Abstract
Testicular self-exam (TSE) is an important tool to prevent late-stage diagnosis of testicular cancer (TC). However, most young men remain unaware of their risk for TC despite a growing number of interventions promoting knowledge and awareness of the disease. Of those interventions, very few discuss perceived vulnerability, perceived value of health promotion, and/or preference for informational materials as viable predictors of behavioral change. In this study, 300 university males were surveyed on their perceptions of vulnerability, perceived value of health promotion methods, TC/TSE knowledge, and preference for health promotional information. The results indicated that men were generally unaware of TC and were unsure of their risk of developing the disease. Participants reported very positive responses to questions about the value of health promotion methods, particularly TSE, and indicated a high intention to perform health promotion behaviors. Most important, participants noted that they preferred personalized, tailored information to learn about TC and TSE. Significant predictors of intention to perform TSE include knowledge and awareness of TC/TSE, perceived value of health promotion, and attitudes. Significant predictors of promotional tool preferences differed among generalized pamphlets, personalized messages, and group training sessions. The authors recommend that researchers tailor promotional messages in TC/TSE awareness campaigns with an individual’s preference for promotional tool.
Background
Overview
Incidence rates of testicular cancer (TC) are rising among the 15- to 54-year-old demographic, with the majority of those cases affecting males aged 35 years and younger (American Cancer Society, 2008). Although early detection through primary or secondary screening is of utmost importance for recovery and survivorship (Cox, McLaughlin, Rai, Steen, & Hudson, 2005; Steadman & Quine, 2004), regular screenings for the disease, including both screening by a primary care physician and testicular self-examination (TSE), are rarely performed (Brenner, Hergenroeder, Kozinetz, & Kelder, 2003). Men generally lack the knowledge and awareness necessary to discuss testicular health in an informed manner with their primary care physician or perform TSE. Cronholm, Mao, Nguyen, and Paris (2009) and Trumbo (2004) goes as far to suggest knowledge of TC among men has increased in recent years partly due to high-profile celebrity cases (i.e., Lance Armstrong and Tom Green), but report screening performance has not increased alongside awareness.
Despite the recent upsurge of TSE promotional campaigns (see Brewer, Roy, & Watters, 2010; Lechner, Oenema, & De Nooijer, 2002; Nasrallah, Nair, Congeni, Bennett, & McMahon, 2000; Rudberg, Nilsson, Wikblad, & Carlsson, 2005), there is a lack of reported long-term TSE performance among men. Fittingly, the American Cancer Society (2008) does not recommend TSE due to lack of evidence demonstrating its effectiveness in reducing mortality rates among males. Health care providers are encouraged to perform TC screening, but similar to TSE, there is no trend toward sustainability (Brenner et al., 2003; Horowitz, Reinert, & Caldamone, 2006). Therefore, empowering men to become aware of TC risks and become comfortable enough to discuss the said risks with their physicians is an important issue for researchers to further explore.
Predictive Variables in TC/TSE Intervention Research
The majority of descriptive research on the TC/TSE knowledge gap report on awareness/knowledge, self-efficacy, and/or cues to action and how they influence TSE behavior (i.e., Khadra & Oakeshott, 2002; McClenahan, Shevlin, Adamson, Bennett, & O’Neill, 2007; McCullagh, Lewis, & Warlow, 2005; Moore, Barling, & Hood, 1998; Steadman & Quine, 2004). Few TSE studies besides Steffen (1990) systematically tested within a multidimensional model, successfully demonstrated an effect, and reported on the relationship of perceived vulnerability and perceived value of health promotion on the decision-making process related to performing TSE. Some research discusses perceived vulnerability but their small sample size raises questions on the actual effect of the variable on behavioral change (see Daley, 2007).
Attitude, or outcome expectancies, has demonstrated its ability to predict TSE performance (Barling & Lehmann, 1999; Brubaker & Wickersham, 1990; Murphy & Brubaker, 1990). This is seen in a variety of behavior research studies, not just TC/TSE. For example, Welbourne and Booth-Butterfield (2005) discuss behavior change in firefighting and fire safety procedures. The authors state that participants scoring higher on theory of planned behavior variables such as perceived behavioral control and attitudes were “more motivated to engage in deeper levels of persuasive processing as a result” (p.152). Wallace et al. (1997) researched the influence of attitudes and subjective norms on oral care promotion for cancer patients, noting that “both attitude and subjective norms were significant predictors of behavioral intention” but that attitude was “the stronger predictor of this behavior” (p. 39). McClenahan et al. (2007) suggests that self-efficacy is the largest predictor of TSE performance but still acknowledges attitudinal influence on the behavior.
