Ethnic Differences Among Black Men in Prostate Cancer Knowledge and Screening: a Mixed-Methods Study

Abstract

Black men are disproportionately affected by prostate cancer (PCa) incidence and mortality. Limited research has been reported on the ethnic differences among Black men in regard to family history, knowledge, and screening habits. Thus, this study was conducted to understand and compare knowledge levels and family history of the three main Black subgroups (African Americans, Caribbean immigrants, and African immigrants) in the USA and to assess the influence of knowledge on past screening behavior and intentionality for screening in the future for PCa. A concurrent mixed-methods design was used with participants (N = 396) recruited from different parts of the country. The grounded theory method of analysis was used for qualitative data and a logistic regression was used to explain the relationship between screening intentionality and PCa knowledge and family history. Qualitative results indicated that subjective PCa knowledge between the three subgroups was relatively similar but differed based on whether a person knew a family member or friend who had been affected by the disease. Themes focused on risk, PCa education, screening, and impact on sexuality. Quantitatively, result revealed that there are ethnic differences in knowledge across the three subgroups. Additionally, regression results revealed that family history is a stronger predictor of screening behavior and intentionality than knowledge. This study was able to unveil a deeper understanding on the role of family history and knowledge on PCa among Black subgroups.

Introduction

Prostate cancer (PCa) continues to gain importance as a public health concern affecting 1 in 9 men in the USA [1]. Black men, however, are disproportionately affected, with a risk of 1 in 4 [1]. Black men also tend to develop PCa earlier than most men, are diagnosed with a more aggressive disease, are more likely to advance to a higher metastatic state, and die at a higher rate than any other ethnic group [2]. The cause of this disproportionality is not fully understood although genetic research points to differences in risk-associated alleles among men of African ancestry [3] and differences in social determinants of health have also been proposed [4]. However, such disproportionality does indicate that PCa screening is crucial for protecting Black men’s health. If detected early, men with localized PCa have a 5-year survival rate of nearly 100%, while men diagnosed with metastatic PCa have a 5-year survival rate of 31% [1].

The digital rectal exam (DRE) and the prostate-specific antigen (PSA) test are the early detection screening measures for PCa [5]. For Black men especially, the combined use of the DRE and the PSA test has proven to be the most beneficial for PCa detection [6] but it has been reported that DRE exams are a deterrent for Black men for a number of reasons including high cost for the visit [7], stigma surrounding the screening procedure [8], discomfort and fear of the and the potential negative screening scores, and fear of homophobia [9, 10]. Participation in screening for early detection is crucial to reducing the high rate of PCa mortality among Black men. However, there is no single predictor of Black men’s decision to participate in PCa screening, though some have argued that screening is influenced by family history and knowledge of prostate-related issues [5, 11].

Family history of PCa has been shown to significantly increase PCa risk [11]. Familial risk for PCa is attributed to inherited genetic and shared environmental risk factors that urge men to get screened more often than those without a history [12, 13]. Research has also revealed that there is a positive association between knowledge and screening [14–16]. Increased knowledge on PCa-related topics increases awareness and has the potential to change behavior. Therefore, it has been argued that while Black men generally have low knowledge of PCa, increasing knowledge would equip them to make informed decisions about screening [17].

While most PCa research in Black men has been conducted with African American [14, 18–20] and Caribbean men [10, 13, 15], few have explored these issues with African immigrants [21, 22]. In terms of knowledge, such studies have assessed PCa-related decision-making process, risk factors, symptoms, and highest risk group leaving much to be explored among Black men in this area [13, 18, 20]. Additionally, previous studies [16, 23] have aggregated the subgroups into one large group of “Black/African American” without assessing any subgroups. Indeed, most studies consider American Blacks as a monolithic group combining data across subgroups despite cultural differences between African American, Afro-Caribbeans, European Blacks, and sub-Saharan African immigrants. By doing so, the heterogeneity within the Black population is ignored and patterns of biological, environmental, and psychosocial predictors of screening are not assessed and may be missed. While family history and knowledge have separately been shown to influence screening, we know little about the combination of the two especially when also assessing these by Black subgroups. Therefore, the purpose of this study was to assess and compare knowledge levels and family history of the three main Black subgroups in the USA and to assess their influence on past screening behavior and intentionality for screening in the future for PCa. Understanding of the differences and similarities between the subgroups in regard to knowledge and family history will better inform practitioners on how to engage each subgroup in screening and health education in an effort to reduce PCa disparity.

Methods

Sampling and Recruitment

A convenience sample of men in this mixed-methods study were recruited from different parts of the country, from various community groups, social groups, and faith-based organizations. Recruitment strategies included church announcements, Facebook communities, community groups, and word of mouth. Men’s health fairs were held (Riverside, Brooklyn, Los Angeles, Ontario, Palm Springs) to provide free health screenings and PCa education for Black men, and to recruit them for the study. Recruitment was conducted by an African American, two Caribbean immigrants, and an African immigrant, all health professionals, who partnered with respective site leaders. Townhall forums were used to explain the study, and create and distribute flyers. Inclusion criteria included men, 21 years and older, who identified as African American, Caribbean immigrant, or African immigrant. All participants completed a consent form prior to participating in either the qualitative or quantitative portion. The institutional review board at Loma Linda University approved the study protocol prior to implementation. This study is nested in a much larger study aiming to assess PCa biomarkers and identify differences between young and older men.

