Knowledge and Perception of Nigerian Men 40 years and above Regarding Prostate Cancer

Abstract

Background

Carcinoma of the prostate is now the most commonly diagnosed male cancer worldwide. However, knowledge and perception of Nigerian men about the disease has not been fully investigated.

Aim

To determine the level of awareness about prostate cancer among men 40 years and older in Ibadan, Southwestern Nigeria.

Method

Four focus group discussions were used to obtain information from 29 randomly- selected Nigerian men, aged 40 years and above, about their knowledge of the common causes of morbidity and mortality among men of their age group as well as prostatic diseases and their perceived causes. In-depth interviews were then conducted among 656 participants using questionnaires.

Results

Generally, the respondents and discussants were unaware of the prostate gland and its diseases; whilst relatively few knew about carcinoma of the prostate and most were ignorant of the symptoms of the disease. Among discussants and respondents who knew about the gland, most thought that benign and malignant prostatic diseases were long-term complications of promiscuity and sexually transmitted infections. All the participants were interested in receiving information about all aspects of carcinoma of the prostate.

Conclusion

. These results indicate that a large proportion of adult Nigerian men are ignorant of the prostate gland and its diseases in general, and carcinoma of the prostate in particular. There is therefore the need for community awareness programs on prostatic diseases in our locality.

Introduction

Carcinoma of the prostate (CaP) is major health problem among middle-aged and elderly men in developed and developing countries1. The disease is now the most commonly diagnosed cancer among men in the United States2, Nigeria3 and Jamaica4, and the second leading cause of cancer-related male deaths in the United States1. Prostate cancer has a higher incidence, a more aggressive course and a higher mortality in black men when compared to their white counterparts5. These disparities persist and despite abundant research, findings continue to be inconclusive about the reasons and the best methods to decrease them6.

According to previous studies in African-Americans, this group of men lack information about the prostate and are more likely to present late with the disease7,8. They were also reluctant to have digital rectal examination and prostate specific antigen tests and had little or no knowledge about these examinations9. In all of these studies, it was established that the hesitancy towards the early detection and treatment of prostate cancer detected in these men could be associated with cultural issues within their community and a lack of health awareness directly tailored towards them7,8,9. This attitude has undoubtedly contributed to their late presentation and the relatively high mortality rate from the disease observed in this subpopulation.

In Nigeria, the mean age of prostate cancer patients at the time of diagnosis has been reported to be about 68.3 years, while the national prostate cancer risk was put at 2% of all patients with most men being diagnosed with advanced stages of the disease10. The early detection and management of CaP through routine screening (with digital rectal examination (DRE) and the prostate specific antigen (PSA) test) and improved access to care have translated to improved long-term outcome for most patients in developed countries11. The stage of the disease at diagnosis is one of the most important predictors of survival from prostate carcinoma. In the United States, the 5-year survival rates for local and regional prostatic cancers are 92% and 82% respectively, compared to 28% for those diagnosed at a distant stage12. In Nigeria, 75% of patients present with locally advanced or metastatic diseases, and mortality due to CaP has been reported to be as high as 64% within two years of diagnosis10.

However, despite increasing high incidence of the disease in Nigeria, and the importance of early detection in carcinoma of the prostate survival, there is little literature on the knowledge and perception of adult men in the country about the malignancy and their awareness about screening tests for its early detection. Furthermore, it is of importance to the physician to understand the existing understanding, beliefs and perceptions about this disease in his local environment so as to add to current knowledge while correcting wrong information.

This study was carried out to determine the level of awareness about carcinoma of the prostate among adult men in Ibadan, Nigeria as a part of a larger study of the elderly. The town of Ibadan in southwestern Nigeria is adjudged the third largest city in size in the country and is the capital city of Oyo state. According to 2006 census figures, the population of the city was about 1.2 million (of a population of 5,591,589 for Oyo Stat13).

Ethical Approval

This study was approved by the University of Ibadan/ University College Hospital, Ibadan Ethics Committee.

