Table Of ContentThe Influence of Culture on the Views of Black African/African-
Caribbean Men Living In the UK Towards Cancer
Betselot Mulugeta
A thesis submitted in partial fulfilment for the requirements for the degree of
Doctor of Philosophy at the University of Central Lancashire
School of Health
November, 2014
Declaration
I declare that while registered as a candidate for the research degree, I have not been a
registered candidate or enrolled student for another award of the University or other
academic or professional institution; and that no portion of the work referred to in this
thesis has been submitted in support of any application for another degree or qualification
in this or any other university or institute of learning.
Abstract
In the United Kingdom (UK), men face a significantly higher risk of contracting and dying
from cancer. Prostate, lung and colorectal cancer are the most common cancers diagnosed
in men; with prostate cancer disproportionately affecting black men. Little is known about
black African (BA) and black African-Caribbean (BAC) men’s view towards cancer; yet
culture and acculturation determine the way in which people understand, explain and
develop their attitudes towards cancer. Hence, cancer prevention and early detection
strategies may not be sensitive to UK-based black men views, affecting their awareness of
risk factors and early detection services. An evidence based understanding about black
men’s views towards cancer is needed to effectively target cancer prevention strategies.
This qualitative study explored the influence of culture on the views of UK based BA and
BAC men towards cancer.
In collaboration with black community organisations based in Leeds, Manchester,
Birmingham, and London, 27 participants were recruited. Convenience and theoretical
sampling methods were used. Data were collected from June 2013-February 2014 using
semi-structured one-to-one interviews. Data were analysed using the grounded theory
analytical method.
BA and BAC men have their own distinct beliefs concerning the causes of cancer, which
influence how they view cancer as a whole. Seven categories: ‘Cultural views’; ‘Religious
beliefs’; ‘Avoiding Babylon’; ‘Alienation’; ‘Suspicious mind’; ‘Advertisements and
information influence very little’, and ‘Gap in service provision (Bridging the gap)’ were
identified as sub-categories revolving around the core category: ‘Cancer through black
eyes’. Cancer was not viewed as a purely medical condition through black eyes. Black
men’s views towards cancer were closely linked to socially constructed perspectives of
themselves, linked with their cultural and religious beliefs; what being black male means in
society, the meanings of historical phenomena like slavery, and the meanings they ascribed
to social systems and establishments, such as healthcare systems. Clinical risk factors such
as smoking and obesity had different meanings and symbolisation through black eyes.
There were macro- and micro-level similarities and differences between BA and BAC men.
Cancer-related services, such as public-health campaigns, aimed at black men need to be
sensitive enough to understand cancer through black eyes. Public health campaigns based
on only the clinical meaning of cancer mismatch with black men’s understandings of
cancer. Accordingly, the effort made to increase public awareness of cancer and to reduce
health inequality in this regard may continue to be ineffective. Findings from this study can
be used to inform public health policy makers, and healthcare professionals more broadly,
including professionals involved in health promotion, as well as charitable organisations
aiming to provide services that will be utilised by BA and BAC men.
