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Modifiable Risk Factors Implicated in 
Prostate Cancer Mortality and Morbidity 
among Nigerian and Cameroonian Men 
Ernest T. Kaninjing*1,2, Getachew Dagne1,3, Sunday E. Atawodi1,4, Adewumi Alabi1,5, Olubanke O. Ogunlana1,6, Patrick T. 
Adegun1,7, Haruna Nggada1,8, Ifeoma Okoye1,9, Abidemi E. Omonisi1,7, Mohammed Faruk1,4, Iya Eze Bassey1,10, Faoziyat 
A. Sulaiman1,11, Nissa Askins1,12, Blaise Nkegoum1,13, Ademola A. Popoola1,11, Anthonia C. Sowumni1,14, Catherine 
Oladoyinbo1,15, Omolara A. Fatiregun1,5, Paul Jibrin1,16, Emeka E. Iweala1,6, Wole Kukoyi1,17, Kayode Adeniji1,11,18, Ayo 
Salako1,19, Iheanyi Okpala1,9 Uche Okoro1,14, Okezie Mbadiwe1,19 Hassan M. Dogo1,8, Mtaku Gali1,8, & Folakemi T. 
Odedina1,12. 
 
*1Prostate Cancer Transatlantic Consortium; 2Georgia College & State University, USA; 3University of South Florida, 
USA; 4Ahmadu-Bello University, Zaria, Nigeria; 5Lagos State University Teaching Hospital, Nigeria; 6Covenant 
University, Ota, Nigeria; 7Ekiti State University, Nigeria; 8University of Maiduguri, Nigeria; 9University of Nigeria College 
of Medicine, Enugu, Nigeria; 10University of Calabar, Nigeria; 11University of Ilorin, Nigeria; 12University of Florida, USA;  
13University Hospital Center, Yaounde, Cameroon; 14Lagos University Teaching Hospital, Nigeria; 15Federal University 
of Agriculture, Abeokuta, Nigeria; 16National Hospital, Abuja, Nigeria; 17Ace Medicare Clinics Limited, Ota, Nigeria; 
18Hebron International Diagnostic & Molecular Pathology Center, Ilorin, Nigeria; 19Obafemi Awolowo University, Ife, 
Nigeria.  *Corresponding author: Ernie.Kaninjing@gcsu.edu 

ABSTRACT 
Prostate cancer is a significant public health problem affecting men globally.  In 2018, it was the second 
most commonly diagnosed cancer among men world-wide and disproportionately impact men of African 
ancestry.  Some of the modifiable risk factors for prostate cancer   include knowledge and attitudes about 
the disease, the belief system of individuals and their diet.  Moreover, physical activity, alcohol and 
tobacco consumption have also been suggested as behavioral factors that contribute to prostate cancer 
disparities.  This study compares modifiable risk factors implicated in prostate cancer among men living in 
Africa and African immigrants living in the United States to identifying behavioral factors that can be 
targeted for intervention.  A cross-sectional study design was employed among Black men in Nigeria, 
Cameroon and African immigrants in United States using the Global Prostate Cancer Measure for Black 
men. Findings indicate that Nigerian and Cameroonian men residing in the United States expressed a 
more positive attitude towards screening than their counterparts in Africa.  Knowledge levels about 
prostate cancer was higher among African Immigrants in the United States compared to those living in 
Africa.  Additionally, fatalism, attitude and knowledge of prostate cancer signs and symptoms were 
statistically significant in the prediction of prostate cancer screening.  Cancer control and prevention 
efforts in Nigerian and Cameroon should focus on educating men about the signs and symptoms of this 
disease to increase knowledge levels and ensure awareness of screening methods.  Prostate cancer 
survivors should be part of health promotion campaigns to reduce fatalistic beliefs. 

KEYWORDS: Risk factors, prostate cancer, health disparity, African ancestry, behavioral factors,   
Citation: Kaninjing et al (2019) Modifiable Risk Factors Implicated in Prostate Cancer Mortality and Morbidity among 
Nigerian and Cameroonian Men. Cancer Health Disparities 4: e1-e13. doi:10.9777/chd.2019.1002 



 
 
 
 
 

