfortability with prostate examinations. In order to develop culturally appropriate outreach strategies for this at-risk population as they grow older and may become eligible for prostate cancer screening, it is important to understand their beliefs toward prostate cancer screening so that information gaps and misconceptions can be identified and addressed early on.
Method
To elicit responses regarding salient behavioral beliefs about prostate cancer screening among young Black men, as well as their comfortability with prostate examinations, an exploratory, qualitative design using focus groups was used. The institutional review board at the University of Texas at Austin approved this study. Focus group participants provided written informed consent. Focus groups were conducted until the point of saturation was reached.
Sample, Setting, and Procedures
Participants were Black men aged 18 to 40 years residing in Austin, Texas. A convenience sample of 20 Black men was recruited through established contacts in the surrounding colleges/universities, word of mouth, and community liaisons using flyers. Participants were compensated with a $20 VISA gift card for their time, and they were also provided educational materials on prostate cancer screening obtained from the National Cancer Institute. Three 90-minute focus groups were conducted in Austin, Texas. The lower limit of 18 years was chosen because it is the age of consent and the upper limit of 40 years was chosen because the ACS recommends that the discussion about prostate cancer should take place at age 40 for men considered high risk (those with more than one first-degree relative who had prostate cancer at an early age).
Focus Group Topics
The main objectives of this study were to identify salient behavioral beliefs about prostate cancer screening (Ajzen, 1991, 2002) and to identify issues surrounding comfortability with prostate examinations in young Black men. Prostate examinations were used interchangeably with DREs. Questions from the salient behavioral beliefs were modeled after the attitudinal component of the theory of planned behavior (TPB; Ajzen, 1991, 2002). According to the TPB, a person’s behavior is determined by their attitude toward the behavior, the opinions of important others and the level of control they have over the outcome. The attitude toward the behavior, the focus of this study, is described as an individual’s evaluation, either positive or negative, toward performing the behavior and consists of salient behavioral beliefs measured in perceived advantages and disadvantages of the behavior. The value of the TPB model is that situation-specific, salient, belief-based attitudes (i.e., the perceived consequences of the behavior) can be assessed (Ajzen, 2002). In addition, two probing questions regarding comfortability were asked to further elicit responses from participants. The following topics guided the focus group discussions.
Behavioral Belief Questions
Comfortability Question
Probe 1: Take a moment to jot down your experience with any physicals that included being touched in places where you were not comfortable? Tell me more about that experience.
Probe 2: Do you think that being exposed early to these kinds of “physicals” might make it easier for Black men to be more comfortable with prostate examination when the time comes?
Data Collection
Three focus group sessions were conducted between June 2013 and July 2013 in Austin, Texas with two trained individuals serving as moderator and assistant moderator/note-taker. These two individuals were part of the research team and underwent qualitative research design training by an expert prior to the focus group data collection and also have experience in moderating focus groups. The focus group discussions were audio-recorded and transcribed for data analyses.
Data Analysis
Transcripts were reviewed and content analyzed by hand by the two research team members to identify primary themes of salient beliefs and comfortability. Transcripts were reviewed multiple times and using topic coding, recurring concepts and phrases were identified and labeled with codes. Concepts that were similar were then grouped into categories via the process of analytic coding. The data were then analyzed for themes regarding salient beliefs and comfortability, using the identified concepts and categories (Richards & Morse, 2007). The two research members compared their results and discrepancies were resolved through discussion. Using an iterative approach, whenever inconsistencies arose, transcripts were re-reviewed until a consensus was reached. This was done to ensure the accuracy and reliability of identified themes. Finally, the themes were tested against the data by checking back with 5 of the 20 focus group participants via an interactive process. These member checks were done to minimize any idiosyncratic biases and to ensure the accuracy of the analysis.
Results
Study Participants
Participants (n = 20, mean age = 27.68 ± 6.4 years) were Black men, aged between 18 and 40 years and 45% (n = 9) of the men were of African American or American origin. Participants mostly had some college degree (55%), were mostly single (70%), and had some form of health insurance (90%). The demographic information of the participants is summarized in Table 1.
Focus Group Participants’ Demographics.
