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The complexities of interviewingItalo-Australian men about sensitivehealth issuesTom A. Laws Lecturera & Murray Drummond Senior Lecturerb

a School of Nursing and Midwifery University of South Australia,Adelaideb School of Physical Education, Exercise and Sports StudiesUniversity of South Australia, AdelaidePublished online: 17 Dec 2014.

To cite this article: Tom A. Laws Lecturer & Murray Drummond Senior Lecturer (2002) Thecomplexities of interviewing Italo-Australian men about sensitive health issues, ContemporaryNurse, 12:2, 144-154, DOI: 10.5172/conu.12.2.144

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Key Wordsprostate; men;ethnic groups;methodologicalresearch;interview;NESC CN

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Copyright © eContent Management Pty Ltd. Contemporary Nurse (2002) 12: 144–154.

The complexities of interviewingItalo-Australian men about

sensitive health issues

ABSTRACT The increase in the incidence of prostate cancer in Australia has been followed byan increase in prostate cancer awareness among Australian adults. However,men’s level of knowledge on the subject has never been systematically assessed(Laws et al, 2000). It was postulated by Laws et al., (2000) that many men fromNon English Speaking Cultures (NESC) experience language and culturaldifficulties that would ultimately impinge on their ability to access informationabout prostate problems. In exploring ‘The knowledge and attitudes of Italo-Australian men toward prostate cancer’ the researchers became aware that themajority of interviewees (n=20) were reluctant to divulge information on allaspects of the topic (Drummond et al., 2001). This report highlights theimportance of using a reflexive phase within the research process as a means ofidentifying factors that can, in part, explain the paucity of data and act a basisfor developing strategies to overcome the problem.The research subsequentlyevolved to incorporate a secondary research question.‘Why were the men atinterview so reluctant to speak of general health problems and healthproblems related to prostatic dysfunction?’ A focus group comprised ofItalo-Australian men was used to explore gender and cultural factors, perceivedby the researchers as, restricting the flow of information. Several barriers thoughtto be limiting the release of information were confirmed.We conclude that ourfindings will have implications for other researchers wanting to maximise theirchances of accessing information rich data from the experiences of men fromNESCs.

Accepted 13 March 2002Received 10 January 2002

TOM A. LAWSLecturerSchool of Nursing andMidwiferyUniversity of SouthAustralia, Adelaide

MURRAY DRUMMONDSenior LecturerSchool of PhysicalEducation, Exercise andSports StudiesUniversity of SouthAustralia, Adelaide

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INTRODUCTION

The importance of this paper lies in thecomplexity of the research process with

Italo-Australian men. Further, its significancelies in how the research evolved to include theidentification of factors that contributed to alack of depth from in-depth interviews con-cerning Italo-Australian men’s descriptions ofthe function of the prostate, prostatic problems,and medical treatment for prostate cancer. Sec-ondly, a thematic analysis of their descriptionsprovided evidence to enable the researchers toidentify the major sources of information onprostatic problems for Italo-Australian men.The ultimate aim of the project was to identify(i) the men’s level of satisfaction with the acces-sibility of current information on prostate can-cer, (ii) the barriers to these men accessinginformation that may aid them in givinginformed consent on screening and treatmentoptions and (iii) the way in which Italo-Aus-tralian men would prefer to acquire their infor-mation on prostate cancer in a culturallyappropriate way.

Even though the research team had consid-ered issues surrounding the interviewing ofmen about sensitive health issues and developedappropriate strategies the collection of infor-mation rich data did not eventuate. For exam-ple, they avoided talking about their anatomy orresponding to questions concerning the impactof medical treatments for prostate cancer ontheir sexual health. Consequently, the methodof data collection occurred in two stages. Ini-tially, in-depth interviews were conducted withItalo-Australian men until a saturation ofthemes had been reached. The second stageevolved out of a reflexive process among fourmembers of the research team. Reflexive analy-sis by the research team led them to concludethat a focus group, comprised of men evaluatedas good informants in previous interviews,would be necessary to identify the factors thatcontributed to men’s silence on or evasion ofquestions.

