A PHENOMENOLOGICAL INQUIRY
DISSERTATION PROPOSAL
Presented in Partial Fulfillment of the
Requirements for the Degree of
Doctor of Philosophy in Nursing
THE LIVED EXPERIENCE OF JAMAICAN MEN IN THE US WHO HAVE UNDERGONE PROSTATE CANCER SCREENING: A PHENOMENOLOGICAL INQUIRY
All Rights Reserved
Background: The US ranks among top five nations with Prostate Cancer (PCa) fatalities, with the highest number of fatalities occurring in African and Caribbean immigrant populations. Jamaican men constitute a high-risk population for PCa incidences and they are least likely to undergo prostate cancer screening or follow up with subsequent screening.
Purpose: The proposed phenomenological study seeks to understand how Jamaican men ascribe meaning based on their experiences after undergoing PCa screening sessions. Method: The researcher will use hermeneutic phenomenology guided by van Manen’s (1990) framework to collect and analyze the primary data. The target population for the study will be Jamaican men living in South Florida who have already undergone PCa screening. A purposive sampling sample of the Jamaican men will be recruited using a referral sampling procedure within the Jamaican community in South Florida. Qualitative data will then be collected using face-to-face interviews, and the participant interviews will continue until emergent themes and contextual categories are saturated.
Results and Conclusions
Pending
CHAPTER ONE: INTRODUCTION TO THE STUDY 1
PROBLEM AND DOMAIN OF THE INQUIRY 1
Prostate Cancer: Global Incidence and Prevalence 1
Prostate Cancer in the Caribbean and Jamaica 4
Prostate Cancer in the United States 7
PCa Screening: A Tale of Two Decisions 9
Experiences Prior, During and After Prostate Cancer Screening 11
Philosophical Underpinnings 14
Interpretivism Paradigm: Constructivist Approach 14
Qualitative Research Methodology 17
Philosophical Assumptions of Qualitative Research 19
Phenomenology for this Study ………………….……….…………31
Significance of the Study to Nursing Error! Bookmark not defined.
Implications of the Study to Nursing Education 35
Implications of the Study to Nursing Practice 35
Implications of the Study to Nursing Research 37
Implications of the Study to Health/Public Policy 38
Scope and Limitations of the Study 39
CHAPTER TWO: REVIEW OF LITERATURE 44
Historical Context of PCa Screening Error! Bookmark not defined.
Jamaican Men in United States and Prostate Cancer Risks 48
Prostate Cancer Screening as an Intervention Measure 49
Research Content Error! Bookmark not defined.
Geographical and Social Profile of Population under Study: Jamaica Men Error! Bookmark not defined.
Previous Research on PCa Screening among Jamaican Men 51
Research on Experience, Adherence, and Impact of PCa Screening 54
Use of Reflexivity and Bracketing 60
Appropriateness of Research Design 67
CHAPTER THREE: RESEARCH METHODS AND METHODOLOGY 63
Qualitative Research Methodology Error! Bookmark not defined.
Research Design: van Manen’s (1990) Model of Hermeneutic Phenomenology 64
Diagrammatic Presentation of the Research Design 67
Research Sample and Setting 70
Access and Recruitment of the Sample 71
Final Sample Size and Justifications 72
Ethics and Ethical Considerations 72
Protection of Human Subjects Error! Bookmark not defined.
Participants’ Informed Consent Error! Bookmark not defined.
Privacy and Confidentiality Error! Bookmark not defined.
Data Collection Process and Procedures 74
Data Collection Process Error! Bookmark not defined.
Data Collection Procedure Error! Bookmark not defined.
Credibility of Research Findings 79
Dependability of Research Findings 80
Confirmability of Research Findings 81
Transferability of Research Findings 82
Appendix A: Sample of Face-to-Face Interview Questions 96
Figure 1. The paradigmatic schema (Foster, S. 2016, adapted from Crotty, 1998 with modifications). 17
Figure 2. The hermeneutic research design (Foster, S. 2016, adapted from van Manen, 1990 with modifications) 66
Prostate cancer (PCa) incidence rates are the highest globally among Jamaican men, yet these men are the most likely to attend such a preventative and control measure as PCa screening (Consedine, Adjei, Horton, Joe, Borrell, Ramirez & Neugut (2009). There is an overwhelming body of evidence linking Jamaican men and non-adherence to PCa screening (Ajzen, 1991; Consedine et al., 2009; Edelstein & Gillath, 2008; Evans, Butler, Etowa, Crawley, Rayson & Bell, 2005). Much is known about Jamaican men’s none adherence to PCA screening, but very little is known about their experience of undergoing the screening process when they do attend. To gain an understanding of the essence of this phenomenon, a qualitative phenomenological inquiry will be conducted. An understanding of how Jamaican men, who are proactive about their prostate health, make meaning of the experience of undergoing prostate cancer screening, may facilitate the development of more effective interventions targeting the group’s overall rates of prostate cancer screening.
The prostate gland is only found in males and, according to the American Cancer Society (2015), it functions to produce a protective and nourishing liquid for sperm cells in the semen. Prostate Cancer (PCa) is the development of cancerous cells alongside natural body cells in the prostate gland through a process referred to as adenocarcinoma (American Cancer Society, 2015). As such, the male gender is the exclusive population at risk of developing the PCa condition, and the risk often starts at the middle age of 40 and worsens as a man progresses towards the age of 80 years. Today, PCa is “the second most common cancer in men” in the world (Globocan, 2015, p. 1).
The study will focus on PCa screening which, according to Dowdle (1999), is a clinical procedure aimed at diagnosing the presence of any cancerous cells in the prostate gland. Today, numerous researchers, practitioners and scholars including Gibson, Hanchard, and Waugh (2010), Aiken, Tulloch, Freeman, Bennett, Coard, Panton and Flanigan (2003), and Haas, Delongchamps, Brawley, Wang and De la Roza (2009) have published research findings that qualified PCa screening as an effective diagnostic tool when controlling PCa. Further, according to Dowdle (1999), controlling, eradicating and preventing Prostate Cancer (PCa) relies on several factors including: (a) how informed health care programs are about PCa, (b) what is known about PCa, (c) appraisal of available interventions against PCa, and (d) an accurate characterization of how specific populations respond to PCa.
The PCa screening procedure helps to detect any cancerous cells in the testicles. Screening enables health care providers to “discover clinically significant disease early in the disease process to prevent mortality and morbidity through treatment” (Aiken & Eldemire-Shearer, 2012, p. 90). The International Agency for Research on Cancer commends screening as the most effective and reliable PCa control strategy mainly because screening enables early diagnosis and successful treatment (Globocan, 2015). PCa screening is justified as both requisite and appropriate. According to Catalona, Loeb and Han (2006), PCa screening helps to determine the presence of cancerous cells when the condition is in its early stages.
The World Health Organization (WHO) reported that over 15,296,000 men died of cancer between 2007 and 2012 (Globocan, 2015).The International Agency for Research on Cancer (IARC) reported on behalf of the WHO and affirmed that in 2012, the world registered over 14,068,000 new cases of cancer (incidences), formally diagnosed and triggering the deaths of 4,653,000 men (Globocan, 2015). In a journal article published for clinicians on global cancer statistics, Jemal, Bray, Center, Ferlay, Ward and Forman (2011) noted that the global incidence risk for all types of cancer was 30% in developed nations and 17% in less developed nations (at Age-Standardized Rate per 100,000 of 300.1). Further, the global mortality risk for all types of cancer was 15% in developed nations and 17% in less developed nations (at Age-Standardized Rate per 100,000 of 160.3). Importantly, for the present study, Jemal et al. (2011) established that among all cancers, PCa incidence risk was the highest, at 7.8% in developed nations and only 2.5% in less developed nations (at Age-Standardized Rate Per 100,000 of 62.0). Finally, among all cancers, PCa mortality was the highest, at 1.2% in developed nations (at Age-Standardized Rate per 100,000 of 12.0) (Jemal et al. 2011, p. 73)
PCa is regarded as the most sensitive type of cancer among men globally based on the annul number of incidences and mortalities recorded. Nearly a decade ago, Garcia, Jemal, Ward, Center, Hao Siegel and Thun (2007) reported that over 782,600 new cases of PCa were recorded, triggering over 254,000 deaths, globally. According to Garcia et al. (2007), PCa had become the sixth leading cause of cancer death among men across the globe by 2007. What Garcia et al. (2007) did not anticipate at the time was that though the trend had worsened by 2007, the rise was only a start point, and PCa risk would become more catastrophic by 2010 (Jemal, Center, DeSantis & Ward, 2010, p. 1899).
Important for the present study is the consequent impact of PCa among men, globally. As affirmed by Sinfield, Baker, Agarwal, and Tarrant (2008), based on statistics, PCa patients recorded the worst experiences compared to the experiences recorded with other type of cancers including breast and stomach cancers. The foregoing reality, alone, prompts urgent review of the resultant experiences from PCa and – in this study, specifically – PCa screening. Prior to further discussion of that, however, it is important to highlight PCa risks and mortality trends by race and ethnicity as well as by nationality, above the foregoing global trends.
Between 1999 and 2012, the Centers for Disease Control and Prevention (2015) reported that “the rate of men dying from prostate cancer has varied, depending on their race and ethnicity” where Caribbean and Black/African men record the highest PCa mortality rate. According to CDC, the PCa incidence/mortality rate was significantly influenced by both race and ethnicity since “black men had the highest rate of getting prostate cancer, followed by white, Hispanic, American Indian/Alaska Native men, and Asian/Pacific Islander” (¶p. 1). The PCa incidence and mortality rate categorized Caribbean men under the same profile as men with African descent. Based on PCa incidence, prevalence, and mortality rates recorded in the Caribbean nations by 2008, it soon emerged that Caribbean men, alongside African men, had the highest recorded risk of developing PCa cancer. Consequently, compared to any other region in the world, the Caribbean region alone triggers the highest number of PCa incidences every year (Prostate Cancer Caribbean, 2008).
Aiken and Eldemire-Shearer (2012) conducted a study on the role of PCa screening to intervene against the rising mortality trends in Jamaica and the wider Caribbean. In the study, the researchers reported that of greater concern in the rising PCa incidence statistics globally is the indication “that the Caribbean region has the highest age-standardized PCa-specific mortality rate in the world at 26.3/100 000/year” (p. 90). The racial profile of black and Caribbean men triggers a genetic weakness that is at a higher risk of developing PCa compared to all other racial profiles (Glover, Coffey, Douglas, Cadogan, Russell, Tulloch, & Walsh, 1998). Aiken and Eldemire-Shearer (2012) highlighted the increasing concern of Jamaica’s rising PCa incidences and mortalities, which are already extremely high given “that the Caribbean region has the highest age-standardized PCa-specific mortality rate in the world” (p. 90).
In agreement, Gibson, Hanchard, and Waugh (2010) reported that Black and Caribbean populations have the highest risk of developing PCa in the world. A similar trend is notable in the Jamaican nation as part of the Caribbean. Prostate Cancer Caribbean (2008) reported that, in the Caribbean region, cancer incidences registered nationally in Jamaica, the Bahamas, Cuba, Trinidad and Tobago, Grenada, and Martinique have qualified the Caribbean as one of the most high-risk locales of PCa. Knowing that Jamaican men, alongside the Caribbean and Black men have the highest PCa incidence and mortality rates would perhaps not be as worrisome to clinicians if something effective was being done about it. After reviewing what this high-risk population is doing to intervene against preventable deaths, clinicians, nurses, and medical scholars/researchers are worried about what is being done. As argued by Aiken and Eldemire-Shearer (2012), “if PCa is identified early in its natural history, it is eminently treatable with great potential for cure” (p. 90). As such, since “the Caribbean has the highest age standardized PCa-specific mortality rates in the world” then “why is this so and what can be done to reduce the morbidity and mortality associated with PCa in the Caribbean?” (p. 90).
Many previous studies have conclusively established the high risk of developing PCa among Jamaican men, most notably Aiken and Eldemire-Shearer (2012), and Gibson, Hanchard and Waugh (2010). Traditionally, “the highest reported incidence of prostate cancer in the world was thought to be among American Black men” and no study focused on the Caribbean immigrants (Glover et al., 1998). However, statistics eventually showed that the incidence rate in the Jamaican capital, Kingston, alone, reached 304/100,000 men, 80% of whom were pathologically confirmed. A higher risk value was identified among Jamaicans in Jamaica, than in African men, with 30% of the patients having “acute urinary retention, 16% presented with bone metastases, 15% with gross hematuria at the time of diagnosis and 42% with an abnormal rectal examination suspicious for cancer” (Glover et al., 1998, p. 1984). Importantly, Prostate Specific Antigen (PSA) measures among Jamaican men diagnosed 7% of the PCa cases in 1989 and reached “48% of cases by 1994” (p. 1984).
Gibson, Hanchard, and Waugh (2010) reported that black and Caribbean populations have the highest risk of developing PCa in the world. Gibson, Hanchard and Waugh (2010) argued that, based on incidences reported between 2003 and 2007, PCa is “the leading cancer affecting men in Jamaica” (p. 456). In agreement, the American Cancer Society (2008) reported that Jamaican men have a high risk of developing PCa among comparable racial profiles. Many other research studies established the high risk of developing PCa among Jamaican men. According to Aiken and Eldemire-Shearer (2012), Jamaica represents the region of the Caribbean territories with the highest rates of PCa.
Morrison, Aiken, and Mayhew (2014) reviewed the “current state of prostate cancer treatment in Jamaica” (p. 456). The researchers reported that in Jamaica, today, PCa “accounts for almost a third of all cancers diagnosed”, with Jamaica having “the highest incidence of PCa in the world, based on a reported rate of 304/100,000 per year” (p. 456). Further, according to records by the Jamaica Cancer Registry, PCa “is the most common cancer overall as well as the most common cancer in men”, with an “age-standardized incidence rate of 78.1/100,000 per year” (Morrison, Aiken, & Mayhew, 2014, p. 456). It is of greater concern that by 2014, PCa was “the most common cause of male cancer-related deaths, with an age-standardized mortality rate of 53.9/100,000 per year” (Morrison, Aiken, & Mayhew, p. 456).
The fact that the PCa incidence and mortality rates are the highest among African and Caribbean Black men — an ethnic profile in which Brazilian men belong as well — can easily but wrongly signify Jamaica as ground zero of PCa research and PCa screening. The proposed study will employ the “racial and ethnic profile” of men when defining their PCa incidence and mortality rates, and when linking such trends with screening experiences. Besides being in African and Caribbean regions, the racial profile amplifies the PCa incidence and mortality rate. This means that the high risk of developing PCa affects not only Jamaicans within Jamaica, but also those who have immigrated to the U.S.
According to Kendrick (2010), “research has shown that prostate cancer is the second leading cause of cancer death among men in the United States and Caribbean, and African American men are more likely to develop the disease than White American males” (p. 6). Jamaican men residing in the U.S. thus depict a similar high PCa risk as those in Jamaica. The American Cancer Society (2008) and Gibson, Hanchard, and Waugh (2010) established that Jamaican men have the highest rates of PCa even within the U.S., when profiled by race and ethnicity as being Caribbean.
