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Self-Reported Reasons Men Decide Not to
Participate in Free Prostate Cancer Screening
Sally P. Weinrich, PhD, RN, FAAN, Martin C. Weinrich, PhD, Julie Priest, MSPH,
and Cathy Fodi, RN
Key Points . . .
Purpose: To determine the reasons why men fail to participate in a
free prostate cancer screening.
Design: Survey and secondary analyses using correlational design.
Economic cost and lack of knowledge of prostate cancer
Setting: Community sites in the Southeastern United States.
screening are major barriers to regular screening.
Sample: The sample (N = 241) ranged in age from 4068 years.
Mean age was 50 years (SD = 7.4). Most of the men were African
The most frequent reason given for not participating in first
American (79%) and married (70%). Almost half of the subjects (44%)
screening opportunity was "time problems."
earned between $9,601 and $25,020 per year.
Method: Telephone survey of men who did not participate in initial
Men with low incomes are more likely to report "physician
prostate cancer screening after educational program.
problems" as the reason for not participating in the first
Main Research Variables: Demographics, self-reported reasons
men decided not to participate in a free screening following a prostate
African American men and men with low incomes often need
cancer educational program, and predictors for subsequent participa-
tion in screening.
assistance with accessing health care even when the cost of
Findings: The main self-reported reason for not participating in a
the health care is covered.
free prostate cancer screening opportunity was time problems. A sig-
nificant relationship between income and physician problems existed
among the men who did not participate. Twenty-one percent of the 241
Literature Review
men participated in a second opportunity for free prostate cancer
screening. Men who cited "lost packet" as their reason for not partici-
Prostate cancer screening increased significantly nation-
pating in the first free screening were more than twice as likely to go for
the second opportunity for free screening when offered another packet
wide in the 1990s. However, African American men were less
or voucher for a free screening with their physician of choice.
likely than Caucasian men to participate in prostate cancer
Conclusions: "Time problems" was the most frequent self-reported
screening (Mettlin, Murphy, Rosenthal, & Mench, 1998).
reason men gave for failure to participate. Providing a follow-up phone
Unfortunately, African American men have the highest inci-
call and vouchers a second time for reimbursement of the cost asso-
dence and mortality from prostate cancer, with an incidence
ciated with a screening increased participation. Men often need assis-
rate of 234.2 in African Americans versus 144.6 in Caucasians
tance with locating physicians and nurse practitioners who will file for
per 100,000 (Jemal, Thomas, Murray, & Thun, 2002; Ries et
financial reimbursement. Appointment reminders are critical.
Implications for Nursing: The findings of this study of the signifi-
cant relationship between income and "physician problems" for not
Sally P. Weinrich, PhD, RN, FAAN, is a professor in the School of
participating has implications for healthcare providers. Future programs
Nursing at the University of Louisville in Kentucky and a research pro-
could provide telephone follow-up with men and remail vouchers, as
fessor in population studies at the University of South Carolina's
needed. In addition, men could be encouraged to designate one place
Cancer Center in Columbia; Martin C. Weinrich, PhD, is a professor
in their households for health-related papers (for safekeeping).
of internal medicine at the University of Louisville; Julie Priest,
MSPH, is a programmer analyst at Inveresk Research in Cary, NC;
and Cathy Fodi, RN, is a primary care nurse practitioner at the VA
Hospital in Asheville, NC. This research was funded by the National
Cancer Institute (R01 CA60561-01) and the South Carolina Cancer
frican American and low-income men, who are at
Institute. This article is based on the authors' viewpoints and is not
high risk for prostate cancer incidence and mortality,
representative of the National Cancer Institute's opinion. (Submitted
often do not participate in prostate cancer screening.
January 2001. Accepted for publication July 1, 2002.)
Little information is known about the reasons for failure to
participate from the perspective of the men.
Digital Object Identifier: 10.1188/03.ONF.E12-E16
ONF VOL 30, NO 1, 2003
al., 2002). In the 1992 National Health Interview Survey, sig-
cluded men who did not participate in a free prostate cancer
nificant differences existed in participation in screening that
screening following an educational program, were contacted by
used a digital rectal examination (DRE). Lower income and
telephone to elicit self-reported reasons for not participating,
African American men were least likely to participate. Signifi-
and were given a second opportunity for a free screening.
cantly fewer African American men (between the ages of 40
In the first stage of the larger study, conducted between
and 70) with family incomes of less than $20,000 had had a
1995 and 1996, 1,901 men at 222 different community sites
DRE in their lifetimes in contrast to African American men
completed a survey, participated in an educational program on
with a household income of $20,000 or more (32% versus
prostate cancer, and were offered free prostate cancer screen-
51%, p = 0.05) (M. Brown, personal communication, Febru-
ing from their physicians of choice (Weinrich, Weinrich,
ary 18, 1997).
