Abstract
Introduction
Globally, prostate cancer ranks as one of the primary causes of cancer-related mortality for men. Prostate cancer death rates in sub-Saharan Africa are 2.7 times higher than the global norm. Delayed detection of the disease is one of the factors that contributes to this high mortality. Currently, little is known about how Rwandan men perceive, know about, and approach prostate cancer screening.
Purpose
This study was designed to evaluate the level of awareness about prostate cancer and screening among men attending Kibogora Level Two Teaching in Rwanda.
Methods
A cross-sectional survey was conducted with a convenience sample of male patients showing symptoms of urinary tract infections or prostate cancer. The survey included questions about demographic characteristics, and prostate cancer risks, signs and symptoms, and screening. Descriptive statistics were utilized to identify frequencies in responses.
Results
A total of 164 men completed the survey. Most men were farmers (88.0%) with 67.1% having primary level education. About a third were between 41 and 50 yeas of age. Only 38.4% had heard of prostate cancer. Participants identified obesity (62.2%), smoking (58.5%), and exposure to agent orange (55.5%) most frequently as risk factors and 31.1% named difficulty urinating most frequently as a symptom of prostate cancer. Other symptoms mentioned were blood in the urine (20.7%) and erectile dysfunction (18.3%). Only five men indicated they had ever been screened for prostate cancer.
Conclusion
The study revealed this sample of Rwandan men had a low level of awareness and knowledge about prostate cancer and very few had engaged in prostate cancer screening. The results support the need for public education about the disease and screening approaches.
Keywords: prostate cancer, knowledge of prostate cancer, screening for prostate cancer
INTRODUCTION AND BACKGROUND
Prostate cancer ranks as the second most widespread cancer in men around the world and a significant contributor to cancer-related fatalities (Wang et al., 2022). By 2040, the global projection anticipates a surge in new prostate cancer cases to exceed two million annually, although the mortality rates are expected to remain relatively stable (Bray et al., 2018; Wang et al., 2022). Individuals of African descent exhibit heightened prostate cancer rates, suggesting the presence of specific genes that increase their susceptibility to more aggressive forms of the illness (Wang et al., 2022).
Prostate cancer death rates in sub-Saharan Africa are 2.7 times higher than the global norm. African ancestry is a major risk factor (Jaratlerdsiri et al., 2022), but it is likely a mix of genetic and non-genetic factors that contribute to these elevated rates. Black men have been shown to have more aggressive types of the disease in comparison to White men and to develop the disease at an earlier age. Nutrition and physical activity have been cited as significant factors in the onset and advancement of prostate cancer (Yeboah-Asiamah et al., 2017).
As with all cancers, timely identification of prostate cancer is vital (Bray et al., 2018). A recent study in Rwanda reported that 64.5% of men diagnosed with prostate cancer were already at an advanced stage (Nzeyimana et al., 2021). Lack of information and poor access to diagnostic and treatment facilities can lead to delay in the discovery of prostate cancer in low- and middle-income settings. Prostate cancer screening is recommended for high-risk populations, but not for the population in general (Rubagumya et al., 2020). Currently there is no formal screening program in the Rwanda for prostate cancer, but healthcare professionals can conduct digital rectal exams (DRE) and order prostate-specific antigen (PSA) tests to screen for the disease (Bosland et al., 2023). Additionally, the National Cancer Control Plan has proposed strategies to increase public and health professional education about prostate cancer (Rubagumya et al., 2020). Without knowledge about the disease, men are not likely to discuss it with their healthcare providers or seek investigation early for worrisome symptoms.
To date, little research has been done in Rwanda regarding men’s knowledge about prostate cancer, its symptoms, or when to seek assistance. One study of 258 males at Kigali University teaching hospital/outpatient department in Kigali, a major urban centre in Rwanda, reported 80% had heard about prostate cancer. Seventy-seven percent of these men learned of the disease from healthcare professionals and knew that frequent urination was a potential sign of the disease. In other African countries, including Uganda (Manuscript, 2014), Kenya (Mutua et al., 2017) and Nigeria (Ojewola et al., 2017), studies with men about prostate cancer and its symptoms revealed low levels of knowledge and very few who have undergone screening for the disease. Factors, other than knowledge about prostate cancer that have been shown to influence screening behaviour include fears of the disease, discomfort of the DRE test, stigma, costs, and worries about sexuality (Saleh et al., 2020). Religious and sociocultural influences also can play a major role in shaping ideas about cancer and screening behaviours (Ogunsanya et al., 2017).
