A Q-Methodological Study of Male Attitudes Towards Testicular Cancer and Testicular Self-Examination

Discussion

As far as it is known, this is the first UK study to investigate TC/TSE knowledge and awareness amongst males aged 18 to 45 using Q-methodology. In doing so, this research has highlighted the potential of Q-methodology in exploring the diverse range of meanings or understandings that young adult males construct in relation to TC and TSE, and the need to explore this diversity as opposed to treating young males as a homogenous group (Darwin & Campbell, 2009). Participants’ Q-sort responses represented four distinct perspectives concerning TC and TSE. These four perspectives were subsequently interpreted and given appropriate descriptive titles, namely Media Influenced, Knowledgeable, Cautious and Mislead.

With the exception of factor E (Mislead) consensus existed regarding the prevalence of TC amongst high risk male populations. This was illustrated by the positioning of statements 9, 16, 33 and 37 across factors A (Media Influenced), C (Knowledgeable) and D (Cautious). Generally speaking, participants exemplifying factors A through to D demonstrated agreement with statements concerning TC incidence rates and statistics, albeit mildly. Equally notable were the contrasting views in relation to statements 21, 31 and 38. While factors C and D see TC as being a relatively rare form of cancer, factors A and E consider TC to be more common than lung and/or breast cancer. Although most participants knew that TC most commonly affects males aged 15 to 45, there was general disagreement concerning the many causes and risk factors involved in TC. Multiple statements (4, 12, 13, 24 and 40) addressed the genetic, biological and ethnic risk factors involved in TC. Whilst different views were expressed between factors on this issue, exemplars tended to be very consistent in their response (i.e. they either did or did not agree that familial history, race and cryptorchidism increases TC risk). Responses to these particular statements were surprising, given that some exemplary participants (loading onto factors C and D respectively) indicated that they had previously lost family members to TC and other forms of cancer. One might expect participants with familial history of cancer to have a heightened awareness of the potential genetic and biological risk factors involved in TC; however this did not prove to be the case. With the exception of factors D and E, participants were completely dismissive of non-factual statements and myths concerning the causes of TC (i.e. statements 3, 11, 27, 28 and 45). Interestingly, factor E exemplars asserted that tight underpants may increase TC risk, despite rejecting all notions of physical trauma and mobile phone usage having an adverse effect on TC risk.

Irrespective of specific factor loadings, participants were unanimous in acknowledging the role that TSE in plays in early detection and treatment of TC (as expressed in the moderately high rankings of statements 20 and 25 across factors A through to E), whilst all participants agreed that TC is highly treatable (item 32). Nonetheless, there were contrasting views concerning the specific symptoms often associated with TC. Participants loading significantly onto factors A, C and D were able to differentiate between the common symptoms of TC and the potential side effects of high-dose chemotherapy and radiotherapy; however factor E exemplars were not able to make the same distinction. Similarly, while participants exemplifying factors A, C and D recognised that testicular lumps and areas of swelling are not always indicative of cancer, the same could not be said for factor E exemplars (as illustrated by the contradictory rankings of statements 10, 26 and 39).

The findings reported above do not confirm past reports that young educated males lack knowledge and awareness of TC/TSE and do not recognise the importance of TSE (e.g. Goldenring & Purtell, 1984; Güleser & Unalan, 2010; Moore & Topping, 1999; Rudberg et al., 2005; Urgulu et al., 2010). Although the sample is not directly comparable to those used in past studies, results of the present research indicate that males in the highest risk age group for TC were more likely to have heard of TC and TSE than in previous studies assessing TC and TSE knowledge amongst males in academic populations. On the whole, participants exemplifying factors A, C and D were informed about the causes and symptoms of TC, and understood the importance of periodic TSE. Perhaps most importantly, the present research provides evidence to suggest that increased media coverage of TC and TSE has led to increased levels of knowledge about the disease and the importance of self-screening. This may be due to the fact that public health awareness campaigns advocating TSE are often endorsed by high profile celebrities (Everyman, 1999, 2002; Orchid, 2007). This was most certainly indicated by the overall positive rankings of statement 41 assessing knowledge of the ‘Know Your Balls... Check ‘Em out!’ campaign. These results point towards an increase in awareness and practice of TSE over the last 10 years, or indeed may reflect the well-educated bias of the male participants in this research. One could reasonably expect psychology undergraduates to have a greater appreciation of health matters than peers in other academic disciplines, or indeed the wider population. Nonetheless, the improved level of TC/TSE knowledge and awareness shown by young adult males in comparison to past research is particularly gratifying.