Boyd, & Mettlin, 1998). The educational program included
Disagreement exists about the effectiveness of prostate can-
information on signs and symptoms of prostate cancer, the
cer screening, in terms of lives saved, among experts who both
American Cancer Society's prostate cancer screening guide-
support and oppose prostate cancer screening (Etzioni et al.,
lines, and benefits and limitations of prostate cancer screen-
1999; Feuer, Merrill, & Hankey, 1999; Johansson, Holmberg,
ing (Weinrich, Weinrich, Boyd, & Mettlin). A total of 1,060
Johansson, Bergstrom, & Adami, 1997; Labrie, 2000; Mettlin,
(56%) men went to their physicians of choice for the free
2000; Weinrich, 2001). Agencies that support screening advo-
prostate cancer screening. The physicians billed those who
cate informed decision making, in which the men are educated
were conducting the research study for the cost of the screen-
regarding the benefits and limitations of prostate cancer
ing. African American and low-income men were the least
screening (Smith et al., 2001; Weinrich). Priority groups for
likely to have participated in the first phase of the larger study
prostate cancer education and research need to be at-risk popu-
(Weinrich, Weinrich, et al., 2000). No record of screening was
lations, which include African American (Eyre & Feldman,
obtained from the remaining 841 men. Follow-up calls to a
1998; Myers, 1999) and low-income men (Weinrich, Ellison,
random list of 275 of the 841 men revealed that 18% of the
et al., 2000; Weinrich, Weinrich, et al., 2000).
men had gone to their individual physician of choice, but the
Increased participation in prostate cancer screening has
physicians had not billed the research study for the cost.
been reported when the barriers of cost and lack of knowledge
In the second stage of this study, conducted in 1997, the
are removed (Abbott, Taylor, & Barber, 1998; Demark-
remaining 566 men were called and asked why they had not
Wahnefried et al., 1995; Myers et al., 2000; Powell, Gelfand,
participated. Of the 566 men, 153 men (27%) could not be
Parzuchowski, Heilbrun, & Franklin, 1995; Powell et al.,
reached after repeated calls. Of the 566 men, 105 men (19%)
1997; Weinrich, Weinrich, Boyd, & Mettlin, 1998). Men most
reported that they had obtained the prostate cancer screening.
likely to participate in prostate cancer screening are those who
Calls to their physicians revealed that 102 of them had indeed
have higher education, favorable views of early detection, and
been screened, although their physician had not billed the re-
strong physician support for early detection (Myers et al.).
search study. The physicians for the remaining men (n = 3)
Unfortunately, decreased participation among African Ameri-
found no record of prostate cancer screening. Six of the 566
can and low-income men has been documented (Weinrich,
men "did not know" whether they had gone for a prostate
R e y n o l d s , et al., 2000; Weinrich, Weinrich, Boyd, &
cancer screening examination.
Atkinson, 1998; Weinrich, Weinrich, Atwood, & Cobb,
During the second stage, the 241 men who stated that they
1999). No published studies are available that examine rea-
had not yet had a prostate cancer screening examination were
sons for the failure to participate in prostate cancer screening
sent another voucher to use at their physician of choice. Stan-
when the barriers of cost and education are removed for low-
dardized telephone procedures, which included a script and
income and African American men, two groups at highest risk
key areas to discuss, were developed and followed for stages
for prostate cancer mortality. Previous published research on
2 and 3.
the South Carolina Prostate Cancer Study has documented
In the third stage of this study conducted in 1997, 302
some barriers, including embarrassment, lack of transporta-
(53%) men out of the 566 men who were reached by tele-
tion, procrastination, inconvenient hours for physicians, and
phone were given a second opportunity for a free screening
lack of knowledge of where to go for medical assistance
with their individual physician of choice. Among the 302
(Shelton & Weinrich, 1999; Weinrich, Reynolds, Tingen, &
men, 241 men gave at least one reason for not accepting their
Starr, 2000).
first free screening opportunity and were included in this re-
Three research questions were formulated based on the lit-
search study. This article reports on reasons for not participat-
ing given by these 241 men.
What were the self-reported reasons for failure to partici-
pate in a free prostate cancer screening?
