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RESEARCH 

Perceived Behavioral Control regarding 
Prostate Cancer Screening among Black 
Men in West Africa and the United States 
 

Motolani E. Ogunsanya1,18*, Iya Eze Bassey2,18, Mohammed Faruk3,18, Catherine Oladoyinbo4,18, Haruna 
Nggada5,18, Abidemi Omonisi6,18, Nissa Askins7,18, Blaise Nkegoum8,18, Ademola A. Popoola9,18, Iheanyi 
Okpala10,18, Omolara Fatiregun11,18, Paul Jibrin12,18, Emeka E. Iweala13,18, Wole Kukoyi14,18, Kayode Adeniji15,18, 
Ayo Salako16,18, Anthonia Sowunmii17,18, Folakemi T. Odedina7,18 

Authors’ Affiliations: 
*1College of Pharmacy, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73117, 
USA 
2Department of Medical Laboratory Science, College of Medical Sciences, University of Calabar, 
Calabar, Cross River State, Nigeria 
3Department of Pathology, College of Health Sciences, Faculty of Basic Clinical Sciences, Ahmadu 
Bello University, Zaria, Nigeria 
4Department of Nutrition and Dietetics, Federal University of Agriculture, Abeokuta, Ogun State, 
Nigeria 
5Department of Pathology, University of Maiduguri, Nigeria 
6Department of Anatomic Pathology, Ekiti State University, Nigeria 
7Department of Pharmacotherapy and Translational Research and Department of Radiation 
Oncology, University of Florida, Lake Nona Campus, FL, 32832, USA 
8Department of Anatomy and Pathology, University of Yaoundé Teaching Hospital, Cameroon  
9Department of Surgery, University of Ilorin Teaching Hospital, Ilorin, Nigeria 
10College of Medicine, University of Nigeria, Enugu, Nigeria 
11Department of Radiology, Oncology Unit, Lagos State University Teaching Hospital, Ikeja, 
Nigeria  
12Department of Pathology, National Hospital, Abuja, Nigeria  
13Department of Biochemistry, Covenant University, Ota, Nigeria  

14Ace Medicare Clinics Limited, Ota, Ogun State, Nigeria  
15Department of  Pathology, Faculty of Basic Medical Sciences, University of Ilorin Teaching 
Hospital, Ilorin, Nigeria16Urology Unit, Obafemi Awolowo University, Ife, Nigeria 
17Department of Radiotherapy and Oncology, Lagos University Teaching Hospital, Idi-Araba, 
Nigeria  
18Prostate Cancer Transatlantic Consortium (CaPTC) 

Corresponding author: Motolani Ogunsanya, email: Motolani-ogunsanya@ouhsc.edu 



 
 
 
 
 

 
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ABSTRACT 
To examine how perceived behavioral control (PBC) is affected by sociodemographic and behavioral 
factors, employing a socio-ecologic approach, and identify the relative importance of these factors. This 
was a cross-sectional, correlational study of 500 Black men from the Prostate Cancer Transatlantic 
Consortium (CaPTC) familial project. A survey using standardized CaPTC and other measures collected 
information on intrapersonal (e.g., age, knowledge), interpersonal (e.g., cues to action, social support), 
and institutional factors (e.g., informed decision) that are predictive of PBC. Black male participants, 
aged between 35-70 years, were recruited from the US, Nigeria, and Cameroon. Descriptive statistics 
(mean, SD, and frequency) were calculated for all variables, and multiple regression was employed to 
determine significant (p<0.05) predictors of PBC. Data were analyzed using SPSS v24. Participants had 
an average age of 48±10 years, a low level of knowledge (mean=10.31±3.66; range 0-20), encountered 
very low cues to action (mean=1.60±2.13; range 0-13), had usual levels of social support (2.41±1.24), and 
were mostly (96.4%) not counseled on the advantages and disadvantages of prostate cancer screening. 
Attitude, knowledge, informed decision, and prostate cancer information seeking behavior were 
significant predictors, and the overall model accounted for 49% (p < 0.01) of the variation in PBC. Using 
a socio-ecologic approach, multi-level factors were integrated to facilitate a fuller understanding of the 
several factors impacting PBC in Black men. The four significant factors (attitude, knowledge, informed 
decision, and prostate cancer information seeking behavior knowledge) could be considered when 
developing culturally-sensitive interventions aimed at engaging at-risk Black men regarding prostate 
cancer prevention and early detection practices. 

