Prostate cancer health and cultural beliefs of black men : The Florida Prostate Cancer Disparity Project

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Prostate cancer health and cultural beliefs of black men : The Florida Prostate Cancer Disparity Project
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Infectious Agents and Cancer 2011, 6(Suppl 2):S10
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Odedina, Folakemi T.
Dagne, Getachew
Pressey, Shannon
Odedina, Oladapo
Emanuel, Frank
Scrivens, John
Reams, R. Renee
Adams, Angela
LaRose-Pierre, Margareth
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BioMed Central
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Abstract:
Background: Since behavioral factors are significant determinants of population health, addressing prostate cancer (CaP)-related health beliefs and cultural beliefs are key weapons to fight this deadly disease. This study investigated the health beliefs and cultural beliefs of black men relative to CaP, and the key socio-demographic correlates of these beliefs. Methods: The study design was a cross-sectional survey of 2,864 Florida black men, age 40 to 70, on their perceived susceptibility, perceived severity, attitude, outcomes beliefs, perceived behavioral control, CaP fatalism, religiosity, temporal orientation, and acculturation relative to CaP screening and prevention. Results: The men reported favorable attitude and positive outcome beliefs, but moderate perceived behavioral control, CaP susceptibility and CaP severity. They also had low level of acculturation, did not hold fatalistic beliefs about CaP, had high religious coping skills and had high future time perspective. Several demographic variables were found to be associated with health beliefs and cultural beliefs. Discussion: Our study provides rich data with regard to the health and cultural beliefs that might serve to inform the development of CaP control initiative for US-born and foreign-born black men.
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Publication of this article was funded in part by the University of Florida Open-Access Publishing Fund.

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PROCEEDINGS OpenAccessProstatecancerhealthandculturalbeliefsofblack men:TheFloridaProstateCancerDisparityProjectFolakemiTOdedina1*,GetachewDagne2,ShannonPressey1,OladapoOdedina3,FrankEmanuel4,JohnScrivens4, RReneeReams4,AngelaAdams5,MargarethLaRose-Pierre4From TheScienceofGlobalProstateCancerDisparitiesinBlackMen Jacksonville,FL,USA.27-29August2010AbstractBackground: Sincebehavioralfactorsaresignificantdeterminantsofpopulationhealth,addressingprostatecancer (CaP)-relatedhealthbeliefsandculturalbeliefsarekeyweaponstofightthisdeadlydisease.Thisstudyinvestigated thehealthbeliefsandculturalbeliefsofblackmenrelativetoCaP,andthekeysocio-demographiccorrelatesof thesebeliefs. Methods: Thestudydesignwasacross-sectionalsurveyof2,864Floridablackmen,age40to70,ontheir perceivedsusceptibility,perceivedseverity,attitude,outcomesbeliefs,perceivedbehavioralcontrol,CaPfatalism, religiosity,temporalorientation,andacculturationrelativetoCaPscreeningandprevention. Results: Themenreportedfavorableattitudeandpositiveoutcomebeliefs,butmoderateperceivedbehavioral control,CaPsusceptibilityandCaPseverity.Theyalsohadlowlevelofacculturation,didnotholdfatalisticbeliefs aboutCaP,hadhighreligiouscopingskillsandhadhighfuturetimeperspective.Severaldemographicvariables werefoundtobeassociatedwithhealthbeliefsandculturalbeliefs. Discussion: Ourstudyprovidesrichdatawithregardtothehealthandculturalbeliefsthatmightservetoinform thedevelopmentofCaPcontrolinitiativeforUS-bornandforeign-bornblackmen.BackgroundAlthoughprostatecancer(CaP)morbidityandmortality ratescontinuetodropamongblackmenintheUnited States(US),[1,2]thedeclinelagsbehindthatofwhite men.Blackmencontinuetobedisproportionately affectedbyCaPandhavethehighestmorbidityandmortalityratesforCaP.AccordingtotheAmericanCancer Society,[1]blackshave1in5lifetimeprobabilityof developinginvasiveCaPcomparedto1in7forwhites. ThelifetimeprobabilityofdyingfrominvasiveCaPis1 in23forblackmenand1in38forwhitemen.Black menalsoexperiencedispariti esrelativetoCaPsurvival withanoverall5-yearsurvivalrateof95%forblackmen and100%forwhitemen.TheBlackracial/ethnicgroupis theonlygroupthathasnotmettheHealthyPeople2010 goalofreducingCaPmortalityrateto28.8/100,000by 2010.TheaverageannualCaPdeathrateforblackmen between2002and2006was56.3and23.6forwhitemen. [1,2]Thisisadifferenceof32.7,withblackmenhaving CaPmortalityrate2.4timeshigherthanthatofwhite men.1,2Withthecontinuousdisparitiesbetweenblacks andwhitesonCaPincidence,survival,anddeaths,akey waytoclosethegapisindividualhealthpromotionand diseasepreventionbehaviorstoreducethebehavioral riskfactorsforCaP.ProstatecancerhealthbeliefsOneofthepotentialsourcesofdisparitiesinCaPisdue tothevariabilityinindividualhealthpromotionanddiseasepreventionbehaviors.[3]Thus,individualbehavioral theoriessuchastheHealthBeliefModel,[4,5]playasignificantroleinpredicting, explainingandmodifying healthbehaviorsincludingCaPprevention,informationseekingandscreeningbehaviors.TheHealthBelief Modelpostulatethatanindividual sbehaviorisaffected *Correspondence:fodedina@cop.ufl.edu1UniversityofFlorida,CollegeofPharmacy,GainesvilleFlorida,USA FulllistofauthorinformationisavailableattheendofthearticleOdedina etal InfectiousAgentsandCancer 2011, 6 (Suppl2):S10 http://www.infectagentscancer.com/content/6/S2/S10 2011Odedinaetal;licenseeBioMedCentralLtd.ThisisanopenaccessarticledistributedunderthetermsoftheCreativeCommons AttributionLicense(http://creativecommons.org/licenses/by/2.0),whichpermitsunrestricteduse,distribution,andreproductionin anymedium,providedtheoriginalworkisproperlycited.

