Keywords
Prostate cancer, Health-seeking behaviour, rural men, cancer awareness, South Africa
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Ntlongweni X, Nomatshila SC, Chitha WW and Mabunda SA. A protocol on Perspectives and Health-Seeking Behaviours of men on Prostate Cancer in Rural South Africa: A Qualitative study of survivors and the general population [version 1; peer review: awaiting peer review]. F1000Research 2026, 15:58 (https://doi.org/10.12688/f1000research.172798.1)
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Study Protocol
A protocol on Perspectives and Health-Seeking Behaviours of men on Prostate Cancer in Rural South Africa: A Qualitative study of survivors and the general population
[version 1; peer review: awaiting peer review]
PUBLISHED 14 Jan 2026
OPEN PEER REVIEW
REVIEWER STATUS
This article is included in the Oncology gateway.
This article is included in the Sociology of Health gateway.
Abstract
Corresponding author:
Xolelwa Ntlongweni
Competing interests:
No competing interests were disclosed.
Grant information:
The author(s) declared that no grants were involved in supporting this work.
Copyright:
© 2026 Ntlongweni X et al.
This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
How to cite: Ntlongweni X, Nomatshila SC, Chitha WW and Mabunda SA. A protocol on Perspectives and Health-Seeking Behaviours of men on Prostate Cancer in Rural South Africa: A Qualitative study of survivors and the general population [version 1; peer review: awaiting peer review]. F1000Research 2026, 15:58 (https://doi.org/10.12688/f1000research.172798.1)
First published: 14 Jan 2026, 15:58 (https://doi.org/10.12688/f1000research.172798.1)
Latest published: 14 Jan 2026, 15:58 (https://doi.org/10.12688/f1000research.172798.1)
Introduction
Prostate cancer is a growing non-communicable disease concern in South Africa and across the African continent.1 While advancements in screening and early detection have led to improved outcomes in high-income countries, men in low-income countries (LMICs) often continue to present with late-stage diseases due to a combination of system level barriers and personal health seeking behaviours.2,3 Despite national-level cancer awareness efforts, access to prostate cancer screening and early detection services remains inequitable, especially in rural provinces like the Eastern Cape.4
Rural men face unique challenges when it comes to prostate cancer. Limited health infrastructure, travel distances to health facilities and a lack of targeted public health messaging contribute to delays in diagnosis and treatment.5–7 There is also strong evidence suggesting that socio-cultural factors particularly norms around masculinity, stigma and traditional beliefs play a major role in how men perceive and respond to prostate cancer risk.8,9 For example, fear of emasculation, concerns about sexual function and embarrassment around rectal examinations are frequently cited reasons why men avoid screening.10,11 Prostate cancer does not only affect individuals medically but it also affects their social, emotional and economic wellbeing. Yet, the voices of men, especially survivors from rural areas are underrepresented in the literature. Their experiences of navigating the health system, coping with diagnosis and managing long-term effects of treatment remain poorly understood. Community perceptions about prostate cancer especially among men without a diagnosis are often shaped by hearsay perceptions, traditional views or general lack of awareness.12,13 These perceptions can influence whether men seek preventive care or avoid services until symptoms become severe.12,13
Existing literature on the South African context has mostly focused on epidemiology, risk factors and screening challenges, with less emphasis on lived experiences and health seeking patterns. A few studies have explored men’s reluctance to access services, but few have incorporated both survivor and general population perspectives within the same study, especially in rural districts.14 Understanding the barriers and motivators from both sides of the spectrum, those who have lived through the illness and those who may be at risk is essential for designing more effective, culturally responsive health promotion strategies. The Eastern Cape Province, more in particular the OR Tambo District provides a critical case study due to its high prostate cancer incidence and rural population profile.15 For example, Lusikisiki (a region that refers to Nelson Mandela Academic hospital) recorded an incidence (53.1 per 100 000) that was almost two times higher than the global incidence (29.3 per 100 000) in the period between 2013 to 2017.16
This study responds to the need for qualitative evidence that projects the voices of rural men. By engaging both prostate cancer survivors and men from the general population, this protocol seeks to explore the real-world perceptions, beliefs and behaviours that influence how men understand and respond to prostate cancer. The findings will help inform community-based interventions that are not only evidence-based but also culturally appropriate and rooted in the lived experiences of the target population.
Methods
Study design
Qualitative phenomenological, semi-structured in-depth interviews of prostate cancer survivors will be undertaken to ascertain their lived experiences, perceptions and beliefs on prostate cancer (survivors), and Qualitative exploratory, semi-structured, in-dept interviews will be undertaken among a general population of males to establish their knowledge on prostate cancer and their health seeking behaviour. This will also establish their attitudes towards orchidectomy as a strategy for managing prostate cancer.
