Prostate cancer risk factors, care utilization and policy options. Focus group findings from an engagement with an African American urban community.
Abstract: This paper presents the findings of a focus group organized in collaboration with the African American urban community of GeorgeTown in Jackson Mississippi. The goal of the study is to identify and understand knowledge of prostate cancer risk factors and symptoms, utilization of existing prevention resources; and health education strategies. In addition, the study seeks to identify health education strategies and policy preferences that could be used in health promotion program development and policy advocacy framing. Findings of gaps in knowledge; low levels of service utilization; and the role of technology in limiting access to health information in the African American community are consistent with findings in other prostate cancer studies. However, some refreshing information regarding utilization, as well as health education and policy emerges from this study. The study painted a three dimensional profile of people who utilize prostate cancer screening services in the community. These are survivors who are enrolled in a prevention group, and have access to a supportive provider environment. There were also surprising reservations about the church as an outlet for prostate cancer health promotion because of discomfort with the topic in churches. Concrete prostate cancer related public policy options are proposed by participants including progressive policy options such as mandatory screening and referral regardless of financial qualification; free screening in emergency rooms; and conservative policy remedies such as tax breaks for facilities which provide free screening. Besides the clarity in policy advocacy themes, the findings provide specific information that could shape prevention programs and intervention research in the GeorgeTown community of Jackson Mississippi.
Article Type: Report
Subject: Health promotion (Research)
Prostate cancer (Risk factors)
Prostate cancer (Demographic aspects)
Prostate cancer (Prevention)
Medical care (Utilization)
Medical care (Research)
Authors: Tataw, David Besong
Ekundayo, Olugbemiga T.
Pub Date: 01/01/2012
Publication: Name: American Journal of Health Studies Publisher: American Journal of Health Studies Audience: Professional Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2012 American Journal of Health Studies ISSN: 1090-0500
Issue: Date: Wntr, 2012 Source Volume: 27 Source Issue: 1
Topic: Event Code: 310 Science & research
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 307184652
Full Text: INTRODUCTION

African American men bear a disproportionate share of prostate cancer disease burden among racial and ethnic groups in the United States (CDC, 2007, American Cancer Society, 2008), yet their utilization of early diagnostic resources is lower than that of other racial and ethnic groups in the United States (American Cancer Society, 2006, 2008). Thus, there is a strong need to design educational and outreach programs that will be a good fit for the health seeking preferences of African Americans. This paper reports on the use of focus groups in community engagement to determine the health promotion and policy preferences of the residents of GeorgeTown community in Jackson Mississippi so that intervention programs could be tailored to knowledge and utilization gaps as well as to reported health promotion and policy preferences.

Despite the disproportionately heavy burden of prostate cancer among African-American men, they often fail to address their own individual health or make decisions to engage in preventive behavior or to access healthcare related to this condition (Myers et al., 1996, 1999; American Cancer Society, 2006; 2008; Lehto, Song, Stein and Coleman-Burns, 2010). Low levels of preventive behavior and utilization of existing prostate cancer prevention and early treatment services are related to the target population's empowerment and acceptability of interventions in research and practice environments (Parket et al., 2006; Sanchez et al., 2007; Dunlop et al., 2002; Du et al., 2006). Specific reasons include distrust of the health care system (Halbert et al., 1999; Ravenell, Johnson & Whitaker, 2006; Fergus, Grey & Fitch, 2002; Forrester Anderson, 2005, Cheatam, Barksdale & Rogers, 2008); lack of self-efficacy due to social and economic disenfranchisement (Drake, Shelton, Gilligan & Allen 2010; Odedina, Campbell, LaRose-Pierre, Scrivens & Hill 2008;Ross, Meade, Powe & Howard, 2009); and stigma and social isolation with reduction in self esteem due to the relation to sexual activity and performance, or being seen as "weak" (Fergus, Grey & Fitch, 2002; Forrester-Anderson, 2005; Gamble, 1997; Wolf et al. 2006; Chan et al., 2005; Powell, 1997; Taylor et al.,1999,2001), fear of prostate cancer and lack of insurance (Ford et al., 2006); fear of digital rectal examination (DRE) (Reynolds 2008, Ross et al., 2007, Woods et al., 2006); and prostate cancer screening intervention message concept, message source, and message channel (Odedina et al., 2004).

Many scholars regard empowerment as both a means and an end in enhancing and promoting health (Wallerstein 1988, 1992; Braithwaite et al., 1994; Labonte 1994; Perkins & Zimmerman, 1995, Tataw et al., 2007; Tataw, James, Bazargan, 2009). The consumer's ability to participate in health services decision making is enhanced when communication during consumer/expert encounters moves from an expert dominated monologue to a dialogue where there is an exchange of information between expert and consumer rather than a transfer of information from expert to consumer (Leea & Garvin, 2003). Dialogue nurture's the consumer's acceptability of the expert's services through active participation and trusting relationships. Trust and participation in decision making has been shown to increase consumer self efficacy and satisfaction with health services in at risk low income populations (Doescher et al., 2000; Tataw, Bazargan, Patel, 2010).

Horizontal participatory approaches have been used to both increase participation of target population in needs assessments and to increase acceptability of intervention programs in the target communities. Therefore, prostate cancer preventive behavior and service utilization among black men could be improved if the target population participated in, and informs the development of outreach and educational interventions. Community health programs with cultural and/or structural horizontal relationships in which decision making is consensual through a give and take process rather than unidirectional from experts to low income consumers have increased the consumer's voice, self efficacy, satisfaction, and greater participation in the health system (Tataw & Bazargan-Hejazi, 2010, Tataw, Bazargan-Hejazi, James, 2010).

