Psycho-Oncology

Pscho-Oncology 21: 457–468 (2012)

Published online 9 September 2011 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/pon.2043

Review

Perceptions of prostate cancer in Black African and Black

Caribbean men: a systematic review of the literature
Vibe Hjelholt Pedersen*, Jo Armes and Emma Ream
Supportive Cancer Care Research Team, Florence Nightingale School of Nursing and Midwifery, King’s College London, UK

*Correspondence to: Abstract

King’s College London, James
Clerk Maxwell Building, 57
Waterloo Road, London, SE1
8WA, UK.
E-mail: vibe.pedersen@kcl.ac.uk
Received: 21 March 2011
Revised: 10 June 2011
Accepted: 1 July 2011
Background: Prostate cancer (PC) is common and affects Black African and Caribbean men
disproportionately more than White men. It is known that PC awareness is low in these groups,
but knowledge is lacking about other factors that may deter Black men from seeking informa-
tion about, or getting tested for, PC. The aim of this review was to appraise research on knowl-
edge and perceptions of PC among Black men.
Methods: Four medical and social science databases were systematically searched, and refer-
ence lists of relevant papers were hand searched. Non-English publications were excluded.
Qualitative findings were synthesised using comparative thematic analysis to which quantitative
findings were integrated.
Results: Thirteen qualitative studies and 20 cross-sectional surveys were included. All except
two were conducted in the USA. The analysis identified individual, cultural and social factors
likely to impact on Black men’s awareness of, and willingness to be tested for, PC. Black men’s
awareness of personal risk of PC varied greatly between studies. Misunderstandings regarding
methods of diagnosis and treatment were widespread. PC testing and treatment were per-
ceived as a threat to men’s sense of masculinity. Mistrust of the health-care system, limited ac-
cess to health care and lack of trusting relationships with health professionals were also
prominent.
Conclusion: The factors impacting on Black men’s awareness of PC may contribute to late
PC diagnosis and should be taken into account when communicating with Black men seeking
prostate care. Further, the review demonstrated a need for high-quality studies in countries
other than the USA to determine the relevance of the review findings for Black men in other
nations and continents.
Copyright © 2011 John Wiley & Sons, Ltd.
Keywords: prostate cancer; oncology; literature review; health attitudes; mixed methods

Introduction PC and available tests. However, according to the

Incidence of prostate cancer (PC) has increased
substantially over the last 20 years with increased
prostate-specific antigen (PSA) testing. Although
PC is a worldwide problem, it is more common
in developed countries [1] and disproportionally
affects Black men more than White men in these
countries [2,3]. In USA, Black men are also at high
risk of dying from PC [4], and annual PC testing is
recommended for Black men over 45 years [5].
Outside the USA, screening for PC is controversial
because of uncertainty over how to treat it best
[6,7], and although recent studies indicate early diag-
nosis and treatment improves outcomes [8,9], the
European Association of Urology does not recom-
mend population screening for PC because of the
great potential for overtreatment [10].
In countries without a screening programme, the
onus is on men to seek testing if they perceive them-
selves at risk of the disease or develop symptoms in-
dicative of PC. Thus, it is important that people at
high risk are aware of their predisposition to develop
Health Behaviour Framework, desired health behav-
iour (e.g. consulting health professionals about PC
testing) is not only dependent on knowledge but is
also influenced by individual factors (e.g. cultural
beliefs) as well as system/societal ones (e.g. physi-
cian’s screening and referral patterns) [11].
Research suggests that attitudes may be as influen-
tial as knowledge on screening behaviour [12–14]. A
recent UK study reported that although both Black
and White men had relatively high knowledge about
main PC risk factors, 20% of the White men but only
5% of the Black men had been tested for PC [15].
Another study reported that Black men were more
embarrassed by their PC symptoms than White
men and were less comfortable in consulting their
doctor about them [16].
Given the greater relative risk of PC in Black men,
these findings indicate that knowledge is indeed not
the only factor influencing Black men’s willingness
to be tested. Health professionals need to appreciate
the complex issues concerning how Black men per-
ceive their personal risk of PC and consider the

Copyright © 2011 John Wiley & Sons, Ltd.