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byperceptionsofthethreatposedbyahealthproblem, thebenefitsofavoidingthethreat,andfactorsinfluencingthedecisiontoact.[4,5]Someofthekeyhealth beliefconceptsinclude:(1)PerceivedsusceptibilityopinionofchancesofgettingCaP;(2)Perceivedseverity -opinionabouttheseriousnessofCaPanditssequel;(3) Perceivedbenefits-opinionaboutthebenefitsofreducingtheriskofgettingCaP;(4)PerceivedbarriersopinionaboutthebarriersimpactingCaPprevention/ earlydetectionbehaviors;(5)Cuestoaction-strategies toinformaboutandactivateCaPprevention/earlydetection;and(6)Perceivedbehavioralcontrol-confidenceof participants abilitytoreducetheriskofgettingCaP. Healthbelieffactorssuchasperceivedbarriers[6,7]and cuestoactionfromhealthcareprovider[8]havebeen foundtosignificantlydetermineCaPscreeninginpast studies.Also,intentiontoparticipateinCaPscreening wasfoundtobedeterminedbyperceivedbehavioralcontrol,perceivedsusceptibility,andcuestoactionbyhealth careprovider.[9]Recently,ourresearchteamfoundmodifiableCaPriskreductionbehaviortobeinfluencedby perceivedseverity,cuestoaction,knowledge,andbehavioralcontrol,whileCaPdetectionbehavior(information-seekingandscreening)wasdeterminedbyperceived susceptibility,attitude,per ceivedbehavioralcontrol, knowledge,andacculturation.[10]ProstatecancerculturalbeliefsAkeypiececurrentlymissingintheCaPliteratureisthe roleofvaryingpersonalculturalbeliefsandvalueson individualbehavioramongblackmen.Ithasbeennoted thatfundamentalelementsrelatedtoethnicityandcultureshapehealthperceptions,attitudesandbehaviors. [11]Itisthusimportanttoacknowledgeculturaldiversity andstudythespecificculturalbeliefsofeachethnic groupasrelatedtohealthandhealthbehaviors.[11]The importanceofcultureintheBlackcommunityhasbeen recognizedbyresearchers,[12-15]includingtheUS DepartmentofHealthandHumanServices.[14] Thereby,knowingtheculturalworldviewofblackmen willfurtherimproveourunderstandingofCaPpreventionandcontrolbehaviors,[16]andultimatelyenhance thedesignofsuccessfulinterventions. AccordingtoLeininger,[17]cultureisdefinedas sharedbeliefs,values,customs,behaviorsandartifacts usedbyindividualswithinasocietytocopewithother peopleandtheworldingeneral,andpasseddownfrom onegenerationtoanotherthroughlearning.Thecultural worldviewofindividualsisrootedinthevalues,beliefs andbehaviorsoftheirethnicpopulation.[18,19]Cultural beliefsandvaluessuchascancerfatalism,religionand spiritualism,temporalorientationandacculturationconsequentlyaffecttheirhealth beliefs,assumptionsand behavior. Cancerfatalism ,definedasanindividual s beliefthatdeathisboundtohappenwhendiagnosed withcancer,isamajorbarriertocancerdetectionand control.[20]Amongblacks,fatalisticperspectiveshave beenreportedtoaffectcervicalcancer,[21]breastcancer, [22,23]colorectalcancer[24]andfecaloccultbloodtesting.[25]Althoughreportsontheimpactof religionand spiritualism oncancerpreventionorscreeningislimited, ithasbeensuggestedthatitmaydeterwomenfromseekingtreatmentforbreastcancer.[26] Temporalorientation describestheroleofsocialpsychologyoftime.Itisan individual sperceptionoftimeasbeinginthepast,presentorfuture[27,28]andhassignificantinfluenceon individualthoughtsandact ions.[29]Forexample,temporalorientationhasbeenfoundtopredictmammographyscreening[23]andparticipationingeneticrisk assessment.[30]Ingeneral,healthpromotionanddisease preventionbehaviorssuchasCaPpreventionandscreeningrequirefuturetimeperspective.[29]Itisinteresting tonotethatBlacks timeorientationhasbeenreportedto beinthepresent.[27,31,32]Thisislikelytohavenegativeconsequencesonblackmen sCaPpreventionbehavior. Acculturation isacross-culturalpsychologyconcept that reflectstheextenttowhichindividuals(froma non-dominantculture)learnthevalues,behaviors,lifestyles,andlanguageofthehost(dominant)culture.[33] Sinceblackmenbelongtoanon-dominantgroupinthe US,overtheyearstheywilladoptvalues,behaviorsand lifestylesofthedominantCaucasiangroup.Theleveland processofacculturationdiffersforeachindividualand arelikelytoinfluenceCaPhealthbehaviors. PublishedliteraturereportontheCaPhealthbeliefsof blackmenislimitedandweareunawareofanypublishedstudyreportingtheculturalbeliefsofblackmen relativetoCaP.Thus,thegoalofthispaperwasto explorethehealthbeliefsandculturalbeliefsforCaP amongblackmen,andthekeysocio-demographiccorrelatesofthesebeliefs.Thehealthbeliefsexaminedwere perceivedsusceptibility,perceivedseverity,attitude,outcomesbeliefs,andperceivedbehavioralcontrol.This paperalsoexaminedthefollowingculturalbelieffactors: CaPfatalism,temporalorientation,religiosity,andacculturation.Wehypothesizedthatthesebeliefswillvaryby socio-demographiccharacteristicssuchasage,education, maritalstatusandethnicitywithintheblackrace.MethodsTheFloridaProstateCancerDisparityprojectisacrosssectionalstudyofover3,000BlackmeninFloridato developa PersonalIntegrativeModelofProstateCancer Disparity (PIPCaDmodel).[10]Across-sectionalsurvey studydesignwasemployedtocollectdatabetweenApril 2008andOctober2009fromblackmenbetweenthe agesof40and70years.ThecomprehensivedetailsoftheOdedina etal InfectiousAgentsandCancer 2011, 6 (Suppl2):S10 http://www.infectagentscancer.com/content/6/S2/S10 Page2of7