Prior to planning relevant educational programs in this low resource setting, there was a need to augment our understanding of men’s knowledge about the disease in Rwanda. The main purpose of this study was to assess the level of awareness about prostate cancer and screening among men attending Kibogora Level Two Teaching in Rwanda.
METHODS
Design and setting
The study utilized a cross-sectional survey design to gather data from men attending the Kibogora Level Two Teaching Hospital, a rural hospital facility located in the Nyamasheke District of Rwanda’s Western Province. The hospital services 13 health centres and is located in a district with a population of 434,221. Approximately 90% of the population resides in agricultural settings. The hospital is a teaching hospital for the province and has 280 in-patient beds. The hospital accommodates 200–230 inpatients and 140–230 outpatients on a daily basis. Patients come from the southwestern region of the country, as well as from nearby districts and provinces, seeking specialized services provided by permanent surgeons, orthopedists, and internists.
Ethical approval was received from the Institutional Review Board of the College of Medicine and Health Sciences, University of Rwanda and Kibogora Level Two Teaching Hospital to conduct the study. Participation was voluntary and all participants were informed about the study participation and signed written consent forms prior to engaging in the study.
Sample and recruitment
The sample for the study included males seeking consultation for urinary issues at the hospital, as an outpatient (emergency or outpatient clinic) or an inpatient (medical or surgical unit). On average, about 252 males seek consultation for urinary issues at the hospital over a six-month period (personal communication, hospital data manager). Applying the Yamane formula and a sampling error of 0.05, a sample of 154 was needed.
A convenience sample was gathered by approaching individuals who were available during the time of data collection and were willing to take part in the survey. Eligible individuals had to be males, 18 years of age or older, and able to understand Kinyarwanda or English. Men were excluded if they were in distress (physical or emotional) and could not concentrate on the study questions.
Trained research assistants approached the men in the hospital setting and explained the study objectives and participation to them. Those who consented signed a consent form prior to completing the questionnaire.
The men who consented were given the questionnaire and a pen to complete the document. The research assistant or researcher was available to assist the individual if there were questions about the questionnaire items. For the participants who were unable to read English or Kinyarwanda, the research assistants read the questions and recorded their answers. No names were written on the questionnaires.
Questionnaire
The questionnaire was designed by the researcher for the purposes of this study based on a previous study conducted at Kitwe Teaching Hospital in Zambia (Gift et al., 2020). Permission to adapt the Zambian questionnaire for the Rwandan context was granted.
The final questionnaire had five sections. Section A included four demographic items (age, marital status, level of education, occupation). Section B assessed knowledge about prostate cancer, causes, risks, and symptoms. Section C explored perceptions of screening importance and behaviour. Section D examined factors that could hinder prostate cancer screening in the local context. Section E gathered suggestions on how men obtain health information about prostate cancer and what could be done to improve awareness about the disease in the future. All questions offered response options as well as an opportunity to write in ‘other’ or additional answers. Two questions were open-ended: one asked about suggestions for improving awareness about prostate cancer and the other asked if the participant had additional comments or questions about prostate cancer.
The questionnaire was reviewed by three experts in the fields of prostate cancer and survey research, to evaluate the content and relevance of the questions to the study objectives and local context. The newly adapted questionnaire was translated into the local language to eliminate ambiguity. A pilot of the questionnaire was conducted with 10% of the sample to assess clarity or any difficulties completing the questionnaire. As this pilot did not result in any changes to the questionnaire, the data from the pilot participants were included in the final analysis.
Analysis
The data were entered into SPSS Statistics (V27). Descriptive statistics, including means, medians, and frequencies were calculated for all relevant variables. The sociodemographic data were examined in relation to knowledge, factors influencing screening behaviour and whether men were ever screened. A new variable for knowledge was created by adding all correct responses to the following questions: awareness of prostate cancer, causes, risks, and symptoms. Each correct response was awarded a score of ‘1’. The number of correct scores was added to create a knowledge score. All scores above the median were considered having good knowledge versus all the scores below the median were categorized as having poor knowledge.
RESULTS
Demographic characteristics
All male participants who were approached about participation consented to take part in the study. Out of the 164 participants, 72% (n = 118) were married, and 67.1% (n = 110) had primary level education (see Table 1). The men ranged in age from 20 to 60 years with the largest number (n = 48, 29.3%) in the 41–50-year age category. The majority (88%) were farmers (see Figure 1).
Table 1.