The National Cancer Institute (NCI, 2015) initiated the Surveillance, Epidemiology, and End Results Program (SEER) under the partnership of the National Institutes of Health, the National Cancer Institute, and the U.S. Department of Health and Human Services. The SEER program focused on the PCa incidence and mortality rates within the U.S. and, by 2015, established the following: between 199 and 2012, 137.9 per 100,000 cases of PCa were reported annually (incidences), which triggered 21.4 per 100,000 mortalities in men per year.
On PCa prevalence by 2012, an estimated 2,795,592 men were already clinically diagnosed as living with PCa in the United States. Further, the lifetime risk for developing cancer ranges at 14% for PCa among men in their lifetime, and PCa represents over 13.3% of all new cancer cases diagnosed in the U.S. Finally, according National Cancer Institute, PCa is the third most common type of cancer diagnosed in the U.S. (NCI, 2015, p. 1-2).
The U.S. is third among all countries based on the PCa incidence and mortality rates, records these significant numbers among the Black and Caribbean males. The tragedy occurs mostly among Jamaican men, than in Black and Caribbean men. According to Glover et al. (1998), Jamaican men in the U.S. “have a high incidence of prostate cancer, much higher than even Black Americans during a similar period” (p. 1984). Notably, PCa impacts are “more significant clinically with greater morbidity” among Jamaican men that any other racial and ethnic profile (p. 1984).
The American Cancer Society (2008) established that, based on global cancer fact and figures, PCa incidences and mortalities are higher in the U.S. than in the Africa and the Caribbean; yet within the U.S., the highest rates are among the Caribbean (notably Jamaican) and African men. Kendrick (2010) established that male Caribbean immigrants to the U.S. have the highest PCa risk based on incidence rates. Further, according to the American Cancer Society (2015), the Caribbean and African-American men are twice more likely to develop PCa than men from other races, such as Asian-American, Hispanic-Latino, and non-Hispanic White men. Research has attributed the high risk to genetic factors dominant in their ethnic profiles (American Cancer Society, 2008b).The proposed study will therefore focus on the immigrant population of Jamaican men in the U.S.
PCa screening has largely been advanced as the most effective and standardized diagnostic tool and intervention strategy for PCa (Concato, Wells, Horwitz, Penson, Fincke, Berlowitz & Peduzzi, 2006; Aiken & Eldemire-Shearer, 2012). PCa screening has been characterized as having no viable competition from alternative options, being the only standardized, affordable, reliable, and effective intervention measure against the rising incidence and mortality rates of PCa. PCa is the second most common cancer in men, with Jamaican men suffering the highest rate of occurrence and mortality from this prostate malignancy (Eldemire-Shearer, James, Morris, Holder-Nevins, Lawes & Harris, 2011; Globocan, 2015). Notably, however, if not diagnosed early, PCa can quickly develop to mature and metastatic stages that are less responsive to treatment (Aiken & Eldemire-Shearer, 2012). PCa screening is commonly done using a Digital Rectal Exam (DRE) and/or a serum analysis of Prostate Specific Antigen (PSA). PCa screening has been associated with favorable prognoses and decreased mortality; and, according to Clarke et al. (2012), high-risk PCa populations should ideally record the highest adherence score.
Nonetheless, PCa screening is not without opposition and, in most parts, controversy. Several studies have disqualified PCa as an effective, even appropriate, preventative and control measure against PCa. Kilpelainen, Tammela, Maattanen, Kujala, Stenman, Ala-Opas and Auvinen (2010), Howrey, Kuo, Lin and Goodwin (2013), and Maattanen, Hakama, Tammela, Ruutu, Ala-Opas, Juusela & Auvinen (2007) faulted PCa screening for generating false PSA positives results and false negative results.
The inaccuracy of PCa screening has thus been faulted and even linked to negative impacts on people falsely diagnosed of PCa, as further noted by others including Berner (2009), Howrey, Kuo, Lin and Goodwin (2013), and Onyiaorah, Onyiaorah, Ukah, Anyiam, Onwukamuche and Efobi (2015). The criticism of PCa screening has valid arguments. To exemplify, it is noteworthy that neither PCa screening procedure, the PSA and Digital Rectal Examination (DRE) procedures, are 100% accurate and only the clinical biopsy of the prostate is the definitive clinical test available (Kilpelainen et al., 2010). Yet PSA and DRE, rather than clinical biopsy, are the most common, most recommended, and only feasible screening options available in many regions. This explains why there has not been any official recommendation for PCa screening agreed upon by major medical and cancer organizations (Basch, Oliver, Vickers, Thompson, Kantoff, Parnes & Nam, 2012).
Regardless of the accuracy attained by the PCa screening procedures, perhaps the most important question is what PCa screening attains or enables. The early PCa diagnosis enabled by PCa screening is not always essential in reducing morbidity and mortality. PCa is a slow-growing type of cancer, and most men die old from other causes regardless of their prostate status. This argument questions the necessity of PCa screening (Howrey et al., 2013; Onyiaorah et al., 2015). Finally, for the present discussion, PCa screening is not mandatory. As such, any such population as Jamaican men who are at a higher risk of developing PCa are not compelled or obligated to participate in screening. No policy can obligatorily require asymptomatic, healthy men to undergo early PCa screening. In question, therefore, is how effective PCa screening can be as a preventative and control measure against PCa.
Jamaican men constitute a high-risk population for PCa incidences, and most research studies identify Jamaican men as a high-risk population for PCa (Aiken and Eldemire-Shearer, 2012). It is also apparent that PCa screening presents the only formidable, reliable, and effective intervention measure that the high-risk population of Jamaican men can employ to reduce their mortality rates. It is logical to expect Jamaican men to be the most loyal supporters and most adherent to PCa screening, yet the real-life data suggests the opposite, justifying the proposed study.
Evidence suggests that Jamaican men avoid PCa screening, either because they do not care or because they do not know of their high PCa risk status or the role of PCa screening. Further, most Jamaican men currently residing in the U.S. do not avoid PCa screening because the requisite screening facilities are inaccessible nor because the services are unaffordable. Rather, Jamaican men avoid PCa screening regardless of whether the results may be positive or negative, deliberately and consciously. The question that emerges, then, is: why do Jamaican men do still avoid PCa screening?
Taitt (2015) generated adequate evidence contending that Jamaican men have a unique set of “lived experiences, perceptions, and beliefs” that influence their decisions regarding PCa screening (p. 4). Modern understanding of PCa screening in the U.S. needs to acknowledge “the perspectives, experiences, and beliefs of Afro-Caribbean men relative to prostate cancer” (Taitt, 2015, p. 199). Outside the U.S., the lived experiences of Afro-Caribbean men residing in the UK have taught them that “it doesn’t make sense to worry too much” as to attend screenings (Nanton& Dale, 2011, p. 62). As such, whether already adequately informed or otherwise, whether PCa screening facilities are accessible, and whether the procedure affordable, Jamaican men perceive PCa screening based on their lived experiences. Of great concern, therefore, are Jamaican men subscribing to “misconceptions on cancer risk,” where PCa is regarded as “a taboo topic,” excluded from consideration by virtue of cultural beliefs and social norms (Friedman, Corwin, Rose, & Dominick, 2009, p. 209).
Even among Jamaican men in the U.S., PCa screening is regarded emotively, such that the decision to screen or otherwise is the outcome of emotional patterns of thought (Consedine et al., 2008). Fear of PCa, fear of undergoing the screening procedure, overwhelming anxiety, and emasculation concerns among immigrant Caribbean men in New York, influencing their perception of and adherence to PCa screening (Consedine, Adjei, Horton, Joe, Borrell, Ramirez & Neugut, 2008). Therefore, the decision to undergo PCa screening among Jamaican men is the product of lived experiences as reflected by cultural, social, and economic realities (Friedman et al., 2009); fear, anxiety, concerns, and negative beliefs (Consedine et al. 2008); level of awareness (McCree-Hale, Hale, Rutley, Aung & Jolly, 2012); as well as accessibility and affordability (Aiken & Eldemire-Shearer, 2012).
PCa incidence and mortality rates of Black and Caribbean men, particularly of Jamaican men, are the highest of all other racial profiles in the world. The U.S. has the third highest national PCa incidence and mortality rates in the world, and the highest rates recorded among the Jamaican immigrant, than in any other racial profiles of U.S. immigrants. PCa screening is the only feasible, standardized, affordable, and reliable intervention and control intervention against PCa available today. Yet despite having the highest PCa incidence and mortality rates, regardless of availability or community health efforts, Jamaican men willingly and persistently refuse to adhere to PCa screening due to their cultural beliefs and knowledge. Evidently, the high non-adherence level among Jamaican men has already been the point of interest for numerous studies over the last three decades, as exemplified by Ajzen (1991), Consedine et al. (2009), Edelstein and Gillath (2008), and Evans et al. (2005) and many other similar studies.
The narrow focus of previous research on non-adherence to PCa screening has neglected the experience of Jamaican men who are proactive about their prostate health. While many avoid PCa screening, some are adherent to, and actively conscious of, the need for screening. We now only know what influences Jamaican men to avoid PCa screening but not what motivates some to adhere to screening, or what happens after some Jamaican men attend the screening sessions. Such scholars as Taitt (2015), Aiken and Eldemire-Shearer (2012), and Aiken, Tulloch, Freeman, Bennett, Coard, Panton & Flanigan (2003) have identified why Jamaican men avoid PCa screening, yet all remain silent about those who undergo screening. The gap of knowledge needs to be remedied by establishing why some Jamaican men willingly chose to attend PCa screening, what happens after undergoing screening, how they feel after the screening, and the likelihood of undergoing future screening. Given the critical essence and role of PCa screening as discussed above, the present study seeks to investigate a significant phenomenon among a PCa high-risk population that willingly and deliberately opts to ignore the screening intervention.
The proposed study seeks to understand the decision that some healthy Jamaican men make to undergo early PCa screening and to be proactive about their prostate health, as well as how their perceived PCa risk influences this choice. The study’s primary purpose is to gain an understanding of the meaning of the lived experience of Jamaican men who have undergone prostate cancer screening.
The research question for the proposed study will be, ‘What is the lived experience of Jamaican men who have undergone prostate cancer screening in the US?’
To attain an understanding of the lived experiences of Jamaican men after undergoing PCa screening, the study cannot adopt standard theoretical foundations of what is already known. New understanding will need a liberal interpretive approach to investigate new realities presently unknown. In social research, a researcher can only assume one of two possible worldviews, when investigating a social reality like PCa screening experiences, namely the objectivistic worldview – otherwise known as positivism – and the constructivist worldview (Crotty, 1998). Positivistic research assumes the objectivism worldview, where reality is investigated in concrete formal measurements, common in quantitative research (Crotty, 1998).
Constructivist research, on the other hand, interprets the meaning of a social phenomenon from the subjective point of view of the participants in a specific context. An interpretivist is a social constructivist and, thus, stands as the opposite of an objective positivist (Munhall, 2007). Interpretivist researchers construct meaning regarding the realities within a unique social context (Creswell & Miller, 2000). Consequently, “constructivists believe in pluralistic, interpretive, open-ended, and contextualized (e.g. sensitive to place and situation) perspectives toward reality” (Creswell & Miller, 2000, p. 125). Interpretivism is, thus, often referred to as an anti-positivist paradigm (reaction to positivism), or constructivism, where such lived experiences of Jamaican men after PCa screening emerge as alterable realities and not absolutely true to conventional/standardized expectations. Indeed, “constructivism’s relativism assumes multiple, apprehend-able, and sometimes conflicting social realities that are the products of human intellects but that may change as their constructors become more informed and sophisticated” (Guba & Lincoln, 1994, p. 110).
Leitch, Hill, and Harrison (2010) suggest that interpretivism research is largely not based on a theory and that it, rather, enables a researcher to internalize its procedure and process “within the underlying research philosophy rather than something to be tested upon completion” (p. 68). This reality “requires a shift from the notion of validity as an outcome to validation as a process” (p. 67). Black (2006) argued for the critical necessity of relativistic research. Interpretivism is anchored on a word-based description of contextual meaning of phenomena. Black (2006) further debated how “words can fully express the meaning inherent in our observations, personal interviews, and pictures when so much of it is subtle, hidden, and contextually bound” (p. 319). After conducting a thematic review of the literature on the interpretivism paradigm, the scholar ultimately credited the paradigm as credible, reliable, restrictively necessary, and essentially comprehensive on precise contexts (Black, 2006).
In agreement, Grix (2004) asserted that “the interpretive epistemology is one of subjectivism, which is based on real world phenomena”, a social reality investigating the subjective meanings ascribed to a phenomenon by human actors (p. 83). Subjectivity anchors a research study within social contexts of a specific population, where findings are only relevant to the perceptions and understanding of people in that phenomenon (Cohen, Manion, & Morrison, 2007). Nursing research focuses on the realistic world where participants are active humans (Upadhyay, 2012, p. 123). Nursing researchers must, therefore, understand what “they see, hear and read from the people and places and from events and activities”, and progressively “learn about some aspects of the social world and to generate new understandings that can be used by that social world” in health care programs (Upadhyay, 2012, p. 123). Derivatively, it emerges that investigating the lived experiences of Jamaican men after PCa screening in a manner that attains reliable understanding requires new meanings to be constructed or interpreted about PCa screening.
Interpretivism frames its legitimacy from the context-dependent meaning generated in phenomenology (Kelliher, 2005). Indeed, according to van Manen (1988), interpretivism establishes the presence of a phenomenon and thus prompts adequate understanding of realities in that phenomenon (phenomenology). In this regard, the lived experiences of Jamaican men after undergoing PCa screening emerge as a unique phenomenon. According to Blaikie (2004), “the study of social phenomena requires an understanding of the social world that people inhabit, which they have already interpreted by the meanings they produce and reproduce as a necessary part of their everyday activities together” (p. 509).
The chosen philosophical approach can be traced from Crotty’s (1998) presentation of the relationship among theoretical perspectives, methodology, epistemology, and research method. Understanding will only be generated after interpreting lived experiences from the unique context of Jamaican men in the U.S., and constructing meaning thereof as the research findings. The figure below illustrates the interpretative paradigm when implemented in this proposed study.
Figure 1. Foster. (2016), The paradigmatic schema, adapted from Crotty, 1998
The proposed study will implement a qualitative research methodology. To Creswell (2007), qualitative research helps to understand people, events, and situations. The proposed study will focus on understanding lived experiences of Jamaican men after undergoing PCa screening. Given that the study will primarily focus on interpreting and constructing meaning, Munhall (2007) commends the qualitative approach as the only feasible empirical process that enables a researcher to construct knowledge regarding a phenomenon. The qualitative research methodology was specifically chosen because it answers the “what,” “how,” and “why” questions rather than merely investigating the “how much” and “how many” questions often answered using quantitative research methods (Polit & Beck, 2004).
Qualitative research utilizes inductive reasoning, where meanings are neither concrete nor objective. Meanings can be constructed from the perspective of lived experiences of humans within the context under study (those experiencing the phenomena being researched). The researcher can therefore only employ open-ended, broad methods of primary data collection (mostly interviews), in order to generate narratives, pictures, and word-based descriptions (the qualitative data) (Creswell, 2007). The qualitative research approach is based on the philosophical underpinnings of post-modernism, where the research deconstructs and reconstructs meaning (Polit & Beck, 2004). Creswell (1998) described qualitative research as an ethnographic and non-experimental study grounded in the lived experiences of participants, being purposed to interpret meaning. This description of qualitative research agrees with Berg’s (2007) definition of qualitative studies as the description of “meanings, definitions, characteristics, concepts, metaphors, symbols, and the description of things” (p. 127).