KEYWORDS: Prostate cancer, young Black men, theoretical model, prevention, screening, health 
disparity 

Citation: Ogunsanya et al (2019) Perceived behavioral control regarding prostate cancer screening among 
Black Men in West Africa and the United States. Cancer Health Disparities. 4: e1-17. 
doi:10.9777/chd.2019.1006 
 
 



 
 
 
 
 

 
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INTRODUCTION 

Prostate cancer has become the leading cancer in 
males of Black ancestry (2016). Black men are more 
likely to have a diagnosis of prostate cancer at an 
early age, a higher grade and stage prostate 
cancer present with complications and therefore 
have higher rates of morbidity and mortality 
compared to other races and ethnicities (Shenoy 
et al., 2016). This disparity in morbidity and 
mortality has been attributed to some factors 
including biological differences in different ethnic 
groups as well as limited access to preventive care 
(Odedina et al., 2009). Positive family history has 
also been found to be a significant risk factor for 
prostate cancer (Sanchez et al., 2007). 

Globally, Jamaican men of African descent, as well 
as African-American men, are known to have the 
highest incidence of prostate cancer (Odedina et 
al., 2009; Rebbeck et al., 2013). Compared to 
Caucasian men, the risk of developing prostate 
cancer in Black men based purely on ethnicity is 
estimated to be 40 to 80% higher (Eeles et al., 
2014). Survival rates comparing Black men with 
Caucasian men show a clear disparity (White et al., 
2011). The risk of developing prostate cancer is 
higher in families with a history of the disease than 
in the general population (Tourville and Nguyen, 
2013). Inherited susceptibility appears to play an 
additional independent role in the development of 
prostate cancer. Men diagnosed with prostate 
cancer are almost twice as likely to have a male 
blood relative (brother or father especially) who 
has been diagnosed with prostate cancer (Ibrayev 
et al., 2013; Murthy et al., 2011) In addition, 
prostate cancer risk increases with an increasing 
number of affected family members, such that 
men with two or three first degree relatives 
affected have a five- and eleven-fold increased risk 

of developing prostate cancer, respectively (Scher 
et al., 2015). 

A major factor responsible for this disparity in 
morbidity and mortality is that Black men are less 
likely to get preventive care, such as prostate 
cancer screening when needed. Several studies 
reveal that even after adjusting for socioeconomic 
status, comorbidities, and access to care, Black 
men are less likely to undergo prostate cancer 
screening (Consedine et al., 2006; Lehto et al., 
2010; Winterich et al., 2009b). Other factors that 
have been associated with lower prostate cancer 
screening include lack of prostate cancer 
knowledge, lower perceived risk and susceptibility 
to prostate cancer, and poor physician 
recommendation (Drake et al., 2010; Gonzalez et 
al., 2008; Ogunsanya et al., 2016c). 

Perceived behavioral control (PBC) has been 
defined as one’s perception of their ability to 
perform a given behavior (Ajzen, 1985). PBC also 
refers to the degree of ease or difficulty of 
performing the behavior of interest, and is 
determined by the power of both situational and 
internal factors that might enable or hinder the 
individual from enacting the behavior (Ajzen, 1991; 
Ajzen and Fischbein, 2005). PBC has been shown 
to be an important precursor of engaging in 
cancer preventative behaviors, such as breast 
cancer screening (Baron-Epel, 2009; Steele and 
Porche, 2005; Tolma et al., 2014). It is important to 
assess an individual’s perceived control over 
resources and skills necessary for engaging in the 
future behavior. In addition, PBC is also assumed 
to be dependent on past experiences as well as 
perceived barriers and obstacles to prostate cancer 
screening (Odedina et al., 2011b). In addition, men 
who perceive themselves to be in control of their 
health are more likely to engage in cancer 



 
 
 
 
 

 
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reduction behaviors such as prostate cancer 
screening (Niederdeppe and Levy, 2007). 

To reduce the prostate cancer disparity gaps in 
morbidity and mortality in Black men and increase 
screening practices in at-risk men, culturally-
sensitive interventions are needed. The likelihood 
of the success of such intervention will rely on 
examining behavioral change theories that identify 
motivations to partake in recommended health 
behaviors (Fishbein and Ajzen, 1975; Hennessy et 
al., 2014b; Riley et al., 2011). Central to behavior 
change theories lies the assumptions that health 
interventions influence behavior through a series 
of influence, such as knowledge levels, beliefs, 
attitudes, PBC, which then impacts behavior 
(Bellcross et al., 2011; Busse and Miranda, 2018; 
Hennessy et al., 2014a; Trivers et al., 2011). 

Moreover, cues to action can also serve as a driver 
in modifying health behaviors. Cues to action can 
also be derived from intrinsic or extrinsic factors. 
Intrinsically, a positive family history of prostate 
cancer has been reported to serve as an influential 
source of prostate cancer information among 
family members (Nivens et al., 2001; Ogunsanya et 
al., 2016a). Outside of the family, health care 
providers remain the most trusted source of health 
information (Hesse et al., 2010; Ogunsanya et al., 
2016c). However, studies have reported lower rates 
of physician-patient discussion regarding prostate 
cancer in Black men (Mitchell, 2011; Winterich et 
al., 2009a). Regardless of the level with which 
prostate cancer communication occurs, other 
factors such as age, education, attitudes, 
education levels, may further impact PBC over 
prostate cancer and screening.  