Study setting
The study will take place in the OR Tambo District, located in the Eastern Cape Province of South Africa. This is a rural, predominantly isiXhosa speaking region marked by poverty, high unemployment and limited access to specialist health services.17 Health-seeking behaviour in the region is often shaped by cultural beliefs, reliance on traditional medicine and systemic challenges such as transport difficulties and long waiting times.6,18 Participants are recruited from both clinical setting. (for survivors), and community-based locations (for general population of men), this includes clinics and public spaces. The entire OR Tambo District has two regional hospitals, 12 district hospitals, 11 community health centres, 49 clinics, 52 health posts and 61 mobiles. All facilities refer cancer patients to the one central Hospital (Nelson Mandela Academic Hospital).19 According to the Eastern Cape Cancer Incidence Report 2013-2017, the incidence of prostate cancer is highest in Lusikisiki (53.1%), and Flagstaff (14.1%), this constitutes 88% of the total prostate cancer cases to originate from the OR Tambo District. This is why this study will be conducted in this district.
Population and sampling
The study population consists of two sub-populations:
First, prostate cancer survivors who were diagnosed and/or treated at Nelson Mandela Academic Hospital or affiliated facilities. Diagnosis should have been made at least six months before the date of interview to ensure that they would have had an opportunity to explore the different treatment options. The sub-study will employ a purposive sampling method; and will also target data saturation to ensure an adequate sample size is achieved. This will allow the gathering of comprehensive insights that might not be captured if the sampling would stop at a predetermined sample size. This sampling strategy will also ensure the validity and richness of the study on cancer patients.
Second, adult males from the general population with no known history of prostate cancer. Persons born as males, with no known prostatectomy and over 40 years of age who reside in the OR Tambo district will be interviewed in their place of residence. Thios will us a purposive sampling method where researchers will sample until a point of saturation is reached. This will ensure that the data collected is rich and diverse enough to fully understand the experiences of the men who will sampled.
Participants will be purposefully samples to ensure there’s variations in age, location (rural vs peri-urban), and exposure to healthcare. For communities that are hard to reach, snowball sampling may be used to reach more participants. A target of 15 participants per group will be recruited.
Exclusion criteria
• Men who are cognitively impaired (who do not have capacity to consent).
• Men who are visibly under the influence of alcohol or cannabis.
• Patients who are medically unfit to consent.
• Men who are undergoing palliative treatment (for the survivors), they may be in severe pain and experiencing severe complications.
• Males with a known prostatectomy.
Data collection
Data will be conducted in isiXhosa by the first author (XN). Interviews will be conducted in the place of residence accompanied by male members of the research team and will last approximately 45-60 minutes. An interview guide (Appendix A) will be used to cover personal experiences and perceptions, discrepancies between behaviour and health-seeking practices, awareness of surgical strategies for cancer prevention and community-0basd health education. The instrument has been systematically designed to gather comprehensive data on demographic characteristics, cultural norms and values, personal experiences and perceptions, discrepancies between behaviour and health seeking practices, awareness of surgical strategies for cancer prevention and community-based health education. The instrument has been systematically designed to gather comprehensive data on demographic characteristics, cultural norms and values, personal experiences and perceptions, discrepancies between behaviour and health seeking practices, awareness of surgical strategies for cancer prevention, and community-based health education. The key variables assessed by the interview guide include cultural norms and values, health-seeking behaviour, perceptions of healthcare services, acceptance of cancer prevention strategies and the impact of community education initiatives.
Qualitative exploratory, semi-structured, in-depth interviews will also be undertaken among a general population of males to establish their knowledge on prostate cancer and their health seeking behaviour (Appendix B). This sub-study will also establish their attitudes towards orchidectomy as a strategy for managing prostate cancer. The interview guide has been structured to comprehensively explore the norms, values, experiences and perceptions of men, with a focus on identifying the gap between their behaviour and health practices. The guide will be divided into specific sections, each targeting key areas of interest. The first section will gather demographic information, followed by an exploration of cultural norms ad values that will influence men’s attitudes towards health. Subsequent sections will delve into their personal experiences and perceptions of healthcare, particularly in relation to seeking health care. Another critical area of exploration will be the acceptance of surgical strategies used to manage prostate cancer, assessing how these interventions are perceived by men in the general population.
Audio recordings will be supplemented by field notes to preserve the exact language. The interviews will be conducted in isiXhosa, with verbatim transcriptions. These transcriptions will undergo a process of translation and subsequent back-translation to ensure accuracy and fidelity to the original content. Reporting will use the Consolidated criteria for reporting qualitative research (COREQ).20
This study protocol has been previously posted as a preprint on OSF and medrxiv.21,22
Informed consent
All participants will be provided with detailed information about the study objectives and procedures. Written informed consent will be obtained from all participants prior to data collection. Participants will be informed that their participation is voluntary and that they can withdraw at any time without penalty. For participants who are unable to provide written consent, verbal consent will be obtained in the presence of a witness (a member of the research team) and this will be documented, dated and timed, according to the ethical guidelines.