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Table of Contents
Declaration ............................................................................................................................. 2
Abstract .................................................................................................................................. 3
Table of Contents ................................................................................................................... 4
List of Tables........................................................................................................................ 12
List of Figures ...................................................................................................................... 13
List of Appendices ............................................................................................................... 14
Acknowledgments ................................................................................................................ 15
The Author ........................................................................................................................... 16
Abbreviations ....................................................................................................................... 17
Introduction .......................................................................................................................... 18
Chapter 1: Background ..................................................................................................... 24
1.1 Overview .......................................................................................................... 24
1.1.1 Culture and Health ........................................................................................... 24
1.2 Men’s health ..................................................................................................... 26
1.3 Global trends in cancer .................................................................................... 28
1.4 Current evidence from the UK and USA ......................................................... 30
1.5 African people in the UK ................................................................................. 32
1.6 Caribbean people in the UK ............................................................................. 35
1.7 Africa and the Caribbean: Population, Language, Culture, and Religion ........ 36
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1.7.1 Africa................................................................................................................ 36
1.7.2 The Caribbean .................................................................................................. 37
1.8 Cancer in the Caribbean and Africa ................................................................. 38
1.8.1 Cancer in the Caribbean ................................................................................... 38
1.8.2 Cancer in Africa ............................................................................................... 39
1.8.3 Cancer prevention, treatment and care in Africa ............................................. 40
1.9 Black African and Caribbean men and cancer in the UK ................................ 41
Chapter 2: Cancer Policy and Public Health Models ..................................................... 43
2.1 Over view ......................................................................................................... 43
2.2 Public health in the UK .................................................................................... 44
2.3 Public health promotion theories and models .................................................. 48
2.3.1 Interpersonal level ............................................................................................ 49
2.3.2 Individual level................................................................................................. 53
2.3.3 Community level .............................................................................................. 56
2.4 Summary .......................................................................................................... 59
Chapter 3: Literature Review ........................................................................................... 60
3.1 Overview .......................................................................................................... 60
3.1.1 Aim of the review............................................................................................. 61
3.2 Search strategy ................................................................................................. 61
3.2.1 Inclusion and exclusion criteria for review ...................................................... 64
3.2.2 Search process and results ................................................................................ 65
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3.3 Data extraction and quality assessment ........................................................... 70
3.4 Syntheses of included papers ........................................................................... 74
3.4.1 Knowledge about cancer .................................................................................. 77
3.4.2 Attitudes towards cancer screening .................................................................. 80
3.4.3 Knowledge and attitudes towards cancer and cancer screening by place of origin .. 81
3.4.4 Mistrust ............................................................................................................ 82
3.4.5 Culturally sensitive information needs............................................................. 83
3.5 Discussion of literature synthesis ..................................................................... 84
3.6 Research Purpose ............................................................................................. 87
3.7 Overall aim and specific objectives ................................................................. 87
3.8 Significance of the study .................................................................................. 88
Chapter 4: Methodology and Working Methods ............................................................ 90
4.1 Overview .......................................................................................................... 90
4.2 Ontology and epistemology ............................................................................. 90
4.2.1 Theoretical perspective .................................................................................... 93
4.3 Choosing a paradigm ....................................................................................... 94
4.4 Symbolic interactionism .................................................................................. 96
4.5 Choosing qualitative methodology .................................................................. 98
4.5.1 Why grounded theory was appropriate methodology ...................................... 98
4.6 Grounded theory ............................................................................................ 100
4.6.1 History of grounded theory ............................................................................ 101
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4.6.2 What is grounded theory? .............................................................................. 101
4.6.3 The three versions of grounded theory........................................................... 102
4.6.3.1 Glaserian grounded theory ............................................................................. 103
4.6.3.2 Strauss and Corbin grounded theory .............................................................. 104
4.6.3.3 Charmaz’s constructivist grounded theory .................................................... 105
4.6.4 Choosing a specific version of grounded theory ............................................ 108
4.7 Working Methods .......................................................................................... 110
4.7.1 Sample technique ........................................................................................... 110
4.7.1.1 Inclusion criteria ............................................................................................ 110
4.7.1.2 Exclusion criteria ........................................................................................... 111