A handful of studies have been conducted in Black 
men to assess their beliefs regarding prostate 
cancer screening (Odedina et al., 2011b; 

Ogunsanya et al., 2016b; Oliver, 2007). However, 
since these studies were conducted in US Black 
men only, it would be interesting also to explore 
these beliefs in native African populations and 
ethnically-diverse Black men who may be 
genetically similar but differ in lifestyle, behavior, 
cultural beliefs, and values. In addition, this is the 
first study, to our knowledge, examining the 
impact of PBC and its correlates over prostate 
cancer screening.  Also, the effects of PBC on a 
target behavior have been reported to be the 
most impactful in modifying behaviors (Madden et 
al., 1992). 

Therefore, the goal of the present research is to 
examine how PBC is affected by 
sociodemographic and behavioral factors, 
employing a socio-ecologic approach in Black 
men from West Africa and the United States. This 
proposal seeks to frame intrapersonal and 
contextual (interpersonal and institutional) that 
might influence Black men’s PBC regarding 
prostate cancer and screening, and identify the 
relative importance of those factors. 

Furthermore, a comprehensive understanding of 
the determinants of this primary outcome could 
inform the development of culturally appropriate 
interventions that might improve prostate cancer 
screening participation in men at the highest risk. 

METHODS 

This was a cross-sectional, correlational study 
designed to recruit 500 Black men from the 
Prostate Cancer Transatlantic Consortium (CaPTC) 
familial project over one year. Data was extracted 
using standardized CaPTC and other validated 
measures that collected information on 
intrapersonal (e.g., age, knowledge), interpersonal 
(e.g., cues to action, social support), and 



 
 
 
 
 

 
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institutional factors (e.g., informed decision-
making) which are predictive of perceived 
behavioral control (PBC). The study inclusion 
criteria were: (i) Black men in Nigeria, Cameroon 
and the US, regardless of history of prostate 
cancer diagnosis, between the age of 35 and 70 
recruited at clinics, health forums and in the 
community; (ii) men who consented to completing 
the study survey; and (iv) men willing to provide 
consent to access their medical records for clinical 
annotations (for those recruited at clinics).   

Study Variables 
Dependent Variable 

Perceived Behavioral Control (PBC) 

In accordance with Ajzen (Ajzen, 1985), three items 
with a 5-point response scale (very difficult to very 
easy) assessed the ease or difficulty of specific 
prostate cancer prevention and early detection 
activities. The items were: 1) making a decision 
about prostate cancer screening is; 2) having a 
digital rectal examination (DRE) every year is; and 
3) giving a blood sample for serum prostate-
specific antigen (PSA) test every year is. Total PBC 
scores ranged from 3 to 15, with a higher score 
indicating a higher level of ease.  

Independent Variables 

Intrapersonal 

Participants were asked what year they were born 
and this response was subtracted from the current 
year (2018) to calculate the age of respondents. 
Attitude, derived from the Theory of Reasoned 
Behavior (Fishbein and Ajzen, 1975), was measured 
accordingly by assessing beliefs toward prostate 
cancer using three items on a 5-point response 
scale ranging from very unfavorable to very 
favorable. The three items were: 1) weighing the 

advantages and disadvantages of prostate cancer 
screening to make a decision about screening for 
prostate cancer; 2) getting tested for prostate 
cancer with the Digital Rectal Examination (DRE) 
every year; and 3) getting tested for prostate 
cancer using my blood sample for Serum Prostate 
Specific Antigen (PSA) test every year. Scores 
ranged from 3 to 15 and higher scores indicated a 
positive attitude toward prostate cancer screening. 
Education was assessed by asking the highest 
grade or year of school completed (Primary 
School, Secondary High School, High School, 
Technical College, University (Degree), or Post-
Graduate). Twenty items assessed knowledge 
about prostate cancer and prostate cancer 
screening using a “true,” “false,” and “don’t know” 
scale (Odedina et al., 2011c). Domains included: 
limitations, diet, symptoms, screening age 
guidelines, risk factors. Responses were scored 
according to whether or not the participants 
responded correctly to each question, and the 
total number of correct responses was calculated 
(range from zero to 20) with higher scores 
indicating higher knowledge levels. Participants 
were classified as either married, divorced, 
widowed, separated, never married, or a member 
of an unmarried couple, to determine marital 
status.  