458 V. H. Pedersen et al.

acceptability of diagnostic tests and modes of treat- Inclusion criteria

ment for the disease. Consequently, this review ap-
praised evidence relating specifically to Black men
to answer the following questions:
• What knowledge and perceptions of PC are held
by Black African and Black Caribbean men?
• How do knowledge, individual circumstances
and cultural perceptions influence Black African
and Black Caribbean men’s willingness to be
tested for PC?
• How do knowledge and perceptions of PC
compare between Black and White men?
Materials and methods
To answer the questions above, we reviewed quanti-
tative surveys and qualitative studies examining
perceptions and knowledge of PC held by Black
men and studies exploring their willingness to be
tested for the disease. Papers comparing knowledge
of PC between Black and White men were included.
As routine PC testing is not recommended in many
countries, we excluded studies that focused exclu-
sively on Black men’s attitudes to PC screening.
Studies about PC testing were included only when
they reported findings on knowledge and perceptions
of PC or PC risk.
Search strategy
From the review protocol (contact corresponding
author for details), a search strategy (Figure 1) was
constructed and run in Medline (April week 2,
2010), PsychINFO (April week 2, 2010), CINAHL
(April week 2, 2010) and the Cochrane Database of
Systematic Reviews (1993–2010). Reference lists
of relevant papers were hand searched. V. H. P.
screened titles and abstracts. Relevant papers were
retrieved and reviewed independently by two team
members (V. H. P. and J. A./E. R.).
AND
• English language publications
• Studies using structured questionnaires, indi-
vidual interviews, focus groups and/or observa-
tional methods
• Studies exploring knowledge, awareness and/
or perceptions of PC and PC testing in Black
male adults of African and Caribbean descent
• Studies comparing knowledge, awareness and/
or perceptions of PC and PC testing in Black
and White men
Exclusion criteria
• Studies only examining quality of life in rela-
tion to PC treatment
• Studies only examining uptake of PC screening
among Black men
• Studies only reporting on Black men’s knowl-
edge of the recommendations for PC testing
• Studies not reporting separate findings for each
included ethnic group of participants
Data extraction and quality
Data were extracted systematically on outcomes relat-
ing to knowledge, awareness and/or perceptions of PC
and PC testing among Black men. Study quality was
assessed as recommended by Pluye et al. (2002)
[17]. Data were extracted by V. H. P. and reviewed
independently by E. R. or J. A. Disagreements were
resolved through discussion. No papers were excluded
because of low quality, but results from poorer studies
were given less weight in the discussion.
Synthesis of findings
The aim of this paper was to present an integrated
review of study findings; findings from qualitative
and quantitative studies were incorporated within
AND

Prostatic Neoplasms Caribbean (SH) Perception (SH)

(SH) caribbean region (free text)
prostat* neoplasm* (free West Indies (SH)
text) west indies (free text)
prostat* cancer (free OR French Guiana (SH)
text) French Guiana (free text)
prostat* tumor* (free Guyana (SH)
text) Guyana (free text)
prostat* (free text) African Continental
Ancestry Group (SH)
African Americans (SH)
african caribbean* (free text)
african american* (free text)
non-caucasian (free text)
black* (free text),
Minority Groups (SH)
minority group* (free text)
ethnic minorit* (free text)
Ethnic Groups (SH)
ethnic group* (free text)
Social Perception (SH
perception* (free text)
social perception* (free text)
OR opinion* (free text) OR
Attitude (SH)
attitude* (free text)
Attitude to Health (SH)
attitude* to health (free text)
Social Values (SH)
social value* (free text)
social norm* (free text)
knowledge (SH)
Knowledge (free text)
Culture (SH)
belief* (free text)
understanding* (free text)

Figure 1. Example of search strategy (Medline)