 
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INTRODUCTION 

Prostate cancer (CaP) is a significant public health 
problem affecting men globally.  According to the 
international agency for research in cancer, it was 
the second most commonly diagnosed cancer 
among men worldwide in 2018 (Bray, 2018)  and 
disproportionately impact men of African ancestry 
(American Cancer Society, 2018).  It accounted for 
359,000 associated deaths globally in 2018, with an 
increasing number of fatalities reported in sub-
Saharan Africa (Bray et al 2018).  Established risk 
factors for this disease include older age; family 
history; and African ancestry (Centers for Disease 
Control and Prevention, 2018).  While these factors 
are non-modifiable, there are other contributing 
factors to CaP disparities that are modifiable.  They 
include knowledge and attitudes about the 
disease, beliefs, and lifestyle factors, such as diet, 
physical inactivity, alcohol and tobacco 
consumption. These behavioral factors exacerbate 
disparities in CaP outcomes among Black men.  
Current literature indicates that low knowledge 
and awareness about the disease, socio-economic 
status, lack of access to quality care, diagnostic 
centers and treatment play significant roles in late 
stage presentation and mortality (Akpuaka et al., 
2013; Baade, Youlden, & Krnjacki, 2009; Cobran et 
al., 2014; McFall, Hamm, & Volk, 2006). 

In the United States (US), CaP is the most common 
cancer diagnosed among men and the second 
ranked cause of cancer mortality, with about 1 
man in 7 likely to be impacted by this disease 
during their life time (ACS, 2018).  It is estimated 
that in 2018 about 164,690 men were diagnosed 
with this disease in the US with about 29,430 
deaths (ACS, 2018).  Ethnic/racial and geographic 
disparities characterize the burden of CaP among 
sub populations and regions within the US.  For 

example, in 2015, Black men in America 
experienced the highest incidence rate (158 per 
100,000 persons) compared to all races (99 per 
100,000 persons).  Similarly, death rates for the 
same year showed Black men were more likely to 
die of CaP than any other racial or ethnic group in 
America (CDC, 2018).  According to the United 
States Cancer Statistics Working Group (U.S. 
Cancer Statistics Working Group, 2017), between 
1999 and 2012, the Northeast region had the 
highest incidence of 115.4 per 100,000 people 
followed by the Midwest with 105.3 per 100,000 
people and the South with 104.3 per 100,000 
people.  In terms of death rates, the Midwest and 
South regions had the highest at 19.8 per 100,000 
people followed by the West region at 19.5 per 
100,000 and the Northeast at 18.8 per 100,000 
people (U.S. Cancer Statistics Working Group, 
2017). Reasons for these unequal distribution in 
health outcomes are complex and include social 
determinants of health such as lack of access to 
medical care, low socio-economic status, and the 
structural determinants and conditions of daily life 
(Marmot, Friel, Bell, Houweling, & Taylor, 2008; 
Schroeder, 2007). 

Significant challenges exist in quantifying the 
burden of CaP in sub-Saharan Africa (SSA) 
(Adeloye et al., 2016).  Few countries in this region 
have established population-based cancer 
registries, and existing registries lack adequate 
resources (Morhason-Bello et al., 2013; Odedina et 
al., 2009).  The African Organization for Research 
and Training in Cancer (AORTIC) estimates that 
while 80% of the United States population is 
covered by cancer registries, only about 1% of 
African population are presently covered 
(Morhason-Bello et al., 2013).  Data from the 
International Agency for Research on Cancer 
(GLOBOCAN 2012) show that in 2012, the most 



 
 
 
 
 

 
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common cancer among men in SSA was prostate 
which accounted for 16.4% of new cancer cases 
(Parkin, Bray, Ferlay, & Jemal, 2014). In SSA, the risk 
of developing CaP before age 75 was estimated at 
3.4% in 2012 affecting almost 1 in 30 men (Parkin 
et al., 2014).  Published data reveals wide 
geographic variations in reported incidence and 
mortality from CaP in Africa.  In 2012, CaP death 
rates were higher in Southern Africa (age-
standardized rate 24.4 per 100,000 population per 
year), Middle Africa (age-standardized rate of 24.2 
per 100,000 population per year), and Western 
Africa (age-standardized rate of 21.2 per 100,000 
population per year) compared to North Africa 
(age-standardized rate of 7.0 per 100,000) which is 
7 times lower than the rates of the other three 
regions (Ferlay et al., 2015).   These figures may 
not reflect the actual burden of this disease in 
Africa as several studies have noted 
underreporting of cancer cases (Angwafo, 1998; 
Chu et al., 2011; Jemal, 2012; Klassen & Platz, 2006; 
Morhason-Bello et al., 2013; Odedina et al., 2009) 
due to lack of population-based cancer registries.   
Moreover, the population of Africa between 2010 
and 2030 is projected to increase by 60% overall 
(from 1.03 billion to 1.65 billion) and by 90% for 
individuals 60 years and older (from 55 million to 
103 million), the age at which cancer frequently 
occurs (United Nations Department of Economic 
and Social Affairs Population Division, 2017).   