LITERATURE REVIEWThe literature review was conducted usingthree interconnected areas of men’s health.Thefirst area pertained to the prevalence ofprostate cancer, men’s knowledge of how thiscancer is detected and the desired and unin-tended effects of the various treatments. Thesecond area concerned the ability of men fromNESC to access information on prostatic prob-lems and treatments. Scant literature was foundin relation to exploring health issues for NESCmen. Importantly, the third area of the litera-ture review focused on investigating men’shealth issues of a sensitive nature such as, adecline in men’s sexual function or alteration ofsexual function following medical/surgicalintervention.

Even though more Australian men die withthe prostate cancer than from it (AHTAC,1996:xii;Weller, 1998) prostate cancer remainsa serious health problem. Many men hold thebelief that screening for prostate cancer resultsin earlier detection of the disease and that inturn leads to earlier treatment and ultimately abetter chance of survival (Ohehir, 1996; Pin-nock & Wakefield, et al.,1998). However,whilst screening for cervical and breast cancerhas been shown to improve survival rates forwomen the benefits of screening for prostatecancer remains in question. Despite this manyAustralians continue to request screening forprostate cancer and General Practitioners(GPs) continue to perform screening tests.However, there are substantial problems associ-ated with screening men for prostate cancer.Firstly, Digital Rectal Examination (DRE) doesnot allow the doctor to palpate all aspects of theprostate therefore some cancers may be missed.Secondly, the blood test, serum Prostate Specif-ic Antigen (PSA), carries a high risk of record-ing a false positive result. The consequence ofthis is that a biopsy of the prostate is needed inorder to achieve a definitive diagnosis and thisbiopsy may cause haemorrhage and septi-caemia. In view of the lack of evidence to show

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that screening works and the risk of complica-tions following further investigation, medicalorganisation produce guidelines to the effectthat screening is not recommended (Laws etal., 2000). However, men presenting withsymptoms of prostate enlargement should betested as a means of verifying a diagnosis.Although the reasons why screening is not rec-ommended are clearly set out in literature pro-duced by the Anti Cancer Foundation the vastmajority of men in Australia are not aware ofthis advice, and are unaware of the recommen-dation. Further, many doctors continue toscreen men for prostate cancer when requestedbecause they either fear litigation for havingadvised against testing when the man later con-tracts prostate cancer, or they are unaware ofthe recommendations not to screen.The pointsjust outlined are not widely publicised perhapsbecause there is no consensus on what would bethe simple messages that can be passed on tothe community (Hirst et al., 1996).

With respect to treatment most men areuncertain about the effectiveness of the varioustreatment options, their side effects and theprobability of success. Laws et al. (2000) con-cluded that if the information outlined in thisreview has not reached Australian born menthen the probability of NESC being cognisant ofthese points would be substantially less. Theknown association between treatments for pro-static problems and altered sexual function wasa compelling reason for reviewing the literatureon the sensitive issue of men’s sexual health.

Pinnock et al. (1998: 368) concluded thatalthough attention had been given to men’shealth per se, “there have been few studies todetermine which issues are important from theview point of men themselves”. However, Pin-nock et al. study concludes unequivocally thatsexual health and sexual function is one of themost important health issues for men. Further,in the presence of pathology that has the poten-tial to diminish sexual function is particularlytroubling for men.

Considerable anxiety about prostate cancerwas expressed by men in this study. Borlandreported cancer as the disease most feared byAustralian men. Prostate cancer adds its owndimension of fear because of the perceivedthreat to sexual function and the importanceof sexual function to older men (Pinnock etal., 1998: 373).

The magnitude of sexual health problems hasonly recently been emphasised in terms ofimpotence.