Several themes were elicited from the focus group sessions that concentrated on opinions regarding prostate cancer screening, behavioral beliefs (advantages and disadvantages of prostate cancer screening), and comfortability with prostate examinations. Table 2 contains themes and subthemes that emerged from the focus group sessions.
Major Themes and Subthemes by Participants.
Behavioral Beliefs Regarding Prostate Cancer Screening
Advantages of Prostate Cancer Screening
Four unique advantages identified by participants included knowing whether one has prostate cancer or not (n = 12), detecting prostate cancer early (n = 9), having to eventually undergo the process (n = 7), and giving peace of mind (n = 4). First, participants indicated that knowing whether one has prostate cancer or not was a major advantage to undergoing screening. For example, several participants agreed that knowing one’s status could help in early detection and early treatment of prostate cancer. Below is a typical response from one participant:
I will also say that I will agree with him as well knowing is good and knowing in terms of treatment availability cos you could have it and then like certain diseases have certain stages, you could be right there at the curable stage and be done with it in no time.
Another example was, “I think that something, there’s always this fascinating idea about knowing that you are clean, health wise . . .” A second advantage to undergoing prostate cancer screening was because it could detect prostate cancer early. This is exemplified by the statements below:
I mean, so, if, for example I have, maybe my father or maybe I have a brother, you know, or probably a grandfather that have died from prostate cancer and the doctor said oh he died because he didn’t get screened. We didn’t detect the cancer very early so, you know that could much make me say, okay yeah prostate cancer (screening) is probably good because it helps to detect it early so that, you know, it doesn’t kill you . . . So, that’s why for me, it’s like if I have to screen myself to get it to detect it early, then I think it’s favorable.
Also, participants agreed that by detecting prostate cancer it can be managed properly before it progresses. Third, participants expressed the eventuality and necessity of having to undergo prostate cancer screening. Specifically, some participants ascribed a degree of importance to get examined when it is required of them. In the words of one participant,
Yeah get checked out man. Um, yeah, ‘cause I mean it’s sad but it’s, you know, sad and true at the same time, and funny but, um, it’s like I said it’s a necessary thing that needs to be done, we should be doing it.
Finally, participants indicated that undergoing prostate cancer screening when it is recommended to them would bring peace of mind. While this was expressed as an advantage, some participants expressed some concerns regarding the “cost” of such peace especially if it comes with a positive prostate cancer diagnosis and huge medical expenses. One participant described such as
And then say you you’re okay. That’s money lost. I mean, you’ll have peace of mind but it is still money lost.
While another participant expressed peace of mind as a double-edged sword as
I will say the peace of mind just like you said that you have them go through all that stuff and then you have to go through all that treatment and then at a certain point it’s like it’s too much, so I think the peace of mind not knowing and you’d be much calmer.
Disadvantages of Prostate Cancer Screening
Incurring unnecessary medical cost (n = 12), leading to the invasion of privacy (n = 6), leading to stigma (n = 5), causing emasculation (n = 4), and being a fearful process (n = 3) were the five unique themes that were identified from participants as disadvantages of prostate cancer screening. Participants perceived prostate cancer screening to be an unnecessary medical cost. For example, one participant expressed embarrassment for stating cost as a disadvantage:
. . . you know when you ask that question, you’re kinda embarrassed because you can’t think of any disadvantages other than cost. So then it’s like, upon reflection, is this even a wise decision to not do it?
Another participant expressed concern as to prostate cancer screening leading to more cost and burden on the family. He stated,
In talking about stages, if you go in and you get a prostate checkup and you realize that it’s metastatic and it’s travelling somewhere, not only is it in your prostate, it’s also in your kidney and it’s like you gotta have chemotherapy, I mean of course you’d get it done but if you don’t have the finances to do so, it’s gonna be really stressful on your family on you and a lot of times people don’t have money to take care of you, that pretty much ends up not too well.
Also, some participants stated that undergoing prostate cancer screening could increase the doctor’s fees in the advent of a positive diagnosis. This was expressed as
Just the money, you know insurance yeah someone can have prostate cancer and the treatment might be, I don’t know about $5,000. If the person’s monthly income is $2000, he’s just gonna have to live with it or you know try to ask family or bring it to the public, you know. So I think financial has like a big role to play, it is definitely a downside to screening. Oh, and if you have insurance, there’s always this fear that if anything is detected, it could impact your doctors’ fees and whatever else.
