USF Libraries
USF Digital Collections

Prostate cancer screening intention among African American men

MISSING IMAGE

Material Information

Title:
Prostate cancer screening intention among African American men an instrument development study
Physical Description:
Book
Language:
English
Creator:
Baker, Susan Anita
Publisher:
University of South Florida
Place of Publication:
Tampa, Fla
Publication Date:

Subjects

Subjects / Keywords:
Health beliefs
Fatalism
Health promotion
Planned behavior
Knowledge
Dissertations, Academic -- Nursing -- Doctoral -- USF   ( lcsh )
Genre:
non-fiction   ( marcgt )

Notes

Summary:
ABSTRACT: Cancer is the second leading cause of death in the United States. Prostate cancer is the leading cause of cancer deaths among African American men, and African American men have the highest incidence of prostate cancer in the world. Limited studies have been conducted that address this critical issue. Existing literature reveals that the primary cause of increased mortality rates of prostate cancer in African American men is lack of participation in prostate cancer screening activities. The purpose of this three-phase study was to develop a valid and reliable instrument to measure prostate cancer screening intention among African American men. Three gender-specific focus groups were conducted in the first phase of the study. Twenty men from two north Florida churches participated in the focus groups.Eight dominant themes emerged from the focus groups and were utilized to develop the items for the intention instrument: fear, healthy lifestyle, hopelessness/helplessness, machismo, mistrust of healthcare providers, social/familial support, job requirements and transportation barriers. The second and third phases of the study consisted of development of the instrument and assessment of the instrument for validity and reliability. The Cancer Screening Intention Scale-Prostate (CSIS-P) consists of 43 items and was developed utilizing the results of the focus groups. The reading level of the CSIS-P was 5.6 utilizing the Flesch-Kincaid index and 7.0 utilizing the SMOG Readability Formula. The CSIS-P was assessed for content validity by a panel of oncology experts. The content validity index for the scale was .90 and internal consistency was found to be .92. The CSIS-P was evaluated for construct validity utilizing factor analysis techniques.Test-retest procedures were also conducted to assess stability of the CSIS-P and the reliability coefficient was .93. Factor analysis techniques demonstrated a three-structure model. The factors that emerged were benefits to prostate cancer screening, barriers to prostate cancer screening, and health promotion. The internal consistency of the three factors were found to be .88, .81, and .86 respectively. Factor analysis procedures reduced the CSIS-P to a 17-item scale. The CSIS-P is a parsimonious, culturally sensitive instrument that is valid and reliable in assessing prostate cancer screening intention. Recommendations for future study of the instrument include replication of the study with a more heterogeneous sample and utilization of the scale with other cancers.
Thesis:
Dissertation (Ph.D.)--University of South Florida, 2008.
Bibliography:
Includes bibliographical references.
System Details:
Mode of access: World Wide Web.
System Details:
System requirements: World Wide Web browser and PDF reader.
Statement of Responsibility:
by Susan Anita Baker.
General Note:
Title from PDF of title page.
General Note:
Document formatted into pages; contains 136 pages.
General Note:
Includes vita.

Record Information

Source Institution:
University of South Florida Library
Holding Location:
University of South Florida
Rights Management:
All applicable rights reserved by the source institution and holding location.
Resource Identifier:
aleph - 002046176
oclc - 495698874
usfldc doi - E14-SFE0002694
usfldc handle - e14.2694
System ID:
SFS0027011:00001


This item is only available as the following downloads:


Full Text

PAGE 1

Prostate Cancer Screening Inten tion Among African American Men: An Instrument Development Study by Susan Anita Baker, MS, RN A dissertation submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy College of Nursing University of South Florida Major Professor: Susa n McMillan, Ph.D, ARNP Janine Overcash, Ph.D, ARNP Cathy Meade, Ph.D, RN Brent Small, Ph.D Date of Approval: November 12, 2008 Keywords: health beliefs, fatalism, hea lth promotion, planned behavior, knowledge Copyright 2008, Susan A. Baker

PAGE 2

Dedication This work is dedicated to my parents, Earl and Lucy Baker. Thank you for your never-ending faith in me and in my work. Y ou have been an invaluable support to me. Your love and prayers have kept me throughout this journey and I will be eternally grateful for that.

PAGE 3

Acknowledgements I would like to thank the following individuals for thei r guidance and direction along this dissert ation journey: My Lord and Savior Jesus Christ who ma kes all things possible and whom I am nothing without. My family for their many prayers, un conditional love, and constant support. The Elizabeth Popular Spring P. B. Chur ch family for their participation and prayers. The Tabernacle M.B. Church family for their participation and prayers. The St. John Progressive M.B. Church Br otherhood for their participation and prayers. Dr. Janine Overcash for participating on my dissertation committee. Dr. Cathy Meade for participating on my dissertation committee. Dr. Brent Small for participating on my dissertation committee. Dr. Susan McMillan for her expert guid ance, continued patience, never-ending support, and unwavering friendship th roughout this learning experience.

PAGE 4

i Table of Contents List of Tables iv List of Figures vi Abstract vii Chapter OneIntroduction 1 Statement of the Problem 4 Research Questions 5 Definition of Terms 5 Significance of the Study to Nursing 6 Chapter TwoReview of Literature 7 Prostate Cancer Knowledge, Informed Decision-Making, and Screening 7 Health Belief Model 18 Health Belief Model and Prostate Cancer Screening 19 Fatalism 30 Fatalism, Cancer, and African Americans 30 Health Promotion 40 Health Promotion and Cancer 41 Theory of Planned Behavior 43 Theory of Planned Behavior and Health Behaviors 44 Theory of Planned Behavior and Cancer Risk Reduction 51 Summary 55 Chapter ThreeMethods Phase One 60 Purpose 60 Sample 60 Procedures 61 Data Analysis 63 Phase Two 63 Purpose 63 Sample 64 Instrument 65 Content Validity 66 Procedures 66

PAGE 5

ii Data Analysis 67 Phase Three 67 Purpose 67 Sample 68 Instruments 68 Demographic Questionnaire 68 Prostate Cancer Knowledge Scale 68 Cancer Screening Intention Scale-Prostate 69 Prostate Cancer Belief Scale 69 Powe Cancer Fatalism Index 70 Health Promoting Lifestyle II 70 Procedures 71 Data Analysis 71 Chapter FourResults 73 Phase One 73 Sample 73 Data Analysis 74 Results 74 Phase Two 79 Sample 79 Data Analysis 79 Results 80 Phase Three 81 Sample 81 Instruments 83 CSIS-P 83 Prostate Cancer Knowledge Questionnaire 83 Prostate Cancer Belief Scale 84 Powe Cancer Fatalism Index 85 HPLP II 85 Construct Validity: Correlation with Other Measures 87 Construct Validity: Factor Analysis 90 Reliability 96 Chapter FiveDiscussion 98 Phase One 98 Sample 99 Data Analysis 99 Results 99 Phase Two 100

PAGE 6

iii Sample 101 Data Analysis 101 Results 101 Phase Three 102 Sample 102 Instruments 103 CSIS-P 103 Prostate Cancer Knowledge Questionnaire 103 Prostate Cancer Belief Scale 103 Powe Cancer Fatalism Index 104 HPLP II 104 Construct Validity: Correlation with Other Measures 105 Construct Validity: Factor Analysis 106 Summary 107 Implications for Nursing 107 Recommendations for Future Research 108 References 109 Appendices 120 Appendix A: Letter of Support 121 Appendix A: Letter of Support 122 Appendix B: Institutional Re view Board Approval 123 Appendix C: Demographic Questionnaire 124 Appendix D: Focus Group Questions 125 Appendix E: Cancer Screening In tention Scale: Prostate 126 Appendix F: Prostate Cancer Knowledge Questionnaire 131 Appendix G: Prostate Cancer Belief Scale 132 Appendix H: Powe Fatalism Index 134 Appendix I: Health Promoting Lifestyle Profile II 135 About the Author End Page

PAGE 7

iv List of Tables Table 1 Number and Percent of Men by Age and Education 74 Table 2 Focus Group Themes by Frequency 75 Table 3 Number and Percent of Men by Age, Marital Status, and Education 82 Table 4 Number and Percent of Men Re porting Previous Pros tate Cancer Screening 82 Table 5 Prostate Cancer Screen ing Intention Scores 83 Table 6 Frequency and Percent of Corr ect Responses to Prostate Cancer Knowledge Questions 84 Table 7 Prostate Cancer Belief Sc ores by Number and Percent 84 Table 8 Frequency and Percent of Pros tate Cancer Fatalism Scores 85 Table 9 HPLP II Subscale Means and Standard Deviations 85 Table 10 Correlations Among Demographi cs, Knowledge, Healthy Lifestyle, and Fatalism 87 Table 11 Health Promotion Correlations 89 Table 12 Correlations be tween Independent Variab les and Intention 89 Table 13 Variance Explained by Extracted Factors 90 Table 14 Factor Loadings 91 Table 15 CSIS-P Items and Corresponding Factor Loadings 92 Table 16 Means and Standard Deviat ions of Reduced CSIS-P 93 Table 17 Factor Loadings of Reduced CSIS-P 94 Table 18 Correlations between Independent Variables and Revised Intention Scale 96

PAGE 8

v Table 19 Factor Coefficient Alphas 96 Table 20 Reliability Results with Reassigning Multiple-Loading Items 97

PAGE 9

vi List of Figures Figure 1. Prostate Cancer Scr eening Intention Model 56

PAGE 10

vii Prostate Cancer Screening Intention Among African American Men: An Instrument Development Study Susan Anita Baker ABSTRACT Cancer is the second leading cause of deat h in the United States. Prostate cancer is the leading cause of ca ncer deaths among African American men, and African American men have the highest incidence of prostate cancer in the world. Limited studies have been conducted that address this critical issue. Existing literature reveals that the primary cause of increased mortality rates of prostate cancer in African American men is lack of participation in prostate cancer screening ac tivities. The purpose of this three-phase study was to develop a valid and reliable instrument to measure prostate cancer screening intention am ong African American men. Three gender-specific focus groups were c onducted in the first phase of the study. Twenty men from two north Florida churches participated in the focus groups. Eight dominant themes emerged from the focus groups and were utilized to develop the items for the intention instrument: fear, healthy lifestyle, hopelessness/he lplessness, machismo, mistrust of healthcare providers, social/familial support, job requirements and transportation barriers. The second and third phases of the st udy consisted of development of the instrument and assessment of the instrument for validity and reliability. The Cancer Screening Intention Scale-Pros tate (CSIS-P) consists of 43 items and was developed

PAGE 11

viii utilizing the results of th e focus groups. The reading level of the CSIS-P was 5.6 utilizing the Flesch-Kincaid index and 7.0 utilizing the SMOG Readability Formula. The CSIS-P was assessed for content validity by a panel of oncology expe rts. The content validity index for the scale was .90 and inte rnal consistency was found to be .92. The CSIS-P was evaluated for construct validity ut ilizing factor analysis techniques. Testretest procedures were also conducted to assess stability of the CSIS -P and the reliability coefficient was .93. Factor analysis techniques demonstrated a three-structure model. The factors that emerged were benefits to prostate cancer sc reening, barriers to pros tate cancer screening, and health promotion. The internal consistenc y of the three factors were found to be .88, .81, and .86 respectively. Factor analysis pr ocedures reduced the CSIS-P to a 17-item scale. The CSIS-P is a parsimonious, culturally sensitive instrument that is valid and reliable in assessing prostate cancer screen ing intention. Recommendations for future study of the instrument include replicati on of the study with a more heterogeneous sample and utilization of the scale with other cancers.

PAGE 12

1 Chapter One Introduction Cancer is the second leading cause of death in the United States. More than 1,437,180 new cases develop annually (America n Cancer Society, 2008) and nearly 152,900 of these new cases are in African Americans. Approximately 62,780 African Americans die from cancer each year (Ameri can Cancer Society, 2007). Overall, the cancer mortality rate is 30% higher in African Americans than in Caucasians (American Cancer Society, 2005). These alarming statis tics have initiated many research programs related to cancer incidence and mortality in African Americans. The statistics related to incidence and mortality rates of prostate cancer are equally alarming. Approximately 186,320 new cases of prostate cance r are expected to develop annually (American Cancer Society, 200 8). The incidence and mortality rates of prostate cancer among African Am erican men are even more disturbing. Prostate cancer is the most commonly diagnosed cancer in African American males (American Cancer Society, 2007), and cancer statistics show th at African American men have the highest incidence of prostate cancer in the world at 272.0 per 100,000. This is compared to an incidence rate of 169.0 per 100,000 among Cau casian men (American Cancer Society, 2006). It also has been reporte d that African American men are at least 50% more likely to develop prostate cancer than men of any other racial and ethnic group.

PAGE 13

2 Reports of survival rates also indicate a disparity when African American men are compared to Caucasian men. Cancer mortal ity rates among African American men (68.1 per 100,000) have been reported to be more th an twice as high as those among Caucasian men (27.7 per 100,000) (American Cancer Society, 2005). Consistent screening for cancer has been shown to improve cancer incidence and mortality rates. However, only small percen tages of the general population participate in cancer screening. For example, amo ng a group of 6,895 women, only 30.2 percent reported recent use of available cancer screenings. Also, among a group of 4,784 men, only 37.1 percent reported recent us e of available cancer screen ings. When ethnicity is delineated, rates of cancer screening part icipation among African Americans remain lower than among Caucasians (Breen, Wage ner, Brown, Davis, and Ballard-Barbash, 2001). Weinrich, Weinrich, Boyd, and Atkinson (199 8) maintain that one explanation for the racial differences in mo rtality is lack of knowledge regarding prostate cancer screening and lack of participation in the sc reening procedures. Th ese investigators found that among 319 African American men who part icipated in the study, only 14 percent of the participants reported a high level of knowledge about prostate cancer. Eighty-two percent of the men reported that they had neve r heard of prostate sp ecific antigen (PSA) and digital rectal examination (DRE), the diagnostic tests fo r early detection of prostate cancer. Implications also have been found rega rding the relationship between literacy levels and health seeking behaviors. Nearly 44 million people in the United States (U.S.) have insufficient basic reading skills (Kirsc h, Jungeblut, Jenkins, and Kolstad, 1993).

PAGE 14

3 Follow-up studies done in 2003 with a smaller database show no significant improvement in literacy levels. A report by the National Center for Education Statistics ( www.nces.ed.gov ) estimates that 46 to 51% of adu lts in the United States have poor reading skills. When exploring the associa tion between literacy levels and health in African Americans, it was reported that more than 80 percent of African Americans have difficulty reading and understa nding health-related materials, a concept termed health literacy. Research conducted by Bennett et al. (1998) discov ered that low levels of literacy were a barrier to early prostate cancer screening. In this study, men who had been diagnosed with advanced prostate cance r were found to have literacy levels below sixth grade. Consequently, instruments and wr itten materials related to health promotion behaviors and health screening activities must be developed at a reading level that is appropriate for the targeted population. Few studies exist that examine the reas ons for lack of knowledge and lack of participation of African American men in pr ostate cancer screening procedures. In order for the National Cancer Institute to reach its’ goal of decreasing cancer incidence by 50 percent by the year 2010 (www.healthypeop le.gov), the disturbing prostate cancer incidence and mortality rates in African Am erican men as well as the underlying causes of these rates must be addre ssed. Health care related discip lines must discover the factors that influence participation of African American men in prostate cancer screening procedures and develop interven tions that incorporate these factors. These measures may in turn lead to increased participation in sc reening activities in this high-risk group. Also, the current position of many health care pr oviders regarding informed decision-making

PAGE 15

4 and the effectiveness of pr ostate cancer scr eening methods (Lim, Sherin, ACPM Prevention Practice Committee, 2008) adds to the complexity of this issue. Statement of the Problem Although prostate cancer knowledge and partic ipation in screeni ng procedures is disproportionately low in African American men, limited studies exist that examine the reasons for this phenomenon. Though instrume nts have been developed to assess screening intention (Ajzen and Fishbein, 1980; Ajzen, l991), few of these instruments utilized African American me n as study participants. Studi es also have been conducted that examine screening behaviors (Godi n and Kok, 1996; Dozier, 1999; Weinrich, Weinrich, Priest, and Fodi, 2003). However, fe w of these studies have included African American men as primary study participants The primary purpose of this study was to develop and assessment designed to increase und erstanding of the behavioral intentions of African American men to pa rticipate in prostate cancer screening so that later studies may test interventions to improve screeni ng rates in this group. This purpose was achieved in three phases. The first phase was to examine attitudes and beliefs of African American men toward prostate cancer scre ening procedures as well as explore the perceived factors that influen ce prostate cancer screening intention in African American men. The second phase was to develop a cu lturally sensitive, valid and reliable instrument for the measurement of prosta te cancer screening in tention in African American men. The third phase was to estimate the validity and reli ability of the newly developed instrument. A concurrent ai m of the study was to identify the sociodemographic variables that are most rela ted to prostate cancer screening intention.

PAGE 16

5 Research Questions The following questions were addressed in this study: Phase I 1. What are the attitudes of African American men toward prostate cancer screening? 2. What are the perceived fact ors that influence prostate cancer screening in African American men? Phase II 1. Does the Cancer Screening Intention Scale-Prostate (CSI S-P) demonstrate evidence of content validity? 2. Is the CSIS-P a culturally sensitive instrument? 3. Is the reading level of the CSIS-P a ppropriate for African American men? 4. Does the CSIS-P demonstrate evid ence of internal consistency? Phase III 1. Does the CSIS-P demonstrate evidence of cons truct validity? 2. Does the CSIS-P reliably measure prostate cancer screening intention in African American men? Definition of Terms For the purposes of this study, the following terms are defined: Digital Rectal Examination (DRE). Palpation of the prostate gland through digital manipulation of the rectum (Groenwald, 2005).

PAGE 17

6 Prostate Specific Antigen (PSA). A blood test that measures a protein made by the prostate cells. The concentration of this prot ein is high in the presence of prostate cancer (American Cancer Society, 2008). Prostate Cancer Screening. Digital rectal examination (D RE) by a health care provider and laboratory testing for prostate sp ecific antigen (PSA) (Groenwald, 2005). Intention. Attitude toward a particular behavior plus the subjective no rms in relation to the behavior (Ajzen and Fishbein, 1980). Significance of the Study to Nursing Prostate cancer incidence and morta lity rates are increasing among African American men. Currently, African American me n have the highest incidence of prostate cancer in the world and cancer death rate s among African American men are twice as high as those among Caucasian men. Limited pa rticipation in prosta te cancer screening activities by African American men has been the most freque nt explanation for increased incidence and mortality rates of prostate can cer in this population. However, few studies exist that explore the reasons for this limited level of pa rticipation. Discovering the factors that influence intent to screen among African American men may positively impact their participation in pros tate cancer screening activities.

PAGE 18

7 Chapter Two Review of Literature This chapter reviews research literature relevant to this study. Several models have been used to develop studies related to cancer screening. This review of literature is organized according to the mode ls and theoretical frameworks that are believed to have the greatest effect on intent to participat e in cancer screening procedures. The first section reviews studies linking prostate cancer knowledge and participation in prostate cancer screening. This section also will in clude studies linking knowledge to informed decision making and prostate cancer screening. Second, the theoretical frameworks that serve as the foundation for the study are su mmarized. Third, research outlining the application of these theories to cancer and can cer screening is discussed. The final section summarizes the literature re view and describes a newly developed model based on a combination of the aforementioned models and theoretical frameworks. This model will be used as the guide for development of the CSIS-P. Prostate Cancer Knowledge, Inform ed Decision-Making, and Screening Research related to prostate cancer k nowledge among African American men has revealed very low levels of knowledge in this very high-risk group. This lack of knowledge among African American men is be lieved to be one explanation for the decreased participation in screening procedures. Als o, the controversy surrounding prostate cancer screenin g and the lack of consistent guide lines has resulted in researchers studying prostate cancer education and informed decision-making (Gwede and

PAGE 19

8 McDermott, 2006; Watson et al., 2006; Weinrich, 2001). This controversy has also required healthcare providers to tailor educational interven tions so that men can make clear informed choices a bout participation in pr ostate cancer screening. Price, Colvin, and Smith (1993) asse ssed prostate cancer knowledge among African American men. The s ubjects were asked to re spond to seven statements regarding prostate cancer risk factors and possi ble signs of prostate cancer. One-third of the respondents could not corr ectly identify signs of prosta te cancer and approximately 20 percent incorrectly identified the risk factor s. Also, nearly 60 pe rcent of the sample did not believe that African American men we re more at risk for developing prostate cancer and as a result stated that they w ould not undergo prostate cancer screening. Prostate cancer knowledge among African American men and Caucasian men was also studied by Demark-Wahnefried et al. ( 1995). The subjects were selected from a sample of men participating in a prostate cancer screening program. The researchers discovered that 68 percent of the men studied felt that their risk of getting prostate cancer was not any higher than the risk of other men. Equal numbers of African American men and Caucasian men reported this response. Collins (1997) surveyed 75 African American men to determine their knowledge of prostate cancer and prostate cancer sc reening procedures. On ly 21 percent of the subjects answered all questions correctly. On e of the most significan t incorrect responses was a negative response to the question related to African American men being at higher risk for getting prostate cancer than Caucasian men. Weinrich, Weinrich, Boyd, and Atkinson ( 1998) agree that one explanation for the racial differences in inci dence and mortality of prostate cancer is lack of knowledge

PAGE 20

9 regarding prostate cancer screen ing. These investigators found th at only 14 percent of the African Americans studied had a high level of knowledge about prosta te cancer and that more Caucasian men in the study reported inte ntion to participate in prostate cancer screening. Differences among African American men and Caucasian men participating in prostate screening were assessed by Barber et al. (1999). African American men scored significantly lower than Caucasian men on the prostate cancer knowledge test. Also, African American men were less likely to correctly identify the early signs and symptoms of prostate cancer, and they also were less lik ely to correctly identify family history as a risk factor. Agho and Lewis (2001) evaluated actual and perceived knowledge of prostate cancer in African American men. The purpose of the study was to explore the relationship between age, income, and edu cation on perceived a nd actual knowledge of prostate cancer. A secondary purpose was to examine the correlation between knowledge of prostate cancer screening a nd participation in prostate cancer screening activities. The sample consisted of 108 African American me n recruited from churches, adult day care centers, and barbershops. Ei ghty-six percent of the sample was below 50 years of age, 57% reported yearly incomes of less than $40,000, and 39% reported educational levels higher than high school. The instrument fo r data collection consisted of a 31-item questionnaire developed by the researchers. The questionnaire measured perceived knowledge of prostate cancer, actual knowledge of prostate cancer, and participation in prostate cancer screening activities. Demogr aphic information also was collected from the research subjects. The results of the study revealed low levels of knowledge of

PAGE 21

10 prostate cancer. All of the respondents sc ored less than 70% on 15 of the 21 knowledge statements. Statistically si gnificant differences were found between respondents less than 40 years old and those more than 40 y ears old in terms of actual knowledge (p = .047). Overall, perceived and actual knowledge of prostate cancer were negatively correlated with age, income, and education. Correlati ons between prostate cancer knowledge and participation in prostate cancer screeni ng activities revealed a moderately positive relationship between actual knowledge of pros tate cancer and partic ipation in screening activities (r = 0.47, p< .001) Finally, a statistically si gnificant relationship was found between perceived knowledge of prostate cance r and participation in screening activities (r = 0.55, p< .001) Taylor, Shelby, Kerner, Redd, and L ynch (2002) carried out a study to assess the prostate cancer knowledge and prostate cancer screening distre ss of Caucasian and African American men. The pur pose of the study was to dete rmine whether participation in prostate cancer screeni ng affected prostate cancer knowledge and distress. One hundred thirty-six men participated in the st udy. Forty-six of the s ubjects were African American men. Seventy percent of the sample was married and more than half of the participants reported educationa l levels of college degree. Prior to screening, an elevenitem knowledge questionnaire was administered to each participant. The items on the questionnaire were related to identifying the risk factors for prostate cancer. The questionnaire was readministered at the conclu sion of each screening. The results of the study indicated that the men had an understandi ng of the risk factors for prostate cancer (M = 3.3, SD = .64). However, knowledge leve ls did not significantly increase after prostate cancer screening.