Methods

Focus Group Discussion

Four focus group discussions (FGDs) were held with randomly-selected volunteers aged 40 years and above in Ibadan, Southwestern Nigeria. The volunteers were representative of the indigenous population and the different socio-economic groups’ class. They were selected from a pool of volunteers by a ballot system to ensure randomness and lack of bias. The study team obtained informed consent from each of the discussants who were then given a serial number for anonymity. The demographic characteristics of the discussants were obtained before commencing the FGDs. Using a pre-tested FGD guide translated into Yoruba (the local language), the discussants were asked questions about their knowledge of common causes of morbidity and mortality among men of their age group, their knowledge about the prostate, its diseases and their perceived causes. The discussions were moderated by a rapporteur and the proceedings were recorded with the aid of a tape recorder. These discussions were held in English or the local language (Yoruba), to ensure that the participants understood the questions and were comfortable with expressing themselves for this purpose. All interviews were conducted in large well-lit and well-ventilated rooms with comfortable chairs and under conditions of strict privacy in order to ensure participant privacy and also to encourage the participants to be freer with their responses to questions. The interviewer utilized pretested questionnaires that had both English and Yoruba translations which acted as an interview guide and answers were sought for questions in the language the participant was most comfortable with. Each of the interview sessions lasted about 45 minutes.

Prostate Cancer Survey

Following the FGDs, the second part of the study was done by surveying men participating in a health screening exercise carried out in the same community in Nigeria. An informed consent was obtained prior to the survey and each of the participants was given a patient identifier number to maintain anonymity. The men were all aged 40 and above, and were from different socioeconomic backgrounds. Out of 700 questionnaires that were sent out, 656 men responded with correct and full information as specified in the questionnaires. Data were obtained using a pre-tested semi-structured questionnaire on participants’ socio-demographic characteristics, beliefs, knowledge and screening practices related to CaP.

Results

Focus Group Discussion

Twenty-nine men participated in the focus group discussions and their mean age was 61.4± 9 years. The profile of their occupation is shown in Table 1. Most of the discussants were ignorant of the existence of the prostate and this was even more apparent in one of the groups where none of the men knew about the gland. In the other three groups, a few men had knowledge of the prostate gland, and among these, some thought that prostatic diseases were long term complications of gonorrhea and other infections of the urinary tract.

Table 1 . Profile of Focus Group Discussants N=29.

	n	%
Age
40-49	4	13.8
50-59	5	17.2
60-69	14	48.3
70-79	6	20.7
Occupation
Retired	14	48.3
Trader / Artisan	5	17.2
Manager/Engineer	10	34.5

The diseases that were considered common in older men by discussants in all the groups were hypertension, diabetes mellitus and body/joint pains (Table 2). Urinary obstruction, as a complication of sexually transmitted infections (STIs) earlier in life, was also mentioned as a major health problem among men in this age group. Benign prostatic hyperplasia (BPH), and not prostate carcinoma, was alluded to as a major health problem in one group. Furthermore, according to the discussants, the diseases considered to be primarily responsible for mortality in this age group were cardiovascular diseases such as hypertension and stroke (Table 3). Diabetes mellitus and urinary obstruction were also perceived to be major causes of mortality. Prostatic diseases (as distinct from, or as a cause of urinary obstruction) were only mentioned as a cause of mortality by a few persons in one group consisting mostly of well-educated men. Indeed, one discussant deemed CaP a significant cause of death among men in Nigeria.

Table 2 . Free listing of perceived common diseases of men by group.

Group 1	Group 2	Group 3	Group 4
Arthritis/ backache Hypertension Diabetes Impaired vision	Hypertension Hernia Impaired vision Urinary tract obstruction	Hypertension Tremors Urinary tract obstruction Body aches and pain	Hypertension/Stroke Impaired vision Arthritis Backache

Table 3 . Free Listing of Discussants’ Perceived Common Causes of Mortality Among Men .

Group 1	Group 2	Group 3	Group 4
Heart attack Hypertension leading to stroke Diabetes mellitus	Hernia Prostate gland diseases Hypertension	Poorly-managed diabetes mellitus Stroke Urinary tract obstruction	DiabetesStroke Hypertension

The main source of information on benign and malignant diseases of the prostate, for the few discussants aware of them, was through contact with people who had suffered from the diseases. Other sources of information included the television, radio and books. As pertaining to the frequency of the diseases in the population, most of the discussants thought BPH and CaP were rare in Nigeria, however in one group a few persons felt that the diseases were common, but that because they were usually not discussed openly, most people were ignorant of their existence. Similarly, most of the discussants were not knowledgeable about the symptoms of either BPH or CaP, but the few who had knowledge of the diseases thought supra-pubic swelling and difficulty in passing urine were related to prostatic diseases.