Tailored Messaging in TC/TSE Research Guided by Promotional Tool Preference
Most TC/TSE research is limited to a few predictive variables but test them independently of one another. This may be a primary contributor to the inability of behavioral interventions to produce long-term behavioral change in participant men. McClenahan et al. (2007) parallel Abraham and Sheeran (2005) and Dachs, Garb, White, and Berman’s (1989) research when they indicate how few studies compare intervention results among different theoretical frameworks and that a best-practices model for establishing a strong theory-based approach is essential to advance the field of TSE intervention research. McClenahan et al. (2007) determined that the theory of planned behavior is more structured and specific as to which constructs influence behavior change compared with the health belief model or other theoretical models used as frameworks for TC/TSE intervention research. Therefore, the semblance of a best-practices model is beginning to emerge in the field. However, more testing is necessary with the model to conclusively state such a claim.
Brewer et al. (2010) suggest that researchers should use tailored message designs in their promotional efforts where TC information is tailored to the individual rather than reporting basic facts to a generalized audience. If researchers can tap into the resources of tailoring messages to individual group attitudes and other predictive behavioral variables, and then test them within a formal theoretical context, such as the theory of planned behavior, TC awareness-raising and informed decision-making interventions could be more explanatory and, thus, more successful. Furthermore, if researchers can tailor a message in a format preferred by the participant, the intervention could see even more successful results.
The presented data provide an evidence-based rationale for conducting larger scale, more unique TC information promotional intervention research that includes the variables of perceived vulnerability, perceived value of health promotion methods, and preference of promotional materials. As such, this study responds to the challenge by Daley (2007) and Brewer et al. (2010) to further explore tailored messaging to promote TSE, specifically among a college cohort, and Robertson, Douglas, Ludbrook, Reid, and van Teijlingen (2008) recommendation that larger scale, more comprehensive studies are needed to effectively test predictor variables of TSE in promotional campaigns.
Method
This study gathered information on awareness/knowledge, perceived vulnerability, perceived value of health promotion, intention to perform TSE, and preferred type of promotional material. A convenience sample of 300 male students aged 18 to 35 years from a large public university in the northeast United States was drawn during the spring 2009 semester.
Primary data on perceptions of TC and TSE were collected via an original 41-item Control Identity Survey. The concept of “control identity” stems from the combination of participant locus of control and illusory control constructs and is used to group survey respondents into a typology defined by health control beliefs, perceived vulnerability, and perceived value of health promotion. This survey was tailored to solicit information on TC/TSE but can be applied to other health and wellness topics.
A secondary Multidimensional Health Locus of Control Survey (Wallston & Wallston, 1981) assessed participant health locus of control orientation and verified that both surveys measured locus of control similarly. Content validation of independent variables was completed using a panel of experts that included faculty from the Temple University’s Department of Public Health and the Department of Educational Psychology who have conducted previous research with the independent variables (see, e.g., DuCette, 1974). Once established, Cronbach’s alpha reliability check was performed. Wallston and Wallston’s (1981) survey was used to verify that both surveys measured outcome variables similarly. Overall, Cronbach’s alpha reliability coefficients of .85 were obtained for each survey section and were considered acceptable.
Survey questions were measured on an 11-point scale (0-10), with lower scores indicating decreasing importance/relevance to the participant and higher scores indicating increasing importance/relevance. The survey was grouped into five sections: overall awareness, perceived health control beliefs, perceived vulnerability, perceived value of health promotion, and preference for promotional information and intention to perform TSE. Sections were developed a priori based on previous behavioral health research demonstrating effectiveness of each construct on successful behavioral change.
Data collection was conducted through classroom site visits by the primary investigator, wherein copies of the survey were given to interested participants after being read a brief statement regarding the volunteer nature of the study and the inclusionary criteria. Participants were recruited at the end of a class to take the survey.
Further data collection occurred via an online collection site (Survey Monkey). Email listserv announcements, flyers, and snowball sampling methods were used to invite participants to visit the survey website. As with onsite classroom data collection procedures, inclusion/exclusion criteria for the study along with a brief description of the study were provided as part of the informed consent to take part in the study.