Data Collection Procedures

Qualitative

To maximize credibility, confirmability of the findings, and dependability [24–26], focus groups (participants n = 51) and key informant interviews (n = 10) were conducted with men of varying ages by subgroups. Key informant interviews were conducted first in Colorado, California, Texas, and Idaho among key members in the community for each subgroup.

Eight focus groups, consisting of 5–7 members in each setting, were conducted in various cities in California, Florida, Colorado, and New York. Female partners of Black men were also interviewed to allow for perspective triangulation, a strategy that seeks validity through convergence in qualitative research because each source reveals a different aspect of reality which increases comprehensiveness [27], rig- or [28], and trustworthiness [24].

A semi-structured outline was used to guide discussion around PCa health. Interviews were conducted by trained qualitative, ethnically, and gender-matched interviewers. Interviews lasted 1.5 to 2.5 h, were audio-recorded to ensure accurate transcription, and transcribed verbatim. In addition, each interviewer/facilitator completed summary field notes after each session.

Quantitative

Participants over the age of 45 years (n = 335) who consented completed a survey assessing PCa screening past behavior and intentionality, and PCa knowledge. PCa knowledge was evaluated using an 11-item true-false questionnaire developed by the University of California, Los Angeles men’s survey [29]. Examples of true-false statements in this questionnaire included the following: “The prostate is located between the bladder and penis, in front of the rectum,” “African American men are at higher risk of getting prostate cancer than Whites,” “A man can have prostate cancer without having any pain or symptoms,” and “Men with prostate cancer always have signs or symptoms of prostate cancer.” Each correct answer was given a value of 1 and an incorrect answer was given a value of 0. Individual knowledge scores were calculated by summing the number of correct items. In addition, a separate 15-item fatalism yes-no questionnaire was used to evaluate personal perceptions on PCa. Examples of yes-no statements included the following: “I think if someone gets prostate cancer, it doesn’t matter whether they find it early or late, they will still die from it,” “I think if someone has prostate cancer and gets treatment for it, they will probably still die from the prostate cancer,” “I think prostate cancer will kill you no matter when it is found and how it is treated.” Responses were coded as yes = 1 or no = 0. Screening behavior was assessed by the following questions: “Have you ever had a prostate-specific antigen (PSA) blood test for prostate cancer,” “Have you ever had a Digital Rectal Examination (DRE) for prostate cancer?,” “Have you ever had both the PSA and DRE tests for prostate cancer?” Responses were coded as yes = 1 or no = 0. Screening intentionality was assessed by the following statement: I intend on getting a DRE this year. Response options were “strongly agree” to “strongly disagree,” and were dichotomized to either agree or disagree for analysis. Data collection was done over a period of 5 years and the survey was revised over time. Screening behavior was collected for all 5 years of data collection, while screening intentionality was added to screening behavior after the fourth year. Seventy percent of data collection was done in person with 30% done through mail.

Data Analysis

Qualitative

All audio recordings were transcribed and checked for accuracy by comparing the recording and transcript.

Transcripts were analyzed using the grounded theory method of analysis [30] by three coders. Emergent line-by-line coding was completed first and a final codebook derived in a facilitated discussion to arrive at a shared language for codes. All transcripts were then coded using this final code-book and quotations aligned with these codes were then abstracted from the transcripts and organized into emerging themes.

Quantitative

Data analysis was conducted by SAS version 9.4. For descriptive purposes, means and standard deviations were generated for continuous variables and frequencies for categorical variables. A logistic regression was used to explain the relationship of our outcome variables (screening behavior/intentionality), and our independent variables (age, subgroup, income, PCa knowledge, family history, and fatalism) in a stepwise manner. Variables identified in the qualitative portion as crucial, along with identified variables based on literature as important, were included in the model. Approximately 20% of the data was missing due to changes in survey content across the years of data collection; given the size of missingness, cases were deleted.

Results

Qualitative Results

There were a total of 61 participants: 40 men and 21 women. Majority of the participants were 40 years and older (76.4%) and most were married (80.6%). Among African Americans, there were 14 men and 7 women, among Caribbean immigrants, there were 14 men and 9 women, and among African immigrants, there were 13 men and 5 women. Qualitative descriptions are presented in Table 1. Subjective PCa knowledge between the three subgroups was relatively similar, but differed based on whether a person knew a family member or friend who had been affected by the disease. Thus, the results are presented in accordance with those who have been affected by PCa or know someone who has been affected by it, and those who had not. In total four themes emerged, risk, perspective on PCa education, screening, and impact on sexuality.

Table 1.

Qualitative Demographics

	African Americans		Caribbean Immigrants		African Immigrants
	Men (n = 14)	Women (n = 7)	Men (n = 14)	Women (n = 9)	Men (n = 13)	Women (n = 5)
Characteristics	n (%)	n (%)	n (%)	n (%)	n (%)	n (%)
Education
High school graduate	3 (21.4)	0 (0.0)	2 (14.3)	0 (0.0)	0 (0.0)	0 (0.0)
Some college	4 (28.5)	2 (28.5)	3 (21.4)	1 (11.1)	0 (0.0)	0 (0.0)
Bachelor’s degree	4 (28.5)	5 (71.4)	4 (28.5)	5 (55.6)	5 (38.5)	2 (40.0)
Master’s or professional degree	3 (21.4)	0 (0)	5 (35.7)	3 (33.3)	8 (61.5)	3 (60.0)
Income
Low income (< $44,999)	6 (42.8)	1 (14.3)	3 (21.4)	3 (33.3)	3 (23.1)	0 (0.0)
Middle class ($45,000–125,000)	6 (42.8)	6 (85.7)	4 (28.5)	4 (44.4)	8 (61.5)	5 (100.0)
High income class (> $125,001)	2 (14.3)	0 (0)	7 (50.0)	2 (22.2)	2 (15.3)	0 (0.0)
Insurance
Yes	11 (78.5)	5 (71.4)	12 (85.7)	8 (88.9)	11 (84.6)	5 (100)
No	3 (21.4)	2 (28.5)	2 (14.3)	1 (11.1)	2 (15.4)	0 (0.0)