PAGE 22

11 The impact of education on prostate cancer knowledge and awareness was the focus of a study conducted by Wilkinson, List Sinner, Dai, and Chodak (2003). The purpose of the study was to determine if an educational program about prostate cancer would affect knowledge and prostate cancer awareness among African American men. The sample consisted of 835 African American men. Thirty percent of the sample was less than 40 years of age, and 9% of the sample was 60 and ol der. Seventeen percent of the sample reported educational levels less than high school and 31% reported that they graduated from high school. Each partic ipant was given an electronic keyboard containing twelve multiple-choice prosta te cancer knowledge questions. After completing the questionnaire, participants attended a one-hour culturally relevant educational program on prostate cancer given by an African American health educator. The preseminar knowledge scores ranged from seven to 56 percent with a mean score of 26%. The postseminar scores ranged from 53 to 89 percent with a mean score of 73%. Significant correlations were found between hi gher preseminar and postseminar scores and increased levels of education. The st udy concluded that prostate cancer knowledge levels among African American men are low an d that a culturally relevant educational program can dramatically improve pros tate cancer knowledg e and awareness. Cultural sensitivity and informed decision making related to prostate cancer screening was the focus of a study by Cha n, Haynes, O’Donnell, Bachino, and Vernon (2003). The purpose of the study was to explore the methods by which African American, Hispanic, and Caucasian couples would want prostate cancer screening information presented in order to make deci sions about participati ng in the screening. Five couples from each ethnic group were pr esented with a videotape and educational

PAGE 23

12 brochures about prostate cancer screening. Th ey were asked to review the brochures for content and design. They also were asked to make comments about how the brochures should be revised to target their respective ethn ic groups. The study results indicated both content and graphic di fferences among the three ethnic groups. Both African American and Hispanic couples thought relating the size of the prostate gland to a walnut was not a good comparison because walnuts ar e uncommon in the Hispanic and African American diet. Also, the Hispanic couples felt that the brochure should have more content outlining the advanced symptoms of pr ostate cancer. They felt that Hispanic men would be more likely to seek out screeni ng if they knew that pain was an advanced symptom. All three groups felt that the colo rs used in the brochures should be more specific to each ethnic group. For example, the African American couples felt that a Kente cloth theme (red, green, black, and yellow) would be more appropriate for them. The study concluded that health care providers should consider cultural sensitivity when promoting informed decision making about cont roversial screening tests such as the PSA and DRE. Assessing prostate cancer knowledge among multiethnic men of African descent was the focus of a study conducted by Magnus (2004). The purpose of the study was to examine prostate cancer knowledge levels in African American, Haitian-American, African, and Afro-Caribbeans. Five hundred twenty-eight men were recruited from barbershops and served as the sample for the study. The sample ranged in age from less than 30 years of age to more than 50 years of age. Forty-five percent of the sample was age 31 to 49. Sixty percent of the sample obtained college degrees while 38% reported educational level at high sc hool. A ten-item questionnaire was administered to each

PAGE 24

13 participant to assess prostate cancer knowledge Demographic data also was collected regarding age, income, ethnicit y, education, and family histor y of prostate cancer. The results revealed no significant differences in knowledge levels based on ethnicity. The mean for correct responses acr oss all ethnicities was 71.2 perc ent. Increased levels of knowledge were found to have significant posit ive correlations to income and family history of prostate cancer. Men who earned more than $50,000 per year scored higher on the knowledge test than those who earned less Also, men who repor ted a family history of prostate cancer scored higher (81.9%) than those with no family history (65.4%). The study concluded that prostate cancer educational programs shoul d be targeted to African American men with lower incomes levels and those who have no family history of prostate cancer. Developing an instrument to measure men’s knowledge of the benefits and limitations of prostate cancer screening was the focus of a study conducted by Weinrich et al. (2004). The purpose of the study was to develop and test an instrument to measure the risks and benefits of prostate cancer sc reening in low-income African American and Caucasian men. Eighty-one men participated in the study. The mean age of the sample was 52 years. Seventy-four percent of the men were African-American, more than half of the men were married (53%), and nearly 60% of the sample reported educational levels higher than high school. The Know ledge About Prostate Cancer Screening Questionnaire was developed by the researcher s and contained twelve questions. The concepts measured by the questionnaire include d limitations, symptoms, risk factors, side effects from treatment, and screening age guide lines. Content validity of the instrument was assessed by five cancer health profe ssionals, but no content validity index was

PAGE 25

14 reported. Internal consistency of the instrument was reporte d to be .77. The scores on the knowledge scale ranged from zero to tw elve, with a mean knowledge score of 6.6. Men with lower incomes had lower levels of knowledge of the risks and benefits of prostate cancer screenin g than men with higher levels of knowledge (44% versus 72%). Also, men who were married had signifi cantly lower scores than men who were unmarried (49% versus 74%). There were no significant relationships found between knowledge and ethnicity. The study concl uded that both African American and Caucasian men had low levels of knowledge of the benefits and risks of prostate cancer screening and that tailored e ducational interventions are ne eded to allow men to make informed choices about prostate cancer screenin g procedures. Forrester-Anderson (2005) explored th e knowledge and attitudes of AfricanAmerican men regarding prostate cancer and prostate cancer screening. The purpose of the study was to qualitatively examine th e knowledge, attitudes, perceptions, and behavior of African-America n men relative to prostate cancer and prostate cancer screening. The sample consisted of 104 me n distributed among fourteen focus groups. Each focus group contained six to twelve partic ipants. Sixty-five percent of the sample was married and approximately half of the sa mple had at least a high school diploma. Fifty-eight percent of the sample had neve r been screened for prostate cancer. A fourteen-item open-ended questionnaire deve loped by the researcher guided the focus group discussions. Six negative-based them es and one positive-based theme were identified from the focus groups: lack of knowledge and awareness of prostate cancer screening guidelines, fear of prostate cancer and prostate cancer screening, negative beliefs regarding screening, embarrassment, dist rust of healthcare pr ofessionals, and lack

PAGE 26

15 of access to services. The positive-based theme was focused on the power of knowledge regarding prostate cancer and the benefits of early detection. Of the six negative-based themes, lack of knowledge emerged as most important among the participants. For example, many of the participants reported that they knew nothing about the DRE or PSA as diagnostic tools for early de tection of pros tate cancer. Educating African American men about pr ostate cancer screen ing was the focus of a study by Taylor, et al. ( 2006). The purpose of the study was to determine the effect of educational interventions on knowledge, decisional conflict, satisfaction with screening decision, and self-re ported prostate can cer screening among African American men. The study was conducted in order to address informed decision making about prostate cancer screen ing among African American men. The sample consisted of 238 African American men from Prince Hall Mason’ s groups. Half of the sample was given print-based prostate cancer information and th e other half were pr esented with a video providing prostate cancer education. The samp le also completed demographic scales, a prostate cancer knowledge scale, and an instrument with items related to prostate cancer screening behaviors and satisfa ction with prostate cancer sc reening decision. Nearly 80% of the sample reported that they intended to have a DRE within the next year, while only 50% had actually had a DRE within the past year. Eighty-eight percent of the sample reported that they intended to have a PSA w ithin the next year, while only 44% of the sample had actually had a PSA within the past year. Results of the study also revealed increased prostate cancer knowledge scores afte r the interventions and reduced decisional conflict about prostate cancer screening. The sample also reported that they were highly

PAGE 27

16 satisfied with their decision about prostate cancer screening, even be fore the educational intervention. Plowden (2006) conducted a qualitative st udy to explore factor s that influence African American men’s decision to participate in prostate ca ncer screening. The sample consisted of twelve African American men. The participants range d in age from 40 to 79. Half of the men in the sample were marri ed and 50% reported past participation in prostate cancer screening. Semi-structured interviews revealed three themes as motivators of prostate cancer screening: learning from ot hers, increasing knowledge, and getting the message out. The men in the samp le reported that signifi cant others (relatives, peers, prostate cancer survivors) were a st rong influence on whether or not they would participate in prostate cancer screening. Lack of informa tion about options related to prostate cancer screen ing was the second factor identif ied from the study. The men reported that knowledge of screening options served as both a motiv ator and barrier to prostate cancer screen ing. The third factor identified from the study was the method by which prostate cancer screening messages we re delivered to African American men. Many of the men reported that negative info rmation received from the media made it difficult to make decisions regarding prosta te cancer screening. Television and radio were viewed as the method most African Am erican men used to get information about prostate cancer and prostate cancer screening. Examination of education and awareness of prostate cancer and prostate cancer screening was the focus of a study by Hughe s, Sellers, Fraser, Teague, and Knight (2007). The purpose of the study was to inve stigate health beha vior, education, and awareness as they relate to pr ostate cancer; explore the factor s that influence decisions to

PAGE 28

17 participate in prostate cancer screening; and asse ss the barriers and benefits associated with prostate cancer screening. The sample consisted of 54 African American males and 37 African American females. Ten focus groups were conducted and eight themes emerged from the focus groups: education leve ls, support groups, pros tate cancer stigma, effect on sexual performance, mistrust of healthcare system, importance of family support, participation in clin ical trials, and importance of culturally sensitive health information. Understanding clinical trials a nd culturally sensitive information materials were two themes that were consistently di scussed throughout all the focus groups. The study concluded that h ealthcare professional must consis tently that African Americans are unique ethnic groups that re quire targeted educational st rategies to increase their participation in early detection procedures. Health information styles of men partic ipating in a prosta te cancer screening informed decision-making intervention was assessed by Williams-Piehota, McCormack, Treiman, and Bann (2008). The purpose of this study was to examine health information styles in terms of a person’s demographic characteristics, knowledge about prostate cancer, and attitudes toward prostate cance r and prostate cancer screening. Health information styles were classified as inde pendent active (IA) and doc tor-dependent active (DDA). Two types of informed decision-maki ng interventions were given to 319 men: a video that presented prostate cancer informa tion only and a video that presented prostate cancer information along with other men’s heal th issues. The sample ranged in age from 40 to 80 and 30% of the sample was Afri can American. The results of the study indicated that IAs tended to be Caucasian, younger, have hi gher educational levels, and higher levels of prostate cancer knowledge. The men that were more dependent on their

PAGE 29

18 healthcare provider for decision-making tended to be African American, older, have lower educational levels, and lower leve ls of prostate can cer knowledge. Increasing prostate cancer knowledg e among African American men and providing men with the appropriate informati on to make an informed decision continues to be an important element in improving prostate cancer screen ing in this group. Tailoring educational interventions to this vulnerable group of men may be an integral part of reducing the disparities in pros tate cancer and African American men. Health Belief Model Components of the Health Belief Model ha ve been linked to participation in health promoting behaviors and serves as a theoretical framework for many studies related to intention of African American men to participate in prosta te cancer screenings. The model grew out of a set of independe nt research problems that confronted investigators in the Public Health Se rvice between 1950 and 1960 (Rosenstock, 1974). There was concern that healthy people were not participating in screening programs. Thus, these investigators dete rmined that a theory was needed to explain preventive health behavior. The people who originally contributed to the deve lopment of the model were trained social psychologists. The model is oriented around the belief that it is the world of the perceiver that determines wh at an individual will do, not the physical environment. The exception to this is when the physical environment becomes a part of the perceptual world in the mind of the behavi ng individual. It was or dained that a major component of the theory would include motiv ation and that the model would focus on the present circumstances confronting individuals and not on their past experiences (Rosenstock, 1974).

PAGE 30

19 The earliest characteristics of the Model in dicated that in order for an individual to act to avoid disease he or she would need to believe: (1) that the occurrence of the disease would at least have moderate severity on some component of his or her life (2) that he or she was personally susceptible to it (3) that taking a part icular action would be beneficial by reducing the susceptibility to that disease and (4) that the act to avoid disease would not involve overcoming impor tant psychological barriers (Rosenstock, 1974). In addition to the beliefs previously out lined, an additional variable was included to complete the study. The original contribu tors felt that an ev ent or cue would be necessary to initiate the process. These cues may be internal such as the perceptions of one’s body, or external such as interpersonal interactions. La ter, the concept of health motivation was added to the Model. Health motiv ation refers to the varying degrees of an individual’s readiness to undertak e health actions (Rosenstock, 1974). In summary, the Health Belief Model c onsists of the following elements: (a) perceived seriousness; (b) perceived susceptibi lity; (c) perceived barriers; (d) perceived benefits; and (e) health motiv ation. While all constructs of the Health Belief Model cannot comprehensively explain health be havior, numerous st udies (Fowler, 1998; Plowden, 1999; Barroso, 2000; Rutledge, 2001; Ga salberti, 2002; Clarke-Tasker, 2002; Champion, 2003; Pierce, 2003) have shown that a relationship exists between one or more of the constructs and health behavior. Health Belief Model and Pr ostate Cancer Screening Price, Colvin, and Smith (1993) examined perceptions of African American males regarding prostate cancer scre ening. They found that 40 percen t of the sample surveyed did not believe they were susceptible to pr ostate cancer, even though 57 percent believed

PAGE 31

20 that prostate cancer was a serious disease. Si xty-six to 75 percent of the sample did not perceive any barriers to prostate cancer sc reening. Ten to 20 percent of the sample reported that they did not perceive any benefits to prostate cancer screening. Watts (1994) examined health beliefs of African American men regarding prostate cancer. The results of the study i ndicated a high correlation between perceived seriousness of prostate cancer and intenti on to undergo screening. There also was a significant relationship between perceived be nefits of prostate cancer screening and intention to participate in prostate cancer screening. Even though there were high correlations with perceived se riousness of disease and perc eived benefits of screening, there also were significant barr iers revealed. The subjects indi cated that the discomfort of the rectal examination and concerns about sexual complications if disease was found were serious barrier s to screening. Positive correlations between elements of the Health Belief Model and intention to undergo prostate cancer screening were found by Myers, Wolf, Balshem, Ross, and Chodak (1994). Men who felt that they were su sceptible to prostate cancer were more likely to participate in screening. There also were positive relationships between seriousness of prostate cancer benefits of prostate cance r screening, and intention to undergo screening. The only signifi cant barriers to screeni ng were cost and fear of abnormal examination. Attitudes of African American men towa rd prostate cancer screening methods were examined by Gelfand, Parzuchowski, Cort, and Powell (1995). The purpose of the study was to identify the positive and negative feelings of African American men related to prostate cancer screeni ng. Three hundred fifty men were surveyed regarding their

PAGE 32

21 attitudes about digital rectal examination (D RE) and prostate specific antigen (PSA). A survey was administered that asked the following questions: 1) Are you offended by DRE? 2) Are you embarrassed by DRE? 3) Do you perceive the DRE as a violation of your masculinity? 4) Do you link DRE to homose xuality? The results indicated that 60 percent of the respondents had a positive atti tude toward DRE, although only 24 percent of the men had ever had a rectal examination. Myers et al. (1996) studied factors related to intention to under go annual prostate cancer screening. The purpose of the study was to assess the va riables related to prostate cancer screening intention among African Amer ican men. The sample consisted of 154 African American men recruited from a larg e primary care practice in the northeastern United States. A telephone survey was conducted by the researchers utilizing a researcher-developed questionnaire that addressed susceptibility to prostate cancer, belief in the value and efficacy of pr ostate cancer screening, and the impact of social influences in encouraging participation in prostate cancer screening. Sixty-four percent of the sample felt that they were susceptible to prostate cancer, 58 percen t felt that prostate cancer was a serious disease, 59 percent felt th at prostate cancer screening was beneficial, and 63 percent believed in the long-term value of screening. All of these variables were positively related to screening intention. Forty-one percent of the sample said that a barrier to screening would be embarrassmen t, while 18 percent said they would not participate in screening because they believe d it would cause “sexual problems” (p. 474). Myers, Chodak et al. (1999) explored adherence by African American men to prostate cancer early de tection. The purpose of the study wa s to identify th e factors that predict compliance by African American men as it relates to prostate cancer screening.

PAGE 33

22 The sample consisted of 413 men recruited from a university health se rvices center in a metropolitan northeastern city. In this study, on ly 14 percent of the sample felt that they were susceptible to prostate cancer and only 19 percent perceived prostate cancer to be a serious disease. However, 89 percent of the participants believed prostate cancer screening was beneficial. Finally, only 38 pe rcent of the sample indicated that they would be willing to undergo prostate cancer screening. Identifying barriers to prostate cance r screening was the focus of a study conducted by Shelton, Weinrich, and Reynolds (1999). The purpose of the study was to investigate the relationship between perceive d barriers and participation in prostate cancer screening. The sample included 1,395 Af rican American men from the southern United States. The men were recruited from barbershops, car dealerships, work sites, civic organizations, subsidized housing areas, and meal sites. The mean age of the sample was 50.0 years and the educational le vels were equally distributed among less than high school, high school graduate, and so me college. The theory of planned behavior served as the conceptual framewor k for this descriptiv e correlationa l study. Perceived barriers were linked to the perceived behavioral co ntrol element of the theory of planned behavior. A 44-item prostate cancer questionnaire developed by the researchers was utilized for data collecti on. Content validity of the instrument was reported at 80 percent while Cronbach alpha ra nged from 0.82 to 0.90. Five barriers were identified as those most frequently reported by the sample. These barriers included lack of knowledge about the need for screening, cost of screening, lack of insurance, not knowing where to go for screening, and being unaware about what type of health care provider to contact for screening. Of all the barriers reported, embarrassment was the

PAGE 34

23 only significant predictor of pa rticipation in prostate cancer screening. In spite of these barriers, 60% of the sample participated in the free screening offered after the study was completed. Plowden (1999) utilized the Health Belief Model to understand pr ostate cancer in African American men. The study results indi cated that African American men were more likely to participate in prostate scr eening if they perceived themselves to be personally susceptible to disease and if they perceived a personal benefit to the early detection of the disease. The study also reve aled that African American men were more likely to present with more advanced prosta te cancer than Caucasian men, implying their disbelief in the seriousness of the disease. Steele, Miller, Maylahn, Uh ler, and Baker (2000) ex amined prostate cancer screening practices of olde r African American men. The purpose of the study was to assess their attitudes, knowle dge, and screening practices as they related to prostate cancer. The sample included 742 African American men selected through random telephone interviews. The men ranged in age from 50 to 74 with 85% of the men between the ages of 50 and 69. Nearly two-th irds of the sample reported educational levels at high school or less. A thirteen -question survey developed by the New York State Department of Health was administ ered over the phone. Only 30% of the men surveyed had ever heard of a PSA and only 7% perceived that they we re at high risk for developing prostate cancer. Physician reco mmendation was a significant predictor of participation in prostate cancer screeni ng. Men who received physician recommendation were 28.5 times more likely to participate in prostate cancer scr eening than those who

PAGE 35

24 didn’t. Income also approached significan ce in that men who had income levels above $25,000 were more likely to get screened. Plowden and Miller (2000) examined health seeking behaviors of African American men. The purpose of the study was to explore the factors that motivate African American men to participate in health seek ing and health promotion activities. The sample consisted of 38 African American me n ranging in age from 24 to 94. The lowest educational level of the sample was 5th grade while the highest was graduate degree. Men were recruited from churches, community centers, and service organizations. The health belief model served as the theoreti cal model for this study. Four focus groups were held to collect data re garding health seeking behavi or. The following questions were asked during the focus groups: 1) What ar e the benefits of seek ing health care; 2) Identify potential barriers to seeking health care; 3) Identify perceived severity of illness in the community; 4) What diseases/illnesses are you prone to; 5) What motivates you to seek health care. Comparative analysis was done on the results of the focus groups. Cost, inconvenient office hours, lack of tr ansportation, feelings of powerlessness, and fatalism were expressed as barriers to health seeking behaviors. Lack of sensitivity by health care providers was also expressed as a barrier. Some of the benefits of seeking health care included prevention of illness and a feeling of comfort. Relieving symptoms of illness and avoidance of death were lis ted as motivators in seeking out health promotion activities. Examining prostate cancer health beliefs and practic es was the focus of a descriptive non-experimental study conducte d by Fearing, Bell, Newton, and Lambert (2000). The purpose of the research was to expl ore the health beliefs and health practices

PAGE 36

25 of African American men as they relate to prostate cancer. A convenience sample of 59 African American men was recr uited from churches, fraterna l organizations, and health fairs in the midwestern United States. The instrument was developed by the researchers, and Pender’s health promotion model was the framework used in its’ development. The questionnaire assessed prosta te cancer knowledge, prostate health screening behaviors, and health beliefs. The results of the study revealed that almost three-fourths of the sample had undergone both PSA and DRE. Fift y percent of the sample believed that they were at high risk for deve loping prostate cancer. Sec ond, 50% of the sample believed that there was nothing that they could do to prevent prostate cancer. Two-thirds of the sample reported sexual dysfunction as the mo st disturbing concern about prostate cancer treatment. Finally, 91% of the sample reporte d their intent to obtain future testing for prostate cancer. Boyd, Weinrich, Weinrich, and Norton ( 2001) examined barriers to prostate cancer screening in African American men. The purpose of the study was to identify the structural obstacles to prostate cance r screening among African American men. Structural obstacles were defi ned as those barriers that fo cused on the social system and the health care delivery system. The samp le consisted of 549 men from the southern United States. Sixty-nine percent of the men were African American. A correlational survey was designed to assess structural obs tacles. The study results revealed that Caucasian men were more likely to participat e in prostate cancer screening than African American men. Married men also were more likely to participate in screening than unmarried men. Some of the st ructural barriers that were identified in th e study included lack of access to a phone to make screening ap pointments, lack of tr ansportation, lack of

PAGE 37

26 knowledge in finding the proper physician, and inability to read the pre-appointment information. Clarke-Tasker and Wade (2002) conducte d a qualitative study to identify attitudes and behaviors of African American men rela ted to prostate cancer screening. The purpose of the study was to assess African American men’s knowledge about prostate cancer and prostate cancer screening as well as examine their attitudes and behaviors regarding participation in pros tate cancer screening activities. The health belief model served as the framework for this study. The sample consisted of twelve African American men. Seven of the men ranged in age from 38 to 49 while the other five ranged in age from 51 to 80. Two focu s groups were conducted and open-ended questions were asked regarding prostate cancer screening behaviors. Results of the focus groups indicated that older men were more knowledgeable about prostate cancer than younger men. The younger men in the study expressed more fear about DRE than the older men. None of the particip ants were aware of the increas ed risk of prostate cancer among African American men. Also, the me n in the sample who had undergone DRE incorrectly believed that the physician had inse rted the entire hand into the rectum. Lambert, Fearing, Bell and Newton (2002) compared the prostate cancer health beliefs and screening practices of African American and Caucasian men. The purpose of the study was to inve stigate the prostate cancer screening practices of men over the age of 45. Fifty-five African Amer ican and 49 Caucasian men served as the sample. A self-administered questionnair e was developed using Pender’s health promotion model as the theoretical framewor k. The study results indicated that African American men were less likely to have ha d a DRE than Caucasian men (75% versus

PAGE 38

27 82%). A second finding in the study was that Caucasian men were more likely to believe that family history of prostate cancer was an important factor in prostate cancer development. Also, significant differen ces were found between the two groups on the factor of faith. African American men were more likely to rely on faith to stay healthy than Caucasian men (t = 2.819, df = 96, p<.01). Odedina, Scrivens, Emanuel, LaRose-Pie rre, Brown, and Nash (2004) explored factors that influence prostate cancer scr eening behavior in African American men utilizing qualitative methods. The purpose of the study was to identify predisposing factors that affect African American men’s decisions to participat e in prostate cancer screening. Forty-nine African American men participated in one of ten focus group sessions. Nearly half of the participants we re married (41%) and nearly a quarter of the participants (24%) had college degrees. Focus group sessions lasted from 44 to 165 minutes. The researchers util ized ethnography to complete the data analysis. Eleven themes were identified from the focus groups and were as follows: impediments to prostate cancer screening, positive outcome beliefs connected with prostate cancer screening, negative outcome be liefs connected with prosta te cancer screening, social influence, prostate cancer knowledge, resource s or opportunities that facilitate prostate cancer screening, perceived susceptibility to prostate cancer, perc eived severity of prostate cancer, perceived thre at of prostate cancer, posi tive health activities, and experiences with illness. Impediments to pr ostate cancer screening were identified by the subjects as the most significant factors affecting screening pa rticipation. These impediments included lack of access to heal thcare, discomfort associated with DRE, mistrust of the healthcare system, illiteracy, feelings of powerlessness, and lack of

PAGE 39

28 information from healthcare provider. The study concluded that id entifying factors that impact African American men’s participa tion in prostate cancer screening can be important in that they can be used to develop culturally se nsitive and relevant interventions that may in turn increase screening participation in a very vulnerable population. Attitudes and beliefs about prostate ca ncer screening among African American men were qualitatively explored by Oliver (2007). The purpose of the study was to describe the personal beliefs and attitudes about prostate cancer and prostate cancer screening among rural African American men. The sample consisted of nine African American men who participated in semi-structu red interviews. The participants ranged in age from 43 to 72 and 78% of the participants were marrie d. Interviews were conducted for sixty minutes utilizing a pre-established interview guide. Content analysis was used to categorize the qualitative da ta. Six themes were gleaned from the data analysis: disparity, lack of understanding, mistrust of the system, fear, traditions, and threats to manhood. The study findings concluded that effo rts to promote prostate cancer screening among African American men must first address their fears and distrust of the healthcare system in order to positively impact th e participation of this high-risk group. Identifying personal factors that affect prostate cancer screening behavior among African American men was the focal point of a study conducted by Odedina, Campbell, LaRose-Pierre, Scrivens, and Hill (2008). Th e study sought to test three hypotheses: 1) behavioral, psychological, a nd social factors determine an African American man’s intention to participate in prostate cancer screening 2) psychologi cal, behavioral, and social factors as well as behavioral intenti on will determine an African American man’s

PAGE 40

29 participation in prostate cancer screening 3) instru mental beliefs, affect toward means, and self-efficacy is significantly related to prostate cancer screening behavior. The Attitude-Social Influence-Efficacy (ASE) model served as the theoretical framework for the study. The sample consisted of 191 Afri can American men. The sample ranged in age from less than 40 years of age to more th an 80 years of age. The majority of the sample (95%) was between 40 and 79 years of ag e. Most of the respondents reported an educational level of “some college” and most of the men were married. The study instrument was the African-American Men Pros tate Cancer Screening Behavior Scale. The scale assessed the following variables: past prostate cance r behavior, social influence, attitude toward prostate can cer screening, perceived efficacy, perceived severity of prostate cancer; perceived susceptibility to pr ostate cancer, intention to participate in prostate cancer screening, instrumental beliefs affect toward means relative to prostate cancer screening, prostate cancer knowledge, and demographic variables. The study results revealed that attitudes, social in fluences, perceived efficacies, instrumental beliefs, and behavioral intentions were high among African American men while perceived susceptibility, perc eived severity, and knowledge about prostate cancer was low. There are a variety of attitudes and belie fs about prostate cancer and prostate cancer screening that can inhibit African Amer ican men from participating in screening procedures. Identifying and examining these attitudes and beliefs is imperative in order to positively impact screening participation.

