A comparative study of prostate screening health beliefs and practices between African America and Caucasian men
Abstract: This descriptive comparative study investigated the prostate screening health beliefs and practices of men over the age of 45. A self-administered questionnaire was used prior to an informational session, which also included a question and answer period, as needed, and handout materials donated by the American Cancer Society on risk factors, screening tests and early detection of prostate cancer. The study results showed that there were no significant differences between African American and Caucasian men on age, self-reported health status and the utilization of a private physician for their health care. Both groups had similar history of blood relatives with cancer, and concern about development of illness. More Caucasian men had the digital rectal exam (DRE) done while African American males had the prostate-specific antigen (PSA) done more often; however, 26% of the entire sample indicated they had never had the screening test done. Group comparisons revealed a significant difference between the groups on the belief that faith contributes to health which was greater for the African Americans, while the Caucasian men had a greater belief that they were likely to develop prostate cancer. Results of this study indicate that there are still a significant number of men reporting never having had a PSA test done even though 75% knew that the test is recommended for early detection of prostate cancer. Continued efforts to educate and increase screening are still needed among both African American and Caucasian men.
Key Words: African American Men, Caucasian Men, Prostate Cancer, Prostate Cancer Screening, Health Practices
Surveillance research by the American Cancer Society (2002a) estimates that 189,000 new cases of prostate cancer will be detected and 30,200 deaths from prostate cancer will occur in the United States during the year 2002. These figures are less than the 2001 estimates; however, in general, this is a high number of cases even though screening tests are available to aid in earlier detection of the disease. Prostate cancer incidence and mortality rates also continue to be higher for African American males than any other ethnic group and remains the second leading cause of death in all male adults. Since early detection of prostate cancer continues to indicate a higher 5-year relative survival rate, screening is still recommended. The American Cancer Society recommends screening at age 50 with the exceptions of all men at higher risk and African American men in which screening should then start at age 45. Recommendations also include patient instruction on screening to facilitate informed decision making. (American Cancer Society, 2002b).
The purpose of this descriptive comparative study was to investigate the prostate screening health beliefs and practices of men over the age of 45. A comparison between the African American and Caucasian participants’ responses were included to describe similarities and differences which could be beneficial in developing future community education programs specific to their health promotion needs.
The conceptual framework used for the study was Pender’s Health Promotion Model which stipulates a relationship between personal perceived health variables and actual health promoting behaviors (Pender, 1997). In relation to this study, the goal was to empower the men to make their personal decision to participate in the health promoting behavior of annual prostate screening based on current information.
REVIEW OF THE LITERATURE
Current studies in the health related literature reveal that prostate cancer screening continues to be recommended and is increasingly utilized in the United States even though testing remains controversial (American Cancer Society, 2002b; Cohen & Jaskulsky, 2001 and Albertsen, 1997). The controversy related to prostate cancer screening centers around the issues of mass screening, limitations of the screening tests and lack of evidence showing definite benefit from the screening (National Cancer Institute, 2000; Gambert, 2001; Steele, et al., 2001 and Mozes, 2002). Recommendations for screening varies among national organizations, as well as medical societies. For example, the U. S. Preventive Services Task Force and the American College of Preventive Medicine (2001) do not recommend routine prostate cancer screening while the American Cancer Society (2002b) and the American Urological Association (2000) recommend annual prostate-specific antigen (PSA) and digital rectal exam (DRE) testing at age 50 with African American men and high risk men testing at age 45 (Steele, et al., 2000, p. 1595; ACPM, 2001; Albertsen, 1997 and Germino, 2001). Conversely, Miller (2000), a medical writer reporting on a study published in the Journal of American Medical Association cites the research by Dr. H. B. Carter, professor of urology and oncology at Johns Hopkins University which suggests that a different approach to prostate cancer screening would be to test men at an earlier age, such as 40 and again at age 45 to obtain baseline testing results. After establishing that baseline then test biannually starting at age 50. Reasons for this new screening model included increasing lives saved with early diagnosis and decreasing the number of screening tests and biopsies being done each year. Not only would men have to physically endure less testing and biopsies, there would also be a decrease in costs for testing during their later adult years (Miller, 2000, p. 1). Even though there are different opinions regarding screening recommendations, most organizations and primary health care providers agree that both screening and treatment decisions should be made by the client after being informed of all issues and options available (ACPM, 2001).