Theme 1: Risk

The perception of risk seems to involve speculation for those not affected by PCa. Their knowledge of risk is based on an overall understanding of health, or what they have heard through the grape-vine. However, for those personally affected by PCa, their knowledge is more in alignment with evidence-based risks of PCa. Although some of the details in their risk perception may be slightly skewed, they are somewhat factual and reflect searching for guidance and answers as to how to protect themselves. Among African Americans, those not affected by PCa speculated on how substance use could affect PCa; however, among African and Caribbean immigrants, factors like motorcycle riding, not eating enough pasta, and an unhealthy balance of spirit, mind, and body seemed to be a contributing factor. The perception of risk is very different within the subgroups especially among those not affected by PCa.

Risk
Those affected by PCa	Those not affected by PCa
I was talking with someone who said that diet and some of these things are good to be attentive to. He also discussed sexuality and talked about the different approaches to sex and the timing and those things; something about the frequency of sex associated with better prostate health. He in fact observed that he and his wife are applying these finding to their lives. - African American (Male focus group) The western diet has not been showing itself to be very helpful - the kinds of things we eat here in north America - the high salts, fats, sugars, red meat etc. when we get affluent we want to eat that. It has not proven to be very helpful. - Caribbean immigrant (Male focus group) When first reflected on my health, I knew I was at increased risk for prostate cancer since my father had prostate cancer. I remember I was turning 40 and I knew its about that time to start to get tested. - Caribbean immigrant (Male focus group) Prostate cancer is an old men disease and its facilitated with unhealthy habits and more so inheritable - African immigrant (Male focus group) Family history plays a big factor in getting this disease but that is what disadvantages Africans. If when someone dies in the village there is no way to know cause of death and so when we ask people their family history, they say there is no way for them to know. But that is important to understand their risk. - African immigrant (Female key informant interview)	I don’t think that there are things that I do that would increase my risk for prostate cancer, like drinking and smoking. But when I do [drink and smoke], I think I am at risk…I don’t know the cause for prostate cancer. I don’t know the things that can be triggers that can be preventing or maximizing my risk for that. I don’t really know if I am at risk for prostate cancer. - African American (Male key informant interviews) I invited a particular brother to come to this focus group and he said he is not coming because they are talking foolishness there. The only reason we have more prostate cancer is because we do not eat enough pasta. And he goes, Italians do not have a high rate of that disease because they eat a lot of pasta. - Caribbean immigrant (Male focus group) I do a lot of riding [motorcycle riding]. The other riders and I are concerned because they said that bike riding, the bike seat you should be careful with it. You need a particular type of seat to allow space between. So, we are concerned about it. I have not really been on my bike the way I really want to. I am serious, the bike is in the garage and I am looking at it every day saying, I am going to ride you tomorrow but I haven’t done it yet. - Caribbean immigrant (Male focus group) To me, it’s a balanced state of physical, mental and spiritual harmony. High stress or any stress whatsoever leads to poor health as energy is divulged from the maintenance of physical, mental and spiritual health. - African immigrant (Male key informant interview)

Theme 2: Perspective on PCa Education

The results reflect the men’s subjective PCa education/knowledge and although they were categorized based on whether they knew someone who had been affected by this malignancy or not, participants argued that there was not enough education/knowledge. All subgroups wanted to know more and spoke about the lack of information about PCa and its prevention in their communities. When speaking about knowledge or lack thereof, there were no differences in the subgroups because they all felt they were not equipped to act accordingly in regard to PCa or screening.

Perspective on PCa education
Those affected by PCa	Those not affected by PCa
As a black man I would want to see some men taught in a way that I can see myself benefitting. I like sports and I can see it incorporated in some type of sport activity. I don’t know exactly how, but I think that’s one way. - African American (Male focus group) For women when they have breast cancer for example they would tell women how to stand in front of a mirror and how to examine themselves and how to check themselves for breast cancer. For us we do not have that kind of information. They do not tell us how to put your hands somewhere and do something. And I think for men, if we have education on how to exercise our prostate, we wouldn’t have these problems. - African American (Male key informant interview) When I came to America the first time, I never knew anybody who was diagnosed with prostate cancer. I never knew of anybody who died of prostate cancer. But when I came to America as the years go by, I came to see that it’s a widespread thing among black men. I came to think that it’s a culture thing because before we never knew about this when we came to America and we never experienced it in the Caribbean. But I am in America now and its part of the American culture. - Caribbean immigrant (Male focus group) I know that it affects men in the 40s and predominantly those of African Descent - African immigrant (Male focus group) My sons are well educated on prostate cancer but that’s only because their father had prostate cancer. Once he got diagnosed, we as a family had to learn, otherwise I don’t think they would have known much about it. - African immigrant (Female key informant interview)	I am trying to stay knowledgeable about health because when it comes to prostate anything, I am clueless. You might as well talk Greek to me. I don’t really know – African American (Male key informant interview) Growing up on the island people did not talk about prostate cancer. Growing up as a kid I would hear people say “oh he have boason”. I never knew what that word meant. But it is enlarged prostate or something like that. It’s when I came to America I understood what that meant. But people used to talk about it, just that he had it, not that they did anything about it. - Caribbean immigrant (Male focus group) They checked for everything…It was a Korean doctor, I knew he worked there. When he was coming to the end he said, bend over. He just said pull down your pants and bend over. And he was so rough, he pushed up his finger. After he was finished I sat down and I cried. It hurt. It hurt. He gave no explanation nor said what he was doing - Caribbean immigrant (Male key informant interview) If the awareness was like breast cancer. I am sure a lot of people would have heard about it - African immigrant (Male focus group) I don’t really know exactly what its about but I’ve heard of it[prostate cancer] but I’ve never met anyone that has it I just know it’s a disease as simple as that. Cancer, once you hear cancer , you that that person is going to go, unless God intervenes - African immigrant (Male key informant interview)