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methodologyforthisstudyhavealreadybeenprovidedin previouspublications.[10,34]ParticipantsTheprimarystudysitesforthestudywereTallahassee, Miami,TampaBay,Jacksonv illeandOrlandocitiesin Florida.Thesecitieswereselectedbasedonthelarge numberofethnicdiversityo fblackmen(i.e.U.S.-born andforeign-born).Thestudytargetedblackmen, regardlessofcountryoforigin,betweentheageof 40and70years.Althoughdatawerecollectedfromall blackmenregardlessofpersonalhistoryofCaP,only themenwhoreportednoper sonalhistoryofCaPwere includedinthefinaldataanalyses. Anaggressiverecruitmentcampaignwaslaunchedby ouracademic-communityresearchteamtorecruita demographicallyrepresentativesampleofblackmen through:barbershops,localblackchurches,mosques, communitypharmacies,fraternitiesandsocialorganizations(FirstFridays,100Blackmenorganizations),and radio/newspaperadvertisementsintheblackmedia.The primarydatacollectionsiteswereatethnicbarbershops andorganizedhealtheventsbycommunity-based/faithbasedorganizations.MeasuresThestudyindependentvariableswere healthbelief factors (perceivedsusceptibility,perceivedseverity,attitudeoutcomesbeliefs,andperceivedbehavioralcontrol) and culturalbelief/valuefactors (cancerfatalism,temporalorientation,religiosity/spiritualism,andacculturation).Thehealthbeliefmeasureswerepreviously developedbyourresearchteamandfoundtobereliable andvalid.[9,10,34-36]Fortheculturalbeliefandvalue measures,thesurveyitem sweredevelopedfrom:(i) findingsofourresearchteamfromanethnographical studyofBlackmen sculturalbeliefsandvalues;[10] and(ii)theadaptationofthefollowingmeasures:acculturationscaleofKlonoffandLandrine,[37]Brownand Segal sHypertensionTemporalOrientationscale,[31] Powe sFatalismInventory,[24,25]andtheReligious CopingscalebyCarveretal.[38]Theoperationaldefinitionofthestudyvariablesareprovidedbelow.PerceivedsusceptibilityPerceivedsusceptibilitycomprisedthreeitemsonparticipants chancesofgettingCaPdisease,with responsesrangingfromstronglyagree(5)tostrongly disagree(1).Oneoftheitemswas: Thereisagood possibilitythatIwillgetCaP. Higherscoreforthis variableindicatedhighperceptionofsusceptibilityto CaPdisease.Thea-priorisco ringclassificationforthis scalewaslowsusceptibilityforscoresof3-7,moderate susceptibilityforscoresof811,andhighsusceptibility forscoresof12-15.PerceivedseverityThemeasureforthisvariablecomprisedthreeitems abouttheseriousnessandconsequencesofCaP.For example,participantsrespondedtothestatement: IfI hadCaP,mywholelifewouldchange. Thescalescore rangedfrom1(stronglydisagree)to5(stronglyagree), withhigherscoreindicatinghighperceivedseverity.The a-prioriscoringclassificationwaslowseverityforscores of3-7,moderateseverityforscoresof8-11,andhigh severityforscoresof12-15.AttitudeAttitudeisthepositiveornegativeevaluationsabout CaP.Fiveitemsmeasuredparticipants attitudetowards CaPscreening,CaPriskreduction,andparticipatingin CaPmedicalresearchonaveryfavorable/veryunfavorablescalewithhigherscoreindicatingpositiveattitude. Anexampleoftheattitudeitemswas: Gettingtested forCaPwiththeDigitalRectalExamination(DRE) everyyearis: .Thea-prioriscoringclassificationforthis scalewaslowattitudeforscoresof5-12,moderateattitudeforscoresof13-19,andhighattitudeforscoresof 20-25.OutcomebeliefsThisisdefinedasthebeliefsabouttheoutcomes(negativeorpositive)ofabehaviorsuchasCaPprevention andscreening.Participantsrespondedtofouritemsona stronglydisagree(1)-stronglyagree(5)responsescale withhigherscoreindicatingpositiveoutcomebeliefs. Anexampleoftheoutcomebeliefitemsis: Preventing CaPthroughactivitiessuchaseatingright,takingsupplementsandexercisingwillsavemylife. Thea-priori scoringclassificationforthisscalewasnegativeoutcome beliefsforscoresof4-9,neutraloutcomebeliefsfor scoresof10-15,andpositiveoutcomebeliefsforscores of16-20.PerceivedbehavioralcontrolPerceivedbehavioralcontrolistheconfidenceofparticipants abilityrelativetoenactingthebehavior.Fiveitems wereusedtoassesshoweasyordifficultitwasfor respondentstoparticipateinCaPscreening,CaPrisk reduction,andCaPmedicalresearchonascaleof1(very difficult)to5(veryeasy)withhigherscoreindicating highperceivedbehavioralcontrol.Forexample,participantsrespondedtothestatement: EatingrightandtakingsupplementstopreventCaPis: .Thea-prioriscoring classificationforthisscalewaslowperceivedbehavioral controlforscoresof5-12,moderateperceivedbehavioral controlforscoresof13-19,andhighperceivedbehavioral controlforscoresof20-25.AcculturationThemeasureofacculturationwasbasedontheacculturationscaleofKlonoff&Landrine[37]andincluded itemssuchas, WhenitcomestothemusicIlistento andthemoviesIwatch,theyaremostlybyAfricanOdedina etal InfectiousAgentsandCancer 2011, 6 (Suppl2):S10 http://www.infectagentscancer.com/content/6/S2/S10 Page3of7