Participants also mentioned invasion of privacy as a downside to undergoing prostate cancer screening. One participant indicated that his impression regarding prostate cancer screening as an invasion was formed by what he saw in the movies. He stated it as
I was about to say in those movies where the doctor puts on the rubber gloves and the person yelling, that’s basically what I thought of. I just feel like it’s the height of invasion of one’s privacy.
Other sample statements include
No, uh uh, I mean, okay. It depends on the mode; you know how do I get screened? I mean like he said, invasion of privacy of your body, um is that the only way to do it?
and
it’s more so like the fact that it’s inside of you the invasion of privacy more so and you’re conscious and you’re also allowing it to happen.
The impact of stigma was also expressed by participants as a disadvantage to screening. Participants equated undergoing prostate cancer with losing one’s street credibility, as stated by “That’s it, the idea that prostate screening reduces your street credibility; there’s a stigma associated with it and I am even 33.” This statement was echoed by several other participants who seemed to ascribe this as a disadvantage to undergoing screening. Another participant emphasized that while stigma was a disadvantage, he would rather share the “miserable” experience with other participants. He expressed this as
I mean, of course yeah, it has a certain stigma, at least for me it does. And so, misery loves company, so I would love to be able to have some other guys experience a prostate screening along with me.
Participants asserted that engaging in prostate cancer screening could be a threat to their masculinity. These male participants discussed how undergoing DRE was like an assault on their manhood. Some even voiced concerns regarding the fear of impotence if there was a diagnosis of prostate cancer. These issues of masculinity and fear of impotence were expressed by several men:
Yeah I would have to say so (regarding emasculation). I mean, my father had a prostate screening by the suggestion of his doctor, but honestly, I knew he was going in there for it, I didn’t talk to him about it, and I had to drive him home, I didn’t talk to him about it, it was, you know it may just be shallow, but I think that, on certain levels, it’s like emasculating, you know? If detected and one needs surgery, the fact is that surgery is a weakness and during the process of taking out the cancer, the person will not be able to perform sexually.
Finally, participants described fear or dread as a major disadvantage of undergoing prostate cancer screening. As one man explained: “Well, I feel like one from the fear of going through the process. I just like, try not to think about it. It just feels like bad news.”
Comfortability With Prostate Examinations
The eight themes identified which factors might make prostate examinations comfortable—[(a) having a female conduct the examination, (b) including the examination as part of a regular physical, (c) having a good first-time experience, and (d) having someone who acts professional conduct the examination] or uncomfortable—[(e) being an awkward process, (f) being touched in a sensitive area during the examination, (g) being macho and not showing any weakness, and (h) the idea of being sedated to get through the exams] when it is recommended by a physician.
Comfortable factors
Several participants (n = 7) expressed preference over the gender of whoever conducts the prostate examination. Overwhelmingly, participants favored a female health care practitioner over a male one, as typified in examples below:
But it is silly because the only reason I’d be more comfortable with a female is one, first thing, they would probably be gentler, and then two, they gon’ finger you, you know it’s a finger. And if I’m sitting around afterwards and do end up talking about it, it’s like, at least she was, at least she was cute. But it is silly, it’s fickle, right? It’s not just gender, but I mean all things equal, if I had to choose between a man and woman, I would choose a woman.
Including prostate examinations as part of routine physicals (n = 6) was mentioned as one of the factors that could make prostate examinations comfortable. One participant expressed the need to having such checkups at an early age and also more frequently, so as to reduce the anxiety associated with the process. He expressed this thought as
So, you would have to, you would have to start, you know, if that was your method to make it easier, is to make it more frequent so you’re not so nervous, you’re gonna have to start it early when you check me for basketball, you gonna have to do those kinds of screenings at the same time to make me more comfortable.
The importance of having a good first-time experience (n = 4) also emerged from the focus groups, with one participant sharing that
I mean it just depends on how your first experience went. So if your first experience was bad, every time you go you just thought of that. You hate doing it but you have to do, so it’s still just kind we have to do it. So it just kinda depends on your experience I guess.