PAGE 41

30 Fatalism Studies have revealed that fatalism may be a deterrent to participation in healthpromoting behaviors. Fatalism involves the conc ept of predestination. It is the belief that there are some things in life that would occu r despite any preventive actions that might be taken by an individual or gr oup of individuals. It is beli eved to be characterized by perceptions of hopelessness, wo rthlessness, meaninglessness, powerlessness, and social despair (West, 1993). Fatalism as it relates to health is the belief that there are some health issues that people cannot control (S traughan and Seow, 1998). Fatalism is believed to vary along a continuum, which ranges from very fatalistic on one end of the continuum to a very strong belief in one’s ability to control outcomes on th e other end of the continuum. Fatalism, Cancer, and African Americans Fatalism in African Americans is view ed as a significant reason for decreased participation in health-promoting activities. It is believed that perceptions of fatalism evolve over time as African Americans face the ch allenges of the racial divide in health care. Underwood (1992) suggests that fa talism is more common among African American men. Vetter, Lewis, and Charny (1991) suggest that fatalism is more prevalent among elderly African Americans regardless of gender. Cancer fatalism is the perception that cancer is inevitable regardless of a pe rson’s actions to prevent it (Wilkes, Freeman, & Prout, 1994). Freeman (1989) focused on poverty as the primary reason for cancer fatalism among African Americans. Powe and Johnson (1995) suggested that other factors such as substandard health care and health care discriminati on also may contribute to the degree of cancer fatalism among African Americans.

PAGE 42

31 Fatalism among African American men wa s studied as the concept of learned helplessness by Underwood (1992). This concept supports the belief that nothing can be done about the status of a person’s healt h. This belief lead s a person to avoid participation in health promotion activities. The purpose of the study was to evaluate the degree to which learned helplessness affected cancer risk reducti on and early detection behaviors in African Amer ican men. A sample of 236 African American men participated in the study. A five-part inst rument was developed by the researcher to assess perceptions of learned helple ssness and examine understanding of and participation in cancer early detection activit ies. Thirty-six percent of the sample perceived themselves to be helpless regard ing control of their health. Seventy-five percent of the sample believed that cancer de aths would not be reduc ed even if screening recommendations were consistently followed. Also, men who perceived themselves as helpless in regard to health status were less likely to participate in cancer risk reduction and early detection ac tivities. Overall, men within th e group consistently expressed a belief that they had little or no control over their health stat us and that good health was a matter of chance. Powe (1995a) conducted a descriptive, corr elational study to assess perceptions of cancer fatalism among older Americans. Th e purpose of the study was to identify predictors of cancer fatalism based on knowledge of colorectal cancer, educational level, and income. The sample consisted of 192 older Americans recruited from congregate meal sites (strategically placed city-wide sites that provide free meals to the elderly) in the southeastern region of the country. Si xty-two percent of the sample was African American and 24% were men. The instrument s in the study consisted of a demographic

PAGE 43

32 questionnaire and the Powe Fatalism Inde x developed by the researcher. The third instrument was the Colorectal Cancer Knowle dge Questionnaire. The results of the study indicated that African American men were more fatalistic (mean= 10.9) than Caucasian men (mean=8.8). This difference was f ound to be statistically significant (p = 0.0001) African American men also were le ss likely to participate in colorectal screening than Caucasian men. Only 29 per cent of the African American men in the sample participated in the screening compared to almost 50 percent of the Caucasian men in the study. Also, significant negative rela tionships were found between cancer fatalism and education, income and cancer fatalism and knowledge of colorectal cancer and cancer fatalism. These results suggest that cancer fatalism is likely to be present in African Americans with lower educational levels, lower income levels, and a decreased knowledge of cancer. Powe (1995b) studied the degree of can cer fatalism among elderly Caucasians and elderly African Americans. The pur pose of the study was to determine the relationship between several demographic fact ors (age, gender, income, education) and cancer fatalism. The sample consisted of 192 Caucasian and African American elders from randomly selected senior citizen cen ters. A demographic questionnaire and the Powe Fatalism Index served as the study instruments. The mean age of the sample was 76 years. Seventy-eight percent of the sample was female. The mean yearly income was $6500 and the mean educational level was eight years. Pearson corre lation coefficients were calculated to determine the relations hip between each demographic factor and cancer fatalism. African Americans were found to be significantly more fatalistic than Caucasians and females were found to be more fatalistic than males. Significant negative

PAGE 44

33 relationships were found between educati on and fatalism and between income and fatalism. There was no relationship be tween age and fatalism. Among all the demographic variables, education provided the greatest degree of variability. Fatalism among elderly African American s was studied by Powe (1995c). The purpose of this study was to assess the relatio nship between fecal occult blood testing and cancer fatalism. The sample was selected from seven congregate meal sites (N=118). The average age of the sample was 73 years. More than 50% of the sample reported educational levels less than 8th grade and income levels below poverty. A demographic questionnaire, the Powe Fatalism Index, and He mocult II kits served as the instruments in the study. Hemocult II kits were distribut ed after videotape instruction, written instruction, and demonstrations were conducted. After inst ruction, only 29% (n=34) of the sample actually participated in fecal occult blood testing. This finding seems to suggest that fatalism may be related to d ecreased participation in fecal occult blood testing by African Americans. Study results also indicated that fatalism was the only significant predictor of fecal occult blood testing (p = 0.0006) among the factors of age, income, education, and fatalism. These results support the belief that fatalism is a vital factor in cancer scr eening behaviors among elderly African Americans. Fatalism and breast cancer in African Am erican women was the focus of a study conducted by Conrad, Brown, and Conrad (1996 ). The sample consisted of 600 people randomly selected from malls and market places. A demographic questionnaire was administered along with a 10-item instrument to measure fatalism. African Americans were found to be more fatalistic than Cau casians. The demographic variables of age, education, and income were found to be sta tistically significant. Pairing of African

PAGE 45

34 Americans and Caucasians with similar ed ucational backgrounds and income levels resulted in a decrease in the differences of the fatalism scor es. This finding suggests that persons with lower income levels and lower educational levels are highly fatalistic and as a result fail to seek medical care at early st ages of disease and may not seek out cancer prevention/risk re duction activities. Fear and fatalism among African Amer ican women was studied by Phillips, Cohen, and Moses (1999). The purpose of the st udy was to explore atti tudes, beliefs, and practices of African Am erican women as they relate to breast cancer and breast cancer screening. The study design was qualitat ive and used the focus group methodology. Twenty-six women of diverse educational and income levels served as the sample. The women ranged in age from 40 to 66. Twenty-s even percent of the sample reported less than high school as their educational level, while 73% reported at least a high school education. Sixteen of the women repor ted annual incomes between $10,000 and $39,999, while eight of the women reported annual incomes greater than $39,999. Two of the women refused to report their annual inco me. Three focus groups were conducted. Semi-structured interviews were developed utilizing the Health Belief Model as the framework. All of the members of the groups stated that fear was the first thing that came to mind when hearing the word breast cancer. Another significant finding from the focus groups was the notion that avoiding disc ussions about breast cancer and refraining from participation in screening practices may make the breast cancer “go away”. Additionally, all the groups in this study linke d breast cancer with death or the possibility of death. The study concludes that in order to counterbalance the fatalism and negative attitudes that African American women have associated with breast cancer, African

PAGE 46

35 American communities need to continue to be presented with culturally relevant programs related to breast cancer and breas t cancer screening. In addition, these programs need to be evaluated regarding their effectiveness. Powe and Weinrich (1999) investigated an intervention to decrease cancer fatalism among rural socioeconomically disadva ntaged elders. The purpose of the study was to assess the effectiveness of a vide o intervention designed to decrease cancer fatalism and increase participat ion in fecal occult blood testin g. The intervention for this study was a 20-minute video (Telling the Story…To Live is God’s Will) that was developed to provide informati on related to colorectal scr eening and address the concept of fatalism. The video was developed ba sed on the premise that persons with less knowledge tend to be more fatalistic. The sample consisted of 70 persons selected randomly from senior citizen centers. The mean age of the subjects was 75 years and their mean level of education was approximately 7 years. Ninety percent of the sample was African American and nearly 90% female. Eighty percent of the sample reported an annual income less than $5,000. A repeated meas ure, pretest/post-test design was used. Forty-two people were in the intervention group, while 28 made up the control group. The pretest instruments included the Powe Fatalism Index developed by the primary author, the Colorectal Cancer Knowledge Questionnaire developed by the secondary author and others, and a demographic questi onnaire developed by the researchers. The intervention group viewed the Telling the Story video. This video reflected the cultural values, attitudes, and belief systems inherent in the African American culture. The video contained several scenes invol ving colorectal cancer and co lorectal cancer screening. Fecal occult blood testing was demonstrated in the video and gospel music was used as

PAGE 47

36 transition between the scenes. The majority of the persons in th e interventional video were African American. The control group viewed a 13-minute video developed by the American Cancer Society. This video provi ded a summary of colorectal cancer and outlined the procedure and purpos es of fecal occult blood tes ting. The majority of the people in the control video were Caucasian. Seven days after the pretest, fecal occult blood testing kits were distribut ed. The Powe Fatalism Inde x and the Colorectal Cancer Knowledge Questionnaire were also readminist ered. The results of the study indicated that cancer fatalism was significantly decrea sed in the intervention group at post-test. The mean pretest cancer fatalism score of the intervention group was 9.90, while the mean post-test score was 8.50. The mean pretest cancer fatalism score of the control group was 9.89, while the post-test mean sc ore was 9.79. Knowledge scores also increased significantly in the intervention group when compared to the control group. Sixty percent of the intervention group and 68% of the control group participated in fecal occult blood testing. These findi ngs suggest that cancer fatalism is a variable that can be affected by culturally sensitive and culturally relevant educational material. It also seems to suggest that culturally relevant cancer education can increase knowledge and may increase participation in cancer risk-reduction activities. Plowden and Miller (2000) examined motiv ators of health seeking behaviors in African American men. The pur pose of the study was to explore factors that motivate African American men to participate in heal th promotion activities. The Health Belief Model served as the framework for the study. The sample for the study consisted of 38 African American men from a northeastern urba n city. The men ranged in age from 2494. The mean income was $10,000-$20,000 and th e educational levels ranged from 5th

PAGE 48

37 grade to graduate degrees. The men were recruited from community organizations such as community centers and churches. Four focus groups were conducted to collect data related to health-seeking beha viors. Demographic inform ation also was collected. Descriptive statistics were utilized to analyze the dem ographic data. Leininger’s qualitative data analysis model was used to analyze the focus group tr anscripts. Themes from the focus group interviews were deve loped by the researcher and reviewed by experts in focus group methodology and patterns of African Am erican health behavior. The subjects reported that some barriers to he alth promotion activities included cost, lack of transportation, limited knowledge about health issues, and lack of sensitivity of health care providers. Fear and inevitability of death also were listed as barriers to participating in health-promotion screenings. Men who e xpressed these fatalistic attitudes also expressed that they would be less likely to seek out health-promoting activities. These findings again confirm the need for culturally appropriate educational materials in order to dispel myths in the African American community regarding health promotion screenings and activities. Powe (2001) examined cancer fatalism am ong elderly African American women. The purpose of this study was to identify the strength of perceptions of cancer fatalism and describe the predictors of high cancer fatalism le vels among elderly African American women. The sample consisted of 204 African American women who ranged in age from 50-99 who were recruited from se nior citizen centers. Almost 90% of the women reported annual incomes less than $10,00 0. The mean educational level of the sample was 7.9 years. The instruments of data collection included the Powe Fatalism Index, the Colorectal Cancer Knowledge Qu estionnaire and a demographic instrument.

PAGE 49

38 The mean score for women with high levels of cancer fatalism was 12.79 (range 0-15), while the mean score for women with low levels of cancer fatalism was 6.08. The differences between the two gr oups of women were found to be statistically significant (df = 202, t = 21, p = .0001) One hundred twenty-nine of the women reported high levels of cancer fatalism. These women al so were found to have lower levels of knowledge about colorectal cancer, were older, and had lower educat ional levels. Also, women with lower income levels tended to re port higher levels of cancer fatalism. However, income was not identified definitively as a predictor of high cancer fatalism. These findings suggest that older women with lower educational levels tend to have higher degrees of fatalism. Cancer fatalism among African American patients and their providers was the focus of a study conducted by Powe, Daniels, and Finnie (2005). The purpose of the study was to examine perceptions of cancer fa talism in African American patients and the healthcare providers that offer services to those patients. A secondary purpose was to explore the relationship between specified demo graphic variables and cancer fatalism. A descriptive comparative design was used to guide the data collection for the study. The sample consisted of 52 patients and 35 pr oviders. The sample was recruited from primary care centers in a large southeastern ci ty. Seventy-five percent of the patients were women and 90% were African American Eighty-eight percent of the providers were women and 71% were Afri can American. The average of the patients was 39 and the average educational level was 12 years. The average of the providers was 41 and the average years within the cancer discipline wa s 9.8 years. The instruments of data collection included the Powe Fa talism Inventory (PFI), the Perceived Patient Fatalism

PAGE 50

39 Inventory (PPFI), and a demographic questionnair e. The PPFI is a modified version of the PFI developed by the researcher to assess providers’ perceptions of their patients’ cancer fatalism. The study results revealed a statistical difference between patients’ cancer fatalism scores and the scores that the providers’ perceived fa talism scores. Also, there was a significant negative correlation be tween cancer fatalism and the patient’s educational level. There were no statistical ly significant relati onships between cancer fatalism and age, income, or marital status. The findings of this study suggest the need for increased communication be tween patients and their hea lth care providers regarding cancer and cancer fatalism so that particip ation in cancer screen ing activities may be increased. Spurlock and Cullins (2006) examined by cancer fatalism and breast cancer screening in African American women. The st udy used a descriptiv e correlational design to explore the relationship between cancer fatalism and breast cancer screening. The researchers also sought to examine the de gree to which income, age, and education influence perceptions of cancer fatalism. The convenience sample consisted of 71 African American women recruited from se nior citizen housing centers, low-income housing developments, churches, and community centers. The particip ants ranged in age from 20 to 73 and the mean educational level was 13.4 years. Thirty -six percent of the respondents reported annual incomes less than $10,000 and 34% indicated that they had no health insurance. Study results reveal ed a higher degree of fatalism among older women, women who were unempl oyed and women who had no hea lth insurance. Higher degrees of fatalism also were reporte d among women who did not practice monthly breast self-examination and those who had not received a clinical breast examination

PAGE 51

40 from their health care provider. Correlati ons between demographic variables and cancer fatalism revealed significant negative correla tions between age, income, education and cancer fatalism. The results of this study r eaffirm the need for more cancer educational programs for older, low-income African Americans. Research regarding cancer fatalism in Afri can Americans reveals that it is a viable reason for lack of participation in illness prevention and early detection activities. This is especially true among elderly, low-income Afri can Americans. Also, culturally relevant educational interventions have proven to be beneficial in he lping to decrease the degree of fatalism among Africans, especi ally African American men. Health Promotion Healthy lifestyles have b een studied as a factor to explain health behavior. Healthy lifestyle is a compone nt of the Health Promotion Model. The Health Promotion Model serves as the framework for explai ning and predicting healthy lifestyles. The premise of the Health Promotion Model is that there are seve n perceptual/cognitive dimensions that directly a ffect healthy lifestyle: percep tion of importance of health, perceived control of health, pe rceived self-efficacy, one’s de finition of health, perceived health status, perceived benef its of health-promoting behaviors, and perceived barriers to health-promoting behaviors (Pender and Pende r, 1996). These dimensions were captured quantitatively in the Health Promotion Life style Profile (HPLP) by Walker and Pender (1990) and the Health Promotion Lifestyle Profile II (HPLP II) by Walker and HillPolerecky (1996). Zhan, Cloutterbuck, Keshian, and Lombardi (1998) investigated health-promoting measures used by ethnic elderly women. The sample consisted of African American

PAGE 52

41 women, Chinese American women, and Eur opean women. The study results indicated that the perception of health status was pos itively correlated with a healthy lifestyle. Analysis also revealed that each ethnic gr oup identified significantly different measures to promote health implying that definition of health is also an im portant indicator of healthy lifestyle. Gender differences in the health-promoti ng lifestyles of African Americans were the focus of a study conducted by Johnson (2005). The purpose of the study was to explore the overall health-promoting lifestyle s of African American men and women and to examine whether sociodemographic factors (gender, age, highest educational level obtained, marital status, and income) influen ce the degree of health -promoting behavior among this group. The sample consisted of 223 African American s, with 108 being African American men. The mean age of the sample was 37 years and 23% of the sample reported educational levels of 12th grade or less. The instruments of measure included a demographic questionnaire and the Health-Promoting Lifestyle Profile II developed by Walker, Sechrist, and Pender (198 7). There were no statistically significant gender differences in health-promoting lifesty les. However, part icipants with higher income and educational levels had higher health-promoting lifestyle scores. Also, African Americans who were married or living with a significant ot her scored higher on the Health-Promoting Lifestyle Profile II. Health Promotion and Cancer Frank-Stromborg, Pender, Walker, and Sechrist (1990) tested the Health Promotion Model as a framework for explaini ng healthy lifestyle in a sample of 385 ambulatory cancer patients. The purpose of the study was to determine the degree to

PAGE 53

42 which cognitive/perceptual variables and modify ing variables are able to explain healthpromoting behaviors in cancer patients. Resu lts from this study demonstrated that 15.8 percent of the variance was explained by cont rol of health, 11.7 pe rcent of the variance was explained by definition of health, and 7.4 percent of the variance was explained by health status. Underwood and Sanders (1990) studied the factors that contribute to health promotion behaviors in African American me n. It was specifically focused on behaviors that lead to the reduction of cancer risk or that involved ea rly detection of cancer. The sample consisted of 177 African American men. Results of the study indicated that attitudes toward cancer screen ing, attitudes related to cancer risk and decreasing exposure to carcinogens, attitudes related to motivation to reduce ca ncer risk, and attitudes related to influence of health professionals were th e strongest predictors for participation in health promoting behaviors, explaining 72 pe rcent of the variance. However, further analysis of the results indicated that the me n did not consider themselves very health conscious. Only 56 percent of the sample reporte d that they paid atte ntion to their bodies and only 42 percent stated that they made conscious attempts to involve themselves in activities of physical fitness. Less than a third of the men in the study reported that their diet contained an adequate amount of vitami ns, minerals, and fiber. Also, only 12 percent of the men reported having a physical examinatio n within the past th ree years. Stepwise regression analysis revealed attitude as the strongest pr edictor of health promoting behaviors. Underwood (1991) analyzed determinants of early cancer detection in African American men. Study results revealed that men with a strong health consciousness were

PAGE 54

43 more likely to participate in cancer risk -reduction behaviors such as screening. In addition, men who perceived themselves to be in control of their hea lth also were more likely to participate in cancer screeni ng and employ cancer risk-reduction behaviors. Attitudes toward prostate cancer screening were studied by Cowen, Kattan, and Miles (1996). They determined that men w ho participated in other health-promoting behaviors were significantly more likely to participate in prostate cancer screening. For example, men who had their serum cholesterol checked annually were twice as likely to complete prostate cancer screening. Also, men who had been tested for colorectal cancer were twice as likely to under go prostate cancer screening. Though limited studies exist that examin e the relationship between health promotion and cancer risk-reduction behaviors, it remains a significant part of cancer prevention and early detection. Future st udies focusing on health-promoting behaviors and prostate cancer screening in African Amer ican men need to be conducted in order to impact the wellness of this susceptible group. Theory of Planned Behavior The theory of planned behavior (TPB) was developed from the social cognitive theory. It was developed to explain the role of beliefs and attitudes in determining behavior. It is based on the premise that behavior is a f unction of inten tion (Ajzen and Fishbein, 1980). They developed a model that stat es “intention is equal to attitude toward the behavior plus the subjective norms in re lation to the behavior”. It serves as the theoretical framework for describing the inten tions of individuals to perform behaviors.