Participants were asked to rate their perceived 
susceptibility of prostate cancer using a 4-item 
questionnaire. The response scale ranged from 
strongly disagree to agree on a scale of 1 to 5, 
with higher scores indicating higher perceived 
susceptibility. This measure was developed from 
the Perceived Susceptibility concept from the 
Health Belief Model (Hochbaum, 1958; Rosenstock, 
1974a, b) and modified appropriately for use in the 
current study population. The four items were: 1) 
my chances of getting prostate cancer are great; 



 
 
 
 
 

 
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RESEARCH 

2) there is a good possibility that I will get prostate 
cancer; 3) I am not at risk for prostate cancer; and 
4) there is no chance that I will get prostate 
cancer. Perception of health was assessed using a 
single item on how participants perceived their 
health with response choices including poor, fair, 
good, very good, excellent, and don’t know/not 
sure. 

Interpersonal 

Cues to action regarding prostate cancer 
screening was measured using a 13-item 
questionnaire with yes/no responses and higher 
scores indicating a higher number of cues 
encountered within the last year. This measure was 
modified from the Cues to Action concept from 
the Health Belief Model (Hochbaum, 1958; 
Rosenstock, 1974a,b). Participants were asked 
about their type of employment to assess current 
employment status. Annual household income 
from all sources was collected and categorized 
into low, medium, and high using specific cutoffs 
for the currencies provided. Personal history of any 
cancer was assessed based on yes/no responses 
to a single question asking participants if they have 
had any type of cancer. Prostate cancer family 
history was measured based on yes/no responses 
to a question asking whether their birth fathers 
have had cancer. Social support was assessed by 
asking participants how often they get the social 
and emotional support they need using a single 
rating scale.  

Institutional  

Two items assessed informed decision-making 
(yes/no) by asking participants if their doctor had 
ever talked to them about the advantages and 
disadvantages of prostate cancer screening (Rimer 
et al., 2004). Prostate cancer information seeking 

was measured using four items with composite 
scores ranging from 4 to 20 and responses 
ranging from strongly disagree to strongly agree 
(Odedina et al., 2011c). Higher scores on this item 
indicated higher levels of engagement in seeking 
information regarding prostate cancer. Provider 
satisfaction was measured with a 6-item question 
with yes/no responses which determined the level 
of trust participants have in their providers. This 
measure was derived from the Trust of Health 
Care Providers scale (Blackman et al., 2018). Higher 
scores on this measure indicated higher levels of 
trust in health care providers. Regular source of 
care was measured using a single item to 
determine if participants had only one, more than 
one, or no person they thought of as their 
personal doctor or health care provider.  

It is important to note that the multi-item 
measures used in this study have been validated 
for use in other studies conducted in Black men 
(Blackman et al., 2018; Cobran et al., 2014; 
Kaninjing et al., 2017; Kumar et al., 2009; Odedina 
et al., 2011a; Ogunsanya et al., 2016a). Table 1. 
contains a description of the scales and construct 
used in the study. 



 
 
 
 
 

 
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Table 1. Scales and Constructs of Measurement. 
DEPENDENT VARIABLE 

DOMAIN VARIABLE DESCRIPTION OF ITEM ITEM(S) SOURCES 

DEPENDENT 
VARIABLE 

Perceived 
behavioral 
control 

Three items with a 5-point response scale measured the ease or difficulty of prostate 
cancer prevention and early detection activities. Scores ranged from 3 to 15, with a higher 
score indicating a higher level of ease (Very Difficult, Difficult, Neutral, Easy, Very Easy). 

3 Ajzen (Ajzen, 1985) 

INDEPENDENT VARIABLES 

INTRAPERSONAL 

Age What is your date of birth (MM/DD/YYYY)? 1 - 

Attitude toward 
prostate cancer 
screening 

Three-item questionnaire with scores ranging from 3 to 15 and higher scores indicating 
positive attitude towards prostate cancer screening. Scores ranged from 3 to 15 and 
higher scores indicating positive attitude towards prostate cancer screening (Very 
Unfavorable, Unfavorable, Neutral, Favorable, Very Favorable). 

3 
Fishbein and Ajzen 
(Fishbein and Ajzen, 

1975) 

Education What is the highest grade or year of school you completed? (Primary School, Secondary 
High School, High School, Technical College, University (Degree), or Post-Graduate). 1 - 

Knowledge of 
prostate cancer 
and screening 

The 20 items on the knowledge scale assessed knowledge about prostate cancer and 
prostate cancer screening using a “true,” “false,” and “don’t know” scale. Domains 
included: limitations, diet, symptoms, screening age guidelines, risk factors. Responses 
were scored according to whether or not the participants responded correctly to each 
question, and the total number of correct responses was calculated ranging from zero to 
20, with higher scores indicating higher knowledge levels.   

20 Odedina et al. 
(Odedina et al., 2011c) 

Marital status Are you…? (Married, Divorced, Widowed, Separated, Never Married, or A Member of an 
Unmarried Couple)  1 - 

Perceived risk of 
prostate cancer 

Four items with scores ranging from 4 to 20, using a 5-point bipolar semantic differential 
scales ranging from 1 – 5 with a set of anchors (Strongly Disagree, Disagree, Neutral, 
Agree, Strongly Agree). 