Finally, participants also emphasized the importance of the professionality of whoever conducts the test (n = 4), by saying,
Well, there were times I had to be touched, it wasn’t, and it wasn’t really uncomfortable to me because I knew it was more of a professional thing. It was, you know, they were straightforward about what we were about to do, and there wasn’t no beating around the bush, no joking, no laughing, no playing. It was, I mean this is what is, this is what you do, like he said left, right, and we’re done. There wasn’t really any need to be uncomfortable. It’s like this is their job, this is what they’re here to do, you know that’s what you need, we’re going to get that done and then we’re all gonna go home.
Uncomfortable factors
Conversely, participants expressed several opinions as to factors that might make prostate examinations uncomfortable for them. First, participants described the process as awkward (n = 7). An opinion regarding prostate examinations as an awkward process is illustrated by an example below:
I have had a physical just regular like turn and cough physical before and to me I felt awkward. I mean that’s the only thought that I had. Besides that it was the same like when she actually touched it was like oh, just kind of like awkward
These participants also acknowledged that the notion of being touched in such a sensitive area (n = 5) was another major factor that made prostate examinations uncomfortable for them. With one participant expressing a strong dislike for being touched in such a sensitive area. He stated this thought as
Yeah, you know it was my body and everything, I don’t really like people touching me (all laugh). Or making me to strip or something like that, so, yeah anything that involves anybody touching me, I don’t like it. No.
Appearing macho and not showing any form of weakness (n = 3) was expressed by participants as potential ways to overcome the uncomfortable feeling from undergoing prostate examination. Several participants articulated the process as a sign of weakness, with one participant ascribing such weakness to the ideology of what a Black man ought not to be seen as. Example statements include
It goes back to the mindset of the black man in general, it’s like a black man, when I think what I’m supposed to be when I grow up, I have to be strong and I have to be able to support my family, I cannot shed a tear, ever, because then I’ll be seen as weak and once I’m seen as weak it’s all over. Yeah, it’s a form of weakness. Hyper masculinity period. My dad he calls himself a Fixer. Like I said earlier he’ll try to fix something like even my grandpa, he died of hyperglycemia and he still didn’t go to the doctor, he didn’t take his glucagon pills, he didn’t do a lot of things he was supposed to do cos I felt like his hyper-masculinity, he doesn’t want to seek help from outside someone else . . . Yeah, you don’t wanna seem vulnerable. But I think a very strong factor is the fact that men generally, we, because just from things I’ve read in the literature as regarding men and health. We are macho, we believe we’re strong, and we shouldn’t be down. So we don’t take health issues as serious as that.
Finally, participants mentioned that being conscious during the process of prostate examination (n = 3) would make the process uncomfortable for them. Some expressed being sedated as a way to escape from the feeling of being touched, as stated below:
Yeah I would feel better like being unconscious like colonoscopy; I would feel better if both were done while you were unconscious so I guess not aware. You’re used to being like outside your body, when people go inside your body it is different. Well, we all hope to be sedated during the process that way we don’t have to feel anything.
Discussion
Using the TPB, this study explored the salient behavioral beliefs of Black men regarding prostate cancer screening, when recommended by a physician. In addition, factors that were related to their comfortability level with prostate examinations were also assessed.
The current, increasing rates of advanced-stage and aggressive prostate cancer among Black men (Antwi, Tucker, Coker, & Fleming, 2013; Taksler, Keating, & Cutler, 2012; Tyson & Castle, 2014) highlight the importance of understanding the salient behavioral beliefs toward prostate cancer screening, as well as their comfortability with prostate examinations. Several issues should be considered when developing targeted educational efforts and tailored counseling in prostate cancer screening (PSA and DRE) for young Black males with the goal of preparing them for decisions regarding potential prostate cancer screening when they are older.