What is the association between the self-reported reasons
The researcher for the telephone survey in stage 2 devel-
for failure to participate and demographic variables?
oped an open-ended question to obtain data on reasons men
What predicts subsequent participation in prostate cancer
did not participate in the first offer for free prostate cancer
screening. It was developed by S. Weinrich, the author, who
is an expert in prostate cancer education and screening among
African American and low-income men (Trossman, 2000;
Design and Study Sample
Weinrich, Boyd, & Powe, 1997). The question was pilot
tested with 15 men. Minor changes in wording were made to
This descriptive, correlational study, which recruited subjects
improve readability and adapt it to an eighth-grade reading
in three stages, was a secondary analyses from a larger study
level. Reasons given by some men were cited as part of the
(Weinrich, Weinrich, Boyd, & Mettlin, 1998). The sample in-
WEINRICH VOL 30, NO 1, 2003
Table 1. Description of Sample
telephone interview. The final wording of the question was
"Several men have told us why they chose not to go for a
African American
Caucasian Men
prostate checkup. Some men did not go because they did not
Men (N = 190)
(N = 51)
have time, some men had problems with their doctor, and
some men did not want to have the digital rectal exam. Can
you tell us why you decided to not have a prostate checkup?"
Age* (years)
Data Analyses
Analyses for this secondary study was performed using
data from stages 2 and 3. The reasons men gave in stage 2 for
not going for the first screening opportunity were recorded
and categorized into seven categories: (a) time problems, (b)
Less than high
lost the voucher for the first offer of free screening, (c) phy-
school (HS)
sician problems, (d) forgot, (e) intended to go, (f) personal
Some HS/HS
problems, and (g) a variety of other individual reasons.
Descriptive statistics were performed using SAS version
More than HS
6.12 software to examine self-reported reasons for failure to
participate in a free prostate cancer screening. Chi-square tests
$9,600 or less
of significance, Fisher's exact test, univariate tests, and multiple
logistic regression were used to test the self-reported reasons
$25,021 or more
for failure to participate, and demographic variables predicted
Marital status
subsequent participation based on self-reported reasons.
Single, widowed,
divorced, or
N = 241
The 241--
men from stages 2 and 3 ranged in age from 40
68 years (X = 50 years; SD = 7.4). Most of the men were
*p = 0.001
African American (79%) and married (70%). When education
was condensed into three categories (less than high school,
some high school or graduated from high school, and more
lems (n = 14). No significant differences by race were seen in
than high school), 57% of the sample had attended or gradu-
the distribution of reasons given for not participating.
ated from high school. More than half of the subjects (62%)
Associations Between Self-Reported Reasons for
had low incomes, defined in this study as a family income of
Failure to Participate and Demographic Variables
less than $25,020 per year. Statistically significant differences
existed by race in the distributions of income and age catego-
A statistically significant relationship was found between the
ries (p < 0.001). The distribution of demographic variables,
income variable and "physician problems" for not participating
including age, race, education, income, and marital status, is
in the first screening. The middle-income group ($9,601
$25,020 per year) was more likely to cite physician problems
summarized in Table 1.
as their reason for not participating than men in the lower-in-
Self-Reported Reasons Men Did Not Participate
come (< $9,600 per year) or higher-income (> $25,021 per
There were different reasons given by the men in stage 2 of
year) categories (p = 0.03). Physician problems included refusal
the study for not accepting the first offer of free prostate can-
of physicians to invoice for payment or the lack of a physician.
cer screening. The most frequent reason given for not going
No other statistically significant relationships between the de-
for the first screening opportunity was "time problems"
mographic variables and the self-reported reasons for failure to
(46%). The remaining reasons included lost the packet (17%),
participate existed. Race was not significant.
physician problems (16%), forgot (11%), intended to go (6%),
Predictors for Acceptance of Second Opportunity
and personal reasons (6%) (see Table 2). A "variety" category
for Free Prostate Cancer Screening
included individual reasons such as "do not like exam," "do
not need it," expressed fear, procrastination, apathy, "did not
Twenty one percent (n = 51) of the 241 men accepted the
know to go," and other reasons (n = 65). The percentages sum
second opportunity for free prostate cancer screening. No sig-
to more than 100% because many men (57) gave more than
nificant differences were seen in race during the second op-
one reason for not participating in the first screening oppor-
portunity for free screening (22% of African American men
tunity. Examples of responses that were coded in the category
versus 18% of Caucasian men).
of "time problems" (n = 110) were "too busy" and "did not
Reasons given by the men for not accepting the first oppor-
take the time to go." Examples of responses that were coded
tunity for free prostate cancer screening were examined as
in the category of "physician problems" (n = 39) were "need
predictors for acceptance of the second opportunity. Predic-
a new doctor," "need to change doctors," and "doctors refused
tors, based on the men's self-reported reasons, were time
to accept the free voucher packet or to perform the prostate
problems, lost the invoice packet, doctor, forgot, intent, and
exam." Specific comments for the "forgot" category (n = 26)
personal reasons.
in addition to "forgot" were "could not remember." Men who
A significant difference in participation in the second free
had personal or health problems were listed as personal prob-
prostate cancer screening was found in the group who said
ONF VOL 30, NO 1, 2003
Table 2. Self-Reported Reasons for Not Participating
ticipating. In contrast, the low-income men were less likely
in Free Prostate Cancer Screening Following an Educational
than the middle-income men to participate in the free prostate
cancer screening (Weinrich, Weinrich, et al., 2000). Nurses
need to recognize that men with middle or low incomes may
Reasons Given
need assistance with navigating the healthcare system.