Participatory efforts in community engagement are those "involving users and communities in all stages of the development process" Narayan (1993, iii). Oakley et al., (1991 P.8) describe participation as "voluntary or other forms of contribution by rural people to predetermined programs or projects" Many activities constitute participation by beneficiaries including completing questionnaires, taking part in a focus group, or responding to key informant interviews, but a true participatory project is one that is initiated and owned by the project beneficiaries and contributes to the empowerment of the beneficiaries (Cummings, 1997, Laverack 2004, 2007). This study adopts a participatory approach to data collection and program development by involving a Community Advisory Board from GeorgeTown in Jackson Mississippi which identifies and encourages study participants to complete surveys. The study seeks to both understand participant needs and identify their health promotion and policy preferences so as to develop health promotion and policy advocacy strategies which are acceptable to the community.

SPECIFIC AIMS

The purpose of this focus group study is to assess prostate cancer health promotion and policy preferences in the GeorgeTown community of Jackson Mississippi in order to determine appropriate prostate cancer policy advocacy themes and to design outreach and educational strategies among African Americans in the Georgetown community of the City of Jackson Mississippi. The purpose of the study is achieved through the following specific aims:

1. To assess knowledge of prostate cancer symptoms, risk factors and causes among focus group participants

2. To assess perceptions of prostate cancer screening and treatment utilization patterns among participants

3. To determine participants' prostate cancer policy and health promotion preferences

4. To discuss the implications of findings in 1 to 3 above on the development of prostate cancer policy advocacy, and health promotion programs for the GeorgeTown community of Jackson Mississippi.

The above specific aims are achieved through a single focus group activity involving 20 residents drawn from the GeorgeTown community of Jackson Mississippi held on February 6, 2008.

SIGNIFICANCE

This study is significant because findings related to needs, service utilization and health promotion preferences could contribute to policy advocacy and intervention strategies developed with the input of the target population. These strategies will be more acceptable to the community since the community will take ownership of what they developed themselves. In addition, prostate cancer imposes a significant and disproportionate disease burden on African American men in Mississippi and the United States and this study advances prevention work in prostate cancer among this at risk population.

CONTRIBUTIONS TO THE LITERATURE

This study contributes to the literature on prostate cancer and health promotion by showing how qualitative research can be used to facilitate the input of target populations in health policy advocacy and health promotion program development. The commonly accepted norm in scientific circles has been for the researcher to engage the community and lead the process forward. However, this does not necessarily imply or involve a community that is engaged in the process, directing and setting the pace for thinking, planning and implementation. The study goes beyond the traditional needs determination common in planning studies and includes identification of the target community's preferred educational and policy intervention strategies in a participatory planning process. In addition, the health promotion strategies identified will increase or reaffirm the tools available for researchers and practitioners involved in prostate cancer reduction work in low income communities.

STUDY SETTING AND POPULATION CHARACTERISTICS

DISPARITIES IN PROSTATE CANCER BURDENS IN MISSISSIPPI AND THE UNITED STATES

Cancer is the second leading cause of death in both the United States (US) and Mississippi (Kung et al., 2008; Mississippi Department of Health Vital Statistics, 2006). The American Cancer Society (ACS) estimates that 13,400 new cases of cancer were diagnosed in Mississippi by the end of 2005, including 2,010 new cases of prostate cancer (American Cancer Society, 2008). By the end of 2004, data from the Centers for Disease Control and Prevention (CDC) revealed that Mississippi ranked second in U.S. in cancer death rates (CDC, 2007). In 2003, the incidence rate for cancer in Mississippi was lower than the average incidence rate for the nation; however, the death rate from cancer in Mississippi as enumerated above was higher than that of the US (Mississippi State Department of Health, Department of Health Cancer Registry, 2005).

In 2005, prostate cancer was the most common type of cancer found among Mississippi men with incidents at 161 per 100,000, closely followed by lung and bronchial cancer with incidents at 111.9 per 100, 000 (Mississippi, Department of Health Cancer Registry, 2005). Although ACS reported that the incidence of prostate cancer is on the decline in Mississippi, prostate cancer still ranks second as the leading cause of death among men. African American men have the highest incidence, prevalence, and mortality due to prostate cancer relative to other racial and ethnic groups in Mississippi.

According to the CDC, between 1970 and 1994, the death rate due to prostate cancer among black males in the state was twice the rate for white males. Mortality rates for white males are 21.2 per 100, 000 versus. 41.91 per 100, 000 for African American males (CDC, 2007). According to National Institutes of Health estimates, in 2008 dollars, the median cost for prostate cancer was $34,500 (Greenberg, Earle, Fang, Eldar-Lissai and Neumann 2010). Also, the overall cost of cancer care in the US in 2007 was estimated to be $219 billion with direct care costs being $89.0 billion of which $18.2 billion were attributed to productivity loss and the balance due to indirect mortality costs (Meropole et al., 2009).

In 2005, United States cancer statistics revealed that the incidence of prostate cancer in Mississippi among African American men almost doubled that of white men i.e. 221.2 per 100, 000 versus 139.2 per 100, 000 (American Cancer Society, 2008). This number clearly shows a disparity in the incidence of prostate cancer in the state with African American men bearing the heaviest burden. African American numbers also drive the higher state distribution when compared to national levels. Table 2 below adapted from the Mississippi Statistically Automated Health Systems(MSTAHRS) shows that from 2005 to 2009 the prostate cancer age adjusted death rate among African American men was about three times the death rate for white men (61.9 per 100,000 for African Americans vs. 20.3 per 100,000 for whites).