Despite the increased interest in human sex-ual function during previous decades verylittle epidemiological data are available aboutmale impotence. Previous estimates indicatethat approximately 10 million men are impo-tent (Jolner et al., 1995)

Whilst Pinnock et al’s (1998: 369) approach toexploring men’s urological health includedfocus groups from different ethnic groups (Ital-ian,Vietnamese) there was no disaggregation ofthemes between English and NESB groups.Theinterviews had not been transcribed because ofthe cost involved.Therefore we were unable toaccess the primary data and determine if cul-tural differences existed.

However, Pinnock et al (1998: 370) madethe general observation that…

Men expressed anxiety, confusion, describedreluctance to talk about the issue, problemsin communication with the doctor, inade-quate counselling on sexual issues and majorimpacts of treatments on quality of lifethrough incontinence and impotence.

Jolner et al. (1995), used a self-administeredquestionnaire to assess the effects of impotenceon the quality of life for 1,680 North Americamen. They concluded that no difference couldbe established between ethnicity and the men’sresponse to two impotence questions. An

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indication of the dearth of data connecting uri-nary symptoms and prostate problems with sex-ual health problems can be demonstrated by areview of health assessment tools used by med-ical practitioners and nurses. Evaluating thefunction of the male urinary system by indexingsymptoms from a questionnaire was performedas early as the 1970. The Danish ProstaticSymptom Score (DAN-PSS-1) was developed asa refinement of indexing methods used fromthis time. In 1995, Hansen et al. conducted astudy to validate the Danish Prostatic SymptomScore (DAN-PSS-1) and concluded that this sys-tem of evaluation was a reliable, valid andresponsive means for assessing the ‘severity ofsymptoms’ amongst patients presenting withlower urinary tract complaints and surgical pro-cedures performed on the genito-urinary tract.However, questions about sexual function werenot included. Schou, Holm & Meyhoff (1996)attempted to address this shortcoming byincluding three questions on sexual function.The items were prevalence of erection, ejacula-tion volume and pain/discomfort during ejacu-lation.The lateness of this refinement suggeststhat either health professionals had not previ-ously perceived alterations in sexual function asan important symptom/side effect of treatmentor they found it difficult to include as a healthitem. As a consequence of these factors quantifi-cation of sexual dysfunction has been difficult.

Up until 1999 the prevalence of erectile dys-function in the Australian community did notappear in the literature and few international orAustralian studies of the prevalence of sexualdysfunction had surveyed the community (Pin-nock et al., 1999: 353, 356; Bortolotti et al.,1997). Pinnock et al. found similar or higherlevels of erectile dysfunction than comparableoverseas studies. Pathology other than prostateproblems were recognised as contributing tothe incidence of impotence.

RESEARCH METHODThe initial research plan involved the use of

semi-structured, in-depth, individual inter-views at a location determined by the intervie-wees as amenable to them. We estimated thatwe would have conducted approximately 20interviews before saturation of themes could beassured. To promote accuracy and encouragedialogue between researcher and subject wechose an interviewer who spoke fluent Italianand was employed as a provider of communityservices for Italians living within the Adelaidemetropolitan area. The interviewer was wellinformed on prostate cancer and the salientissues facing men who had received prostatetreatment. He also possessed first hand expo-sure to the prostate awareness information thathad been recently broadcast on Italian televi-sion.The sex of the interviewer was not seen tobe a factor that might influence selection of theinterviewer. In our recruitment we were onlyconcerned that the interviewer was sensitive tothe needs of men with prostate problems andattuned to their cultural norms.