Among men in Nigeria, CaP is the most common 
malignancy with an incidence rate of 30 per 
100.000 cases and mortality rate of 26 per 100,000 
cases (Ferlay et al., 2013).  A hospital-based study 
showed incidence of 127/100,000 cases with a 
national population risk of 2% (Osegbe, 1997). This 
was compared to the low incidence in previous 
years owing to gross underestimation of the 
disease. Alabi and colleagues (Alabi, Sowunmi, 

Alabi A.S., & Fatiregun, 2016) reported an 
incidence of 12.1% in Lagos Nigeria, which was 
comparable to other studies from Kano, Zaria, 
Benin, and Maiduguri with incidence of 16.5%, 
9.2%, 7.13% and 6.15% of all male cancers 
respectively (Akinremi, Ogo, & Olutunde, 2011). 
These results are contrary to previous perception 
on the rarity of the disease in Africa.   

 In Cameroon, CaP is the leading cause of death 
from cancer among men (Orock, Ndom, & Doh, 
2012).  In 2012, the population-based age 
standardized incidence for CaP among men was 
23.0 per 100,000 persons and mortality rate was 
18.6 per 100,000 persons (Ferlay et al., 2015).  This 
number might not reflect the true burden of the 
disease as there is no active national surveillance 
system, and some cancer deaths are neither 
reported nor recorded (Angwafo et al., 2003; Doh, 
2006). 

Behavioral factors have been shown to offer the 
single greatest opportunity to bring about 
reduction in cancer incidence, improvement in 
health outcomes and reduction in the global 
burden of cancers (Klein et al., 2014; Schroeder, 
2007; Stein & Colditz, 2004).  A study by  Mokdad 
and colleagues (Mokdad, Marks, Stroup, & 
Gerberding, 2004; Stein & Colditz, 2004) showed 
that behavioral factors account for nearly 40% of 
all deaths in the United States. Behavioral factors 
provide an opportunity to understand the etiology 
of cancer and effectively address potential areas 
for cancer control and prevention intervention.  
This study aimed to identify the behavioral factors 
associated with CaP among men with common 
ancestral background, living in three countries:  
United States, Nigeria, and Cameroon.  We 
examined the similarities and differences in 
modifiable risk factors such as diet, health literacy, 



 
 
 
 
 

 
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physical activity, cigarette smoking, attitudes, 
fatalism and knowledge about the signs and 
symptoms of this disease.  Results of this study 
indicate that Nigerian and Cameroonian men 
residing in the United States expressed a more 
positive attitude towards screening than their 
counterparts in Africa.  Knowledge levels about 
prostate cancer was higher among African 
Immigrants in the United States compared to 
those living in Africa.  Additionally, fatalism, 
attitude and knowledge of prostate cancer signs 
and symptoms were statistically significant in the 
prediction of prostate cancer screening.  One 
public health application of this result entail 
tailored interventions in Nigeria and Cameroon 
that seek to improve attitudes and knowledge 
about this disease and address fatalistic beliefs.  

METHODS 

Study Design and Sites 
This was a cross-sectional study design 
implemented by the Prostate Cancer Transatlantic 
Consortium (CaPTC) investigators in three 
countries (United States, Nigeria and Cameroon). 
The study sites included: Federal University of 
Agriculture Abeokuta, Covenant University Otta, 
Lagos State University Teaching Hospital, Lagos 
University Teaching Hospital, ACE Medicare Clinic 
Lagos, Ekiti State Teaching Hospital, Obafemi 
Awolowo University Teaching Hospital Complex 
Ile-Ife, University of Ilorin, National Hospital Abuja, 
University of Maiduguri, Ahmadu Bello University 
Zaria, and the University of Calabar.  In Cameroon, 
the University Hospital Center of the University of 
Yaounde 1 participated, and in the United States, 
the University of Florida.  

 
Participants  

Participation in this study was limited to Nigerian 
and Cameroonian men between the age of 35 and 
70 years residing in Nigeria, Cameroon, or the 
United States regardless of any cancer diagnosis. 
The inclusion criteria were men with a first-degree 
male relative living in one of the three countries. 
Exclusion criteria were men below age 35 or older 
than 70 years. 