Marshall and Rossman (2006) have argued that qualitative researchers operate under the assumption that a community is structured with logic and order, such that knowledge is contextually determined rather than an objective truth. Consequently, to implement a qualitative study, the researcher must describe the phenomenon under study (PCa screening) based on the lived experiences of the participants (Jamaican men). As such, qualitative researchers need to integrate the information they collect with the description of the context and observation of the participants to develop or construct meaning of lived experiences. The researcher must be immersed within the data collection setting, in an effort to understand the phenomenon under study from the viewpoint of the participant who lives within that setting (Creswell, 2007).
According to Marshall and Rossman (2006), to understand this contextual meaning, the researcher must approach such knowledge from the perspective of the participants who operate within the context under study. The active and interactive engagement of the researcher with the participants is therefore essential to construct meaning from qualitative data (Creswell, 2007). By investigating and exploring the lived experiences of those who determine the knowledge under study inter-subjectively, a researcher can then establish a neutral meaning of the context-specific knowledge. Consequently, the qualitative research approach is most appropriate for constructing multiple realities/meanings of a phenomenon and, by doing so, enables a comprehensive understanding of variant circumstances from the perspective of such participants as Jamaican men (Creswell, 2007).
Typical of naturalistic research that constructively interprets meaning, Creswell (2007) and Munhall (1994) asserted that the qualitative research approach seek the understanding of lived experiences. In the proposed study, the qualitative research approach will help understand how Jamaican men interact with PCa screening sessions and how they make sense or develop meanings based on their lived experiences. Quantitative research seeks to test the relationship of variables with statistical measures, while qualitative research describes such relationships with rich and in-depth narratives, written words, and pictures rather than measuring the variables statistically. The proposed study needs a qualitative research approach to describe and interpret meanings as understood by the Jamaican men who undergo PCa screening, interpretively and without generalization.
Five philosophical assumptions are foundational to scientific inquiry. These assumptions serve as the scientific lens from which the investigator approaches the investigation. In this qualitative study, the five philosophical assumptions, namely (a) ontological, (b) epistemological, (c) axiological, (d) rhetorical, and (e) methodological (Creswell, 2007) will be reviewed and discussed from that perspective:
Ontology Assumption
The ontological assumption proposes that the nature of reality is subjectively constructed to reflect the world, such that qualitative research focuses on what is known of the world (Creswell, 2009). The proposed study will seek to investigate the lived experiences of Jamaican men to understand the subjectively constructed meanings evoked by PCa screening.
Epistemology Assumption
The epistemology assumption focuses on the relationship holding between the researcher (knower) and reality (what is known and is being investigated), where a qualitative researcher participates in the study based on the transactional subjectivism foundation. The researcher will participate in the data collection from the position of a Jamaican man in the US, within the high-risk age bracket, and thus sharing identity with the participants.
Axiological Assumption
The axiological assumption is concerned with the role of values when constructing meaning (van Manen, 1990). In qualitative research, meaning is constructed based on significant influences of the researcher and participants’ values to yield value-based findings. The proposed study will generate findings from the perspective of Jamaican men in the US, and is based on their own understanding and interpretation of the PCa screening procedure, without imposing any third party perspective. This meaning will be the product of their cultural, social, economic, and political environment, and thus unique from any other meaning generated outside that context.
Rhetorical Assumption
The rhetorical assumption supports the informal and literal language used when conducting qualitative research. To understand the lived experience of Jamaican men after undergoing PCa screening, it cannot be described in a formal and statistical language that is otherwise suitable for quantitative studies. The findings will be described in a manner that derives meaning with an in-depth and detail-rich language that is widely accepted in qualitative research (van Manen, 1997; Creswell, 2007).
Methodological Assumption
The methodological assumption centers on the inductive research methodology employed in qualitative study (Creswell, 2007). Qualitative research investigates “a topic within its context and continually revise[s] questions based on experience[s] gained” and, thus, cannot have a predefined and standardized research method (Creswell, 2007, p. 18). van Manen (1990, 1997) concluded that there are no fixed set of research methods for qualitative research, particularly phenomenology. This conclusion accrues from the fact that “there is no prescription about the unanimous methodological sets of doing a hermeneutic phenomenological research” and that it can only “suggest for few methodological guidelines” (Kafle, 2011, p. 194). The methodological assumption, thus, proposes a variant of qualitative research methods on “the purposive sampling with information rich cases” (Merriam, 1998, p. 62). Further, for data collection and generation, a qualitative researcher can collect data using interviews, observations, and protocols to generate “life world stories of the research participants, depending on the context and the area of research the appropriate tool can be applied” (Kafle, 2011, p. 194).
Notably, while van Manen (1997) recommended that collected data should be and processed by “uncovering the thematic aspects” (p. 59), Laverty (2003) recommended a data analysis performed by “applying the hermeneutic cycle that constitutes of reading, reflective writing and interpretation in a rigorous fashion” (p. 24). The proposed study will employ thematic analysis of face-to-face interview data and observations in order to create meaning after reading, reflecting and interpreting resultant meanings. Only such a process will help conclusively understand the lived experience of Jamaican men in the US, following PCa screening.
Largely a philosophical framework, phenomenology has gradually evolved as a central research method in health science, and while contemporary phenomenology is the child of such scholars as van Manen (1994), Edmund Husserl and Martin Heidegger originally inspired the research framework.
Husserl and Heidegger are the philosophical fathers of two distinctive meanings and brands of phenomenology, namely interpretive (employed by the present study) and descriptive (Munhall, 2012). Husserl focused on tracing central ground of lived experience when defining the world based on human understanding (Moustakas, 1994). Husserl thus inspired a descriptive brand of phenomenology, where the investigation of a phenomenon can come from an isolated and objective standpoint. Researchers must therefore investigate phenomena without feelings/bias “by seeing, clarifying, and determining meaning, and by distinguishing meanings” objectively (Munhall, 2012, p. 64). Notably, Husserl focused on epistemology, thus mandating the use of descriptive bracketing to eliminate potential bias. From an epistemological approach, Husserl conceived the use of descriptive brackets to eliminate biased subjective participation of a researcher in the research process.
Heidegger differed with Husserl’s worldview and introduced interpretive phenomenology in what became “hermeneutical transformation of phenomenology” (Munhall, 2012, p. 67). To Heidegger, a researcher is human and can thus only interpret the meanings of phenomena by subjectively experiencing and journaling the experiences shaped by the culture, history, values, and worldviews of actual participants from their perspective (Munhall, 2012). Since individuals can only interpret what they experience subjectively (not objectively), Heidegger defined phenomenology as an accurate reflection of knowledge, awareness, and beliefs shared by people who experience the phenomenon.
Ultimately, Husserl conceived humans as constitutes of states of consciousness while Heidegger countered that consciousness is peripheral to the dominance of an individual’s existence. In comparison, Husserl focused on epistemological use of descriptive bracketing whereas Heidegger focused on ontology, thus eliminating the need for descriptive bracketing when a researcher subjectively interprets phenomena as a participant in the research process.
As Creswell (2013) observed, such studies rely on “intentionality of consciousness” as a research methodology where a researcher’s consciousness becomes the very basis of giving meaning to a reality (p. 59). Heidegger thus became the father of hermeneutic phenomenology as adopted by the present study. Hermeneutic phenomenology enables a researcher to interpret the lived experiences of people, and the interpretive process is achieved through a hermeneutic circle, which moves from the parts of lived experiences. This view is different from descriptive phenomenology of Edmund Husserl, who believed in the experience of living or being, not the process of how things are known (Creswell, 2007).
Eventually, after Husserl and Heidegger inspired the philosophical foundation of phenomenology (both interpretive and descriptive), the ground was set for subsequent expansion of phenomenological research. Several researchers have advanced the field in history but for the present discussion, this inquiry will exclusively focus on Maxvan Manen (1990) who inspired the contemporary brand of phenomenology principles. Rather than adopting either an interpretive or a descriptive approach as inspired by Husserl and Heidegger, van Manen (1990) integrated and overlapped descriptions and interpretation as part of the research process, and further added language and lived experiences as part of investigating processes of world meanings. Contemporary phenomenology is a systematic approach to expose and explain the composition of the lived experience interpretively (van Manen, 1990).
van Manen’s contemporary phenomenology was inspired by Heidegger but progressively introduced a lived-experience perspective to the research process and is implemented as a research methodology with two philosophical perspectives, namely hermeneutics and phenomenology (Creswell, 2007). According to van Manen, (1990), phenomenology is enriched by understanding and meaning from the perspective of both the participants and the researcher, where experiences lived in a phenomenon reveals significant meanings for accurate interpretation and description. Modern scholars concur, notably Creswell (2009), Munhall (1994), and Crotty (1998), that the structured reflection of a people’s consciousness is what defines phenomenology today.
To construct the reality, therefore, the researcher must first interpret individuals’ reflection within the context of the phenomenon under review. From the outset, therefore, the interpretivism approach involved phenomenology, or the study of phenomena as proposed by van Manen (1988), where the focus was to understand the meaning of experiences within a social context. Phenomenology enables researchers to interpret the perceptions of actors/people within the context of a phenomenon, rather than outsiders. In agreement, Heron and Reason (1997) argue that in order “to experience a world is to participate in it, simultaneously molding and encountering it” (p. 3). Today, phenomenology asserts that the way in which individuals perceive phenomena is premised upon their experiences, and from their perspective/consciousness; and interpretivism research assumes this perspective to understand such meanings.
According to van Manen (1994), scientific research needs to interpret a phenomenon with conscious understanding of the human perspectives involved. Indeed, Creswell (2009) defined phenomenology as the study of describing “the meaning of the lived experiences for several individuals about a concept or the phenomenon” (p. 51). As such, “phenomenology is concerned with the study of experience from the perspective of the individual” before such experiences are generalized for the target population wherein the individual is a member and actor (Lester, 1999, p. 2). Phenomenology is an esteemed research method, in identifying and establishing “experiences and perceptions of individuals” drawn from their personal perspectives, regardless of the normative assumptions invoked, in a manner that accurately explains a phenomenon in its realistic context (Lester, 1999, p. 2).
Ideally, therefore, the systematic study of a people’s reflection regarding what Husserl (1970) calls “common sense” can be structured as people’s consciousness regarding a phenomenon (Creswell, 2009). Therefore, the proposed study will adopt the phenomenology research design. According to van Manen (1997), phenomenology interprets a phenomenon with conscious understanding of the human perspectives involved. To Creswell (2009), phenomenology is the study of describing “the meaning of the lived experiences for several individuals about a concept or the phenomenon” (p. 51). Edmund Husserl is credited as having inspired the descriptive phenomenology foundations (Crotty, 1998).
Phenomenology is an attempt to construct meaning of a social reality as a phenomenon. Phenomenology demands that a researcher adopt relativism (rather than positivism) when eliminating “the prevailing understandings of the phenomena” so that the scientific inquiry is significantly defined by the “immediate experience of the phenomenon” thus enabling “possibilities for new meanings as an authentication and enhancement of former meaning” (Crotty, 1998, p. 78). A central underlying meaning is defined by a person’s individual experiences within a social context (Husserl, 1970).
In philosophy, phenomenology is concerned with a person’s reality or personal meanings about their “life world” from the perspective of a specific phenomenon (Smith, 2003). Phenomenology as a research approach, thus, seeks to achieve deeper understanding of the meaning of people’s everyday experiences (van Manen, 1990). People’s awareness and consciousness is subjectively defined in concurrence to the world around them (Munhall, 2007). As such, “distinct subjective and objective worlds do not exist since objectivity is only achieved through subjective consciousness or perception” (Munhall, 2007, p. 22). Phenomenology constitutes investigating the meaning of lived experiences, where such meanings are understood in the context of the everyday, subjective world (Schwandt, 2001). The four major constructs of phenomenology are: (a) consciousness, (b) embodiment, (c) naturalistic attitude, and (d) experience and perceptions.
Consciousness
Consciousness denotes the awareness of an individual as existing in the world. An individual has a sense of being alive and living in the world, and this awareness is his or her consciousness. When reviewing the phenomenological concept of consciousness, Munhall (1994) quoted Merleau-Ponty (1962) who defined consciousness as the “sensory awareness of and response to the environment” (p. 14). Rather than being a definite measure of what a person feels or thinks (in the interior), or what he or she sees, hears, smells and touches (on the exterior), consciousness focuses on the overall existence of a being (having a body) as part of the world (Munhall, 1994). The study will investigate the consciousness of Jamaican men in the US as a lived experience of being in the world, and after having undergone PCa screening, which is an experience that an individual cannot step out of given that it is the reality.
Embodiment
Embodiment denotes consciousness or awareness of individuals’ being in the world, in addition to their sense of consciousness of the world around them (Munhall, 1994). According to Ellingson (2009), “embodied knowledge is sensory, [and] it highlights smell, touch, and taste as well as more commonly noted sights and sounds” (p. 245). Phenomenology investigates the meaning of reality from the context in which human individuals understand the world, and this meaning is often defined by what the body tastes, sees, feels, hears, thinks and smells (what the body experiences) (Munhall, 1994). Their understanding of the world around them is embodied by their sensual awareness and consciousness.
Conducting phenomenological research involves employing the qualitative research methods that establish the lived meaning as embodied by what individuals within a context experience/understand about a phenomenon. As argued by Finlay (2009), “phenomenological researchers generally agree that our central concern is to return to embodied, experiential meanings aiming for a fresh, complex, rich description of a phenomenon as it is concretely lived” (p. 6). The qualitative perspective of nursing research seeks to understand a phenomenon based on what Munhall (2007) regards as the realities of a patient’s context. According to Todres (2007), embodiment defines the “touchstones” of phenomenological research, where a researcher inquires about the embodied meaning of a phenomenon as understood/experienced by people within a specific context.
The question of embodiment is essential in nursing research as established by Munhall (2007) and in general health care research as argued by Ellingson (2006). Phenomenology constructs the unique meaning to how people in a particular social situation understand a specific phenomenon (Husserl, 1965). Given that what an individual knows (knowledge) is “grounded in bodily experience encompasses uncertainty and ambiguity” of everyday life, phenomenology, then, involves “eschewing sanitized detached measurement of discrete variables” that embody an individual’s consciousness within the specific contexts in which they live (Ellingson, 2008, p. 245). Derivatively, phenomenology is thus a study of lived experiences as embodied by their consciousness and awareness of the world around them (Munhall, 1994). Phenomenology thus focuses on the contextual-depth of lived experiences (Cohen, Manion & Morrison, 2007), or the in-depth qualitative knowledge of reality in a social context (Creswell, 2009). As argued by Crotty (1998), phenomenology seeks to understand how individuals’ “consciousness engages with objects which are already pregnant with meaning” (p. 43) for a phenomenon. In the proposed study, the researcher will seek to understand the meaning that Jamaican men in the U.S. ascribe to PCa screening experience, based on their real-life consciousness and awareness.
