Culture, Black Men, and Prostate Cancer: What Is Reality?

V. Diane Woods, DrPH(c), MSN, RN; Susanne B. Montgomery, PhD, MPH, MS; Juan Carlos Belliard, PhD, MPH; Johnny Ramírez-Johnson, EdD; Colwick M. Wilson, PhD


Cancer Control. 2004;11(6):388-396. 

In This Article

Abstract and Introduction

Background: The worldwide incidence of prostate cancer is higher among American black men than any other male group. In the United States, lack of participation in screening for prostate cancer by black men is influenced by several cultural factors, including knowledge, health beliefs, barriers, and relationships with primary healthcare providers.
Methods: We used the qualitative and paralleling descriptive quantitative findings of a mixed-method longitudinal study exploring prostate cancer screening behaviors among 277 black men.
Results: Five themes were identified as critical elements affecting men's screening for prostate cancer: lack of knowledge, communication, social support, quality of care, and sexuality. These themes were associated with a sense of disconnectedness by black men from the healthcare system and contributed to nonparticipation in prostate cancer early detection activities.
Conclusions: Lack of discussion about the decision to screen for prostate cancer and general lack of culturally appropriate communication with healthcare providers has engendered distrust, created fear, fostered disconnect, and increased the likelihood of nonparticipation in prostate cancer screening among black men.

Prostate cancer is the leading cancer diagnosed among men in the United States. Black men in America continue to have the highest incidence rate of prostate cancer in the world -- 180.6 per 100,000 population.[1] Between 1996 and 2000 in the United States, the age-adjusted death rate of prostate cancer among black men (73.0 per 100,000 population) was more than double that of non-Hispanic white men (30.2 per 100,000 population).[2,3] The causes of higher rates of prostate cancer among black men are largely unknown. However, higher mortality is associated with late detection.

Screening is the most common method for early detection of disease in asymptomatic populations. One problem with early detection in prostate cancer prevention is a lack of consensus regarding screening and early detection guidelines among medical professional groups.[4] Current guidelines of the American Cancer Society (ACS)[5] recommend that men at high-risk (eg, family history, black) should begin early detection with the prostate-spe-cific antigen (PSA) blood test and the digital rectal examination (DRE) at 45 years of age. Furthermore,ACS guidelines suggest that the decision for high-risk men to be tested should be made within the doctor/patient relationship. The US Prevention Services Task Force recently concluded that there was insufficient evidence for or against routine screening for prostate cancer using PSA or DRE.[6] According to the Task Force, however, good evidence exists that PSA screening can detect early-stage prostate cancer, but it is unclear how early detection improves health outcomes.[7] The National Cancer Institute (NCI) has concluded that there is insufficient evidence that prostate cancer mortality can be reduced by early detection and screening methods.[8] It is not clear however, that studies on which these recommendations are based included sufficient numbers of black men, despite the fact that they have the highest disease burden of all ethnic and racial groups.

This confusion is complicated by the fact that men are less likely than women to seek assistance when health problems arise.[9] Furthermore, compared with women or with any other group of men, black men are less likely to seek care and participate in health-related activities. Such health activities are preventive and self-care practices, which places them at high risk for nonparticipation in prostate cancer early detection and screening.[10] Researchers attribute the lack of participation in prostate cancer prevention activities to economic limitations, low level of education, poor access to health care, lack of awareness about studies, past negative experiences, physicians' attitudes, and cultural and religious beliefs/atti-tudes.[11,12] In addition, some researchers have identified sexual dysfunction as a sensitive issue for black men, which discourages their involvement in prostate cancer screening and early detection activities.[13,14]

Braithwaite[10] discusses the concept of "stoicism" as a possible explanation of why black men are disconnected from the American healthcare system and are reluctant to participate in health-related activities. The theory of stoicism suggest that black men become "indifferent to pain or discomfort and do not seek healthcare services until absolutely necessary, and then most often in the emergency room."[10] Additional factors that contribute to their nonparticipation in screening include lack of adequate health insurance, traditional attitudes about male gender roles, fear of a poor prognosis, and distrust of the medical community. Difficulty in obtaining information about black health behavior is compounded by limited participation by this population in all forms of research.

Historically, researchers have studied the impact of culture on health-seeking behaviors among many ethnic groups such as Asian, Native Americans, and Latinos to better understand the role of culture in health-related behav-[15,16,17] In contrast, little is known about the effect of culture in health-seeking behaviors and disconnectedness among black men.[18,19,20,21] One problem has been a focus on blacks as a race rather than as an ethnic group with unique cultural traits.[22] The National Institutes of Health (NIH) 2000 enrollment of non-Hispanic black men and women in extramural research was 11.3%; male participation was [23,24,25] The syphilis experiments conducted at Tuskegee, Alabama, have left a legacy of distrust and profound fear among blacks for research participation.[26,27,28] Distrust and fear are strong deterrents for black men to engage the healthcare system.

A goal of Healthy People 2010 is to eliminate racial health disparities.[29] Black men suffer a disproportionately higher burden of disease than any other ethnic and racial group.[3,30] Black men in particular have been labeled an "endangered species"[10] due to health, sociopolitical, and psychological issues affecting this group. To achieve the Healthy People 2010 goals of decreasing health disparities, innovative strategies must be used to overcome this barrier of distrust and create mechanisms to engage, support, and reinforce black men to make healthy choices.[31]

This study explores how culture and communication with healthcare providers influence black men's knowledge, health beliefs, and practices regarding prostate cancer screening. We utilized a mixed-method research approach to investigate these issues in a cohort of 277 black men and 94 primary care providers. In this article, we present the qualitative results of the black participants in our study. Quantitative data are used to show that the qualitative findings were verified in the subsequent survey work.


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