Copyright © 2011 John Wiley & Sons, Ltd. Pscho-Oncology 21: 457– 468 (2012)
DOI: 10.1002/pon
Black men’s perception of prostate cancer
themes. Thematic synthesis was employed to inte-
grate findings from the qualitative research studies.
This enabled analytical abstraction through rigor-
ously comparing and contrasting results across stud-
ies using different methodologies and translating
their findings into descriptive themes [18]. Findings
from quantitative studies were subsequently incorpo-
rated within these themes using the multi-source
synthesis method [19].
Results
The literature search generated 628 citations, 341
were excluded based on titles or abstracts and 254
were duplicates. From hand search of reference lists,
two more papers were included. Two discussion
papers were excluded (Figure 2); thus, 33 papers
were included.
Study characteristics
Of the 33 studies included, 13 used qualitative meth-
ods, whereas 20 adopted a quantitative approach.
Details about methodology, sample size and analysis
are provided in Tables 1 and 2.
Participants
In total, 603 people participated in the qualitative stud-
ies. Sample sizes ranged from 9 [20] to 104 [21], and
participants’ ages ranged from 33 to 80 years. The
quantitative studies incorporated 11 198 people, with
sample sizes varying from 27 [22] to 1866 [16].
Ages ranged from 25 to 80 years. Twelve studies in-
cluded men of non-African/Caribbean descent
[15,16,23–32]. One study included Black Nigerian
Medline: 414 Cinahl: 141 PsychInfo: 73
Total no. of papers
identified: 628
Rejected from Full text retrieved:
title/ abstract: 341 35
Added from hand
search of references: 2
Total reviewed:
37
Excluded after
review: 2
Included in
Qualitative: 13 review: 33 Quantitative: 20
Figure 2. Data retrieval and assessment
Copyright © 2011 John Wiley & Sons, Ltd.
459
men residing in the USA and Black men living in
Nigeria [33]. Three studies incorporated women
[34–36].
Perceptions of prostate cancer and prostate cancer
risk
Analysis of the studies identified various individual
factors and cultural/social factors central to Black
men’s knowledge and perceptions of PC.
Individual factors
Knowledge on the prostate gland, prostate cancer
symptoms and prostate cancer risk
Black men typically displayed little knowledge
about the prostate gland [25,28,37–40]. However,
some evidence suggested that they were relatively
more knowledgeable about PC itself, particularly
men who were educated to graduate level [34], lived
in urban areas [22] and were older [41,42]. The US
studies reported high awareness of PC symptoms
among Black men [28,34,40]. Knowledge of PC risk
factors varied; some reported high awareness of the in-
creased risk of PC for Black men [23,27,28,34],
whereas others reported low awareness of all main
risk factors; race, age and family history of PC
[15,16,37,38,41,42]. Hard work, stress, drinking in-
sufficient water, unhealthy diet and lack of exercise
were cited as risk factors [16,21,34,35,38,43], as
were sexually transmitted diseases, urinary tract
infections and too much or too little sexual activity
[21,27,28,37]. Studies comparing Black and White
men reported that Black men had less general knowl-
edge about PC and identified fewer PC symptoms
[15], whereas findings regarding awareness of PC
risk for Black men varied. One study reported that
Black men were more aware of this risk [23],
Cochrane: 0
whereas another reported the opposite [32] and a
third reported equally low knowledge across both
groups [15,16].
Knowledge on diagnostic tests and treatment
Knowledge of diagnostic tests for PC varied
considerably between studies but appeared in two to
Duplicates:
254 be associated with testing rates [44,45]. Across a num-
ber of studies, Black men had a high level of under-
standing regarding the PSA test and digital rectal
examination (DRE) [21,27,28,31,34,39]. However,
in others, knowledge of these procedures was poor
[28,39,41,42]. Concerning PC treatment options,
some participants believed that surgery was the only
treatment available [34,42] or that surgery typically
entailed castration and consequential impotence
[42]. Fear of pain, reduced libido and impaired urinary
control were prevalent in three studies [37,39,43].
One US study reported the majority of Black men
who believed PC could be cured if detected early
[43], whereas a UK study suggested that more White