Another issue discussed in the literature was the limitations of the PSA and DRE screening tests. Steele, et al. (2000) in their study stated that positive predictive values were quite low with “range of 32-49% for the PSA test and 21-55% for the DRE” (p. 1595). The problem of false negatives and false positives of these tests was included in an article by Weinrich (2001) along with the fact that there are some physical risks to the participants which should be considered (p. 82). Varying results being identified in the literature suggest that these screening tests may not be very accurate or reliable. False test results pose both physical and serious health threats by unnecessary or omitted diagnostic procedures and treatments. Therefore, limitations of the screening tests is another information fact that men should be aware of when deciding to participate in prostate screening (National Cancer Institute, 2001; ACPM, 2001 and Miller, 2000).
Several researchers alluded to the fact that there is still no conclusive evidence that prostate cancer screening decreases the prostate cancer morbidity or mortality rates. Brawley and Barnes (2001) related in their article that screening has impacted areas such as prostate cancer diagnosis, incidence and an earlier stage of cancer at the time of diagnosis; however, the results of screening upon the death rate is still uncertain (p. 72). On the other hand, these authors also attribute screening as the reason that the 5-year prostate cancer survival rates have increased substantially (p. 73). Weinrich (2001) discussed prostate cancer mortality in her article indicating that the results of screening and discovering prostate cancer at an earlier stage may decrease the mortality of prostate cancer. She indicated that prostate cancer mortality decreases that have occurred since 1990 could also be attributed to other causes aside from better screening methods (p. 82). The study by Steele, et al. (2000) indicated that there still have not been any “randomized studies” showing “that screening for prostate cancer reduces morbidity or mortality” (p. 1595). The National Cancer Institute (2000) in their screening for prostate cancer information for doctors and health care professionals included the fact that there is not enough evidence to indicate that a lower mortality rate occurs from prostate cancer screening even with using the three most common methods. In reporting on a research study done by Dr. John D. Voss of the University of Virginia, Mozes (2002) indicated that not only is it questionable that screening decreases mortality but almost half the doctors in the study continued their usual rate of ordering screening while the same number reported they increased their ordering of the PSA. Voss also mentioned that caution should be used with screening because unnecessary testing may cause serious consequences for the patient involved.
Overall, many researchers and authorities appear to agree on the fact that men should decide for themselves if they want to participate in prostate cancer screening; however, they need to make informed choices with advice, facts and information from their doctors or health care providers based on awareness of all options available to them and the possible outcomes of the options being considered (Gambert, 2001; Steele, et al., 2000; Schapira & Van Ruiswyk, 2000; Weinrich, 2001 and Brawley & Barnes, 2001). Weinrich (2001) and Brawley & Barnes (2001) in their articles stress the importance of educating men regarding decision making for prostate cancer screening and related that nurses are in a unique position to provide education programs in the community as well as advanced practice nurses who are involved in primary health care.
Fifty-five African American and 49 Caucasian men, over the age of 45, completed a self-administered questionnaire for this descriptive comparative study. The questionnaire assessed knowledge of health practices and beliefs related to screening and early detection of prostate cancer. The convenience sample was recruited from fraternal organizations, health fairs, and churches in a Midwestern community.
The researchers utilized a questionnaire adapted from a study of breast cancer health beliefs and screening practices (Lambert, Newton, and deMeneses, 1998). Piloting of the questionnaire was done prior to the study. The researchers obtained Institutional Review Board approval. Participants received an explanatory cover letter, and completion of the questionnaire implied consent to participate in the study. Visually impaired or reading disabled participants received the questionnaire in oral form. At some sites an education program about prostate cancer was presented according to American Cancer Society guidelines after participants had completed the questionnaire. At other sites education materials were distributed and questions answered, as appropriate.
