Relationships Between Perceived Barriers and Prostate-Cancer Screening in African American Men







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Nursing Theses and Capstone Projects Hunt School of Nursing


Relationships Between Perceived Barriers and

Prostate-Cancer Screening in African American


Monica Covan Gardner-Webb University

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Covan, Monica, "Relationships Between Perceived Barriers and Prostate-Cancer Screening in African American Men" (2012).Nursing Theses and Capstone Projects.Paper 111.


Relationships Between Perceived Barriers and Prostate- Cancer Screening in African American Men


Monica Covan, BSN

A scholarly thesis presented to the faculty of Gardner-Webb University School of Nursing in partial fulfillment of the requirements for the

Degree of Master of Science in Nursing Boiling Springs, North Carolina


Submitted by: Approved by:

_________________________________ _________________________________ Monica Covan, BSN Reimund Serafica, PhD, MSN, RN _________________________________ _________________________________


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iii Table of Contents List of Tables... v List of Figures ... vi Acknowledgments ... vii Abstract ... viii Chapter 1. Introduction ... 1 Problem Statement ... 1

Background and Social Significance ... 4

Purpose ... 4

Conceptual Framework ... 5

Definitions of Terms ... 8

Health Disparities in South Carolina ...10

Significance to Nursing ...13

Theoretical Assumptions ...14

Research Questions and Hypothesis ...15

Summary ...15

2. Literature Review ...17

Family History as a Risk Factor ...18

Barriers to Screening ...20

Screening Measures ...33

Strengths and Limitations of the Literature Review ...36

Summary ...37

3. Method ...38

Setting ...38

Sample and Inclusion Criteria ...39

Design ...39

Protection of Human Subjects ...40

Instrument ...42

Data-Collection Procedure ...43

Data-Analysis Procedures ...44

Summary ...44

4. Results ...46

Descriptive Analysis of the Demographic Data ...46



Research Question 2...51

Research Question 3...59

Summary ...59

5. Discussion ...61

Significance of the Findings ...61

Implications for Nursing Practice ...63

Limitations of the Study ...64

Recommendations for Future Research ...64

Final Summation ...65

References ...67

Appendix A. Demographic Questionnaire ...73

B. Institutional Review Board Approval ...74

C. Gardner-Webb University Human Subjects Committee Informed Consent Form ...75

D. American Cancer Society and the Texas Department of Health Prostate Cancer and Screening Educational Pamphlet ...76

E. Health Belief Model Scales for Measuring Beliefs Related to Prostate Cancer ...78

F. Permission Letter to use Champion’s Health Belief Model Scale ...79

G. Site Approval Letter...80

H. Research Study Flyer ...81



List of Tables

Table Page

1. Demographic Data...48

2. Perceived Barriers Scale ...50

3. Age Compared to the 15 Perceived Barriers ...52

4. Educational Level Compared to the 15 Perceived Barriers ...53

5. Income Level Compared to the 15 Perceived Barriers ...54

6. Health Insurance Compared to the 15 Perceived Barriers ...55

7. Knowledge Level of Prostate Cancer Screenings Compared to the 15 Perceived Barriers ...56

8. Self-Reported Likelihood of Having a Prostate-Cancer Screening in the Future Compared to the 15 Perceived Barriers ...57



List of Figures

Figure Page

1. Health belief model ... 6 2. Health belief model constructs chart. ... 7




I would like to acknowledge Dr. Reimund Serafica for his guidance and wisdom as my Thesis Advisor. The time, expertise, and ideas that he contributed to this research were invaluable.

I greatly appreciate Dr. Margaret Hindman, Director for the Joint Center for Nursing Research at the University of South Carolina–Upstate; her guidance and expertise in statistical formulations were instrumental to completing this thesis.

I thank my friend, Heidi Grossweiler, RN, who persuaded me that attending Gardner-Webb University was the most appropriate program to enroll for the quest of my Master’s degree.

To my editor and formatter, Rocky Citro; I thank you for your diligent and meticulous review and corrections of my thesis.

Most important, my family deserves the biggest thank you for their continued support and patience over the past two years. Their sacrifices—financially and

emotionally—were humbling as I made this project a reality. My sons now realize that with hard work and sacrifice, goals do come true and are well worth the challenge.




Cancer is the second leading cause of death in the United States, and prostate cancer is the leading cause of cancer-related death among African American men. The literature has revealed that the primary cause of increased mortality rates of prostate cancer in African American men is the lack of participation in prostate-cancer screening activities. This descriptive cross-sectional study identified the relationships between perceived barriers to prostate-cancer screening and actual screening practices among African American men. Using the health belief model as a theoretical construct, current prostate cancer screening practices and perceived barriers to screening were examined in a sample of 30 African American men located in upstate South Carolina. Perceived barriers were measured by Champion’s Health Belief Model Scale, and participation in prostate-cancer screening was measured by a history of having a digital rectal exam, a prostate specific antigen test, or both in the preceding 12 months. A greater understanding of perceived barriers to prostate-cancer screening may provide health care professionals with the information they need to implement strategies to address these barriers. The aim is to increase prostate-cancer screening among African American men and ultimately decrease the rate of mortality from prostate cancer. The results of this study may help health care professionals increase prostate-cancer awareness and facilitate education and screening behaviors among African American men through early detection and intervention.


Chapter 1 Introduction Problem Statement

Prostate cancer is the most commonly diagnosed cancer in men and is the second leading cause of cancer deaths among men in the United States (Jones, Steeves, & Williams, 2009). The American Cancer Society (ACS, 2011) has estimated that 168,900 men in the United States will be newly diagnosed with prostate cancer in 2012 and approximately 27,000 will die from the condition. Prostate cancer affects African American men disproportionally; at 248.5 cases per 100,000, they have the highest

incidence of prostate cancer, compared to 156.7 cases per 100,000 for Caucasian men and 138.0 cases per 100,000 for Hispanic men (Delancey, Thun, Jemal, & Ward, 2008). An estimated 35,110 cases of prostate cancer are expected to occur among African American men in 2012, accounting for 40% of all cancer diagnoses in African American men (Ward, Halpern, Schrag, 2008). Although prostate cancer morbidity and mortality rates continue to drop among African American men in the United States, the decline lags behind the trend for Caucasian men.

African American men continue have the highest morbidity and mortality rates for prostate cancer. According to the ACS (2011), African Americans have a 1-in-5 lifetime probability of developing invasive prostate cancer compared to a 1-in-7 probability for Caucasians. The lifetime probability of dying from invasive prostate cancer is 1 in 23 for African American men and 1 in 38 for Caucasian men. African American men also experience disparities relative to prostate cancer survival, with an overall 5-year survival rate of 95% for African American men and 100% for Caucasian


men (ACS, 2011). The average annual prostate cancer death rate between 2007 and 2011 was 56.3 for Black men and 23.6 for Caucasian men. This is a difference of 32.7, with African American men having a prostate cancer mortality rate 2.4 times higher than that of Caucasian men. With these continuous racial disparities in incidence rates, survival, and deaths, a key way to close the gap is individual health promotion and

disease-prevention behaviors to reduce the behavioral risk factors for prostate cancer (Odedina et al., 2011).