The Mississippi State Department of Health Vital Statistics, 2005, reported that, other than respiratory (trachea, bronchus, and lung cancer), prostate cancer is the second leading cause of cancer deaths among Mississippi men, and a heavy burden of the disease is still borne by black men in the state (Mississippi Department of Health, Vital Statistics, 2006). Unless innovative programs are put in place to combat this trend, it will continue to be a major health issue in the state, costing lives and resources. Increased awareness of risk factors for this disparity, effective planning and implementation of prevention programs and policy development/adjustment are major requirements to address the disparate incidence and prevalence of disease among minority populations (Guerra et al., 2007; Ford et al., 2006; Taylor et al., 2001; Bennet et al., 1998; Parker et al., 2006; Sanchez et al., 2007).

THE COMMUNITY

The targeted community of GeorgeTown is at the center of a mostly minority population which usually comes with high levels of poverty and other demographic, socio-economic risks for negative health outcomes, including prostate cancer (Sanchez et al., 2007; Dunlop et al., 2002; Du et al., 2006; Myers et al., 1999)..

Table 1 below presents the demographic statistics for Mississippi, Hinds County, and City of Jackson. The GeorgeTown community is part of Hinds County district 2 with a population of 28,939 (U.S. Census Bureau, 2010, retrieved July 14, 2011). The African American population of GeorgeTown is 86.4%, with Black males being 11,574 (45.13%). Black males 45 years and over numbered 3,372 or 29.14%. The City of Jackson (of which GeorgeTown forms about 40% of City Council Ward 3), has a population of 175,283 (U.S. Census Bureau, 2010, retrieved July 14, 2011). African Americans make up 76.77% or 134,567 of City Council Ward 3.

While the specific population characteristics of GeorgeTown are not available, the community nevertheless reflects the trends in the City of Jackson itself. For Jackson, the median household income (2007-2009) was $32,306 (African Americans: $28, 007; White: $51,337) compared to that of Mississippi ($37,034) and Hinds County ($38,250). With regard to educational attainment for people 25 years and older, 76.18% of African Americans had high school and higher education, compared to 92.02% of whites in Jackson. This is higher than the state rates at 69.12% for African Americans and 83.03% for whites.

Table 3 above provides age-adjusted prostate cancer mortality rates for Hinds County which is the metropolitan area of the City of Jackson from 2007 to 2009 and Table 4 presents screening rates for the State of Mississippi from 2004 to 2010. Prostate cancer mortality rates for African Americans drive the high rates in the state compared to national figures. Prostate cancer mortality is much higher among African Americans than Whites across all age groups affected. However, even with these glaring rate differences, African American men tend to engage in prostate cancer screening at much lower levels than white men, with rate differences widening from 2006 through 2010.

METHODS

RESEARCH DESIGN

This is a qualitative study involving a single focus group of 20 participants drawn from the GeorgeTown community in the City of Jackson Mississippi. The study uses a community engaged-participatory-action approach involving a Technical Assistance Board and Community Advisory Board. Discussions covered six questions developed by the Technical Assistance Board (TAB) and validated by the Community Advisory Board (CAB). The Technical Board and Community Advisory Board were also responsible for recruitment and facilitating the focus group. The CAB consisted of representation from community stakeholders including: prostate cancer sufferers/survivors; prostate cancer support groups; faith based organizations; community based and ethnic organizations (FBOs, CBOs, EOGs); researchers and educators; care givers/providers; policy representatives from state and local governments; target community members; representatives from the private sector including the local chambers of commerce, business owners, other community coalitions and networks. The Technical Advisory Board consisted of prostate cancer research and education experts and the community.

DATA COLLECTION.

This study was approved by the Jackson State University Mississippi and the Indiana University Kokomo Institutional Review Boards. Data were collected during one focus group session which took place from 6.00PM to 8.00PM on February 6, 2008 involving 20 members drawn from the GeorgeTown community of Jackson Mississippi. The Technical Assistance Board developed the questions and The Community Advisory Board administered both the questions and the consent forms.CAB members also facilitated the focus group discussions. The questions developed by the Technical Assistance Board were reviewed and validated by the Community Advisory Board. The Informed consent form administered by CAB members was read and explained to all attendees, then signed by all participants. Participants' focus group questions were asked by a CAB member while responses and discussions were recorded by a Technical Assistance Board members and project interns via:

* Flip charts

* Audio recorder (Olympus N 4123--Olympus Imaging Corp)

* Focus group participants' notes

* Project Director's notes

SAMPLING AND RECRUITMENT

Participants were chosen using a modified snowball sampling methodology which was supported by the Community Advisory Board (CAB). The Community Advisory Board was selected using a snowball sampling method. Focus group participants were then recruited by CAB members who invited additional participants during community association meetings, community events, at barbershops, at service stations, via telephone calls, and house-to-house visits.

Before the focus group meetings, community representatives were trained in needed outreach skills for the Community Advisory Board. Meetings of the TAB and CAB were held and training was provided to members on their role in both research and advocacy. Focus group agenda and fliers were distributed to CAB members who distributed the fliers and meeting information through announcements at Churches, Community centers, Community events, Barber shops, Television, Radio and Telephone calls. No specific incentives were provided for participation, however, dinner was provided due to the time of activity (6.00 pm-8.00 pm)

INCLUSION AND EXCLUSION

To be part of the focus group, participants must be male African Americans; female African American related to a male survivor or sufferer of prostate cancer, 18 years or older; live in the community of GeorgeTown in Jackson Mississippi; and be willing to complete a written consent form. Participants must not have reported or exhibited symptoms of substance use or mental health.