Beliefs About Prostate Cancer Screening
Participants indicated that a major advantage of prostate cancer screening was the knowledge of whether or not that they had prostate cancer. Participants underscored the importance of screening early to detect prostate cancer so as to get early treatment; which is consistent with findings from other studies (Clarke-Tasker & Wade, 2002; Demark-Wahnefried et al., 1995; Odedina et al., 2004). Peace of mind and having to eventually get the exam done were the main benefits described by participants as reasons to undergo prostate cancer screening when it is recommended by their physician. Though the participants in the current study were mostly younger (younger than 30 years), they recognized the future necessity of potentially undergoing prostate cancer screening, when recommended by a physician. This finding is similar to other studies in older populations who have actually participated in early detection programs (Bryan et al., 2008; Myers, 1999; Weinrich, 2006). Thus, if these benefits are reinforced in younger Black males consistently over time, then they can be equipped to make effective, informed decisions about screening (if recommended) when they are older. This focused education for Black men may save lives, given that Black men have been reported to be diagnosed with more aggressive forms of prostate cancer at a younger age (Drake et al., 2006; Karami, Young, & Henson, 2007; Woods et al., 2006).
Empirical findings have identified several barriers to participation in prostate cancer screening among Blacks, which include cost of the test, invasion of privacy, stigma associated with screening, emasculation, access to health, disinterest in their health, and fear (Blocker et al., 2006; Cheatham et al., 2008; Clarke-Tasker & Wade, 2002; Debes et al., 2004; Oliver, 2007; Pedersen, Armes, & Ream, 2012; Weinrich, Reynolds, Tingen, & Starr, 2000; Winterich et al., 2009). The current findings regarding young Black males support existing literature, most particularly the expressions of stigma, cost, invasion of privacy, fear, and emasculation. Together, these findings suggest that these factors are very important to Black men, regardless of their age groups. Perhaps, if some of these factors were discussed between patients and providers early on, the decision-making process of Black men at an older age will be a more effective one.
To mitigate some of these negative beliefs and myths regarding prostate cancer, the Black community, as a whole can be used as a communication channel. For example, Black churches, family members (father-to-son, brother-to-brother, uncle-to-nephew), Black media (e.g., BET, radio stations) are important components that can serve as vehicles for disseminating positive messages regarding the benefits of early prostate cancer detection (Friedman, 2009; Nivens, Herman, Weinrich, & Weinrich, 2001; Ross, Kohler, Grimley, Green, & Anderson-Lewis, 2007). These suggestions have strong roots in health education efforts in other diseases like HIV/AIDS where studies have reported how Black men identified the importance of social institutions like churches, and the media as sources of providing relevant information regarding health promotion (Akers et al., 2010; Corbie-Smith et al., 2010; Marcus et al., 2004), and were also supported by anecdotal comments during the focus groups.
Furthermore, in spite of most participants having some form of health insurance (n = 15, 75%), findings from the current study identified how screening, especially DRE, was perceived to be a very expensive procedure. This could probably be due to assumptions about the high cost associated with DRE, as it is part of the copay of a regular doctor’s visit. There are also several community clinics where individuals can have a regular, affordable source of care. Spreading this information to Black men may serve as a way to minimize the cost barriers when screening is recommended by their doctors.
Summarily, although the participants in the current study held some negative beliefs regarding prostate cancer screening when it is recommended to them by a physician, participants were aware of the benefits of early screening and detection. This awareness of the benefit of screening could be attributed to the observation of the increasing racial difference in overall diagnosis and death rates of prostate cancer (Howlader et al., 2013).
Comfortability With Prostate Examinations
This current study adds to the growing body of research as it underscores the importance of masculinity and its relationship to the health care-seeking practices of Black men. Across all the participants in this study, there appeared to be an echoing theme of masculinity ideology, especially with the traditional portrayal of Black men. These include avoiding health care, exhibiting fearlessness, and embracing risk (Abernethy et al., 2005; Courtenay, 2000), which have all been identified to play significant roles in the health beliefs of Black men and their health-seeking behaviors (Griffith et al., 2007; Sanders Thompson, Talley, Caito, & Kreuter, 2009; Wade, 2009). Even though a majority of the participants viewed prostate cancer screening as a form of early detection of prostate cancer, they also in turn expressed concerns on how undergoing screening, especially the DRE, was a threat to their masculinity. Similar to findings from other research, participants in the current study were more concerned as to how others perceived their masculinity (Griffith et al., 2007; Sanders Thompson et al., 2009; Wade, 2009). Furthermore, they asserted that being masculine meant being invulnerable to disease and appearing tough, even when their health is compromised. Studies have reported that in a bid to gain the respect of their peers, most young, Black men place a huge emphasis on masculinity and are more likely to put themselves in physical danger (Courtenay, 2000; Rich & Stone, 1996). Unlike past research conducted in older Black men whereby the aversion to DRE was linked to homophobia (Allen, Kennedy, Wilson-Glover, & Gilligan, 2007; Bloom, Stewart, Oakley-Girvans, Banks, & Chang, 2006; Webb et al., 2006), this current study did not find such parallels. Participants strongly expressed their dislike for DRE because of its perceived impact on their masculinity without any cross-reference to homosexuality.