African Americans are more likely to be diagnosed with a neoplasm that has spread beyond the immediate adjacent organs or tissues and to have tumors metastasized to distant lymph nodes (Feldman-Stewart, Brundage, Manen, & Svenson, 2004). In 2011 the ACS reported that the overall relative survival rate for prostate cancer among African Americans was 96%, (compared to nearly 100% for Caucasian men). Ninety percent of all prostate cancers among African Americans are diagnosed at the local and regional stages, compared to 92% for Caucasians; the 5-year survival rate for African Americans whose tumors are diagnosed at these earlier stages approaches 100%. Among African American men, the 5-year survival rate drops to 29% when the cancer has spread to distant sites.

Consistent screening for cancer has been shown to improve incidence and mortality rates and is one of the most commonly used techniques in the diagnosis of prostate cancer (Williams & Corbie-Smith, 2006). However, only small percentages of the African American population participate in cancer screenings; for example, among a group of 4,784 African American men, only 37.1% reported recent use of available cancer screenings (Delancey et al., 2008). The ACS (2011) recommends that health care


providers should offer a prostate specific antigen (PSA) blood test and a digital rectal exam (DRE) yearly, beginning at age 50. Men at risk should begin testing at age 45; examples include African American men and men who have a first-degree relative (e.g., a father, brother, or son) who was diagnosed with prostate cancer before age 65.

Researchers agree that regular screening examinations with the PSA and DRE can result in detection of prostate cancer at earlier stages, when treatment is more likely to be successful and may detect significant prostate cancers at earlier, more favorable stages (Menashe, Anderson, Jatoi, & Rosenberg, 2009).

Compared with Caucasian men, African American men have a 60% higher incidence rate of prostate cancer, and their mortality rate from prostate cancer is nearly double that of Caucasian men (ACS, 2011). Despite these troubling statistics, research has shown that African American men are less likely than Caucasian men to undergo prostate cancer screening tests (Wolin, Yan, Colditz, & Lee, 2009). Research has suggested that although regular prostate cancer screening is the most effective technique available to detect prostate cancer early, different barriers, such as DRE pain, knowledge, education level, family history, and access to health care have been identified as factors that influence a person’s decision to have a screening. Understanding the barriers that influence the decision to have a prostate cancer screening may allow health care professionals to implement strategies to address them. This in turn may increase the participation of prostate cancer screenings among African American men and ultimately decrease the rate of mortality from the disease. To better understand why African American men are less likely to participate in prostate cancer screenings, scholars have


begun to examine perceived barriers to cancer prevention and control (Jemal, Center, DeSantis, & Ward, 2010).

Background and Social Significance

Research has demonstrated that detecting prostate cancer early can significantly improve the chances of survival among African American men. However, African American men frequently decline PSA tests and DREs in their clinical examinations (Jones & Wenzel, 2005), despite them having the highest incidence and mortality rate for prostate cancer. The problem is that decreased participation in prostate cancer screening increases the likelihood of discovering prostate cancer at more advanced stages, thus decreasing survival rates. African American men tend to be diagnosed with prostate cancer at an age less than 60 years old, with more poorly differentiated tumors, often presenting with later stage prostate cancer than Caucasian men (Jones & Wenzel, 2005).

By examining the relationship between perceived barriers and prostate cancer screening practices in African American men at ages when they are prone to the disease (40 to 70 years old health care professionals can learn how to more effectively address those barriers. The results from such an analysis could help health care professionals reduce mortality from prostate cancer among African American men. Moreover, through early detection and intervention, health care professionals should also be able to increase prostate cancer awareness and facilitate education and screening of African American men.


Examining health-seeking practices based on the beliefs and perceptions of subpopulations is particularly relevant in health-disparities research. Health care


utilization patterns have raised questions about how health professionals can integrate an understanding of social norms and ideologies into an analysis of men’s use of health services. The purpose of this study was to determine if a correlation was present between perceived barriers and prostate-screening patterns among African American men in upstate South Carolina.

Conceptual Framework

The health belief model (HBM) was the theoretical framework used in this study. The essence of the HBM is that individuals’ beliefs affect the actions they take relating to their health (Stretcher & Rosenstock, 1988). The HBM was developed over 50 years ago by social psychologists Rosenstock, Hochbaum, and Kegels, who tried to understand the lack of participation in a free tuberculosis-screening program (McNaughton-Collins & Barry, 2011.). In 1958 Hochbaum stated, “Although the public stands to gain most from the success of health programs, its willingness to participate has all too often been disappointing, in spite of well-organized attempts to arouse popular interest and to make participation easy” (as cited in Stretcher & Rosenstock, 1988, p. 183). Currently, the HBM is the most frequently used theory in health education, health promotion, and disease prevention (“Health Belief Model,” 2010) and is commonly used to examine patient motivations for adopting health-related behaviors and in assessing health-behavior interventions. The HBM provides a comprehensive framework for understanding

psychosocial factors associated with compliance (Black, Hawks, & Keene, 2006). The core components of the HBM are shown in Figure 1. Definitions and applications of key terms in the model are shown in Figure 2.


Figure 1. Health belief model. From Health behavior and health education: Theory, research, and practice (5th ed.), by K. Glanz, B. Rimer, and F. Lewis, 2002, San

Francisco, CA: Josey-Bass. Copyright 2002 by Josey-Bass. Adapted with permission. Background • Sociodemographic factors • Education • Age • Sex • Race • Ethnicity Perceptions Threat

• Perceived susceptibility to disease or acceptance of the diagnosis

• Perceived severity of ill-health condition

Action Cues to action • Media • Personal influence • Reminders • Education • Symptoms Behavior to reduce threat based on expectations Expectations

• Perceived Benefits of action (minus)

• Perceived barriers of action


Concept Definition Application Perceived Susceptibility One’s opinion of chances of getting a condition Define population(s) at risk, risk levels; personalize risk based on a person’s features or behavior; heighten perceived susceptibility if too low.

Perceived Severity One’s opinion of how serious a condition and its consequences are

Specify consequences of the risk and the condition

Perceived Benefits One’s belief in the efficacy of the advised action to reduce risk or seriousness of impact

Define action to take; how, where, when; clarify the positive effects to be expected.

Perceived Barriers One’s opinion of the tangible and

psychological costs of the advised action

Identify and reduce barriers through reassurance, incentives, assistance.