(93%) than Black (74%) men held this belief [15].
Pscho-Oncology 21: 457– 468 (2012)
DOI: 10.1002/pon
 Table 1. Qualitative studies
Study
Allen et al. [37]
Blocker et al. [34]
Copyright © 2011 John Wiley & Sons, Ltd.
Clarke-Tasker and Wade [41]
Forrester-Anderson et al. [21]
Friedman et al. [38]
Hughes et al. [35]
Maliski et al. [25]
McFall et al. [27]
Pscho-Oncology 21: 457– 468 (2012)
DOI: 10.1002/pon
460
Country Sampling Methods N Participants Findings Quality
USA Purposive FGs, interviews, thematic analysis 65 Black men - # PC knowledge and PC risk factors Fair
- Misunderstand tests and treatments
- Impact PC, DRE on masculinity
- Cancer taboo
- Mistrust of HPs
- Limited health-care access
- Doctors unresponsive to men’s needs
USA Convenience FGs, thematic analysis 29 M: 14, F: 15 Black - Some knowledge of PC symptoms, PSA, DRE Fair
- Impact PC, DRE on masculinity
- Cancer taboo
- Mistrust of HPs
- Limited health-care access
- Religion/fatalism
- Doctor prompts testing
USA Purposive FGs, content analysis 12 Black men - Older men " knowledge of PC Low
- # Knowledge of PC risk factors, DRE
- # Understanding of own risk
- Impact PC, DRE on masculinity
- Mistrust of HPs
USA Purposive FGs, thematic analysis 104 Black men - Some knowledge of PC risk factors Fair
- # Knowledge of PSA, DRE
- Impact PC, DRE on masculinity
- Cancer taboo
Mistrust of HPs
- Limited health-care access
- Knowing someone with PC promotes testing
USA Purposive Interviews, FGs, thematic analysis, health literacy theory 25 Black men - Some knowledge of PC risk factors High
- Fear inhibits information seeking
- Limited health-care access
- Cancer taboo
- Culturally specific information important
USA Random FGs, content analysis 91 M: 54, F: 37 Black - # Knowledge of risk factors Low
- Impact PC, DRE of masculinity
- Cancer taboo
- Mistrust of HPs
- Celebrity endorsement, spouses prompt testing
USA Convenience FGs 41 Black, Filipino, Chinese and White men - # Knowledge of PC High
- Some knowledge of Black race and genetic risk factors
- # Knowledge of treatment options (except surgery)
- Cancer taboo
USA Convenience FGs 90 Black, Hispanic and White men - Some knowledge of PC symptoms, PSA, DRE and PC risk factors High
- Cancer taboo
- Believe early detection improves treatment outcomes
V. H. Pedersen et al.
 Nash and Hall [28]
Oliver [20]
Richardson et al. [42]
Copyright © 2011 John Wiley & Sons, Ltd.
Sanchez et al. [39]
Wray et al. [36]
Woods et al. [40]
FG, focus group; HP, health-care professional; PC, prostate cancer; DRE, digital rectal examination; F, female; M, male; PSA, prostate-specific antigen.
DOI: 10.1002/pon
Pscho-Oncology 21: 457– 468 (2012)
USA Convenience FGs, Health Belief Model 37 43% Black, 57% White - Some knowledge of PC, symptoms, tests, Black race and treatments Low
- Impact PC, DRE on masculinity
- Cancer taboo
- Preventive health checks not routine
- Limited health-care access
- Spouses, friends and relatives prompt testing
USA Convenience Interviews, content analysis 9 Black men - # Knowledge of PC symptoms High
- Impact PC, DRE on masculinity
- Cancer taboo
- Mistrust of HPs
- Limited health-care access
- Doctors difficult to understand
USA Convenience FGs, pattern and thematic analysis 15 Black men - # Knowledge of PC symptoms, PSA Fair
- Some knowledge of genetic risk, treatments and side effects
- Impact PC, DRE on masculinity
- Cancer taboo
- Limited health-care access
USA Convenience FGs, descriptive analysis 31 Black men - # Knowledge of PC symptoms and risk factors Fair
- Some knowledge of PSA, DRE, treatment, side effects
Black men’s perception of prostate cancer
- Impact PC, DRE on masculinity
- Cancer taboo
- Mistrust HPs
- Limited health-care access
- Religion versus stigma of testing
- Knowing PC sufferer promotes testing
USA Convenience FGs 79 M and F, all Black (no’s not reported)- # Knowledge of PC symptoms, risk factors, diagnostic tests and treatment methods Low
- Impact PC, DRE on masculinity
- Cancer taboo
- Mistrust of HPs
- Limited health-care access
USA Convenience Interviews, FGs, grounded theory 277 All Black men - # Knowledge of PC, PC treatment High
- " Knowledge of symptoms (81%)
- Insecurity about personal risk (50%), # risk (78%)
- 45% unaware of PSA, 27% unaware of DRE
- Early diagnosis improves outcome: 94%
- Impact PC, DRE on masculinity
461
 Table 2. Quantitative studies
462