PAGE 55

44 The theory postulates that there are thr ee basic factors that determine a person’s behavioral intentions: a persona l or attitudinal factor, a so cial or normative factor and perceived behavioral control. The personal or attitudinal factor re fers to the person’s attitude toward participating in the behavior. It defines whet her the person has a favorable or unfavorable feeling toward performing th e behavior (Ajzen and Fishbein, 1980). For example, in cancer screening, the attitudinal f actor refers to whethe r an individual feels that there are benefits to participating in cancer screening or negative consequences associated with participating in cancer sc reening. The social or normative component involves the influence of the environment on in tentions and behavior. It deals with an individual’s perception that important others desire the performance or nonperformance of the behavior. The premise is that the grea ter the perceptions of important others to perform the behavior, the higher the level of intention to perf orm the behavior (Ajzen and Fishbein, 1980). Perceived beha vioral control was added to the model by Ajzen (1991). Perceived behavioral control is the belie f that most behavior s are located along a continuum that moves from total control to complete lack of control. Perceived behavioral control is a product of control beli ef and perceived power. Control belief is a person’s perception that there are benefits and barriers to performing the behavior. Perceived power is the person’s perception that the benefits and/or barriers will make performing the behavior easier or more diffi cult (Redding, Rossi, Velicer, and Prochaska, 2000). Theory of Planned Behavior and Health Behaviors Brubaker and Wickersham (1990) applied th e theory of planned behavior (TPB) to testicular self-examination. The purpose of the study was to examine the relationship

PAGE 56

45 between the components of th e theory of planned behavi or and the performance of testicular self-examination. The sample consisted of 232 ma le students in an undergraduate health class. The researcher s did not report a raci al breakdown of the subjects in the study. The instruments for the study included a theory of reasoned action (TRA) questionnaire and a demographic ques tionnaire. The results of the study indicated that attitude towa rd the behavior and subjectiv e norm accounted for 39 percent of the variance in intention. It was also noted that attitude made a greater contribution to intention than subjective norm. McCaul, Sandgren, O’Neill, and Hinsz (1993) examined the value of the theory of planned behavior in forecasting health-prote ctive behaviors. The purpose of the study was to explore the predictive ability of the TPB in determining intentions to participate in breast self-examination (BSE) and testicular self-examination (TSE). The relationship between intention and actual perf ormance of the behavior also was explored. The sample consisted of 138 undergraduate college student s. Forty-eight percent of the sample (n=66) were women while 52% of the sample (n=72) were men. The researchers reported no other demographic characteristics of the sample. The instruments for the study included a BSE and TSE knowledge pretes t and a researcher-developed tool based on the variables of the TPB. The TPB inst rument consisted of a ten-item attitude subscale, a single item subscale to measur e subjective norm, two items to assess perceived behavioral control, and a single item subscale to measure intention. The study results found that there were significant co rrelations between att itude and intention (r=0.58 for BSE, r=0.65 for TSE; p<.05), subj ective norms and intention (r=0.38 for BSE, r=0.31 for TSE; p<.05), and perceived be havioral control and intention (r=0.63 for

PAGE 57

46 BSE, r=0.89 for TSE; p<.05). Perceived behavi oral control was found to be the strongest predictor of BSE and TSE intention. Inte ntion also predicte d actual BSE and TSE performance accounting for nine and eleven pe rcent of the variance, respectively. This study concluded that the TPB is an appropr iate model to explai n cancer screening intention and behavior in young adults. It also concluded that perceived behavioral control is a very strong predic tive variable among young adult men. Compliance with breast cancer screeni ng behaviors was the focus of a study conducted by Friedman, Woodruff, Lane, Weinberg, Cooper, and Webb (1995). The purpose of the study was to explor e predictive ability of the theory of planned behavior in obtaining yearly mammograms and yearly c linical breast examinations. The sample consisted of 312 women age 50 and older. The mean age was 55.9 and the mean educational level was 14.8 years. Fiftyseven percent (n=179) of the sample was Caucasian and 43% (n=133) were non-Caucas ian. Seventy-nine of the non-Caucasian subsample was African-American and 23 were Hispanic. Subjects were recruited from female employees of a hospital in the midwes tern U.S. Two questionnaires were mailed to the subjects. The first was a demographi c tool developed by th e researchers. Study participants also were asked to report if they had received a mammogram or clinical breast examination within twelve months pr ior to the study. The second instrument was related to intention. Intention was measured by a single item related to the likelihood that the subject would get a mammogram in the next year. Responses to this item were rated on a five-point Likert-type scale that range d from “not at all” to “extremely”. Approximately 80% of the study participants re ported that they had received a clinical breast examination and mammogram at least twelve months prior to the study. Eighty-

PAGE 58

47 eight percent reported that they were “very likely” or “extremely likely” to get a mammogram in the following year while 87% responded in the same manner when asked about the likelihood of getting a clinical breast examination in the following year. The study results also indicated that efficacy of mammogram and clinical breast examination was significantly related to intention (p .05). Significant relati onships also were found between intention and barriers to mammogr aphy and clinical breast examination (p .001) as well as between intention and physician recommendation for mammogram and clinical breast examination (p .001). In relation to the TPB model, efficacy in this study is most closely related to perceived behavioral cont rol. Barriers are related to the attitude component of the model while physician recomm endation is related to subjective norms. Conclusions from the study indicated that perceived barriers to mammography and physician recommendation were the strongest predictors of breas t cancer screening intentions and behaviors. Van Ryn, Lytle, and Kirscht (1996) explored the relationship be tween breast selfexamination (BSE) and the theory of planne d behavior. The purpose of the study was to test the usefulness of the theory in predicti ng performance of BSE. The sample consisted of 185 telephone company employees in a midwes tern state. The participants ranged in age from 26 to 61. Fifty-five percent of th e sample was female and 89% were Caucasian, while 11% were from other ethnic groups. The authors did not report a more specific breakdown of the other ethnic groups. The inst ruments used to eval uate the relationship between BSE and the TPB included a self-reporte d health risk appraisal and an interview containing questions derived from the elements of the theory of planned behavior. The interview included questions related to attitude toward BSE, frequency of BSE, and

PAGE 59

48 whether the subjects had inten tion to change their personal behavior. The interview was repeated 6 months later to determine if th e participants had move d from intending to complete the behavior (BSE) to actually pe rforming the behavior. The results of the study indicated that attitude and subjective norms had a direct effect on intention to perform BSE. When age and education were added as controls, there was no change in the effect pattern. Identifying factors that influence par ticipation in mammography screening and BSE performance was the focus of a study by Savage and Clarke (1996). The purpose of the study was to investigate th e predictability of attit udes and subjective norms in intention to execute BSE and intention to obtain mammogram. One hundred seventy women aged 50 to 70 served as the sample. The sample was recruited from a large city in Australia. Educational levels of the wo men ranged from 5 to 21 years with a mean educational level of 10.7 year s. Seventy-eight percent of the women were housewives. Telephone interviews were conducted and each study participant was asked 35 questions. The following variables were measured: demogr aphic, social influence (related to social norm), previous health behaviors, access to screening, perceived self-efficacy of BSE (related to perceived behavi oral control), attitude to ward BSE, and knowledge of mammography and BSE. The study found that 87% of the women reported favorable attitudes toward mammography and BSE. Fortyeight percent of the sample reported that they were either “extremely” or “quite” lik ely to acquire a mammogram within the next two years and practice BSE every month duri ng the twelve months following the study. The conclusions of this study indicated th at women were favorable towards BSE and mammography, but that less than half of the samp le was actually willing to participate in

PAGE 60

49 these cancer screening behaviors. A second important finding from this study was that the strongest predictor of BSE intention wa s prior performance of BSE (r=0.76). This finding supports the importance of self-efficacy and perceived behavioral control in motivating behavior. Jennings-Dozier (1999) tested the theory of planned behavior to predict intentions to obtain a Pap smear in African American and Latino women. The purpose of the study was to determine the empirical adequacy of the theory in predicting Pap smear intention in African American and Latino women. The sample consisted of 108 African American women and 96 Latino women. The sample wa s obtained from nonprofit agencies in the mid-Atlantic area of the United States. The participants ranged in age from 18 to 83. The instruments for the study included the Pap Smear Questionnaire and the Demographic Assessment Survey. The Pa p Smear Questionnaire was a 75-item questionnaire created to determine the relatio nship between Pap smear intentions and the variables of the theory of planned beha vior. The Demographic Assessment Survey collected information related to socioeconomic status, ethnicity, and ag e. The results of the study indicated that att itude toward Pap smear ( =0.58; p < .001) and perceived behavioral control ( = 0.30; p < .001) were significantl y related to intention to obtain Pap smear in African American women. The same results held true for Latino women, but to a lesser degree. Am ong Latino women, both attitude ( = 0.40; p < .001) and perceived behavioral control ( = 0.35; p < .001) weighed similarly. Sheeran and Orbell (2000) tested atti tude, subjective norms, and perceived behavioral control in predicting attendance at cervical cancer screenings. The sample consisted of 114 women who were scheduled for routine gynecol ogical examinations

PAGE 61

50 within a three-month period. These women we re recruited from a single medical practice in England. The subjects ranged in age from 20 to 67. There were no racial or educational descriptors given in the study. A questionnaire th at assessed attitude toward cervical cancer screening was mailed to the wo men prior to their office visit. All the items on the questionnaire were measured on a 5point Likert type scal e. Ninety-two of the 114 participants received screening within 3 months from when the questionnaire was administered. The results of the study reveal ed that elements of the theory of planned behavior were able to differentiate betw een 89% of attendees versus nonattendees. Subjective norm and perceived behavioral cont rol were stronger predictors than attitude in terms of obtaining a cervical cancer ex am within the allotted 3-month period. A prospective longitudinal study testing th e predictive ability of the TPB was conducted by Rutter (2000). The purpose of th e study was to test th e ability of the TPB to predict attendance at a mammography scr eening and then predic t reattendance three years later. The first sample cons isted of 1215 women who had never had a mammogram. The second sample included 638 women from the first sample. These women were part of the initial sample a nd were those who returned for mammography screening three years after th e initial screening. Questionna ires were mailed to the study participants. Subscales for attitude ( =0.76), subjective norm ( =0.86), and perceived behavioral control ( =0.77) were developed by the resear chers. Intention was measured by a single item asking if the subjects inte nded to attend the ma mmography screening. Study results exhibited positive correlations between attitude and intention (r=0.45), subjective norm and intention (r=0.36), and perceived behavioral control and intention (r=0.40). The TPB components explained 29% of the variance in mammography

PAGE 62

51 screening intention. Additionally, the corr elation between attendance and reattendance was 0.37, while the correlation between inten tion and attendance also was 0.37. Finally, the correlation between intention and reat tendance was 0.21. Conclusions drawn from the study suggested that inten tion was the strongest predic tor of attendance. Second, subjective norm appeared to have the greatest effect on intention. This seems to suggest that the opinion of important others may ha ve greater value than the individual’s own opinion with regard to attendance at ma mmography screening. Finally, the study concluded that prior attendance at mammogra phy was the only significant factor related to reattendance at ma mmography screening. Theory of Planned Behavior and Cancer Risk Reduction Hillhouse, Adler, Drinnon, and Turrisi ( 1997) applied the TPB to predict tanning salon use, sunbathing, and use of sunscreen in tention and behavior. The purpose of the study was to explore the rela tionship between the components of the TPB and behaviors that affect exposure to ultraviolet light. These behaviors included intentions related to tanning salon use, sunbathing, and suns creen use. The sample included 131 undergraduate and graduate students from a southern university. The measurement instruments included a demographic questionnai re and a researcher-d eveloped instrument to measure the three elements of the TPB. The researchers did not report the number of questions contained in the in strument. Reliability coeffi cients were reported between 0.76-0.96. The instrument was administered in three sections over a 2-week period. Finally, the subjects were aske d to report their sun exposure behaviors. The results of the study denoted that the variables of the TPB explained nearly 60% of the variance overall

PAGE 63

52 in relation to ultraviolet light exposure (R2=0.59). Conclusions from the study support the use of the TPB to explain intention related to these thre e high-risk cancer behaviors. Hillhouse, Turrisi, and Kastner (2000) appl ied the theory of planned behavior to assess intentions to use tanning salons. Th e purpose of the study was to explore the predictive ability of the TPB to describe tanning salon use. One hundred ninety-seven students from freshman and sophomore classes at a university in the southeastern US served as the sample. The sample was 60% female and the mean age was 22.4 years. Only students with skin types that have been shown to be associated with increased cancer risk were selected as participants. A researcher-developed questionnaire patterned after guidelines from Ajzen a nd Fishbein served as the pr imary instrument for data collection. Attitude was assessed using a seven-point semantic differential scale ( =0.94). Subjective norm was measured by a single item dealing with whether those important to the subjects thought they should or should not utilize a tanning salon. They also were asked about their le vel of motivation to comply wi th the opinion of important others. Perceived behavioral control was assessed by a single item related to the ease or difficulty associated with using a tanning sa lon. Intention was eval uated with a single item asking about the likelihood of attending a tanning salon. Behavior also was assessed by a single item that asked the subjects to re port the frequency of ta nning salon use in the 12 months prior to the study. The results of the study revealed that intention and perceived behavioral control accounted for 41% of the variance in tanning salon use. It also was determined that as perceived be havioral control incr eased, the relationship between intention and actual tanning salon use became more positive. Third, the study indicated that the variable s of the TPB accounted for 49% of the variance in tanning

PAGE 64

53 salon use. Finally, the study results disclo sed that as perceive d behavioral control increased, the relationship between attitude and intention became more positive. A significant conclusion from the study suggests that focusing on variables related to attitude may be the best st rategy to change intention, a nd subsequently behavior. Describing the social and psyc hological factors associated with early detection of cancer was the focus of a study conducted by de Nooijer, Lechner, and deVries (2003). The purpose of the study was to identify factor s that explained inten tion to pay attention to cancer symptoms and intentions to seek medical intervention for possible cancer symptoms within an appropriate time fr ame. A convenience sample of 534 people recruited from local Dutch newspapers served as the study participants. Seventy-seven percent of the sample was female and the m ean age was 48 years. Ninety-two percent reported that someone in their household had a prior experience with cancer, while nine percent reported a personal experience with cancer. The first part of the questionnaire was a 67-item questionnaire developed by the re searchers. This questionnaire included items related to the components of the TPB as well as questions related to self-efficacy, moral obligation to seek hel p, and modeling. Part two of the questionnaire included questions related to knowledge of cancer symp tomatology (n=15). Study results revealed that attitude and perceived be havioral control were significa ntly related to attentiveness to cancer symptoms, accounting for 16% of th e variance. Social norm and perceived behavioral control were si gnificantly related to seeki ng help for possible cancer symptoms, accounting for 20% of the variance. Conclusions from this study supported the predictive ability of the TPB with re gard to paying attention to possible cancer

PAGE 65

54 symptoms and seeking help for cancer symptoms However, the low variances reflect the need for numerous replications of studies of this type. Parchment (2004) studied the health belie fs about prostate health among African American men. The purpose of the study was to investigate the beliefs about prostate early detection in a sample of African Am erican men. The sample consisted of 37 African American men recruited from three c hurches in the southern United States. The men ranged in age from 37-89. The instrument s for data collection included a “Cancer Awareness” survey. The survey included questio ns related to prosta te health, questions concerning reasons for delayed screening, and demographic questions. Eighty percent of the men reported the dislike for the digital rectal exam as th e reason for not participating in prostate cancer screening. Also, 75 percent of the men in the sample reported that the information they received from their physicia ns about prostate cancer had no effect on their participation or nonparticipa tion in prostate cancer screening. Understanding factors that infl uence the intention to participate in prostate cancer screening was the focus of a study conducte d by Ford, Vernon, Havstad, Thomas, and Davis (2006). The purpose of the study was to evaluate the factors related to prostate cancer screening perceptions among African Am erican men. The sample consisted of 21 African American men recruited from a large, mid-western nonprofit health system. The men in the sample were divided into two groups. The men in group one ranged in age from 55-87 years and the men in group two ra nged in age from 55-81 years. Focus groups served as the method for data collec tion and the Preventive Health Model served as the conceptual framework in the devel opment of the focus group questions. Five recurrent themes were identified from the focus groups: knowledge of prostate cancer

PAGE 66

55 and prostate cancer screening, bac kground factors of race and gender, cognitive/psychological factors, social support and influence factors, and programmatic/systematic factors. The results indicated that the participants had a lack of knowledge about the PSA test, but were aware of the increased inci dence and mortality rates of prostate cancer in Af rican American men. Participants in the group also reported fear of cancer and a degree of “shame” if others knew they had developed cancer. A third finding from the study was the wide ra nge of people that were influential in the men’s participation in prostate cancer scre ening. These influences included spouses, children, medical personnel, media, and the church. Summary Lack of participation in pr ostate cancer screening activities by African American men has been the most significant justifica tion for increased incidence and escalating mortality rates of prostate cancer in this population. Limited studies exist that examine the reasons for low levels of participation of African Amer ican men in prostate cancer screening procedures. An investigation of the lit erature reveals that knowle dge of prostate cancer and attitude toward prostate can cer screening procedures may be related to intention to participate in screening. Cancer fatalism is also believed to be related to prostate cancer screening such that it helps explain the level of belief in predestination that a person possesses (Powe, 1995; Straughn and Seow, 1998) Healthy lifestyle also has been shown to be a strong indicator of prostate cancer sc reening intention in that persons who perceive health to be important and perceive themselves to be in control of their health are more likely to participate in health promoting activities (Pender, 1996). Also,

PAGE 67

56 sociodemographic variables such as age, inco me, and educational levels have been shown to negatively impact wellness and decrease health-s eeking behaviors. Though several instruments ex ist that examine these variables individually, no instrument has been developed to examine th em concurrently. In addition, few of these individual instruments have been utilized exclusively with African American men. Development of a valid and reliable measure of prostate cancer screening intention that is both culturally sensitive and read ing level appropriate is critic al if we intend to positively impact the health and wellness of African American men. Based on the foregoing review of literatu re, the following conceptual model is proposed (Figure 1). Figure 1. Prostate Cancer Screening Intention Model

PAGE 68

57 Intention The concept of intention is based on th e Theory of Planned Behavior (Ajzen and Fishbein, 1980). The theory of planned behavior was developed from the social cognitive theory. It was deve loped to explain the role of beliefs and attitudes in determining behavior. The theory was devel oped by Ajzen and Fishbein (1980) and is based on the premise that behavior is a f unction of intention. They developed a model that states that "intention is equal to atti tude toward the behavior plus the subjective norms in relation to the behavior". It serves as the theoretical framework for describing the intentions of individu als to perform behaviors. The theory postulates that there are thr ee basic factors that determine a person's behavioral intentions: a persona l or attitudinal factor, a so cial or normative factor and perceived behavioral control. The personal or attitudinal factor refers to the person's attitude toward participating in the behavior. It defines whet her the person has a favorable or unfavorable feeling toward performi ng the behavior. The social or normative component involves the influence of the envir onment on intentions and behavior. It deals with an individual's perception that impor tant others desire the performance or nonperformance of the behavior. The premise is that the greater the perceptions of important others to perform the behavior, the higher the level of intention to perform the behavior (Ajzen and Fishbe in, 1980). Perceived behavioral control was added to the model by Ajzen (1991). Perceived behavioral control is the be lief that most behaviors are located along a continuum that moves from to tal control to complete lack of control.

PAGE 69

58 Sociodemographic Factors Sociodemographic factors in this model include age, educational level, and income. They also include the subject’s prev ious medical history and previous exposure to prostate cancer screening. Finally, influence of family and important others are included in the background fact ors that are believed to be related to prostate cancer screening intention. It has been reported that age is negativ ely related to prostate cancer screening intention. Educational level and inco me are believed to be positively related to prostate cancer screenin g intention. Previous medical hist ory, prior exposure to prostate cancer screening, and influence of family and im portant others have al so been noted to be positively related to prostate cancer screeni ng intention. Background factors are related to the social-normative component of the Theory of Planned Behavior. Prostate Cancer Screening Knowledge Knowledge of prostate cancer screening re fers to whether the subject is aware that a screening for early detection of prostate cancer exists and what that screening entails. It has been proposed that increased levels of knowledge increase intent to participate in prostate cancer screen ing. Prostate cancer screeni ng knowledge is related to the personal-attitudinal component of the Theory of Planned Behavior. Attitude Toward Prostate Cancer Screening Attitude toward prostate cancer screeni ng includes elements of the Health Belief Model (Rosenstock, 1974). This variable refe rs to the subject’s pe rceived susceptibility to prostate cancer, perceived se riousness of prostate cancer, pe rceived benefits of prostate cancer screening, and perceive d barriers to prostate cancer screening. Perceived susceptibility, perceived seriousness, and percei ved benefits are reported to be positively

PAGE 70

59 related to prostate cancer scre ening intention. Perceived ba rriers are believed to be negatively related to intent to participate in prostate cancer screen ing. Attitude toward prostate cancer screenin g is related to the personal-attit udinal component of the Theory of Planned Behavior. Degree of Cancer Fatalism Fatalism refers to the belief that there are some things in life that would occur despite any action that might be taken by an individual. Fatalism is believed to vary along a continuum, which ranges from very fata listic on one end of the continuum to a very strong belief in one’s abilit y to control outcomes. In this model, cancer fatalism is believed to be negatively related to prostate cancer screening inten tion. Cancer fatalism is related to the perceived behavioral control component of the Theory of Planned Behavior. Healthy Lifestyle Healthy lifestyle is related to the subject ’s participation in other health-promoting activities. These activities include choleste rol screening, annual physical exams, healthy diets, and exercise. Healthy lifestyle is repo rted to be positively related to intent to participate in prostate cancer screening. Health y lifestyle is related to the personalattitudinal component of the Theory of Planned Behavior.

PAGE 71

60 Chapter Three Methods The research methods and procedures used in this study are reviewed and presented in this section. First, the overall focus of the CSIS -P is described. Second, the purposes of each phase of the study are stated. Third, the methods of each phase of the study are outlined. This includes identification of the sample, description of the sample criteria, details of the outlin e for the process of ensuring th e protection of human subjects, explanation of the data collection methods and the procedures for data analysis. Phase One Purpose The purpose of Phase I of this study was to explore the attitudes and beliefs of African American men toward prostate can cer. A second purpose was to identify and understand the perceived factors that influence the intention of African American men to participate in prostate cancer screening ac tivities. A qualitative approach was used in Phase I. Sample The sample consisted of twenty African American men divided into three focus groups. The following inclusion criteria were used: 1) over the age of 35; 2) African American; 3) able to understand written a nd spoken English. African American men

PAGE 72

61 under 35 were excluded due to the decreased in cidence of prostate cancer in this age group. Africans, Caribbean Africans, and Hisp anics with African he ritage also were excluded from the study because multiple ethn icities and cultural heritages may confound the study. The ethnicity of the subjects was id entified by the investig ator. There were no income or educational restrictions. Subjects were obtained from local African American churches. The homogeneous phenomenal variation of purposeful sampling was the technique used in this study. Phenomenal variation sampli ng allows the researcher to examine differences among the men in the group about a target phenomenon. Homogeneous phenomenal variation samp ling focuses on the variation of the phenomenon (attitude toward prostate cance r screening, for example) among a relatively homogeneous sample (African American men) This sampling method is appropriate for this study because it allows for identification of the variables most likely to be important in understanding attitudes of African American men toward prostate cancer screening (Sandelowski, 1995). Procedures Authorization to conduct the study was obtai ned from the pastors at the target churches (Appendix A). Following their ap proval, application was made to the University of South Florida Institutional Re view Board for Protect ion of Human Subjects (Appendix B). The pastor identif ied the appropriate subject gr oups. The investigator then contacted the potential subj ects by phone. The purpose of the study was explained. The potential subjects were then asked to read a consent form further e xplaining the study and were given an opportunity to ask questions re lated to the study. Subjects were assured that the data would be used for research purposes only, all information would remain

PAGE 73

62 confidential, identifying codes would appear on the data forms rather than names, and that all data would remain in a locked cabin et in a locked office. Consent from each participant was then obtained and a copy of the consent was given to each study participant. Prior to the interviews, a demographic quest ionnaire was administered to each potential subject (Appendix C). The exploratory qualitative descriptive me thod was used to guide data collection from the focus groups. Qualitative descriptiv e method is utilized to discover themes and patterns about a particular phenomenon. Th e exploratory approach to qualitative descriptive method allows the researcher to explore the meaning of some life event for a group of individuals. Data collection in this method may in clude interviews, observations, or questionnaires (Parse, 2001). For the purposes of th is study, interviews were conducted. The interviews were conducted via stru ctured focus groups. Focus groups are a beneficial tool to use when gathering info rmation from a target population about some phenomenon. They have been proven to be a successful method for assessing behavior that is influenced by attitudes. They also promote self-disclosure when group members have common characteristics (Krueger & King, 1997). An interview schedule was developed to guide the focus group session (App endix D), and the prin cipal investigator served as the moderator of the focus groups Data collectors included the principal investigator and a master’s pr epared individual who served as the assistant moderator and recorder and was trained in focus group methodology by the principal investigator. The sessions were audiotaped and the assistan t moderator took fieldnotes consisting of observations during the interview sessions. The focus groups were 60-120 minutes in

PAGE 74

63 length. The audiotapes and fi eldnotes were transcribed by th e principal investigator and the assistant moderator. Data Analysis The principal investigator and qualitativ e research expert reviewed the data utilizing the content analysis method in or der to identify emerging themes related to prostate cancer screenin g. Content analysis method has been identified as an efficient and objective way to describe phenomena in qualitative research. It provides a method by which qualitative data can be organized in to categories that reflect similar content, allowing themes to be more easily iden tified (Downe-Wamboldt, 1992). Weber’s approach for conducting content analysis (1995) was followed in analyzing data from this study. First, the categories were create d and defined; this was accomplished by frequency counts of common words and phrases throughout the transcript. Second, a pretesting of the category definitions was done by a thorough review of the transcripts and a category creation by a second qualitative research er. Reliability was then assessed. The second coder independently classified the tran script and compared it with the coding of the principal investigator in order to assess inter-coder reliability. The resulting themes were then used to begin Phase II of the study. Phase Two Purpose The purpose of Phase II was to utilize the themes identified in Phase I of the study as well as the review of literature to devel op a valid and reliable instrument to measure prostate cancer screen ing intention in African Ameri can men. A second purpose was to evaluate the cultural sensitivity of the instrument.