A brief statement on TC and TSE was given to each participant before the survey was administered in order to introduce the study. Participants were not asked for their current socioeconomic status, name, or any personal identifying information. Data collection began in January 2009 and concluded June 2009. Participants were asked for age and race and were given an identification number to protect privacy. All survey protocols were approved by the university institutional review board.
Analysis
This analysis aimed to illustrate predictors of “intention to perform TSE” and “preference for promotional information” among the sample. Data were not analyzed by race or age for this particular analysis, as the goal of the study was to assess knowledge and perceptions of TC and TSE for all males. Responses to the survey were aggregated, and a mean response score was derived for each section. Each question was scored on an 11-point scale of 0 to 10, with 0 indicating very little or no importance to the individual and 10 indicating very much importance to the individual. For example, if a mean score of 10 was recorded, we suggest that the individuals highly agree with the statement. If a mean of 1 was recorded, we suggest that the individuals do not agree with the given statement. A mean of 5 would indicate that the individuals were unsure about their feelings on the statement.
A series of multivariate linear regressions were run to determine what variables were predictive of “intention to perform TSE” and “preference for promotional information.” The independent variables for predicting “intention to perform TSE” included five composite variables extracted from a principal components factor analysis and two variables selected from survey responses. The composite variables include the following: IContol, OthersControl, and Manipulation (related to the health control beliefs section); Vulnerability (related to the perceived vulnerability section); and ValueHealthPromotion (related to the perceived value of health promotion section). The variables extracted from the primary survey included InformedTC and InformedTSE from the knowledge/awareness section.
The independent variables for predicting “preference for promotional information” (pamphlet, personalized information, and training sessions) included the composite variables IContol, OthersControl, Manipulation, Vulnerability, ValueHealthPromotion; the raw survey data variables InformedTC and InformedTSE; and Intention, which was developed from a mean score of three questions from the “intention to perform TSE” section.
Results
The racial makeup of the sample consisted of 70.7% White, 14.3% Black, 6.3% Asian, 4.3% Hispanic, and 3.3% Mixed/Other, which was similar to the university’s overall racial profile. All participants were college students aged between 18 and 35 years: 64.6% were between 18 and 22, 29.3% were between 23 and 30, and 6.1% were between 31 and 35. The mean age was 22.74 years, with a standard deviation of 4.11 years. A comparison of hardcopy survey takers and online survey takers was conducted, and it was found that no significant differences were present between the groups on core variables.
Knowledge and Perceived Value of Health Promotion
Participant men are generally uninformed on TC risk and screening procedures with means ranging between 4.14 and 5.72 on the 0 to 10 scale, as seen on Table 1. In addition, although the men perceive TSE as a valuable tool in fighting TC (x̄ = 8.36), prolonging life (x̄ = 8.35), and as a responsible thing to do (x̄ = 8.53), their reported lack of knowledge on TC/TSE raises questions about the validity of their responses. The men are highly optimistic about the value of overall health promotion (x̄ = 8.79) and they see the benefits of performing health behaviors (x̄ = 8.60), not just TSE.
Knowledge and Perceived Value of Health Promotion
Vulnerability
Men reported (0-10 scale base) relatively high scores on perceived vulnerability. Table 2 reveals that men believe they are vulnerable to TC at their age (x̄ = 5.57), can contract a life-threatening illness (x̄ = 7.63), and recognize that they could die prematurely (x̄ = 8.05). These data suggest that men generally are aware that they are susceptible to disease and early death.
Vulnerability
Intention
Mean values related to likely performance of TSE are demonstrated in Table 3. The mean score for “I will consider performing TSE sometime soon” was 7.52 on the 0 to 10 scale and 6.24 for “I will perform testicular self-examination this month and will plan to continue to perform it monthly.” At the same time, “I will not perform TSE” only rated a 1.83. This suggests that, in general, this sample is willing to regularly perform TSE at some point in the near future.
Intention to Perform Testicular Self-Exam
Preference for Promotional Material
Participants indicated that they are not only willing to receive promotional information but, depending on how that information is presented, also indicate that said information would influence their decisions on actually performing TSE. Table 4 shows that participants gave high positive scores to receiving promotional information via pamphlets (x̄ = 7.22) and one-on-one personal counseling sessions (x̄ = 7.63). However, men were slightly less positive about taking part in a group training session for TSE promotional information (x̄ = 6.18). These data suggest that men are willing to perform TSE and are receptive to promotional information.