Cues to Action Strategies to activate “readiness”

Provide how-to information, promote awareness, reminders.

Self-Efficacy Confidence in one’s ability to take action

Provide training, guidance in performing action.

Figure 2. Health belief model constructs chart. From Health behavior and health

education: Theory, research, and practice (5th ed.), by K. Glanz, B. Rimer, and F. Lewis, 2002, San Francisco, CA: Josey-Bass. Copyright 2002 by Josey-Bass. Adapted with permission.


Definitions of Terms

Perceived susceptibility occurs when an individual perceives that she or he is susceptible to contracting a morbid condition.

Perceived severity is the degree to which an individual believes that contracting a given illness could have serious physical, psychological, or social consequences. The combination of perceived susceptibility and perceived severity is perceived threat.

The perceived benefits of an action refer to a reduction in the perceived severity or susceptibility of a disease. The HBM suggests that people will not change their behaviors even if they have a high degree of perceived threat unless the actions in question are perceived as efficacious.

Perceived barriers are the conclusion that an individual draws after conducting a cost–benefit analysis to determine if a particular health action would be effective enough to overcome factors such as pain, inconvenience, and other unpleasant side effects.

Self-efficacy is another concept that has been added to the HBM since 1988 to better meet the challenges of altering unhealthy habitual behaviors (such as being sedentary, smoking, or overeating). Self-efficacy, a concept originally developed by Albert Bandura in social cognitive theory and social learning theory, is simply a person’s confidence in her or his ability to successfully perform an action.

Other variables that are believed to play a role in the HBM but have not been studied conclusively include cues to action, age, gender, ethnicity, personality, and socioeconomic status. Cues to action could be internal or external and could include symptoms (internal) or suggestions by a physician, friend, or relative (external).


In general, the HBM suggests that individuals will take action if they believe themselves to be susceptible to what they perceive to be a serious threat to their health. Thus, if a man perceives that getting screened for prostate cancer will reduce the threat of the disease, he will be more likely to get screened. The action that he would take must be perceived as feasible and efficacious. Finally, the potential negative aspects of a

particular health action (i.e. perceived barriers) may act as impediments to taking action. Thus, as Stretcher and Rosenstock stated, “the combined levels of susceptibility and severity provide the energy or force to act and the perception of benefits (less barriers) provides a preferred path to action” (Bloom, et all, 2006, p. 2168). Regarding prostate-cancer screening, men with a family history will perceive themselves as more vulnerable and therefore tend to view the benefits as outweighing the barriers (sensitivity of the PSA test and consequences of cancer treatment); consequently, these men are more likely to have received a recent test (Jacobsen et al, 2004; Vadaparampil, Jacobsen, Kash, Watson, Saloup, Pow-Sang (2004). Men without a family history of a disease do not usually perceive themselves as vulnerable; in this case the barriers outweigh the benefits, and these men are less likely to be screened (D’Amico, 2012; Schröder, Hugosson, & Roobol, 2012). Identifying barriers is a key concept in the HBM general and in prostate-cancer screening in particular, and the likelihood of going for regular prostate-cancer screening is determined by each man’s understanding of the condition and its sequelae, his

perceived susceptibility, and benefits minus his perceived barriers (Hart & Bowen, 2004). In the more than 50 years of its existence, the HBM has been embraced and developed and has become a prolific framework for explaining and predicting preventive health care behaviors. Added dimensions have furthered its abilities, making it a useful


framework in the area of sick-role behaviors as well (Toles, 2008). The model has garnered significant support across many types of applications. Components of the HBM have been linked to participation in health-promoting behaviors, and the model has served as a theoretical framework for many studies related to the intention of African American men to participate in prostate-cancer screenings (Wade, 2009). The HBM has been used to explain, understand, and predict behaviors of people related to their

preventative health practices (Wolin et al., 2009) and thus was a suitable model for the present study. The HBM provides a framework that allows the researcher to focus on the relationships between the population’s perceptions, risk factors, and health-seeking behaviors. Finally, the model assists the researcher in developing tools and methods to support the analysis of relationships to support or reject the research hypothesis.

Health Disparities in South Carolina

Prostate cancer is the most commonly diagnosed cancer in men in the United States. It disproportionately affects African American men compared to other ethnic groups. African American men are 2.5 times more likely to die of prostate cancer than Caucasian men (Toles, 2008). The reasons for the disparity remain unclear, but several factors may be involved, such as age, race, nationality, nutrition, exercise, and family history of cancer. Detection of prostate cancer in high-risk African Americans is important but continues to be controversial.

Jones, Underwood, and Rivers (2007) reviewed the current issues and challenges regarding prostate cancer in African American men. The reasons for the disparity remain unclear, but several factors may be involved, such as age, race, nationality, nutrition, exercise, and family history of cancer (Jones, Underwood, and Rivers (2007). Nurses


play a vital role in the health care and education of patients; therefore, they must be aware of these issues. Jones et al (2007) speculated that the mortality rate will continue to grow despite effective treatment regimens. To help decrease prostate-cancer morbidity and mortality rates among African Americans, nursing research must help increase health care professionals’ and the public’s knowledge and awareness of how the disease affects this population (Jones & Wenzel, 2005).

According to the South Carolina Department of Health and Environmental Control (SCDHEC, 2011), in 2011 South Carolina ranked third in the nation in prostate-cancer deaths, and over 460 African American men died in the state as a result of the disease. In addition, South Carolina statistics indicate that, compared to Caucasian men, African American men are 80% more susceptible to prostate cancer, are usually

diagnosed with the most aggressive form of the illness at younger ages, and are 3 times more likely to die from the illness than other populations (SCDHEC, 2011).

Drake et al. (2006) suggested that there may be qualitative differences in the natural history of prostate cancer by race. South Carolina proved to be a useful context in which to study the etiology of the disease because of the presence of unique

environmental exposure. For example, soil selenium and cadmium concentrations unique to South Carolina might have a differential effect in the rural areas of the state, where groundwater use is more common and where African Americans are more likely to live. These metals have been found to accelerate the development of prostate metabolism and cancer, so the possible interaction of geological factors with underlying biological factors, such as expression of metal transporter genes by race, needed to be explored in South Carolina (Drake, 2006).


As noted above, diet and exercise are consistently seen as possible primary prevention strategies for prostate and other cancers. There may be very good reasons to intervene in these areas, but if the intention is to generate practical implications regarding prostate-cancer prevention and control, then studies must be designed to test the effects of these modalities in rigorous ways at specific points in the natural history of prostate carcinogenesis.