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Americanartists onaresponsescalerangingfrom stronglydisagree(1)tostronglyagree(5).Highscoreon theacculturationscaleindicatedlowlevelofacculturation,i.e.lowadoptionofthevalues,behaviorsandlifestylesofothers.Thea-prioriscoringclassificationfor thisscalewashighacculturationforscoresof4-9,moderateacculturationforscoresof10-15,andlowacculturationforscoresof16-20.TemporalorientationThethreeitemsusedtoassesstemporalorientation werebasedonBrownandSegal s[27]Hypertension TemporalOrientationscale.Forexample,participants respondedtothestatement: Ionlylivefornowand willnotworryaboutscreeningforCaPorpreventing CaP. Astronglydisagree(1)tostronglyagree(5) responsescalewasemployedtocaptureparticipants responses.Lowscoreonthismeasureindicatedfuture timeperspective.Thea-prioriscoringclassificationfor thisscalewashighfuturetimeperspectiveforscoresof 3-7,moderatefuturetimeperspectiveforscoresof8-11, andlowfuturetimeperspectiveforscoresof12-15.ProstateCancerfatalismIndividual sbeliefthatdeathisboundtohappenwhen diagnosedwithcancerisamajorbarriertocancerdetectionandcontrol.[20]ThemeasureofCaPfatalismwas adaptedfromthePoweFatalismInventory.[24,25]Participantsrespondedtothreeitemsonastronglydisagree (1)tostronglyagree(5)responsescale.Oneoftheitems was IbelievethatifsomeonehasCaP,itisalreadytoo latetodosomethingaboutit .Ahighscoreonthisscale isanindicationofstrongbeliefthatdeathisboundto happenwhendiagnosedwithCaP.Thea-prioriscoring classificationforthisscalewaslowfatalismforscoresof 3-7,moderatefatalismforscoresof8-11,andhighfatalismforscoresof12-15.ReligiosityReligiosityisorganizedsystemofbeliefs,practices, rituals,andsymbols.[39]Carveretal. sscale[38]was adaptedforthereligiouscopingmeasuresandincluded itemssuchas: IusuallyputmytrustinGod and My spiritualitywillhelpmetodealwithanyhealthproblem. Thescalescorerangedfrom1(stronglydisagree) to5(stronglyagree),withhigherscoreindicatinghigh religiosity.Thea-prioriscoringclassificationforthis scalewaslowreligiosityforscoresof3-7,moderatereligiosityforscoresof8-11,andhighreligiosityforscores of12-15.DataCollectionDatawerecollectedbytrainedresearchassistantswho providedthestudysurveystoblackmenaftertheyprovidedconsenttoparticipateinthestudy.Thesurvey wasintheEnglishlanguageandwasself-administered byparticipants.Uponcompletionofthesurveys, participantswereprovideda$15giftcertificatetowards ahaircutatparticipatingbarbershopsora$10WalMartgiftcardasincentivefortheirparticipation.AnalysesTheanalysesofsurveyresponseswereconductedusing thePC-SASanalyticalsoftwareafterthedatacodingand entry.Thestatisticalanalysesincludedfrequencyanalysis ofthevariablestoconfirmresponseswereappropriately enteredandtocorrectanyerrors,andtheinternalconsistencyofthestudymeasurestoestablishthereliability ofthemeasures.Subsequently,descriptivestatisticswere employedtosummarizesocio-demographicandstudy variables.Finally,multiplelinearregressionanalyseswere conductedtoconfirmthekeysocio-demographiccorrelatesofCaPhealthandculturalbeliefs.ResultsAtotalof2,864responseswerefoundtobecompleteand validforthisstudy.Thestudyscaleswerefoundtobe reliablebasedonNunnaly s[40]suggestionof0.7tobe anacceptablereliabilitycoefficient.Thereliability(alpha) ofthestudymeasureswere:0.87forattitude;0.83for perceivedbehavioralcontrol;0.87forperceivedsusceptibility;0.85forperceivedseverity;0.93foroutcome beliefs;0.71foracculturation;0.85fortemporalorientation;0.92forcancerfatalism;and0.91forreligiosity. Thecharacteristicsofstud yparticipantsaresummarizedinAdditionalfile1.MajorityofthestudyparticipantswereUS-bornblackmen,between40and49years, married,hadfull-timeemployment,ataneducationlevel ofhighschooldiploma,andearnedlessthan$20,000.HealthandculturalbeliefsofparticipantsAdditionalfile2providesasummaryofthehealthbeliefs andculturalbeliefsofparticipants.Themen soverall attitudewasfavorablewithamedianof20onascalerangingfrom5to25.Foreachofthefollowingitemsonthe attitudescale,themedianwas 4(i.e.,favorableattitude): (1)GettingtestedforCaPwiththeDREeveryyear;(2) GettingtestedforCaPusingSerumProstateSpecific Antigen(PSA)Testeveryyear;(3)Doingactivitiessuch as,eatingrightandtakingsupplements,topreventCaP; (4)Doingactivitiessuchas,exercising,topreventCaP; and(5)ParticipatinginCaPmedicalresearch. Theoverallperceivedbehavioralcontrolforthemen wasmoderate,withamedianof19onascalerangeof 5-25.Itwasinterestingtonotethatwhilethemen s responsesindicatedthatitwaseasyforthemtoparticipateinCaPscreeningbyPSA,eatrightandtakesupplement,andexercise;theirmedianresponseswereneutral (neithereasyordifficult)forDREeveryyearandparticipatinginCaPmedicalresearch.Relativetooutcome beliefs,participantsgenerallyhadpositiveoutcomeOdedina etal InfectiousAgentsandCancer 2011, 6 (Suppl2):S10 http://www.infectagentscancer.com/content/6/S2/S10 Page4of7