“Catherine Koholer Riessman (1987) pointsout how ethnic and class differences overridegender in achieving understandings in inter-views; D. Millen (1997) examines potentialproblems when feminist researchers workwith women who are not sympathetic tofeminism” (Olsen, 2000)

In structuring the interviews the interviewerwould first ask about what prompted the men’smove to Australia, their experience as migrants,what characterised their working life and theirfamily connections in south Australia.This wasdone to establish a rapport and sense of trustbetween interviewer and interviewee. Thesequestions were followed by questions aboutmen’s knowledge of the prostate, urinary symp-toms associated with prostatic enlargement andtheir concept of cancer in general. Specificquestion about prostate cancer and their knowl-edge of this pathology were linked to knowl-edge of treatments and effects of treatments on

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sexual function. The interviewer we chose,whilst bringing many positive qualities to thestudy, did not have a health background; wesuspected that this could be a contributing fac-tor to the lack of depth in some interviewsregarding sensitive health issues. Consequentlywe developed strategies to minimise this effect.We provided the interviewer with literature onprostatic problems and we made sure the inter-viewer was familiar with some basic medicalterminology about the prostate and prostaticproblems. A member of the research team whohad cared for patients undergoing prostatic sur-gery and had contact with men who subse-quently developed impotence accompanied theinterviewer on an initial interview.The researchteam perceived that these strategies would con-tribute to the formulation of questions aboutmen’s sexual health in a sensitive manner andguide the timeliness of such questioning at theinterview. Patton (1990) states that the inter-viewer is required to be adept at wording andsequencing the questions appropriately to spe-cific respondents in the context of the inter-view, and we accompanied him on an initialinterview. The research team deemed thesepreparations as being appropriate and sufficientto secure rich and accurate data. Ethicsapproval for conducting individual interviewsand focus groups was obtained simultaneouslyand prior to their commencement of the study.

PRELIMINARY ANALYSIS OF DATAAND REFLEXIVE PROCESSAlthough communication between theresearchers and interviewer occurred as indi-vidual transcripts were received, a meeting wasscheduled between the research team and inter-viewer at the 10th interview. The purpose ofthis meeting was two-fold. First, it allowed theresearch team to review interviewing tech-niques and assess whether the informationbeing obtained was rich and descriptive enoughto base recommendations upon. Secondly, itgave the research team a sense of understanding

of how Italo-Australian men perceive issues sur-rounding prostate cancer awareness.

The data was analysed using an inductiveapproach to theorisation. Such an approachcomplements in depth interview basedmethodology very well. Upon analyses of thedata, similarities and differences were noteddrawing on personal understanding, profession-al knowledge, and the literature (Strauss,1987). The problem the researchers faced inthis instance was based on limited “explicit”themes. That is, the themes emerging fromwithin the interview data.

On review of the first 8 transcripts theresearch team were alerted to a lack of depthavailable from a majority of interviews. A fur-ther two interviews were conducted whilst theresearchers sought an explanation for this phe-nomena. Several meetings were held as part ofa reflexive process between the research teamand interviewer. Reflexivity was seen as a cru-cial component of this study. Crooks (1998:326) defines reflexive thought as “criticallythinking through the dynamic interactionbetween self and the data occurring during theanalysis of qualitative data.”

As part of the reflexive process it was decid-ed that the research team would interview theinterviewer with the objective of gaining hisperceptions of the difficulties he was experienc-ing in obtaining depth in the data. He relatedinstances where men obviously with drew fromthe interview process at which point he cor-rectly withdrew sensitive questions and easedthe interview into closure.

For example: One man crying

Apart from the themes identified in relation tothe men’s knowledge and attitude towardprostate cancer, several non-explicit themeswere emerging. We were beginning to under-stand how issues relating to regional differenceslinked to the men’s cultural background andexperience of immigration coalesced as factors

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limiting men’s willingness to divulge informa-tion. It was decided that a focus group wouldbe an effective method of triangulating the dataand verifying the interviewer’s perceptions.

Fontana and Frey (1994:364) point out that:

The use of the group interview is not meantto replace the individual interview, but it isan option that deserves considerationbecause it can provide another level of datagathering or a perspective on the researchproblem not available through individualinterviews.

Further to this point, the focus group interviewwould allow members of the research team tobe more closely involved in the interviewprocess and to raise particular issues thatrequired further clarification and discussion. Itwas also decided that in light of this new infor-mation we would continue with the individualinterviews until the focus group could be con-vened.