MEASUREMENTS

Focus Group discussion themes designed by the Technical Assistance Board and validated by the Community Advisory Board covered the following topics: knowledge of prostate cancer; knowledge of existing prostate cancer prevention facilities; perceptions of utilization of existing prostate cancer facilities; current prostate cancer educational strategies; and prostate cancer related policy recommendations to the Local Department of Health.

The complete discussion topics with the sub themes are listed below.

1. What do we know about Prostate Cancer?

a. Symptoms

b. Causes

c. What puts us at risk for developing prostate cancer?

d. How do we prevent it?

2. What do we know about facilities for Prostate Cancer Prevention in our area?

a. Where are they?

b. When are they open?

c. What services do they provide?

d. Do we know if they provide screening services?

e. Who are the people in the facilities?

3. Are the facilities being used by members of the community?

a. If yes, what about the facilities make us want to use them?

b. If the facilities are not being used, why?

c. What would we like to see or experience in the facilities that will make us want to use them?

4. How do we get prostate cancer prevention information to the community?

a. What kind of information?

b. How do we present the information?

c. Who should present the information?

d. Where and who does the information go to?

5. What policies are needed to prevent prostate cancer in this community?

a. Issues to be addressed

b. How to establish the policies in the Health Department

c. Who should implement the policies?

d. What role(s) should health care providers play?

e. How will we present and follow up on the policies to ensure appropriate implementation?

DATA ANALYSIS

In this study, focus group data are transcribed into Microsoft word documents and subjected to thematic analysis. Responses are analyzed qualitatively by theme, domain, sub domain, source statement, research question and hypotheses. The thematic approach identifies common themes expressed by participants. Words used are also analyzed to ensure consistency in meaning. Emerging patterns in the themes are then used to understand the community's knowledge; utilization; and health promotion and policy preferences.

RESULTS

Table 5 below presents the number of statements made by focus group participants for each focus group question. Table 6 presents a data analysis grid including the question, the domain of the question, the theme, the sub theme, original statements and potential research implication of participant responses.

Overall, 20 participants attended the focus group meeting (male=70% and female=30%) age between 25 and 75 years. In all, 110 statements were collected and transcribed. These statements were divided into the question numbers that were asked as shown in Table 5 below.

The grid of statements and their relevant themes are presented in Table 6 below. The responses showed gaps in knowledge of symptoms, risk factors, causes of prostate cancer, prevention behavior; and existing prevention facilities. The responses also offered reasons for utilization of prevention facilities and identified barriers to utilization. Information dissemination and prostate cancer prevention policy options were also discussed. Technology infrastructure was also noted as a barrier to information dissemination.

A summary of statements made by themes are listed below:

* Symptoms, risk factors, and causes of prostate cancer identified include: urinary frequency, comfort, color, blood and urgency, being black, testosterone, improper diet, nutrition, lifestyle, beverages, being in a night club all night, not seeking medical examination, inheritance and heredity.

* Prevention behavior needed for prostate cancer identified include the following: risk awareness, early screenings, annual screenings, dietary patterns, and screenings for African Americans over age 40. Some of the participants were unaware of the preventive aspects.

* Prostate Cancer prevention/care service facilities and providers are known and identified by some of the participants while some do not know any. Those who know identified two facilities and five practitioners (urology, family medicine and primary care who also provide referral to urology). Prostate Specific Antigen and Digital Rectal Exam (DRE) are identified as screening services provided.

* Facilities are used by a select number of survivors who join a prevention group. Participants who use facilities identify positive provider staff attitude towards the men and effective information dissemination through constant reminders as reasons for using facilities. In addition, barriers to care facility usage include unfriendly provider staff attitudes towards the men, fear of discovery, unclear messages (incomprehension), inertia, apathy, unemployment, and lack of insurance coverage for care.

* Suggested solutions to overcome barriers included culturally competent communications; having a community spokesperson; increase health literary, working through community identified centers of influence (clergy, etc), centers of living and social activities (barber shops, salons, churches, work places) and transit (billboards, etc) were also identified. It was also suggested that health professionals should be involved in health fairs and that the use of technology including DVDs should be limited as many people might not have the hardware to use DVDs.

* Prostate cancer policy options identified include the following: mandatory screening and referral regardless of financial qualification; free screening in emergency rooms; tax breaks for facilities that provide free screening; and mandatory referrals.

DISCUSSION

This study's findings of gaps in knowledge and service utilization in the African American community are consistent with findings in other prostate cancer studies. However, the study has some refreshing revelations related to utilization, cultural competencies of researchers, health education outlets and policy preferences. The study provides a clear profile of the community member who overcomes barriers to the utilization of existing prostate cancer facilities and advances refreshing concrete proposals for health promotion and public policy. A revelation which merits separate mention is the class, linguistic, and cultural competency of the focus group questions. The fact that the Community Advisory Board had to reframe the focus group questions in a number of instances shows a deficit in the ability of experts to speak at a level that is comfortable to this low income African American community. In addition, the technology divide between this low income community and the rest of America represents a continuous source of disparity in health information access for African Americans.