Theme 3: Screening

Regardless of subgroup, men spoke of their fear of being screened for PCa. These fears were around losing their masculinity, fear if homophobia, the intrusiveness of the screening process, and ambiguities about the necessity. Those without a family history of PCa either had speculative ideas of what might happen during screening (especially worrisome for many was the DRE exam) deterring them from screening, though many others noted not knowing much at all about the process. Those with a family history of PCa were generally well informed of what happens during a screening exam and strongly disliked the DRE, but were willing to endure it as part of the screening process. Of concern among all men was the lack of participation in decision-making and education from their physicians. With screening, comments on fatalistic beliefs also presented themselves with African immigrants arguing that talking about an illness is inviting that illness into one’s life.

Screening
Those affected by PCa	Those not affected by PCa
The DRE is not the worst in my opinion. I have been going for several years and they have a thing where they go up through the penis to look at the bladder… now that is bad. There is a lot more than the DRE. If you have a good doctor they are going to do whatever they can to try to cure you - African American (Male key informant interview) I was very disappointed that time when I went to the doctor when I asked him for the PSA test and he said, we don’t do that anymore. And that really hurt me. We did the cholesterol, we did the sugar, they did the kidney and all the parts but no PSA test. I was upset. I was taking my health into my own hands and they couldn’t help me. They also couldn’t give me a reasonable answer as to why the PSA test was not being done anymore. And that was from one of the major health care carriers in this community. - African American (Male focus group) There is a lot of people, men, who I talk to they try to avoid the physical examination part of it. They think it’s a little bit gruesome and I think it is like I don’t know I think at first when I really did the test I thought this was really uncomfortable and I think as the years go by, I became more comfortable doing it. I remember when I first did it, I was about 40 years old and since then I have been taking it and I think it is very uncomfortable and sometimes I don’t want to do it. - Caribbean immigrant (Male focus group) With screening you can know and start planning what next…the negative side is that knowing comes with stress and fear. - African immigrant (Male focus group) I watched a film once, I think one of the methods of checking is they have to put their hands in there to check for lumps. Based on that film alone, ahhh, that man ehhh, truly truly ehn, my husband that I know, he wouldn’t go for that thing. But because we know people with the disease and we have seen what it has done, he has gathered his energy to go. - African immigrant (Female key informant interview)	Some people go as far as to say, like one guy said to me if he goes to do the prostate screening DRE, the doctor might be gay and might get sexual urges for him and may want to be very intrusive in his body and things like that. And that to me is an extreme, but that is what he expressed to me. He didn’t want a woman. And if it is a man, suppose the man gets a “hard on”. That was his belief - African American (Male focus group) My husband went to the doctor when he turned 40 and said to the doctor he wanted to get a complete physical, everything. And the doctor said, “you want everything?” he said “yes, I want everything. I want my prostate checked and everything”. The doctor said ok and he did everything and he came down to doing the prostate exam. The doctor said drop your pants. He dropped his pants. The doctor said turn around. he turned around. now he thought it was a strange position to be in, why would the doctor want him to turn around. So the doctor said, bend over. Strange he thought. So, when the doctor proceeded to insert his digits, he jumped up backed the doctor up to the door, put him in a head lock and proceeded to say, “you pervert! What are you doing?” the doctor said, “but you asked for this”. He said, I “didn’t ask for this you pervert.” So now the nurse is knocking on the door and saying, “what is going on in there? What is going on in there?” the children are crying outside saying, “daddy, daddy”. So he called his mother on the phone because his mother is a nurse saying, “mom how do they check the prostate? How do they check the prostate?” The mother then told him how the prostate was checked, then he unlocked the doctor and said I am sorry. - Caribbean immigrant (Female Focus Group) Is there an age to screen? Young men don’t bother with this because they think that they are invisible but is there an age for this? - Caribbean immigrant (Male key informant interview) Some people believe that if they get checked they are inviting the sickness into their lives and so most people won’t even bother getting checked… If you are meant to have it you will have it [PCa] if not, you won’t. - African immigrant (Male focus group)

Theme 4: Impact on Sexuality

The perceived impact on sexuality for those who do not know anyone affected by PCa is either a haphazard correlation of PCa and end of sexuality, or an incorrect perception of PCa being a disease affecting the elderly and thus at that point being sexually active would no longer matter. On the other hand, those affected by PCa know the realities of the illness and the treatment well enough to know that although impotence may happen, it does not affect all who undergo treatment.