4 

Hochbaum 
(Hochbaum, 1958), 

Rosenstock 
(Rosenstock, 1974a, b) 

Perception of 
health 

Would you say that in general your health is…? (Poor, Fair, Good, Very Good, Excellent, 
Don’t know/Not sure) 1 - 



 
 
 
 
 

 
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INTERPERSONAL 

Cues to action A 13-item measure with yes/no responses on cues regarding prostate cancer screening. 
Higher scores indicated higher number of cues encountered within the last year (Yes, No). 13 

Hochbaum 
(Hochbaum, 1958), 

Rosenstock 
(Rosenstock, 1974a, b) 

Employment 
status 

What is your current employment status?  1 - 

Household 
income 

What is your annual household income from all sources?  1 - 

Personal history 
of any cancer 

Have you ever been told that you had any type of cancer? (Yes, No) 2  

Prostate cancer 
family history 

Has your birth father ever had cancer? (Yes, No) 2 - 

Social support How often do you get the social and emotional support you need? 
(Always, Usually, Sometimes, Rarely, Never). 

1 - 

INSTITUTIONAL 

Informed 
decision-making 

Before you were tested for prostate cancer, did a doctor EVER talk with you about the 
advantages of prostate cancer screening? (Yes, No) 
Before you were tested for prostate cancer, did a doctor EVER talk with you about the 
disadvantages of prostate cancer screening? (Yes, No) 

2 Rimer et al. (Rimer et 
al., 2004) 

Prostate cancer 
information 
seeking Behavior 

Four items with scores ranging from 4 to 20, using a 5-point bipolar semantic differential 
scales ranging from 1 – 5 with a set of anchors (Strongly Disagree, Disagree, Neutral, 
Agree, Strongly Agree). 

4 Odedina et al. 
(Odedina et al., 2011c) 

Provider 
satisfaction 

Six items focused on the individual’s perception of trust with their health care provider. A 
composite score was created from the items with higher scores indicating higher provider 
satisfaction (Yes, No) 

6 Blackman et al. 
(Blackman et al., 2018) 

 Regular source of 
care 

Do you have one person you think of as your personal doctor or health care provider? 
(Yes – Only one, More than one or No). 1 - 



 
 
 
 
 

 
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Study Participants and Recruitment 
This was a multi-institution study which included 16 
universities/ medical health institutions in Nigeria, 
Cameroon, and the US. The institutional lead PI for 
each study site obtained local ethics 
committee/institution research board permission 
to conduct the studies. Informed consents were 
obtained by research assistants. One copy from 
each participant was retained by the research 

assistant and a second copy provided to the 
participant. Data were collected from participants 
who met the selection criteria and provided 
informed consent to participate in the study. The 
sample size estimated to power this study 
adequately was 290 respondents. The study model 
with all of the variables of interests is shown in 
Figure 1. 

 

Data analysis  
Each continuous/interval variable was examined 
for its distribution, range, mode, median, mean, 
and standard deviation. Normality tests, skewness, 
and kurtosis were carried out on continuous and 
interval-level variables. All interval-level data 
(dependent variable only) were screened to ensure 
that the normality assumptions were met before 
applying statistical tests. Independent samples t-
tests (for explanatory variables with two levels) and 

ANOVA (for explanatory variables with more than 
two levels) were conducted on study variables. For 
dichotomous and nominal-level variables, 
frequencies were assessed to determine if the 
requirements for cell sizes are met. Finally, the 
data was screened for missing values and outliers. 
We tested the socio-ecological model using 
multiple regression analyses. In the interest of 
parsimony, the variables included in the final 
model were assessed regarding their statistical 

 

   
    

  
   
     

 

INTRAPERSONAL 
- Age 
- Attitude toward prostate 

cancer and screening 
- Education 
- Knowledge of prostate 

cancer and screening 
- Marital Status 
- Perceived risk of prostate 

cancer 
- Perception of health 

INTERPERSONAL 
- Cues to action 
- Employment status 
- Household income 
- Personal history of any 

cancer 
- Prostate cancer family 

history 
- Social support 

 

INSTITUTIONAL 
- Informed decision-

making 
- Prostate cancer 

information seeking 
behavior 

- Provider satisfaction 
- Regular source of care 

 



 
 
 
 
 

 
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significance (p<0.05). This approach allowed the 
final model to include combined intrapersonal, 
interpersonal, and institutional variables.  

To create meaningful and interpretable categories, 
variables with multiple levels of categories were 
collapsed. Education was recoded into high school 
or less, college/university, and postgraduate. 
Marital status was recoded into two categories: in 
a relationship (married/member of unmarried 
couple) and not in a relationship (divorced, 
widowed, separated, and never married). 
Employment status was recoded into: currently 
employed (employed for wages, self-employed) 
and not currently employed (out of work, 
housewife, student, retired, unable to work, 
disability). Probability values with p<0.05 were 
considered significant. Reliability was assessed 
using an index of internal consistency (e.g., 
Cronbach’s alpha). All analyses were coded and 
analyzed using SPSS version 24. 