PAGE 75

64 The focus of the development of the CS IS-P was to determine the subjective probability (intention) that African American men will participate in prostate cancer screening activities by iden tifying what variables may increase or decrease that probability. This subjective pr obability is believed to be rela ted to a person’s attitude toward the behavior (prostate cancer screeni ng), the degree to which a person believes in and participates in other illness-preventive behaviors, the extent to which a person believes that prostate cancer screening will reduce the risk of getting prostate cancer, and pertinent participant background factors (age, educational le vel, income, past medical history, previous exposure to prostate cancer screening). Intention is believed to be equal to the sum of three basic factors: attitudinal factor, normative factor, and perc eived behavioral control. Items related to these three factors as well as direct questi ons related to intention will be asked (example: I plan to have a prostate cancer screening examination within the next year). The responses to these questions were scored based on 4-point Likert-type scaling. The items were then correlated within and between each factor as well as with th e direct intention questions. The direct intention questions were also correlated with the responses on the measures for fatalism, healthy lifestyle, health beliefs, and with the sociodemographic variables. The expectation is that all these items will correla te highly (positively or negatively) with the aim being to utilize the results to focu s on future educational interventions. Sample The sample for Phase II consisted of th e twenty African Am erican men from the focus groups who reviewed the items of the in strument for content and clarity. All men for this phase met the following inclusion cr iteria: 1) over the ag e of 35; 2) African

PAGE 76

65 American; 3) able to understand written a nd spoken English. African American men under 35 were excluded due to the low inciden ce of prostate cancer in this age group. Africans, Caribbean Africans, and Hispanics with African heritage also were excluded from the study because multiple ethnici ties and cultural heritages may confound the study. There was no income or educational re striction. Subjects were obtained from local African American churches. Instrument Items for each subscale of the CSIS-P (A ppendix E) were developed utilizing the themes identified from Phase I of the study and the corresponding variables from the literature review. The items were then forma tted and scoring criteria were developed. The definitions associated with the scor es on each subscale were then outlined. As the instrument was being developed, the “Guidelines for Cultural Competency in Oncology Nursing Research” developed by the Oncology Nursing Society (Oncology Nursing Society, 2000) were used to evaluate the cultural sensitivity of the instrument. These guidelines state that if an instrument is to be deemed culturally sensitive, it must meet the following criteria: 1) the questions to be studied must reflect the researcher’s awareness of the culture; 2) the problem to be studied must be significant to the group to be studied; 3) the theoretical framework suppor ting the instrument must be appropriate for use with the cultural gr oup; 4) the theoretical fram ework must incorporate the concepts of ethnicity an d race; 5) the health beliefs and va lues of the target group must be incorporated into the tool; and 6) member s of the targeted cultural group must be involved in the development of the instrument. The instrument was then presented to the men from Phase I of the st udy for theme confirmation.

PAGE 77

66 Content validity from experts. One African American urologist, two African American oncology nurses (one male), one African American nurse educator, and one Caucasian oncology nurse educator made up the panel of experts that evaluated the instrument for content validity. Each item was presented to the panel and they were asked to assess each item by responding to the following questions: 1) Does this item measure prostate cancer screening intention? 2) Is this item appropriate for African American men? The panel responded “yes” (+1) “no” (-1), or “un certain” (0) to each question. A content validity index (CVI) was generated for each item and for the total instrument. Content validity from sample. The CSIS-P was given to the sample of African American men in Phase II of the study to ev aluate the accuracy of the content of the items based on the information obtained from the focus groups. They also were asked to assess the length and clarity of the tool. Refinement of the CSIS-P was completed based on the evaluations of the experts and the a ssessment of the African American men from Phase I. The CSIS-P was then administered to the final sample in Phase III. Procedures Permission to conduct the study was acqui red from the pastors of the local churches. Authorization to conduct this phase of the study was obtained from the University of South Florida Institutiona l Review Board for Protection of Human Subjects. The purpose of the study was expl ained to the men. Next, the potential subjects were asked to read a consent fo rm further explaining th e study and were given an opportunity to ask questions related to the study. Subjects were a ssured that the data would be used for research purposes only, al l information would remain confidential,

PAGE 78

67 identifying codes would appear on the data fo rms rather than names, and that all data would remain in a locked cabinet in a locked office. Consent from each participant was obtained and a copy of the consent was given to each study participant. The CSIS-P was then given to each of the men from Phase I of the study for review. Data Analysis The results of the CVI were used to answ er the first research question from Phase II of the study. The CSIS-P was presented to an expert panel for content validity analysis. The CVI was analyzed assessing bot h the index of each item and the average index of the entire instrument. Content vali dity indices for each item ranged from .40 to 1.0. Items with correlations less than .70 we re revised, replaced, or deleted. A content validity index of .90 was estimated by the pane l. Guidelines from the Oncology Nursing Society’s criteria for ensuring cultural competency in instruments were used to analyze the CSIS-P (Oncology Nursing Society, 2000) an d answered the second research question from Phase II of the study. Assessment of the reading level was completed using the Flesch-Kincaid Reading Ease test and SMOG formula to answer the third research question from Phase II of the study. Final revi sion of the CSIS-P was then done based on the above data. Phase Three Purpose The purpose of Phase III of the study was to estimate the validity and reliability of the Prostate CSIS-P. A second purpose was to identify the sociodem ographic factors that influence prostate cancer screening in tention in African American men.

PAGE 79

68 Sample The sample in the final phase of the study consisted of 203 African American men. Inclusion criteria for the sample included the following: 1) must be over the age of 35; 2) must be African American; 3) must be able to understand written and spoken English. African American men under 35 we re excluded due to the low incidence of prostate cancer in this age group. Africans, Caribbean Africans, and Hispanics with African heritage also were excluded from the study because multiple ethnicities and cultural heritages may confound the study. The ethnicity of the sample was identified by the investigator. There were no income or educational restrictions African American subjects were obtained from African American churches. Instruments Six instruments were administered to th e sample of 203 African American men. All instruments are appended. Demographic Questionnaire. The first instrument administered was a demographic questionnaire developed by the pr incipal researcher. This questionnaire included items related to age, educational leve l, and previous exposure to prostate cancer education and prostate can cer screening (Appendix C). Prostate Cancer Knowledge Questionnaire. The second instrument was an amended version of a prostate cancer scre ening knowledge scale developed by Maliski (2007). The amended scale consists of seven que stions related to risk factors for prostate cancer, symptoms of prostate cancer, treatm ent for prostate can cer, and risk reduction measures related to prostate cancer (Appendi x F). There was no va lidity or reliability data reported by the author. However, this researcher submitted the questionnaire to a

PAGE 80

69 panel of experts to assess the scale for cont ent validity. Each item was presented to the panel and they were asked to assess each it em by responding to the following questions: 1) Does this item measure prostate can cer screening knowledge? 2) Is this item appropriate for African American men? The panel was asked to respond with “yes” (+1), “no” (-1), or “uncertain” (0 ) to each question. A cont ent validity index (CVI) was generated for each item and for the total instru ment. Content validity for the instrument was estimated at .80. The possible knowledge scores ranged from zero to seven with a mean score of five. Cancer Screening Intention Scale-Prostate. The final version of the CSIS-P was a 43-item tool that was designed to meas ure prostate cancer screening intention (Appendix E). Responses to items were scor ed using a 4-point Likert-type scale. Responses included strongly agree, agree, disagree, and strongly disagree and were numerically scored from four to one. Negativ e items were reverse scored. Higher scores on the CSIS-P reflected higher in tentions to participate in prostate cancer screening. Prostate Cancer Belief Scale. The Prostate Cancer Belief Scale (Appendix G) is a 10-item scale modified from Gibson’s Prostate Cancer Belief Instrument (Gibson, 1995). There was no recorded validity or reliability data on the instrument developed by Gibson. However, this researcher submitted the modified scale to a panel of experts for assessment of content validity. Each item was presented to the panel and they were asked to assess each item by responding to the following questions: 1) Does this item measure health motivation, benefits of prosta te cancer screening, ba rriers to prostate cancer screening, susceptibility to prostate cance r, and seriousness of prostate cancer? 2) Is this item appropriate for African Ameri can men? The panel was asked to respond with

PAGE 81

70 “yes” (+1), “no” (-1), or “un certain” (0) to each question. A content validit y index (CVI) was generated for each item and for the total instrument. Item CVIs ranged from .20 to 1.0. Content validity for the instrument was estimated at .80. The possible scores ranged from ten to forty. Powe Cancer Fatalism Index. The Powe Cancer Fatalism Index (Powe, 1995) is a 15-item scale that was developed to asse ss degrees of cancer fatalism (Appendix H). Content validity estimates were reported obtained from pilot testing. Reliability testing reported a Cronbach alpha of .84. Higher scores on the index reflect higher degrees of fatalism. A score of zero to five indicates a low degree of fatalism, scores from six to ten indicate a moderate degree of fatalism, and sc ores from eleven to fifteen reflect a high degree of fatalism. Health Promoting Lifestyle Profile II. The final instrument was the Health Promoting Lifestyle Profile II (HPLP II) (Pe nder, Walker, and Sechrist, 1990; Pender, 1996). The HPLP II is a revision of the orig inal HPLP developed by Walker and Pender (1990). Psychometric evaluation of the HP LP II was detailed by Walker and HillPolerecky (1996). The HPLP II contains six su bscales: spiritual growth, interpersonal relations, nutrition, physical ac tivity, health responsibility, and stress management. For this study, the subscales of nutrition, physical activity, and health responsibility were used (Appendix I). Scores for each item range from one to four with higher scores indicating higher levels of health promotion. Content validity was es timated by literature review and content experts. Construct vali dity was evaluated by factor analysis which confirmed the six factors. Internal c onsistency for the HPLP II was .94 and alpha coefficients for the subscales ranged from .79 to .87 (Walker & Hill-Polerecky, 1996).

PAGE 82

71 Procedures Permission to conduct the study was acqui red from the pastors of the local churches. Authorization to conduct this phase of the study was obtained from the University of South Florida Institutiona l Review Board for Protection of Human Subjects. The men were approached in gr oups. The purpose of the study was explained. The potential subjects were then asked to re ad a consent form further explaining the study and were given an opportunity to ask questi ons related to the study. Subjects were assured that the data would be used for research purposes only, all information would remain confidential, identifying codes would appear on the data forms rather than names, and that all data would remain in a locked cab inet in a locked office. Consent from each participant was then obtained and a copy of the consent was given to each study participant. The subjects we re then asked to complete and return the instruments. A subset of 21 men was asked to complete th e CSIS-P a second time two weeks after the first administration of the instrument. Data Analysis Descriptive statistics were used to an alyze the demographic data. Correlational analyses were conducted betw een the CSIS-P and the esta blished instruments (Powe Fatalism Index, Prostate Cancer Knowledge Scale, Prostate Cancer Belief Scale and Health Promoting Lifestyle Profile) in order to estimate construct-rela ted validity. Factor analyses were completed to determine whet her there are subscales in the CSIS-P and whether the items are a good f it. Factor analysis is fr equently utilized in scale development. It is primarily used to de termine intercorrelation among the items in a scale (Whitley, 1996). Cronbach’s alpha coeffi cients were calculated to estimate the

PAGE 83

72 internal consistency of the CSIS-P. Cronbach ’s alpha is a common approach to assess the consistency among items when multiple it ems are used to assess a trait (Whitley, 1996). Pearson’s correlation coefficients uti lizing the test-retest pr ocedures with a twoweek delay also were conducted to determine the stability of the CSIS-P (Tabachnick & Fiedell, 1990). Test-retest reliability evaluates consis tency across time and is an appropriate method to assess the stability of an instrument (Tabachnick & Fiedell, 1990).

PAGE 84

73 Chapter Four Results The results of the research study are reviewed in this sect ion. First, the results of the qualitative phase of the st udy are reported. Next, the resu lts from the second phase of the study are reviewed. Finall y, results from the third phas e of the study are detailed. Phase One Qualitative methods were used to answ er the following research questions in phase one of this study: 1) What are the attitudes of African American men toward prostate cancer screening? 2) What are the perceived factors that influence prostate cancer screening in African American men? Focus groups were used as the method of data collection and the results are presented below. Sample The sample consisted of twenty Africa n American men in three focus groups. There were nine men in the first focus gr oup, five men in the second group, and six men in the third group. The men ranged in ag e from 35 to72 with a mean age of 50. Educational level ranged from eighth grade to master’s degree, with a mean of 14.1 years. None of the sample reported a histor y of prostate cancer and only 25% (n = 5) reported having a family history of prostate cancer. Eighty percent of the sample reported that they had received a PSA, while 60% reported receiving a DRE. The detailed demographic data is outlined below (Table 1).

PAGE 85

74 Table 1. Number and Percent of Men by Age and Education Number Percent Age Group 35-44 4 20 45-54 11 55 55-64 3 15 65-72 2 10 Education Less than high school 2 10 High school graduate 4 20 Some college and above 14 70 Totals 20 100 Data Analysis All the audiotapes were transcribed by th e principal investigator. The transcribed tapes were reviewed by the principal investig ator, and recurrent themes were identified using content analysis. The notes from the a ssistant moderator also were reviewed. The transcriptions also were reviewed by an i ndependent coder and a qualitative expert in order to estimate inte r-rater reliability. Results Ten themes emerged from the focus group an alysis by the principal investigator. Eight of the ten themes identif ied by the principal investigator also were identified by an independent coder and supported by a qualitati ve expert. These eight dominant themes along with their frequency count s are summarized (Table 2).

PAGE 86

75 Table 2. Focus Group Themes by Frequency Theme Frequency Count Health promotion 10 Fear 10 Lack of knowledge/education 9 Hopelessness/helplessness 5 Social/familial support 5 Machismo 2 Barriers (job, transportation) 2 Mistrust of healthcare providers 1 Health Promotion When asked about the things they did to stay healthy, most of the men reported consistent exercise and nutritio us eating as methods utilized to maintain good health. However, most of the men in the sample also reported that they did not get regular annual physical exams or regularly participate in scre ening activities for prevention or early detection of disease. Fear Fear was a very frequent and for ceful theme among the men in the focus groups. It was reported as the most significan t reason for the lack of participation in prostate cancer screenin g procedures. Responses to the question “What gets in the way of people getting tested for prostate cancer” included: “As for myself, I think for me, it’s a scary disease. It can sneak up on you” “Fear. You know fear of knowing, fear of thinking you got it or something like that” “And I think it’s because they’re scared of finding out they actually do have it because there have been cases wher e men have found out they had it and

PAGE 87

76 they didn’t do any follow-up” “And I think it’s because they’re afraid of it. You know, thinking that they might have it” When the men spoke of fear of prostate cancer and fear of the screening, they also voiced a dislike for the test itself, particul arly the DRE. During this exchange, the assistant moderator noted fidgeting and nervous facial expressions. This behavior was exhibited in all three groups. Lack of knowledge/education Cancer awareness and e ducation was identified by the focus groups as the single most important way to increase participation in prostate cancer screening. Some of the responses related to lack of knowledge included: “I don’t think a lot of men are educ ated on it, so they don’t know what the test is really about” “Basically, if we get some type of education program, you know, started in the church, you know, and coordinate it with a church function. So I think education is the key because if you don’t know about it, you tend to overlook it” “I think also too, it needs to start in the home. The men who know about it have to tell their sons that at a certain age you need to get tested for prostate cancer” “Education, the knowledge of and understa nding of what the test is, what it’s about. The education just hasn’t filtered like it should into that neighborhood, you know what I mean, into the black neighborhoods” “The awareness again, if you hold one of these seminars on a men’s meeting or hold one of these semina rs in church five minutes, just the awareness. Because a lot of young black men are not aware, so it goes on” Hopelessness/Helplessness Twenty-five percent of th e sample voiced attitudes of hopelessness when referring to prostate cancer and prostate cancer tr eatment. They felt that a diagnosis of prostate cancer meant terminality and that the treatment of prostate

PAGE 88

77 cancer resulted in th e end of sexuality. Though only five men made verbal statements that reflected a fatalistic attitude, many nods of affirmation were noted by the assistant moderator. One of the focus group participan ts made this comment related to fatalism: “When your equipment through working, you through working” This was the general sentiment throughout all of the focus groups and has emerged as a common theme among African American men when discussing prostate cancer and prostate cancer treatment. Social support Twenty-five percent of the sample stated that encouragement from significant others was an influent ial factor in participating in prostate cancer screening. Several men reported that they would not see a doctor if their family members had not urged them to go. Responses relevant to social support from focus group members included: “Thank God for my wife, because she was really encouraging me, having me go back for this test or that test” “I also think having wives or girl friends pressure their husbands or boyfriends to tested” When asked whether they received appropr iate health screeni ngs, one of the men responded: “I get them, but I probably w ouldn’t if my wife didn’t stay on me”. Machismo Two of the men from the focus gr oups (10%) made direct references to machismo as the reason for nonparticipation in prostate cancer sc reening. When asked about things that prevent African American men from participating in prostate cancer screening, one man responded: “The process itself, you know, the machismo of a man”.

PAGE 89

78 Barriers Lack of transportation and work condi tions were identified as barriers to prostate cancer screen ing by two of the men in the focus groups. In regards to work conditions, one of the men stated: “I can take off, but then I run the risk of being harassed when I get back because my load of the work had to be shifted b ecause I had to go do this. I think a big thing, you know, that if it was made mandatory that employers, you know not harass or put any added pressure on the person that’s got to go and have checkups” Mistrust Only one man in the focus groups ci ted mistrust of healthcare providers as a reason for lack of participation in pros tate cancer screening. When the men were speaking about how often they received physic al examinations, one of the men responded with this comment: “Me myself, I dislike doctors and don’t trust them. I don’t know why, but even growing up, I didn’t have a good relati onship with the hospital, period” There were several important finding s from the focus groups. The first significant finding was that even though half of the men in the focus group reported that they maintained a healthy lifestyle, few of them reported that they participated in prostate cancer screening activities. Secondly, fear emer ged as the principal factor that influenced participation in prostate cancer screening procedures by African American men. The men reported fear of the screening as well as f ear of the disease itself. Finally, the third noteworthy finding from the gr oups reaffirmed the belief that education of African American men about prostate cancer and pr ostate cancer screeni ng is an integral component of successful partic ipation in prostate cancer screening activities. Proper education and information about prostate cance r and prostate cancer screening resonated consistently from all three focus groups.

PAGE 90

79 Phase Two Quantitative methods were used to answer the following research questions in phase two of this study: 1) Does the CSIS-P demonstrate evidence of content validity? 2) Is the CSIS-P a culturally sensitive instrume nt? 3) Is the reading level appropriate for African American men? 4) Does the CS IS-P demonstrate evidence of internal consistency? The methods for development a nd refinement of the CSIS-P are outlined in this section. Sample The sample consisted of the twenty Af rican American men from the focus groups. The men ranged in age from 35 to 72 with a mean age of 50. Educational level ranged from eighth grade to master’s degree, with a mean of 14.1 years. Ei ghty percent of the sample reported that they has received a PSA, while 60% reported receiving a DRE. Data Analysis Utilizing the results of the qualitative study and relevant literature review, the CSIS-P was developed. Guidelines for cult ural sensitivity set forth by the Oncology Nursing Society in 2000 were used in the de velopment of the CSIS -P. These guidelines state that if an instrument is to be deemed culturally sensitive, it must meet the following criteria: 1) the questions to be studied must reflect the re searcher’s awareness of the culture; 2) the problem to be studied must be significant to the group to be studied; 3) the theoretical framework supporting the instrument must be ap propriate for use with the cultural group; 4) the theoretical framework must incorporate the concepts of ethnicity and race; 5) the health beliefs and values of the target group mu st be incorporated into the tool; 6) members of the targeted cultural gr oup must be involved in the development of

PAGE 91

80 the instrument. Criterion one was met in that the researcher is Af rican American and has worked extensively with African Americans in the areas of health promotion and illness prevention. Criterion two was met because of the increased incidence and mortality rates of prostate cancer among African American me n. Criterion three was met in that planned behavior theories are appropriate for use in African Americans. Criterion four was met in that one component of the theoretical fram ework guiding this study includes research by Powe (1995, 1995a, 1996, 2001) where African Amer icans were utilized exclusively as study participants. Criterion five was met b ecause results of the focus groups were used in the development of the CSIS-P. Finally, th e sixth criterion was me t in that feedback from the men in the focus groups was used to revise and refine the CSIS-P. After development of the CSIS-P, the in strument was given to the twenty men from the focus groups to assess the scale for content accuracy and clarity. Each man was asked to indicate whether the scale reflect ed their thoughts and responses during the focus groups. They also were asked if they understood the content of the questions. The instrument also was presented to five e xperts to estimate content validity. Results The original CSIS-P contained 80 ques tions. The men from the focus groups reported that they felt seven of the items could be combined and that nineteen of the items could be deleted because they were repetitive and would glean the same information as other items in the instrument. They were then asked to choose the clearest of the repetitive items. The content validity index (C VI) from the experts for th e total instrument was .90. Item CVIs ranged from .40-1.0. Items with indices of less than .70 were revised or

PAGE 92

81 deleted. Twenty-six items from the CSIS-P were deleted or combined based on the recommendations from the focus groups. Six of the items assessed by the content experts had indices less than .70 and were deleted. Six additional items were combined to include both DRE and PSA instead of as king the same question about each test individually. Deletions, re visions, and combination of items were done based on the recommendations from the three focus groups and the content experts. The revised instrument consisted of 43 items. The scal e was organized by domains. The reading level of the CSIS-P was assessed utilizing the Flesch-Kincaid grade level and SMOG readability formulas. The Flesch-Kincaid grad e level of the final 43-item instrument was 5.6 and the SMOG formula determined grade leve l to be 7.0. Internal consistency of the newly revised CSIS-P was assessed by Cronbach’s alpha and found to be .92. Phase Three Quantitative methods were used to answer the following questions in phase three of this study: 1) Does the CS IS-P demonstrate evidence of c onstruct validity? 2) Does the CSIS-P reliably measure prostate cancer screen ing intention in African American men? First, descriptions of the sample and inst ruments are outlined. Next, correlational analyses are detailed. Next, factor analysis results are reviewed. Finally, reliability estimates are described. Sample The sample consisted of 203 African American men from local churches in Florida. The men ranged in age from 40 to 96. Nearly 40% of the participants were age 40 to 49 and 90% of the subjects were less than 70 years of age. Most of the men were

PAGE 93

82 married, and educational levels ranged from th ird grade to doctoral degree. More than half of the men reported educational levels above high school graduate (Table 3). Table 3. Number and Percent of Men by Age, Marital Status, and Education Number Percent Age group 40-49 81 39.0 50-59 71 34.0 60-69 32 17.0 70-79 14 7.0 80-89 4 2.0 90-99 1 1.0 Totals 203 100.0 Marital status Single 23 11.3 Married 122 60.1 Divorced 38 18.7 Widowed 20 9.9 Totals 203 100.0 Education Less than high school 16 8.0 High school graduate 57 28.0 Some college and above 130 64.0 Totals 203 100.0 Table 4. Number and Percent of Men Reporti ng Previous Prostate Cancer Screening Previous Screening Number Percent Ever had DRE 139 68.5 DRE within previous year 83 40.9 Ever had PSA 128 63.1 PSA within previous year 87 42.9 More than two-thirds of the sample reported that they had received a DRE while 63% reported receiving a PSA test. When asked if they had received a DRE or PSA

PAGE 94

83 within the past year, more than half of the sample indicated that they had not received either screening test in th e previous year (Table 4). Instruments Cancer Screening Intention ScaleProstate (CSIS-P). More than three-quarters of the men in the study reported that they intend ed to get a DRE within a year. However, only 45% of the men reported that they had already scheduled an appointment for the DRE. Nearly 80% of the men reported that they intended to get a PSA within a year, while only 45% reported that they had alrea dy scheduled an appointment for the PSA. Most of the study participants reported moderate to high degrees of intention to participate in prostate can cer screening based on CSIS-P scores (Table 5). It is interesting to note that there were no low intention scores, though 57 percent of the men reported that they had not had a PSA done w ithin the previous y ear and 59 percent reported that they had not had a DR E within the previous year. Table 5. Prostate Cancer Sc reening Intention Scores Intention Scores Number Percent 43-85 (Low intention) 0 0 86-129 (Moderate intention) 141 69 130-172 (High intention) 62 31 Totals 203 100 Prostate Cancer Knowledge Questionnaire. Nearly three-quarters of the sample responded correctly to six of the seven knowledge questions. Less than one-half of the sample responded correctly to the question “I f you have brothers or sons, they are at higher risk for prostate cancer”. Also, only ha lf of the participants recognized that soy products reduced the risk of prostate cancer (Table 6).