Impact on sexuality
Those affected by PCa	Those not affected by PCa
You know my father passed away. I’ll never forget what he said, he said because he couldn’t perform anymore, he felt he couldn’t satisfy my mom. They were married for over 50 years. - African American (Male focus group) I have a friend who had that experience of being diagnosed with prostate cancer and he was struggling for years with weight. He decided to go ahead and have the surgery and he is impotent now. I guess they cut a nerve of some kind that would have allowed him to maintain his sexuality. - Caribbean immigrant (Male focus group) If you have had prostate cancer it doesn’t mean that your sexuality is gone. If you check and get early diagnosis you will have a chance. A lot of people do not know that if it is detected early your chances of getting rid of it are great. - Caribbean immigrant (Male key informant interview) For me, I am comfortable sharing that I am a survivor and I love sex. That for me is the core of the fear of this illness. This illness affects that experience to all of us. And it determines to a certain extent the treatment options that one chooses. - African immigrant (Male focus group)	We think that when people have prostate cancer their sexuality is gone. - African American (Male key informant interview) If I do get it [prostate cancer], by the time I get it I don’t think sexuality will be a concern at that point. Like my grandfather got it when he was way into his 80s. But I don’t think that sexuality was that important that late in life and I would think that. And yet I would think that there are a number of things that affect sexuality like erectile dysfunction and I don’t think that any of those were caused by prostate cancer. I am not saying prostate cancer does not affect sexuality, but when I get prostate cancer, I won’t be worried too much about my sexuality. - Caribbean immigrant (Male focus group) Men fear the stigma around it [prostate cancer] and the community’s perception around masculinity. Prostate cancer would diminish a lot of men’s sense of manhood in many African Contexts. - African immigrant (Male focus group) They don’t talk too much about their health because they feel it reduces their manhood or masculinity or their ego. Like my dad, you understand we had to force him, we had to really force him to make him go see a doctor. - African immigrant (Female key informant interview)

Quantitative Results

A diverse group of Black men (n = 335) participated in completing a survey about the same issues, which included 150 African Americans, 134 Caribbean immigrants, and 51 African immigrants (Table 2). The majority of the participants were married, most were middle class, possessed medical insurance, with African immigrants reporting the highest level of educational attainment with 64% holding a bachelor’s degree or higher which was significantly higher compared to Caribbeans and African Americans. Our demographic descriptions also show statistically significant differences in screening behavior and fatalism between the subgroups.

Table 2.

Quantitative Demographics descriptive

	African Americans (n = 150)	Caribbean immigrants (n = 134)	African immigrants (n = 51)
Characteristics	n (%)	n (%)	n (%)	p-value
Age n (SD) range	59.34 (9.07) 46, 95	58.78 (8.58) 45, 80	56.23 (8.04) 45, 78	0.14
Marital Status	c		a	0.008
Single (never married)	36 (24.00)	24 (19.05)	5 (10.64)
Married (first marriage/living together)	94 (62.66)	100 (79.37)	34 (72.34)
Re-married	14 (9.33)	2 (1.59)	4 (8.51)
Separated/divorced	3 (2.00)	-	4 (8.51)
Widowed	3 (2.00)	-	-
Income				0.13
Low income (< $44,999)	60 (40.82)	49 (41.18)	12 (26.67)
Middle class ($45,000–125,000)	64 (43.54)	54 (45.38)	25 (55.56)
High income class (> $125,001)	23 (15.65)	16 (13.45)	8 (17.78)
Education	b,c	a,c	a,b	<.001
Less than high school graduate	7 (4.70)	24 (19.35)	1 (2.08)
High school graduate	25 (16.78)	29 (23.39)	7 (14.58)
Some college	58 (38.93)	36 (29.03)	9 (18.75)
Bachelor’s degree	18 (12.08)	11 (8.87)	11 (22.92)
Master’s or professional degree	41 (27.52)	24 (19.35)	20 (41.67)
Medical insurance				0.85
Yes	127 (78.40)	97 (74.05)	39 (78.00)
No	35 (21.60)	34 (25.95)	11 (22.00)
Past PSA screening		c	b	0.04
Yes	90 (58.44)	71 (56.80)	21 (42.00)
No	64 (41.56)	54 (43.20	29 (58.00))
Past DRE screening	c	c	a,b	0.03
Yes	76 (49.35)	59 (46.46)	18 (36.73)
No	78 (50.65)	68 (53.54)	31 (63.27)
Past both screening				0.29
Yes	60 (39.22)	49 (39.52)	13 (26.53)
No	93 (60.78)	75(60.48)	36(73.47)
DRE intentionality				0.16
Yes	117 (80.14)	108 (84.38)	40 (83.33)
No	29 (19.86)	20(15.63)	8(16.67)
PCa fatalism		c	b	0.04
No fatalistic beliefs	61 (25.4)	26 (29.5)	30 (17.0)
Fatalistic beliefs	179 (74.6)	62(70.5)	146(83.0)

^a:P < .05 different from African Americans

^b:P < .05 different from Caribbean Americans

^c:P < .05 different from African Immigrants

Based on the qualitative results, identifying differences in knowledge by family history was important and is presented in Table 3 for each subgroup. All subgroups regardless of family history had low knowledge of the role of family history on PCa risk. Additionally, across all subgroups, the knowledge of soy consumption and how it decreases PCa risk was low. Knowledge on watchful waiting was lower than expected for African American and African Immigrant’s when compared to Caribbean immigrants for those with and without history.

Table 3.