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beliefsandagreedthat:(1)PreventingCaPthroughactivitiessuchaseatingright,takingsupplementsandexercisingwillsavetheirlives;(2)PreventingCaPthrough activitiessuchaseatingright,takingsupplementsand exercisingwillhelpthemtopreventotherdiseases;(3) ScreeningforCaPeveryyearwillallowthemtodetect thediseaseearlyandgetappropriatetreatmentontime; and(4)GettingscreenedforCaPeveryyearwillgive thempeaceofmind.Ontheotherhand,theblackmen s perceptionofCaPsusceptibility(medianof9onascale rangeof3-15)andperceivedCaPseverity(medianof11 onascalerangeof3-15)werefoundtobemoderate. Themedianscoreforacculturationwas16(scale rangeof4-20),6fortemporalorientation(scalerange of3-15),6forcancerfatalism(scalerangeof3-15),and 13forreligiosity(scalerangeof3-15).Basedontheaprioriscoringclassificationsforthesescales,themen hadlowlevelofacculturation,didnotholdfatalistic beliefsaboutcancer,hadhighreligiouscopingskillsand hadhighfuturetimeperspective.DemographiccorrelatesofhealthandculturalbeliefsAdditionalfile3summarizesthemultiplelinearregressionsresultsforthedemographiccorrelatesofparticipants healthbeliefsandculturalbeliefs.Thedemographic correlatesofperceivedsuscep tibilitywereethnicityand age.Theindividualcoefficientsforthecorrelatesindicated thatUS-bornblackmen sperceivedsusceptibilityscore issignificantlyhigherthanCaribbean-bornblackmen. Ethnicity,ageandincomewerefoundtobeassociated withperceivedseverity.US-bornandAfrican-bornblack menreportedhigherperceivedseveritycomparedtoCaribbean-bornblackmen.Inaddition,participantswho earnedmorethan$100,000annuallyreportedhigherperceivedseveritycomparedtothosewhoearnedlessthan $100,000annually. Thecorrelatesofattitudewereethnicity,age,education,incomeandinsurance.Thefollowingwerethefindingsfromtheindividualcoefficientestimates(notshown inAdditionalfile3):US-bornblackmenandAfricanbornUScitizenshadmorefavorableattitudecompared toCaribbean-bornblackmen;Blackmenbetween60and 69yearshadmorefavorableattitudecomparedtothe menbetween40and49years;Blackmenwhodidnot completehighschoolandthosewithhighschooldiploma hadlessfavorableattitude comparedtothosewithpostcollegedegrees;Blackmenwhoearned$100,000ormore annuallyhadmorefavorableattitudecomparedtothe menwhoearnedbetween$20,000and$39,999annually; andBlackmenwhohadhealthinsurancehadmore favorableattitudecomparedtothosewithnohealth insurance. Ethnicity,education,maritalstatus,incomeandinsurancewereassociatedwithoutcomebeliefs.US-bornblack menhadmorepositiveoutcomebeliefscomparedto Caribbean-bornblackmen;Blackmenwithhighschool diplomaorlowerhadlesspositiveoutcomebeliefscomparedtothosewithpost-collegedegrees;singlemenhad lesspositiveoutcomebeliefscomparedtowidowedmen; Blackmenwhoearned$100,000ormoreannuallyhad morepositiveoutcomebeliefscomparedtothemenwho earnedbetween$20,000and$39,999annually;andblack menwhohadhealthinsurancehadmorepositiveoutcome beliefscomparedtothosewithouthealthinsurance.The demographiccorrelatesofperceivedbehavioralcontrol wereage,education,incomeandinsurance.Thefollowing werethefindingsfromtheindividualcoefficientestimates: Blackmenbetween60and69yearsreportedhigherperceivedbehavioralcontrolcomparedtothemenbetween 40and49years;Blackmenwithsomecollegetraining, highschooldiplomaandlessthanhighschooleducation reportedlowerperceivedbehavioralcontrolcomparedto thosewithpost-collegedegrees;andblackmenwithhealth insurancereportedhigherperceivedbehavioralcontrol comparedtothosewithouthealthinsurance. Fortheculturalbeliefs/valuesfactors,thedemographic correlateswere:incomeandinsuranceforacculturation; ethnicity,education,maritalstatus,employmentstatus, incomeandinsuranceforbothtemporalorientationand cancerfatalism;andethnicity,education,incomeand insuranceforreligiosity.Participantswhoreporteda householdincomelesstha n$60,000werelessacculturatedcomparedtothosewhoreportedannualincomeof $100,000ormore.Blackmenwhohadhealthinsurance werelessacculturatedcomparedtothosewithnohealth insurance.Relativetotemporalorientation:US-born blackmenweremorefutureorientedcomparedtoCaribbean-bornblackmen;Blackmenwithhighschool diplomaorlowereducationwerelessfuture-oriented comparedtothosewithpost-collegedegrees;menwho reportedbeingretiredweremorefuture-orientedcomparedtounemployedmen;menwhoearn$100,000or moreweremorefuture-orientedcomparedtothemen whoearnlessthan$80,000annually;andmenwith healthinsuranceweremorefuture-orientedcomparedto themenwithouthealthinsurance. Forcancerfatalism:US-bornblackmenandCaribbean-bornUScitizensreportedlesscancerfatalismcomparedtoCaribbean-bornblackmen;Blackmenwith highschooldiplomaorlowereducationwerereported highercancerfatalismcomparedtothosewithpost-collegedegrees;menwithpart-timeemploymentreported highercancerfatalismcomparedtounemployedmen; menwhoearnedlessthan$80,000annuallyreported highercancerfatalismcomparedtomenwhoearned $100,000ormoreannually;andmenwithouthealth insurancereportedhighercancerfatalismcomparedto thosewithhealthinsurance.Odedina etal InfectiousAgentsandCancer 2011, 6 (Suppl2):S10 http://www.infectagentscancer.com/content/6/S2/S10 Page5of7

