Family and Friend Interactions Among African-American Men Deciding Whether or Not to Have A Prostate Cancer Screening

Abstract

Introduction

African-American men are approximately 2.4 times more likely to die of prostate cancer when compared to Caucasian men. Since prostate cancer screening is controversial, there lies a greater need to understand the decision-making factors for screening.

Purpose

Cancer patients and patients at high risk for cancer face difficult decisions in choosing what is most appropriate for them and how to access resources. The purpose of this study was to examine how rural African-American men decide whether or not to have a prostate cancer screening.

Methods

A qualitative research design was used to examine rural African-American men’s experiences in decision making as it relates to prostate cancer screening. A hermeneutic phenomenological approach was used to analyze data. This approach focuses on the lived experiences of participants, as well as the meanings of their experiences.

Findings

Seventeen rural African-American men were interviewed about whether or not to have a prostate cancer screening. Three themes emerged from the findings: 1) family and friend involvement is important, 2) trust in the doctor is necessary, and 3) knowing a friend or family member with prostate cancer impacts decision making. The involvement of family and friends in the decision-making process for prostate cancer screening became prominent among the participants.

Conclusions

Opinions of family and friends were highly valued and had a great impact on the participants’ decision-making process. A combination of informal and formal support resources influenced the men’s decision for prostate cancer screening.

Prostate cancer is the most commonly diagnosed cancer in men, and it is the second leading cause of death from cancer in the United States. Prostate cancer is diagnosed among African Americans more often than other ethnic groups in the United States. In 2009, approximately 27,130 African-American men were diagnosed with prostate cancer, and approximately 3,690 African-American men died of prostate cancer (American Cancer Society, 2009). African Americans are approximately 2.4 times more likely to die from prostate cancer when compared to their white counterparts (American Cancer Society, 2009). Prostate cancer screening, particularly screening for prostate-specific antigen (PSA), remains highly controversial and has not yet been definitively proven effective through randomized clinical trials. The American Cancer Society has recently updated its screening guidelines for prostate cancer, which now places an emphasis on the informed and shared decision-making method (Wolf et al., 2010). Family and friends may play an important role in the decision-making process (Davison, Oliffe, Pickles, & Mroz, 2009; Jones, Steeves, & Williams, 2009a). Although evidence of prostate cancer screening effectiveness has not been sufficient to recommend for or against routine screening, it does offer the only possibility at this time for early detection, which is important among those individuals who are considered to be at higher risk, such as being African American, men having a first-degree relative who has been diagnosed with prostate cancer before 65 years of age, and men with multiple family members diagnosed with prostate cancer before 65 years of age.

Prostate cancer is a disease that produces physical and emotional effects. Men may feel embarrassed and uncertain about obtaining prostate cancer screening due to the myths and stigmas that surround having prostate cancer. Some myths may include prostate cancer is always symptomatic (Lange & Adamec, 2003); prostate cancer screening involves the insertion of a tube into the rectum to collect saliva (Richardson, Webster, & Fields, 2004); and that an orchiectomy is the only way to treat prostate cancer (Richardson et al., 2004). Stigmas that men may face if diagnosed with prostate cancer after screening may include having issues with incontinence and impotence. Many men believe that if they are diagnosed with prostate cancer, they will have sexual dysfunction and not be able to have continence, regardless of treatment or when they receive treatment. These myths and stigmas may prevent men from seeking prostate cancer screening.