Because much of South Carolina’s African American population resides in rural areas, outreach is challenging for both researchers and clinicians. Rural residents are more likely than urban residents to live in poverty, report poorer health status, and not have private health insurance (Drake et al, 2006) and have less access to basic public health services (Toles, 2008). Local public health departments are absent in many rural communities, and rural hospitals continue to close, removing needed services (Toles, 2008). The closing of public hospitals correlates significantly with increases in the percentage of people without a primary health care provider as well as the percentage of people denied care (Toles, 2008). Public health departments are particularly important to rural residents, as they serve as the main avenue for public health and clinical care for this group. Issues such as limited access to care, low quality of care, and lack of frequent physician visits have a negative impact on outcomes for men with prostate cancer,

particularly in terms of staging (Toles, 2008).

In collaboration with the South Carolina Cancer Disparities Community Network –II, the South Carolina Cancer Alliance is currently developing a proposal to create a decision guide for prostate screening targeted toward African American me (SCDHEC, 2011). The alliance plans to pilot test new, culturally appropriate materials in southern


South Carolina because of the area’s comparatively large African American population and high rate of residential stability. South Carolina is one of only a few states to adopt expanded Medicaid coverage to treat breast cancer (SCDHEC, 2011). Prostate cancer should receive equal recognition. Likewise, the ACS (2011) estimated that 3,770 men in South Carolina would be diagnosed with prostate cancer and 440 would die from the disease in 2012. The South Carolina budget sets aside one million dollars for breast-cancer and cervical-breast-cancer patients, but no money is allotted to prostate-breast-cancer patients. Finally, the state has several high-quality prostate-cancer treatment, research, and referral resources. Collaborations across agencies, institutes, and organizations throughout South Carolina would prove beneficial in reaching the most rural and inaccessible populations; therefore, increasing positive outcomes and better futures for South Carolinians.

Significance to Nursing

Despite the current context of uncertainty surrounding prostate-cancer screening and treatment, it is important to enhance the healthcare professional’s understanding of the factors that influence African American men’s decision to participate in prostate cancer screening. Increased knowledge will contribute to current efforts focused on promoting informed decision making and future efforts when improved screening and treatment options become available. The information might also provide insight into how to reduce racial disparities in prostate cancer. The presence of health insurance, the level of education, and a limited income resonate in the current literature and remain the primary barriers to an African American male’s participation in prostate cancer screening (Husani et al, 2008). The psychological, social, and cultural factors that may affect the participation level are not well delineated. If these factors were better understood, more


effective programs could be designed to motivate men to seek and obtain screening (Mastalski, Elliot, Coups, Ruth, Raysor, & Giri, 2008). For example, if men do not believe that early detection of prostate cancer will make a difference in their outcomes with the disease, then a fatalistic attitude can develop and discourage screening behavior. The belief in one’s ability to obtain screening and support from family and friends has been found to positively influence screening and treatment behaviors for many health conditions (Wallner et al, 2008). In general, cultural sensitivities related to personal or historical experiences with the medical community play a role in African American men’s attitudes toward preventive health screenings. It is important to determine what barriers are most salient to African American men and the differences in perceived barriers compared with their White counterparts (Byars-Winston, 2010).

Few studies have explored the reasons for this limited level of participation. Therefore, the purpose of this descriptive study was to assess the correlations between perceived barriers and prostate-screening patterns among African American men in upstate South Carolina. Determining the factors that influence African American men’s intentions to get screened for prostate cancer will assist health care professionals identify individuals at risk because of not participating in screenings.

Theoretical Assumptions

This study was based on several assumptions:

1. The sample population had been exposed to information on prostate-cancer screening, either by visual, verbal, or written literature.

2. Health is a priority for most men.


4. Health behavior is rationally determined by a person’s perceptions of vulnerability, benefits, and barriers to adopting a new behavior. 5. The participants would have some knowledge of prostate cancer. 6. The cultural environment would have some effect on health-promotion


7. The participants would be honest when answering the questions on the instruments.

Research Questions and Hypothesis

During the process of this study, the answers to three key questions regarding the relationship between perceived barriers and prostate-screening patterns among African American men in upstate South Carolina were sought:

1. What are the perceived barriers to prostate-cancer screening among African American men?

2. Is there a relationship between selected demographics (age, education, income, health insurance, knowledge of prostate-cancer screening) and perceived barriers?

3. What is the relationship between perceived barriers and the likelihood of future participation in prostate-cancer screening among African American men?


Today in the United States, prostate cancer remains a significant problem among African American men. Research has shown that African American men have a higher incidence and mortality rate for prostate cancer. According to the ACS, one of the ways


to decrease the mortality rate from prostate cancer in this population is to implement early screening practices with a DRE and PSA test. The goal of the DRE and PSA is to detect prostate cancer early in the localized stages rather than waiting until the condition has advanced and increased the risk of mortality. Exploring the variables that hinder participation in prostate-cancer screening among African American men is essential to promoting early detection practices and decreasing mortality rates for the disease. Therefore, the goal of this study was to investigate the relationship between perceived barriers and participation in prostate-cancer screening among African American men. The HBM was used as the theoretical framework. To develop better targeted, more efficient interventions for prostate cancer, new research paradigms are needed. The results may raise health care professional’s awareness about the importance of exploring perceived barriers regarding prostate-cancer screening practices.


Chapter 2 Literature Review

A comprehensive review of the literature was completed using PubMed, OVID, COCHRANE, and Google databases. The review was conducted between May 2012 and July 2012 using several English key words and phrases: prostate cancer, DRE, PSA, prostate-cancer screening barriers, fear of prostate screening, educational level and prostate screening, socioeconomic status and prostate screening, pain with a DRE, Victoria Champion’s Health Belief Model Scale (HBMS), and the health belief model. The following literature review outlines some of the factors that are likely to affect a person’s stated intent to engage in prostate-cancer screening. In this study, a theoretical model was constructed with the aim of predicting African American men’s intentions to undergo screening for prostate cancer based on sociodemographic characteristics and perceived barriers to screening. The literature review laid the foundation for

incorporating education, income, family history, and knowledge into a model for predicting intention to undergo screening for prostate cancer. The additional benefit of researching intent is the direct correlation with actual behavior that is yielded when conducted in larger studies.

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 health care providers (Wolf et al., 2010). Lack of discussion about the decision to screen for prostate cancer and general lack of culturally appropriate communication with health care providers has


engendered distrust, created fear, fostered disconnect, and increased the likelihood of nonparticipation in prostate-cancer screening among Black men (Woods, Montgomery, Belliard, Ramirez-Johnson, & Wilson, 2005). Factors and potential barriers that affect the willingness of Black men to engage in prostate-cancer screening are discussed. In the United States, a 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 health care providers (Weinrich, et al., 2004).

Family History as a Risk Factor

African American men have two major risk factors for prostate cancer. The first is ethnicity: African American men have twice the risk of European American men of developing prostate cancer (Siegel, Naishadham, & Jemel, 2012). Having a family history (brother or father with prostate cancer) also doubles their risk.