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Finally,ethnicity,education,incomeandinsurance werefoundtobeassociatedwithreligiosity.US-born blackmenreportedhigherlevelofreligiositycompared toCaribbean-bornblackmen,whilemenwithouthealth insurancereportedlowerlevelofreligiositycomparedto themenwithhealthinsurance.DiscussionTodate,thedisparateburdenofCaPinblackmenis stillpoorlyunderstoodand hasnotbeeneffectively addressed.Althoughblackmenmayhaveseveralbiologicalfactorscontributingtothehigherincidenceof CaP,thepotentialsourcesofCaPdisparityoccurat individual(personalorprovider),andinstitutionalor healthsystemslevels.[3]Sincebehavioralfactorsisa significantdeterminantofpopulationhealth,[41] addressingCaP-relatedhealthbeliefsandculturalbeliefs arekeyweaponstofightCaP. Inarecentstudy,blackmen sCaPpreventionbehaviorwasfoundtobeinfluencedbyperceivedseverity andperceivedbehavioralcontrol,andCaPdetection (includinginformation-seekingandscreeningbehaviors) determinedbyperceivedsus ceptibility,attitude,perceivedbehavioralcontrol,andacculturation.[10]The confirmedassociationsamongCaPhealthbehaviors, healthbeliefs,andculturalbeliefsunderscoretheimportanceofhealthbeliefsandculturalbeliefsinthepromotionofCaPriskreductionbehavioraswellasearly detectionamongblackmen. Ourcurrentstudyfoundlowperceivedbehavioralcontrolamongyoungermen,menwhowerenotcollegeeducated,andmenwithouthealthinsurance.Blackmen whoearnedlessthan$100,000annuallyreportedlow perceivedseverityforCaP.Theknowledgeofthesepersonalfactorsprovideskeyinformationtodeveloptailored andtargetedCaPeducationalinterventionsforblack men.Basedonourfindings,menwithlowsocioeconomicstatusandmenlessthan50yearsreportedlow confidenceintheirabilitytoreducetheirriskofgetting CaPandearlydetectionofCaP.Educationalinterventionsshouldthereforefocusonteachingthemhowtoeat healthytopreventCaPandhowtoaccessaccurateinformationtomakeinformeddecisionaboutCaPscreening. AninterestingfindingisthelowerperceptionofCaP susceptibilityandseverityamongCaribbean-bornblack mencomparedtoUSblackmen.Inanotherstudy,Odedinaetal.[34]foundwithin-groupdifferencesbetween native-bornandforeign-bornUSblackmenonCaPrisk reductionandearlydetectio npractices.Riskreduction behaviors(suchasreducedmeatconsumptionanduse ofchemoprevention)andsel f-initiatedCaPdiscussion withadoctorwaslowerinnative-bornblackmen, althoughtheywerebetterinsuredandhadhigherCaP knowledgecomparedtoAfrican-bornandCaribbeanbornUSblackmen.[34]Futurestudiesshouldfocuson thedifferentialeffectofUSnativityandimmigration statusonCaPhealthdisparitiesamongblackmen.The studyofmigrationandhealthwillenhanceourunderstandingofCaPetiologyamongBlacksandalsofoster betterunderstandingofhealthrisksamongBlack immigrants. Anotherimportantcontributionofthisstudyisthe explorationofsocio-culturalexperiencessuchascultural beliefsandvalues.Currently,thereislimitedpublished studythathasexploredtheroleofblackmen scultural worldviewonCaPriskreductionanddetectionbehaviors. Theparticipantsofthisstudyreportedlowacculturation, lowcancerfatalism,highreligiouscopingskillsandhigh futuretimeperspective.Interestingly,wefounddifferential effectofforeignbornoncancerfatalism,religiosityand temporalorientation.Giventhatpreviousstudieshave alsonotedhealthvariationsbetweenUSbornandforeign bornBlacks,withahealthadvantageproposedforUS Blackimmigrants,[42-46]moreresearchisneededtoclarifyifandhowculturalbeliefsandvaluesimpactCaPpreventionandearlydetection.AssuggestedbytheIOM report,[3]ourpremiseisthatthehealthbehaviorofblack mencontributestoCaPhealth disparity.Byconfirming theculturalbeliefsandvaluesthataffectthisbehavior,targetedprogramscanbedevelopedtopromoteCaPpreventionanddetectionamongblackmen. Theprimarylimitationsofthisstudyareinherentin therepresentationofparticipantsandthenatureofthe studydesign.Sinceparticipantswereconvenientsample, studyresultscannotbereadilygeneralizedtoallblack men.Anotherlimitationisthattheassessmentofstudy variablesisbyself-administeredsurveywhichmaybe biasedbysocialdesirability(lyingtolookgood),acquiescence(tendencytoagree),andextremity(tendencyto useextremeratings).AdditionalmaterialAdditionalfile1:Participants demographics Additionalfile2:Summaryofhealthbeliefsandculturalbeliefsof participants Additionalfile3:Multipleregressionanalysesresultsfor demographiccorrelates Acknowledgements TheFloridaProstateCancerDisparityProjectwasfundedbytheDepartment ofDefenseProstateCancerResearchProgramW81XWH-07-1-0026. Thisarticlehasbeenpublishedaspartof InfectiousAgentsandCancer Volume6Supplement2,2011:ProceedingsoftheFirstBiennialConference ontheScienceofGlobalProstateCancerDisparitiesinBlackMen.Thefull contentsofthesupplementareavailableonlineathttp://www. infectagentscancer.com/supplements/6/S2.Odedina etal InfectiousAgentsandCancer 2011, 6 (Suppl2):S10 http://www.infectagentscancer.com/content/6/S2/S10 Page6of7