Informal support systems may be a critical part in the decision-making process of men, particularly African Americans, as it relates to screening and the treatment of disease. A study by Myers et al. (1996) randomly selected 218 African-American men in Philadelphia and explored whether these men would get an annual prostate cancer screening. The authors reported that informal support and advice from family and friends were significantly associated with African-American men seeking cancer screening and advice from health care professionals. It has been noted in earlier studies (Crump, Mayberry, Taylor, Barefield, & Thomas, 2000; Mandelson et al., 2000) that not receiving a referral by a physician or nurse practitioner to get a cancer screening is a barrier for African Americans. Sussman, Robins, and Earls (1987) conducted 3004 surveys relating to psychiatric status, sociodemographic variables, and health service utilization, and explored the differences between African Americans and Caucasian Americans in seeking treatment for depression. The study also identified groups who were least likely to seek professional health care. The study found that African Americans were more likely to seek informal advice from family members, friends, and members of the community than Caucasians. Holt and colleagues (2009) explored the implementation of a spiritually based prostate cancer screening informed decision-making intervention for African-American men who attended church, an informal setting, to determine its efficacy. A trained community health advisor (identified by the pastor of each participating church) delivered the intervention to the men. Although it was difficult to confirm significant efficacy of the intervention due to a small sample size, a trend that the intervention influenced the ability of men to make an informed decision about having a screening was reported. In light of the inconsistencies in recommending prostate cancer screening, together with the misinformation available, support from family and friends may play an important part in influencing African-American men about prostate cancer screening.

Purpose

There is a dearth of literature (Ilic, Risbridger, & Green, 2005; Jernigan, Trauth, Neal-Ferguson, & Cartier-Ulrich, 2001) examining the interaction between family/friends and men deciding whether to participate in prostate cancer screening. Family and friends are important sources of social support for African Americans. Since patients may hear different opinions and recommendations about prostate cancer screening that can make participating in the screening a difficult decision, the interaction between African-American men and their family members/peers may be significant in the decision-making process. The purpose of this study was to examine the impact family members and friends have in the decision-making process in prostate cancer screening activities.

Methods

Sample, Setting, and Procedures

This report is an exploration of a portion of a larger study examining the factors that helped African-American men decide whether or not to have a prostate cancer screening. Some findings of the overall study have been reported elsewhere (Jones et al., 2009a). The overall study used a hermeneutic phenomenological qualitative approach to obtain participants’ experiences in the narrative form.

In this portion of the study, participants were asked specifically about how interactions with their family and friends affected their decision-making process. A qualitative research design was also applied to this portion to help explore and interpret the complexity of the decision-making process as it relates specifically to interactions with family and friends. Participants were encouraged to express their experiences in narrative form concerning the impact of communication with family and friends on decision making about prostate cancer screening.

Participants were recruited from rural Central Virginia utilizing several strategies, including radio public services announcements, flyers placed in African-American-owned barbershops, and word of mouth to enhance participation in the African-American community (Jones, Steeves, & Williams, 2009b). Study participation inclusion criteria consisted of 1) identification of self as Black/African-American (non-Hispanic), 2) age 40 years and older, 3) able to speak and understand English, 4) not diagnosed with prostate cancer, and 5) willing to provide informed consent. A total of 17 participants were recruited and consented. Participation consisted of an individual interview conducted by the author (R.J.), who has had extensive experience and training in conducting interviews. Each interview was conducted at a time and place convenient and comfortable for each participant, which included their homes and library conference rooms. Each participant received $30 as compensation for study participation.

Data Analysis

Each interview was audiotaped, with field notes recorded after the interview was completed. Each audiotaped interview and set of field notes were transcribed verbatim and underwent a qualitative analysis (Cohen, Kahn, & Steeves, 2000). The interview narratives were analyzed using an iterative approach, which enhances the understanding of the beliefs and attitudes of the participants with regard to prostate cancer screening. The iterative comparative analysis involved each of the authors continuously revisiting the narratives to examine for any new themes. Data saturation was reached at a sample of 17 (Lincoln & Guba, 1985). Using the computer software program NVivo®, keywords or phrases (“codes”) were identified and organized into categories. The first author performed initial coding, and each research team member separately created categories and organized them into themes. The research team convened and discussed the themes to come to a consensus.

Results

Participants in this study ranged in age from 40 to 71 years (mean = 52 years; SD = 10). Twelve participants (71%) reported an annual income between $1000 and $30,000. The majority of participants (71%) were employed. Eight participants (47.1%) had private health insurance, and five men (29.4%) had Medicare/Medicaid. Less than half of the participants (35%) were high school graduates. Among the participants, seven (41.2%) were married, three (17.6%) were divorced, and seven (41.2%) were single. All men stated that they had male friends with whom they often came in contact.