Study variables and Measures 
The Global Prostate Cancer Measure for Black men 
developed by CaPTC and the African Caribbean 
Cancer Consortium (AC3) investigators was used 
for data collection.  This multi-item standardized 
instrument has been validated for use in other 
studies conducted in Black men (Odedina et al., in 
Press; Blackman et al., 2018; Cobran et al., 2014; 
Kaninjing et al., 2017; Kumar et al., 2009; Odedina 
et al., 2011a; Ogunsanya et al., 2016a).  The study 
variables and measures are presented next: 

Demographic variables included participants’ age, 
educational level, religion, marital status, and 
employment.  Age was categorized into four strata 
(35-44); (45-54); (55-64); and 65 plus.  Marital 
status was categorized into single or married.  
Religion was stratified into three categories: 
Christian, Muslim, and Other.  Employment status 
was divided into three groups: employed, not 
employed, and refused to provide information.  
Education included four levels: less than high 
school, high school, university and refused to 
provide information. 

Outcome variables for this study was having had a 
prostate specific antigen test (PSA) and or digital 
rectal examination (DRE).  Both were measured by 
asking participants “How long has it been since 
you had your last PSA test?” and “How long has it 
been since you had your last DRE exam?”  



 
 
 
 
 

 
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Response options were: A) Within the past year; B) 
Within the past 2 years; C) Within the past 3 years; 
D) Within the past 5 years; E) 5 or more years ago; 
and F) Never.  Both variables were dichotomized 
into 1 (if participant had received a PSA test- 
options A-E) or 0 (if participant had not received a 
PSA test- option F). 

Independent variables were smoking status, 
fatalism, attitude, health literacy, knowledge, meat 
diet, poultry diet, fish diet, physical activity, and 
alcohol consumption. With regards to smoking 
status, participants were asked “What are your 
smoking habits?” with the following response 
options: A) I smoke daily; B) I smoke daily but I 
have cut down; C) I smoke every once in a while; 
D) I used to smoke, but quit less than 6 months 
ago; E) I used to smoke, but quit more than 6 
months ago; F) I have never smoked; G) I used to 
smoke, quit time unknown; H) Don’t know/Not 
sure G) Refused.  This variable was categorized as 
current smoker if response was either A, B, or C.; 
past smoker if response was either D, or E; and 
never if response was F or G.  Participants were 
also asked, “Have you smoked at least 100 
cigarettes in your entire life?”.  The equivalent of 
100 cigarettes is 5 packs.  Participant choices were 
A) Yes, B) No, C) Don’t know/not sure and D) 
Refused.  Four items were used to measure cancer 
fatalism among study participants with response 
captured on a Likert-type scale (Strongly Agree; 
Agree; Neutral; Disagree; Strongly Disagree).  The 
items were: A) I believe if someone has prostate 
cancer, it is already too late to do something 
about it; B) Getting prostate cancer means the end 
of the world; C) If someone is told “You have 
prostate cancer”, there is nothing to be hopeful 
for; and D) The first thing that comes to my mind 
when I hear “prostate cancer” is death.  The score 
range for this variable was 4 – 20.  Higher scores 

indicate higher fatalism or the sense that things 
are beyond the control of the individual.  

Three items measured participant’s attitude 
towards screening for prostate cancer with 
responses in a scale (Very Favorable; Favorable; 
Neutral; Unfavorable; Very Unfavorable).  The 
items include: A) Weighing the advantages and 
disadvantages of prostate cancer screening to 
make a decision about screening for prostate 
cancer; B) Getting tested for prostate cancer with 
Digital Rectal Examination (DRE) every year; and C) 
Getting tested for prostate cancer using my blood 
sample for serum prostate specific antigen (PSA) 
test every year.  The score range for this variable 
was 3 – 15.   Higher scores indicate positive 
attitude. 

Health literacy was measured by four items with 
responses in a Likert-type scale (Always; Often; 
Sometimes; Rarely; Never).  The items were: A) I 
have someone help me read health materials; B) I 
am confident filling out health forms by myself; C) I 
have problems understanding written information 
about prostate cancer; and D) When someone 
discusses prostate cancer with me, I have 
problems understanding the information.  The 
score range for this variable was 4 – 20.  Lower 
scores indicating low literacy levels. 