Distribution of the Study Sample by Socio-Demographic Characteristics (n = 164)
| Variables | Frequency (n) | Percentage (%) | Std. Error |
|---|---|---|---|
| Age | |||
| 20–30 | 27 | 16.5 | 0.029 |
| 31–40 | 35 | 21.3 | 0.032 |
| 41–50 | 48 | 29.3 | 0.036 |
| 51–60 | 36 | 22 | 0.032 |
| Age Above 60 | 20 | 12.2 | 0.026 |
| Marital status | |||
| Single | 38 | 23.2 | 0.033 |
| Married | 118 | 72 | 0.035 |
| Divorced | 4 | 2.4 | 0.012 |
| Separated | 4 | 2.4 | 0.012 |
| Education level | |||
| Primary | 110 | 67.1 | 0.037 |
| Secondary | 39 | 23.8 | 0.033 |
| Tertiary | 15 | 9.1 | 0.023 |
| History of Hearing about prostate cancer | |||
| Yes | 63 | 38.4 | 0.038 |
| No | 101 | 61.6 | 0.038 |
Figure 1.
Illustration of the Participants’ Occupations
Knowledge about prostate cancer
Of the 164 participants, 63 (38.4%) had heard about prostate cancer.
The most frequently identified cause of prostate cancer, identified by 64.6% (n = 106) of the men, was family history (see Table 2). Smoking (n = 75, 45.7%) was the next most commonly identified cause, followed by obesity (n = 55, 51.8%), and a diet high in red meat (n = 55, 33.5%). Fifty-four men (32.9%) identified exposure to agent orange as a cause.
Table 2.
Knowledge About the Cause of Prostate Cancer*
| Variables | Response | Frequency (n out of 164) |
|---|---|---|
| Causes prostate cancer | Family history | 106 |
| Diet high in red meat | 55 | |
| Smoking | 75 | |
| Obesity | 55 | |
| Exposure to Agent Orange | 54 | |
| Others | 9 |
Note.
Participants could provide more than one answer.
The most commonly identified risk factor for prostate cancer was obesity with 102 (62.2%) of the men naming it (See Table 3). The next most commonly identified risk factors were smoking (n = 96, 58.5%), exposure to agent orange (n = 91, 55.5%), family history (n = 87, 53.0%), and age (n = 84, 51.2%).
Table 3.
Knowledge About the Risk Factors of Prostate Cancer*
| Variables | Response | Frequency (n out of 164) |
|---|---|---|
| The risk factors for prostate cancer | Age | 84 |
| Family history | 87 | |
| Diet high in red meat | 20 | |
| Smoking | 96 | |
| Obesity | 102 | |
| Exposure to Agent Orange | 91 | |
| Others | 8 |
Note.
Participants could provide more than one answer.
The most commonly identified symptom of prostate cancer, named by 51 men (31.1%), was difficulty urinating (see Table 4). About a third of the men named blood in the urine (n = 34, 20.7%) and erectile dysfunction (n = 30, 18.3%) as symptoms. A total of 63 (38.4%) wrote in other symptoms they thought could indicate prostate cancer. These include lower abdominal pain, back pain, nausea, and fatigue.
Table 4.
Knowledge About the Symptoms of Prostate Cancer*
| Variables | Response | Frequency (n out of 164) |
|---|---|---|
| The symptoms of prostate cancer | Frequent urination | 23 |
| Difficulty urinating | 51 | |
| Blood in the urine or semen | 34 | |
| Erectile dysfunction | 30 | |
| Bone pain | 1 | |
| Others | 63 |
Note.
Participants could provide more than one answer.
Overall, when correct responses were assigned to ‘good’ knowledge (above the median) and ‘poor’ knowledge (below the median) categories, 109 (66.4%) were categorized as having poor knowledge while 55 (33.5%) had good knowledge (see Table 5).
Table 5.
Overall Knowledge Scores of the Participants (N = 164)
| Knowledge scores categorized as above and below the median | Frequency | Percentage |
|---|---|---|
| Poor | ||
| Total knowledge score below the median | 109 | 66.5 |
| Good | ||
| Total knowledge score above the median | 55 | 33.5 |
Screened for prostate cancer
In total, only five individuals indicated they had ever been screened for prostate cancer. Yet, when asked about the significance of screening, almost all (163) acknowledged the importance of screening (see Table 3). Only one man in the ‘good’ knowledge category had been screened.
Men’s recommendations to improve awareness about prostate cancer
Most participants recommended general education (n = 60, 36.5%) and mass education (n = 59, 35.9%) about prostate cancer as important strategies for informing the public (See Figure 2.) Several men also mentioned training (n =10), sensitization (n = 6), access to screening facilities (n = 6), and advocacy (n = 4). Other suggestions included ideas such as supporting the poor families to access the healthcare services.
Figure 2.