Bloom, Stewart, Oakley-Girvans, Banks, and Chang (2006) tested several hypotheses related to family history, namely that men with a family history would perceive their risk to be higher, be more worried about getting prostate cancer, and be more likely to have used cancer-screening tests than men without a family history. A sample of 208 African American men ages 40 to 74 years were recruited through

relatives or friends whose prostate cancer diagnosis was reported to the California Cancer Registry between 1997 and 2001 and from churches and African American social groups. Following a screening interview to determine eligibility, 88 men with self-reported, first-degree family history of prostate cancer and 120 without such a history were interviewed by telephone. Logistic regression was used to create models of perceived risk, concerns about prostate-cancer, receipt of a DRE, and receipt of a PSA test. Men with a


self-reported family history of prostate cancer did not perceive a higher risk or express more concern about the disease than participants without a family history. Participants with a family history were more likely to report having a recent PSA test but not a DRE. An above average perceived risk was associated with being younger, having a college education, having poorer mental health, reporting more concern about prostate cancer, and having had a recent PSA test. In conclusion, controversy about PSA testing

continues, these results suggest that African American men at above-average risk for the disease are inclined to be screened.

Men with a family history of prostate cancer are known to be at increased risk for the disease; however, relatively little is known about their risk perceptions or screening behaviors. To address these issues, Jacobsen et al. (2004) examined the relationship of family history of prostate cancer with perceived vulnerability of developing prostate cancer and prostate-cancer screening practices. The participants included 83 men with a family history of prostate cancer and 83 men with a negative family history of prostate cancer. As predicted, men with a family history reported greater perceived vulnerability of developing prostate cancer and stronger intentions to undergo screening. They also reported greater past performance of prostate-specific antigen screening and were more likely to request information about prostate cancer. Additional analyses indicated that perceived vulnerability mediated the relationship between family history and intentions to undergo prostate-cancer screening. Findings confirm the increased likelihood of men with a positive family history to undergo prostate-cancer screening and suggest that heightened concerns about developing the disease are an important motivating factor.


Barriers to Screening

Knowledge of prostate cancer. Research has revealed that, despite being a

high-risk group, African American men tend to have very little knowledge of prostate cancer (Fyffe, Hudson, Brown, & Fagan, 2008; Blocker et al, 2006). Scholars have pointed to this lack of knowledge as one explanation for this population’s low participation rate in screening procedures (Blocker et al, 2006; Naccarato, Reis, Matheus, Ferreira, & Denardi, 2011). Additionally, recent controversy surrounding inconsistent prostate-cancer screening guidelines has led researchers to study prostate-prostate-cancer education and informed decision-making of African American men (Mitta et al., 2011; Wolf et al., 2010). This controversy has also required health care providers to tailor educational interventions so that men can make clear, informed choices about being screened for prostate cancer.

Using the HBM as a framework for their qualitative study, McNaughton-Collins and Barry (2011) identified the knowledge of, attitudes toward, and behaviors related to prostate-cancer screening in a sample of 12 African American men. Seven of the men ranged in age from 38 to 49, and the other five ranged in age from 51 to 80. Two focus groups were conducted, and open-ended questions were asked about their prostate-cancer screening behaviors. The results indicated that older men knew more than younger men about prostate cancer. The younger men in the study expressed more fear than the older men about DREs. None of the participants were aware of the increased risk of prostate cancer among African American men. Also, the men in the sample who had undergone a DRE incorrectly believed that the physician had inserted the entire hand into the rectum.


Because higher percentages of African American men are poor, less educated, uninsured, or underinsured than White men, they typically have less access to health care and therefore are less likely to receive information and routine care aimed at prevention, early diagnosis, and effective treatment. Brett and Ablin (2011) surveyed 528 Black men in Miami and Fort Lauderdale, Florida, to assess knowledge of prostate cancer among African American, Haitian American, African, and English-speaking Caribbean men in America. Knowledge levels were assessed by education, ethnicity, age, income, family history of prostate cancer, and perceived knowledge of the disease. Twenty-five

barbershops were visited during Fridays, Saturdays, and Sundays over 5 months. The response rate was 99%. As the Black men waited to be seen by their barbers, three interviewers asked them demographic and knowledge questions. For the knowledge questions, 68.4% of the men’s responses were correct. Approximately 19.1% of respondents answered 80% of the questions correctly, and 7.1% answered 100% of the questions correctly. There were no statistically significant differences in knowledge among Black men of different ethnicities. Only two demographic factors were

significantly related to prostate cancer knowledge: Men who earned more than $50,000 per year and men with a family history of prostate cancer scored significantly higher than lower income men and men with no family history of prostate cancer. As the percentage of Caribbean American men and African men in the United States continues to increase, especially in metropolitan centers, men at highest risk need to be targeted to reduce the disproportionate rates of prostate cancer among Black men.

Wade (2009) evaluated actual and perceived knowledge of prostate cancer in African American men. The purpose of the study was to explore the relationship


between age, income, and education on perceived and actual knowledge of prostate cancer. A secondary purpose was to examine the correlation between knowledge of prostate-cancer screening and participation in prostate-cancer screening activities. The sample consisted of 108 African American men recruited from churches, adult day-care centers, and barbershops. Eighty-six percent of the participants were below 50 years of age, 57% reported yearly incomes of less than $40,000, and 39% reported educational levels higher than high school. Data were collected with a 31-item questionnaire developed by the researchers that measured perceived knowledge of prostate cancer, actual knowledge of prostate cancer, and participation in prostate-cancer screening activities. Demographic information was also collected. The results of the study revealed low levels of knowledge of prostate cancer. All of the respondents scored less than 70% on 15 of the 21 knowledge statements. Statistically significant differences were found in the actual knowledge of respondents under and over 40 years old. Overall, perceived and actual knowledge of prostate cancer were negatively correlated with age, income, and education. Correlations between prostate cancer knowledge and

participation in prostate-cancer screening activities revealed a moderately positive correlation between actual knowledge of prostate cancer and participation in screening activities. Finally, a statistically significant relationship was found between perceived knowledge of prostate cancer and participation in screening activities.

The impact of education on prostate cancer knowledge and awareness was the focus of a study conducted by Griffith et al. (2007). The study examined whether an educational program about prostate cancer affected knowledge and awareness of prostate cancer among a sample of 835 African American men. Thirty percent of the participants


were under 40 years of age, and 9% of the participants were 60 and older. Seventeen percent of the participants reported having less than a high school education, and 31% reported that they had graduated from high school. Each participant was given an

electronic keyboard containing 12 multiple-choice prostate-cancer knowledge questions. After completing the questionnaire, participants attended a 1-hour, culturally relevant educational program on prostate cancer given by an African American health educator. The preseminar knowledge scores ranged from 7 to 56%, with a mean score of 26%. The postseminar scores ranged from 53 to 89%, with a mean score of 73%. Significant correlations were found between higher preseminar and postseminar scores and increased levels of education. The researchers concluded that prostate-cancer knowledge levels among African American men are low and that a culturally relevant educational program can dramatically improve prostate cancer knowledge and awareness for men with a higher education.

