Challenging Dogma - Fall 2007

...Using the social and behavioral sciences to improve the practice of public health.

Thursday, December 13, 2007

Public Health Intervention Failures in Reducing the Incidence and Mortality Rates of Prostate Cancer Among African-American Men- Anthony Agosto

Prostate Cancer is a disease that develops in the prostate, a gland in the male reproductive system, which occurs when there is a mutation within the cells of the prostate leading to an abnormal multiplication. Prostate Cancer is the second leading cause, after lung cancer, of cancer deaths of men in the United States, and the third leading cause of cancer deaths among African-American men. Although mortality rates for prostate cancer in the United States have declined for all racial/ethnic groups, there are studies showing that the incidence and mortality rates are higher among African-American men than any other racial/ethnic group. The purpose of this paper is to critique Public Health intervention failures in addressing certain aspects of three important health models; The Health Belief Model, Ecological Model and Theory of Reasoned Action, which have led to both higher incidence and mortality rates of prostate cancer among African-American men.

Failure in Addressing Certain Aspects of The Health Belief Model

According to the oldest and most widely used individual model, the Health Belief Model, individuals act upon reasoned behavior, whereby if they are able to perceive that positive outcomes outweigh negative barriers, then they are most likely to engage in preventive health action. Public Health interventions, based on the Health Belief Model, have failed to address how African-American men will overcome their fear of being diagnosed with prostate cancer, which is the greatest barrier that has limited their participation in preventive measures.

There is direct correlation between a fear of diagnosis as such, a corresponding reluctance to engage in preventive action such as DRE (Digital Rectal Examination) and PSA (Prostate Specific Assay) and higher incidence and mortality rates among African-American men. According to various studies, African-American men are most susceptible among racial/ethnic groups to a fear of diagnosis that is so consuming that they are likely to drop out of screening programs, if they participate in them at all (1). In addition, it is evident that the embarrassment and stigma associated with having a doctor insert a lubricated glove into the anus to check for prostate abnormalities during a DRE has led African-American men choose private prostate cancer appointments or self care, over mass screening programs, and to seek prostate-related complementary and alternative medicines. In order to be most effective, Public Health interventions for prostate cancer using the Health Belief Model need to be aware of how powerfully fear and embarrassment influence patients in their willingness to take precautionary measures to monitor their health periodically.

Failure in Addressing Certain Aspects of The Ecological Model

Behavioral decisions are influenced by many individual factors and by the environment which, when taken together, form the Ecological Model. Within this model, the important factor of preventive knowledge has not been considered when implementing public health interventions for prostate screening among African-American men. According to recent studies, there have been recommendations by professional organizations to inform men about known risks and potential benefits of screening, and even so, there continues to be limited knowledge among men, particularly African-American men (2). As stated in the American Journal of Public Health (AJPH) “ There is an uncertainty between what African-American men know and what they ought to know in order to make an informed decision about screening”. This uncertainty was addressed by coming to an understanding of the basic facts that all men should know in order to make an informed decision regarding preventive health measures, moreover, there is also limited knowledge that screening test may reduce prostate cancer mortality rates, but that they do occasionally result in false-positive, negative results. Twenty-two percent of African-American men believed, wrongly, that DRE (Digital Rectal Examination) was a blood test for prostate cancer (3). It is therefore important to focus on this target group, first by highlighting the essential facts they must know about screening that will hopefully demystify the process and destigmatize the experience of screening or treatment, leading to greater efficacy.

Failure in Addressing Certain Aspects of The Theory of Reasoned Action

Limited faith among African-American men in the efficacy of screening or treatment has been another deterrent in taking preventive health measures for prostate cancer. There is no scientific evidence to prove that screening tests for prostate cancer do in fact decrease the incidence of mortality. Public Health interventions have difficulty convincing African-American men to take preventive actions in light of this culture of stigmatization and fear. The Theory of Reasoned Action, an individual-oriented theory, incorporates an individual’s attitude regarding preventive measures based on expectations of (limited) positive or negative outcomes. Without evidence confirming that the benefits of screening outweigh the discomfort of the experience for many, it is unlikely that men’s attitude will shift towards taking preventive health action for prostate cancer more seriously. Research has suggested that faith in the efficacy of screening or treatment correlates more frequently with a willingness to take preventive action for prostate cancer (4).

Public Health interventions have failed to consider those aspects of the health models; The Health Belief Model, Ecological Model, and Theory of Reasoned Behavior, which may explain higher incidence and mortality rates of prostate cancer among African-American men. In order to develop effective public health interventions for prostate cancer among this target group, there needs to be further research and funding readily available for such interventions, informative material distributed that would be self-explanatory regardless of patients’ educational background and effective communication between providers and patients. Most importantly, there needs to be continuing effort to promote more informed decision-making, so that men can overcome hesitation they may have about screening and be more fully engaged in the prevention and treatment of prostate cancer.


1. Roumier, X. Azzouri. Adherence to an annual PSA screening program over 3 years for brothers and sons of men with prostate cancer. European Urology, 45, 280-286.

2. Denmark-Wahnefried W, Strigo T, Catoe T. Knowledge, beliefs and prior screening behavior among blacks and whites reporting for prostate cancer screening. Urology. 1995; 46:346-351.

3. C.Y. Chan Evelyn, MD Vernon, W Sally, PhD, T O’Donnel Frederick, MS. Informed Consent for Cancer Screening with Prostate-Specific Antigen: How Well are Men Getting the Message? The American Journal of Public Health 2003; 93:779-784.

4. Consedine S Nathan, PhD, Horton David, Ungar Tracy, PhD, Joe. K Andrew, MD, Ramirez Paul, PhD and Borrel Luisa, PhD. Fear, Knowledge, and Efficacy Beliefs Differentially Predict the Frequency of Digital Rectal Examination Versus Prostate Specific Antigen Screening in Ethnically Diverse Samples of Older Men. The American Journal of Public Health 2007; 1:29-42.

5. Edberg Mark. Essentials of Health Behavior Social and Behavioral Theory in Public Health. Washington, DC, 2007.

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  • At December 18, 2007 at 6:43 PM , Anonymous Sarah said...

    Anthony: this was an interesting paper, especially because there is such a push for access & universal healthcare, and this will not help if people still will not go for routine screenings due to other reasons. I think it really exemplifies the need for better-conceived education for everyone.

  • At December 19, 2007 at 6:53 PM , Anonymous vanessa said...

    Great Topic! In order for people to understand the high incidence of mortality rates and prostate cancer among african americans interventions need to focus on certain aspects of health models. Your paper did a great job in explaining how each model affects african american men.


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