Naturalistic Attitude
Phenomenology constructs meaning for a reality – a socially constructed, naturally occurring reality in most cases (Myers, 1997). Phenomenology adopts a realistic approach when interpreting the awareness and consciousness of a people to construct meaning on what “already is”, on the notion of “being”, and on what is considered to be an abstract “truth” (Husserl, 1982). People understand the world as is, in its natural form, such that any phenomenon is regarded as a natural reality. This contextual meaning is socially constructed, mainly because “the world does not exist independently of our knowledge of it” (Grix, 2004, p. 83). As such, because of the natural attitude, people regard “everything worldly” with an acceptance of being, where existence in the world is a natural truth (Husserl, 1982). Phenomenology constructs meaning for “this being-beforehand”, where “the world that is always existent beforehand” and reality emerges from “constant accepted-ness of a basis” as true (Husserl, 1982, quoted in Fink, 1995, p. 166). Phenomenology is, thus, the study of natural meaning that people accord to phenomenon since “a tree is not a tree without someone to call it a tree” (Crotty, 1998, p. 43). The natural process of consciousness and or awareness is bound to change with time and with context variations, as demonstrated in nursing research (Munhall, 2007).
Phenomenology explores the reality a phenomenon, as it already is (Remenyi et al., 1998) and expands the theoretical knowledge available on a phenomenon. According to van Manen (1988), phenomenology helps to expand the theoretical knowledge regarding a phenomenon; or, to Yin (2003), phenomenology generates meanings of a naturally accruing phenomenon. People in any social context, therefore, approach life with a naturalistic attitude and give a subjective meaning to a phenomenon. Qualitatively ascribing meaning to phenomena is a firm foundation of social research, given that reality only emerges when human beings encounter consciousness and ascribe meaning to diverse phenomenon (Crotty, 1998). Given that phenomenology is defined by context, individuals, and by subjective meaning attributable to a reality based on the experiences and perceptions of such people (Creswell, 2009; Gephart, 1999; Willis, 1995), the proposed study will seek to understand PCa screening experiences from the perspective of individual Jamaican men in the U.S. context.
Experience and Perceptions
In phenomenology, meaning is derived from the experiences and perceptions that define how people in a specific context understand a phenomenon. As such, phenomenology helps construct subjective meaning of a social phenomenon, based on the experiences and perceptions of a specific population who live in a specific context. Reeves and Hedberg (2003) asserted that the phenomenology “stresses the need to put analysis in context” since the meaning derived regarding a phenomenon is subjectively unique to the experiences and the perceptions that people give to that phenomenon (p. 32). Derivatively, phenomenology seeks “to understand how members of a social group, through their participation in social processes, enact their particular realities and endow them with meaning, and to show how these meanings, beliefs, and intentions of the members help to constitute their actions” (Orlikowski & Baroudi, 1991, p. 13).
As soon as people adopt a naturalistic attitude towards a reality in their world and use their embodied experiences of awareness and consciousness to adopt meaning for that context, then reality becomes the outcome of their experiences and perceptions. Phenomenology seeks “to understand the fundamental nature of the social world at the level of subjective experience” and, by doing so, constructs an “explanation within the realm of individual consciousness and subjectivity within the frame of reference of the participant” (Burrell & Morgan, 2005, p. 28). The subjective experiences and perceptions of individual Jamaican men in the U.S. will thus define the meaning they give to the phenomenon of PCa screening after undergoing the procedure.
A researcher can choose from several approaches when implementing a phenomenological study. The proposed study will adopt a hermeneutic phenomenological approach to interpret lived experiences of individuals in a community. Hermeneutic phenomenology focuses on interpreting people’s lived experience in a natural setting by describing the meanings accruing from such experiences. To van Manen (1990), a human science needs to combine phenomenology and the hermeneutics approach. Such a study seeks to investigate how everyday human experiences gain specific meanings via human science (van Manen, 1997). Creswell (2007) concurs that phenomenology is the study of describing “the meaning of the lived experiences for several individuals about a concept or the phenomenon” (p. 51). While phenomenology focuses the lived experience from the perspective of a phenomenon, the hermeneutics approach specializes on understanding the phenomenon from the context of humans (van Manen, 1997).
While phenomenology helps “construct an animating, evocative, description of human actions, behaviors, intentions and experiences as we meet them in the life world”, hermeneutics uses human-centered descriptions and interpretation of the lived experiences (van Manen, 1997, p. 19). Conducting phenomenology from a hermeneutic approach optimizes the findings of a research study. According to van Manen (1990), research needs to interpret a phenomenon with conscious understanding of the human perspectives involved. Phenomenology principles integrate hermeneutics to mold a philosophy on experiences of living, rather than on the process of how things are known (Rodgers, 2005). The proposed study will thus investigate the phenomenon of PCa screening and the lived experiences that result from undergoing the screening from the perspective of Jamaican men. In conclusion, therefore, the proposed study will adopt a qualitative research background with a constructivism approach, employing interpretivism perspectives when implementing a phenomenological research study.
Hermeneutic Phenomenology for this Study
Several studies, including Consedine, Adjei, Horton, Joe, Borrell, Ramirez and Neugut (2009), Rivera-Ramos and Buki (2011), Nanton and Dale (2011), Morrison, Aiken and Mayhew (2014), McCree-Hale, Hale, Rutley, Aung and Jolly (2012), Jones (2008), Eldemire-Shearer, Mitchell-Fearon, Laws, Waldron, James & Holder-Nevins (2014), Edelstein and Gillath (2008), Anderson and Marshall-Lucette (2013) have established non-adherence of Jamaican men to PCa screening. These studies have established what is known about Jamaican men and PCa screening, precisely that there are social, cultural, and economic barriers to their PCa screening adherence. What is absent in the contemporary knowledge is the lived experience of Jamaican men after undergoing PCa screening. Understanding this meaning requires that lived experiences are not discovered as concrete standard truths but instead as uniquely constructed realities absent in current knowledge. Since “constructivists do not assume any single reality and believe that empirical reality and theoretical concepts are mutually constitutive” (Blatter& Blume, 2008, p. 327), the constructivist philosophical background, as the one adopted here, is most suitable for such a study.
This study is inspired by a realization that PCa incidences have reached disastrous levels among Jamaican men, both in prevalence and mortality. As the literature review establishes in Chapter 2 of the dissertation proposal, PCa is treatable if diagnosed early enough. Unfortunately, Jamaican men are dying by the thousands simply because they are not diagnosed or because they were diagnosed too late when successful treatment was no longer feasible.
The proposed study will attempt to understand what the arguably controversial procedure means to some Jamaican men who choose to undergo PCa screening when they are still asymptomatic and healthy. Most importantly, researchers have previously identified cultural influences and biases as the major deterrents for Jamaican men to undergo PCa screening. The proposed study will seek to understand how healthy Jamaican men resolve or reframe these negative forces. By understanding the meaning and interplay of the knowledge, attitudes, and beliefs that healthy Jamaican men ascribe to PCa screening, the study may identify specific resources and possible interventions for the entire group of Jamaican men currently facing the health disparity and optimize their adherence to the critical nursing intervention.
The findings generated by the proposed study may serve the best interests of all health care stakeholders in the U.S. who pursue PCa screening-aided benefits among high-risk communities. These stakeholders incorporate all Jamaican men in South Florida and beyond, health care professionals (notably nurses), hospitals and clinics, health insurance firms, and the government.
Nurses have a social contract to protect and promote individual and public health and well-being. A major responsibility of this relationship is to identify and ameliorate health disparities. Men of color and Jamaican men, in particular, face clear health disparities in prostate cancer morbidity and mortality and in PCa screening (Eldemire-Shearer et al., 2014). The ethical, professional, and social duty of nurses is to employ the best possible strategies to improve the health status of any community, particularly if facing disparate morbidity and mortality rates from a condition that can be successfully treated if diagnosed early. According to Davies (2011), modern “nurses are well placed to encourage and support patients to make healthy choices” (p. 20). It is therefore essential that nursing researchers and scholars investigate this issue as an urgent and significant health problem.
An empirical investigation of the choice to undergo PCa screening by adherent Jamaican men may reliably help to identify context-specific motivations to improve standard PCA screening practices towards optimized effectiveness. Researching the meaning and importance that healthy Jamaican men ascribe to PCa screening may help to inform nurses in understanding what motivates positive health-seeking and preventative behaviors in this at-risk population (Kelly et al., 2011). Based on this knowledge, nurses may be better positioned to identify and advocate for health policies to reallocate resources and to redesign educational materials that may not only facilitate adherence to PCa screening but may also decrease the health disparities in PCa and PCa screening that disproportionately impact Jamaican men. The results of this inquiry may not only advance nursing knowledge, it may also advance the science of nursing.
Contemporary nurses are being educated, like their pioneer trainees, and are learning how, why and when to implement PCa screening as standard nursing intervention. This, however, has failed to increase the adherence to such vital screenings, and the standard anti-PCa campaigns have been ineffective for the Jamaican group of immigrants. Without question, therefore, nursing education needs to go beyond a standard care approach and needs to cater to diverse contextual, cultural, and socio-economic patient profiles to improve the health outcomes of communities that have previously been secluded and unequally considered.
As such, future nursing education needs to incorporate “essential transcultural nursing concepts, principles, practices, and policies” that adequately prepare future nurses to offer optimal health care for a multi-cultural globe (Leininger, 2002a, p. 8). Ideally, the findings generated by the proposed study might inspire modern nursing education to accommodate a new era of fighting PCa with effective strategies for diverse contexts. The proposed study may help to identify specific resources and possible interventions for a population such as Jamaican immigrants, who often ignore and deliberately avoid an essential nursing intervention, based on the understanding of the meaning and interplay of knowledge, attitudes, and beliefs held by the healthy Jamaican men who adhere to such intervention.
The effectiveness of a practicing nurse is not premised merely upon doing what is possible, what a patient wants, or what should be done for any patient in a specific clinical procedure. Nursing, rather, further involves the active participation of the professional nurse to recruit and motivate the commitment and cooperation/support of a patient when exercising positive health behavior. Nursing practice thus needs to acknowledge the contextual differences of patients, and to refine their approach in a manner that best serves the health interest of such patients. Consequently, the study readily acknowledges the need to optimize the effectiveness of community health care programs, particularly those aimed at providing PCa screening to American immigrants.
As previous studies have affirmed, an element of cultural, social, health knowledge and event economy significantly influences and defines the adherence of Jamaican men to PCa screening. This is what the nurse must know, understand, and refine to approach the non-adherent community based on the insights generated from the healthy men who do attend PCa screening. Only then will the nurses be able to deliver optimal PCa screening programs to the Jamaican men, with positive health outcomes. The proposed study was primarily designed to inform this gap in knowledge and to generate findings that will be invaluable to community and clinical nurses within the U.S.
From the perspective of practicing nurses, therefore, the findings generated by the study is hoped to be invaluable to practicing nurses — not only those facilitating PCa screening for Jamaican men, but also every professional nurse offering community health in diverse contexts. Contemporary health and public policy often provide a collective and generalized health program for all citizens in a country. Some communities negatively receive standard health care programs due to their lived experiences. Cultural, economic, and social ideologies of immigrant communities, for instance, mold some living experiences that require more than standard community health programs. Health programs and policies need new anti-PCa programs that strategically provide for the unique experiences of Jamaican immigrants. The findings may inform nurses working in health care facilities on the best way to attend to diverse contexts and to optimize PCa screening outcomes. Practicing nurses may be informed by the findings generated by the study to understand how a community’s lived experience, following PCa screening, mandates the use of variant nursing approaches for optimal health outcomes.
According to Powers and Knapp (1995), nursing research was designed to develop knowledge about issues of importance to nurses in a way that enables practicing nurses to describe the characteristics of a particular nursing situation about what little is known. Nursing research aims at explaining a phenomenon that must be considered in planning nursing care, predicting the possible outcomes of certain nursing decisions, controlling the occurrence of undesired outcomes, and initiating activities that may promote desired health behavior as argued by Polit and Beck (2001). Indeed, as Polit and Beck (2001) concurred, advancement of nursing research enables the acquisition of knowledge necessary for the nurse to practice competently and design efficacious interventions based on scientific data to continually improve patient care.
It is therefore notable that previous research has failed to review outcomes of PCa screening for such a community as Jamaican men. Almost all research findings generated in the last two decades regarding the high-risk population of Jamaican men and their non-adherence to PCa screening has exclusively focused on those who avoid screening. The questions have ranged from why Jamaican men avoid PCa screening, to how they can be informed and encouraged to undergo the screening. Previous nursing research has only focused on one side of the phenomena and never considered those who do attend such screenings. In truth, previous research on PCa screening and Jamaican men has been inadequately informing.
Consequently, the findings generated by the proposed study may help to redefine nursing research to be more comprehensive. Communities need more than just the scientific merit of PC screening when fighting the worsening PCa mortality. There is urgent need for accurate research findings on what happens during and after PCa screening. Besides the traditional approach to nursing practice, modern nursing needs to extend into the concept of caring, where patients become more than recipients of health care services – where they are regarded as human beings who need a nurse’s personal involvement (Leininger, 1969).
The study may provide a new approach to nursing research, captivating a novel understanding of the context in which PCa screening is delivered, among unique patients. Beyond recommending the benefits of PCa screening, the proposed study may embrace the need for the diverse patient care for optimal PCa screening outcomes. Most notably, the study will be based on the lived experiences of the patients who devotedly opt to seek for such interventions despite coming from a community that prefers to avoid screening as a health care intervention.
When a government invests increased resources to improve the health status of a community – focusing on the provision of resources and man-power to enable a community preventative, management, and control strategy with respect to such a disastrous disease like – PCa, the chances of success are improved. This has been the norm of community health policy in the U.S. and particularly among the otherwise marginalized immigrant communities. Arguably, Jamaican men in South Florida have higher opportunities of fighting the PCa disaster that has previously threatened their health than any other ethnic and racial group. The number of facilities available, manpower committed to the PCa screening programs, and the reduced cost of undergoing the procedure is evidently very hospitable than it is in many other areas across the globe.
These advantages, however, are meaningless to a community that devotedly and intentionally avoids such screening for whatever reason, be it cultural, social, or economic. Regardless of how much is invested and planned, any health care policy that does not attain desired outcomes is misinformed, as are most PCa screening policies for immigrant populations in the U.S. These screening policies need to be updated and modified. An empirical investigation of the choice to undergo PCa screening by adherent Jamaican men may reliably help identify context-specific motivations to improve standard PCa screening practices towards optimized effectiveness. Researching the meaning and importance that healthy Jamaican men ascribe to PCa screening may help to inform nurses in understanding what motivates positive health seeking and preventative behaviors in this at-risk population and revise contemporary health policy appropriately (Kelly, Melnyk, Jacobson & O’Haver, 2011). Based on this knowledge, advocacy for health policies can seek out the reallocation of resources and the redesign of educational materials to not only facilitate adherence to PCa screening, but also to decrease the health disparities in PCa and PCa screening that disproportionately affect Jamaican men.
The proposed research study will consist of a purposeful sampling of men presently residing in South Florida, who have Jamaican origin but are now immigrants to the U.S., and who have already undergone PCa screening. The proposed research participants will incorporate English speakers aged above 40 years, who have already participated in a single PCa screening procedure in a standard health care setting. The study will be conducted within the jurisdiction of South Florida, where the population of Jamaican men is highest within the U.S., and based on strategic convenience of the researcher.