Jones, Shipp, and Thompson (2005) administered a random-digit-dialed telephone survey to 235 male residents in Georgia. The results revealed that risk-factor knowledge was lowest among rural Black men. Beliefs across subgroups were more similar than were knowledge levels. Of the urban White men, 26% perceived their risk for prostate cancer as high, compared to 10% for other groups. Predictors of a low, no, or uncertain level of self-perceived risk included not knowing that age increases risk. Many of the men appeared to have low levels of knowledge about prostate cancer, especially personal risk. Educational and counseling interventions might assist such men in making


In a qualitative study of 104 African American men randomly assigned to four focus groups, Forrester-Anderson (2005) explored knowledge, attitudes, perceptions, and behaviors related to prostate cancer and prostate-cancer screening. Each focus group contained six to 12 participants. Sixty-five percent of the sample was married and approximately half of the sample had at least a high school diploma. Fifty-eight percent of the sample had never been screened for prostate cancer. A 14-item open-ended questionnaire developed by the researcher guided the focus-group discussions. Six negative themes and one positive theme were identified from the focus groups: lack of knowledge and awareness of screening guidelines, fear of prostate cancer and screening, negative beliefs regarding screening, embarrassment, distrust of health care professionals, and lack of access to services. The positive theme was focused on the power of

knowledge regarding prostate cancer and the benefits of early detection. Of the six negative themes, lack of knowledge emerged as most important among the participants. For example, many of the participants reported that they knew nothing about the DRE or PSA as diagnostic tools for early detection of prostate cancer (Shah, Zu, Palmer, & Wu, 2007).

Socioeconomic status. Diagnosis of advanced prostate cancer is a major health

problem, especially among low-income men. Opportunities vary for early detection of prostate cancer for low-income Black and White men because of financial, cultural, and social factors. In this study, evaluation of an association of poor literacy skills to higher rates of presenting with an advanced stage of prostate cancer among low-income Black and White men who received care in equal-access medical systems. Andriole, Crawford, and Grubb (2009) studied 377 men diagnosed with prostate cancer at the San Francisco


public hospital between 1998 and 2008 and found that 61% had either high- or intermediate-risk prostate cancer or had tumors that had already spread beyond the

prostate. The difference did not appear to be explained by disparities in access to medical care, as the researchers noted that many men at the public hospital had undergone routine prostate-cancer screening. Black men were at higher risk of prostate cancer than other racial groups, and the San Francisco General Hospital group had a larger percentage of African Americans than the two databases used for comparison. However, racial

differences did not appear to fully account for the greater burden of intermediate- to high-risk cancer among low-income men.

Income was found to be associated with perceived severity in a study by Odedina et al. (2011). A total of 2,864 responses were found to be complete and valid for this study. A majority of the study participants were U.S.-born Black men who were between 40 and 49 years old, were married, had full-time employment, had a high school diploma, and earned less than $20,000 per year. Participants who reported household incomes of less than $60,000 were less acculturated compared to those who reported an annual income of $100,000 or more. Black men who had health insurance were less acculturated compared to those with no health insurance.

Low-income prostate-cancer patients are likely to die earlier than higher income patients (Schroder, Hugosson, & Roobol, 2009). In Schroder et al.’s (2009) study, low-income prostate cancer patients received poorer care than their wealthier counterparts. The analysis included 2,738 patients identified through the Geneva Cancer Registry. Patients with prostate cancer were classified as having high, medium, or low


researchers compared patient and tumor characteristics and different therapy types among the different socioeconomic groups. Compared with patients with high socioeconomic status, those with low socioeconomic status were less likely to have their cancer detected by screening, had more advanced stages of cancer at diagnosis, underwent fewer tests to characterize their cancer, were less likely to have their prostates removed, and were more likely to be managed with watchful waiting or careful monitoring.

Schroder et al.’s (2009) results also showed that patients with low socioeconomic status were twice as likely as high-socioeconomic patients to die from prostate cancer. The increased mortality risk of low-socioeconomic patients was almost completely explained by delayed diagnosis, poor work ups, and less complete therapy, all of which indicated inequities in the health care system. Lead-time and length-time biases were associated with early detection through PSA screening and may have partially explained the survival advantage observed among high-socioeconomic patients. However,

Schroder et al. observed that the differences by socioeconomic status in prostate cancer mortality were limited to patients with advanced disease, for whom the impact of such biases was not as strong, and that therapy choice probably played a more important role. The authors argued that reducing health inequalities associated with socioeconomic status should receive high priority in public health policies and that improving patients’ access to prevention and early diagnostic tests and ensuring that they receive standard therapies could help reduce the socioeconomic differences observed in their study.

Education level. Education is one of the most used measures of socioeconomic

status in older adult health studies because the information is relatively easy to obtain and is potentially measurable for every respondent. Another benefit is that education is


typically completed before the onset of health problems. Education has been treated as a proxy for access to social and economic resources that influence health status and the use of preventive services (Rudkin & Markides, 2011). The effect of education on health is mediated through other socioeconomic indicators such as income or occupation

(Lahelma, Martikainen, & Laaksonen, 2004). In general, less educated individuals have fewer economic resources, and thus economic barriers could be an important explanatory factor for disparities in screening methods. Education also has been interpreted to

influence health through higher cognitive functioning, healthier lifestyles, and mastery over one’s health.

Low literacy, which correlates with low education, might also affect cancer screening. Low literacy may impact functioning in the health care environment, influence the dynamics of patient–physician communication, and inadvertently lead to substandard medical care. Low literacy is associated with a poor understanding of written or spoken medical advice, adverse health outcomes, and decreased use of preventive services. Low literacy also has negative effects on the health of the population. In addition, cancer screening information may be ineffective with less literate individuals because they often do not understand or have limited knowledge of cancer-screening concepts, such as health vocabulary and anatomy (Davis, Williams, & Marin, 2012)

Studies conflict on whether race or socioeconomic status affects knowledge of prostate cancer and screening. Winterich et al. (2009) study compared education, race, and screening status to determine how each factor alone or together shape men’s


African American and White men ages 40–64 with diverse educational backgrounds. Education, not race or screening status, was associated with knowledge about the prostate gland, prostate-cancer symptoms and screening tests, and fear of prostate cancer. The exception was knowledge about the PSA blood test, which was associated with education and screening status. Therefore, education, not race, was found to be associated with prostate cancer and screening knowledge. Understanding men’s knowledge and beliefs about prostate cancer and screening is important for physicians in their efforts to engage men in shared decision making about screening. Interventions should focus on men with low education to correct misinformation about prostate cancer and to engage them in shared decision making about screening.