PAGE 95

84 Table 6. Frequency and Percent of Correct Responses to Prostate Cancer Knowledge Question Question Frequency Percent Treatment 173 85.2 Prostate location 172 84.7 Side effects 170 83.7 Treatment 151 74.4 Symptom 151 74.4 Risk reduction 115 56.7 Risk factors 100 49.3 Prostate Cancer Belief Scale. Scores for the belief scale ranged from ten to forty with a mean score of 32. Half of the samp le felt that prostate cancer was a serious disease and nearly two-thirds of the men felt th at they were susceptible to prostate cancer and that they were motivated to participate in prostate cancer screening. More than 60% of the sample reported that they felt that there were benefits and barriers to prostate cancer screening (Table 7). Table 7. Prostate Cancer Belief Scores by Number and Percent Component Number Percent Barriers to prostate cancer screening 138 68 Prostate cancer screening motivation 125 62 Seriousness of prostate cancer 124 61 Benefits to prostate cancer screening 122 60 Susceptibility to prostate cancer 102 50

PAGE 96

85 Powe Cancer Fatalism Index. Fatalism scores for this sample ranged from zero to fifteen with a mean score of five. Most of the sample reported low degrees of fatalism (Table 8). Table 8. Frequency and Percent of Prostate Cancer Fatalism Scores Frequency Percent 0-5 (Low fatalism) 79 55.6 6-10 (Moderate fatalism) 45 31.7 11-15 (High fatalism) 18 12.7 Totals 142 100.0 Health Promoting Lifestyle Profile II (HPLP II). In the present study, mean scores for the nutrition subs cale ranged from 2.08-2.84. Me an scores on the physical activity subscale ranged from 1.85-2.52. The lowest score from this subscale came from responses to the statement “check my pulse ra te when exercising”. The mean scores on the health responsibility subscale ranged from 1.94-2.66. The lowest score in this subscale came from responses to the statem ent “attend educational programs on personal health care” (Table 9). Table 9. HPLP II Subscale Means and Standard Deviations Question Mean SD Nutrition Eat breakfast 2.84 .98 Eat only 2-3 servings from the meat, poultry, fish, dried beans, eggs, and nuts group each day 2.61 .86 Eat 2-4 servings of fruit each day 2.53 .91 Limit use of sugars and food containing sugar (sweets) 2.44 .94

PAGE 97

86 Table 9 (continued). HPLP II Subsca le Means and Standard Deviations Question Mean SD Choose a diet low in fat, saturate d fat, and cholesterol 2.38 .96 Read labels to identify nut rients, fats, and sodium content in packaged food 2.32 1.10 Eat 3-5 servings of vegetables each day 2.27 .94 Eat 2-3 servings of milk, yogurt or cheese each day 2.27 .91 Eat 6-11 servings of bread, cereal, rice and pasta each day 2.08 .97 Physical activity Get exercise during usual daily activities 2.52 .90 Exercise vigorously for 20 or more minutes at least three times a week 2.32 1.08 Take part in light to modera te physical activity 2.31 .91 Take part in leisure-time (recr eational) physical activities 2.31 1.04 Follow a planned exercise program 2.29 .97 Do stretching exercises at least 3 times per week 2.25 .99 Reach my target heart rate when exercising 2.00 .99 Check my pulse when exercising 1.85 .97 Health responsibility Report any unusual signs or symptoms to a physician or other health professional 2.66 .96 Discuss my health concerns with health professionals 2.63 .96 Question health professionals in order to understand their instructions 2.60 .93 Ask for information from health professionals about how to take good care of myself 2.54 .90

PAGE 98

87 Table 9 (continued). HPLP II Subscale Means and Standard Deviations Question Mean SD Seek guidance or counseling when necessary 2.53 .94 Inspect my body at least monthly for physical changes 2.52 .99 Get a second opinion when I question my health care 2.40 .96 provider’s advice Read or watch TV programs about improving health 2.31 .97 Attend educational programs on pe rsonal health care 1.94 .95 Construct Validity: Correlat ion with other measures Several relationships were found between the variables within the study. First, relationships between the demographic da ta and the remaining model independent variables are reviewed. Next, relationships between specific items within the CSIS-P and established instruments are reviewed in orde r to support construct va lidity of the CSIS-P (Polit and Hungler, 1995). Finally, correlati onal analyses between model variables and intention is presented. Demographic variables, Knowledge, Atti tude, Healthy Lifestyle, and Fatalism. A significant negative correlation was found between age and education. Positive correlations were found between education and knowledge as well as between healthy lifestyle and education. A weak positive corre lation was found between educational level and attitude toward prostate cancer scr eening as well as between knowledge about prostate cancer and attitude to ward prostate cancer screenin g. Negative correlations were found between fatalism and all other independent variables (Table 10).

PAGE 99

88 Table 10. Correlations Among Demographics Knowledge, Healthy Lifestyle, and Fatalism Variables Know. Att. Ed. H. Life Fat. Age Knowledge 1.0 (Know.) Attitude .35 1.0 (Att.) .01 Education .30 .15 1.0 (Ed.) .01 .05 Healthy .18 .21 .29 1.0 Lifestyle .05 .05 .01 (H. Life) Fatalism -.32 -.28 -.24 -.36 1.0 (Fat.) .01 .01 .01 .01 Age -.04 .06 -.37 -.02 .11 1.0 (Age) NS NS .01 NS NS Health Promotion in CSIS-P and HPLP II. Moderate positive correlations were found between each health promotion item in the CSIS-P (CSIS-PHP) and the total scores on the HPLP II. A strong positive correlation of .68 (p = .01) also was found when summing the health promotion items in the CSIS-P and correlating them with the total scores on the HPLP II (Table 11). Fatalism in CSIS-P and PFI. An unexpected finding occurred when analyzing the relationships between the fatalism items in the CSIS-P and the PFI. Only one of the fatalism items in the CSIS-P significantly correlated with the PFI. The item stated “there is nothing I can do to prevent me from ge tting prostate cancer” and there was a weak correlation at .34 (p = .01) A weak positive correlation of .31 (p = .01) also was found

PAGE 100

89 when summing the fatalism items in the CSIS -P and correlating them with the total scores on the PFI. Table 11. Health Promotion Correlations Variables N r p CSIS-PHP item 1 and HPLP II 203 .58 .01 CSIS-PHP item 3 and HPLP II 203 .58 .01 CSIS-PHP item 5 and HPLP II 203 .53 .01 CSIS-PHP item 2 and HPLP II 203 .49 .01 CSIS-PHP item 4 and HPLP II 203 .48 .01 Independent Variables and Intention. Several positive significant correlations were found between prostate cancer screening in tention and other inde pendent variables. The strongest positive correlation was with a ttitude toward prosta te cancer screening from the Prostate Cancer Belief Scale, while the weakest was with knowledge scores. A moderate correlation was found w ith healthy lifestyle total sc ores. Also, a weak negative correlation was found with fa talism scores (Table 12). Table 12. Correlations Between Inde pendent Variables and Intention Variable N r p Attitude toward prostate cancer screening 203 .61 .01 Healthy lifestyle 131 .43 .01 Knowledge 203 .38 .01 Education 203 .14 .05 Age 203 .11 NS Fatalism 143 -.33 .01

PAGE 101

90 Multiple weak and moderate correlati ons were found between the independent variables and intention. A strong positive corr elation was found between attitude toward prostate cancer screenin g and intention. There were moderate positive correlations noted between the health promotion items on the CSIS-P and the HPLP II. An unexpected finding was that only one of the fatalism items on the CSIS-P correlated with the PFI. Construct Validity: Factor Analysis The 43-item CSIS-P was subjected to an exploratory factor analysis in order to further support construct validit y. Factor analysis was used for two primary purposes: to identify the interrelatedness of the data and to delineate patterns w ithin the data and to reduce the data in order to define a parsimonious set of factors. Identifying clusters of related items in a scale is a valuable tool in construct validation (Polit and Beck, 2006). Principal component analysis (PCA) was th e method used for factor extraction. The scree plot of the eigenvalues demonstrated a th ree-factor structure. Determining the point at which the factors curve a bove the straight line on the sc ree plot identifies the number of factors (Pett, Lackey, and Sullivan, 2003). A review of the proportion of variance in the items explained by the factors also was utilized to extract the factors and reveal ed a three-factor stru cture (Table 13). Table 13. Variance Explained by Extracted Factors Factor Total Variance Percentage of Variance I 12.171 28.306 II 3.200 7.441 III 2.990 6.971

PAGE 102

91 Pett, Lackey, and Sullivan (2003) suggest that one should only retain those factors that explain greater than five percent of the variance. This suggestion was used to determine the three-factor structure. Three factors were retained and rotated fo r final interpretation. Factor loadings greater than .40 were retained using the guideline set forth by Straub, Boudreau, and Gefen (2004). Factor loadings with correspond ing factors and item nu mbers are presented (Table 14). Table 14. Factor Loadings Item Number Factor I Factor II Factor III 13 .82 .04 .20 12 .78 -.02 .14 22 .76 .10 .03 21 .69 .12 .08 24 .67 .19 .15 23 .65 .18 .15 26 .64 .08 .12 15 .62 -.03 .28 25 .59 .18 .37 27 .57 .06 -.01 30 .55 .03 -.03 1 .49 .16 .18 7 .48 .06 .39 43 .43 .42 .27 38 .17 .72 .09 39 .39 .56 .24 40 .06 .75 .21 41 .29 .65 .09 42 -.07 .82 -.05 8 .27 .08 .70 9 .10 .17 .71 10 .32 .29 .51 36 .19 .04 .67

PAGE 103

92 Factors were analyzed for common themes among the item loadings and were named accordingly. After examining the item s within each factor, the factors that emerged were benefits to prostate cancer sc reening, barriers to pros tate cancer screening, and health promotion. Table 15. CSIS-P Items and Corresponding Factor Loadings Factor Item Number Item Content I 1 DRE Intention 7 DRE barrier 12 DRE/PSA barrier 13 DRE/PSA barrier 15 DRE benefit 21 PSA benefit 22 PSA barrier 23 PSA barrier 24 PSA barrier 25 PSA barrier 26 PSA benefit 27 PSA barrier 30 Seriousness of prostate cancer 43 Informed decision-making II 38 Healthy lifestyle 39 Healthy lifestyle 40 Healthy lifestyle 41 Healthy lifestyle 42 Healthy lifestyle III 8 DRE barrier 9 DRE barrier 10 DRE barrier 36 Fatalism Benefits to prostate cancer screening reflect the belief that participating in prostate cancer screening w ould be advantageous in that it would reduce the

PAGE 104

93 susceptibility to the disease. Barriers to prostate cancer screeni ng are related to those issues or circumstances (internal or external ) that would prevent a man from participating in prostate cancer screening. Health pr omotion is reflective of the multidimensional pattern of actions and/or per ceptions that retain a person’s current level of wellness or enhance a person’s level of wellness. Table 15 illustrates the content of the CSIS-P items with their corres ponding factors. The reduced scale consisted of 23 items, and these items were subjected to a second factor analysis in order to further refine the instrument. The scree plot from this analysis again demonstrated the three-f actor structure with 17 items retained (Table 16). Items that loaded greater than .40 we re retained (Table 17). Table 16. Means and Standard Deviations of Reduced CSIS-P Item Content Item Number Mean SD DRE intention 1 3.08 .74 DRE barrier 7 3.15 .61 DRE benefit 15 3.11 .64 PSA benefit 21 3.14 .61 PSA barrier 22 3.15 .61 PSA barrier 23 3.04 .65 PSA barrier 24 3.10 .63 PSA barrier 25 3.05 .67 PSA benefit 26 3.08 .62 PSA barrier 27 3.08 .68 Serious prostate cancer 30 3.37 .61

PAGE 105

94 Table 16. Means and Standard Deviations of Reduced CSIS-P Item Content Item Number Mean SD Healthy lifestyle 38 2.75 .69 Healthy lifestyle 39 2.94 .75 Healthy lifestyle 40 2.57 .79 Healthy lifestyle 41 2.67 .78 Healthy lifestyle 42 2.43 .72 Decision making 43 3.10 .65 Table 17. Factor Loadings of Reduced CSIS-P Item Number Factor Factor Loading 7 I .48 21 I .47 22 I .81 23 I .74 24 I .74 25 I .71 27 I .61 1 II .65 15 II .69 21 II .58 26 II .43 27 II .42 30 II .55 42 II .51 43 II .61 38 III .85 39 III .78 40 III .71 41 III .69 42 III .60 43 III .43

PAGE 106

95 Examining the items in factor one re vealed a cluster around items related to barriers to prostate cancer scr eening. The items in factor three clustere d around health promotion. However, the items in factor tw o did not reveal a clea r clustering. Two of the items that loaded on factor two were rela ted to benefits of pr ostate cancer screening, one was related to fatalism, one was related to motivation to participate in prostate cancer screening, one was related to seriousness of prostate cancer, one was related to health promotion, and one was related to making an informed decision about prostate cancer screening. Several items loaded on multiple fa ctors and are addressed in the subsequent section which addresses the internal consistency of the items. Reliability Internal consistency of the CSIS-P was assessed by Cronbach’s alpha and an alpha coefficient of .92 was obtained. Stability of the CSIS-P was ev aluated using the test-retest approach to reliability. The CSIS-P was r eadministered with a two-week delay to 21 men. A reliability coefficient of .93 was obtaine d demonstrating the stab ility of intention. The revised 17-item CSIS-P was correlated with the independent variables in the model and several positive correlations we re found. The strongest correlation was between attitude toward prosta te cancer screening and intention in the revised scale. A moderately positive correlation was found betw een healthy lifestyle and intention. A weak positive correlation wa s found between education and intention in the revised model. A very weak correlation between e ducational level and in tention was found and there was no correlation between age and intention (Table 18).

PAGE 107

96 Table 18. Correlations Between Independent Variables and Revise d Intention Scale Variable N r p Attitude toward prostate cancer screening 203 .65 .01 Healthy lifestyle 131 .47 .01 Knowledge 203 .36 .01 Education 203 .18 .05 Age 203 .07 NS Fatalism 143 -.34 .01 Internal consistency of the items that lo aded on each factor was assessed by using Cronbach’s alpha. Strong internal consiste ncy among the items indicates that the items are homogeneous. Strong alpha coefficients we re found for each factor (Table 19). This leads to the conclusion that the variance of the total scores for each factor can be attributed to reliable variance. Table 19. Factor Coefficient Alphas Factor N I 7 .88 II 8 .81 III 6 .86 Several items loaded on multiple factors. Pett, Lackey, and Sullivan (2003) suggest these items be examined to determin e if they should be reassigned to only one factor or eliminated from the scale. It ems were examined to assess the need for additional item reduction. Items 21 and 27 lo aded on factors one and two. Item 42 and

PAGE 108

97 43 loaded on factors two and three. Item 21 lo aded higher on factor two than factor one. Though the coefficient alpha for either factor did not increase if item 21 is removed, the item fit better with factor two than factor one Item 27 loaded higher on factor one than factor two. Again, removing this item from e ither factor did not increase the coefficient alpha, but item 27 appeared to fit better with factor one. Item 42 loaded higher on factor three than factor two. Removing item 42 from factor two increased the coefficient alpha to .84 so it was assigned to fact or three. Item 43 loaded higher on factor two than on three. Removing item 43 from either fact or did not increase the coefficient alpha, but item 43 fit better with fa ctor two and was placed there (Table 20). Table 20. Reliability Results with Reassigning Multiple-Loading Items Coefficient Alpha Factor Before After Change I Item 21 .88 .86 -0.2 Item 27 .88 .88 None II Item 27 .81 .79 -0.2 Item 42 .81 .84 +0.3 III Item 42 .86 .84 -0.2 Item 43 .86 .84 -0.2 Factor refinement and examination of th e consistency of the items within the factor loadings reduced the 43-item CSIS-P to a 17-item parsimonious scale. Clear definition of the internal structure of the items and factor grouping lend support to the construct validity of the CSIS-P. Also, the strong reliability coefficients that were obtained for each factor prior to and afte r item reassignment support the internal consistency of the items.

PAGE 109

98 Chapter Five Discussion The study results are summarized in this se ction. First, a sy nthesis of the study results within each phase is discussed along with the conclusions that were drawn. Limitations of the study also are detailed. Finally, implications and recommendations for future research are outlined. The purpose of this three-phase study was to develop a valid and reliable measurement of prostate cancer screening intention. The following research questions were addressed in this study: 1) What are th e attitudes of African American men toward prostate cancer screening? 2) What are the perceived factors that influence prostate cancer screening in African American men? 3) Does the Cancer Screening Intention Scale-Prostate (CSIS-P) demonstrate evidence of content validity? 4) Is the CSIS-P a culturally sensitive instrument? 5) Is the re ading level of the CSIS-P appropriate for African American men? 6) Do es the CSIS-P demonstrate ev idence of construct validity? 7) Does the CSIS-P reliably measure prosta te cancer screening intention in African American men? This study utilized qu alitative and quantitative methods of study. Phase One The first phase of this study utilized qual itative methods to expl ore the attitudes of African American men toward prostate cancer screening. Focus groups were the method of data collection.

PAGE 110

99 Sample The sample of 20 men was large enough to provide sufficient qualitative data. The age range of the men in the groups was 3572. One of the limitations of this phase of the study was the age of the men in the focus groups. Most of the men were less than 55 years of age. Also, a majority of the sample reported educational levels of at least “some college”. The limited number of elderly men and men with lower educational levels did not allow for the opinions of the men that ar e especially vulnerable to prostate cancer. This might have occurred because all of the men in the sample were accrued from a city with two large universities. Data Analysis Content analysis was the method used to analyze the transcripts from the focus groups. This is an appropriate method when seeking to explore some phenomenon about a unique population. This method also allows the researcher to assess validity and reliability of qualitative data, which can be difficult when analyzing qualitative data. Results Eight dominant themes resulted from th e qualitative study. Health promotion emerged as the primary theme from this study. A majority of the men in this phase reported that they exercised regularly and pres cribed to a balanced diet. However, most of the men reported that they only sought healthcare when they “felt sick” and that they rarely participated in illness prevention or early detection sc reening activities. Fear and lack of knowledge and information also were reported as important factors in influencing pros tate cancer screening. The fears about prostate cancer expressed by the men included fear of side effects of treatment, namely impotence and

PAGE 111

100 incontinence. Fear of the unknown also was expressed by several men in the focus groups. There also was a fear of the sc reening examinations expressed by the men, particularly the DRE. Lack of knowledge about prostate cancer and prostate cancer screening was a constant theme among th e three groups. The men reported that information about prostate can cer and screening should begin within the family and then move to the church and the community. Th ey also reported that there are limited educational seminars or forums about prostate cancer directed to African American men. Suggestions were made by the men for mobile prostate cancer educat ion and intervention in communities with large African American populations. Familial and social support from friends also emerged as important factors that influence prostate cancer screening behaviors. Twenty-five percent of the sample stated that their spouses, family members, and frie nds were instrumental in maintaining their health status. One surprising result from this phase of the study was the limited number of men who expressed mistrust of the healthcare system. In other qualitative studies (Weinrich, 2001; Clarke-Tasker and Wade, 2002; Plowden, 2006), this was a consistent theme and the results of the Tuskegee Experiment were frequently mentioned. The results from this phase of the study provide d the foundation for developing the CSIS-P and beginning the second phase of the study. Phase Two The second phase of the study utilized the data from the first phase to develop a valid and reliable measurement of prosta te cancer screening in tention. Cultural sensitivity and reading level of the instru ments also were assessed during this phase.

PAGE 112

101 Sample The sample in phase two of the study were the men from phase one. Again, the age of the men in the sample was a limitati on of this phase of the study. Assessment of the instrument by elderly African American men with lower educational levels would have allowed for a more generalized evaluati on of the CSIS-P. This would have been especially helpful because prostate cancer oc curs most often in older African American men. Data Analysis The CSIS-P was developed using guidelines for cultural sensitivity and cultural competence developed by the Oncology Nurs ing Society (ONS) ( 2000) and felt to be culturally sensitive to the African Ameri can population. Cultural competence and cultural sensitivity is important when working with diverse ethnic groups. In order to develop tools to measure health behaviors in a particular ethnic group, one must be aware of the group’s culture and have an understanding of the beliefs and values of that target group. The ONS guidelines provided a sta ndard by which to measure the cultural sensitivity of the CSIS-P. Results Examination of the CSIS-P by the men fr om the focus groups and a group of five experts resulted in reduction of the items in the original instrument by half. The content validity index (CVI) from the experts for the total instrument was .90. Instruments with CVIs of .80 or greater are deemed acceptabl e according to Polit and Beck (2006). The internal consistency of the CSIS-P was a ssessed at .92. Reliability coefficients are

PAGE 113

102 deemed especially appropriate when they are to be used to make decisions about individuals (Polit & Hungler, 1995). Phase Three Sample The sample in this phase of the study consisted of 203 African American men from local churches in Florida. One of the limitations of this study relative to the sample is the lack of heterogeneity within the sample. All of the men in the sample regularly attended worship service which implies that spirituality is important to them. Often, attitudes toward illness among pe ople with high degrees of spir ituality differ greatly from those among people who do not have high levels of spirituality. Th e homogeneity of the sample as it relates to spirituality makes it di fficult to generalize the results to the African American male population. Also, many of the study participants were familiar with the researcher. This raises the limitation of soci al desirability respons e in that the men may have responded in a manner that they felt the researcher would see as favorable. Third, the fact that the study was car ried out in two university to wns decreased the number of men with lower educational levels. Another concern regarding the sample wa s the age of the group. Seventy-five percent of the men in phase three were less than 60 years of age. This limited the number of assessments from elderly African Ameri can men and may have impacted the positive findings related to intention. More than 60% of the sample reported th at they had received a DRE and/or PSA, while less than 50% reported that they had received either test in the past year. It is interesting to note that although nearly two-th irds of the sample had participated in

PAGE 114

103 prostate cancer screenin g procedures, most of the men in the sample did not get other annual screenings or participate in illness-prevention activities. Instruments Cancer Screening Intention Scale-Prostate (CSIS-P) Sixty-nine percent of the men in the sample reported moderate intentions to participate in pr ostate cancer screening and 31% reported high intentions to particip ate in prostate cancer screening. It is important to note that there were no low inte ntion scores. This ra ises the concern of social desirability response. Many of the men know that participation in prostate cancer screening is socially acceptab le and may have adjusted th eir responses accordingly. Prostate Cancer Knowledge Questionnaire. The results of this questionnaire revealed that African American men had high levels of knowledge relative to prostate cancer and prostate cancer screening. This is in contradiction to many of the other studies that have examined prostate ca ncer knowledge among African American men (Weinrich, Weinrich, Boyd, and Atkinson, 1998; Barber et al. 1999; Agho and Lewis, 2001). This may have been due to the limited validity evidence of the Prostate Cancer Knowledge Questionnaire, or may be a re flection of bias c ontributed by age and education. Prostate Cancer Belief Scale. Most of the participants in the study felt that prostate cancer was a serious di sease and that they were susceptible to prostate cancer. However, many of the men did not believe that they were at greater risk than men from other ethnic groups. This fi nding reaffirms the need for continued education among African American men regarding risks of pr ostate cancer. Also, though many of the men reported that they believed there were benef its to prostate cancer screening, there were

PAGE 115

104 equal numbers of them who reported that there were a multitude of barriers that prevented them from engaging in prostate cancer screening. This again reaffirms the need for tailored prostate cancer educational programs for African American men that will address the barriers and methods to reduce or remove the barriers. Powe Cancer Fatalism Index. Most of the men in the sample reported low degrees of fatalism. This finding does not align with results obtained by Powe (Powe, 1995; Powe, 1995a; Powe, 1995b; Powe, 1995c) who repor ts that African American elderly men have high degrees of fatalism. One reason for this finding may be that the sample in this study did not include a large number of elderly African American males. A second reason may be that much of Powe’s work has been with fatalism relative to colorectal cancer among African Americans, and that he r research was begun more than a decade ago. Health Promoting Lifestyle Profile II (HPLP II). Most of the low scores on the HPLP II were related to exercise and receipt of health information. Item scores ranged from zero to four with higher scores reflec ting higher degrees of health promotion. Several scores on the physical activity s ubscale were lower than two. This is a confirmation of the decreased levels of exerci se that were reported by the men in phase one of this study. Low scores also were noted when referencing attendance at educational programs promoting health. This is also reflective of comments made by the men in phase one who stated that they only at tended these types of programs if motivated by a significant other.