The foregoing scope of the study will predefine the potential limitations of the study. The sample will be recruited using purposive sampling, anchored in convenience and reference. Not only will the age bracket of respondents make the PCa screening overly sensitive, but also the timing for interview sessions will have to be sensitive to the age bracket. Many of the respondents will predictably speak the Jamaican dialect of English, rather than Standard English, which will limit communication when recorded and quoted for the dissertation. Further, upon recruitment, the researcher will collect data using broad and open interviews, where the open-ended questions posed to the participants will be highly reliant on their understanding and interpretation. In agreement with van Manen (1997), the researcher will actively participate in the interviews so that during the interaction, the lived participants may be understood based on their meanings within an accurate context (Polit & Beck, 2004). Nonetheless, the potential limitations have been accepted as central to phenomenological nursing research, and the findings will be qualitatively comprehensive and reliably accurate (van Manen, 1997).
Demographic Considerations and Representation
The proposed study will exclusively focus on a specific population of Jamaican men currently residing in the US., Jamaican men originating from the Commonwealth nation of Jamaica, still a monarch of England under the rule with of Queen Elizabeth II as well as an administrating head of state. Among all Caribbean islands, Jamaica is the third largest with an assortment of mountainous typography bordering a lengthy but narrow coastal plain (Sherlock & Bennett, 1998). The capital city of Jamaica is Kingston, which is the largest of urban areas in the country alongside such cities Ocho Rios, Mandeville, Port Antonio, and Montego Bay (BBC, 2015).
With a censured total population of 2.7 million based on United Nations profile (UN, 2011), Jamaica is dominantly occupied by Black population with an African ancestry (BBC, 2015). Indeed, the Black population represents 92.1% of the total population in Jamaica, in contrast to other ethnic profiles including Asian at merely 0.8% of the population. An outcome of the slave trade triangle, Jamaica was a porting site for slaves arriving to the U.S. from West Africa, which explains the close political and social link between Jamaica, Britain, and the U.S. (Mullally, 2003). Surely, according to Richardson, Tibbles, and Schwarz (2007), the dominant black population in Jamaica are either “of African or partially African descent”, most of whom “trace their origins to West Africa” (p. 41).
However, while most identify themselves as black, they have mixed ancestry commonly denoted as Anglophone Caribbean (Richardson, Tibbles & Schwarz, 2007). Within and without Jamaica, the people have their major and official language being English (official), although the majority of the citizens speak the English dialect, Patois (Jones, 2008). Majorities are dominantly of the Christian religion, and the life expectancy of Jamaican men is 71 years, slightly below the 76-year life expectancy of Jamaican women (BBC, 2015). Jamaicans have migrated with an overwhelming number to the U.S., Europe and of recent, Asia. As such, “more than half of migrants absent from Jamaica in 2007 went to the United States, while around 15 percent went to the United Kingdom”, as according to Glennie and Chappell (2010, p. 3).
Most Jamaicans presently reside in the U.S. and England, which can largely be credited to the slavery roots of their ancestors (Sherlock & Bennett, 1998); while new generations of Jamaicans have also immigrated to seek for education and employment outside the Caribbean island (Mullally, 2003; Glennie & Chappell, 2010). The Jamaicans in the U.S. are referred to as Jamaican Americans, who are American citizens of either partial or full Jamaican ancestry, with a distinctive cultural identity (Jones, 2008). Today, most Jamaicans reside in New York City, South Florida, Philadelphia, New Jersey, Tampa, Boston, and Atlanta. State-wise, the 2010 national census recorded 965,355 American residents of Jamaican origin, the largest Jamaican populations being in (i) New York (305,285), (ii) Florida (246,478), and (ii) New Jersey (55,351) (Glennie & Chappell, 2010). Above that, among the communities with highest percentage of Jamaican residents is Miami, Florida, with over 6.3% of Jamaican adults (Jones, 2008).
This chapter discussed the background of the proposed study and introduced the area of interest under research. The chapter thus justified the proposed research undertaking on PCa risks from the perspective of the global, Caribbean, and American PCa risk factors of Jamaican men. Based on the background, the chapter developed a literature-based statement of the problem shaping the study’s purpose, broad aim, narrow objectives, and research questions on understanding the lived experiences of Jamaican men in the U.S. after having undergone PCa screening. The chapter also critically reviewed the philosophical underpinnings upon which the study is anchored (qualitative research methodology, interpretivism paradigm, phenomenology research, and hermeneutic phenomenology research design). Finally, the chapter briefly reviewed the significance of the proposed research findings to nursing, nursing education, nursing practice, nursing research, and public health policy before highlighting the scope and limitations of the proposed study.
This qualitative, interpretive phenomenological study will seek to explore the lived experience of Jamaican men who have undergone prostate cancer (PCa) screening. Knowledge generated from a greater understanding of how Jamaican men make meaning of this experience may improve the nursing field’s ability to develop evidence-based interventions that promote prostate cancer screening in this vulnerable population. The apriori literature review has been historically discouraged in qualitative research (citation). This is largely due to concerns that the review may bias the data analysis and ultimate study results. More recently, however, scholars argue that a cursory literature review may serve to situate or anchor new research within the current discourse regarding a given phenomenon (citation).
The following computerized databases were used for this search, where the following key terms an phrases – prostate cancer, prostate cancer screening, Jamaican men and prostate cancer, Jamaican men and prostate cancer screening, and PCa screening experiences – were identified and utilized: PUBMED, Centers for Disease Control (CDC), Cumulative Index to Nursing and Allied Health Literature (CINHAL) Plus, and Ovid E-Books. Citations were limited by language to English and by subject to exploration of the phenomenon. While all sources since 1982 were considered, priority was given to studies carried out between 2011 to 2016, and seminal works, since they likely contained the most relevant and current information on the phenomenon of interest.
The literature review opens with the historical context of prostate cancer and prostate cancer screening. It is within this context that the health disparity among Jamaican men related to PCa mortality is highlighted. This discussion is followed by an examination of the barriers and facilitators influencing Jamaican men’s adherence to PCa screening recommendations. Scholarly discourse related to Jamaican men’s experience of PCa screening revealed a knowledge gap relevant to the research focus of the proposed inquiry.
Historical Context of PCA Screening
Prostate cancer (PCa) is the most common cancer diagnosed in men in developed regions of the world, and second only to lung cancer, globally (Ferlay et al, 2010). Worldwide, however, disparities in the incidence of prostate cancer vary considerably. The highest incidence of PCa is in Australia/New Zealand (104 per 100,000), and the lowest incidence is in South-Central Asia (4 per 100,000) (p. 2907). The variation in incidence rates globally has been attributed to more widespread use of prostate specific antigen testing (PSA) and subsequent diagnostic biopsies in developed countries. Since PSA testing would be expected to have a greater effect on incidence rates than mortality rates, it is not surprising that there is less variation on PCa mortality rates globally. While prostate cancer is the sixth leading cause of cancer deaths in men worldwide, the mortality rate is almost equal between developed and undeveloped nations (p.2908). It is this variance in prostate cancer incidence and mortality rates globally that suggests a more significant health issue for specific groups of men.
Now start to discuss how the global information points to specific health disparity in mortality rates from PCa … Consider adapting this chart to illustrate the point.
Figure X: The above chart is an adaptation of …
Then move into the discussion on what prostate cancer screening tests could change this… the digital exam is the most cost-effective (I’m assuming here)
Prostate Cancer Risks across the Globe
Globally, PCa has emerged as one of the most sensitive types of cancers based on the number of incidences and mortalities recorded annually. In the second edition published at end of 2015, Djavan, Bostanci and Kazzazi (2015) addressed the “epidemiology, screening, pathology, and pathogenesis” of PCa. According to the authors, PCa is now the leading type of cancer among men, both in the incidence and mortality rate, particularly among the black and Caribbean populations. According to Sinfield, Baker, Agarwal, and Tarrant (2008), PCa patients recorded the worst experiences compared to the experiences recorded with other type of cancers including breast and stomach cancers.
Center, Jemal, Lortet-Tieulent, Ward, Ferlay, Brawley and Bray (2012) reviewed the “international variation in prostate cancer incidence and mortality rates”, noting an increase in global incidences (largely in developed nations), and mortalities (in less developed nations) (p. 1079) Center et al. (2012) reported that “estimated PCa incidence rates remain most elevated in the highest resource counties worldwide including North America, Oceania, and western and northern Europe” (p. 1079). Above the question of economic development, there emerged a notable trend about where most incidences and mortalities were recorded. Indeed, when reviewing global statistics of PCa incidences, there is also a unique bias for a specific racial profile.
Centers for Disease Control and Prevention (2015) reported a PCa deaths/mortality trend defined by both race and ethnicity. Between 1999 and 2012, CDC reported that the “the rate of men dying from prostate cancer has varied, depending on their race and ethnicity” where Caribbean and black/African men are “more likely to die of prostate cancer than any other group, followed by white, Hispanic, American Indian/Alaska Native, and Asian/Pacific Islander men” (p. 2). Confirming this trend, the International Agency for Research on Cancer, on behalf of the World Health Organization, reported that in 2012, the world registered over 14,068,000 new cases of cancer incidences, formally diagnosed and triggering the deaths of 4,653 000 men (Globocan, 2015). According to the report, over 15, 296, 000 men had died of cancer between 2007 and 2012 (Globocan, 2015).
From a global perspective, the Caribbean region alone triggers the highest number of incidences every year, compared to any other region (Prostate Cancer Caribbean, 2008). Based on PCa incidence, prevalence, and mortality rates recorded in the Caribbean nations by 2008, showed that Caribbean men alongside African men recorded the highest recorded risk of developing PCa cancer. The genetic makeup of black and Caribbean men triggered a risk value higher than that of any other racial profile (Glover, Coffey, Douglas, Cadogan, Russell, Tulloch & Walsh, 1998). Consequently, Gibson, Hanchard, and Waugh (2010) reported that black and Caribbean populations have the highest risk of developing PCa in the world.
In the Caribbean region, cancer incidences registered nationally in Jamaica, the Bahamas, Cuba, Trinidad and Tobago, Grenada, and in Martinique have qualified the Caribbean as one of the most high-risk locales of PCa (Prostate Cancer Caribbean, 2008). Aiken and Eldemire-Shearer (2012) reported that, of greater concern in the rising PCa incidences statistics globally, is the indication “that the Caribbean region has the highest age-standardized PCa-specific mortality rate in the world at 26.3/100 000/year” (p. 90). Confirming on the global and Caribbean incidence rates, a unique PCa trait becomes evident, from the perspective of the Jamaican nation. PCa is now most common among black populations in the world, among whom Jamaica is perhaps the most predominant representative of nations with the highest rate of PCa incidences (Gibson, Hanchard & Waugh, 2010; Glover et al., 1998). Aiken and Eldemire-Shearer’s (2012) findings confirmed that Jamaica represents the Caribbean nation with the highest rates of PCa. According to Gibson, Hanchard, and Waugh (2010), based on incidences reported between 2003 and 2007, PCa is “the leading cancer affecting men in Jamaica” (p. 456).
Traditionally, “the highest reported incidence of prostate cancer in the world was thought to be among United States black men” and never did any study focus on the Caribbean immigrants (Glover et al., 1998). Eventually, statistics showed that the incidence rate in Jamaican capital, Kingston alone, reached 304/100,000 men, 80% of whom were pathologically confirmed. A higher risk value was subsequently identified among Jamaicans in Jamaica, than in African men with 30% of the patients having “acute urinary retention, 16% presented with bone metastases, 15% with gross hematuria at the time of diagnosis, and with 42% with an abnormal rectal examination suspicious for cancer” (p. 1984). Most importantly, Prostate Specific Antigen (PSA) was measured among Jamaican sat only 7% of the PCa cases in 1989 reached “48% of cases by 1994” (p. 1984).
Morrison, Aiken, and Mayhew (2014) reported that in Jamaica today, PCa “accounts for almost a third of all cancers diagnosed” with Jamaica having “the highest incidence of PCa in the world based on a reported rate of 304/100,000 per year” (p. 456). According to records by the Jamaica Cancer Registry, PCa “is the most common cancer overall as well as the most common cancer in men” with an “age-standardized incidence rate of 78.1/100,000 per year” (p. 456). Even more concerning is that, by 2014, PCa was “the most common cause of male cancer-related deaths, with an age-standardized mortality rate of 53.9/100,000 per year” (Morrison, Aiken, & Mayhew, 2014, p. 456).
It is also apparent that the high risk of developing PCa affects not only Jamaicans within Jamaica, but also those who have immigrated to the U.S. According to Kendrick (2010), “research has shown that prostate cancer is the second leading cause of cancer death among men in the United States[,] and [that] Caribbean and African American men are more likely to develop the disease than White American males” (p. 6). Jamaican men residing in the U.S. thus depict a similar high PCa risk as those in Jamaica.
The American Cancer Society (2008) and Gibson, Hanchard and Waugh (2010) established that Jamaican men have the highest rates of PCa even within the U.S., when profiles by race and ethnicity are Caribbean. In their study, Gibson, Hanchard, and Waugh (2010) reviewed all cancer cases recorded in Jamaica’s biggest cities (St. Andrew and Kingston) totaling to 4981 cases, among 2536 of which were males between 2003 and 2007. For men, the “age standardized rates per 100,000 per year” stood at 188.8, with the leading type of cancer being PCa.
Glover et al. (1998) conducted an epidemiology of PCa in Jamaica, whose population is predominantly of African descent, and compared their statistics with those “of white and black Americans” (p. 1984). To conduct the study, the researchers profiled 1,121 PCa diagnoses between 1989 and 1994, sourcing the information from the government pathology laboratory, Jamaican Cancer Registry, clinic and hospital records as well as physician office records, and ultimately computing the incidence rates with the 1991 national census in Jamaica. Following the study, Glover et al. (1998) confirmed that Jamaican men “have a high incidence of prostate cancer, much higher than even black Americans during a similar period”, notably with PCa showing as “more significant clinically with greater morbidity in Jamaica than in the United States” (p. 1984). The American Cancer Society (2015) affirmed that, based on global cancer fact and figures, PCa cancer incidences and mortalities are higher in the U.S. than in the Africa and the Caribbean, yet within the U.S., the highest rates are among the Caribbean (notably Jamaican) and African men.
PCa screening has been linked to distinctively significant experiences among Jamaican men. A section of the literature suggests that Jamaican men approach, regard, and respond to PCa screening based on their awareness and knowledge of PCa and PCa risks. In the paragraphs that follow, the paper first reports, reviews and critically synthesizes several recent studies on the most essential fields of knowledge relevant to the proposed study.
Roumier et al. (2004) conducted an experimental study to assess “the adherence to an annual PSA screening program” in a period of 3 years, as well as identified the “characteristics of men who failed to undergo the full screening process” (p. 280). The 442 sampled men had a first-degree relative diagnosis of PCa, and participated in an “annual serum PSA testing over a 3-year period”, and data was collected using questionnaires (p. 280). The study found that participants without genetic PCa susceptibility recorded high levels of non-adherence, but those with close relatives already diagnosed with PCa had an 88% adherence rate. Having a close relative diagnosed with PCa increases the adherence of an individual to screening. Moreover, it is logical to specifically assume, from their study, that those individuals without genetic susceptibility faced an enhanced risk of non-adherence to a PCa screening as compared with individuals who indeed exhibited genetic risk. This was an important finding seeing as it suggested the prevalence of both a distinct barrier and limitation to PCa screening procedures. In addition to ascribed, genetic status as a suggested barrier and limitation to screening, social-familial indicators – namely the presence or absence and knowledge or ignorance of relatives diagnosed with PCa – seemed to be of equal significance, as such indicators would either serve to directly encourage or discourage intentions and decisions to seek screening, as well as decisions to comply with undergoing the screening program in its entirety.