Sample selection of the focus group occurredby two methods.We invited those men who hadbeen good informants at the individual inter-views to be reinterviewed. Further, the inter-viewer invited men, who were from clientswithin his community service groups, to partic-ipate in the focus group. He chose men who heconsidered to be potential good informants. Aconscious effort was made by the team toensure that the focus group consisted of menfrom the various regions of Italy that were asso-ciated with distinct ethnic groups. Patton(1990) contends that the logic and powerbehind purposeful selection of informants isthat the sample should be “information rich”.This method of sampling is determined accord-ing to the needs of the study, and not accordingto external criteria, such as random selection.Our choice of purposeful sampling was alsoguided by the logic of Morse (1994:229) whoexplains that participants should be selectedbecause they are representative of the same

experience and knowledge (in this study, men’scultural background and the prostate prob-lems); not so they can be evaluated as represen-tative of the demographics in the generalpopulation.

The men were informed that we found it dif-ficult to gain sufficient in-depth information inthe individual interviews initially conducted.Therefore they were being invited back toexplore possible explanations for such anoccurrence. Consequently, the men in the focusgroup were not primed to give more in-depthinformation about prostate cancer per se butwere orientated toward explaining what theythought might be the reasons for a lack of depthin previous interviews. Two of the keyresearchers, assisted by the bilingual interview-er, conducted the focus group meeting.

FINDINGS OF FOCUS GROUPThe vast majority of the focus group interviewwas conducted in English. However, partici-pants confided in each other using Italian toclarify terms and interpret the occasional ques-tions. Overall the focus group meeting did notreveal any new factors that influenced the depthof disclosure than had been identified in theresearch team’s reflexive process. Region oforigin in Italy and the trials of immigrationwere overwhelmingly the obvious reasons whyItalo-Australian men do not talk about them-selves and their health problems.

Regional differencesThe key interviewer stated early in the focusgroup proceedings that it was widely recog-nised among Italians that men from southernItaly keep their thoughts to themselves and donot enter into discussion freely with peoplethey do not know well. The men at interviewconfirmed that the men from southern Italywere less likely to divulge about themselves andtheir family on any matters let alone sensitivehealth issues.The three men in the focus groupwere from the central and northern regions of

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Italy. Several men, known to be from southernItaly, could not attend focus group so theirviews were not presented.

By way of explanation all three men in thefocus group agreed that southern Italy has alwaysbeen known as an agricultural area whereasnorthern Italy is perceived as being more con-temporary, particularly in terms of embracingnew technologies. Linked to this was theunderstanding that men from southern Italywere believed to have lower levels of educationthan those in northern Italy and as a conse-quence were less likely to be exposed to andwelcome new ideas.These links and the socio-economic divide between southern and north-ern regions appear formally in the literature.For example, Bertelli (1985:52) in an historicalaccount, identifies the effects of invasions andoppression on the present day pyschie of Italianfamilies and social structure:

The decisive effects of these historical, politi-cal and socio-econmic forces on the Italianfamily can be seen in some striking differ-ences among the southern regions, such asSicily on the one hand and Calabria and Sar-dinia on the other.

Further, the extent of the social division is bestexemplified by calls for the separation of thetwo regions (secession) found in the Italiannews paper Il Globo. There is even a politicalparty called the Northern League which hasbeen claimed to be xenophobic by the press(Carroll, 2001).

Linked to the rural background was the ideathat men from southern Italy valued a more tra-ditional form of masculinity.The masculinisedideology that accompanies labouring occupa-tions is well documented throughout theworld, as is the fact that, ultimately this particu-lar view of manhood affects men’s health (Con-nell, 1995:93–95).

The activities of informal political organisa-tions were also cited as a reason for men from

the southern regions not wanting to reveal theirtrue thoughts or offer information. Althoughthe men who mentioned this at interview fellshort of naming the Mafia, the inference wasunmistakable.