PCa knowledge among the Black subgroups

Statements	% Correct
	African American		African Immigrants		Caribbean Immigrants
	w/ history n = 37	w/o history n = 62	w/ history n = 15	w/o history n = 36	w/ history n = 40	w/o history n = 48
The prostate is located between the bladder and penis, in front of the rectum	93.2%	93.8%	88.2%	96.2%	90.2%	100%
If you have prostate cancer and have brothers or sons, they are at higher risk for prostate cancer	40.9%	38.9%	52.8%	57.7%	31.6%	46.2%
A man can have prostate cancer without having any pain or symptoms	81.8%	88.9%	82.9%	88.5%	73.3%	69.2%
Antibiotics can be used to cure prostate cancer	77.3%	84.2%	72.2%	92.3%	82.9%	92.3%
Surgery or radiation can cure prostate cancer in its early stage	88.6%	94.7%	100%	96.2%	87.8%	92.3%
Prostate cancer treatment can increase your sex drive	87.0%	78.9%	47.1%	72.0%	76.9%	92.3%
Eating soybean products such as tofu and soymilk can lower the risk of prostate cancer	54.5%	66.7%	57.6%	62.5%	63.9%	7.7%
Men older than 50 years of age are more likely to develop prostate cancer	82.2%	94.4%	97.2%	84.6%	87.5%	84.6%
Men of African descent are at higher risk of getting prostate cancer than Whites	93.3%	89.5%	79.4%	84.6%	90.2%	92.9%
Men with prostate cancer always have signs or symptoms of prostate cancer	68.2%	70.0%	48.6%	84.6%	68.3%	64.3%
Watchful waiting is a good treatment option for African American men	62.8%	55.0%	65.7%	50.0%	70.0%	78.6%
Total correct average score	75.4%	77.7%	71.9%	79.0%	74.7%	74.5%

African immigrants with a family history had significantly lower knowledge of PCa treatment as it affects one’s sex drive in comparison to the other subgroups. African immigrants when compared to the other two subgroups had lower knowledge of the fact that men of African ancestry have the highest risk of PCa, even for those with history. There was a significant difference in knowledge among African immigrants on signs and symptomatology of PCa; those without a family history scoring higher (84.6%) than those with a family history (48.6%). Overall, there was no statistical difference for total knowledge score between groups as determined by one-way ANOVA for those with a known family history, F(7,98) = 1.01, p = .426) and those without a known family history, F(7,51) = 1.17, p = .335). Average knowledge scores for each subgroup with and without a known family history were similar across all subgroups though for African Americans and African Immigrants the knowledge was slightly lower for those with a family history of PCa vs those without (p < .05).

A logistic regression was used to assess screening behavior and intentionality (Table 4). Variables included in the models were variables noted as being significant in the focus groups and key informant interviews. Results in model 1 indicate that older age, higher income, and being a Caribbean immigrant significantly increased the likelihood of PSA screening. Those that are older have an 11% higher odds of being screened whereas those with and have higher income have a 9% higher odd of being screened with a PSA. Compared to African Americans, Caribbean immigrants have 73% higher odds of being screened, while African immigrants have 55% lower odds of being PSA screened compared to African Americans. For past DRE screening and screening for both PSA and DRE, those with increased income had 10% and 11% increased odds, respectively. With the variables of interest included in model 2, those with a family history of PCa had a 150% increased odd of being PSA screened. Knowledge was not found to be a significant predictor for screening behavior or intentionality. Overall the models chi-square were found to be significant and the Nagelkerke pseudo R² indicated a high goodness fit as the models accounted for 18%, 15%, 12%, and 14% of the variance, respectively. An interaction effect of knowledge and family history was conducted in model 3; however, there was no significant association.

Table 4.