Promotional Material Preference
Note. TSE = testicular self-exam.
Regression Analysis
A series of linear regressions determined which variables were predictive of “intention to perform TSE” and “preference for promotional information.” Predictors for intention to perform TSE are listed in Table 5. A 37% variance explained value was obtained from the model predicting intention to perform TSE. Significant predictors included knowledge/awareness of TC and TSE, OthersControl (i.e., subjective norms), manipulation (an attitude derivative), and perceived value of health promotion.
Predictors of Intention
Note. CI = confidence interval; TC = testicular cancer; TSE = testicular self-exam.
Predictor variables for individuals who prefer to have a pamphlet provide information and those who prefer personalized messages regarding TC and TSE are included in Table 6. The model demonstrated 27% variance explained with significant predictors including knowledge/awareness of TSE, perceived value of health promotion, and intention. Predictor variables for individuals who prefer to have a personalized tailored message provide information regarding TC and TSE are included in Table 7. The model demonstrated 31% variance explained with significant predictors including knowledge/awareness of TSE, perceived value of health promotion, vulnerability, and intention. Predictor variables for individuals who prefer to have training sessions regarding TC and TSE are included in Table 8. The model demonstrated 15% variance explained with knowledge/awareness of TSE, IControl, and intention.
Predictors of Pamphlet Preference
Note. CI = confidence interval; TC = testicular cancer; TSE = testicular self-exam.
Predictors of Personalized Information Preference
Note. CI = confidence interval; TC = testicular cancer, TSE = testicular self-exam.
Predictors of Training Session Preference
Note. CI = confidence interval; TC = testicular cancer, TSE = testicular self-exam.
Discussion
Consistent with existing literature, this study reports that men are uninformed about TC, the risks associated with the disease, and screening procedures, including TSE. This suggests that men are exposed to little, if any, promotional TC/TSE information in primary, secondary, and/or higher education. These data implicate that men most vulnerable to the disease know little about the risks or prevention methods that may prevent or lead to early diagnosis. However, it is encouraging that the value of health promoting behaviors is recognized.
Although the overall reported lack of TC/TSE knowledge and awareness in this study seem contradictory with participant judgments that TSE is a valuable tool to fight cancer and that TSE can assist in prolonging their lives, men overwhelmingly indicated that there was value in, and personal benefits to, performing health behaviors (x̄ = 8.79 and 8.60, respectively). Furthermore, they felt that performing TSE was a responsible thing to do. These data suggest that although men do not specifically know about TC and preventative tools (i.e., TSE), they are optimistic and willing to perform promotional behaviors.
Participants also reported feeling vulnerable to life-threatening diseases in their lives and that they recognize that they could die prematurely from such diseases. Although some literature suggests that men mask their sense of vulnerability due to their social environment and the burdens of living up to a masculine ideal (Henwood, Gill, & Mclean, 2002; Stansbury, Mathewson-Chapman, & Grant, 2003), this may be slightly overstated by some studies. This sample of men reported that vulnerability and mortality were something of which they were mindful. However, this study did not assess the influence of masculinity on perceptions of TC and TSE. More studies are needed to link health behavior decision making with perceived masculinity, perceived risk, perceived susceptibility to disease and death, and preference for promotional information.
Men in this study also stated that they would perform the TSE behavior either now or sometime in the near future. Although each man individually may be different in his willingness, on average, the sample is at least contemplating performing healthier behaviors. Their willingness to continue, or begin, performing healthy behaviors (i.e., TSE) and the fact that they feel vulnerable and are open to receiving promotional information suggests that a campaign/intervention targeted to this age group could be quite successful.
Predictors of Intention and Promotional Tools
The major variables predicting “intention to perform TSE” include knowledge/awareness of TC and TSE, subjective norms, manipulation, and perceived value of health promotion. This suggests that if men were more informed on the disease, its risks, and options for prevention, and if they have a more active sense of self-efficacy, had peer-group support, and a higher value of health promotion methods, they are more likely to perform TSE. This finding supports the current trend of informed decision-making promotion in men’s health research in the sense that if we increase participant knowledge of the disease and its risks, supply them with the confidence to discuss these topics with their physician, and allow them to perceive health promotion methods in a more positive manner, men will more than likely be more open to the idea of a more healthy lifestyle and perform health promotion behaviors. Such behavior could include TSE or discussing testicular health and wellness with their primary care physician.