The causes of, and risk factors for, prostate cancer were unknown to most of the discussants, but a few thought promiscuity in early adulthood and previous history of STIs could be risk factors. Methods of diagnosis of the disease were also unknown to most of the discussants, but a few supposed it could be detected early through regular medical check ups and specialist care. In terms of where to seek treatment for the disease, it was agreed in all the groups that treatment was best sought at orthodox medical hospitals.

All the participants were interested in receiving information about all aspects of carcinoma of the prostate (CaP) i.e. risk factors/causes, prevention/early detection, signs/symptoms and treatment. The preferred mode of dissemination of the information included handbills, media talk shows and talks in churches/mosques.

Prostate Cancer Survey

Six hundred and fifty six (656) men participated in the study. Of these, 115 (17.5%) men were between 40-49 years, 280 (42.7%) between 50-59 years, 175 (26.7%) were between 60-69, 66 ranged between 70-79, and 20 above 80 years (Table 4). Majority, 583 (90.5%) were married, 13 (2%) had never been married, 28 (4.4%) were separated or divorced, while 20 (3.1%) were widowers. Information on educational background revealed that 287 (43.8%) had a High School education (Table 4).

Table 4 . Demographic details of Participants in the Community-Based Prostate Diseases Survey .

Index	Age-decade group												p value
	Total		40-49		50-59		60-69		70-79		80+
	No	%	No	%	No	%	No	%	No	%	No	%
Participants	656	100	115	17.5	280	42.7	175	26.7	66	10.1	20	3.0
Marital Status
Never married	13	2.0	3	2.6	7	2.5	2	1.2	0	0	1	5.3
Married	583	90.5	107	93.9	249	90.2	157	92.4	56	86.2	14	73.7
Separated/Divorced	28	4.4	3	2.6	12	4.3	7	4.1	4	6.2	2	10.5
Widowed	20	3.1	1	0.9	8	2.9	4	2.1	5	7.7	2	10.5
Completed High School
No	369	56.2	51	44.3	168	60	94	53.7	46	69.7	16	80	0.001
Yes	287	43.8	64	55.7	112	40	81	46.3	20	30.3	4	20
Med. Examt
Yes	383	58.4	49	42.6	184	65.7	102	58.3	39	59.1	9	45.0	<0.0001
No	273	41.6	66	57.4	96	34.3	73	41.7	27	40.9	11	55.0
*BMI
<25	390	73.6	66	66	194	75.5	93	72.1	26	83.9	11	84.6
25-29.9	121	22.8	28	28	53	20.6	34	26.4	5	16.1	1	7.7
≥30	19	3.6	6	6	10	3.9	2	1.6	0	0	1	7.7

Awareness of the prostate and prostate cancer

Forty-three percent of the respondents (283), had prior knowledge of the prostate gland while 190 (29%) had heard of prostate cancer. In contrast, a larger proportion (58%) of them had knowledge of other cancers and 336 (51.2%) men had heard of urinary problems in old age. The main sources of information about prostate carcinoma among the respondents who knew of the disease were mostly obtained from radio (33%), health workers (23.8%), friends/family/colleagues, and the television (33%, 23.8%, 19%, and 19.5%). Other sources of information mentioned include newspapers (13%), with other sundry sources accounting for 3.2%.

1. Knowledge of Prostate cancer

Sexually Transmitted Infections (STIs) and sexual promiscuity were considered the main risk factor for prostate cancer by some of the respondents (17.9%). Sexual promiscuity was also considered another major risk factor (17.1%), while old age (9.9%), family history (7.2%), and being from the African race (3.4%) were considered risks by only a small proportion of the respondents. Less than a third of the respondents (31.7%) were aware of the symptoms associated with CaP, while 21.2% were aware of difficulty in urination being a symptom and 3.7% of respondents described suprapubic swelling as a symptom. In terms of the appropriate treatment for the disease, 48% were of the opinion that orthodox treatment in the hospital was the best method of treatment for prostate cancer; while a few (4.3%) preferred the traditional form of treatment.

2. Health-seeking behaviour regarding Prostate Cancer

Majority of the respondents had not been evaluated for prostatic disease previously. This as one hundred and forty-one (21.5%) of the respondents had undergone a digital rectal examination (DRE) prior to the screening and 112 (17.1%) had undergone a Prostate Specific Antigen (PSA) test. Interestingly, most of the respondents (81.5%) were interested in receiving information about prostate cancer. Of these 478 (72.6%) were interested in specific information about the specific causes/ risk factors of the disease, 437 men(66.6%) indicated interest in information on the signs and symptoms of the disease, while 433 (66%) were interested in having information on treatment options for the disease. Specific information about prevention of prostate cancer was also considered of relevance by 461 (70.3%), whilst 245 (32.3%) thought information about populations at risk of the disease was important. The preferred modes of information dissemination opined by respondents who required information about prostate cancer were: handbills (44.1%); the radio (32.9%), the television (25.2%), health centres or health workers (30.4%), and religious houses (29%).

