Knowledge, attitudes and screening practices regarding prostatic diseases among men older than 40 years: a population-based study in Southwest Nigeria

Introduction Despite the global increase in awareness of prostatic diseases resulting from widespread availability of screening tools, there is no evidence that the knowledge, attitudes and screening practices of Nigerian men have improved regarding prostatic diseases. Methods A descriptive cross-sectional study amongst 305 community-dwelling men. Respondents were selected using multi-staged sampling techniques. Knowledge, attitudes and screening practices were determined based on responses to a semi-structured KAP questionnaire. Data were analyzed using SPSS version 18. Pearson's chi-square and Fisher's exact test (two-tail) with level of significance set at 0.05 were used to determine the level of statistical significance. Pearson's correlation coefficient was used to establish correlation between variables. Results Mean age of respondents was 63.4±11.8 years. Slightly less than half, 145(47.5%) were aware of prostate cancer (PCa) while only 99(32.5%) and 91(29.8%) were aware of BPH and prostatitis respectively. About a quarter (25.1%) had heard of PSA. The main sources of information were radio and television. Overall, 143(46.9%) respondents had good knowledge while 162(53.1%) had poor knowledge. Sexually transmitted disease was the commonest misconception as the cause of prostatic diseases. Overall, 44.3% had good attitudes. Only 31(10.2%) respondents had ever carried out screening for PCa. Only educational and occupational status had significant associations with level of knowledge and attitudes of participants. The only factor that influenced screening practices was educational status. Conclusion There is a poor level of knowledge, attitudes and screening practices regarding prostatic diseases in Nigeria. We recommend a widespread public health education to improve knowledge, attitudes and screening practices for prostatic diseases.


Introduction
With the "graying" of the "baby boomers", awareness of prostatic diseases has increased dramatically [1]. In particular, prostate cancer (PCa), which is now the most common male malignancy and other prostatic diseases such as benign prostatic hyperplasia (BPH) and prostatitis, are widely discussed in the media and are the subject of increasing interest from family physicians and the general public alike. Prostate cancer is a significant healthcare problem due to its high incidence and mortality and the cost associated with its detection and treatment [2,3]. The awareness of prostatic diseases has increased in recent times with the recognition of early detection of PCa as a key factor in reducing mortality and morbidity. It is however sad that majority of patients in our sub-region present with locally advanced and metastatic diseases [4][5][6]. Several reasons have been suggested for this trend including a low level of awareness and knowledge, erroneous beliefs about prostatic diseases and poor healthcare-seeking behaviour of patients amongst other factors related to available facilities and poverty.
Even though prostatic diseases have received much media attention, studies of the public's knowledge, perceptions or screening practices are not many in Nigeria especially in the rural communities where more than half of Nigerians live [7]. Recently, there has been growing interest in the role of knowledge, attitudes and screening practices in PCa prevention and control [8,9]. A good knowledge or understanding of diseases is generally associated with a better healthcare-seeking attitude and behaviour [10]. Therefore, efforts at improving awareness about diseases should not be directed at malignant diseases only as efforts towards benign conditions which are by far commoner than malignant ones will also reduce morbidity and mortality significantly. Despite the global increase in awareness as a result of widespread availability of screening tools for prostate diseases, there is no evidence that the knowledge, attitudes and screening practices of Nigerian men have changed regarding prostatic diseases. The aim of the study therefore, is to determine the level of awareness, knowledge and attitudes towards treatment for prostatic diseases as well as screening practices amongst community-dwelling men. The minimum sample size required for this study was 264.

Methods
Sampling techniques: Participants were recruited using a multistage sampling technique. This involved the following stages: firstly, the selection of 3 of the 11 electoral wards in the study area. This was followed by the selection of 1 community from each selected ward. Thirdly, 15 to 20 streets were chosen in each community.
These first 3 stages were carried out using a simple random sampling technique by balloting. Fourthly, about 5 to 15 houses in these streets were selected by systematic random sampling depending on the length of the street. Finally, an individual was chosen for the survey by simple random technique amongst all men above 40 years of age in each selected house. All men selected who consented to participate were recruited for the study.

Data Collection:
The date of the data collection was announced a week before data collection in the three selected communities using

Results
A total of 319 adult males older than 40 years were recruited but only 305 men completed the questionnaires and had adequate data for analysis. This translates to a response rate of 95.6%. Awareness of prostatic diseases and screening: Slightly more than half, 158 (51.8%) respondents had heard of prostatic diseases before the time of this study. Slightly less than half, 145 (47.5%) were aware of PCa while less than one-thirds, 99 (32.5%) and 91 (29.8%) were aware of BPH and prostatitis respectively. Only a quarter (25.1%) had heard of prostate specific antigen (PSA) as a screening tool for PCa. The main sources of information amongst those who were aware of prostatic diseases were radio and television in 59.5 and 49.4% respectively. Other details about awareness and sources of information are depicted in Table 1. Knowledge of participants on some key questions about prostatic diseases is shown in Figure 1. About 39.0% and 59.7% did not know that prostatic problems are curable and treatable respectively.
Also, very few participants knew that prostatic diseases can cause kidney failure (15.1%) and that prostate is part of male reproductive system (17.0%).