Also concerned with the phenomenon of PCa screening adherence was Evans et al. (2005), who conducted an empirical study that informs, shapes, inspires, and affirmatively justifies the research study proposed herein; and, like the present study, the researchers investigated the impact of demographic, racial, cultural and gender features to the adherence and non-adherence of a target population to PCa screening alongside breast cancer. The study provided a contextualized understanding of the concept of adherence and non-adherence as employed in the proposed study, with this particular instance focusing on the target population of Jamaican males currently residing in Broward. Evans et al. (2005) employed a participatory-action research method when collecting data from focus groups on two occasions/during two phases. The sampled participants were five African-Nova Scotian men and women, sampled from a population of 57 individuals who were already validated as free from or diagnosed as having either prostate cancer and breast cancer. Ultimately, Evans et al. (2005) established that there is a significant link between culture and gender (particularly of femininity and masculinity perceptions) among the African-Nova Scotian community in Canada.
This influential background “unavoidably interact[s] with other social structures such as race and class to affect women and men’s perceptions and experiences of these two cancers” (p. 257). Consequently, Evans et al. (2005) validated the need to consider the meanings and implications that social, cultural and demographic features impose on such critical health interventions as PCa screening and breast cancer tests. In their words, it is mandatory for “health care professionals to have an understanding of the overlapping and contextualized nature of gender, class, and race, and to be willing and able to work in partnership with African-Nova Scotian communities to identify and develop strategies that reflect the realities of peoples’ lives” (p. 257).
Key among the argument used when supporting, recommending, and qualifying PCa screening is the prospect of conducting PCa screening at almost any demographic context, easily, with a standard procedure at an affordable cost, and regularly. Significantly important for the present study proposal is that the adherence of Jamaican men to PCa screening invokes a consideration of their lived experiences, and by so doing invokes an influence of their Jamaican culture. Evans et al. (2005) researched how cultured relations influenced African-Nova Scotians to attend breast and prostate cancer tests in Canada as part of their lived experiences and resultant perceptions. Further, while the study proposed herein will focus on the male gender when investigating the non-adherence of Jamaicans to PCa screening, Evans et al. (2005) provided a broader research parameter by investigating gendered relations (male and female), that differently influence breast and prostate cancer tests among the African-Nova Scotians. From the study, Evans et al. (2005) found that the act of seeking health care services, particularly those focused on reproduction health, is one perceived by men as being weak, vulnerable and feminine.
Like Evans et al. (2005), Consedine, et al. (2009) explored PCa information screening behaviors in the U.S. in a manner that related to normative perceptions of gender, but with emphasis given to the notion or incidence of fear. They used a stratified cluster sampling method to recruit 5333 individuals from four distinctive ethnic groups namely, (a) Jamaican immigrants, (b) African Americans, (c) European-American, and (d) immigrants from Trinidad and Tobago. The researchers synthesized three previous empirical studies that they had conducted on the fear/loathing of PCa screening among Caribbean ethnic sub-populations in Brooklyn, New York. The data revealed that even among Jamaican men in the US, screening is regarded emotively, such that the decision to screen or not is the outcome of emotional patterns of thought (Consedine et al. 2009). The fear of PCa, fear of undergoing the screening procedure, overwhelming anxiety, and emasculation concerns among immigrant Caribbean men in Brooklyn, New York influence their perception of and adherence to PCa screening (Consedine et al. 2009).
Similarly, Friedman et al. (2009) focused on “cancer information-seeking behaviors, capacity to use information, and recommendations for messages and message delivery” among the sampled participants. Therefrom, Friedman et al. (2009, p. 204) identified the major barriers to effective PCa communication with African-American men to include fear of PCa, cultural bias for privacy of matters related to sexuality, sex and reproductive health, poor resources to enable community health intervention, limited family communication, and negative social perception of reproductive health.
What Friedman et al. (2009) revealed was a complex phenomenon of privacy/individualized, economic, social, cultural, and community health influences to how an immigrant community that has perhaps the highest risk of infection, and whose approach to the fatal condition, is questionable. Optimizing communication with this target population even within the South Carolina context required an integration of the economic, social, cultural, and community health factors that influenced their understanding and perception of PCa. It is predictable that these men would also face similar barriers, when deciding on PCa screening, and most probably, they would not adhere to such PC screening sessions. This derived assumption however, was given credence by the empirical findings generated by Kendrick (2010).
Kendrick (2010) employed a phenomenological interpretive research design among a purposive sample of 11 African American men, to investigate “the relationship of erectile dysfunction relative to prostate cancer screening among African American men” (p. 7). The participants were aged 35 years and above, all of whom were college-educated, with a middle-class social status, and residing in the California Metropolitan region of Greater Sacramento. Following the study’s implementation, Kendrick (2010) established that, “African American men avoid prostate cancer screening due to the perception that a positive diagnosis and treatment may impact sexual relations” (p. 6). Importantly, this reality is what shapes the approach that African American men takes when PCa conditions trigger erectile dysfunction, and even worse, any erectile dysfunction that is not related to PCa conditions. Among these immigrant communities, attending a PCa screening is perceived as a man’s response to erectile dysfunction (Kendrick, 2010).
Rivera-Ramos and Buki (2011) conducted a qualitative hermeneutic phenomenological research design study to “examine cultural and gender beliefs, and how these influence Latino men’s attitudes, beliefs, and behaviors related to prostate cancer screening” (p. 13), from a purposive sample of 10 Latino men, aged 40 and above years, who were not linked to PCa, and or had attended any PCa screening. In this study, the researchers conducted a structured survey alongside face-to-face interviews. They analyzed data that (a) all participants valued the manly image of ‘Machismo’ which overruled the need for PCa screening, (b) misconceived screening procedures as having healthcare professionals “insert a finger!” and (c) the perception of manliness defied seeking health care assistance with sexuality-related issues, thus influencing their PCa screening non-adherence.
A quantitative survey was conducted by Bowen et al. (2011). The quantitative survey investigated the decision making of Jamaican men and their attendance at PCa screening. Bowen et al. (2011) conducted the survey across the Washington state, randomly sampling men above 50 years in age. “[A] simple random sample of primary care physicians [was] conducted in the same geographic area”, focusing on PCa screening rates and practices among men, either through PSA or DRE, among the practicing physicians (p. 155). The findings revealed that while PCa screening was commended by all sampled physicians, Bowen et al. (2011) found that the provision of relevant information enabled “increasing informed decision making about prostate cancer screening” (p. 155). The link between informed decision making among all men besides Jamaican men, adequately aware about PCa, and attendance to PCa screening was also affirmatively generated by Bowen et al. (2011) in their empirical study.
McCree-Hale, Hale, Rutley, Aung and Jolly (2012) conducted an experimental survey to “evaluate the impact of a theory-based health education intervention on the awareness of prostate cancer” and the resultant intention to undergo screening among Jamaican men (p. 580). To implement the study, the researchers sampled 188 Jamaican men who attended outpatient clinics. Data was collected using pre and post-test interviews and surveys, both before and after “a health education intervention” on PCa and PCa risks (p. 580). In the study, McCree-Hale et al. (2012) purposed to evaluate the impact of a theory-based health education intervention on awareness of PCa and intention to screen among men in Jamaica.
Ultimately, the researchers found that health education on PCa significant increases the acceptance, adherence, and consistence of PCa screening decisions among aware and informed Jamaican men. Indicatively, therefore, based on McCree-Hale et al. (2012) findings, most Jamaican men would avoid, ignore and fail to undergo PCa screening for lack of awareness and knowledge on their risk of developing PCa and the role of PCa screening. McCree-Hale et al. (2012) asserted that “theory-based patient education can promote awareness of prostate cancer and informed screening methods including potential risk associated with screening behaviors” (p. 580).
Six years later, after their study in 2009, Consedine et al. (2015), again, conducted a systematic review of PCa trends among Caribbean migrants to the U.S. – both of African descent and Caribbean natives – but this time, in 2015, from a slightly difference perspective that was more so concerned with the factor of cancer risk misunderstandings. From the 15 research articles previously published, they concluded that “Caribbean men of African descent screen less frequently than is recommended” (p. 915). As such, whether already adequately informed or otherwise, whether PCa screening facilities are accessible, and the procedure affordable, Jamaican men perceive PCa screening based on their lived experiences. It is of great concern that some Jamaican men subscribe to “misperceptions about cancer risk” where PCa is regarded as “a taboo topic” excluded from discussion or consideration by virtue in cultural beliefs and social norms (p. 209).
Facilitators to PCa Screening in Jamaican Men
One pioneering study gave regard to how an emphasis on the “perceived benefits” of cancer screening can facilitate active decisions to undergo screening processes. For instance, Tingen et al. (1998) “conducted a correlational study” in which 1,522 men were involved (72% African-American, aged 40-70 years; 28% Caucasian, aged 50-70 years). The study sought “to explore the perceived benefits as facilitators of participation in prostate cancer screening”. Indicative of the results was “that men who perceived participation in prostate cancer screening as a benefit were more likely to participate in screening”. The study proved influential, and is surely helpful to the study at hand, because it reinforced the simple yet powerful notion that knowledge of, and active education on, prostate cancer is a likely facilitator to ongoing involvement in screening.
Quite similarly, in another pioneering study published within less than 30 days of the previous one, Weinrich et al. (1998) determined the impact of prostate cancer knowledge on cancer screening. They utilized a quasi-experimental research design, sampling 319 men (82% of which were African-American). In the study, prostate cancer knowledge was measured using a Prostate Cancer Knowledge Questionnaire prior to a community-based educational program. The findings yielded that prostate cancer knowledge was a major predictor in the incidence of screening participation. The study documented the significance of the availability of prostate cancer educational plans aimed at advancing active and continual participation in screening programs.
In a quantitative study that utilized stratified cluster sampling in order to identify barriers and facilitators to digital rectal examination screening (DRE) among African-American and Afro-Caribbean men, Lee, Consedine, and Spencer (2011) identified that while “screening fear predicts the likelihood of undergoing initial screening”, it does not predict the likelihood of undergoing an annual DRE screen. This was attributed to having a regular physician who engaged in comprehensive and culturally sensitive discussion on the importance and benefits of screening, thereby encouraging African-American and Afro-Caribbean men to undergo annual screening. The discovery was an optimistic one, therefore, because it was suggestive of a legitimate facilitative factor to cancer screening. Furthermore, the study provided inspiration to the present one at hand. It gave thought to how visiting a physician, like a family doctor, regularly could go a long way with regard to increased screening participation. For instance, a family doctor who would offer culturally sensitive education on PCa as well as encourage PCa screening from the strategic standpoint of added emphasis given to preaching the very favorable nature of early detection – thereby helping to dispel or significantly diminish notions and emotions of fear – could indeed be construed as a noteworthy facilitator to screening.
Clarke, Soler-Vila, Fleming, Christ, Lee and Arheart (2012) thematically analyzed data from National Health Interview Survey, alongside a detailed document analysis in the US, to compare screening trends and adherence among all cancer survivors, working survivors, and the general population since 2000. After recruiting 174,393 participants, the researchers quantitatively “compared the screening trends among all cancer survivors, working survivors, and the general population over the last decade” followed by a thematic analysis of the results (p. 190). During the analysis, the investigators observed a decrease in PCa diagnosis in the U.S. beginning the year 2000, accompanied by an increase in the number of recorded cancer survivors after successful treatment. According to the scholars, “cancer screening behaviors among survivors may play an important role” in the diagnosis and treatment process of cancer, particularly the early detection of such cancers as prostate cancer since the “screening protocol increases early detection of secondary tumors and reduces potentially limiting side-effects” (p. 190).
However, for diagnosis and treatment, the concept of adherence is a critical mark after initial diagnosis, including during the post-treatment stages of cancer. It also appears that PCa screening only increases when men understand their risk factors of developing PCa. On the overall, therefore, the study thus affirmed that “healthy people’s goals as a measure of desired adherence” principle helps to emphasize the need for consistent, reliable, and best-practice health behavior when fighting such a disease as fatal as PCa (Clarke et al., 2012, p. 190).
Recently, however, several empirical studies have aided in contextualizing the PCa screening adherence rates. One study was conducted by Anderson and Marshall-Lucette (2013). Employing a qualitative research design, Anderson and Marshall-Lucette (2013) – using a purposive sampling method – they recruited 214 African and Afro-Caribbean men at a hospital in the UK, and then employed face-to-face interviews. Following the in-depth interviews, the researchers conducted thematic analyses of the primary data with the purpose of gaining “an insight from these men’s perspectives and [of] ascertain[ing] whether a more focused health promotion strategy, and specific UK-based research, was needed” concerning PCa careening (p. 1296). The data generated four main themes of “disease-prompted awareness, checking up as a necessary evil, defining and constructing factors influencing prostate cancer screening uptake, and appraising perceived myths about prostate cancer through personal beliefs” (p. 1296).
Marshall-Lucette (2013) established that the socioeconomic status of men in the community, such as education and professional background, were factors that influence their level of awareness of PCa and prompted their decisions to seek help. Further, according to the study, the men’s perspectives that a more specific health education strategy that promotes early detection and management, targeting African and Afro-Caribbean men would help in demystifying PCa and encourage them to seek help earlier. Similar findings as those generated by Marshall-Lucette (2013) were reported nearly a decade earlier in the US.
Conclude this section with a BRIEF recap of the barriers and facilitators, showing that research is needed on the facilitators. Talk about how we know a lot about what impedes Jamaican men’s adherence to PCa screening recommendations, but we know little about the experiences of Jamaican men who are proactive about their sexual and reproductive health. Conclude with how your study addresses this gap.
The proposed study captures an extremely sensitive area of interest for the researcher. Being a practicing nurse within the genre of the study, and in the jurisdiction of the study – South Florida – this researcher will explore the best possible interventions that can help to protect a vulnerable community that this researcher feels rather obligated to serve. It is, therefore, important to elaborate by mentioning that this researcher is Jamaican-born, having immigrated to the U.S. for further education and to pursue a professional career. The Jamaican community in the U.S., and globally at large, has recorded immense economic, political, and social progress in the last few decades. This progress is owed to exceptional athletes, committed politicians, highly trained economic experts, advanced scholars, and numerous other Jamaican nationals who have positively contributed to the community in various ways and through hundreds of diverse, separate fields.
This researcher thus acknowledges, with appreciation, the need to contribute to the community in my area of training and expertise, namely nursing. As the country progresses in health care provision, within and without Jamaica, the highest numbers of men who die because of PCa are Jamaicans. As noted severally in the foregoing sections, this is similarly true among Jamaicans who reside in the world’s sole superpower. It is an obligation and a professional commitment of this researcher to explore ways to avert this trend, and to demonstrate my social responsibility by participating in the active improvement in the quality of life for a group of people with whom this researcher shares an identity with. Such knowledge would be critically important not only for Jamaicans – in the U.S. and elsewhere – but also for a number of other communities facing the aggressive impact of PCa.