Study Country Design Sampling N Methods Participants Findings Quality

Agho and Lewis [49] USA Cross-sectional Convenience 108 Survey, ANOVA, Pearson Z-scores Black men - Young men " knowledge High
about age, Black race, PC
tests, symptoms and
treatment
- Urban men " knowledge
than rural men
- # Education and income;
# knowledge
Clarke-Tasker USA Cross-sectional Convenience 67 Survey regression analysis Black men - Knowledge of Black race as risk: High
and Dutta [46] 85%

Copyright © 2011 John Wiley & Sons, Ltd.

Demark-Wahnefried et USA Cross-sectional
al. [23]
Fearing et al. [43] USA Cross-sectional
Jones et al. [24] USA Cross-sectional Random digit dialling 235
- PC tests embarrassing/
painful: 9–38%
- Rather not know the
diagnosis: 30%
- Get tested if free: 70%
- At risk of PC: 31%
Convenience 1504 Interviewer admin. survey, 19% Black, 81% White - PC asymptomatic: 54% B, Fair
logistic regression, Cochran– men 71% W
Mantel–Haenszel test - Hereditary: 41% B,
56% W
- Black race: 53% B, 33% W
- Own risk " average: 8%, as
average: 68%
- PC curable if found early:
91–95%
- Doctor never mentioned
PC tests: 72%
Convenience 59 Self-admin. survey Black men - " Knowledge of Low
genetic risk: 67%
- Own risk " average: 50%
- Worry about PC: 32%
- PC impair sexual function:
64%
- Comfortable talking to
GP: 57%
- Faith = health behaviour:
50%
Telephone survey, Cochran–Mantel–Haenszel test 42% Black, 58% White - Knowledge of risk: age: 67% Low
men B, 86–94% W, Black race:
70% all urban, 49–39%
B–W rural
- Black urban: 37% medium
risk, 33% low risk
V. H. Pedersen et al.

Pscho-Oncology 21: 457– 468 (2012)

DOI: 10.1002/pon
 - Black rural: 30% medium
risk, 15% low risk
Magnus [51] USA Cross-sectional Convenience 521 Interviewer admin. survey, ANOVA Black men - Knowledge of risk: Black High
race: 51%
McCoy et al. [26] USA Cross-sectional Random digit dialling 897 Telephone survey Black, Hispanic and - DRE uncomfortable: 72% Fair
White men B, 62% W
- DRE embarrassing: 41% B,
37% W
- Early diagnosis improves
outcome: 52% B, 68% W
- Doctor could be more
respectful: 36% B, 18% W
- No insurance: 2%

Copyright © 2011 John Wiley & Sons, Ltd.

- Costs too much: 5%
Metcalfe et al. [16] UK Cross-sectional Purposive 1866 Interviewer admin. survey logistic, multivariate and 39% Black, 61% White - Knowledge of risk: age: High
multinomial regression men 66% B vs 85% W, genetic:
45% B vs 37% W
- Symptoms embarrassing:
33% B vs 25% W
Black men’s perception of prostate cancer