Twenty items assessed participants’ knowledge of 
prostate cancer signs and symptoms.  Responses 
were “True”; “False”; and “Don’t Know”, with “Don’t 
Know” and blank responses coded as wrong 
response. 

Participants were asked about their diet, 
particularly consumption of meat, poultry, fish, 
animal organs and animal fats.  Participants had 
the option to report their frequency of 
consumption of these items per week, or per 



 
 
 
 
 

 
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month.  Physical activity was measured by a single 
item with a “Yes” or “No” response to the following 
question: “Are you involved in vigorous-intensity 
activity that causes large increases in your 
breathing or heart rate (for example carrying or 
lifting heaving loads, digging or construction work) 
for at least 10 minutes continuously?”.  The internal 
consistency of sampling instrument was 
established at 0.88 Cronbach’s alpha for cancer 
fatalism, 0.84 for attitude and 0.47 for health 
literacy. 

Recruitment and Data collection 
After Institutional Review Board approval from 
each participating institution, data collection 
commenced in May 2017 and is still ongoing. The 
data reported in this paper is the data collected 
between May 2017 and July 2017. The Global 
Prostate Cancer Measure for Black men was 
administered by trained investigators, research 
staff and student assistants. Prior to administration 
of study survey, informed consent was obtained 
from each participant.  Recruitment took place in 
community settings at all participating sites. In 
addition, there were recruitment at clinics in 
Nigeria and Cameroon.  The first 500 participants 
who participated in the study were included for 
this report.  Participants in the United States were 

provided a $25.00 gift card for completing 
questionnaire while those in Nigeria and 
Cameroon received either a T-shirt or a small 
monetary incentive.  

Data Management and Statistical Methods 
The Research Electronic Data Capture (REDCap) 
was used for data entry and management. The 
data was exported to SAS software for data 
analyses. Descriptive statistics was used to 
summarize the study variables. We then computed 
proportions for quantitative measures and 
compared qualitative measures using t and chi-
square tests. Logistic regression was used to assess 
the effects of demographic and independent 
variables on outcome variables.    

RESULTS 

A total of 500 participants completed 
questionnaire for this study, with 428 (85.6%) 
participants from Nigeria, 34 (6.8%) from 
Cameroon and 38 (7.6% African immigrants from 
the US with first-degree male relatives living in 
either Cameroon or Nigeria.  Majority of the 
participants had achieved university level 
education, were married, identified as Christians, 
and were employed.  Table 1 shows the 
demographic variables for study participants. 

Table 1. Demographic characteristics of study participants (n=500). 
 Countries 

Variables Cameroon n=34 (6.8%)     Nigeria n=428 (85.6%)      United States n=38 (7.6%) 
Age 
35-44 8 (23.53) 189 (44.25) 19 (50.00) 
45-54 12 (35.29) 133 (31.15) 15 (39.47) 
55-64 9 (26.47) 68 (15.93) 4 (10.53) 
65+ 5 (14.71) 37 (08.67) 0 (00.00) 
Education  
< High School 8 (23.53) 79 (18.77) 0 (00.00) 
High School  10 (29.41) 97 (23.04) 1 (02.63) 
University 14 (41.17) 243 (57.72) 37 (97.37) 



 
 
 
 
 

 
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Refused  2 (05.88) 2 (00.48) 0 (00.00) 
Marital Status 
Single 4 (11.76) 28 (6.55) 5 (13.89) 
Married 30 (88.24) 399 (93.44) 31 (86.11) 
Religion 
Christian 31 (96.88) 288 (68.74) 35 (94.59) 
Muslim 0 (00.00) 128 (30.55) 1 (02.70) 
Other 1 (03.13) 3 (00.72) 1 (02.70) 
Employment Status 
Employed 23 (67.65) 372 (88.15) 32 (86.44) 
Not Employed 11 (23.53) 50 (11.86) 5 (12.95) 
Refused 3 (08.82) 0 (00.00) 1 (00.61) 
 