Three major themes emerged from this study: 1) family and friend involvement is important, 2) trust in the doctor is necessary, and 3) knowing a friend or family member with prostate cancer impacts decision making.

Family and Friend Involvement Is Important

Universally, these participants stated that family and friend involvement was important in the decision-making process. The men stated the involvement of their family and friends in the decision whether or not to have a prostate cancer screening was valuable to them. These men trusted the opinions of their relatives, and believed that family and friends had their best interest related to health issues at the forefront. This finding supports the previous work of Sussman and colleagues (1987), which articulated that African Americans are more likely to seek health advice from informal and familiar sources (such as family and friends) than Caucasian Americans. One participant described this as follows:

I had a friend of mine who stayed on me about taking the prostate cancer test. Yeah, constantly, every time I would see her she used to ask me if I had got the test done yet. I would say, “No,” but I finally got it done because of her. I felt kind of embarrassed at first. You know how men are. But now I don’t feel that way anymore. I used to feel embarrassed, but now it’s just a test… I really thank her for sticking by me. My wife, she was with me too, though.

Another participant stated that both his wife and daughters helped him make a decision to be screened for prostate cancer:

Yeah, my wife and daughters, they talk about me going to get my prostate checked all the time. “Go get it done and keep a check on it,” they say. They were involved in helping me go ahead and getting my prostate checked.

The role family members had in placing health as a priority was described by one participant as:

My wife keeps up with my appointments more so than I. Usually, my wife tells me to get this checked and get that checked…She would tell me to go to the doctor or something to get my prostate checked. I would go.

Family and friends played an important role in advising the men in this study of whether or not to get a prostate cancer screening. The men trusted their friends and members of their family in helping them make the decision. Family and friends who were concerned about the men’s health appeared to be actively sought after for their opinions about prostate cancer screening.

Trust in Health Care Providers Is Necessary

Trust in health care providers was an important factor among these participants in their decision to take part in prostate cancer screening activities. The men noted that having a good rapport with their health care provider is a necessity and does influence their health decisions. When asked, one participant described how his decision was influenced:

My doctor talked to me about prostate cancer and the test. He said, “You’re a Black male, you’re getting closer to the age, and that you need to have the test done.” So I did it…I’m around a lot of medical people around this area, so it’s the environment that’s comfortable to me right now.

In previous literature, some studies (Doescher, Saver, Franks, & Fiscella, 2000; Earle, Neumann, Gelber, Weinstein, & Weeks, 2002; Halbert, Armstrong, Gandy, & Shaker, 2006) have concluded that race is an important factor in trust between a patient and a health care provider. Conversely, this study’s authors found that study participants believed having a good rapport with their health care provider (for example, nurse practitioner and physician) was more important than the race of the provider. A trusting relationship between patient and health care provider appeared to be based on whether the health care provider seemed sincere about caring for patients. When a participant was asked whether the race of the physician mattered to him, he said:

I figure the doctors and nurses try to help everybody. They will try to tell you what your illnesses are. We’re Black people, and we got prostate cancer, and White people, they got leukemia you know. I think the doctors and nurses try to help us all, so I have no problem with them… I trust them to help me any way that they can.

Another man stated:

The doctors and nurses have helped me out good. I’m pretty sure they helped my family out good, too, no matter what color they are. Me and my daughter, my girlfriend, all of us, we go to the same clinic, and we never complain because we trust them.

The men described the importance of believing that a trusting relationship between health care providers is essential. Participants’ trust in the provider influenced their decisions in getting the screening. Trust in the health care provider took priority over the race of the health care provider. The men believed that having a good rapport with their provider is a major factor in the decision-making process of prostate cancer screening.