RESULTS 
Sample Characteristics 
A total of 500 Black men with an average age of 
48±10 years (range 35 to 75 years) were recruited 
into the study. Participant demographics and 
characteristics are included in Table 2. The final 
model included the following significant variables 

from the bivariate analyses: attitude, education, 
knowledge, marital status, cues to action, informed 
decision, and information-seeking behavior. 

Perceived Behavioral Control (PBC) 
The internal consistency, as measured by the 
Cronbach’s alpha α, was 0.77, which indicates 
acceptable reliability. The composite PBC score 
was 10.51±2.54 out of a possible score range of 3 
to 15 (higher scores indicating greater ease of 
PBC), which means that participants neither had 
ease or difficulty in engaging in specific prostate 
cancer prevention and early detection activities. 
PBC correlated positively with attitude (r=0.271, 
p<0.05), knowledge (r=0.115, p<0.011), cues to 
action (r=0.140, p<0.002), and prostate cancer 
information seeking behavior (r=0.251, p<0.001). 
Those with a postgraduate degree (10.75±2.46) 
and college degree (10.68±2.51) had significantly 
higher PBC scores than those with high school or 
less degree (10.07±2.59). 

Participants in a relationship had significantly 
higher PBC scores than those not in a relationship 
(10.52±2.54 vs. 8.13±2.61, respectively). Finally, 
those who were informed about the advantages 
and disadvantages of prostate cancer screening 
(12.47±2.83) had significantly higher scores than 
those who were uninformed (10.44±2.50). The 
results are contained in Table 2. 

Table 2. Participant Demographic and Characteristics (N=500). 

Characteristics na (%) Mean±SD of 
PBC scores 

Bivariate 
significance 

(t, F,r)b 
p 

DEPENDENT VARIABLE     
Perceived Behavioral Control  10.51±2.54   

INDEPENDENT VARIABLES     
INTRAPERSONAL     

Age  48±10 r=0.073 0.111 
Attitude towards prostate cancer screening  10.56±3.69 r=0.271 <0.001** 



 
 
 
 
 

 
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Education   

F= 3.255 0.039* 
High school or less 150 (30.0) 10.07±2.59 
College/University  216 (43.2) 10.68±2.51 
Postgraduate 123 (24.6) 10.75±2.46 

Knowledge of prostate cancer and screening  10.31±3.66 r=0.115 0.011* 
Marital status    

t=2.678 0.021* 
In a relationship (married/member of 
unmarried couple)  

463 (92.6) 10.52±2.54 

Not in a relationship (divorced, widowed, 
separated, and never married) 34 (6.8) 8.13±2.61 

Perceived risk of prostate cancer  10.27±2.89 r=0.027 0.566 
Perception of health   4.43±8.72 r=-0.038 0.406 

INTERPERSONAL     
   Cues to action  1.60±2.13 r=0.140 0.002** 

Employment status      
Currently employed (employed for wages, 
self-employed)  427 (85.4) 10.45±2.52 F=1.404 0.237 

Currently unemployed (not currently 
employed (out of work, housewife, student, 
retired, unable to work, disability)  

71 (14.2) 
10.85±2.70   

Household income     
Low  117(23.4) 10.39±2.46 

F=1.234 0.292 Middle 90 (18.0) 10.36±2.61 
High 178 (35.6) 10.80±2.59 

Personal history of any cancer     
Yes 17 (3.4) 11.18±3.63 

t=-1.096 0.274 No 481 (96.2) 10.49±2.50 
Prostate cancer family history      

Yes 10 (2.0) 10.11±1.54 
t=0.363 0.717 No 418 (83.6) 10.41±2.47 

Social support   2.41±1.24 r=-0.080 0.086 
INSTITUTIONAL     

Informed decision-making     
Yes 18 (3.6) 12.47±2.83 

t=3.268 0.001** No 482 (96.4) 10.44±2.50 
Prostate cancer information seeking behavior  14.73±3.19 r=0.251 p<0.001** 
Provider satisfaction  4.05±1.35 0.064 0.164 
Regular source of care     

No 260 (52.0) 10.45±2.55 
0.476 0.753 Yes, only one 142 (28.4) 10.79±2.50 

More than one 78 (15.6) 10.39±2.57 
aTotal does not equal 500 because of missing responses.  
bt represent t-test statistics, F from the analysis of variance (ANOVA) test and r from Pearson’s correlation 
*p < .05 (two-tailed). **p < .01 level (two-tailed) 



 
 
 
 
 