Several participants voiced extreme discomfort and embarrassment as an impediment to screening. In their opinion, DRE was viewed as problematic and associated with emasculation. In congruence with other research, men, especially Black men, dislike DRE (Harvey & Alston, 2011; Winterich et al., 2009; Woods, Montgomery, Belliard, Ramirez-Johnson, & Wilson, 2004). A majority of the current sample of younger Black men downplayed the importance of DRE as they labeled that part of their body as off-limits. This prioritization of masculinity over health could result in a health paradox (Courtenay, 2000). By prioritizing their masculinity via resisting DRE, undetected cancers are allowed to grow which can be a health risk to Black men. In addition, studies indicate that Black men do not like to talk about examinations regarding the rectum, particularly DRE (Weinrich, 2006; Winterich et al., 2009), which was echoed by participants in the current study. Studies have reported that Black men fear to talk about DRE with other men for fear of teasing or being ridiculed (Consedine et al., 2007; Ferrante, Shaw, & Scott, 2011; Parchment, 2004; Winterich et al., 2009; Woods et al., 2006). Perhaps, if conducive environments were created by Black men to allow for free expressions of perceptions regarding DRE, they could share important findings with other at-risk men, which may reduce the perceived stigma, alleviate fear, and dispel the myths surrounding prostate cancer screening.
By not sharing important health information with other men, Black men could put other men at risk of preventable diseases, such as prostate cancer (Winterich et al., 2009). Participants expressed that they would be more comfortable with DRE if other “uncomfortable” physicals involving the private areas (e.g. testicular checkups) were included as part of a regular examination. An explanation for this is that unlike girls and women in the United States, the importance of regular physical exams is not instilled in men. Courtenay (2000) suggested that the greater use of the health care system by women for routine physical exams is a learned behavior that can also be taught to boys and men. A classic example is how women are taught at a younger age that physical examinations involve genital examinations (Reagan, 1997; Winterich et al., 2009). The same cannot be said of men who do not have the same social upbringing; it is not until much later in life when rectal examinations need to be done on a regular basis (Reagan, 1997). Perhaps, if men were exposed early on to similar examinations via education, they may see prostate cancer screening exams less as a threat to their masculinity when the time comes to engage in them (Reagan, 1997).
The current study findings demonstrated how young Black men preferred female doctors to conduct DREs. This is inconsistent with the medical literature, where it has been reported that patients prefer to be examined by doctors of the same gender (Eisinger et al., 2011; Fennema, Meyer, & Owen, 1990; Ng et al., 2013). The study by Fennema et al. (1990) reported that almost 70% (130 out of 185) of patients surveyed indicated a preference for same-sex physicians for examinations involving the anal or genital area. The reason behind this finding could be that 69% of those surveyed were women. Male patients older than 40 years have been reported to prefer a male physician for fear of embarrassment if the examination were to be conducted by a female physician (Heaton & Marquez, 1990). This could explain why the current participants—who were all male and younger (younger than 40 years)—demonstrated a higher preference for female physicians over male physicians. Another study conducted among Black men in Barbados also reported that African Barbadian men were not comfortable discussing their prostate health with a female physician (Ng et al., 2013).