The men at the focus group qualified theircomments by saying that some men from south-ern Italy would feel comfortable with disclosingdetails about themselves and their health statusbut generally, we as researchers could expectconsiderable resistance to our in-depth ques-tioning. The focus group members warned usthat should we do further studies we shouldexpect discussions about health issues to beguarded.

Experience of immigrationOn the basis of data from individuals and thefocus group we concluded that the men’s livedexperience of immigration had a profoundeffect on the way that these men seek and giveinformation. Essentially the men were ill at easein seeking information in general from non-Ital-ians and were reticent to disclose informationabout themselves. It was also evident that theywere cautious about any new information-seek-ing experience so they tended to adhere towhat was easiest, what they knew best.

It was evident from the individual transcriptsthat most of the men found their early experi-ences in Australia emotionally challenging.Some men claimed that they would havereturned home within a few weeks of arriving ifthat had been at all possible. However, theirfinancial constraints left them in a situationwhere they could do no better than survive onthe resources available to them. The mainsource of emotional and physical support camefor men and families who were in similar cir-cumstances. Such friendships provided themwith a sense of camaraderie in the face of adver-sity.The tendency to socialise within their ownculture in part explains why many of the mendid not achieve a good grasp of the English lan-guage — the transition from Italian to compre-

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hendible English would have been difficult andwith few tangible rewards in the short term.However, those with little knowledge of theEnglish language found only labouring positionsor work as tradesmen. Only one of the men hadgained a university degree but several had madetheir way to a middle management positionlater in life. Notably they had received a ‘good’level of education before immigrating to Aus-tralia.

The researchers had been very much awarethat Italo-Australian men’s inability to grasp thecomplexities of the English language wouldlimit their ability to understand contemporaryhealth issues in general and prostate cancerspecifically. For the majority of the men inter-viewed, the English language has often been abarrier to various aspects of their lives. As newimmigrants the men experienced difficulties inreading and writing basic English.They devel-oped a sense of inferiority with respect to theEnglish language and, for many of them, thishas had a lingering effect.This effect is particu-larly noticeable when the men come into con-tact with professionals whom they perceive asbeing highly educated and above them in termsof social hierarchy. Since these factors are rele-vant with respect to their GPs a number of themen confessed to feeling somewhat inferior totheir GP and a little intimidated in their pres-ence. Some of the men also perceived that a sig-nificant communication barrier existedbetween them and their GP and this created achasm that was difficult to bridge.Where healthinformation is concerned the men opted simplyto take their GP’s advice without reservation.This was simplest way of dealing with their lackof English communication skills. One of themen highlighted this issue by stating that:

Some professionals, they do take time toexplain it to you but if there is a block incommunication or some obstacles in com-munication then it would be hard for theprofessional to try and explain.

We believe that this simple way of dealing withprofessionals, discussing health issues, wasextended to the researchers in this study.Thiswas confirmed at the focus group and this pointis expanded on in the following theme “percep-tion to social status”.

Perception of social statusA further limitation stems from the use of indi-vidual interviews. First, the interviewer notedthat the men at the individual interviews per-ceived researchers as important people to betreated with respect. Despite the creation ofrapport before beginning the interviews few ofthe men appeared relaxed.The impression wasthat the men interviewed wanted to assist andfelt that, because they did not have much to say,they were not aiding us. This may have con-tributed further to feelings of inadequacy.Thisfactor is significant in the complexities of inter-viewing Italo-Australian men.

This sub theme ran parallel with our identifi-cation of a major theme in which these menwould not challenge the bio-medical model ofpatient management and were guided almostentirely by their GPs recommendations. Inshort respect for credentials/authority figureswere strong.

Spouse at interviewOne of the interesting culturally related issuesto emerge within this research project was thata number of the Italo-Australian men had invit-ed their wives to be a part of the interviewprocess.The original research methodology hadspecifically stated that men’s opinions and atti-tudes would be sought via in-depth individualinterviews with respect to prostate cancer andprostate cancer awareness. However, in someinstances it was the perception of the researchassistant that the women added to the data byclarifying facts, times and dates and so forth.Conversely, it is possible that, as a consequence

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of the spouses’ presence, some of the interviewdata may not be as rich as it could have been.