- Dislike seeing doctor: 20%

B vs 14% W
Odedina et al. [33] USA, Cross-sectional Convenience 249 Interviewer admin. survey Black men: N = 121 US, US and NI men: High
Nigeria - Positive attitudes to PC
testing
N = 128 Nigeria - # Knowledge of PC
- " Worry about PC
- # Perceived risk of PC
Price et al. [47] USA Cross-sectional Convenience 321 Interviewer admin. survey, ANOVA Black men - Knowledge of genetic High
risk: 33%
- Early diagnosis improves
outcome: 83%
- Uncomfortable exam:
13%
- PC fatal: 45%
- PC fear prevent test: 19%
Pruthi et al. [29] USA Cross-sectional Purposive 112 Telephone survey, various statistical tests and logistic 42% Black, 58% White Brothers of men with PC: Fair
regressions - 60% no increased
knowledge
- 85% had not commenced
screening
Rajbabu et al. [15] UK Quasi-experiment—post- Convenience 871 48-item validated questionnaire 53% White, 47% Black Non-information group: Fair
test only - Unaware of PC: 63% B,
48% W
- White men identified
greater number of symptoms
(mean 2.5 vs 1.6; p < 0.001)
463

DOI: 10.1002/pon
Pscho-Oncology 21: 457– 468 (2012)
 Table 2. Continued
Study Country
Ross et al. [44]
Copyright © 2011 John Wiley & Sons, Ltd.
Shavers et al. [30]
Smith et al. [50]
Spain et al. [31]
Steele et al. [45]
Talcott et al. [32]
Watts [22]
Weinrich et al. [52]
ANOVA, analysis of variance; W, White; B, Black; PC, prostate cancer; GP, general practitioner; DRE, digital rectal examination; NI, Nigerian; PSA, prostate-specific antigen.
Pscho-Oncology 21: 457– 468 (2012)
DOI: 10.1002/pon
464
Design Sampling N Methods Participants Findings Quality
- Knowledge of risk: Black
race: 18% (control group)
- Early diagnosis improves
outcomes: 93% W, 74% B
- PC will change close
relationships: 55% W, 70% B
- Better not to know if had
PC: 12–13% W–B
USA Cross-sectional Subsample of national 736 Interviewer admin. survey, Wald w2 test, odds ratios Black men - Aware of PSA: 63% B High
survey
USA Cross-sectional Random digit dialling 1075 Telephone survey, multivariate logistic regression analyses 9% Black, 91% White Black men: High
and Hispanic - Knowledge of risk: Black race: 68%
- Low–medium risk: 50%
- Risk " average: 18%
USA Cross-sectional Purposive 897 Interviewer admin. survey Black men - Knowledge of genetic risk: 42% Fair
- Knowledge of risk: Black race: 30%
USA Cross-sectional Purposive 555 Telephone survey, multivariate logistic regression 63% White, 37% Black - Underestimate own risk: 19% B vs 9% W High
- Avoid PC test because of fear: 75% B vs 57% W
- Trust physician: 86% B vs 90% W
- # Trust versus diagnosed symptomatically:
p > 0.05
USA Cross-sectional Random digit dialling 742 Telephone survey Black men - Own risk medium to low: 42% High
Logistic regression - Not at risk: 16%
- Heard of PSA: 43%
USA Longitudinal (same sample Purposive (555) Telephone survey 63% White, 37% Black - Own risk small: 46% B vs 58% W High
as Spain et al 2008) - Rather not know PC status: 43% B vs 21% W
- Delay test because of fear: 76% B vs 57% W
- Trust GP: 85% B vs 90% W
USA Exploratory descriptive Convenience 27 Self-admin. survey, Pearson product–moment correlations Black men - " Knowledge of all symptoms and risk of Black Low
race
- " Worry about PC
- Impact PC, DRE on masculinity
- Treatment leads to
sexual problems
- Limited health-care access
USA Cross-sectional Random 79 Telephone survey, ANOVA and Wilcoxon non-parametric statistics Black men - Knowledge of risk of having brother with PC: Low
80%
- Knowledge of risk of having >3 family members
with PC: 82%
V. H. Pedersen et al.
Black men’s perception of prostate cancer
Patient–provider communication
Arguably, health professionals’ communication skills
could influence whether men with PC symptoms seek
care. A number of studies suggested better communi-
cation between health providers and patients as a way
of improving Black men’s understanding of PC and
promoting PC testing [20,31,36,37,39,40]. One study
described Black men as passive in their interactions
with health-care providers concerning PC [37]. Fur-
ther, some Black men appeared to have received lim-
ited information about PC from their physician
[21,41] or perceived that physicians are unwilling
to help them and their partners fully understand PC
[35]. In one study, a substantial number of Black
men who had been tested for PC had not received
an explanation regarding why they had taken a
PSA test (43%) or DRE (58%) [40].
Perception of personal risk
The majority of respondents in studies examining
Black men’s perceptions of personal risk did not ap-