Table 2 provides a comparison of the study variables 
across the three study sites.  The variables that were 
statistically significant (p<.05) across the three study 
populations were cancer fatalism, attitude, 
knowledge, diet of poultry, intensive physical activity, 
PSA test and DRE.  Nigerian and Cameroonian men 
residing in the US had a lower mean score for cancer 
fatalism (6.6666) compared to participants in 
Cameroon (8.9642) and those from Nigeria (8.7839).  
This means that participants in the US felt they had 
the power to influence their behavior and health 
outcome, as opposed to participants from the other 
sites who considered the events around their health 
as inevitable and controlled by fate.   Regarding 
attitude and Knowledge, Nigerian and Cameroonian 
men residing in the US expressed more positive 
attitude (13.2500) compared to those from Nigeria 
(11.2052) and from Cameroon (11.5357).  Knowledge 

level about CaP was higher among Nigerian and 
Cameroon men residing in the US than those in 
Cameroon and Nigeria.  Concerning diet, 
participants from Cameroon and Nigeria consumed 
less poultry than those living in the US.  Higher 
physical activity was reported among participants 
from Nigeria (2.1392) followed by participants from 
the US (2.0833) and those from Cameroon reported 
the lowest physical activity (1.0000).  Reported PSA 
test was more common among participants from 
Cameroon (0.8928) followed by participants from the 
US (0.6666) and least common among participants 
from Nigeria (0.2919).  History of DRE was more 
commonly reported by participants from the US 
(0.7500) followed by participants from Cameroon 
(0.6071) and least reported among participants from 
Nigeria (0.2267). 

 
Table 2. Descriptive Statistics of behavioral factors across study sites. 
Variable Cameroon (N=30) Nigeria (N=355) US (N=36) Pvalue 
Smoking Status (%) 
         Current smoker 
         Past smoker 
         Never  

3.57% 
25.00% 
71.43% 

4.94% 
16.36% 
78.70% 

2.94% 
17.65% 
79.41% 

0.8123 

 

Fatalism 8.96 8.78 6.66 0.0048 
Attitude 11.53 11.20 13.25 <.0001 
Health Literacy 12.78 13.38 14.66 0.1500 



 
 
 
 
 

 
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Knowledge 6.75 6.79 9.66 0.0002 
Diet (meat) 1.74 1.65 1.53 0.6258 
Diet (poultry) 1.33 1.42 2.08 0.0009 
Diet (fish) 2.45 2.11 1.68 0.0621 
Diet (organ) 1.08 1.32 0.94 0.1353 
Diet (fats) 2.09 2.13 2.05 0.2832 
Physical Activity 1.00 2.13 2.08 <.0001 
Alcohol consumption 2.43 1.67 1.91 0.2709 
PSA  (1=yes; 0=no) 0.89 0.29 0.66 0.0001 
DRE (1=yes; 0=no) 0.60 0.22 0.75 0.0006 
 

Regarding DRE, participants from Nigeria had an 
81% lower odds of getting a DRE compared to 
participants in the US, whereas no difference was 
found between participants in Cameroon and those 
in the US (Table 3). When examining the effect of 
diet, individuals consuming meat on average had a 
52% lower odds of having a DRE relative to those 
who did not consume meat (OR = 0.48; 95% CI: 0.29 
– 0.80); furthermore, the odds of having a DRE was 
2.15 times higher for study participants who 
consumed fish (OR= 2.15; 95% CI:1.46 – 3.16), 
compared to those who did not. In terms of PSA, a 
meat-based diet was found to be a significant 
predictor whereby meat-consuming participants, 
with an OR of 0.56 (95% CI 0.37 – 0.85) had a 44% 
lower odds of having a PSA test compared to those 
who did not consume meat. Conversely, participants 

who reported a fish-based diet OR of 1.77 (95% CI: 
1.28 – 2.44) on average had a 77% higher odds of 
getting a PSA test than participants whose diet did 
not contain fish. These findings indicate that 
participants who were more likely to exhibit CaP 
preventative behavior were also more likely to 
participate in CaP screening. For all other variables 
no difference was found in the odds of having a 
DRE. 

Attitude in this analysis was found to be a significant 
predictor of CaP screening, with an OR of 1.21 (95% 
CI: 1.05 – 1.39) meaning that for each unit increase in 
the score for attitude, the odds of having a PSA on 
average increased by 21% (Table 3). All other 
remaining variables assessed for an association with 
the PSA were not found to be significant. 