The problem of the physicians refusing the invoice high-
Time problem
lights the need for the payor of the invoice to intervene di-
Lost the voucher
rectly with the healthcare provider to ensure that service is
Physician problems
provided. The problem of "did not have a physician" high-
lights the need to provide names, addresses, and phone num-
Intended to go
bers of healthcare providers who accept vouchers. Indeed, the
Personal or health problem
Other (apathy, procrastination, do not like exam)
South Carolina Prostate Cancer Study demonstrated that when
men are provided assistance using the Client Navigator
Percents total more than 100% because some subjects listed more than
Method, increased screening occurs (Weinrich, Weinrich,
one reason for not participating.
Boyd, & Mettlin, 1998). The Client Navigator Method con-
N = 241
sisted of a nurse or social worker who contacted the men by
telephone, identified barriers, and assisted with individual
problems. The method also included three reminders: a key
they had lost the voucher packet. More than one third (37%)
ring, calendar, and refrigerator magnet to record a physicians'
of the 41 men who said they did not go for the first offer for
name and telephone number.
free screening because they lost the voucher packet did par-
The lack of association with race with any of the self-re-
ticipate in the second opportunity for a free screening. This
ported reasons is a mystery that needs additional research. Af-
was statistically significant (p = 0.008). These men were more
rican American men in both this study (Weinrich, Weinrich,
than twice as likely to go for the second opportunity of free
Boyd, & Mettlin, 1998) and nationwide (Mettlin et al., 1998)
screening when offered another voucher (OR = 2.62, p =
are less likely to participate in prostate cancer screening in
0.01). No other significant predictors were found.
contrast to Caucasian men. Additional research using qualita-
tive methodology is needed to identify the reasons.
Before the opportunity for free screening, all of these men
had received a prostate cancer educational program that dis-
cussed different treatment options, including watchful wait-
Results can be generalized to men in southern community
ing. The potential side effect of sexual dysfunction from some
settings who received education on prostate cancer screening.
prostate cancer treatments was discussed in the question and
These self-reported reasons cannot be generalized to men who
answer session. Of interest, none of the men reported poten-
decide not to be screened but who have not received educa-
tial incontinence or erectile dysfunction from treatment as
tion on prostate cancer screening.
reasons for not participating in the prostate cancer screening.
The age of the data, which were first collected in 1995 and
Another implication for healthcare providers working with
1996, is a limitation. However, the lack of other studies in the
at-risk men is the low participation with the second opportu-
literature on self-reported reasons for failure to participate in
nity--approximately one man in five participated. The predic-
prostate cancer screening following education merit this pub-
tor for subsequent participation of "losing the voucher" has
lication. The design of this secondary analyses, which col-
implications for healthcare providers. Issuing a new voucher
lected data from the men two years after they received prostate
led to improved participation. Future programs could benefit
cancer education, is a strength. Currently, the answer for the
from this information by providing telephone follow-up with
national debate on the efficacy of prostate cancer screening is
the men and remailing vouchers for men who fail to partici-
for each nurse practitioner or physician to inform and actively
pate. Also, men could be encouraged to designate one place
involve each man in the decision-making process for or against
in their household for health-related papers and keep their
prostate cancer screening after the benefits and limitations are
v o u c h e r in this place until their appointment with the
discussed. This is the only article published on the self-re-
healthcare provider. Healthcare providers need to explore a
ported reasons, by a cohort of men who received prostate can-
more effective manner of payment for the examination. Lost
cer education, for failure to participate in free screening. Simi-
vouchers for reimbursement were a significant reason that the
larly, no other published data are available on men who have
men did not participate. Direct communication with the men's
been given a second opportunity for free screening.
physicians of choice is an option.
The healthcare barriers identified in this research may ap-
Nursing Implications
ply to other populations. Future research should continue to
The significant relationship between income and "physician
focus on prostate cancer mortality rates for high-risk groups:
problems" has implications for healthcare providers regarding
African American (Eyre & Feldman, 1998) and low-income
why men decide not to participate in prostate cancer screening.
men (American Cancer Society, 1990). A qualitative study
Men often need assistance with accessing or making appoint-
could further clarify reasons for failure to participate in pros-
ments for health care even when the cost for the care is free. The
tate cancer screening.
assistance can include access to phone numbers, reminders such
as calendars to keep the appointments, and transportation.
Author Contact: Sally P. Weinrich, PhD, RN, FAAN, can be
Specifically, the middle-income group of men was more
reached at sally.weinrich@louisville.edu, with copy to editor at
likely to cite physician problems as their reason for not par-
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