Recommendations From Participants on How to Improve Awareness About Prostate Cancer
The men indicated that healthcare providers were the main source of information about prostate cancer and screening. A hundred and forty (85.4%) of the men named healthcare providers as the source of their health information. Family and friends accounted for the second most commonly identified source (n = 119, 72.8%).
DISCUSSION
This study was conducted to explore the level of awareness Rwandan men had about prostate cancer, as little evidence had been reported about their knowledge despite the incidence rate in the country. The demographics of the participants align with similar studies concerning prostate cancer knowledge in Africa. One study conducted at the University of Nigeria reported that 60.2% of respondents were married and most had at least a first degree (Adibe et al., 2017). The one other study conducted in Rwanda also found that most participants were married and had primary-level education (Benurugo et al., 2020). Conversely, a USA-based study reported most respondents were single and not in a relationship (Ogunsanya et al., 2017). Of note, most participants in this study were farmers, which reflects the rural setting of the hospital and offers insight into the awareness of this group of men.
The study revealed various misconceptions and a lack of detailed knowledge about prostate cancer among the participants. For instance, many believed that prostate cancer symptoms were similar to other urinary issues, potentially leading to delays in seeking proper medical advice. Clearly there is a need for public education for men, perhaps targeted to the agricultural setting. This may also raise questions about the nature of conversations healthcare professionals are having with men about prevention and screening related to prostate cancer and could be the focus of a future study.
The low number of men who engaged in screening is concerning. This study showed that most participants, whether in possession of good or poor knowledge had not been screened. Moreover, most participants who thought being screened for prostate cancer was important (n = 158) were not screened. This result is consistent with a Kenyan study where only 2.4% of participants had been screened (Mutua et al., 2017) and a study in Ghana in which 90% of male teachers had never been screened for prostate cancer (Yeboah-Asiamah et al., 2017). The Rwandan study highlights a significant gap in knowledge and awareness about prostate cancer and screening among the men who participated, but also raises questions about whether there are other factors influencing screening engagement. A perception of importance alone appears insufficient. Future work ought to explore men’s knowledge about where to go for screening and the availability of facilities close to their homes.
A study conducted in Kenya showed information, and fear of screening processes, were not associated with the intent to screen for prostate cancer (Mutua et al., 2017), while a study conducted to identify the factors perceived by African-American men as influencing their behaviour relative to prostate cancer screening showed that the lack of access to prostate cancer screening facilities were reported by the participants as a barrier toward prostate cancer screening (Odedina et al., 2004).
The low screening rates are consistent with similar studies in Nigeria, Rwanda, Kenya, and Ghana. These consistent findings underscore the widespread lack of prostate cancer awareness and screening in various African communities. The demographic contrast with the USA study indicates potential cultural and social differences affecting marital status and relationship status among study populations (Ogunsanya et al., 2017).
Finally, this study indicated that most participants have found prostate cancer-related information from radio and healthcare providers. These results are quite similar to those of a study conducted to assess the knowledge, attitudes, and screening practices regarding prostatic diseases among men older than 40 years: a population-based study in Southwest Nigeria. In that study the results showed that the main sources of information were radio and television (Ojewola et al., 2017). These data emphasize a potential route for public education with this population of rural dwelling men. It also emphasizes the importance of healthcare professionals taking the time to discuss prostate cancer with men, particularly those in the high-risk age group.
Limitations of the study
The study sample included only men who visited Kibogora Level Two Teaching Hospital. The results of the study should not be generalized to the entire nation. The low level of screening behaviour precluded advanced statistics exploring factors affecting screening behaviour.
CONCLUSION
This study reveals a low level of knowledge about prostate cancer among men in a rural Rwandan setting, with radio and healthcare providers serving as the primary sources of information. Misconceptions regarding its causes, including the belief that a high-fat diet contributes to prostate cancer, were prevalent. Both awareness and screening practices remained poor, underscoring the need for targeted public health interventions. To address these gaps, widespread awareness campaigns utilizing mass media, healthcare facilities, and religious institutions are recommended to enhance knowledge, attitudes, and screening practices related to prostatic diseases.
ACKNOWLEDGEMENT
The author wishes to acknowledge the University of Rwanda’s Dr. David C. Ikwuka and Professor Margaret Fitch for providing guidance while conducting this study.
Footnotes
AUTHOR CONTRIBUTIONS: KJMV conceptualized this study, gathered and analyzed the data, and developed the manuscript. DI and MF oversaw the work and approved the final manuscript.
ETHICAL APPROVAL: IRB has approved the study with approval reference number CMHS/IRB/415/2024.
CONFLICT OF INTEREST: The authors declare that there were no conflicts of interest.
FUNDING: None reported.
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