Table 3. Odds Ratio Estimates of the Association between Behavioral Factors and Having a DRE or a PSA.  
PSA DRE 

S2Q1: Cameroon vs US 2.17 (0.52 - 9.02) 0.68 (0.14 - 3.28)  
S2Q1: Nigeria vs US 0.57 (9.02 - 1.51) 0.19 (0.06 - 0.58)  
Fatalism 1.02 (0.94 - 1.12) 1.02 (0.92 - 1.14) 
Attitude 1.21 (1.05 - 1.39)  1.06 (0.90 - 1.24)  
Health Literacy 1.01 (0.92 - 1.10) 1.03 (0.93 - 1.15)  
Knowledge 1.04 (0.97 - 1.11) 1.02 (0.94 - 1.11)  
Diet (meat) 0.56 (0.37 - 0.85) 0.48 (0.29 - 0.80)  
Diet (poultry) 1.30 (0.90 - 1.88) 1.08 (0.72 - 1.62) 
Diet (fish) 1.77 (1.28 - 2.44) 2.15 (1.46 - 3.16)  
Diet (organ) 0.99 (0.75 -1.29) 1.10 (0.80 - 1.51)   



 
 
 
 
 

 
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Diet (fats) 0.80 (0.57 - 1.11) 0.83 (0.56 - 1.23) 
Physical Activity 1.11 (0.82 - 1.49) 1.03 (0.71 - 1.48)  
Alcohol Duration 1.14 (0.96 - 1.36) 1.14 (0.92 - 1.41)  
Smoking status: Current smoker vs Past smoker 1.38 (0.31 - 6.19) 0.67 (0.10- 4.66)  
Smoking status: Never vs Past smoker 0.78 (0.35 - 1.73) 0.67 (0.26 - 1.71)  

 
DISCUSSION 

Since human behavior is a significant contributor to 
the etiology and management of cancer outcomes 
(Klein et al., 2014; Mokdad et al., 2004), effective 
cancer prevention and control efforts can benefit 
from behavioral intervention strategies. This study 
uniquely focuses on exploring modifiable behavioral 
factors for CaP among Nigerian and Cameroonian 
men residing in Nigeria, Cameroon and the United 
States.  The important findings with implications for 
health promotion and CaP awareness among this 
population are summarized next.   

Cancer fatalism and prostate cancer detection 
While participants in the US felt they had the power 
to influence their behavior and health outcome, 
participants from Nigeria and Cameroon considered 
the events around their health as inevitable and 
dependent on fate.  This perception has been 
described as cancer fatalism- a belief that death is 
inevitable following a diagnosis of cancer, and it is a 
major barrier to cancer detection and control (West, 
1993). Other studies from Nigeria and Cameroon 
have reported strong perception of fatalism about 
this disease as conversations about cancer in these 
countries are often shrouded in fear and strongly 
held superstitious beliefs (Aderounmu et al., 2006; 
Kaninjing et al., 2018; Ojewola et al., 2017).  Similarly, 
a 2011 study among ethnically diverse Black men in 
Florida (Odedina et al., 2011) noted that US-born 
Black men and Caribbean-born US citizens reported 
less cancer fatalism compared to African-born Black 
men.  Another study among men in a rural Kenyan 

community reported relatively high fatalistic beliefs 
of prostate cancer screening (Mutua, Pertet, & 
Otieno, 2017).  This feeling of powerlessness or the 
fear of “getting to know” one’s status is detrimental 
to early detection of CaP and management of the 
disease.  Therefore, cancer prevention and control 
efforts should focus on educating men in Nigeria 
and Cameroon on measures and behaviors that are 
within their reach in maintaining their health.  
Education about signs and symptoms for this 
disease, screening and diagnostic tests and 
treatment options can increase perception of control 
over one’s overall health. In addition, it is important 
to involve CaP survivors in education and awareness 
campaigns. If men in Nigeria and Cameroon are 
exposed to men who have survived the disease and 
living a productive life as survivors, this may diminish 
cancer fatalism. 

Attitude and Knowledge 
Participants from the US expressed a more positive 
attitude towards screening for CaP compared to 
those from Nigeria and Cameroon. Additionally, 
knowledge levels about CaP was higher among 
participants from the US than those from Cameroon 
and Nigeria. The knowledge gap among participants 
from these two sites on risk factors, signs, symptoms, 
and treatment options for CaP may be linked to their 
literacy levels. While 97% of US-based participants in 
this study had university education, only about 57% 
of the participants from Nigeria and 41% of 
participants from Cameroon had university 
education. This is consistent with the findings of 
Damiani et al (2015) who reported an increased level 



 
 
 
 
 

 
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RESEARCH 

of cancer screening in women with highest level of 
education. Among participants in the Florida study 
(Odedina et al., 2011), low CaP fatalism was 
associated with increase in education level. 
Therefore, lower level of education has the potential 
to negatively affect uptake of screening advice and 
early cancer detection (Damiani et al., 2015).  
However, this finding is contrary to results from a 
study by Magnus (2004) that found no significant 
difference in knowledge and nativity in participants 
who screened for CaP  (Magnus, 2004). This may be 
due to the fact that participants in the Magnus study 
were all Americans with higher literacy level. 