PAGE 116

105 Construct Validity: Correlat ion with other measures Correlation of the CSIS-P with other es tablished measures is an appropriate method for assessing construct validity (Pe tt, Lackey, and Sullivan, 2003). A strong positive correlation was found between health promoting items on the 43-item version of the CSIS-P and the HPLP II. Strong corre lations also were found between the health belief items on the CSIS-P and the Prostate Ca ncer Belief Scale. However, the health belief items on the CSIS-P and the Prostate Canc er Belief Scale were worded so similarly that they were almost equivalent items. Only one of the fatalism items in the CSIS-P correlated significantly with the PFI. Also, the summed fatalism items in the CSIS-P correlated weakly (.31) (p = .01) with the total scores on the PFI. This is an unexpected finding and may be due to the fact that there were only four fatalism items on the CSIS-P. A very strong correlation was found betw een attitude toward prostate cancer screening and intention to participate in pros tate cancer screening. This finding leads one to believe that perceptions of the seriousne ss of prostate cancer, the susceptibility one feels to the disease, the benef its believed to be associated with prostate cancer screening, and the motivation one feels toward partic ipating in prostate cancer screening are essential to intention to pa rticipate in prostate cancer screening. There was also a moderate positive correlation between healthy lifestyle and intention to participate in prostate cancer screening. This is due to the fact that men who participate in other illness prevention activities such as getting regular annual physical exams, maintaining a healthy weight, and participating in regular exercise are likely to participate in prostate cancer screening as well.

PAGE 117

106 Construct Validity: Factor Analysis Factor analyses were conducted to furt her support the constr uct validity of the CSIS-P. Factor analysis is an appropriate and reliable tool in instrument development (Pett, Lackey, and Sullivan, 2003). Principal co mponent analysis was used to extract the factors. The first run revealed a three-factor structure. Th e three factors were rotated and factor loadings greater than .40 were retained. This reduced the 43-item scale to 23 items. The common themes among the item loadi ngs were determined to be benefits to prostate cancer screenin g, barriers to prostate cancer screening, and health promotion. It is interesting to note that health promoti on was the theme discussed most frequently among the men in the focus group in phase one of this study. The 23-item scale was then subjected to a second factor analysis run in order to continue refinement of the instrument. Afte r rotating the factors and retaining items with loadings greater than .40, the scale was reduced to 17 items. Items in factor one clustered around barriers to prostate cancer and items in factor three clus tered around health promotion. However, the items in factor tw o did not definitively cluster around a theme and were placed where they theoretically fit best. Internal consistency among the items wa s assessed by Cronbach’s alpha. Strong alpha coefficients were obtaine d on all factors illustrating th e homogeneity of the items. This is also strong evidence that the varian ce among the items is attributed to reliable variance. A strong alpha coefficient from the te stretest also illustrates stability of the CSIS-P over time.

PAGE 118

107 Summary Refining the factors in the CSIS-P and ex amining the internal consistency of the retained items provides clear internal struct ure of the scale. The CSIS-P was reduced from a 43-item scale to a 17-item parsimonious scale that can now undergo further testing and reduce subject burden when administering the tool to future study participants. Implications for Nursing This study has several implications fo r nursing practice and nursing education within community settings. Despite less than reliable methods for prostate cancer screening and the recent cont roversies surrounding the bene fits of screening, it still remains the best available method for early detection of prostate cancer. African American men have one of the lowest partic ipation rates in prostate cancer screening among all other ethnic groups. Thus, an importa nt intervention for nur sing practice is to develop tailor-made prostate cancer educati on programs for African American males. These programs must be developed with an awareness of the variety of cultural and health values of African Americans. Th ese programs must be developed with the assistance of African American healthcare pr ofessionals and must be carried out in settings where large numbers of African Americans frequent. Healthcare professionals must also be aw are of the barriers that African American men face that prevent them from taking part in prostate cancer screening. These barriers must be identified, addressed, and removed wh en attempting to schedule prostate cancer screening in the African American community. Lack of clear, precis e information is one the barriers African American men discussed. Decision guid es about prostate cancer screening, such as the one developed by the Department of Health and Human Services,

PAGE 119

108 should be used when presenting educational pr ograms to African Americans. Careful, step-by-step outlines of prostate cancer scr eening procedures should be given. This is especially true when instructions regarding the DRE are given. Implications for nursing education from this study include better training of healthcare professionals to d eal with culturally diverse popul ations. Nursing and medical education programs should offer more c ourses in cultural sensitivity and cultural competence. Information related to prosta te cancer and prostate cancer screening among African Americans should be integrated into healthcare curricula since prostate cancer is such a significant health concern in this population. Recommendations for Future Research The following recommendations for future research are made: 1. Replicate the study using a more hete rogeneous African American sample 2. Replicate the study using a knowledge scale with psychometric evidence 3. Further refinement and testing of the CSIS-P 4. Test the CSIS with other cancers in males 5. Conduct comparison studies using the CS IS-P in men from multiple ethnic groups 6. Test the CSIS with breast cancer in women 7. Conduct an intervention study to determine differences in intention based on different types of educational interventions

PAGE 120

109 References Agho, A.O. and Lewis, M.A. (2001). Correlates of actual and perceived knowledge of prostate cancer among African Americans. Cancer Nursing, 24 (3), 165-171. Ajzen, I. (2002). Perceived behavior control, self-efficacy, locus of control, and the theory of planned behavior. Journal of Applied Social Psychology, 32 (4), 665-683. Ajzen, I. (1991). The theory of planned behavior. Organizational Behavior and Human Decision Processes, 50, 179-211. Ajzen I. and Fishbein, M. (1980) Understanding Attitudes an d Predicting Social Behavior. Prentice Hall Publishing : Englewood Cliffs, NJ. American Cancer Society (1994). Cancer Facts and Figures, 1994 Atlanta: American Cancer Society. American Cancer Society (2000). Cancer Facts and Figures, 2000 Atlanta: American Cancer Society. American Cancer Society. (2002). Cancer Facts and Figures, 2002 Atlanta: American Cancer Society. American Cancer Society (2005). Cancer Facts and Figures, 2005 Atlanta: American Cancer Society. American Cancer Society (2006). Cancer Facts and Figures, 2006 Atlanta: American Cancer Society. American Cancer Society (2007). Cancer Facts and Figures, 2007. Atlanta: American Cancer Society. Barber, K.R., Shaw, R., Folts, M., Taylor, D.K., Ryan, A., Hughes, M., Scott, V., and Abbott, R.R. (1998). Differences between African American and Caucasian men participating in a community based prostate cancer screening program. Journal of Community Health, 25 (6), 441-451. Barroso, J. (2000). Comparison between African American and white women in their beliefs about breast cancer a nd their health locus of control. Cancer Nursing, 23 (4), 268-276.

PAGE 121

110 Bastani, R., Maxwell, A.E., Carbonari, J ., Rozelle, R., Baxter, J., and Vernon, S., (1994). Breast cancer knowledge, attit udes, and behaviors: A comparison of rural health and non-health workers. Cancer Epidemiology Biomarkers Prevention, 3 (1), 77-84. Beeker, C., Kraft, J.M., Goldman, R. a nd Jorgensen, C. (2001). Strategies for increasing colorectal cancer sc reening among African Americans. Journal of Psychosocial Oncology, 19 (3/4), 113-123. Bennett, C.L., Ferreira, R., Davis, T.C., Kaplan, J., Weinberger, M., Kuzel, T., Seday, M.A., and Oliver, S. (1998). Relation between literacy, race, and stage of presentation among low-income patients with prostate cancer. Journal of Clinical Oncology, 16, 3101-3104. Bloom, J., Hayes, W., Saunde rs, F., and Flatt, S. (198 7). Cancer awareness and secondary prevention practices in black Americans: Implications for intervention. Family and Community Health, 10 (3), 19-30. Boehm, S., Schlenk, E.A ., Funnell, M.M., Parzucho wski, J., and Powell, LJ. (1995). Prostate cancer in African Am erican men: Incr easing knowledge and self-efficacy. Journal of Community Health Nursing, 12 (3), 16 1-169. Boyd, M.D., Weinrich, S.P., Weinrich, M., and Norton, A. (2001). Ob stacles to prostate cancer screening in African American men. Journal of National Black Nurses’ Association, 12 (2), 1-5. Breen, N., Wagner, D.K., Brown, M.L., Davis, W.W ., and Ballard-Barbash, R. (2001). Progress in cancer screening over a decade: Results of cancer screening from the 19 87, 1992, and 1998 nati onal health interview surveys. Journal of the National Cancer Institute, 93 (22), 1704-1713. Brubaker, R.G. and Wickersham, D. (1 990). Encour aging the practice of testicular selfexamination: A field ap plication of the th eory of reasoned action. Health Psychology, 9 (2), 154-163. Burks, D.A. and Littleton, R. H. (1992). The epidemiology of prostate cancer in black men. Henry Ford Hospital Medical Journal, 40, 89-92. Catalano, W., Richie, J., Ahmann, F., Hu dson, M., Scardino, P., Flanigan, R., DeKernion, J.,Ratliff, T., Kavous si, L., Dalkin, B., Waters, B., MacFarlane, M., and Southwick, P. (1994). Comp arison of digital rectal examination and serum prostate-specifi c antigen in the ear ly detection of prostate cancer: Result s of a multi-center clin ical trial of 6,630 men. Journal of Urology, 151, 1283-1290.

PAGE 122

111 Chan, E.C., Haynes, M.C., O’Donnell, F.T., Bachino, C., and Vernon, S.W. (2003). Cultural sensitivity and informed deci sion making about prostate cancer screening. Journal of Community Health, 28 (6), 393-405. Clarke-Tasker, V.A. and Wade, R. (2002 ). What we thought we knew: African American males’ percepti on of prostate cancer and screening methods. The American Black Nursing Faculty Journal 13 (3), 56-60. Collins, M. (1997). Increasing prostate cancer awareness in African American men. Oncology Nursing Forum, 24 (1), 91-95. Conrad, M.E., Brown, P., and Conrad, M.G. (1996). Fatalism and breast cancer in Black women. Annals of Internal Medicine, 125 (11), 941-942. Cowen, M.E., Kattan, M.W ., and Miles, B.J. (1996). A national survey of attitudes regarding pa rticipation in prosta te carcinoma testing. Cancer, 78 (9), 1952-1957. Crocker, L. and Al gina, J. (1986). Introduction to Classical & Modern Test Theory: Riehardt & Winston Publishers: New York, NY. Davison, B.J. and Degner, L.F. (1997). Empowerment of men newly diagnosed with prostate cancer. Cancer Nursing, 20 (3), 187-196. Demark-Wahnefried, W., Catoe, K., Paske tt, E., Robertson, C., and Rimer, B. (1993) Characteristics of men reporting for prostate cancer screening. Urology, 42, 269-273. Demark-Wahnefried, W., St rigo, T., Catoe, K., C onaway, M., Brunetti, M., Rimer, B.K., and Robertson, C.N. (1995). Knowledge, beliefs, and prior screening behavior among blac ks and whites reporting prostate cancer screening. Urology, 4 (3), 346-351. Deibert, C., Malishi, S., Kwan, L., Fink, A., Connor, S ., and Litwin, M. (2007). Prostate cancer knowledge am ong low income minority men. Journal of Urology, 177 (5), 1851-1855. Downe-Wamboldt, B. (1992). Content analysis: Method, applications and issues. Health Care for Wome n International, 13 (3), 313-321. Fearing, A., Bell, D., Newt on, M., and Lambert, S. (2 000). Prostate screening health beliefs and practices of African American men. The American Black Nursing Faculty Journal, 11 (6), 141-144.

PAGE 123

112 Ford, M.E., Vernon, S.W. Havstad, S.L., Thomas, S.A., and Davis, S.D. (2006). Factors influencing behavioral intention regarding prostate cancer screening among older African American men. Journal of the National Medical Association, 98 (4), 505-514. Forrester-Anderson, I.T. (2005). Prosta te cancer perceptions, knowledge, and behaviors among African American men: Focus group findings. Journal of Health Care for the Poor and Underserved, 16 22-30. Freeman, H. (1989). Cancer and the socioeconomic disadvantaged. Atlanta: American Cancer Society. Friedman, L.C., Woodruff, A., Lane, M ., Weinberg, A.D., Cooper, H.P., and Webb, J.A. (1995). Breast cancer sc reening behaviors and intentions among asymptomatic women 50 years of age and older. American Journal of Preventive Medicine, 11 (4), 218-223. Gelfand, D.E., Parzuchowski, J., Cort, M. and Powell, I. (1995). Digital rectal examinations and prostate cancer screening: Attitudes of African American men. Oncologv Nursing Forum, 22 (8),1253-1255. Gibson, W.H. (1995). Attitudes of men in their he alth beliefs related to prostate cancer. Unpublished master’s thesis, University of South Florida, Tampa, Florida. Godin, G. and Kok, G. (1996). The theory of planned behavior: A review of its applications to health-related behaviors. American Journal of Health Promotion, 11 (2), 87-98. Groenwald, S. (2000). Cancer Nursing: Principles and Practice. Philadelphia, PA: Jones and Bartlett Publishing. Gwede, C.K. and McDermott, R.J. (2006). Prostate cancer screening decision making under controversy: Implicati ons for health promotion practice. Health Promotion Practice, 7, 134-146. Hillhouse, J.J., Adler, C.M., Drinnon, J. and Turrisi, R. (1997). Application of Ajzen’s theory of planned behavior to predict sunbathing, tanning salon use, and sunscreen use intentions and behaviors. Journal of Behavioral Medicine, 20 (4), 365-378. Hillhouse, J.J., Turrisi, R., and Kastne r, M. (2000). Modeling tanning salon behavioral tendencies using appearance motivation, self-monitoring and the theory of planned behavior. Health Education Research, 15 (4), 405-414.

PAGE 124

113 Hughes, G.D., Sellers, D.B., Fraser, Jr., L., Teague, R., and Knight, B. (2007). Prostate cancer community collabor ation and partnership: Education, awareness, recruitment, and outreac h to southern African-American males. Journal of Cultural Diversity, 14 (2), 68-73. Jennings-Dozier, K.J. (1999). Predicti ng intentions to obtain a Pap smear among African American and Latina women: Testing the theory of planned behavior. Nursing Research, 48 (4), 198-205. Johnson, R. (2005). Gender differences in health-promoting lifestyles of African Americans. Public Health Nursing, 22 (2), 130-137. Krueger, R.A., and King, J. (1997). The Focus Group Kit. Oakland Hills, CA: Sage Publications. Kurtz, M.E., Given, B., Given, C.W., and Kurtz, J. C. (1993). Relationships of barriers and facilitators to breast self-examination, mammography, and clinical breast examination in a worksite population. Cancer Nursing, 16, 251-259. Lambert, S., Fearing, A ., Bell, D., and Newton, M. (2002). A comparative study of prostate screening health be liefs and practices between African American men and Caucasian men. The American Black Nursing Faculty Journal, 13 (3), 61-63. Landis, S.H., Murray, T., Bolden, S ., and Wingo, P.A. (1998). Cancer statistics: 1998. CA: A Cancer Journal for Clinicians, 48 (1), 6-11. Lim, L.S., Sherin, K., and ACPM Pr evention Practice Committee. (2008). Screening for prostate cancer in U. S. men: ACPM position statement on preventive practice. American Journal of Preventive Medicine, 34 (2), 164-170. Magnus, M. (2004). Prostate cancer knowl edge among multiethnic black men. Journal of the National Medical Association, 96 (5), 650-656. Mainous, A.G. and Hagen, M. D. (1994). Public awareness of prostate cancer and the prostate specific antigen test. Cancer Practice 2, 217-221. McCau1, K.D., Sandgren, A.K., O’Neill H.K., and Hinz, V.B. (1993). The value of the theory of planned behavior, perceived control, and selfefficacy for predicting health-protective behaviors. Basic and Applied Social Psychology, 14 (2), 231-252. McCoy, C.B., Anwyl, R.S., Metsch, L.R., Inciardi, J. A., Smith, 5.5., and Correa, R. (1995). Prostate cancer in Florida. Cancer Practice, 3 (2), 88-93.

PAGE 125

114 Morse, J.M. (1994). Strategies fo r sampling. In J.M. Morse (Ed.). Qualitative Nursing Research: A Co ntemporary Dialogue. Rockville, MD: Aspen Publishing. Myers, R.E., Wolf, T.A., McKee, L., McGrory, G., Burgh, D.Y., Nelson, G., and Nelson, G.A (1995). Factors asso ciated with intention to undergo annual prostate can cer screening among Afri can American men in Philadelphia. Cancer, 7 (3), 471-479. Myers, R.E., Chodak, G.W., Wolf, T.A ., Burgh, D.Y., McGroy, G.T., Marcus, S.M., Diehl, J.M., a nd Williams, M. (1999). Adherence by African American men to prostate cancer education and early detection. Cancer, 86 (1), 88-104. Myers, R.E., Ross, E., Jepson, C., Wolf T., Balshem, A., Millner, L., and Leventhal, H. (1994). Modeling a dherence to colorectal cancer screening. Preventive Medicine, 23, 142-151. Myers, R.E. (1999). African American men, prostate canc er early detection examination use, and informed decision-making. Seminars in Oncology, 26 (4), 375-381. Myers, R.E., Wolf, T.A., Ba lshem, A.M., Ross, E.A., and Chodak, G.W. (1994). Receptivity of African American men to prosta te cancer screening. Urology 43 (4), 480-487. Myers, R.E., Wolf, T.A., McKee, L., McGrory, G., Burgh, D.Y., Nelson, G., and Nelson, G.A. (1996). Factors associated with intention to undergo annual prostate can cer screening among Afri can American men in Philadelphia. Cancer, 78 (3), 471-479. Muhlenkamp, A.F. and Broerman, N.A. (198 8). Health beliefs, health value, and positive health behaviors. Western Journal of Nursing Research, 10 (5), 637-646. National Cancer Institute. (2003). Retrieved July 27, 2003, from http://www.cancer.gov National Center of Educ ational Statistics. (2006) Retrieved August 8, 2008 from http://www .nces.ed.gov. Odedina, F.T., Campbell, E. S., LaRose-Pierre, Scrivens, J., and Hill, A. (2008). Personal factors affecting African-American men’s prostate cancer screening behavior. Journal of the National Medical Association, 100 (6), 724-733.

PAGE 126

115 Odedina, F.T., Scri vens, J., Emanuel, A., LaRose -Pierre, M., Brown, J., and Nash, R. (2004). A focu s group study of factor s influencing AfricanAmerican men’s pr ostate cancer sc reening behavior. Journal of the National Medical Association, 96 (6), 780-788. Oliver, J.S. (2007). Attitudes and belief s about prostate cancer and screening among rural African American men. Journal of Cultu ral Diversity, 14 (2), 74-80. Oncology Nursing Society. (2000). On cology nursing soci ety multicultural outcomes: Guidelines for cultur al competence. Pittsburgh, PA. Parchment, Y.D. (2004). Pr ostate cancer screening in African American and Caribbean males: Detriment in delay. The American Bl ack Nursing Faculty Journal, 15 (6), 116-120. Parker, S.L., Davis, K.J., Wingo, P.A., Ries, L.G., and Heat h, C.W. (1998). Cancer statistics by race and ethnicity. CA: A Cancer Journal for Clinicians, 48 (1), 31-33. Parse, R.R. (2001). Qualitative Inquiry: Th e Path of Sciencing. Sudbury, MA: Jones and Bartlett Publishing. Pender, N.J. and Pe nder, A.R. (1996). Health Promotion in Nursing Practice. Appleton and Lange: Stamford, CT. Pender, N.J. and Pender, A.R. (1986). Attitudes, subjective norms, and intentions to engage in health behaviors. Nursing Research, 35 (1), 15-18. Pender, N.J., Walker, S.N ., and Sechrist, K.R. (1990 ). Predicting healthpromoting lifestyles in the workplace. Nursing Research 39 (6), 326-332. Pett, M.A., Lackey, N.R., an d Sullivan, J.J. (2003). Making Sense of Factor Analysis. Thousand Oaks, CA: Sage Publications. Phillips, J.M., Cohen, M.Z., and Moses, G. (1999). Breast cancer screening and African American women: Fear, fatalism, and silence. Oncology Nursing Forum, 26 (3), 561-571. Plowden, K.O. (1999). Using the health be lief model in understanding cancer in African American men. The American Black Nursing Faculty Journal, 10 (1), 4-8. Plowden, K.O. (2006). To screen or not to screen: Factors influencing the decision to participate in prostate cancer screening among urban AfricanAmerican men. Urologic Nursing, 26 (6), 477-481.

PAGE 127

116 Plowden, K.O. and Miller, J.L. (2000). Mo tivators of health seeking behavior in urban African American men: An exploration of triggers and barriers. Journal of National Black Nurses ` Association, 11 (1), 15-20. Polit, D.F. and Beck, C.T. (2006). Essentials of Nursing Research: Methods, appraisal, and utilization. Philadelphia, PA: Lippincott Williams & Wilkins. Polit, D.F. and Hungler, B.P. (1995). Nursing Research: Principles and Methods. Philadelphia, PA: J.P. Lippincott. Powe, B.D. (1995c). Fatalism among elderly African Americans: Effects on colorectal screening. Cancer Nursing, 18 (5), 385-392. Powe, B. (1995a). Pe rceptions of cancer fatalism among African Americans: The influence of education, income, and cancer knowledge. Journal of National Black Nurses' Association, 7 (2), 41-48. Powe, B. (2001). Ca ncer fatalism among elderly African American women: Predictors of the intensity of the perceptions. Journal of Psychosocial Oncology. 19 (3/4), 85-95. Powe, B.D. and Johnson, A. (1995). Fatalism among African Americans: Philosophical perspectives. Journal of Religion and Health, 34, 119-125. Powe, B. D. ( 1996). Cancer fata lism among African Americans: A review of the literature. Nursing Outlook, 44 (1), 18-21. Powe, B.D. (1995b). Canc er fatalism among elderly Caucasians and African Americans. Oncology Nursing Forum, 22 (9),1355-1359. Powe, B. and Weinrich, S. (1999). An intervention to decrease cancer fatalism among rural elders. Oncology Nursing Forum, 26 (3), 583-588. Powe, B.D., Daniels, E.C. and Finnie, R. (2005). Compari ng perceptions of cancer fatalism among African American patients and their providers. Journal of the American Academy of Nurse Practitioners, 17 (8), 318-324. Price, J.H., Colvin, T.L., and Smith, D. (1993). Prostate cancer: Perceptions of African American males. Journal National Medical Association, 85 (12), 941-947. Redding, C.A., Rossi, S.R., Velicer, W.F., and Prochaska, J.O. (2000). Health behavior models. The International Journal of Health Education, 3, 180193.