Resultantly, the foregoing testimony captivates this researcher’s unique professional and personal perspective, which will significantly influence how the findings are interpreted and narrated. This researcher is considerably focused upon determining the accurate and reliable empirical meaning that Jamaican men attribute to PCa screening. It is this researcher’s hope that such findings will aid in optimizing the role of screening among a high-risk population and, thus, prevent unnecessary deaths that can and should be avoided. van Manen (1997) recommends that researchers investigate a phenomenon that they feel connected to (and indeed commends this), yet one in which the researcher avoids being too intimate with in a manner that determines the knowledge attained.
Nonetheless, this researcher will collect and analyze the primary data with significant risks, even with all of the preceding strategic steps. This fear is real for this researcher, and is a valid cause of concern. Reviewing qualitative research studies among health professionals, Jeanfreau and Jack (2010) concur with this point, observing that “many practicing health educators do not feel fully confident in their ability” to conduct qualitative studies (p. 612). Certainly, Jeanfreau and Jack (2010) have cited numerous previous studies and scholarly books – most notably Porter (1993), Jootun, McGhee, and Marland (2009) – who all encourage “qualitative researchers [to] acknowledge that there is a possibility that their values and beliefs may influence their research studies” (p. 612).
With this fear, therefore, this researcher will employ strategic bracketing of the data, and precisely accommodate reflection as part of the data collection process. According to Jeanfreau and Jack (2010), bracketing denotes how a researcher acknowledges “the possible influence and an intentional setting aside of conscious thoughts and decisions influenced by the particular mindset” while reflexivity denotes a “researcher’s self-awareness and the strategies the researcher used to manage potentially biasing factors while maintaining sensitivity to the data” (p. 612). In agreement with Porter (1993), and Speziale and Carpenter (2007), Jeanfreau and Jack (2010) recommend that, any “possible effect of the researcher’s influence can be reduced through bracketing and reflexivity”, where a researcher’s core responsibility in the qualitative area is anchored on being “self-aware of one’s own reactions, reflections, and even one’s personal growth along with the researcher and participant relationship” (p. 612).
The present study will adopt Chan, Fung and Chien’s (2013) qualification of bracketing. According to the scholars, the use of bracketing helps demonstrate “validity after initiating a phenomenological study” particularly in “the data collection and analysis process” regarding a phenomenon (p. 1). Based on the commendation, bracketing the data will be initiated not only during the actual data collection and during analysis process, but also now as this researcher prepares for the study. According to Chan, Fung and Chien’s (2013), “the concept of bracketing should be adopted upon initiating the research proposal and not merely in the data collection and analysis process” (p. 1) to ensure that this researcher does not negatively influence or invalidate the planned study.
Therefore, this researcher appreciates that the shared background with the prospective research subjects may influence how the participants express the values, experiences, feelings, and assumptions, and how they are subsequently interpreted by this researcher. The influence, however, will help to make the meanings clearer and more accurate, but not to inhibit how such experiences and feelings are interpreted using bracketing. As van Manen (1990) argues, phenomenology requires the researcher to participate actively in investigating the reality, and thus knowledge emerges as a co-creation of both the researcher and the participants. As such, being a Jamaican man within the age bracket of the participants will be vital in co-creating knowledge when implementing the study, since this researcher will be able to better understand the participant’s perspective, identify with it, and to interpret it precisely and accurately.
Further, the graduate training and professional experience of this researcher will help to anchor the study from the perspective of nursing, and only incorporate personal involvement as a reflection of the data collection process. PCa screening will be reviewed and investigated as a nursing intervention in the control of PCa. This researcher will understand the participants from the perspective of a practicing nurse, as they explain their experiences during and after screening. As such, the study will better capture the meaning of such narrated experiences, with the additional nursing edge, than would be possible without the nursing perspective.
This second chapter provided a comprehensive and critical review of the most reliable knowledge on, PCa screening experiences, and Jamaican men. The chapter provided a historical context of PCa screening, reviewing PCa risks in the globe, in the Caribbean, in Jamaica, and the U.S., highlighting PCa risks for Jamaican Men in the U.S., and qualifying PCa screening as an intervention measure. This was then followed by a review of the research content, providing a geographical and social profile of Jamaica men as the population under study, reviewing previous research on PCa screening among Jamaican men, and sampling previous research on the experience, adherence, and impact of PCa screening. The chapter then terminated with the experiential context, focusing on the researcher’s experimental background, involvement, experience and interests, the use of reflexivity and bracketing, and justifying the appropriateness of the phenomenological research design used. The next chapter will now discuss the research methodology and methods, to be used when implementing the study to investigate the forested gap in contemporary knowledge.
The purpose of the proposed phenomenological study is to explore the lived experience of Jamaican men residing in the U.S., after undergoing PCa screening. Moreover, the study will explore the meaning that Jamaican men ascribe to undergoing PCa screening as a phenomenon, based on their lived experiences, and thereafter construct a new understanding of how they perceive, think of, and regard PCa screening based on self-constructed meanings. The proposed method will focus on providing a detailed and comprehensive explanation of the research strategies design to be used when conducting the proposed study.
The proposed study will implement a qualitative research method in order to describe the meaning of lived experiences of Jamaican men in the U.S. Creswell (2007) argues that qualitative research is designed to help understand people, events, and situations based on their lived experiences. The qualitative research methodology was specifically chosen as a means to better understand such people, events, and situations grounded in the lived experiences of the individuals involved – namely Jamaican men who have undergone PCa screening – rather than merely investigating the ‘how much’ and ‘how many’ questions that are often answered via the employment of quantitative research methods (Polit & Beck, 2004).
Given that the study will primarily focus on interpreting and constructing meaning, Munhall (2004) commends the qualitative approach as the only feasible empirical process that enables a researcher to construct knowledge regarding a phenomenon. Based on Creswell (2007) and Munhall’s (1994) arguments, then, the qualitative research approach will help understand how Jamaican men experience PCa screening and how they develop meanings based on their experiences. Quantitative research seeks to test the relationship of variables with statistical measures whereas qualitative research describes such relationships with rich and in-depth narratives and written words, rather than measuring the variables statistically.
Qualitative research helps to construct multiple realities of a phenomenon and to enable a comprehensive understanding of variant circumstances from the perspective of participants (i.e. Jamaican men) (Creswell, 2007). The proposed study will focus on attaining an understanding of PCa screening experiences, as narrated and described by Jamaican men, in order to construct meaning of these lives experiences. No other research methodology can serve this purpose as reliably and accurately, above a qualitative research methodology.
Selecting an effective research design as a guideline for the implementation process was now the next important step of the research process. As aforementioned, the proposed study will employ a phenomenological research design. Given the onset, history, and progressive improvement of phenomenology as the most reliable and appropriate design in nursing research, the approach was determined as the most fitting to the proposed study. Besides adopting a qualitative research approach, the proposed study will also adopt a hermeneutic phenomenology approach since the meanings constructed will be based on how individuals (Jamaican men), perceive PCa screening. As presented in a diagrammatic illustration hereafter, the proposed study will employ the six activities constituting the hermeneutic research design as proposed by van Manen (1990), which includes: identifying the phenomenon of interest, exploring the phenomenon under study, conducting a reflection on the phenomenology of interest, initiating a phenomenological writing process with interpretive narrative and qualitative descriptions of lived experience meanings, implementing pedagogical relation in reporting the study, and maintaining absolute research balance when preparing the report.
This phenomenological investigation of PCa screening will focus exclusively on the lived experiences of Jamaican men in the U.S. van Manen (1990) defined phenomenology as an empirical attempt to establish the deep understanding of a target group of people hold regarding the nature of their experiences with a phenomenon. van Manen (1990) contended that a human science study about a phenomenon needs to combine phenomenology and the hermeneutics in order to adopt the human perspective. Creswell (2007) and Munhall (1994) qualify the qualitative approach as ideal when investigating the descriptive trait of peoples’ experiences. Munhall (1994) further commends the use of a phenomenological study for investigating experiences and occurrences of a phenomenon.
Creswell (2009) described phenomenology as a study to determine the deep meaning that people’s experiences ascribe to that phenomenon. This reality introduces the element of people as participants to be studied with a phenomenon, using a research design and philosophy is referred to as hermeneutic phenomenology (Munhall, 1994). van Manen (1994) suggests that scientific research needs to be used to interpret a phenomenon with conscious understanding of the human perspectives involved.
Creswell (2009) defined phenomenology as the study of describing “the meaning of the lived experiences for several individuals about a concept or the phenomenon,” thus integrating the need to include people when constructing meanings of a phenomenon (p. 51). Similarly, van Manen (1990) best explains phenomenology as an empirical attempt to establish the deep understanding a target group of people hold regarding the meaning of their lived experiences with a phenomenon (i.e., PCa screening). Investigating the lived experiences of Jamaican men after undergoing PCa screening will require the constructivist phenomenology approach, as advocated by Munhall (1994), Creswell (2009), van Manen (1990), and Crotty (1998).
The proposed study will adopt a hermeneutic phenomenological design. Hermeneutic phenomenology focuses on interpreting people’s lived experience in a natural setting by describing the meanings accruing from such experiences. Phenomenology principles integrate hermeneutics to mold a philosophy on experiences of living, rather than on the process of how things are known (Rodgers, 2005). van Manen (1990) proposes the need for a human science to combine phenomenology and the hermeneutics approach in order to investigate how everyday human experiences gain specific meanings via human science (van Manen, 1997). Creswell (2007) concurs that phenomenology describes “the meaning of the lived experiences for several individuals about a concept or phenomenon” (p. 51).
While phenomenology investigates lived experience from the perspective of a phenomenon, hermeneutics investigates the understanding of a phenomenon from the context of humans (van Manen, 1997). Phenomenology helps to “construct an animating, evocative, description of human actions, behaviors, intentions and experiences as we meet them in the life world,” but hermeneutics uses human-centered description and interpretation of the lived experiences (van Manen, 1997, p. 19). Conducting phenomenology from a hermeneutic approach optimizes the findings of a research study, since research needs to interpret a phenomenon with conscious understanding of the human actors involved (van Manen, 1990).
The proposed study will thus investigate the phenomenon of PCa screening and the lived experiences that result from undergoing the screening from the perspective of Jamaican men. By adopting an interpretative hermeneutic phenomenology research design, the study will contextualize the lived experiences (hermeneutic) witnessed by the target population (Jamaican men) and accruing from a PCa screening encounter (phenomenon). Qualitative research primarily focuses on “the interpretation of social world especially of cultures and people’s life-ways rather than seeking causal explanations for cultural practices” (Upadhyay, 2012, p. 123), making interpretivism essential for the study. Consequently, the hermeneutic phenomenology approach will help the interpretative study investigate the meaning, lived experiences, and implications of the case study phenomenon (PCa screening) to the Jamaican men who have already undergone what that the community often avoids.
The figure below was designed as a customized diagrammatic representation of the hermeneutic research design proposed by van Manen (1990), customized to highlight the interests of the proposed study when investigating the lived experiences of Jamaican men in the U.S., after undergoing the PCa screening phenomenon.
Figure 2: The Hermeneutic Research Design and Component Activities (Foster, S. 2016, adapted from van Manen, 1990 with modifications)
The study’s population and setting are directly derivable from the study’s title and area of interest. The proposed qualitative research study will target the Jamaican immigrant community who presently reside in South Florida, U.S. Since the study is solely concerned with PCa screening, the population will be further limited to the males. The study will target the population of male Jamaicans aged between 40 and 75 years – the age bracket with the highest PCa risk, and who have already undergone PCa screening.
Given that the proposed study will exclusively target the population of male Jamaican immigrants to the U.S., who currently reside within the South Florida jurisdiction, the sampling procedure will employ a purposive procedure, strategically executed to select the most appropriate participants. Towards this end, the researcher has developed the inclusion and exclusion criteria to be used to ensure that the sample recruitment process is conducted with accuracy and precision for the right participants.
Inclusion Criteria
The inclusion criteria will consist of Jamaican male immigrant to the U.S., fluent when communicating in American English, currently residing in South Florida, born in Jamaica, aged between 40 and 70 years of age, and self-identify as having undergone PCa screening.
Exclusion Criteria
When selecting participants for the face-to-face interviews, candidates will be excluded from the sample if they are not Jamaican immigrants to the U.S., not within the 40 and 75-year age bracket, are not male, self-identify as having not undergone PCa screening, and if they are unable to communicate in standard American English.
Qualitative research mandates a sampling strategy that allows a narrow sample range, where the sampled participant meet a predetermined criterion of importance (Patton, 2002); and, as such, the proposed studies will employ a purposive sampling procedure, strategically executed to select the most appropriate participants. Ideally, the study will use a snowball sampling procedure to recruit participants in the qualitative research process. Snowball sampling provides the most appropriate sampling method for allowing a researcher strategically select sources of information-rich data (Creswell, 2007; Patton, 2002).
In the proposed study, the snowball sampling procedure will ensure that selected participants have already undergone the phenomenon of PCa screening, an attribute critical to the nature of the study (Patton, 2002). The researcher will seek access permission from the people in charge of settings where Jamaican men congregate – for instance, barbershops, churches and community centers. After documented permission to access the prospective participants is obtained, the researcher will place a flyer announcing the study in the approved accessed location, and then discretely and personally meet with any volunteer, inform them about the study, its purpose, and their potential role. Selection of participants will be guided by the inclusion/exclusion criteria. Finally, participants will be invited to select a pseudonym in an effort to maintain confidentiality. If the participant is not able to or does not wish to identify a pseudonym, then one will be assigned.
According to Creswell (2007), the ideal sample size for a phenomenological study should range between 5 and 25 participants. As such, sample selection will include a maximum of 20 participants or until saturation is reached.
The proposed study will be conducted in accordance with all ethics standards criteria. The ethical considerations to be observed have been described and signed in the IRB form, alongside complementary documents attached as appendices to the dissertation proposal. Among the ethical considerations and standards to be observed will be the optimal protection of the participants as human subjects. While the researcher will participate in the reflection of lived experiences after PCa screening, the reflection will assume a non-personalized approach when posing questions to respondents. The researcher will ensure that all participants are treated with respect and dignity, and that they are addressed with social decorum and privacy. The researcher will provide adequate time for respondents to respond to questions and discuss the phenomena, while collecting the data. The participants will face no significant risks or harms in their participation.
The study will only involve participants who are able to express consent. Even without compulsion to participate, participants will be informed about the study and its purpose before being requested to participate voluntarily. The research purpose, objective, and research question will be provided and explained to all respondents during recruitment and in preparation for the data collection process. This guarantee will not only ensure that they are adequately informed/aware of what is required of in their participation, but to ensure that their participation is based on an informed decision. Each participant will only be involved after signing consent form.
The proposed primary data collection process will require the recruitment and participation of human subjects from South Florida. It is expected that one of the biggest barriers the researcher will face when recruiting participants for the study will be the unwillingness of the men to discuss such a culturally sensitive topic as PCa with a stranger. This will potentially delimit the recruitment of participants. The researcher acknowledges that the respondents will predictably be uneasy when addressing PCa. Consequently, recruitment will be voluntary and without coercion. All participants will be approached and recruited with absolute confidentiality. It will also be important to consider their image, respect, and dignity in all ways during the data collection process. Personal identity used to recruit participants will be held in absolute confidence. As such, since the study will be addressing a culturally and socially sensitive subject of reproductive health, with men as old as 70 years, the researcher will assertively assure all respondents that their participation will be held with confidentiality and with optimal privacy.