Pain with the digital rectal exam. Compared to the large amount of

prostate-cancer screening literature, very little has been written about patient pain or discomfort during DREs. Although several patient-information guides report that DRE causes no pain or a slight discomfort, it has been reported that physicians tend to give lower ratings of patients’ pain than the patients themselves. Anticipated pain or discomfort is an important barrier to prostate-cancer screening and may impair compliance with future examinations.

To help in patient information and counseling for prostate-cancer screening Romero et al. (2008) evaluated 200 patients’ perceptions of pain and discomfort during DREs. The study also evaluated the impact of discomfort on potential future screening compliance and whether emptying the bladder immediately before the DRE reduced patient discomfort. Pain and discomfort during DRE were not negligible but they did not affect the participants’ intention to have a prostate exam in the future. Urinating


immediately before examination did not significantly reduce the incidence of pain, urinary urgency, or bowel urgency during the DRE.

Conversely, Nagler et al. (2005) asked 13,580 healthy men undergoing PSA-only population-based screening whether they would still participate in screening if it included a DRE. The researchers used these responses to examine whether using a DRE would reduce screening participation, detection rates, or both. The survey was modeled on previous studies. The results indicated that only 78% of men would participate in screening that included both a DRE and PSA. Thus, 7,800 men of a theoretical

population of 10,000 would participate in a screening that included both DRE and PSA. Using these figures, the positive screening rate (PSA ≥ 4.0 ng/mL or abnormal DRE) would have been 2,013, with 472 prostate-cancer cases and 1,540 negative biopsies. In the PSA-only screenings, all 10,000 men would have agreed to participate, and the positive screening rate (PSA ≥ 4.0 ng/mL) would have been 1,480, with 499 prostate cancer cases and 980 negative biopsies. The PSA-only screenings would thus have detected 27 more cancers and performed 560 fewer negative biopsies. In conclusion, the results of the study demonstrated that DRE is a significant barrier to participation in prostate-cancer screening. Programs using both tests detect fewer cases of prostate cancer and produce higher numbers of negative biopsies. Nagler et al. suggested that future mass screening efforts include only PSA tests and omit the DRE.

Sanders, Talley, Caito, and Krueter (2009) sought to examine the effect of race and ethnicity and fear on the initiation and maintenance of DRE screening. A sample of 533 men from Brooklyn, New York, ages 45–70, was classified into four racial and ethnic groups: U.S.-born White, U.S.-born African American, Jamaican, and Trinidadian


or Tobagonian. The participants recorded the number of DREs in the past 10 years. The demographic variables, structural variables, concern about prostate cancer, and fear of screening were measured using validated instruments. Overall, 30% of subjects reported never having a DRE, and 24% reported having a DRE annually. Compared to the White men in the sample, African American, Jamaican, and Trinidadian or Tobagonian men expressed more concern about prostate cancer and were less likely to have an annual DRE. The men with low screening fear were more likely to have had an initial DRE but were no more or less likely to undergo an annual DRE. Having a regular physician, comprehensive physician discussion, and annual visits were also associated with

undergoing DREs. Several ethnically varying barriers and facilitators to DRE screening were identified. African American and African Caribbean men had a DRE less

frequently and had greater concern about prostate cancer and fear of screening than did White men. Screening fear predicted the likelihood of undergoing an initial but not annual DRE screening. Access to a physician and annual visits facilitated DRE

screening. These results propose that culturally sensitive education, resource navigation for the patient, and consistent screening guidelines are necessary to address the prostate cancer epidemic in African American males.

Access to health care providers. Improving access to and utilization of the

health care system may benefit African American prostate cancer patients’ more than educational or motivational interventions (Talcott et al, 2007). In Talcott et al (2007), a survey of 84 African American and 253 White North Carolinians who had recently been diagnosed with prostate cancer were studied to better characterize the roles of knowledge and attitudes, socioeconomic status, demography, and health care access in the diagnosis


of prostate cancer and racial trends in health. The results revealed that the African American participants were well educated about their risk of prostate cancer and the benefits of screening and that socioeconomic factors were more important barriers to adequate care. Additionally, the study found that the African American participants accessed health care resources (including primary care physicians) infrequently because of limited availability and that this results in distrustful and irregular interactions when they did access care. The researchers found that compared to the White participants, the African American participants were younger, had more underlying illnesses, and were at a socioeconomic disadvantage at the time of diagnosis. Although the African American participants had comparable if not better knowledge of prostate cancer than the White participants, the African American participants were more distrustful of physicians but less likely to reject conventional Western medical treatments. Despite lower educational attainment, the African American participants were aware of their increased risk of cancer, the importance of treatment, and their responsibility for their health. Obstacles to timely diagnosis and appropriate care, including greater physician distrust, appear to arise more from reduced access and continuity of medical care arising from their

socioeconomic position, which was related to less access to care; discontinuity of care; lack of insurance; and a lower likelihood of seeking routine care, having physical examinations, seeing the same physician, following up on medical complaints, or utilizing emergency care. The African American participants were also more likely to have to request prostate-cancer screening tests than Whites, whose physicians were more likely to order them routinely.


Participants in over half of the studies compiled in the present literature review discussed the costliness of screening and the lack of health care insurance as barriers for men who lack financial resources. In other studies, having the ability to pay for services is often cited as a strong predictor of whether a prostate-cancer screening will be

received. For African American men, the main barriers to timely diagnosis and screening identified in this study arose from their constrained opportunities for health care access and utilization and an absence of strong ties to a primary physician, which was often related to less trust in physicians.

In a study by McDougall, Adams, and Voelmeck (2004), African American men participated in a screening initiative and completed the 22-item Barriers to Prostate Cancer Screening Checklist. Forty-three men received a DRE and PSA laboratory test. The mean age of the participants was 56.4 years (range = 45–76); 47% were compliant with the American Cancer Society annual screening guidelines for high-risk individuals. Nineteen men from the screened group completed a 22-item Response to Barriers

Checklist. The barrier that participants identified as a “big problem” for not getting a prostate exam was “too many things going on in their lives.” This was also ranked as the greatest barrier by 32% (n = 6) of the sample. All of the participants ranked “takes too long to get an appointment” as the least problematic issue. Based on their results,

McDougall et al. recommended that, when planning a health screening in the community, it is important to evaluate both barriers and advantages during the planning and

preimplementation phases of the project.