One of the goals of Healthy People 2020 (U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion, 2012) is to reduce prostate cancer mortality to 21.2 deaths per 100,000 males, a 10% improvement from 2007. In order to ensure that the nation reaches this goal by the year 2020, there is a need to address the alarming incidence and mortality rates of prostate cancer in Black men when screening is recommended. Future research should consider our findings along with extant research in the development of interventions that are intended to improve prostate cancer screening rates in at-risk Black men. Educational interventions, incorporating these beliefs, are also needed to encourage health-promoting behaviors in younger Black men as they ease into adulthood, especially those who will need to eventually undergo prostate cancer screening. Finally, future studies can explore the extent to which prior knowledge or family history of prostate cancer can affect the beliefs and norms of these young Black men and change the way we educate based on a positive family history.
Limitations
The authors acknowledge some limitations in this study. First, responses of young Black men in this study do not necessarily reflect those of young Black men in other regions of the United States. Second, given that the moderator and note-taker/recorder were both women (an African and a Caucasian, respectively), it is possible that participants could have been more reserved when discussing personal matters like comfortability with prostate examinations. However, their frank discussion about masculinity issues makes this limitation less likely.
This study did not examine potential differences in responses by age or physician gender preference but such differences should be the subject of future studies. Longitudinal research may also be conducted to see if the beliefs of young Black men change over time and if educational interventions might need to be tailored to those temporal changes.
Finally, while efforts were made to center the recruitment efforts and discussion sections on prostate cancer screening, some participants could have confused prostate cancer screening with colorectal screening given some references to sedation and consciousness during the focus group sessions. Such misunderstanding has been reported in other qualitative studies (Dale, Sartor, Davis, & Bennett, 1999; Davis, Williams, Marin, Parker, & Glass, 2002) where participants were reported to confuse DRE with sigmoidoscopy and other “invasive” screening procedures. These misconceptions could be rooted in participants’ limited knowledge of prostate cancer and cancer screening. Research examining prostate cancer knowledge among Black men has reported a deficit of knowledge in this very high-risk group (Arnold-Reed et al., 2008; Demark-Wahnefried et al., 1995; Jones & Wenzel, 2005). More research is hereby needed to possibly address these misconceptions and to also assess the knowledge levels of this prescreening age group. Specifically, assessing such knowledge levels is important in effective prostate cancer control as limited health literacy could have affected the current participants’ perceptions of the benefits of early detection and risk factors associated with prostate cancer.
Conclusion
This study used qualitative methods to elicit salient behavioral beliefs regarding prostate cancer screening and comfortability with prostate examinations among Black men aged 18 to 40 years. Particularly, the use of these qualitative methods added richness, clarity, and depth to the understanding of salient beliefs that these young Black men held regarding prostate cancer screening, which can be useful in educational interventions targeted at young Black men as they grow older. While the importance of preventive behaviors such as prostate cancer screening is shrouded with controversies, early detection still remains a key to controlling prostate cancer. This is especially important in Black men who are the most at-risk for prostate cancer so that the disease can be treated early to increase survival rates and reduce disparity gaps. Ultimately, our hope is that the information identified in this study will contribute to the development of practice changes such as perhaps making certain “sensitive” exams (such as testicular examinations) more routine early on for Black men and designing culturally sensitive messages aimed at increasing participation of at-risk Black men in prostate cancer screening later in life. Sensitizing them early on will also serve as a way to dispel the myths regarding prostate examinations and prepare these young men for the “invasion of privacy” that they might likely encounter at a later age.
Furthermore, given that Black men are more likely to be diagnosed with prostate cancer at an earlier age (Karami et al., 2007) and die from the disease more often than men of other ethnicities, it is important to examine their beliefs regarding prostate cancer screenings so that education can be tailored to their needs. Understanding these beliefs could improve Black men’s involvement with their physicians when making an informed decision regarding whether or not to engage in prostate cancer screening when it is recommended.
Footnotes
Authors’ Note
The term Black refers to a person having origins in any of the Black racial groups of Africa. The Black racial category includes Blacks; those from sub-Saharan Africa, such as Kenya and Nigeria; and Afro-Caribbean, such as Haiti and Jamaica. This was used as a general term for U.S.-born, African-born, and Caribbean-born Black men. Prostate examinations were used interchangeably with digital rectal examinations.
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 research was supported by a grant, awarded to Dr. Carolyn Brown from The University of Texas, Office of the Vice President for Research.