Discussion

Although the efficacy of prostate cancer screening in reducing disease mortality in asymptomatic men remains controversial14, recent reports continue to suggest that early detection is beneficial15. It is noteworthy to state that past studies have been conflicting on the influences of race or socioeconomic background on knowledge, perceptions and beliefs about prostate cancer and early detection16, 17,18,19.

Public awareness about the causes, methods of detection, investigation and treatment of diseases are a pre-requisite for their early detection and treatment. There is paucity of literature, using both quantitative and qualitative measures, on the knowledge and perceptions of Nigerian men regarding the prostate and its diseases, including prostate cancer. In these studies, we found out that awareness about diseases of the prostate, especially carcinoma of the prostate (CaP), among discussants in the focus group discussion and respondents in the prostate screening study was low, in contrast to awareness about diseases such as hypertension, diabetes mellitus and arthritis. The high level of awareness about these second group of diseases could be attributed to the fact that they are more prevalent among people of this age group in our community20,21. Indeed it is probable a number of the discussants and respondents were affected by one or more of these diseases. Furthermore, the symptoms of arthritis and diabetes and the sequlae of hypertension are easily identifiable and have been the subject of long-running public health education programs in Nigeria. Another factor of importance is a lack of a national screening program for prostate cancer which has given the impression of a low incidence of the disease in Nigerians22,23,24.

Whilst the poor knowledge about benign and malignant prostatic diseases among our discussants and respondents is in keeping with reports from similar studies in African Americans25, their ignorance of the prostate gland itself was unexpected. This apparent lack of awareness about the gland (and thus its diseases and screening) by most of the participants is probably due to the fact that it is an internal organ that has not been previously identified as a body organ in the local language (Yoruba). Indeed and the word now being used to identify it (‘iseto’ or ‘aseto’) literally means ‘that which obstructs the flow of urine’. However, recognition of difficulty in urination as a major cause of morbidity in older men by some participants was considered significant. This was notwithstanding the general lack of awareness of the gland, and the non-recognition of association of this symptom with prostatic diseases by those who were aware of the gland. This finding is probably due to the fact that in southwestern Nigeria, diseases are identified by the literal description of their symptoms. Consequently, obstructive uropathy due to prostatic enlargement could be confused with that due to urethral stricture (a complication of poorly treated STIs) due to the knowledge of the fact that difficulty in urination is more commonly seen in men with a previous history of STI. In addition, the identification of urinary obstruction as a cause of mortality by some participants may be explained by the fact that urinary retention occurs as a late event in bladder outflow obstruction due to either urethral strictures or prostatic enlargement, and may be pre-terminal if not treated promptly or effectively.

Recent health education strategies in Africa as a whole and Nigeria specifically have focused mainly on HIV/AIDS as well as other infectious diseases; the awareness of which has been reported to be quite high in different populations26,27. This is mainly due to the extensive media coverage and widespread health information obtainable on the disease. It is also due to a large extent to the Nigerian government’s focus on the disease, as well as the attention it receives from various Non-Governmental Organisations and multi-government organizations including the World Health Organisation. This study indicates that there is an urgent need to educate Nigerian men about the risk of CaP and the early detection and screening measures that are currently available. This especially as recent studies have suggested that, although there is evidence of a molecular basis for the more aggressive disease in blacks28,29,30, race/ethnicity as an independent predictor of CaP is conditional and dependent on age, stage at diagnosis, and treatment31,32. Furthermore, radical treatment (prostatectomy) has been shown to result in a similar responsiveness in black and white men with disease of similar stage and grade31 whilst treatment of advanced disease in usually of limited benefit on the continent33. As such, early diagnosis and treatment of the disease can be expected to translate to a reduction in mortality and improved survival in Nigeria.

Conclusions

Our findings suggest that most adult Nigerian men are ignorant of the prostate gland and its diseases in general, and prostate cancer in particular irrespective of their socio-economic status and level of education. Health education programs are therefore required to increase the awareness of the adult men about this major health issue to reduce the health burden due to the disproportionately high morbidity and mortality from the disease of the gland.