Knowing a Friend or Family Member with Prostate Cancer Impacts Decision Making

The men stated that knowing that a relative or friend had prostate cancer affected their decision about participating in prostate cancer screening activities. It is well established that a man with a family history of prostate cancer has an increased risk to acquire prostate cancer (American Cancer Society, 2009). One man stated:

My dad died; it [prostate cancer] took my dad about 10 years ago…you constantly hear about it now you know, “Get yourself checked.” So you either are going to ignore it or you are going to do something about it. If you do not do something about it, you are almost like you are being selfish, because you are not thinking about other people that you might mean something to.

Another participant stated:

I have two older brothers, and they are just finding out [that they have prostate cancer]… I guess they are being treated now… I will get my screening done soon.

The men had not heard much about prostate cancer screening until a relative or friend had been diagnosed with prostate cancer. When a participant was asked how he heard about prostate cancer, he stated:

My father, he had problems with prostate cancer, and a few other people I know. They [health care providers] fixed it [prostate cancer], and he is not having a problem anymore.

Another man stated,

My father-in-law had prostate cancer, and they wanted to remove his prostate. I know he says he can’t conceive children anymore, and he suffered from hot flashes. He is the only one I actually knew [who had] had prostate cancer. Now, it is important to me to get a prostate cancer screening done. I want to live as long as I can and be around for my children and grandchildren.

Knowing that a friend and/or family member had prostate cancer was important in helping the study participants decide about prostate cancer screening. The men became more aware about prostate cancer when someone close to them was diagnosed with the disease. Family members and/or friends had an impact on the decision due to the personal connection with the participants.

Discussion and Limitations

The participants stated that the impact of family, friends, and health care providers was important to their decision of whether or not to participate in prostate cancer screening activities. Previous studies (Charles, Gafni, & Whelan, 1997; Denberg, Beaty, Kim, & Steiner, 2005) have shown that relatives play a major part in advising on health care, and family members are key individuals in the decision-making process, particularly within the African-American community. It has been noted in the literature (Wilson et al., 1995) that African Americans are more likely to seek informal support systems (such as family and friends) because it may buffer conditions that may be considered stressful. The decision-making process appears to involve a combination of interactions between the men and their family, friends, and health care providers. In addition, knowing a family member or friend who has had prostate cancer may contribute as a deciding factor in the issue of having a prostate cancer screening done.

A limitation to this study was that the individuals recruited to participate lived in rural central Virginia; thus, they may not be representative of rural populations in other areas of the United States. In addition, this study included only those individuals who were interested in the study and agreed to be interviewed, whereas there is a lack of data from those individuals who were not interested in prostate cancer screening. Future studies should include individuals who may lack interest in receiving prostate cancer screening to get a broader perspective and experience with decision making about prostate cancer screening.

Implications for Nursing Practice

It is important for nurses and other health care providers to understand the type of support networks African-American men may use in their health care decision making. Nurses and other health care providers should recognize that informal support networks (such as family or friends), in addition to formal support networks (such as nurses and physicians), may be utilized by African-American men to decide whether or not they should get a prostate cancer screening. Nurses as educators must be aware of the current prostate cancer screening guidelines (Wolf et al., 2010) to provide adequate health care information to men, particularly those men who are considered to be at higher risk for developing prostate cancer. Since trust plays a significant role in the lives of African-American men, nurses and other health care providers must also provide an open and welcoming clinical environment for this population to form a good patient-provider relationship. This trusting relationship will assist in the enhancement of education and informing the patient about prostate cancer screening to develop an informed and shared decision-making process.

Conclusion

Themes that emerged from this study may have a significant influence on how African-American men decide whether or not to have a prostate cancer screening. It is important to recognize that family and friends are essential factors in the decision-making process, particularly in the African-American community, where they are more likely to use informal resources. This makes it even more important for health care providers to be aware of the importance of family and friends in the health care decision process. In addition, a trusting relationship between the patient and health care provider is essential and has an influence on how a patient makes a decision about screening.

Prostate cancer disproportionately affects African-American men. Family, friends, and trust in health care providers are factors that influence the decision making of African-American men when determining whether or not to get a prostate cancer screening done.