 
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Model Testing 
Participants had a neutral attitude towards 
prostate cancer screening based on their score 
10.56±3.69 (possible range of 5 to 15). The total 
knowledge score was low 10.31±3.66  (possible 
range of 0 to 20). Cues to action were also very 
low 1.60±2.13 (possible range of 0 to 13). 
Responses regarding prostate cancer seeking 
information were neutral: 14.73±3.19 out of a 
possible range of 4 to 20. Majority of the 
respondents were those with a college/university 

degree (n=216, 43.2%).  More than 90 percent of 
the respondents reported being in a relationship 
(n=463, 92.6%). Similarly, majority of the 
participant (n=483, 96.3%) were not informed of 
the advantages and disadvantages of prostate 
cancer screening. The PBC regression model was 
significantly different from zero, F=9.32, df=8,463; 
p<0.001. The final model accounted for 49% of the 
variation in PBC (R2=0.49). The results are shown in 
Table 3. 

Table 3. Multiple Regression Analysis of Overall Perceived Behavioral Control (N=500). 
Variables Unstandardized 

Coefficients 
Standardized 
Coefficients 

 95.0% Confidence 
Intervala  

 B Std. Error Beta Lower 
Bound 

Upper 
Bound P-values 

Intercept 6.60 0.79  5.04 8.16 <0.001** 
INDEPENDENT VARIABLES       
Intrapersonal Factors       

Attitude  0.15 0.04 0.21 0.00 0.08 <0.001** 
Educationb       

College/University 0.10 0.16 0.03 -0.21 0.41 0.523 
     Postgraduate 0.30 0.27 0.21 -0.23 0.84 0.269 
Knowledge  0.92 0.57 0.27 0.49 1.33 0.017* 
Marital statusc -0.34 0.49 -0.36 -1.31 0.62 0.482 

Interpersonal Factors        
Cues to actions 0.04 0.06 0.03 -0.07 0.15 0.493 

Institutional Factors       
Informed decision 
making 

2.24 0.74 0.18 0.78 3.70 0.003* 

Prostate cancer 
information seeking 
behavior 

0.13 0.05 0.17 0.03 0.22 0.008* 

F statistic =9.32; df=8, 463; Model p-value <0.001; R2=0.49; Adjusted R2=0.41                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
 

DISCUSSION  

This was a study of a heterogeneous mix of Black 
men from the Nigeria, Cameroon, and the US. The 
objectives of this study were to examine the PBC 
of Black men in West Africa and the US and to 
determine its correlates. This study has several 

findings. First, perceived control over engaging in 
prostate cancer screening were neither easy nor 
difficult. Second, these beliefs are stronger in 
individuals with positive attitudes, when controlling 
for other factors. Third, a higher knowledge level 
are associated with higher level of PBC. Fourth, 



 
 
 
 
 

 
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when participants are given the balanced 
information regarding the advantages and 
disadvantages of prostate cancer screening, their 
perceived control over engaging in the behavior is 
higher. Fifth, individuals who are more proactive in 
seeking information regarding prostate cancer and 
screening have higher levels of PBC.  

Though there is a lack of consensus among 
medical professional groups about its usefulness, 
prostate cancer screening remains the most 
common method for early detection of disease in 
men without symptoms (Carter et al., 2013; 
Ogunsanya et al., 2016b). The overall PBC score 
was neutral meaning that participants neither had 
ease or difficulty in engaging in specific prostate 
cancer prevention and early detection activities. 
The neutral overall PBC score could be because 
Black men are less likely to seek care and 
participate in preventative health-related activities, 
such as prostate cancer screening (Blocker et al., 
2006; Griffith et al., 2011; Pedersen et al., 2012). 
Furthermore, on examining the individual items 
that made up the PBC scale, participants 
responded having a higher degree of ease in 
engaging in making decisions regarding prostate 
cancer screening and engaging in PSA screening. 
However, the question regarding DRE had the 
lowest score, indicating a degree of difficulty in 
engaging in that behavior. As a result, the 
composite PBC score was neutral. The finding 
regarding unfavorable beliefs toward DRE have 
been reported in studies where Black men in 
general show greater resistance to DREs and 
found it embarrassing and a threat to their 
masculinity (Ogunsanya et al., 2016b; Sanchez et 
al., 2007; Winterich et al., 2009b).  

Others explanations for the neutral PBC scores 
include the costs of the tests, poor access to 

healthcare facilities, low level of education, lack of 
awareness about prostate cancer screening, fear of 
loss of masculinity, physicians’ attitudes, fewer 
options of treatment, and religious and cultural 
beliefs/attitudes (Ogunsanya et al., 2016b; 
Winterich et al., 2009a). These factors may result in 
men presenting with late stages of prostate cancer 
with complications when they are diagnosed 
(Adeloye et al., 2016; Akinremi et al., 2011), 
consequently resulting in increased morbidity and 
mortality (Olapade-Olaopa et al., 2014). However, 
unlike previous studies which have mostly been 
conducted in US Black and Caucasian males, the 
current study is the first to focus on a 
heterogeneous sample of Black males from the US 
and West Africa. 