Impact of knowledge and family history on PCa screening and intentionality

	PSA screening n = 97		DRE screening n = 96		Screened for both n = 96		DRE intentionality n = 98
	OR	CI	OR	CI	OR	CI	OR	CI
Model 1
Age	1.11**	1.03, 1.18	1.04	0.16, 1.04	1.05	0.99, 1.12	0.99	0.93, 1.07
Black subgroup
African Americans	1.00	Ref	1.00	Ref	1.00	Ref	1.00	Ref
African immigrants	0.45*	0.16, 1.28	0.53	0.19, 1.47	0.47	0.16, 1.36	0.60	0.16, 2.17
Caribbean immigrants	1.73*	0.57, 5.26	1.11	0.40, 3.03	1.34	0.49, 3.67	0.52	0.14, 1.88
Income	1.09*	1.00, 1.19	1.10*	1.01, 1.21	1.11**	1.02, 1.21	0.90	0.80, 1.01
Model 2
Age	1.06	0.96, 7.05	1.03	0.96, 1.09	1.03	0.96, 1.10	0.99	0.92, 1.08
Black subgroup
African Americans	1.00	Ref	1.00	Ref	1.00	Ref	1.00	Ref
African immigrants	0.43	0.12, 1.46	0.63	0.19, 2.07	0.58	0.17, 1.98	0.54	0.11, 2.78
Caribbean immigrants	0.87	0.23, 3.28	0.82	0.24, 2.72	0.91	0.27, 3.01	0.18	0.03, 1.04
Income	1.04	0.94, 1.16	1.08	0.98, 1.19	1.08	0.97, 1.19	0.86*	0.74, 0.99
Knowledge	1.08	0.75, 1.51	0.94	0.68, 1.29	1.04	0.75, 1.44	1.13	0.76, 1.69
Family history
No	1.00	Ref	1.00	Ref	1.00	Ref	1.00	Ref
Yes	2.50*	0.84, 7.44	1.17	0.42, 3.27	2.20	0.77, 6.30	2.46	0.57, 10.50
Fatalism	1.05	0.88, 1.25	0.97	0.83, 1.14	1.01	0.85, 1.18	0.94	0.77, 1.13
Model 3
Age	1.06	0.99, 1.13	1.03	0.96, 1.08	1.03	0.97, 1.10	1.03	0.95, 1.12
Black subgroup
African Americans	1.00	Ref	1.00	Ref	1.00	Ref	1.00	Ref
African immigrants	0.52	0.15, 1.72	0.60	0.19, 1.88	0.67	0.21, 2.23	0.71	0.14, 3.64
Caribbean immigrants	0.72	0.20, 2.59	0.63	0.20, 2.04	0.78	0.24, 2.50	0.32	0.06, 1.57
Income	1.01	0.24, 4.12	2.77	0.73, 10.53	1.39	0.34, 5.63	0.002	<0.001, 10
Knowledge	1.14	0.82, 1.58	1.07	0.79, 1.44	1.19	0.84, 1.68	0.98	0.68, 1.43
Family history
No	1.00	Ref	1.00	Ref	1.00	Ref	1.00	Ref
Yes	5.98	0.39, 9.07	0.78	0.06, 9.14	9.61	0.53, 15.87	1.47	0.06, 34.7
Knowledge*family history	0.85	0.62, 1.17	1.05	0.78, 1.39	0.81	0.57, 1.12	1.00	0.69, 1.44
Fatalism	1.01	0.86, 1.20	0.95	0.82, 1.11	0.97	0.83, 1.14	0.92	0.75, 1.11

^*p < 0.05,

^**p < 0.01,

^***p < 0.001

Discussion

The purpose of this study was to assess and compare knowledge levels and family history of the three main Black subgroups in the USA, and to assess their influence on past screening behavior and intentionality for future PCa screening. Four knowledge themes (risk, PCa education/knowledge, screening, and sexuality) were identified as being critical with family history playing a significant role amidst them.

Family History

Family history was identified as the link tying all our themes and quantitative results together. In our qualitative results, family history was synonymous with subjective knowledge; men with a family history knew most about PCa; however, this was not reflected quantitatively. Logistic regression results revealed that family history was a stronger predictor of screening behavior and intentionality than knowledge. Thus, education interventions should be aimed at outreach around men with a family history of PCa rather than only stressing knowledge-based approaches. For instance, providing a more personalized education for those at higher risk due to family history and communicating with more weight the effects of PCa among those without family history will increase their motivation for screening [31]. Additionally, encouraging male community forums where men talk and interact with their peers discussing an array of topics including PCa would be beneficial [32, 33]. The main difference between speculative knowledge and true PCa knowledge was having some association with someone who had PCa. For some, it was a family member, for others, it was friends, pastors, or men they knew from church. This association increased their knowledge and peaked their interest to research more about PCa thus equipping themselves with information.

Risk

PCa disproportionately affecting Black men is linked to the high risk of developing the disease earlier, having an increased risk for an aggressive diagnosis, and thus a higher rate of mortality [1, 2]. Our results revealed that the perception of risk seems to involve speculation for those not affected by PCa. Their knowledge of risk was based on various perspectives. For instance, among Caribbean men, risk was linked to factors such as riding a motorcycle and eating pasta, among African immigrants, it was related to omens or being cursed, while African Americans focused on substance use as being the cause of risk. However, among those personally affected by PCa, their assessment of risk was more in alignment with evidence-based risks of PCa. Knowing factors that may increase risk of PCa in one’s life (i.e., diet, exercise, etc.) is important; however, knowing one’s risk based on family history is critical, and yet, this knowledge was low across subgroups.

Although there is insufficient genetic research on Black men and PCa, recent research has identified genes in Black men that are frequently mutated in PCa reinforcing the fact that there are biological, ancestral differences in Black men worth exploring[34, 35]. Understanding the risk associated with family health history can prepare one to start taking the appropriate steps to prevention and screening, but lack thereof puts one at risk of a late diagnosis of PCa [36]. Among African immigrants, there was low knowledge of PCa being of high risk among men with African ancestry, and even lower knowledge of family history risk. This was due to a lack of transparency due to a stigma around PCa resulting in men not talking about it in an effort to protect their masculinity. This aligns with our previous findings that among African immigrants, knowledge is very limited while incorrect perceptions are high and often go un-checked for accuracy [22]. In light of the high educational levels of the African immigrant men, it is important to point out that educational level should not be confused with PCa knowledge levels. In this study, while African immigrants held the highest degrees and were the most educated, when it came to PCa and risk associated with family history specifically, they had the lowest knowledge when compared to African Americans and Caribbean immigrants.

Knowledge/Education

Qualitative results indicated that despite differences in ethnicity, culture, and history, Black men’s subjective knowledge of PCa and screening was linked to knowing someone in the family or a close friend who had PCa. Those who knew someone who had PCa had more knowledge than those who did not. Surprisingly, African immigrants without a family history knew that PCa has noticeable signs and symptoms, whereas those with a family history of PCa had very low knowledge of this. One plausible explanation is that African men tend not to talk about their health even when sick. Thus, a family member may die of PCa but the family may or may not find out until after the fact due to a prevalent cultural belief of bad omens or witchcraft [22]. This perpetuates concealment of signs and symptoms, making it difficult for their family members to know [22].