Group means were calculated on demographic items describing health status, health history, and prostate screening practices and beliefs. There were no significant differences between African American and Caucasian subjects on age, self reported health status, and utilization of a private physician for health care. More Caucasians (86%) were married than were African Americans (76%). Both groups expressed similar levels of concern about development of illness. Both groups had a similar history of blood relatives with cancer.
African American males were less likely to have had a DRE (75%) than were Caucasians (82%). Sixty-nine percent of Caucasians and 71% of African Americans reported having the PSA test done. Twenty-six percent of the entire sample indicated they had never had the test. Sixty-seven percent of the sample had the PSA drawn as part of a routine physical exam, and 15% had the test done because of prostate symptoms. Ninety-eight percent of the total sample indicated they were at least fairly comfortable discussing health problems with their health care provider. Caucasians were slightly less comfortable than African Americans.
Caucasians were more likely to believe that family history of prostate cancer increased their risk and that maintaining good health reduces risk. African Americans were more likely to believe that a healthy diet and exercise decreased the risk. African Americans were also more likely to believe that prostate cancer and treatment would adversely affect sexual function.
T tests of group comparisons revealed a significant difference between groups on belief that faith contributes to health. African Americans were more likely to rely on faith to stay healthy (t 2.819, df 96, p<.01). Caucasian males expressed significantly greater belief that they were likely to develop prostate cancer (t 2.05, df 97, p<.05). African Americans reported a stronger intent for future screening (t 2.851, df 97, p<.01).
The study demonstrated that African Americans have slightly greater concern about developing prostate cancer and the impact of the disease on sexual health and functioning. The groups were quite similar on beliefs and screening practices in contradiction of previous studies that indicated a lower incidence of screening among African Americans.
Barber, et al., (1998) found in their study that the “knowledge levels of clinical factors differed significantly between white men and minority men” (p. 441). They also stated that “African American men were significantly less likely than white men to correctly identify early symptoms of prostate cancer and the basic components of a prostate checkup” (p. 441). More than 60% of the men in our sample reported that prostate screening was done on a regular basis. This indicates a level of knowledge of the importance of screening, in this sample, that was much higher than that found by Gerard (1998) and Barber, et al., (1998). Since this present study included an African American sample the knowledge level is also higher than what has been reported in some earlier studies by Collins (1997) and Millon-Underwood (1998). A high percentage of these men indicated an understanding of the importance of regular PSA and DRE for screening. In the future almost all the men reported that they will engage in these screening activities on a regular basis in the future with the African American men reporting a stronger intent for participation than the Caucasian men.
The findings indicate that reliance on faith helps this sample with health promotion. This supports the impact of spirituality found by Parks’ study done in 1998. In light of these findings efforts for prostate cancer education should be expanded in churches. Parish nurses should also be encouraged to conduct prostate cancer education programs (Fearing, Bell, Newton & Lambert, 2000, p. 143).
This study shows that there are still a significant number of men reporting never having had a PSA test done even though 75 percent had knowledge that the test is recommended for early detection of prostate cancer. Therefore, continued efforts by nurses and advanced practice nurses are still needed to educate and increase screening participation among both African American and Caucasian men.
Partial support funding was provided by Sigma Theta Tau International, Inc., Epsilon Eta Chapter.
Albertsen, P. C. (1997). Urologic `nuisances’: How to work up and relieve men’s symptoms. Geriatrics, 52(2), 46-55. http:// newfirstsearch.oclc.org/WebZ/FSPage?
American Cancer Society (2002a). Cancer facts and figures-2002. Atlanta: American Cancer Society.
American Cancer Society (2002b). Cancer Prevention & Early Detection: Facts and Figures 2002. Atlanta: American Cancer Society.
American College of Preventive Medicine and Medem. (2001). Understanding prostate cancer screening, http:// www.medem.com/medlb/article_
American Urological Association (2000). Prostate-specific antigen (PSA) best practice policy. Oncology, 14(2) http:// www.cancernetwork.com/journals/oncology/o0002e.htm
Barber, K. R., Shaw, R., Folts, M., Taylor, D. K., Hughes, M., Scott, V., Abbott, R. & Ryan, A. (1998). Differences between African American and Caucasian men participating in a community-based prostate cancer screening program. Journal of Community Health, 23(6), 441-451 as reported in http://newfirstsearch.oclc.org/ WebZ/FSPage?_
Brawley, O. W. & Barnes, S. (2001). The epidemiology of prostate cancer in the United States. Seminars in Oncology Nursing, 17(2), 72-77.