Findings of lack of knowledge of symptoms, risk factors, and the causes of prostate cancer; as well as low levels of resource utilization among participants are consistent with other findings in the literature. Other prostate cancer studies have found low levels of knowledge and preventive activity for this condition among African Americans (Myers et al., 2002; American Cancer Society, 2006; Wallner et al., 2008).

Barriers to utilization identified by participants are tied to lack of self efficacy, lack of self esteem, lack of trust of the health system, disrespectful treatment in the healthcare system, fear of knowing prostate cancer status, lack of knowledge; lack of ability to pay, and technology barriers including the lack capacity to use DVDs as a source of health information. Except for technology barriers, prior studies on prostate cancer among African Americans have offered similar explanations for low levels of utilization including the following specific reasons: distrust of the health care systems (Ravenell, Johnson & Whitaker, 2006; Fergus, Grey & Fitch, 2002); lack of self-efficacy due to social and economic disenfranchisement; and stigma and social isolation with reduction in self esteem due to the relation to sexual activity and performance, or being seen as "weak" (Fergus, Grey & Fitch, 2002; Gamble, 1997; Wolf et al. 2006; Chan, Gann, Giovannuccci et al., 2005; Powell, 1997; Taylor et al. , 1999). Unlike similar studies, these findings provide a rare glimpse into the three dimensional profile of people who use existing resources. These are people who are survivors, have joined a prevention group, and are lucky to have a supportive provider environment. This profile suggests that knowledge or experience with prostate cancer is an important factor in increasing utilization. It also underscores the need for education, acceptable provider environment, and social support.

Concrete proposals for overcoming existing barriers include culturally competent prevention messages; using familiar community spokes persons such as rap artists; working through community identified centers of influence (e.g.clergy); centers of living and social activities (barber shops, salons, churches, work places); and transit (e.g. billboards). There was a rare statement of caution regarding the use of the church as an information center for this particular condition since the church might be uncomfortable with messaging even remotely related to sex. It is also remarkable that these proposals do not include contemporary technology such as hand-held devices or second generation web technologies including social networking sites, wikis and blogs which are already part of the health information system in mainstream communities (Wagner et al. 2009).

Prostate cancer policy options identified included the following: mandatory screening and referral regardless of financial qualification; free screening in emergency rooms; tax breaks for facilities that provide free screening; and mandatory referrals. The suggestion of tax breaks for providers is an unusual policy proposal from a low income African American community and shows how tax code remedies are entering health promotion conversations.

LIMITATIONS OF STUDY

Despite the similarities between many findings in this study and other studies on prostate cancer; and the clarity of health promotion and health policy preferences that emerged from the study, it still has its limitations. As with most focus groups, key drawbacks in this study are the lack of anonymity and limitations to generalizability. It was not completely clear if participants gave their frank perspectives since they were speaking openly among other community members. Also, readers should be cautious about generalizing the findings from this single focus group to the entire population of Georgetown in Jackson Mississippi without corroboration with other findings from comparable focus groups or assessments using other methods of inquiry. These findings by themselves might not represent or explain all prostate cancer prevention patterns in the entire population of GeorgeTown in Jackson Mississippi.

CONCLUSION AND IMPLICATIONS FOR PROGRAM DEVELOPMENT AND INTERVENTION RESEARCH

This paper has described the use of focus groups in a community engagement with the African American urban community of GeorgeTown Mississippi to identify and understand prostate cancer knowledge; patterns of resource utilization; and health promotion and policy options. Besides the clarity in policy advocacy themes, the findings provide specific information which could be used to shape prevention programs and intervention research in the GeorgeTown community of Jackson Mississippi.

Based on the findings in this study, programs or intervention research to improve prostate cancer prevention behavior in GeorgeTown and similar communities should be rooted in empowerment approaches with specific tools to activate self efficacy, self esteem, trust, knowledge, ability to pay, and acceptability of the provider environment. Trust and participation in decision making has been shown to increase consumer self efficacy and satisfaction with health services in at risk low income populations (Doescher et al., 2000; Tataw, Bazargan, Patel, 2010). Prostate cancer preventive behavior and service utilization among black men could be improved if the target population participates in, and informs the development of educational and policy interventions. Community health programs with cultural and/or structural horizontal relationships in which decision making is consensual have created the appropriate ecological context which has increased at risk consumers' voice, self efficacy, satisfaction, and greater participation in the health system (Consedine et al., 2011; Tataw & Bazargan-Hejazi, 2010, Tataw, Bazargan-Hejazi, James, 2010). A paradigm shift that includes contextual balance between the community and expert perspective can help to enhance self-efficacy, satisfaction, greater participation, and acceptability of intervention initiatives.

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David B. Tataw, MMIS, MPA, PhD, is affiliated with Indiana University Kokomo, Charles R. Drew University Los Angeles, and The Institute for Health Policy and Systems Effectiveness. Address Correspondence to: 2411 Schick Dr, KOKOMO, IN 46902 dbtataw@yahoo.com. Olugbemiga T. Ekundayo, MD, MPH, DrPH is affiliated with the Department of Epidemiology and Biostatistics, School of Health Sciences, College of Public Service, Jackson State University, Mississippi.
Table 1: Demographic characteristics for Mississippi, Hinds
County and city of Jackson.