The face-to-face interviews will be purposed to collect data from the recruited Jamaican men on their lived experiences after undergoing PCa screening. The interview will explore meaningful themes in participant specific expression with meaningful description. The themes, however, will not be pre-defined, but rather emergent from the primary data collected during the interviews, towards attaining data saturation. The interview will begin with the explanation of the study’s purpose with the research participant by the researcher.
The researcher will ask open-ended questions (Appendix…), in order to elicit an exploration of their lived experience. The response to the questions will enable the researcher to gain an understanding of what it is like for a Jamaican man in the U.S. to have undergo PCa screening. These broad questions will be customized to follow up on each interview progress: why did you attend the PCa screening, was it your first session or several sessions you have undergone, how old were you when you realized or heard about the need for PCa screening for Jamaican men, and why did you attend the screening session? A list of these questions has been attached as an appendix to the present proposal.
The proposed study will employ focus groups and face-to-face interviews, although nearly the entire data collection process will rely on the interviews and the focus groups will only be complementary to the data collection process. The focus groups will only be facilitated after all interviews have been conducted, incorporating a few interviewees, and only to confirm the findings generated by the interviews.
Based on the foregoing explanation, therefore, the data collection process will largely rely on conducting the interviews progressively. In this respect, the proposed study will adopt the approach commended by Creswell (1998), where the entire process is envisioned in component phases interconnected to form a circle, while conducting the interviews. According to Creswell (1998), data collection involves “engaging in activities that not only include but go beyond collecting data” (p. 117). The personal involvement of the researcher will determine the progress of data collection since, as van Manen (1990) recommends, the personal experience of the researcher should be used to shape the data collection process. When participants are selected, informed, and recruited of their participation, they will have signed their consent form and reviewed the ethical template.
The next step will be arranging one interview followed by a second interview session, 90-minutes in total, and hosted at social places most convenient to the participants (in place and time). The researcher will identify areas of interest for the study not addressed by the first interview, whose findings are inadequate or inspiring new areas of interest. The goal of each interview will be to collect “good information to answer emerging research questions” (Creswell, 1998, p. 118). These areas will then be addressed by the subsequent interview, progressively, until the research data reaches saturation, and until no further areas of research are required (Munhall, 2007). Interviews will be conducted with a guiding schedule, but conducted and maintained in the best possible manner, being cordial and mutually communicative.
The data collection will similarly primarily involve conducting the face-to-face interviews. Upon approval from Barry University IRB to conduct the study, the researcher will place the fliers seeking to recruit participants. It is hoped that the researcher will recruit at least 30 names of Jamaican men who have undergone PCa screening. From the list of 30 potential respondents contacted in absolute confidence, the researcher will select the first 20 who agree to participate. A brief on the research purpose, the ethical template, and the participant’s consent form will be sent to the selected candidates. The potential respondents will be required to have read and understood the documents prior to the first introductory meeting with the researcher.
After the first meeting during which the researcher will respond to any inquiries or questions from the potential respondents, the participants will be requested to sign and hand in their consent forms. Only the informed respondents who sign the consent form will be recruited. After recruitment, each respondent will complete a short demographic questionnaire. Ultimately, upon recruitment, the researcher will progressively conduct interviews, each respondent at a time, for between one and three interviews sessions, until data saturation is attained.
When interviewing each respondent, the researcher will use an interview schedule and take brief field notes. The researcher will note both the verbal responses and non-verbal behavior and observe how each participant appears during the interview to capture not only what is said, but also what is indicated by emotions, feelings, and attitudes. The researcher will listen actively, engage in in-depth reflection, follow intuition, maintain cordial conversation tone, and always seek clarification where necessary. The interview sessions will be audiotaped using a (a) cell phone, (b) tablet, and (c) a laptop; and the best audio copy from the three devices used will then be selected for transcription. At the conclusion of interviews with each respondent, each participant will receive a $25 gift card as a token of appreciation for participating. The researcher will maintain contact with participants, seeking further information via phone and email messages. The data will be collected, processed, and stored throughout the process with absolute privacy.
After collecting the primary data, the researcher will analyze the collected data in a manner that responds to the research question and the research purpose in order to attain progressive saturation after the first interview. Most importantly, the data analysis process will follow van Manen’s (1990) guidance on analyzing data following a phenomenological study. Thus, following the completion of interviews with each respondent, the researcher will select the best possible audio file among the three recorded during each session and complete the audio file transcription. All the audio files for each respondent will be combined into a single transcript file. After receiving transcribed interview scripts, the researcher will edit them to include commentaries and reviews of the content to integrate the field notes taken during the interviews. The researcher will also review the demographic data for each interviewee from the demographic questionnaire, and combine the data with the edited interview transcript. The demographic data alongside the field notes will be used to enrich the meanings of the interview data.
Thereafter, the transcribed files will be analyzed thematically and categorized according to how the respondent addresses the selected themes. The data analysis process will thus explicitly align the thematic analysis method, and the resultant findings will be dependent upon the qualitative themes emerging from the primary data, categorized, narrated, and described to respond to the study’s research question. The process will require that the transcripts be read repetitively by the researcher. Munhall (2007) argued that qualitative data analysis involves examining and arranging data in precise themes, with the goal of gaining an understanding of the researched phenomena.
Further, since the thematic analysis of initial interviews will help refine questions posed in subsequent interviews, in order to best address the themes under analysis, the analysis process will be progressive and improved during the data collection process. Finally, during the data analysis, the researcher will identify how participants duplicate, differ, concur, or broaden the data until a point of data saturation. After the thematic analysis, the researcher will then describe, classify and create a summative interpretation of themes accruing from the data to generate the findings. Derivatively, the researcher will employ reflexivity to look back on the data collected, relate it to each respondent, contextualize the data with the field notes, and actively participate in the overall analytic process of the themes to construct their respective meanings. Ultimately, the researcher will focus on answering the research question in the most accurate, reliable, and comprehensive manner, based on the collected primary data.
It is also important to note that the study will collect some critically essential demographic data (Appendix…) from the participants. Consequently, the study will use specially designed questionnaire to be completed by all participants prior to the actual interviews, where each participant will provide their demographic profile to accompany the primary data collected during the interviews. The demographic data will assist the researcher understand the situational context better, regarding the phenomenon from the perspective of each participant, and to identifying any commonalities in the data as well as accurately describe the findings based on the profile of the research participant. The specific demographic information to be collected will include nationality (both origins and residence), ethnicity, age of the participants, educational background, profession or occupation, marital status and number of PCa screenings sessions ever attended.
To conclude the third chapter of the proposal, it is also important to review how the researcher will observe the obligatory criteria for research rigor during the study’s implementation. Scholarly and scientific research must necessarily conform to the standards of quality that imbue them with trustworthiness and evaluated validity, as reflected by standards of credibility, dependability, confirmability, and transferability (Lincoln & Guba, 1985). As such, in its implementation, the researcher will adopt the standard tradition of qualitative data analysis in pursuit of attaining optimal rigor in terms of these standards, as advanced below.
According to Lincoln and Guba (1985), credibility of qualitative research findings refers to the confidence level attained by the data collection process, and the resultant analysis and interpretation, to be true. Research findings gain credibility if they can be believed, and when the entire research process can be understood throughout, as likely to generate credible results for the readers and scholars to and for whom the new knowledge is advanced.
Munhall (2007) alongside Denzin and Lincoln (2003) qualify credibility of qualitative research studies and findings if the quality of the data generated adequately reflect the true human experience being studied. In this way, according to Munhall (2007), credible phenomenology necessarily attains the confidence level with believability, if the data generated and interpreted depicts the true reflections of the human actors under review. In the proposed study, the researcher will ensure that the entire study is conducted in a manner where trustworthiness is credible, validated, and confirmed.
All of the primary data analyzed will have originated from the participants, documented with accuracy, and rerecorded in exactness with accurate interpretations from the perspective of the participants. As such, the findings generated will represent accurate and trustworthy interpretations of the primary data collected, absent of the bias and participation of the researcher. The role of the researcher prior to, during, and after the data collection is not to influence the interpretations derivable from the interviews, but to facilitate – through active interactions – the participants to provide adequate, comprehensive, and truthful reflections of their experiences.
Dependability of qualitative research findings represents the stability of the data collected and analyzed, independents of contextual elements of time, as well as place and circumstances (Lincoln & Guba, 1985). In the proposed study, the researcher will document the entire research process, so that future researchers as well as the assigned supervisors can follow through the research process and concur with the same interpretations and conclusions that the researcher makes concerning the experiences of Jamaican men following PCa screening. If future researchers seek to reconstruct the research process, every action will be viable and backed by adequate research evidence to generate similar findings and conclusions.
Thus, the researcher will maintain an accurate audit trail, such that the research process will be accurately documented rather than abstract, when generating dependable findings and conclusions. From the sampling procedure, selection of sample, data collection, and data analysis, the study will be resolutely dependable if evaluated, regardless of the time and environmental factors in which the study is conducted. It is hoped that the final report will incorporate a broad and adequately descriptive research procedure for data collection and analysis, and that the report will be based on accurate and comprehensive data. These strategies will be taken to ensure that a similar approach can be used in future, and that future research can affirm and support the findings generated.
Denzin and Lincoln (2003) qualify qualitative findings as confirmable only if they attain objectivity and or neutrality in the manner the data was collected and analyzed. To Munhall (2007), phenomenological research ought to employ bracketing and objective reflectivity when deriving the interpretations in a manner that guarantees that similar findings and conclusions can be confirmed for the phenomenon under study. Munhall (2007) recommends the use of journaling in a manner that all data can be authenticated, and where researchers’ opinions, feelings, and subjective experiences do not delimit the objective research process.
In the proposed study, the primary data collected during the interviews will also be complemented by a compilation of field notes in the journal, such that the data analysis is not just what the participants said, but also what will not be expressed or communicated non-verbally. The resultant interpretation therefore, will be open to confirmation by parties outside the research process (third parties). The transcribed files will include descriptions of feelings, reactions and reflective judgments, all based on the perspectives of the participants and not of the researcher. As argued by Creswell (1998) and Crotty (2004), perhaps the most important element of qualitative data analysis to attain research trustworthiness is using member check and confirmation.
Consequently, the researcher will employ focus groups as the second and complimentary data collection instrument. After the interviews have been conducted, and the data analyzed, the researcher will then facilitate a focus group. The need to attain credibility, dependability, and confirmability of the findings will also require the concurrence of the participants. The participants will also be given a copy of their transcript alongside the thematic analysis of the interview. Further, the research interpretation of meanings presented as the study’s findings will be read to the participants, seeking their feedback, verification and corrections for any misinterpretation and misinformation, as well as additional commentary on the meanings as interpreted.
Long after the proposed study has been concluded among Jamaican men in South Florida, the researcher hopes that the scientific research process and the findings generated are transferable to similar contexts. While qualitative findings rarely attains the generalizability of quantitative research findings, qualitative research findings should attain transferability to similar contexts (in settings and sample) besides the locale of the study (Creswell, 1998; Munhall, 2007). To attain this quality of findings, the researcher will document and logically describe the research process in a manner that allows future researchers to implement a similar study outside South Florida, with another set of sampled participants, and generate similar findings.
As such, the research process from data collection to analysis, will only be employed if it is the most appropriate and feasible for the study, and when bracketing attains credible findings whose conclusions can validly to fill the current gap in knowledge. This will be sensitively crucial in the data analysis stage of the study, where the thematic analysis will be tuned in a manner that is detailed, comprehensive and can be collaborated. In the proposed study, the researcher will implement the thematic data analysis using thematic bracketing, where the data will be categorized ‘as it is’ without bias or subjective influence of the findings generated. Ideally, the researcher will focus on enhancing the believability, trustworthiness, and credibility of all findings generated from the study, to ensure that the findings are transferable to other contexts with similar phenomenological constraints.
This third chapter of the dissertation proposal provided a comprehensive explanation of the research strategies to be used when conducting the proposed study. The research strategies were selected and planned in an attempt to formulate accurate, reliable, and adequate answers to the study’s research question. In conclusion, therefore, a hermeneutic phenomenology research design will be used targeting the Jamaicans in South Florida. The study will employ a snowball sampling procedure to recruit between 15 and 30 Jamaican men in South Florida, aged between 40 and 70 years, and who have undergone PCa screening. The leading interview question will be ‘what participants think about PCa screening sessions, based on their experiences, and whether they are happy that they underwent the procedure’.
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Appendix A: Sample of Face-to-Face Interview Questions
Sample Schedule for face-To-face Interviews(Jamaican Men Residing in South Florida, Between Ages of 40 – 70 Years) |
Part A: Introduction Brief |
Lived Experience of Jamaican Men after Undergoing Prostate Cancer Screening The purpose of the present research is to: Conduct a phenomenological exploration of lived experience of Jamaican men residing in the US, after undergoing PCa screening.Thank you for accepting to participate in this study, upon referral. You are guaranteed of full confidentiality for your participation. Nothing you say during this interview will be linked to or identified by your name, or personal identity in the documentation of the study The information provide during our interviews shall be treated confidentially, only for the purposes of this study and shall not be provided to any other third party for any purpose whatsoever If there is any question during the interview you do not understand, or any form of clarification you need, please feel free to inform me at any time. |
Part B: Demographic Data |
Please Tell Me a Few Details About Yourself… Name: __________ ________________ ___________Age: __________ yearsNationality of Origin: ________________Country of Residence: ________________Education Level: _______________________________Marital Status: ________________Children: ________________Ever Attended a PC Screening: ___________ and if so, When ________________ |
Part C: Main Body of Research Interests |
Leading Interview Question What do you feel/think about PCa screening sessions, based on your experiences? Are you happy that you underwent the procedure?’ |
Follow Up Questions Why did you attend the PCa screening session?Was it your first session or one among many sessions you have undergone?How old were you when you realized or heard about the need for PCa screening for Jamaican men, or for men in general?So, why did you attend the PCa screening session?Were you surprised about what they had to do to you, during the PCa screening session?Did you know exactly what to expect during the PCa screening session?Did it matter who conducted the PCa screening procedure, in terms of gender and age? How did you feel during and after the PCa screening procedure?What do you think now about the PCa screening procedure?What about the PCa screening procedure was offensive to you, if any?Do you think that attending PCa screening sessions is important for Jamaican men? Why?What about PCa screening would you like done differently, based on your experience?As a Jamaican man, do you feel that other Jamaican men should adherently attend PCa screening sessions now? If there were any other way of testing for PCa, would you prefer the alternative or the screening procedure? Would you like to, and will you, attend another PCa screening session after one or two years?In summary therefore, what do you feel/think about PCa screening sessions, based on your experiences? Are you happy that you underwent the procedure? |
Part D: Survey Summary |
Is there anything else you like to share with me on PCa screening for Jamaican men?—————————————————————————————————————————————————————————————————————————————————————————————————— Thinking about the areas we have covered in this interview, especially in regards to the experiences of Jamaican men during PC screening, is there anything else that you would like to add? If Yes, Please Explain:—————————————————————————————————————————————————————————————————————————————————————————————————— |
That will be all.Thank you for your time and participation in this study. Your contribution is highly appreciated. |
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