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Authordetails1UniversityofFlorida,CollegeofPharmacy,GainesvilleFlorida,USA.2UniversityofSouthFlorida,CollegeofPublicHealth,TampaFlorida,USA.3FloridaBlackLivingNavigator,TampaFlorida,USA.4FloridaA&MUniversity, CollegeofPharmacy&PharmaceuticalSciences,TallahasseeFlorida,USA.5CentralFloridaPharmacyCouncil,OrlandoFlorida,USA. Contributiontoliterature Ourstudyprovidesrichdatawithregardtothehealthandculturalbeliefs thatmightservetoinformthedevelopmentofcancercontrolinitiatives, includingCaPprevention,CaPscreeningandCaPeducationprogramsin thesehighrisktargetpopulations. Competinginterests Theauthorsdeclarethattheyhavenocompetinginterests. Published:23September2011 References1.AmericanCancerSociety: CancerFacts&FiguresforAfricanAmericans 2009-2010. AmericanCancerSociety.Atlanta,GA;2009. 2.AmericanCancerSociety: CancerFacts&Figures2010. AmericanCancer Society.Atlanta,GA;2010. 3.InstituteofMedicine: Unequaltreatment:Confrontingracialandethnic disparitiesinhealthcare. WashingtonDC,NationalAcademyPress;Smedley BD,StithAY,NelsonAR2003:1-27. 4.RosenstockIM: Historicaloriginsofthehealthbeliefmodel. HealthEduc Monogr 1974, 2 :344. 5.BeckerMH,MaimanLA,KirschtJP, etal : Thehealthbeliefmodeland predictionofdietarycompliance:afieldexperiment. JHealthSocBehav 1997, 18 :348-366. 6.ShaneL,WilsonT: Prostatecancer,incomeandeducationamongAfroAmericansinFlorida. McNairJournal 1999,39-42. 7.SheltonP,WeinrichS,ReynoldsWAJr: Barrierstoprostatecancerscreening inAfricanAmericanmen. JNatlBlackNursesAssoc 1999, 10(2) :14-28. 8.NivensAS,HermanJ,WeinrichSP, etal : Cuestoparticipationinprostate cancerscreening:atheoryforpractice. OncolNursForum 2001, 28(9) :1449-1456. 9.OdedinaFT,CampbellE,ScrivensJ,EmanuelA,LaRose-PierreM,BrownJ, NashR: PersonalFactorsAffectingAfricanAmericanmen sprostate cancerscreeningbehavior. JNatlMedAssoc 2008, 100(6) :724-733,PMID: 18595577. 10.OdedinaFT,ScrivensJ,LaRose-PierreM,EmanuelA,AdamsAA,GagneGA, PresseySA,OdedinaAO: ModifiableProstateCancerRiskReductionandEarly DetectionBehaviorsinBlackMen. AmJHealthBehav 2011,Forthcoming. 11.LeiningerM: Nursingtheoriesandculture:Fitormisfit? JTranscultNurs 1995, 7(1) :41-42. 12.HarrisonI,HarrisonD: Theblackfamilyexperienceandhealthbehavior. HealthandtheFamily:Amedical-sociologicalanalysis.NewYork: Macmillan;CrawfordC1971:171-199. 13.HogleJ: Ethnicityandutilizationofhealthservices:Anurbanresponse toaCommunityHealthCenter. AnnArbor,Michigan:UniversityMicrofilms International;1982. 14.USDepartmentofHealthandHumanServices: ReportoftheSecretary s TaskForce:BlackandMinorityHealth,ExecutiveSummary. Government PrintingOffice;1985: 1 :187-194. 15.BaileyEJ: Socioculturalfactorsandhealthcare-seekingbehavioramong BlackAmericans. JNatlMedAssoc 1987, 79(4) :389-392. 16.HughesC,FasayeGA,LaSalleVH,FinchC: Socioculturalinfluenceson participationingeneticriskassessmentandtestingamongAfrican Americanwomen. PatientEducCouns 2003, 51 :107-114. 17.LeiningerM: Nursingandanthropology:Twoworldstoblend. NewYork: JohnWiley&Sons;1970. 18.MyersLJ: UnderstandingandAfrocentricworldview:Introductiontoan optimalpsychology. Dubuque,IA:Kendall-Hunt;1998. 19.JacksonAP,SearsSJ: ImplicationsofanAfrocentricworldviewinreducing stressforAfricanAmericanwomen. JCounsDev 1992, 71 :184-190. 20.PoweBD,FinnieR: Cancerfatalism:Thestateofthescience. CancerNurs 2003, 26 :454-467. 21.ChavezLR,MishraSI,HubbellFA,ValdezRB: Theinfluenceoffatalismonself reporteduseofpapanicolaousmears. AmJPrevMed 1997, 13 :418-424. 22.MayoRM,UredaJR,ParkerVG: Importanceoffatalisminunderstanding mammographyscreeninginruralelderlywomen. JWomenAging 2001, 13 :57-72. 23.RussellKM,PerkinsSM,ZollingerTW,ChampionVL: Socioculturalcontext ofmammographyscreeninguse. OncolNursForum 2006, 33(1) :105-112. 24.PoweBD: FatalismamongelderlyAfricanAmericans:Effectson colorectalcancerscreening. CancerNurs 1995, 18 :285-392. 25.PoweBD: CancerfatalismamongelderlyCaucasiansandAfrican Americans. OncolNursForum 1995, 22(9) :1355-1359. 26.LanninDR,MathewsHF,MitchellJ, etal : Influenceofsocioeconomicand culturalfactorsonracialdifferencesinlate-stagepresentationofbreast cancer. JAMA 1998, 279 :1801-1807. 27.BrownCM,SegalR: Thedevelopmentandevaluationofthe hypertensiontemporalorientation(HTO)scale. EthnDis 1997, 7 :41-54. 28.HolmanEA,SilverRC: Gettingstuckinthepast:Temporalorientationand copingwithtrauma. JPersSocPsychol 1998, 74 :1146-1163. 29.GrahamRJ: Theroleofperceptionoftimeinconsumerresearch. J ConsumRes 1981, 7 :335-342. 30.HughesC,FasayeGA,LaSalleVH,FinchC: Socioculturalinfluenceson participationingeneticriskassessmentandtestingamongAfrican Americanwomen. PatientEducCouns 2003, 51 :107-114. 31.BrownCM,SegalR: Ethnicdifferencesintemporalorientationandits implicationsforhypertensionmanagement. JHealthSocBehav 1996, 37 :350-361. 32.JonesJM: Culturaldifferencesintemporalperspectives:Instrumentaland expressivebehaviorsintime. In TheSocialPsychologyofTime. Newbury Park,Calif:SagePublications;McGrathJE1988:21-38. 33.ZaneN,MakW: Majorapproachestothemeasurementofacculturation amongethnicminoritypopulations:Acontentanalysisandan alternativeempiricalstrategy. In Acculturation:AdvancesinTheory, Measurement,andAppliedResearch. Washington,DC:American PsychologicalAssociation;ChunKM,OrganistaPB,MarinG2003:39. 34.OdedinaFT,GagneGA,LaRose-PierreM,EmanuelA,ScrivensJ,AdamsAA, PresseySA,OdedinaAO: Within-groupdifferencesbetweennative-born andforeign-bornBlackmenonprostatecancerriskreductionandearly detectionpractices. JImmigrMinorHealth 2011,Forthcoming. 