Other studies have shown that poor knowledge and 
attitudes regarding prostate cancer screening exist 
even among health care providers (Bourne, 2010; 
McNaughton-Collins & Barry, 2011). Effective cancer 
control efforts should include sensitization among 
physicians as they are a trusted source for cancer 
prevention and control information (Morrison BF, 
Aiken WD, Mayhew R, Gordon Y, 2017; Walsh-
Childers, et al., 2018).  Therefore, the negative 
attitude and lower knowledge levels exhibited by 
study participants from Nigerian and Cameroon 
indicate barriers that should be addressed to 
improve early cancer detection among men in these 
countries. Health care providers as well CaP 
survivors/advocates are a good source for such 
education. 

Another important finding from this study was that a 
fish-based diet was a significant predictor of 
screening with PSA test and or DRE.  One 
explanation of this finding could be that participants 
who consumed a fish-based diet were more health 
conscious and pro-active in their health seeking 
behaviors compared to those who favored a meat-
based diet.  While the role of diet in the etiology of 
prostate carcinogenesis is still unsettled, some studies 

have noted the preventive role of diet, particularly 
vegetables, fruits, and nuts, to different classes of 
natural compounds, including polyphenols.   

In this study, higher levels of physical activity was 
reported among participants from Nigeria followed 
by participants from the US while participants from 
Cameroon reported lower physical activity. 
According to the 2008 Physical Activity Guidelines for 
Americans (CDC, 2014) adults need a minimum of 
2.5 hours (150 minutes) of moderate-intensity 
aerobic activity each week.  Globally, physical 
inactivity is prevalent with 51% of people in the US 
(CDC, 2014) and 31% of people worldwide not 
attaining recommended physical activity levels (Hallal 
et al., 2012).  A study by Moore and colleagues, 
found higher levels of physical activity were 
associated with an increased risk of prostate cancer 
(HR=1.05, CI:1.03–1.08).  Although there is no 
conclusive evidence showing physical activity as a 
protective factor for prostate cancer, higher levels of 
physical activity has been associated with lower risk 
of 13 cancers including colon, breast and 
endometrial cancers but higher risk of malignant 
melanoma (Moore et al., 2016).  The World Cancer 
Research Fund has estimated that 27–39% of the 
main cancers can be prevented by improving diet, 
physical activity and body composition (World 
Cancer Research Fund & American Institute for 
Cancer Research, 2007). 

This study identified some important differences in 
modifiable CaP risk factors among Nigerian and 
Cameroonian men residing in Africa and their 
counterparts living in the US.  It is evident that men 
living in Nigeria and Cameroon will benefit 
significantly from behavioral interventions on CaP 
prevention and early detection. Based on this study, 
the modifiable behavioral factors that can be 
targeted with tailored messages for CaP control and 



 
 
 
 
 

 
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RESEARCH 

prevention in Nigeria and Cameroon include 
attitudes, cancer fatalism, knowledge about CaP, and 
physical activity. Health care providers and CaP 
survivors should be integral in any behavioral 
intervention to address fatalistic beliefs and increase 
awareness about this disease. 

Acknowledgements 
We acknowledge the support of the research 
assistants who assisted with data collection at 
various sites, notably Ms. Ruth Agaba, Mrs. Sarah 
Adewumi, Mrs. Nike Obafemi, and Ms. Christiale 
Feuatsap. 

Funding Support 
Funding for this study was made available by a 
grant from the Carnegie Corporation in New York, 
Moffitt Cancer Center Support Grant Federal 
Award No: 3P30CA075292-19S2, and 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 
Design; Kaninjing, Odedina, Dagne. Introduction; 
Faruk, Sulaiman, Ogunlana, Atawodi, Alabi. 
Methods; Askins, Nggada, Kaninjing. Results; 
Dagne, Kaninjing, Odedina, Adegun. Discussion; 
Okoye, Bassey, Nkegoum, Popoola, Omonisi, 
Sowumni. Data Collection; Sowumni, Oladoyinbo, 
Fatiregun, Jibrin, Iweala, Kukoyi, Adeniji, Salako, 
Okpala, Okoro, Mbadiwe, Dogo, Gali 
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