Among Caribbean immigrants quantitatively, their lowest knowledge, despite family history, was on the association between family history and heightened risk for PCa. This presents a point of intervention within this population to address how a family member having PCa should give pause for the family to consult their doctor. Among African Americans, the knowledge of the relation of certain foods and how they affect PCa risk was low. This also presents an area worth discussing among this subgroup. Qualitatively, each subgroup had their own idea of what affected PCa and this was confirmed in the quantitative assessment as knowledge on various topics differed across subgroups. Had this study only focused on the qualitative or the quantitative portions separately it would have missed the depth and broadness afforded by a mixed methodology. While it is important to focus on, and increase knowledge for Black men in PCa, it is worth noting that each subgroup lacks knowledge in its own particular area and motivation for screening may be driven by more than just knowledge.

Overall, family history proved to be a driver of knowledge. Education, although very important and having a positive association, was not significant predictor of screening.

Screening

In general and especially for older White men who get PCa and present with mostly slow-growing tumors [37], watchful waiting of PCa has been identified by most screening guidance organizations as the best approach to avoid over-treatment and its negative side effects affecting quality of life [38]. However, for Black men, low-grade PCa has the potential to grow and spread faster than in men of other races [39]. Thus, while watchful waiting may work for other racial groups, evidence suggests it may not work for Blacks [38]. This notion is not clearly communicated to Black men, contributing to the differences seen in their knowledge (Table 2).

Our qualitative results also revealed that when most men go to their physicians to get screened, there is a lack of discussion with the physician and lack of shared decision-making process for the men to be thoroughly informed. For instance, there was a lack of discussion of alternative PCa screening when a physician informed a patient that PSA tests were no longer available and lack of discussion over the process of a DRE prior to the physician conducting the exam. This study also identified that those without a family history of PCa had speculative ideas of the screening process and some did not know much at all leading to very uncomfortable health visits. Those with a family history were better informed and knew what to expect. However, regardless of family history, all men strongly disliked the DRE, but were willing to endure it as part of the screening process if it was absolutely necessary.

While the subgroups in this study had some knowledge of PCa, they were not as well informed as they should be given their elevated risk status and screening recommendations. The US Preventive Services Task Force, American Cancer Society, and American Urologic Association have issued clinical practice guidelines recommending that clinicians inform patients on the screening process, the pros, cons, and uncertainties [40, 41]. However, like this study, national surveys [42] and other studies [16, 19, 43] have shown that Black men are often more poorly informed about this issue, even among those who undergo screening. It is our recommendation that PCa education and awareness should be a point of intervention for both Black men and their physicians so that both parties can effectively share in the decision-making dialogue.

Fatalistic beliefs also presented themselves qualitatively especially among African immigrants in discussion of screening. This subgroup argued that talking about an illness or pursuing screening is inviting that illness into one’s life. Although an important contributor to Black men’s health, fatalism, however, was not found to be a significant predictor of screening behavior. While no association was discovered in this study to PCa screening, fatalism is still important and worth assessing in PCa research.

Sexuality

The distinction between those who know someone affected by PCa in comparison to those who do not was evident in their perception of sexuality and masculinity as it is impacted by PCa. The fear and stigma of losing one’s masculinity as a result of PCa was very evident among the men but more so among those who did not know anyone who has or had PCa. To this population, the presence of PCa was correlated with a decline in sexuality and thus their masculinity would be put to question. However, among those who did know someone with PCa, presence of PCa did not automatically mean the end of one’s sexuality and masculinity but it was a possibility given one’s treatment procedure. This perspective is supported by literature that state loss of masculinity experienced by PCa patients is dependent on course of treatment [44, 45].

Conclusion

This study revealed that culture and ethnic patterns matter. In our findings, knowledge differed by subgroups even when family history and education history were factored in. For instance, African immigrants had the highest educational background but the least amount of knowledge on PCa compared to the other subgroups. Each subgroup varied in their knowledge of PCa and family history which influences their current perspectives and screening perceptions. When assessing PCa among Black men, this study reveals that it is important to avoid assuming that all Black men are the same, and to be mindful of the fact that exposure to a family member or friend with PCa, ethnic, and cultural background plays an important role.

The results of this study should be interpreted in light of several limitations. We relied on self-reporting measures which are affected by recall bias. Secondly, the quantitative measures were cross-sectional in nature, not allowing for causal inferences to be made. Also, questions about PSA were later added to the DRE and overall screening questions, thus limiting our ability to explore intentionality for PSA. The African immigrant sample was smaller due to a shorter data collection period in comparison to the other subgroups. Nevertheless, our mixed-methods approach was able to aid a deeper understanding of the role of family history and knowledge on PCa among Black subgroups.

While it has been argued that screening is influenced by family history and knowledge of prostate-related issues, this study identified that family history plays a stronger role in screening behavior, and actually influences the knowledge a person has. We also found that due to the heterogeneity within the Black population, especially African immigrants who while holding higher levels of formal education presented with less knowledge about PCa regardless of family history. Both qualitative and quantitative results also indicated that it does matter whether a Black man is African American, Caribbean immigrant, or African immigrant. There are ethnic and cultural differences that influence the knowledge and screening process of PCa among Black men and this is worth noting for health care professionals. This further supports cautions to avoid stereo-types about Black men as being a monolithic group and to assess ethnic subgroup differences, as these affect men’s decision and preparedness to be active participants in their health care decisions, regardless of family history.