                     Mississippi   Hinds County   Jackson

Total Population      2,937,976        248,018    175,283
Black                 1,093,403        163,401    134,567
Total Male            1,423,071        116,966    81,513
Black Male              513,830         76,387    63,635
Black Male 45+          138,747         19,174    15,886
Median Household        $37,034        $38,250    32,306
  Income (Total)
Median Household        $24,289        $29,620    $28,007
  Income (Black)
Median Household        $46,630        $54,140    $51,337
  Income (White)
Per Capita Income       $19,743        $20,822    $19,605
  (Total)
Per Capita Income        12,488        $15,015    $15,151
  (Black)
Per Capita Income       $24,536        $33,274    $39,119
 (White)
Education * (Black)      69.12%         77.08%    76.18%
Education (White)        83.03%         91.94%    92.02%

* Population 25 years age and over;

Source: U.S. Census Bureau 2007-2009 three year data set.

Table 2: Prostate Cancer *** Age Adjusted Deaths and Rates *, in Metro
Jackson Race (2005-2009)

                                Race (3 Group)

            White           Black         Other  **       Total

Year   Number   Rate   Number   Rate   Number   Rate   Number   Rate

2005   169      22.8   164      66.4   0        0.0    333      33.3
2006   174      21.1   179      66.6   0        0.0    353      31.9
2007   166      20.1   165      62.5   1        7.1    332      29.8
2008   165      19.4   158      56.3   1        7.7    324      28.0
2009   158      18.5   150      59.0   2       14.1    310      27.4
Total  832      20.3   816      61.9   4        6.5    1,652    29.9

* Age-adjusted rates expressed as per 100,000 population, based on
standard population of census year 2000

** Rates in cells for "Other" are based on less than 20 events and
are unstable

*** Prostate cancer rates based on male specific population
Adapted from: Mississippi Statistically automated Health Resource
system (MSTAHRS)

Table 3: Prostate Cancer *** Age Adjusted Deaths and Rates* in Metro
Jackson Race (2005-2009)

                                Race (3 Group)

            White           Black        Other **        Total

Year   Number   Rate   Number   Rate   Number  Rate   Number   Rate

2005   10       22.0   19       69.8   0       0.0    29       39.1
2006   5        10.6   18       58.0   0       0.0    23       28.7
2007   5        10.4   18       58.4   0       0.0    23       28.3
2008   10       20.3   14       47.3   0       0.0    24       29.9
2009   6        11.4   15       52.0   0       0.0    21       24.7
Total  36       14.7   84       56.5   0       0.0   120       29.8

* Age-adjusted rates expressed as per 100,000 population, based on
standard population of census year 2000

** Rates in cells for "Other" are based on less than 20 events and
are unstable

*** Prostate cancer rates based on male specific population
Adapted from: Mississippi Statistically automated Health Resource
system (MSTAHRS)

Table 4: Prostate Cancer Screening (PSA)

Men aged 40+ who have had a PSA test within the past
two years. Mississippi 2004-2010

                               Race

Year              White                      Black

        %         CI         n     %         CI

2004   54.2   (50.4-58.0)   453   51.3   (44.4-58.2)
2006   55.7   (52.3-59.1)   623   53.6   (47.1-60.1)
2008   57.2   (54.1-60.4)   938   49.8   (44.3-55.4)
2010   57.3   (54.0-60.7)   937   46.9   (41.1-52.7)

             Race

Year                     All

        n     %         CI         n

2004   152   53.0   (49.7-56.3)   636
2006   172   54.7   (51.7-57.7)   826
2008   272   54.5   (51.8-57.2)   1261
2010   290   53.6   (50.7-56.5)   1274

% = Weighted Percentage, CI = Confidence Interval,
n = Cell Size (Numerator)

Source: Adapted from the US CDC Office of Surveillance,
Epidemiology and Laboratory Services, BRFSS Prevalence
and Trends Data

Table 5. Number of Statements Made by Focus Group Question Respondents

Question               Question                     n-Stmts *  Totals
#

1         What do we know about Prostate Cancer?

          a. Symptoms                               9          34
          b. Causes                                 7
          c. What puts us at risk for developing    6
          prostate cancer?
          d. How do we prevent it?                  12

2         What do we know about facilities for
          Prostate Cancer Prevention in our area?

          a. Where are they?                        1          10
          b. When are they open?                    1
          c. What services do they provide?         2
          d. Do we know if they provide screening   6
          services?
          e. Who are the people in the              -
          facilities?

3         Are the facilities being used by members
          of the community?

          a. If yes, what about the facilities      4          18
          make us want to use them?
          b. If the facilities are not being        10
          used, why?
          c. What would we like to see or           4
          experience in the facilities that will
          make us want to use them?

4.        How do we get prostate cancer prevention
          information to the community

          a. What kind of information?              4          16
          b. How do we present the information?     4
          c. Who should present the information?    8
          d. Where and who does the information     -
          go to?

5         What policies are needed to prevent
          prostate cancer in this community?

          a. Issues to be addressed                 9          32
          b. How to establish the policies in the   11
          Health Departments
          c. Who should implement the policies?     4
          d. What role(s) should health care        5
          providers play?
          e. How will we present and follow up on   3
          the policies to ensure appropriate
          implementation?