pear to perceive themselves as particularly suscepti-
ble to PC [40,43,46]. One study revealed that
Black urban men underestimated their risk more than
Black rural men [24]. Studies comparing Black and
White men reported that Black men worried more
than White men about developing PC [32] and when
experiencing symptoms, worried more that they may
be because of something serious [16]. However,
Black men’s assessment of personal risk was found
to be more inaccurate than that of White men [31].
Other individual factors
Individual factors suggested by study authors as poten-
tially influencing Black men’s willingness to be tested
for PC included having a friend or family member with
PC and/or having previously been tested for the disease
[21,39], as well as being prompted by a friend, fam-
ily member, partner or doctor to be tested [35,40,44].
A potential deterrent to PC testing was found in a
UK study in which 70% of Black participants feared
PC would change their close relationships with their
spouse and family, compared with 55% of White
participants [15].
Sociocultural factors
Threat to masculine identity
A dominant theme was the association of DRE with
homosexuality and violation; Black men sampled tended
to perceive the test as a threat to their masculine identity
[20,25,28,34–37,39,41,42] and consider it a painful
and undignified procedure [20,21,28,34,36,42]. Fear
of erectile dysfunction, sterility and decreased sex
drive associated with treatment were also identified
as potentially deterring men from being tested for
PC [22,40,43,47]. Studies comparing Black and
White men reported higher levels of fear and embar-
rassment regarding PC testing in Black men, even
Copyright © 2011 John Wiley & Sons, Ltd.
465
when doctors attempted to minimise embarrassment
and physical discomfort [16,25,26,28,32].
Fear of cancer
Perceptions of PC as a death sentence and/or a taboo
topic were prevalent [20–22,25,28,34,35,37,39,42].
In one study, 45% of Black respondents believed
that PC could be fatal, and 19% had abstained from
seeking care because of fear, despite experiencing
urinary symptoms [47].
Mistrust of the health-care system
Another prevalent theme was general mistrust in the
health-care system. Nearly 40% of respondents in
one study felt that the US health-care system did
not help Black men, and 45% believed that they re-
ceived poor quality health care because of their race
[40]. The Tuskegee syphilis study [48] was men-
tioned in support of this belief [20,35,37]. Trusting
relationships with health-care providers also appeared
important; Black men who trusted their physician
were more likely to have regular prostate examina-
tions and had lower risk of being diagnosed symp-
tomatically [31]. Unfortunately, one UK study
found that Black men generally disliked seeing their
doctor more than White men [16].
Culturally specific information
The importance of culturally relevant information
and media messages was emphasised in both qualita-
tive [20,25,35,37,38,40] and quantitative studies
[24,26,49,50]. One study advocated verbal (rather
than printed) information provided by respected
members of the Black community to promote PC
testing [40], whereas another proposed celebrity en-
dorsement of PC testing [35].
Other sociocultural factors
A lack of tradition in Black communities concerning
regular medical check-ups or preventive care was
prevalent [20,21,28,36,37,42]. Tendencies for Black
men to prioritise work and caring for their families
over taking time for medical check-ups were re-
ported [28,39,42]. Religious fatalism was identified
as a possible barrier in two studies [28,34], although
this was not examined systematically in any of the
reviewed studies. Limited access to health care im-
pacted on US Black men and influenced both the ser-
vices and the information they could access
regarding PC [20,21,28,34,36–38]. Some studies
suggested practical initiatives to increase access to
PC health services, for instance, providing free
PSA testing [22,26,32,36,50] at easily accessible
venues [35,37]. Public health initiatives that estab-
lished long-lasting partnerships between PC service
providers and community leaders were considered
important to create trusting relations with Black
communities [37].
Figure 3 provides an overview of the most consis-
tently identified themes from this review impacting
Pscho-Oncology 21: 457– 468 (2012)
DOI: 10.1002/pon
466
Access to health care
Knowledge of risk, symptoms,
diagnostic methods and treatment
Perception of
personal risk