Parker et al. (2006) assessed the demographic factors, past prostate-screening behavior, perceived risk, and cancer worry of 1,680 men who participated in a free


screening for prostate cancer (mean age was 58.2 years; 56% were White; 76% had health insurance). Men with insurance were more likely to have had a previous PSA test and DRE. White men were more likely to have had a previous PSA and DRE and to have discussed PSA testing with a physician than African American men. African American men reported greater perceived risk and more worry than White men. Screening differences between African American and White men were explained by insurance status. These results suggest that the development and promotion of future screening programs should be directed at increasing awareness about screening procedures for prostate cancer.

Screening Measures

Victoria Champion (1998; 1984) used the constructs of the HBM as the foundation for developing Champion’s Health Belief Scales for Mammography

Screening (CHBMS). Instruments using HBM constructs in breast cancer screening in previous studies were developed and tested for American women by Champion, and since then, these have been revised twice (Gözüm & Aydin, 2004). Champion's Health Belief Model Scale (HBMS) has been translated and tested in various studies in other countries and cultures (Gözüm & Aydin, 2004). The translated version of the Champion HBMS was found to be a valid and reliable tool for use with ethnically diverse

populations (Parsa et al, 2008). Champion developed items for the HBM constructs of susceptibility, seriousness, benefits, barriers, health motivation, and confidence. These items focused on BSE and perception of risk for breast cancer, but Champion stated that the scales developed from her HBM research could be used with substitution of a word or phrase for different types of cancer (Champion, 1984; Jacobs, 2002). The scale was


found to be appropriate for the measurement of health beliefs about prostate cancer screening. The scale may be used in prostate cancer screenings for males who are 40 years and older to measure perceived susceptibility, perceived seriousness, health motivation, perceived barriers and perceived benefits with regard to prostate cancer screenings (Capık & Gözüm, 2011)

Tavafian et al. (2008) examined constructs arising from the HBM as predictors of BSE behavior in a sample of 240 Iranian women who lived in small cities and had limited access to mammography and clinical breast examinations. Thus, BSE became an

important and necessary approach to detecting breast cancer in its early stages to limit its resultant morbidity and mortality. The sample consisted of women who were referred to a health center, were at least 30 years old, and could read and write Farsi. Women who had breast cancer, were pregnant, or were breast feeding were excluded from the study. Data were collected using a self-administered questionnaire that included demographic characteristics and Champion’s HBMS. This instrument measures the concepts of disease susceptibility (3 items), seriousness (6 items), benefits (4 items), barriers (8 items), and self-efficacy (10 items). The findings indicated that perceived barriers and perceived self-efficacy were predictors of BSE behavior among this sample of women. Therefore, the authors recommended BSE training programs that emphasize self-efficacy and address perceived barriers to screen for breast cancer. Several studies have predicted attendance for mammography as a function of the HBM, which suggests that patient participation in screening will be affected by the perceived seriousness of and susceptibility to the disease (Whaley, 2006).


Breast cancer is the leading cause of cancer deaths in Malaysian women, and the use of BSE, clinical breast examination, and mammography remain low in Malaysia. Parsa, Kandiah, Nasir, Hejar, and Afiah (2008) recognized a need to develop a valid and reliable tool to measure the beliefs that influence breast-cancer-screening practices. The CHBMS is a valid and reliable tool to measure beliefs about breast cancer and screening methods in Western culture. The purpose of this study was to translate the use of

CHBMS into the Malaysian context and validate the scale among Malaysian women. A random sample of 425 female teachers was taken from 24 secondary schools in Selangor state, Malaysia. The CHBMS was translated into Malay and was validated by an expert panel, back translated, and pretested. Analyses included descriptive statistics of all the study variables, reliability estimates, and an examination of construct validity using factor analysis. The translated version of the CHBMS was found to be a valid and reliable tool for use with Malaysian women. It can be used easily to evaluate health beliefs about breast cancer, BSE, clinical breast examination, and mammography and for planning interventions. For greater applicability, the authors recommended that this tool be tested among ethnically diverse populations. The results of this study will benefit future interventions to support at-risk men, including African- American men, to develop the health habit of getting a yearly prostate specific antigen (PSA) and digital rectal examination (DRE). The development of reliable and valid assessment survey questions to measure patient knowledge, attitudes and cultural beliefs that can identify variations in individuals' decision making processes and benefits or risk perception.

Dündar et al. (2006) recruited 244 women by means of cluster sampling to complete a questionnaire consisting of sociodemographic variables, an instrument that


measured risk factors and signs of breast cancer, and an adapted version of the CHBMS. The mean age of the women was 37.7 ± 13.7 years (49.2% were primary school

graduates, 67.6% were married). Although 76.6% of the women in this study reported that they had heard or read about breast cancer, our study revealed that only 56.1% had knowledge of breast cancer, half of whom had acquired the information from health professionals. The results demonstrated that the women in the sample who used BSE were more confident about using BSE, perceived greater benefits of and fewer barriers to BSE, and possessed more knowledge of breast cancer.

Strengths and Limitations of the Literature Review

A strong association between the presence of barriers to and the level of

participation in prostate screening among African American men has been documented in multiple studies. Recent studies have indicated that low participation in prostate

screening remains a significant problem in the African American male population despite 15 years of research showing the importance of screening in preventing morbidity and mortality from prostate cancer. In comparison, the literature has not identified the factors that influence men’s concerns about and decisions to participate in prostate-cancer

screening (Gwede & McDermott, 2006). Relatedly, few studies have specifically addressed health disparities in prostate cancer among African American men.

The HBM has been utilized in several studies to explain or predict behaviors by focusing on attitudes and beliefs. Not many studies have used the HBM as a conceptual framework to evaluate South Carolinian men’s perceptions of, beliefs about, and attitudes toward participation in prostate-cancer screening.



This chapter provided a comprehensive review of the literature that supports this study. The incidence and mortality rates of male prostate cancer are higher among African Americans than among any other race in the United States. Additionally, prostate cancer is typically detected at more advanced stages in African American men. The findings suggest that social, environmental, and cultural factors, such as access to care, inadequate community exposure, fear, lack of knowledge, monetary resources, and customary beliefs and traditions related to seeking health care, may also affect the willingness and ability of African American men to participate in health-promoting behaviors.

Strategies are needed to increase participation in the health-promoting and cancer-screening activities. This is especially critical for the African American men in regard to prostate screening. The goal is to reduce morbidity and mortality associated with prostate cancer in this population. Cognitive and perceptual factors such as knowledge of the disease, diagnosis, treatment modalities, and perceived barriers can be influential in screening for prostate cancer. Enhancing providers’ understanding of these factors may facilitate the development of educational programs that focus on early detection. The literature review is consistent with the HBM in that the greater the perception of perceived barriers, the less likely one is to have a prostate-screening exam. Therefore, this study used the HBM to evaluate the prostate-screening practices of African American male beneficiaries in upstate South Carolina.



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