Misconceptions about causes of prostate problems:
Numerous misconceptions and unfounded beliefs about the aetiology of prostatic diseases amongst the participants are depicted in Table 2. Positive history of sexually transmitted diseases was the most common misconception on the aetiology of prostatic diseases in 198 (64.9%) participants. Table 3 shows the responses of respondents to attitude questions regarding prostate diseases screening and treatment.

Attitudes to screening and treatment of prostatic diseases:
Overall, 42.6% of the respondents had good attitude to screening and treatment of prostatic diseases compared with 57.4% with poor attitude. Details of respondents' responses are contained in the

Discussion
The Over the past decade, these assays have completely revolutionized the approach to PCa-from initial screening and staging through to monitoring during therapy [13]. The results of this study showed an average level of awareness of prostatic diseases but overall level of knowledge was poor as only 47% of the participants had good knowledge about prostatic diseases. Though the level of awareness was still poor, it however represents an improvement on the earlier reports from Nigeria [11,14]. About a quarter of the participants in our study had heard about PSA screening compared to 5.8% documented in an earlier study [11]. This finding is very similar to the awareness level reported in an Ugandan population-based study some years earlier [15]. In addition, about two-thirds have heard of PCa, which is also an improvement on the earlier findings in Nigeria. This is probably due to increasing use of PSA for screening and increasing public health enlightenment about PCa in recent times.
However, information about benign prostatic conditions namely BPH and prostatitis was still very poor.
A lot more has to be done to educate people about these diseases, as 48.2% of participants in this study had never heard about any of the three main prostatic diseases. Surprisingly, 67.5% had not heard about BPH, which is the most common prostatic disease.
They claimed to have heard about it for the first time during the publicity for data collection for this project. Despite the growing trend of increased uptake of screening for PCa worldwide, less than one third of the respondents in our study knew about screening for PCa while only a quarter had heard about PSA screening [16,17].
Amongst the respondents who had previous information about prostate and prostatic diseases, the most common sources of information were radio, television and newspapers. It is surprising that fewer respondents got their information from the hospitals that are supposed to be a major source of information for diseases like this. This might be due to emphasis on curative treatment rather than preventive which makes general practitioners (GPs) in Nigeria concentrate on the presenting complaints rather than holistic assessment of the patients and recommendation of other tests relevant to the patient's age and clinical demands [18]. Enlightening patients on other medical conditions they are at risk of developing during consultation for another illness will help in early detection of other diseases and improve prognosis particularly for malignancies.
The religious institutions did not contribute much to dissemination of information to patients about prostatic diseases, as religious worship centres were sources of information in less than 15% of participants. The findings of this study also suggest that the mass media have also not fared well as expected in dissemination of information about prostatic problems to the populace. The best of these mass media was radio, which was the source of information for 59.5% of those who had heard about prostatic diseases before which translates to only 30.8% of the entire participants. Therefore, a widespread public health education using the mass media, hospitals and religious centres is advocated to encourage early presentation of men suffering from prostatic diseases, which ultimately will reduce the morbidity and mortality rates of these diseases.
About three-quarter of the participants were aware of the positive role of age and family in the development of prostate pathologies.  [11,14]. Similarly, only about 34.4% of the men could remember DRE being performed on them before. This shows the underutilization of DRE as a screening tool for PCa by the GPs, which may lead to non-detection or failure to detect PCa cases at an early stage [20]. In this study, educational status was found to be associated with knowledge and attitudes towards prostatic diseases as respondents with higher level of education were more likely to have positive attitude to treatment of prostate diseases and screening. Furthermore, occupation also played a positive role as civil servants, business men and retirees were found to have better level of awareness as well as more positive attitude to prostatic diseases than people of other occupations. Notably, these occupations are also associated with higher levels of education. This is in keeping with the findings amongst African Americans where socio-economic status was found to significantly affect the level of knowledge and attitudes with people of higher socio-economic factors having a higher level of awareness and knowledge about PCa and more positive attitude and behaviour towards screening for CaP [21].
This study also found a positive correlation between the levels of knowledge and attitudes to prostatic diseases. Most of the participants with good knowledge correspondingly had positive attitude and vice versa. This also concurs with previous reports [9,21,22]. In this study, the most common reason why most of the men have never done any screening for PCa was lack of recommendation from primary care physicians. More than threequarter of respondents had never been asked to do PCa screening by their primary care physicians and more than half gave this as a

Competing interests
The authors declare no competing interest.

Acknowledgments
We are grateful to the resident doctors in the Department of Surgery, Federal Teaching Hospital, Ido-Ekiti that assisted with data collection. Figure   Table 1: Awareness and sources of information about prostatic diseases Table 2: Common misconceptions about the aetiology of prostatic diseases Table 3: Attitudes of the participants to prostatic diseases