4.7.2 Sample size..................................................................................................... 111
4.7.2.1 Study location ................................................................................................ 113
4.7.3 Gaining access and participant recruitment ................................................... 113
4.7.4 Methods of data collection ............................................................................. 115
4.7.5 Interviews ....................................................................................................... 116
4.7.6 Interview questions ........................................................................................ 119
4.7.7 Service user group involvement ..................................................................... 121
4.8 Data collection ............................................................................................... 122
4.8.1 Ethical issues and approval ............................................................................ 126
4.9 Data analysis .................................................................................................. 130
4.9.1 Initial coding .................................................................................................. 131
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4.9.2 Focused Coding .............................................................................................. 133
4.9.3 Theoretical coding .......................................................................................... 136
4.9.4 Developing theory .......................................................................................... 136
4.9.5 NVivo-10 CAQDAS ...................................................................................... 138
4.9.6 Research rigour .............................................................................................. 140
Chapter 5: Findings ......................................................................................................... 147
5.1 Introduction .................................................................................................... 147
5.1.1 Research participants ..................................................................................... 147
5.1.2 Overview ........................................................................................................ 150
5.2 Cancer through black eyes ............................................................................. 154
5.2.1 Cancer is not our disease ................................................................................ 154
5.2.2 Cancer is caused by processed food ............................................................... 157
5.2.3 Cancer is a deliberate plan to reduce the population...................................... 159
5.2.4 Late diagnosis................................................................................................. 160
5.2.5 Lack of awareness in the community ............................................................. 162
5.3 Cultural views ................................................................................................ 163
5.3.1 Digital rectal examination (DRE) is culturally disgraceful............................ 164
5.3.2 Smoking herbs as a healthy and happy lifestyle ............................................ 166
5.3.3 Big is beautiful ............................................................................................... 168
5.3.4 Strong physical superiority ............................................................................ 170
5.3.5 Hierarchy’s power to command ..................................................................... 170
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5.3.6 We do not go to hospital ................................................................................ 172
5.4 Religious beliefs ............................................................................................. 174
5.4.1 Eternal life ...................................................................................................... 175
5.4.2 Life will be more meaningful ......................................................................... 176
5.4.3 The Power of God .......................................................................................... 177
5.5 Avoiding ‘Babylon’ ....................................................................................... 179
5.5.1 Me not going to Babylon (modern medicine as ‘Babylon’) .......................... 179
5.5.2 A person like me - black doctors.................................................................... 180
5.5.3 Traditional (natural) herbs versus Western medicine .................................... 181
5.6 Alienation ....................................................................................................... 184
5.6.1 Controlled by the system ................................................................................ 184
5.6.2 Doesn’t want to be black ................................................................................ 185
5.6.3 Money and class ............................................................................................. 186
5.6.4 Identity clash - where to belong ..................................................................... 187
5.7 Suspicious mind ............................................................................................. 188
5.7.1 Mistrust of the healthcare system (NHS) ....................................................... 188
5.7.2 Conspiracy ..................................................................................................... 190
5.7.3 Suspicion ........................................................................................................ 191
5.8 Advertisement and information influence very little ..................................... 193
5.8.1 Linked to money-making ............................................................................... 193
5.8.2 Not specific or appealing enough to blacks ................................................... 194
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5.8.3 Preferences and modes of presentation .......................................................... 196
5.9 Gap in service provision (bridging the gap) ................................................... 199
5.9.1 Negotiating the needs ..................................................................................... 200
5.9.2 Black-led clinic .............................................................................................. 201
5.9.3 Grass-roots level community involvement .................................................... 203
5.10 Summary ........................................................................................................ 205
Chapter 6: Discussion ...................................................................................................... 207
6.1 Introduction .................................................................................................... 207
6.1.1 Overview ........................................................................................................ 208
6.2 Cancer through black eyes ............................................................................. 211
6.2.1 Misconception about risk factors ................................................................... 212
6.2.2 Lack of receptiveness to health promotion messages .................................... 217
6.2.3 Mistrust and Conspiracy ................................................................................ 219
6.2.4 Potential for late presentation of symptoms ................................................... 221
6.2.5 Minimal engagement with healthcare system and delayed diagnosis ............ 225
6.2.6 Diminished communication ........................................................................... 227
6.2.7 Failing to address micro-level differences ..................................................... 228
6.3 Revisiting the Public Health Models ............................................................. 229
6.3.1 Relevance of the findings to public health models ........................................ 230
6.3.2 Application of the theory to the Community Organization Model ................ 236
6.4 Evaluating the theory ..................................................................................... 242
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