          Total number of statements                110

TABLE 6: Focus Group Questions and Data analysis Grid

Question #   1.Domain          Statement
             2.Theme
             3.Sub theme

1a           1.Symptoms        * Cannot understand the term
             2.Knowledge       symptoms, when explained--
             3.Knowledge       * frequent urination,
             of the            * frequent incomplete
             disease           urination,
                               * discomfort,
                               * pain on urination
                               * change in the color of
                               urine,
                               * enlarged prostate,
                               * blood in urine,
                               * urgency to urinate

Total Statements                       9
for Question 1a

1b           1.Causes          * Being a black man,
             2.Knowledge       * Testosterone,
             3.Knowledge       * Improper diet,
             of the cause      * Nutrition,
             of disease        * Lifestyle,
                               * Beverages,
                               * Being in a night club all
                               night

Total Statements                       7
for Question 1b

1c           1.Risks           * Age,
             2. Knowledge      * Being black,
             3. Knowledge      * High testosterone,
             of risks for      * Not seeking medical exam,
             the disease       * Inheritance,
                               * Hereditary

Total Statements                        6
for Question 1c

1d           1.Prevention      * Early testing,
             2. Prevention     * Early examination,
             Behavior          * Yearly examination,
             3.Knowledge       * Watch your diet intake,
             of Prevention     * Proper nutrition,
                               * Attending free screenings
                               at churches,
                               * Young men,
                               * Screening at 40 year s
                               and above age for African
                               Americans,
                               * 45 years American cancer
                               society,
                               * Acknowledge the risk,
                               * Good health practices.
                               * Don't know how to prevent
                               it (3)

Total Statements                        12
for Question 1d

Total Statements                        34
for Question 1

2a           1.Knowledge       * Don't know, only know
             2.Knowledge       about UMMC, St. Dominic's
             3.Knowledge
             of location

2b           1.Knowledge       * Know UMC/JMM working hours
             2.Knowledge
             3.Knowledge
             of timings of
             location

2c           1.Knowledge       * Annual digital rectal
             2.Knowledge       examinations,
             3.Knowledge       * prostate specific antigen
             of the            are some of the tests that
             services          were done before
             provided          the referral

Total Statements for                    4
Questions 2 a, b and c

2d           1.Knowledge       * Sometimes about free
             2.Knowledge       screenings,
             3.Knowledge       * Announcements in paper,
             about the         * Prostate support groups.
             screening         * Dr. Frazier, Dr. Ron
             services          Davies, Dr. Ross, Dr.
                               Morrison, are some of the
                               health care providers in the
                               community.
                               * Most of the hospitals
                               have urologists.
                               * Family medicine physicians
                               like Dr. Robert Smith may
                               refer to urologist.

Total Statements                        10
for Question 2

3a           1.Prevention      * Technology,
             2.Services        * Reminders from the health
                               care providers,
             3.Experiences     * Friendly nature of the
                               staff in the surroundings,
                               * Referral from the family
                               physician.

3b           1.Prevention      * Men don't pay attention.
             2.Services        * How do you can get people
             3.Barriers        who don't lane
                               * They make excuses,
                               * Fear might stop them.
                               * Lack of knowledge,
                               * Lack of proper
                               explanation,
                               * Not bringing the issue of
                               interest to the
                               level of patient, and men
                               do not want to deal with
                               prostate cancer.
                               * Other than that:
                               --unemployment and lack of
                               insurance might be the
                               reasons

Participants were asked to     * The fear of having
explain the term fear in       prostate cancer,
detail.                        * Fear of going to doctor
                               and finding it out.
                               * Technology,
3c           1.Prevention      * reminders from the health
             2.Services        care providers,
             3.Expectations    * Friendly nature of the
                               staff in the surroundings,
                               * Referral from the family
                               physician

Total Statements for                     18
Question #3

4a           1.Health          * inviting people,
             education and     * people might not respond
             Promotion         or interact until something
             2.Information     strikes home,
             3.kind            * family members involved,
                               or
                               * someone close to us are
                               going through it

Total Statements for                     4
Question 4a

4b           1.Health          * Have spokes persons to
             education and     come and present it.
             Promotion         * Center of influences like
             2.Education       church, pastor,
             3.Presentation    * try to get people's
                               attention on to the issue.
                               * Announcements through
                               the mass media

Total Statements for                     4
Question 4b

4c           1.Health          * The places where the
             promotion         information has to go to are
             2.Education       * Churches
             3.Target          * Work places
             population        * Bulletin boards
                               * Commercials
                               * Rap videos about the
                               prostate cancer
                               * Community organizations
                               bring them
                               * Can have a working frame
                               of peer groups

Total Statements for                      8
Question 4c

Total Statements for                     16
Question #4

5a           1.Policy          * Communication with the
             advocacy          community members through
             2.Policy          churches, fraternities,
             3.Issues of       sororities, barbers shop.
             participation     * Insurance,
             in screening      * Free screening,
                               * Drafts have to be worked
                               out.
                               * Issues regarding follow up
                               care even without adequate
                               resources,
                               * Vocational rehab,
                               * Lack of knowledge of
                               status,
                               * All community clinics
                               should screen,
                               * Follow up regardless of
                               screen.

Total Statements for                      9
Question 5a

5b           1.Policy          This question was not clear
             advocacy
             2. Policy         to participants,
             3. Establishment  Question was reframed to how
             in the health     the agencies make survivors
             departments       know the services they
                               provide.
                               * Service education,
                               * Health literacy,
                               * Sign in the hospitals, and
                               inform people they will get
                               care without money.
                               * Cannot refuse care in the
                               emergency rooms for people
                               who do not have insurance,
                               * Cannot go to emergency
                               room for prostate cancer
                               screening.
                               * Hospitals have to obligate
                               into the communities,
                               * tax exemptions for those
                               health care providing
                               facilities which offer free
                               screenings,
                               * Is health care a right or
                               privilege,
                               * Issues regarding corporate
                               citizens.