While having the wives present at the inter-views was perceived as a being a barrier toobtaining as much in-depth information as pos-sible, it was important for the research team tounderstand the cultural underpinning’s that hadled to such an occurrence. Within the Italiancommunity a woman’s role in marriage is notinsignificant. She does not sit back and allowher husband to make all the decisions. She isjust as involved as he is in considering impor-tant family-related matters.

The husband expects a lot of love from thewife, considers her socially inferior, but, atthe same time – once she has proven herworth – leaves her extensive freedom andresponsibility. He will not acknowledge inpublic, however, that this is so, and hisbehaviour outside the home will be differentfrom that at home. (Bertelli, 1985:61)

A research project such as this one, involvingboth the Anti-Cancer Foundation of South Aus-tralia and the University of South Australia, wasan important meeting that warranted both hus-band and wife in attendance. It was particularlyimportant that wives be present because Italianwomen are often perceived as the health careproviders within the family. Some of the menviewed their wife’s presence as being crucial tothe meeting because the spouse was able toprovide an accurate health history and healthinformation.The ability to recount informationabout their husband’s health, past and present,was a consequence of women finding out thenecessary information and passing it on to theirhusbands.

In some instances the women’s presence atmeetings was particularly valued when the menfound difficulty in either finding the appropri-ate words to express themselves or elaboratingupon information they may not have felt com-fortable in divulging. For example, in one inter-

view, a participant was asked if he had everheard of prostate cancer. After a long pause hiswife said:

His father had a prostate cancer. I keeptelling him to go to the doctor to have itchecked. He is scared. He is embarrassedabout the procedure.

It is not clear whether the presence of a spousewas a significant limitation to obtaining therichest, most descriptive information possiblefrom each of the participants. One of theresearch team members found that specificquestions were modified in the focus groupinterview to accommodate the presence of awoman.That is, several of the questions relatedto the side effects of treatment for prostate can-cer were not as probing as they would havebeen with only men in the focus group. Inrecognition of this situation, at the time theinterview was taking place the team sponta-neously embraced this cultural attitude (of theItalian community) rather than probe deeper atthe risk of embarrassing the interviewees andthe women.

CONCLUSIONAdditional depth on sensitive health issues sur-rounding prostate problems and prostate cancerwas not evident in the focus group data. Wethink there were two reasons for this occurring.Firstly we had informed the men in the focusgroup that we had encountered a problem ingaining depth in the individual interviews andthat we wanted to explore possible reasons asto why that was. Consequently, these were notfocused on giving more depth but explainingwhat they thought might be the reasons for alack of depth in the individual interviews. Sec-ondly, one of the men in the focus group wasaccompanied by his wife and this may have hada limiting effect on what information the othermen in the group were prepared to divulge.We

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have already discussed the effect of having awife present had on the men being interviewed.

The identification of non-explicit themesfrom individual interviews alerted the researchteam to the need for triangulation of data.Thiswas achieved through the formation of a focusgroup. This additional approach strengthenedthe validity and reliability of the study and theadditional data contributed greatly to the for-mulation of the recommendations. It is impor-tant to note that although the themes emerge as‘stand alone’ themes they are, in manyinstances, interconnected. Significantly, thethemes represent what many of the Italo-Australian men identified as issues, but they are themes and they do not represent everyindividual.

Finally, the experience of immigration, forthese men, is likely to be similar to those ofmany Australian immigrants. This point wasraised in the focus group as a reflection on thehardships associated with assimilating into anew culture and particularly a new culture ofhealth and health provision. On this point weconcluded that much of what we have identifiedas salient themes, both explicit and non-explic-it, for Italo-Australian men, will be applicableto men from different cultures. Consequently,the approach we have taken will be relevant toother studies that seek both to identify barriersin gaining knowledge and to explore attitudestowards the ways of gaining that knowledge.

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