PAGE 128

117 Rosenstock, LM. (1974). Histori cal origins of the health belief model. In Becker, M.H. (Ed.). The Health Belief Model and Personal Health Behavior (pp. 1-9). Thorofare, NJ: Charles B. Slack. Sandelowski, M. (1995). Sample size in qualita tive research. Research in Nursing and Health, 18, 179-183. Savage, S.A., and Clarke, V.A. (1996). Factors associated with screening mammography and breast self -examination intentions. Health Education Research, 11 (4), 409-421. Sheeran, P., and Orbell, S. (2000). Using implementation intentions to increase attendance for cervical cancer screening. Health Psychology, 19 (3), 283289. Shelton, P., Weinrich, S., and Reynolds, W. A. (1999). Barriers to prostate cancer screening in African American men. Journal of Black Nurses’ Association, 10 (1), 14-28. Spurlock, W.R. and Cullins, L.S. (2006). Cancer fatalism and breast cancer screening in African American women. American Black Nursing Faculty Journal, 17 (1), 38-43. Steele, C.B., Miller, D.S., Maylahn, C., Uhler, R.J., and Baker, C.T. (2000). Knowledge, attitudes, an d screening practices am ong older men regarding prostate cancer. American Journal of Public Health, 90 (10), 1595-1600. Straub, D., Boudreau, M-C., and Gefen, D. (2004). Validation guidelines for IS positivist research. Communications of the Asso ciation for Information Systems, 13, 380-407. Straughan, P.T. and Seow, A. (1998). Fatalism reconceptualized: A concept to predict health screening behavior. Journal of Gender. Culture, and Health, 3 (2), 85-100. Stromborg, M.F., Pender, N.J., Walker S.N., and Sechrist, K.R. (1990). Determinants of health promoting lifes tyle in ambulatory cancer patients. Social Science Medicine, 11 (10), 1159-1168. Taylor, K.L., Shelby, R., Kerner, J., Re dd, W., and Lynch, J. (2002). Impact of undergoing prostate carcinoma scr eening on prostate-cancer related knowledge and distress. Cancer, 95 (5), 1037-1044. Underwood, S.M. (1991). African American men: Perceptual determinants of early cancer detection an d cancer risk reduction. Cancer Nursing, 14 (6), 281-288.

PAGE 129

118 Underwood, S.M., Sanders, E., and Davis, M. (1993). Determinants of participation in state-ofthe art cancer prevention, early detection/screening, and treatm ent among African Americans. Cancer Nursing, 16 (1), 25-33. Underwood, S.M. (1992). Cancer risk re duction and early detection behaviors among black men: Focus on learned helplessness. Journal of Community Health Nursing, 9 (l),21-31. Underwood, S.M. and Sanders, E. (1990) Factors contributing to health promotion behaviors among African American men. Oncology Nursing Forum, 17 (S), 707-7 12. VanRyn, M., Lytle, L.A., and Kirscht, J.P. ( 1996). A test of the theory of planned behavior for two hea lth-related practices. Journal of Applied Social Psychology, 26 (10), 871-883. Vetter, N., Lewis, P., and Charny, M. (1991) Health, fatalism, and age in relation to lifestyle Health Visit, 64, 191-194. Walker, S., Sechrist, K., and Pender, N. (1987). The health-promoting lifestyle profile: Development and psychometric characteristics. Nursing Research, 36, 76-81. Watson, E., Hewitson, P., Brett, J., Bukach, C., Evans, R., Edwards, A., Elwyn, G., Cargill, A., and Austoker, J. (2006). Informed decision making and prostate specific antigen (PSA) tes ting for prostate cancer: A randomized controlled trial exploring the impact of a brief patient decision aid on men’s knowledge, attitudes and intention to be tested. Patient Education and Counseling, 63, 367-379. Watts, RJ. (1994). Beliefs about prostate disease in African American men: A pilot study. The American Black Nursing Faculty 102-105. Weber, R. P. (1995). Basic content an alysis. In Lewis-Beck, M.S. (Ed.). Research Practice International Handbook of Qualitative Application in the Social Sciences. London: Sage Publishing. Wehrwein, T. C. and Eddy, M.E. (1993). Br east health promotion: Behaviors of midlife women. Journal of Holistic Nursing, 11, 223-236. Weinrich, S. (2001). The debate about pros tate cancer screen ing: What nurses need to know. Seminars in Oncology Nursing, 17 (2), 78-84.

PAGE 130

119 Weinrich, S.P., Seger, R., Miller, B.L ., Davis, C., Kim, S., Wheeler, C., and Weinrich, M. (2004). Knowledge of the limitations associated with prostate cancer screenin g among low-income men. Cancer Nursing, 27 (6), 442-451. Weinrich, S.P., Weinrich, M.C., Boy d, M.D., and Atkinson, C. (1998). The impact of prostate cancer knowledge on cancer screening. Oncology Nursing Forum, 25 (3), 527-534. Weinrich, S.P., Weinrich, M.C., Priest J., and Fodi, C. (2003). Self-reported reasons men decide not to participat e in free prostate cancer screening. Oncology Nursing Forum, 30 (1), E12-E16. Weinrich, S.P., Yoon, S., and Weinrich, M. (1998). Predictors of participation in prostate cancer screening at worksites. Journal of Community Health, 15 (2), 113-129. Wilkes, G., Freeman, H. and Prout, M. (1994). Cancer and pove rty: Breaking the cycle. Seminars in Oncology Nursing, 10 79-88. Wilkinson, S., List, M., Sinner, M., Da i, L., and Chodak, G. (2003). Educating African-American men about prostate cancer: Impact on awareness and knowledge. Urology, 61 308-313. Williams-Piehota, P.A., McCormack, L.A ., Treiman, K., and Bann, C.M. (2008). Health information styles among par ticipants in a prostate cancer screening informed deci sion-making intervention. Health Education Research, 23 (3), 440-453. Zhan, L., Cloutterbuck, J., Keshian, J., and Lombardi, L. (1998). Promoting health: Perspectives from ethnic elderly women. Journal of Community Health, 15 (1), 31-44.

PAGE 131

120 Appendices

PAGE 132

121 Appendix A: Letter of Support

PAGE 133

122 Appendix A: Letter of Support

PAGE 134

123 Appendix B: IRB Approval

PAGE 135

124 Appendix C Demographic Questionnaire Age: ______________ Marital Status: ( ) Never married ( ) Married ( ) Divorced/Separated ( ) Widowed Educational level: How many years of formal education have you had? ___________ (Example: High school would be 12 years, 2 years of vocational training after high school would be 14 years, college graduate would be 16 years, masters’ degree would be 18 years, etc) Have you ever had a rectal exam for prostate cancer? YES NO Have you had a rectal exam for prostate can cer in the past 12 months? YES NO Have you ever had a blood test for prostate cancer? YES NO Have you had a blood test for prostate cancer in the past 12 months? YES NO Have you ever had prostate cancer? YES NO Has any male member of your immediate family ever had prostate cancer? YES NO

PAGE 136

125 Appendix D Focus Group Questions 1. Tell the group how long you’ve been a member of this church and what ministries you’re involved in. 2. What does health or being healthy mean to you? 3. What kind of things do you do to stay healthy? 4. Do most of the people you know get physical exams? 5. How do you think people your age feel abou t getting tested to prevent disease? 6. What are some specific health screen ings that you’ve participated in? 7. Does anyone you know have prostate cancer? (If yes, ask “tell me what you know about their experience”) 8. What do you think is the risk for peopl e your age getting prostate cancer? 9. How many of you have ever been tested for prostate cancer? 10. What do you think gets in the way of peopl e getting tested for prostate cancer? 11. Tell me what you think might be three benefits of getting tested for prostate cancer. (Moderator will write th e responses on a flip chart) 12. If you had to convince one of your friends or one of the brethren to get tested for prostate cancer, what would you tell him? (Moderator will write responses on a flip chart) 13. Of all the things that you would say to c onvince your friend or one of the brethren to get tested for prostate cancer, which do you think is most important? 14. Is there anything we didn’t cover that we should have?

PAGE 137

126 Appendix E Cancer Screening Intention Scale-Prostate Instructions: Please read each sentence carefully and circle the response that best describes your belief about the sentence. Digital Rectal Exam (DRE): A gloved finger is placed in the rectum to check the prostate 1. I intend to get a DRE this year. Strongly agree Agree Disa gree Strongly Disagree 2. I have already scheduled an appo intment to get a DRE this year. Strongly agree Agree Disa gree Strongly Disagree 3. I believe that getting a DRE will benefit me. Strongly agree Agree Disa gree Strongly Disagree 4. I believe that getting a DRE and the blood test for prostate cancer will lower my chances of getting prostate cancer. Strongly agree Agree Disa gree Strongly Disagree 5. Getting the DRE and the blood test fo r prostate cancer will help find prostate cancer early. Strongly agree Agree Disa gree Strongly Disagree 6. Getting the DRE and the blood test for prostate cancer will keep me from worrying about getting prostate cancer. Strongly agree Agree Disa gree Strongly Disagree 7. I believe that a DRE will be harmful to me. Strongly agree Agree Disa gree Strongly Disagree 8. I believe that the DRE will be a painful experience for me. Strongly agree Agree Disa gree Strongly Disagree

PAGE 138

127 9. Getting the DRE is embarrassing to me. Strongly agree Agree Disa gree Strongly Disagree 10. Thinking about getting the DRE scares me. Strongly agree Agree Disa gree Strongly Disagree 11. I think most African American (B lack) men don’t know about the DRE and the blood test for prostate cancer. Strongly agree Agree Disa gree Strongly Disagree 12. The hours at my job will keep me from getting the DRE and the blood test for prostate cancer. Strongly agree Agree Disa gree Strongly Disagree 13. Lack of transportation will keep me from getting the DRE and the blood test for prostate cancer. Strongly agree Agree Disa gree Strongly Disagree 14. I believe that it is completely up to me whether or not I have a DRE and the blood test for prostate cancer. Strongly agree Agree Disa gree Strongly Disagree 15. I am confident that I will be able to get a DRE. Strongly agree Agree Disa gree Strongly Disagree 16. I believe that it would be wo rthless for me to have a DRE. Strongly agree Agree Disa gree Strongly Disagree 17. The people in my life whose opinio ns I value think I should have a DRE. Strongly agree Agree Disa gree Strongly Disagree 18. Most of my male family memb ers and friends have had a DRE. Strongly agree Agree Disa gree Strongly Disagree

PAGE 139

128 Prostate Cancer Blood Test 19. I intend to get the blood test for prostate cancer this year. Strongly agree Agree Disa gree Strongly Disagree 20. I have already scheduled an appoin tment to get the blood test for prostate cancer this year. Strongly agree Agree Disa gree Strongly Disagree 21. I believe that it would be valuable for me to get the blood test for prostate cancer. Strongly agree Agree Disa gree Strongly Disagree 22. I believe that the blood test for prostate cancer will be harmful to me. Strongly agree Agree Disa gree Strongly Disagree 23. I believe that the blood test for prostate cancer will be a painful experience for me. Strongly agree Agree Disa gree Strongly Disagree 24. Getting the blood test for prosta te cancer is embarrassing to me. Strongly agree Agree Disa gree Strongly Disagree 25. Thinking about getting the blood test for prostate cancer scares me. Strongly agree Agree Disa gree Strongly Disagree 26. It will be easy for me to go get th e blood test for prostate cancer. Strongly agree Agree Disa gree Strongly Disagree 27. I believe it is useless for me to get the blood test for prostate cancer. Strongly agree Agree Disa gree Strongly Disagree

PAGE 140

129 28. The people in my life whose opinions I value think that I should have the blood test for prostate cancer. Strongly agree Agree Disa gree Strongly Disagree 29. Most of my male family members a nd friends have had the blood test for prostate cancer. Strongly agree Agree Disa gree Strongly Disagree Prostate Cancer 30. I believe that prostate cancer is a serious disease. Strongly agree Agree Disa gree Strongly Disagree 31. Prostate cancer would threaten my relationship with my partner. Strongly agree Agree Disa gree Strongly Disagree 32. I worry about getting prostate cancer. Strongly agree Agree Disa gree Strongly Disagree 33. I believe that I am at risk for getting prostate cancer. Strongly agree Agree Disa gree Strongly Disagree 34. I believe that I am at higher risk for getting prostate cancer than other men. Strongly agree Agree Disa gree Strongly Disagree 35. It is likely that I will get prostate cancer in the future. Strongly agree Agree Disa gree Strongly Disagree 36. I believe there is nothing I can do to prevent me from getting prostate cancer. Strongly agree Agree Disa gree Strongly Disagree

PAGE 141

130 37. Doing what my family and friends th ink I should do is very important to me. Strongly agree Agree Disa gree Strongly Disagree Lifestyle 38. I eat well-balanced meals daily. Strongly agree Agree Disa gree Strongly Disagree 39. I get yearly physical check-ups. Strongly agree Agree Disa gree Strongly Disagree 40. I exercise at least three times a week. Strongly agree Agree Disa gree Strongly Disagree 41. I go see the doctor even when I’m not sick. Strongly agree Agree Disa gree Strongly Disagree 42. I eat at least five servings of fruits/vegetables daily. Strongly agree Agree Disa gree Strongly Disagree Decision Making 43. I am confident that I can talk to my healthcare provider about the benefits and risks of prostate cancer screening. Strongly agree Agree Disa gree Strongly Disagree

PAGE 142

131 Appendix F Prostate Cancer Knowledge Questionnaire (Sally Maliski, 2007) DIRECTIONS: Please answer each ques tion by circling “TRUE” or “FALSE” 1. The prostate is located between the bladder and penis, in front of the rectum. TRUE FALSE 2. If you have brothers or sons they ar e at higher risk for prostate cancer. TRUE FALSE 3. A man can have prostate cancer with out having any pain or symptoms. TRUE FALSE 4. Antibiotics can be used to cure prostate cancer. TRUE FALSE 5. Surgery or radiation can cure pros tate cancer in its early stage. TRUE FALSE 6. Prostate cancer treatment can increase your sex drive. TRUE FALSE 7. Eating soybean products such as tofu and soymilk can lower the risk of prostate cancer. TRUE FALSE

PAGE 143

132 Appendix G Prostate Cancer Belief Scale DIRECTIONS: Please read each sentence ca refully and circle the response that best describes your belief about the sentence. 1. I search for new informatio n to improve my health. Strongly agree Agree Disa gree Strongly disagree 2. I feel it is important to carry out ac tivities which will improve my health. Strongly agree Agree Disa gree Strongly disagree 3. When I have a recommended digital rectal exam (DRE or finger test), I feel good about myself. Strongly agree Agree Disa gree Strongly disagree 4. Having a DRE will decrease my chances of dying from prostate cancer. Strongly agree Agree Disa gree Strongly disagree 5. Having a DRE would take too much time. Strongly agree Agree Disa gree Strongly disagree 6. Having a DRE would cost too much money. Strongly agree Agree Disa gree Strongly disagree 7. I feel I will get prostate cancer in the future. Strongly agree Agree Disa gree Strongly disagree 8. There is a good possibility I will get prostate cancer. Strongly agree Agree Disa gree Strongly disagree 9. I am afraid to think about prostate cancer. Strongly agree Agree Disa gree Strongly disagree

PAGE 144

133 10. If I developed prostate cancer, I would not live longer than five years. Strongly agree Agree Disa gree Strongly disagree

PAGE 145

134 Appendix H Powe Fatalism Index (1995) Directions: Please answer the following questions. 1. I think if someone is meant to have prostate cancer, it doesn't matter what kinds of food they eat, they will get prostate cancer anyway. YES NO 2. I think if someone has prostate cancer, it is already too late to get treated for it. YES NO 3. I think someone can eat fatty foods all their life, and if they are not meant to get prostate cancer, th ey won't get it. YES NO 4. I think if someone is meant to get prostate cancer, they will get it no matter what they do. YES NO 5. I think if someone gets prostate cancer, it was meant to be. YES NO 6. I think if someone gets prostate cancer, their time to die is soon. YES NO 7. I think if someone gets prostate can cer, that's the way they were meant to die. YES NO 8. I think getting checked for prostate cancer makes people scared that they may really have prostate cancer. YES NO 9. I think if someone is meant to have prostate cancer, they will have prostate cancer. YES NO 10. I think some people don't want to know if they have prostate cancer because they don't want to know they may be dying from it. YES NO 11. I think if someone gets prostate cancer, it doesn't matte r whether they find it early or late, they will still die from it. YES NO 12. I think if someone has prostate can cer and gets treatment for it, they will probably still die from the prostate cancer. YES NO 13. I think if someone was meant to have prostate cancer, it doesn't matter what doctors and nurses tell them to do, th ey will get prostate cancer anyway. YES NO 14. I think if someone is meant to have prostate cancer, it doesn't matter if they eat healthy foods, they will st ill get prostate cancer. YES NO 15. I think prostate cancer will kill you no matter when it is found and how it is treated. YES NO

PAGE 146

135 Appendix I Health Promoting Lifestyle Profile II DIRECTIONS: This questionnaire contains statements about your present way of life or personal habits. Please respond to each item as accurately as possible, and try not to skip any item. Indicate the frequency with which you engage in each behavior by circling: N for never, S for sometimes, O for often, or R for routinely 1. Choose a diet low in fat, satura ted fat, and cholesterol. N S O R 2. Report any unusual signs or symptoms to a physician or other health professional. N S O R 3. Follow a planned exercise program. N S O R 4. Feel I am growing and changing in positive ways. N S O R 5. Limit use of sugars and food c ontaining sugar (sweets). N S O R 6. Read or watch TV programs about improving health. N S O R 7. Exercise vigorously for 20 or mo re minutes at least three times a week (such as brisk walking, bicycling, aerobic dancing, using a stair climber). N S O R 8. Eat 6-11 servings of bread, cereal, rice and pasta each day. N S O R 9. Question health professionals in order to understand their instructions. N S O R 10. Take part in light to moderate physical activity (such as sustained walking 30-40 minutes 5 or more times a week). N S O R 11. Eat 2-4 servings of fruit each day. N S O R 12. Get a second opinion when I question my health care provider’s advice. N S O R 13. Take part in leisure-time (re creational) physical activities (such as swimming, dancing, bicycling). N S O R

PAGE 147

136 14. Eat 3-5 servings of vegetables each day. N S O R 15. Discuss my health concerns with health professionals. N S O R 16. Do stretching exercises at least 3 times per week. N S O R 17. Eat 2-3 servings of milk, yogur t or cheese each day. N S O R 18. Inspect my body at least monthl y for physical changes/ N S O R danger signs. 19. Get exercise during usual daily act ivities (such as walking N S O R during lunch, using stairs inst ead of elevators, parking car away from destination and walking). 20. Eat only 2-3 servings from the meat poultry, fish, dried beans, N S O R eggs, and nuts group each day. 21. Ask for information from health prof essionals about how to take N S O R good care of myself. 22. Check my pulse when exercising. N S O R 23. Read labels to identify nutrien ts, fats, and sodium content in packaged food. N S O R 24. Attend educational programs on personal health care. N S O R 25. Reach my target heart rate when exercising. N S O R 26. Eat breakfast. N S O R 27. Seek guidance or counseling when necessary. N S O R

PAGE 148

About the Author Susan A. Baker is a native Floridian. She received her BSN from Florida A&M University. Susan received her MSN from the University of South Fl orida. Her research interests lie in racial di sparities in cancer and health. She is especially interested in breast and prostate cancer in African Americans. Susan A. Baker is a board member of the Diversity Council at H. Lee Moffitt Cancer Center and the American Cancer Soci ety Operating Committee. Susan is an avid volunteer with the American Cancer Society.


xml version 1.0 encoding UTF-8 standalone no
record xmlns http:www.loc.govMARC21slim xmlns:xsi http:www.w3.org2001XMLSchema-instance xsi:schemaLocation http:www.loc.govstandardsmarcxmlschemaMARC21slim.xsd
leader nam 2200397Ka 4500
controlfield tag 001 002046176
005 20100104090101.0
007 cr bnu|||uuuuu
008 100104s2008 flu s 000 0 eng d
datafield ind1 8 ind2 024
subfield code a E14-SFE0002694
035
(OCoLC)495698874
040
FHM
c FHM
049
FHMM
090
RT41 (Online)
1 100
Baker, Susan Anita.
0 245
Prostate cancer screening intention among African American men :
b an instrument development study
h [electronic resource] /
by Susan Anita Baker.
260
[Tampa, Fla] :
University of South Florida,
2008.
500
Title from PDF of title page.
Document formatted into pages; contains 136 pages.
Includes vita.
502
Dissertation (Ph.D.)--University of South Florida, 2008.
504
Includes bibliographical references.
516
Text (Electronic dissertation) in PDF format.
520
ABSTRACT: Cancer is the second leading cause of death in the United States. Prostate cancer is the leading cause of cancer deaths among African American men, and African American men have the highest incidence of prostate cancer in the world. Limited studies have been conducted that address this critical issue. Existing literature reveals that the primary cause of increased mortality rates of prostate cancer in African American men is lack of participation in prostate cancer screening activities. The purpose of this three-phase study was to develop a valid and reliable instrument to measure prostate cancer screening intention among African American men. Three gender-specific focus groups were conducted in the first phase of the study. Twenty men from two north Florida churches participated in the focus groups.Eight dominant themes emerged from the focus groups and were utilized to develop the items for the intention instrument: fear, healthy lifestyle, hopelessness/helplessness, machismo, mistrust of healthcare providers, social/familial support, job requirements and transportation barriers. The second and third phases of the study consisted of development of the instrument and assessment of the instrument for validity and reliability. The Cancer Screening Intention Scale-Prostate (CSIS-P) consists of 43 items and was developed utilizing the results of the focus groups. The reading level of the CSIS-P was 5.6 utilizing the Flesch-Kincaid index and 7.0 utilizing the SMOG Readability Formula. The CSIS-P was assessed for content validity by a panel of oncology experts. The content validity index for the scale was .90 and internal consistency was found to be .92. The CSIS-P was evaluated for construct validity utilizing factor analysis techniques.Test-retest procedures were also conducted to assess stability of the CSIS-P and the reliability coefficient was .93. Factor analysis techniques demonstrated a three-structure model. The factors that emerged were benefits to prostate cancer screening, barriers to prostate cancer screening, and health promotion. The internal consistency of the three factors were found to be .88, .81, and .86 respectively. Factor analysis procedures reduced the CSIS-P to a 17-item scale. The CSIS-P is a parsimonious, culturally sensitive instrument that is valid and reliable in assessing prostate cancer screening intention. Recommendations for future study of the instrument include replication of the study with a more heterogeneous sample and utilization of the scale with other cancers.
538
Mode of access: World Wide Web.
System requirements: World Wide Web browser and PDF reader.
590
Advisor: Susan McMillan, Ph.D.
653
Health beliefs
Fatalism
Health promotion
Planned behavior
Knowledge
690
Dissertations, Academic
z USF
x Nursing
Doctoral.
773
t USF Electronic Theses and Dissertations.
4 856
u http://digital.lib.usf.edu/?e14.2694