Total Statements for                      9
Question 5b

5c           1.Policy          * Meetings for the people
             advocacy          not coming,
             2.Policy          * So got the people with
             3.Provision of    information like DVD's,
             health care       * Might implement with
             with              education,
             implementation    * Bringing pressure to
             of the policy     implement the policies

Total Statements for                     4
Question 5c

5d           1.Policy          * Culturally sensitive
             advocacy          methods to display
             2.Policy          information
             3.Policy          * Lots of people might
             implementation    not have the DVD's.
                               * Faith based organizations,
                               * talks at the health fair
                               by health care
                               professionals, might help.
                               * personal priorities are
                               the first thing, may be not
                               media;

Total Statements for                        5
Question 5d

5e           1.Policy          * Churches are the best
             advocacy          place to catch most of them.
             2.Policy          * Education means not just
             3.Policy          books, but spreading
             implementation    information through prostate
                               cancer survivors and
                               in form of personal
                               sufferers testimonials.
                               * Sometimes churches might
                               have issues to have
                               discussions about the
                               prostate cancer then we have
                               to discuses about it
                               outside.

Total Statements for                        3
  Question 5

Total Statements for                       30
  Question #5

Question #   1.Domain          Research
             2.Theme
             3.Sub theme

1a           1.Symptoms        Knowledge of prostate cancer,
             2.Knowledge       symptoms
             3.Knowledge
             of the            When asking questions,
             disease           researchers need to use terms
                               appropriate to the community
                               in framing questions--Cultural/
                               linguistic competence

Total Statements
for Question 1a

1b           1.Causes
             2.Knowledge
             3.Knowledge       Race, hormones, diet and
             of the cause      lifestyle play a etiological
             of disease        role in prostate cancer

Total Statements
for Question 1b

1c           1.Risks           Age, race, hormones, lack of
             2. Knowledge      screenings, genetic factors are
             3. Knowledge      some of the risk for prostate
             of risks for      cancer.
             the disease

Total Statements
for Question 1c

1d           1.Prevention      Screening Details:
             2. Prevention     Early screenings, annual
             Behavior          screenings, dietary patterns,
             3.Knowledge       screenings for African
             of Prevention     Americans over age 40 are
                               some of preventive practices
                               for prostate cancer, while
                               some of the participants are
                               unaware of the preventive
                               aspects

Total Statements
for Question 1d

Total Statements
for Question 1

2a           1.Knowledge       The participants are unaware
             2.Knowledge       of the location of facilities
             3.Knowledge       that specifically address the
             of location       issue of prostate cancer.

2b           1.Knowledge       Facilities Availability
             2.Knowledge
             3.Knowledge
             of timings of
             location

2c           1.Knowledge       Prostate cancer screening
             2.Knowledge       Knowledge
             3.Knowledge
             of the
             services
             provided

Total Statements for
Questions 2 a, b and c

2d           1.Knowledge       Participants have knowledge
             2.Knowledge       about existing health care
             3.Knowledge       providers in the community,
             about the         the screening services
             screening         available. However the
             services          awareness of free screening
                               programs to all the
                               people in the community was
                               doubtful.

Total Statements
for Question 2

3a           1.Prevention      Health care facilities as well
             2.Services        as providers have to meet
                               the needs and the level
             3.Experiences     of understanding of the
                               community.

3b           1.Prevention      Men's attitude, beliefs, fears
             2.Services        due to lack of knowledge,
             3.Barriers        education

                               Support and insurance might
                               hinder the preventive aspects
                               of prostate cancer.

Participants were asked to     Fear of personal discovery
explain the term fear in
detail.

3c           1.Prevention      Information, Technology,
             2.Services        Customer Service and
             3.Expectations    Referrals

Total Statements for
Question #3

4a           1.Health          Engaging prostate
             education and     cancer survivors and
             Promotion         community members
             2.Information     might draw the
             3.kind            attention of other
                               members

Total Statements for
Question 4a

4b           1.Health          Church, celebrities
             education and     influence the attention
             Promotion         span of the community
             2.Education       personnel
             3.Presentation

Total Statements for
Question 4b

4c           1.Health          Development of
             promotion         community structures
             2.Education       involving them through
             3.Target          active participation,
             population        these structures help in
                               bridging the gap between
                               community needs and
                               researcher's objectives

Total Statements for
Question 4c

Total Statements for
Question #4

5a           1.Policy          Developing community based
             advocacy          and engaged networks to
             2.Policy          address identified issues
             3.Issues of       through legislative and
             participation
             in screening

Total Statements for
Question 5a

5b           1.Policy          Dissemination of information
             advocacy
             2. Policy         about health services related
             3. Establishment  to prostate cancer care
             in the health
             departments       Monitoring community and
                               survivor response to
                               information dissemination

                               Monitoring impact of
                               information on community
                               health outcomes through
                               information surveillance
                               systems

Total Statements for
Question 5b

5c           1.Policy
             advocacy          Engaging the community
             2.Policy          in health promotion and
             3.Provision of    disease prevention
             health care       3Monitoring outcome
             with              and impact
             implementation
             of the policy

Total Statements for
Question 5c

5d           1.Policy
             advocacy          Cultural Competence
             2.Policy
             3.Policy          Dissemination format and
             implementation    context

                               Community problem
                               prioritization

Total Statements for
Question 5d

5e           1.Policy
             advocacy
             2.Policy
             3.Policy
             implementation
                               Reaching community
                               Prostate Cancer survivors
                               (PCSs)

Total Statements for            3
  Question 5e

Total Statements for            30
  Question #5
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