Cohen, S. P. & Jaskulsky, S. R. (2001). Prostate cancer tx: Therapeutic options based on tumor grade, life expectancy, and patient preferences. Geriatrics, 56(2), 39, 42,47-48, 51-52.
Collins, M. (1997). Increasing prostate cancer awareness in African American men. Oncology Nursing Forum, 24(1). 94-95.
Fearing, A., Bell, D., Newton, M., & Lambert, S. (2000). Prostate screening health beliefs and practices of African American Men. The ABNF Journal, 11(6), 141-144.
Gambert, S. R. (2001). Prostate cancer: When to offer screening in the primary care setting. Geriatrics, 56(1), 22-24, 26, 29-31.
Gerard, M. J. & Frank-Stromborg, M. (1998). Screening for prostate cancer in asymptomatic men: Clinical, legal, and ethical implications. Oncology Nursing Forum, 25(9), 1561-1569.
Germino, B. B. (2001). Psychosocial and educational intervention trials in prostate cancer. Seminars in Oncology Nursing, 17(2), 129-137.
Lambert, S., Newton, M., & deMeneses, M. (1998). Barriers to mammography in older, low-income African American women. The Journal of Multicultural Nursing & Health, 4(2), 16-19.
Miller, K. (2000). Prostate cancer screening: Is less more? http:// health.medscape.com/cx/viewarticle/227691
Millon-Underwood, S. M. (1998). Reducing the cancer burden among African Americans. Cancer (Supplement), 83(8), 1877-1884.
Mozes, A. (2002). Prostate cancer screenings rise, despite concerns. Reuters Health Information Condensation of article (2001). Journal of General Internal Medicine, 16, 831-837. http:// www.nlm.nih.gov/medlineplus/news fullstory_5484.html
National Cancer Institute, (last modified 2000). Screening for prostate cancer: Cancermail from the National Cancer Institute: PDQ supportive care/screening/prevention information: http:// www.graylab.ac.uk/cancernet/304727.html
National Cancer Institute (last modified 2001). Screening for prostate cancer: (PDQ) screening/detection patients. http://cancernet.nci.nih.gov/cgi-bin/srchgi.exe?DBID_
Parks, C. P. (1998). Spirituality and religious practices among African Americans: Neglected health promotion and disease prevention variables. Journal of Health Education, 29(2), 126-129.
Pender, N. (1997). Health promotion and illness prevention. (3rd ed.). Norwalk, CT: Appleton-Lange.
Schapira, M. M. & VanRuiswyk, J. (2000). The effect of an illustrated pamphlet decision-aid on the use of prostate cancer screening tests. The Journal of Family Practice, 49(5), 418-424.
Steele, C. B., Miller, D. S., Maylahn, C., Uhler, R. J. & Baker, C. T. (2000). Knowledge, attitudes, and screening practices among older men regarding prostate cancer. American Journal of Public Health, 90(10), 1595-1600.
Weinrich, S. (2001). The debate about prostate cancer screening: What nurses need to know. Seminars in Oncology Nursing, 17(2), 78-84.
Sharon Lambert, RN, DNS, is an assistant professor of Nursing at McKendree College, Lebanon, Illinois. Arleen Fearing, RN, EdD is an associate professor of Nursing at Southern Illinois University Edwardsville School of Nursing, Edwardsville, Illinois. Doris Bell, RN, PhD is a professor of Nursing at Southern Illinois University Edwardsville School of Nursing, Edwardsville, Illinois. Marguerite Newton, RN, PhD is an associate professor of Nursing at Southern Illinois University Edwardsville School of Nursing, Edwardsville, Illinois.
COPYRIGHT 2002 Tucker Publications, Inc.
COPYRIGHT 2003 Gale Group