Trustworthiness
To ensure rigor several strategies will have to be employed to enhance trustworthiness and credibility of the findings following principles outlined by Ritchie21 Namely:
1. Trustworthiness: This will involve clearly documenting the research process and ensuring transparency in data collection and analysis
2. Audit trail: An audit trail will be maintained throughout the study, this will provide a detailed account of all research decisions, data collection and data anlysis procedures. This documentation will allow others to follow the research process and assess the consistency and dependability of the findings.
3. Peer checking: To enhance credibility and reduce researcher bias, peer checking will be employed. Colleagues with expertise in qualitative research and prostate cancer will review the data and preliminary findings to provide feedback and ensure that the interpretations are sound and unbiased. Furthermore, original audio-recordings will be transcribed into isiXhosa, the local language; transcripts translated into English by a [professional interpreter; and back-translated into isiXhosa by another independent language expert. Consensus will be sought by having the two language experts and the principal author (XN) listening to the original transcripts and making references to fieldnotes to correct discrepancies.
4. Member checking: After data analysis, member checking will be conducted by sharing preliminary findings with a subset of participants. This will allow participants to confirm the accuracy of the interpretations and provide additional insights, this will enhance the credibility of the results.
5. Triangulation: By comparing data from the two sub-studies and supplement with their respective field notes thus ensuring that the findings are consistent and reliable across multiple points.
Reflexivity
Customary to qualitative study research, this study will disclose reflexivity of the principal researcher (XN) and interviewer as a black, South African female of the amaXhosa tribe who is married with male children, she has intricate knowledge of the cultural practices of the community. The researcher is a health promoter and a researcher with public health training. In this culture where participants will be interviewed, it is difficult to openly discuss male sexual organs and male sexuality when conversing with males or elders. The Researcher will therefore have to overcome the cultural barriers and stereotypes of being perceived to be wanting to be treated differently because of her education and perceived socio-economic status when undertaking this research. Having been raised in rural areas of the Eastern Cape, the researcher possesses an understanding of the social cues specific to amaXhosa men. The co-authors are males, two of whom are medical doctors (SAM and WWC) and two of whom (SCN and WWC) are familiar with cultural practices from the population being interviewed.
Data analysis
Interpretative phenomenological analysis (IPA) and thematic analysis will be utilised. Transcribed data will be exported to NVIVO 14 for analysis. Thematic coding will be used to identify themes within the data. Inductive analyses will be used to help develop themes which emerge from the data. Themes will be derived using a six steps approach of familiarisation, coding, theme development, review of themes, defining of themes and reporting. Rich data will be represented by having multiple direct quotes from participants. Data will be summarised using graphs and Tables.
Dissemination
The findings from this study will be shared using a multi-level dissemination strategy to ensure accessibility and impact across academic, clinical and community audiences. At academic level, results will be submitted for publication in peer-reviewed, open-access journals such as F1000, enabling broad access for researchers and clinicians worldwide. Findings will also be presented at national and international conferences. Beyond academia, key results will be communicated to healthcare professionals and policy makers through seminars and stakeholder engagements, while community-level dissemination will include simplified summaries and outreach activities to raise awareness and foster informed decision-making among the public.
Study status
Ethical approval for this study has been obtained; participant recruitment and data collection has not yet begun.
Ethical considerations
This study has received ethical approval from the Human Research Ethics Committee of the Faculty of Medicine and Health Sciences at Walter Sisulu University (Reference Number: 014/2025). Additionally, access approval is granted by the Eastern CAPE provincial Research Committee (Reference Number: EC_202503_009) and the Nelson Mandela Academic Hospital. There will be no personal information that could be used to re-identify individuals. These measures will be taken to protect the data and safeguard patient information. For the other sub-studies where primary data will be collected will be obtained from participants before data collection. Confidentiality will be maintained by anonymising participants through unique identifiers, and all personal information will be de-identified prior to analysis. Explicit consent for recording will be obtained, and participants will be assured that their responses will remain confidential. Data will be stored and will be password protected. Only the Principal investigator will have access to the data. The records will be kept for five (5) years after completion of the study. Participants will be informed of their right to withdraw at any stage without repercussions.
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how to cite this article
Ntlongweni X, Nomatshila SC, Chitha WW and Mabunda SA. A protocol on Perspectives and Health-Seeking Behaviours of men on Prostate Cancer in Rural South Africa: A Qualitative study of survivors and the general population [version 1; peer review: awaiting peer review]. F1000Research 2026, 15:58 (https://doi.org/10.12688/f1000research.172798.1)
NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article.
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