Doctor-patient Willingness
communication/ trust
Friend/ relative
previously screened
Prompt by doctor/
relative/ partner
Social factors
Individual factors
Cultural factors
Suggested factors; not systematically examined
Figure 3. Overview of themes associated with willingness to have prostate cancer test
on Black men’s willingness to undergo PC testing.
Arrows represent associations between variables
as presented in the literature. This illustrates a com-
plex interplay between individual and cultural factors,
which impact on how willing Black men are to have
PC tests.
Discussion
This review identified poor PC knowledge across all
groups of men, but particularly in Black men. Under-
standing of personal risk was inaccurate and varied
across studies. This could be associated with access
to health care, as most studies were conducted in
the USA, where private health insurance regulates
access. Fears and taboos associated with PC as well
as historical mistrust in health professionals may
also impact men’s willingness to discuss PC with
health professionals.
The review findings suggest that efforts should be
made to increase awareness of PC in all men—irre-
spective of ethnicity. Black men bear the highest
burden of the disease [2,4,5], yet limited efforts have
been made to ensure they have access to relevant in-
formation to support informed decisions about PC
testing. Little is known about where Black men
access PC information. More innovative services
may be needed to facilitate their access to PC infor-
mation and health services. For instance, drawing
on local ‘champions’, that is, Black men living with
PC, to raise awareness and support men in making
informed choices regarding PSA testing, or provid-
ing culturally relevant PC information and testing
services in venues accessible and acceptable to
Black communities.
Copyright © 2011 John Wiley & Sons, Ltd.
V. H. Pedersen et al.
Income, education
Culturally relevant
information materials
Priority of work/
family needs
Fear of emasculation
to have
Preventive care
PC tests
not routine
Fear of death/ cancer
Religious fatalism
Mistrust in HC system
The main limitation of the review is that most
studies were conducted in the USA. Differences be-
tween the USA and other nations’ health systems re-
garding access to care and national guidelines for PC
testing make it difficult to transfer findings from this
review outside the USA. Another important limita-
tion is that 45% of reviewed studies were of low
quality; small samples, limited information on data
analysis and response rates and lack of demographic
characteristics of the sample were common. Only a
third of US studies reported health insurance held
by study participants; those that did revealed most
participants (60% to 98%) were insured. This sug-
gests relatively affluent samples that may not repre-
sent the US Black male population. Thus, it may
be impossible to draw conclusions about all factors
influencing Black men’s perception of PC and PC
testing, such as the impact of limited health insur-
ance cover. Finally, relationships between knowl-
edge and perceptions of PC and uptake of testing
for PC were not examined in detail. The review thus
identifies perceptions and factors likely to impact
Black men’s willingness to be tested (Figure 3), but
it cannot conclude with confidence the impact of
these on behaviour.
The strength of the review is that the majority of
identified themes are present in a large number of
studies, indicating robustness of its findings. Find-
ings from quantitative and qualitative studies
broadly agree, further confirming this. However,
perceptions and knowledge of men outside the
USA regarding PC are clearly under represented
within the review. Although results from two UK
studies broadly reflected those from the USA, this
evidence is not substantial enough to determine
how barriers such as fear of cancer, perceived threat
Pscho-Oncology 21: 457– 468 (2012)
DOI: 10.1002/pon
Black men’s perception of prostate cancer
to masculine identity or patient–provider relations
impact on Black African and Caribbean men’s use
of prostate services outside the USA. This review
thus highlights a need for high-quality studies inves-
tigating perceptions of PC among Black men in
nations other than the USA.
Acknowledgements
This article was funded in part by a grant from The Prostate
Cancer Charity. As this article describes a systematic review of
the literature, no ethical approval was needed for the study.
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