Health education programs aimed at increasing 
levels of control an individual has over engaging in 
behaviors such as prostate cancer screening can 
target improving attitude. While attitude is yet to 
be explored as a determinant of PBC, it has been 
reported to be a strong predictor of engaging in 
prostate cancer preventative behaviors (Mitchell, 
2011; Ogunsanya et al., 2016a). It was observed in 
this study that higher knowledge levels are 
associated with higher PBCs. Sometimes education 
may be reflection of other socioeconomic factors 
such as income or health literacy (Winterich et al., 
2009a). A higher income may increase access to 
health care services. This may be the reason for 
higher PBCs observed in men with higher levels of 
education. So future interventions should also 
focus on men with low education as well as ensure 
the information in media campaign is 
understandable to audiences with low literacy 
levels. 

Black men’s knowledge and perceptions of 
prostate cancer screening have been studied 



 
 
 
 
 

 
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extensively (Morrison et al., 2017; Ogunsanya et al., 
2017; Owens et al., 2015). The current study shows 
that when men know the essential domains of 
prostate cancer and screening, such as diet, 
limitations, risk factors, and screening age 
guidelines, they were more likely to have higher 
levels of perceived control over engaging in 
prostate cancer screening. Black men who were 
told of the advantages and disadvantages of 
prostate cancer screening were more likely to have 
a higher perception of control over screening. 
These findings highlight the importance of 
healthcare providers incorporating informed 
decision-making practices in messages aimed at 
increasing levels of prostate cancer screening 
engagement. The pivotal role providers play is well 
documented in the extant literature (Ogunsanya et 
al., 2016c; Pucheril et al., 2015).  This observation is 
in line with the findings from another study which 
reported that majority of Black men acted on their 
doctor's instruction to undergo prostate cancer 
screening after they had complained to their 
doctor about their symptoms (Enaworu and 
Khutan, 2016). Finally, being proactive about one’s 
health and actively seeking information regarding 
prostate cancer prevention and early detection 
was positively associated with higher levels of PBC.  

Several limitations of this study must be 
considered. The study design was cross-sectional, 
which only provides a one-time snapshot. Given 
this was a self-reported survey, recall bias could 
also be a limitation as responses given by 
participants may have been inaccurate. Cameroon 
is a Francophone country, therefore including only 
English-speaking participants, who may not be 
bilingual, reduces the generalization of our study 
findings. Regardless of these limitations, this study 
fills a critical gap in assessing PBC in a group of 
heterogeneous Black men from Nigeria, 

Cameroon, and the US, and it provides insights for 
future studies.  

CONCLUSION 

Using a socio-ecologic approach, multi-level 
factors were integrated to facilitate a fuller 
understanding of the several factors impacting 
PBC in Black men. The four significant factors 
(attitude, knowledge, informed decision-making, 
and prostate cancer information seeking behavior), 
which are all modifiable, could be considered 
when developing culturally-sensitive interventions 
aimed at engaging at-risk Black men regarding 
prostate cancer prevention and early detection 
practices. While attitude and knowledge have 
been reported as positive correlates in engaging in 
prostate cancer screening in Black males, the 
unique contribution of this study are the roles 
informed decision-making and prostate cancer 
information seeking behavior play as well, 
especially in ethnically-diverse Black males. 

Acknowledgements 
We acknowledge the support of all the men who 
participated in this study. We also acknowledge 
the support of the research assistants who assisted 
with data collection at various sites, notably Ms. 
Ruth Agaba, Mrs. Sarah Adewumi, and Mrs. Nike 
Obafemi. Funding support for this project was 
provided by the Prostate Cancer Transatlantic 
Consortium (CaPTC). 

Conflict of interest 
The authors declare that no competing or conflict of 
interests exist. The funders had no role in study 
design, writing of the manuscript, or decision to 
publish. 

Authors’ contributions 



 
 
 
 
 

 
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RESEARCH 

Motolani Ogunsanya conducted the statistical 
analysis of the project.Motolani Ogunsanya, Iya 
Bassey, Mohammed Faruk and Catherine 
Oladoyinbo provided content and generated the 
initial draft of the article.Haruna Nggada, Abidemi 
Omonisi, Nissa Askins, Blaise Nkegoum, Ademola 
Popoola, Iheanyi Okpala, Omolara Fatiregun, Paul 
Jibrin, Emeka Iweala, Wole Kukoyi, Kayode Adeniji, 
Ayo Salako, and Anthonia Sowumni contributed to 
the acquisition of data and the conduct of the 
project.Folakemi Odedina provided content and 
reviewed the final manuscript  

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