The major variables predicting “promotional tool preference” are relatively similar across the three options offered to the sample, but they differ in some meaningful ways. Across all three of the preference choices, knowledge/awareness of TSE and intention were predictive of each preference. This suggests that men prefer to be aware of the subject and have some intention to perform a health behavior in order to be open to health promotional campaign suggestions.
There are some slight differences in predictors between the three preferences. Pamphlet prediction include perceived value of health promotion along with knowledge/awareness of TSE and intention while preferences for personalized tailored messages include knowledge/awareness of TSE, intention, perceived value of health promotion, as well as perceived vulnerability. This suggests that those men preferring personalized tailored messages may have a heightened sense of vulnerability to death and disease, thereby demanding a more personalized touch to their promotional information versus those men who prefer just a pamphlet of generalized information on TC/TSE. For those individuals who prefer a training session, knowledge/awareness of TSE, IControl, and intention were predictive, thus suggesting that these particular men may feel a certain predisposed desire to have more information regarding the disease for their own personal curiosity and want to know about each topic; however, they may not know enough to make a judgment on the value of the particular behavior in question. Therefore, these individuals will want to have a trained professional teach or demonstrate the behavior in order to become more familiar with the procedure. Furthermore, peer-group influence is predictive of intention to perform but not for pamphlet and personalized training session promotional tool preferences. This is indicative of the sensitive nature of TC/TSE and that actually performing TSE or discussing it among peers is a bit more complex than reading a generalized or personalized pamphlet or information or private message on the subject.
Limitations
There were limitations in how this study was conducted. First, the cross-sectional study design prohibits the establishment of cause and effect relationships between variables. Furthermore, the convenience sampling approach limits the generalizability of the study findings, as it is not a true probability sample, even though the sample was drawn from all majors and ages within the university male population.
Relative to the survey and participant responses, there are some concerns regarding introduced error. First, the brief statement at the beginning of the survey defining TC and TSE may have influenced questions regarding knowledge and awareness. Second, the self-report nature of the data must be recognized as a possible source of bias. Furthermore, some of the surveys were taken in large classrooms among many of the participants’ peers. It is possible that peer presence could have influenced responses.
It is acknowledged that an education bias may be evident given that only college men were surveyed. As such, external validity/generalizability is indeed limited. It is also recognized that literacy and social justice factors may affect access to health promotion resources by certain sectors of the male population.
Attrition and loss to follow-up were not an issue in this research due to the cross-sectional study design. Data were collected at one time for each individual and there were no follow-up assessments. The content validity of the study’s core concepts (vulnerability, perceived value of health promotion methods, and health outcome control) was enhanced through the use of a panel of experts to evaluate the study instrumentation, whereas the test–retest procedure was used to verify instrument reliability. Furthermore, the use contributed to the construct validity of the survey.
Recommendations
Daley (2007) indicates “there is no literature on the manner in which college students would like to be educated on testicular cancer” (p. 174). Brewer et al. (2010) suggest that strategies designed to promote TSE should be sensitive to individual differences in the influences on a person’s motivation to engage in TSE. This study reports on predictors of what may create those differences. This study is unique to the field in that there is evidence to suggest that there are different predictor variables for different forms of promotional information. In other words, different “types” of men may benefit more from a pamphlet of generalized information than personalized tailored messages or more so than a group training session, or vice versa.
Overall, the results suggest that participants prefer individualized, tailored messages over group sessions with other males present. The preference for individualized, tailored messages over group sessions suggests that although they want the information to perform the behavior, they still feel somewhat uncomfortable receiving the information when other males are present. This may reflect the influence of masculinity stereotypes on a man’s decision to perform TSE.
Future studies thus need to focus on developing new and innovative ways to tailor TC/TSE promotional messages to populations of men instead of using mass-marketed awareness campaigns (Trumbo, 2004). We suggest that if a tailored message using key predictive variables were targeted to men in this age group, TC informed decision-making skills and/or TSE compliance could be substantially increased.
We further suggest that future research should more closely examine the role that perceived masculinity plays in male health decision making. Extremes in perceived masculinity could blunt a man’s feelings of vulnerability and/or contribute to a perceived loss of “face” or social status. The existence of hypermasculinity could contribute to poor health behaviors and delay the adoption of important disease prevention techniques and prevent men from discussing testicular health with their primary care physician.
Footnotes
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported in part by the Foundation for Informed Medical Decision Making’s George Bennett Fellowship.