35.OdedinaFT,ScrivensJ,XiaoH, etal : AfricanAmericanmales viewson prostatecancerscreening. MinorityHealth 2000, 1(6) :28-34. 36.OdedinaFT,ScrivensJ,EmanuelA, etal : Afocusgroupstudyoffactors influencingAfrican-Americanmen sprostatecancerscreeningbehavior. JNatlMedAssoc 2004, 96(6) :780-788. 37.KlonoffEA,LandrineH: RevisingandimprovingtheAfricanAmerican Acculturationscale. JBlackPsychol 2000, 26(2) :235-261. 38.CarverCS,ScheierMF,WeintraubJK: Assessingcopingstrategies:a theoreticallybasedapproach. JPersSocPsychol 1989, 56 :267-283. 39.ThoresenCE: Spirituality,Health,andscience:thecomingrevival? In The EmergingRoleofCounselingPsychologyinHealthCare. NewYork:W.W. Norton;R.S.Roth&S.R.Kurpius1998:. 40.NunnalyJ: PsychometricTheory. NewYork:McGraw-Hill;1978. 41.McGinnisJM,Williams-RussonP,KnickmanJR: Thecaseformoreactive policyattentionstohealthpromotion. HealthAff 2002, 21(2) :78-92. 42.ReadJG,EmersonMO,TarlovA: Implicationsofblackimmigranthealth forU.S.racialdisparitiesinhealth. JImmigrHealth 2005, 7(3) :205-212. 43.PallottoEK,CollinsJWJr,DavidRJ: Enigmaofmaternalraceandinfant birthweight:Apopulation-basedstudyofUS-bornBlackandCaribbeanbornBlackwomen. AmJEpidemiol 2000, 151(11) :1080-1085. 44.SchmidleyAD: Profileoftheforeign-bornpopulationintheUnited States:2000. U.S.CensusBureau,CurrentPopulationReports,Series Washington,DC:U.S.GovernmentPrintingOffice;2001,23-206. 45.SinghGK,SiahpushM: Ethnic-immigrantdifferentialsinhealthbehaviors, morbidity,andcause-specificmortalityintheUnitedStates:Ananalysis oftwonationaldatabases. HumBiol 2002, 74 :83-109. 46.DavidRJ,CollinsJW: DifferingbirthweightamonginfantsofU.S.-born blacks,African-bornblacksandU.S.-bornwhites. NEnglJMed 1997, 337(17) :1209-1214.doi:10.1186/1750-9378-6-S2-S10 Citethisarticleas: Odedina etal .: Prostatecancerhealthandcultural beliefsofblackmen:TheFloridaProstateCancerDisparityProject. 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Table 1 Participants’ Demographics Variable Fre q uenc y Percent ( % ) Ethnicit y African American of American ori g i n 2066 79.86 African American of African ori g i n 145 5.60 African American of Caribbean ori g i n 153 5.91 African 108 4.17 Caribbean 115 4.45 Fre q uenc y Missin g 277 A g e 40 to 49 1365 50.15 50 to 59 971 35.67 60 to 69 386 14.18 Fre q uenc y Missin g 142 Educatio n Less than hi g h school 342 12.84 Hi g h school de g ree 1046 39.28 Some colle g e trainin g 540 20.28 Colle g e de g ree 531 19.94 Post-colle g e de g ree 204 7.66 Fre q uenc y Missin g 201 12.84 Marital Status Sin g le 1057 38.53

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Married 1279 46.63 Divorce d 333 12.14 Widowe d 74 2.70 Fre q uenc y Missin g 121 Em p lo y ment Full time 1333 48.83 Part time 312 11.43 Disabilit y 252 9.23 Retire d 251 9.19 Unem p lo y e d 582 21.32 Fre q uenc y Missin g 134 Household Income ( $ ) 0-19 999 1052 39.30 20 000-39 999 659 24.62 40 000-59 999 360 13.45 60 000-79 999 24 9.15 80 000 – 99 999 5 5.90 100 000 and above 158 7.58 Fre q uenc y Missin g 203 Insurance Yes 1710 63.81 No 970 36.19 Fre q uenc y Missin g 184

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Table 2 Summary of Health Beliefs and Cu ltural Beliefs of Participants Stud y Variables Scale Ran g e Mean ( SD ) Median Perceived susceptibility 3-159.23(2.84) 9 Perceived severity 315 10.35 (2.95) 11 Attitude 5-2519.64 (4.08) 20 Perceived Behavioral Control 5-2518.46 (3.98) 19 Acculturation 420 15.42 (3.16) 16 Temporal Orientatio n 3-157.09 (3.29) 6 Cancer Fatalism 3-15 6.35 (3.29) 6 Religiosity 3-1512.47 (2.96) 13

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Table 3 Multiple Regression Analyses Results for Demographic Correlates Variable / Item F-Values and Probability Values (Pr > F) for Ethnicity Age Education Marital Status Employment status Income Insurance Perceived susceptibility 4.64 (0.0010) 3.99 (0.0186) 0.91 (0.4570) 2.35 (0.0706) 0.38 (0.8213) 0.97 (0.4357) 2.21 (0.1369) Perceived severity 3.02 (0.0171) 3.21 (0.0404) 0.60 (0.6621) 2.21 (0.0854) 1.46 (0.2109) 2.67 (0.0205) 1.36 (0.2438) Attitude 3.23 (0.0119) 16.03 (<.0001) 10.64 (<.0001) 1.84 (0.1382) 1.73 (0.1413) 6.71 (<.0001) 5.60 (0.0180) Outcome Beliefs 7.46 (<.0001) 2.31 (0.0992) 9.88 (<.0001) 2.91 (0.0332) 2.23 (0.0630) 3.62 (0.0029) 8.94 (0.0028) Perceived behavioral control 0.81 (0.5206) 12.46 (<.0001) 7.83 (<.0001) 1.88 (0.1317) 1.77 (0.1324) 2.31 (0.0421) 10.34 (0.0013) Acculturation 0.77 (0.5455) 0.94 (0.3908) 1.51 (0.1965) 0.74 (0.5255) 0.37 (0.8316) 4.30 (0.0007) 8.86 (0.0029) Temporal orientation 6.02 (<.0001) 1.23 (0.2935) 13.04 (<.0001) 7.19 (<.0001) 2.60 (0.0342) 5.93 (<.0001) 14.92 (0.0001) Cancer fatalism 8.69 (<.0001) 0.34 (0.7129) 9.26 (<.0001) 5.13 (0.0016) 3.18 (0.0130) 4.39 (0.0006) 9.68 (0.0019) Religiosity 5.66 (0.0002) 0.70 (0.4988) 3.12 (0.0143) 1.88 (0.1303) 1.24 (0.2920) 2.47 (0.0308) 29.67 (<.0001) † Results in bold-font are statistically significant at p<0.05 level.