The negative effects of socially constructed views of gender and masculinity on men’s information-seeking and health-promoting behaviours are well documented (Lantz et al., 2001; Moynihan, 1998). As discussed earlier, adherence to these traditional masculine values often influence men’s overall attitude towards healthcare, their preparedness to practice TSE, their willingness to seek cancer screening, and the ways in which they might seek help should they ever be diagnosed with TC. Whilst results of the present research do not appear to support the current research position concerning the negative influence of masculine values on men’s health-seeking behaviours, factors C (Knowledgeable), D (Cautious) and E (Mislead) may be interpreted using components of the TRA (Ajzen & Madden, 1986). Of particular interest is the existence of a possible negative correlation between social support and TC/TSE knowledge in young adult males. Although factor E exemplars demonstrated some basic knowledge of TC and TSE, they were ultimately misguided about the causes and symptoms of TC. Perhaps more importantly, factor E exemplars indicated that they had formed their views through informal conversation with parents, peers and teachers. Consequently, as the amount of social support increased, overall TC/TSE knowledge may have perhaps decreased. These findings may have important implications for the formulation of strategies aimed at improving young men’s knowledge and awareness of TC and their adherence to self-screening practices. Recent recommendations put forward by healthcare professionals for improving TC awareness and encouraging TSE practice include the provision of dedicated health information websites and enhancements to doctor-patient relationships, together with an increase in the number of screening clinics at sports clubs and gymnasiums (Hall, 2003). Additionally, it has been suggested that females should be encouraged to promote health-seeking and related self-screening behaviours in their male partners (Norcross, Ramirez & Palinkas, 1996). In any case, young adult males should be reached through channels other than the medical arena, since they consult their GP (and other healthcare providers) less often than females, or indeed older males (de Nooijer et al., 2002).

Four distinct perspectives were identified during the course of this Q-methodological research. Still, it is important to note that these may not be the only ways in which young adult males construct meanings or understandings about TC and TSE. If the research was to be carried out again using alternate statements, different participants, or perhaps at a different point in time, it is likely that new perspectives may emerge from any analysis. Whilst Q-methodology focuses on distinct perspectives as opposed to the overlap between perspectives, those males holding mixed (confounding) perspectives accounted for 33.3% of participants in the sample. Consequently, it would have been of some interest to learn how these participants construct their meanings and understandings of TC and TSE.

Although participant samples in Q-methodological research do not necessarily need to be representative, efforts should be made to ensure breadth and diversity so that a greater number of standpoints, meanings and understandings may be accessed (Darwin & Campbell, 2009). A diverse group of young males loaded both significantly and exclusively upon each of the four factors. Nonetheless, male participants from diverse ethnic backgrounds were mostly under-represented in this research; including males of varied socioeconomic or educational backgrounds, sexual orientations and/or gender identities might also have provided a more complete picture (Brownlie, 2006). Moreover, whilst the sample size is not inconsistent with other studies employing Q-methodology, a larger sample size might have enabled the findings to be developed further by providing additional insight about the degree to which participant’s constructions of TC and TSE varied. It has previously been argued that Q-sorting often requires reasonably high levels of cognitive processing, and therefore it may well be the case that some participants do not fully understand the various requirements of the Q-sorting tasks (Jones, Guy & Ormrod, 2003). Throughout the research process, participants were invited to elaborate on their sorting choices by providing open-ended comments. Few participants indicated that they had encountered problems completing the Q-sorting task, though it is worth noting that participants’ open-ended responses often contradicted the views being expressed in the positioning of specific Q-sort statements.

TC is the most common malignancy in males between the ages of 15 and 45, and predominantly strikes during the prime of life, at a time when important personal, career and family decisions are made (Moore & Higgins, 2009). Cancer registries and support groups in the UK recommend that young men should be provided with, at minimum, a basic awareness of TC, and the knowledge that medical advice should be sought in the event that testicular lumps or masses are found. Overall, results of this Q-methodological study indicate that males in the highest risk age group for TC were more likely to have heard of TC and TSE, in comparison to past research assessing TC and TSE knowledge and awareness amongst males in academic populations. Nonetheless, some participants (namely those exemplifying factor E) were ultimately misguided about the causes and symptoms of TC. Clearly, there is a need for continued research to understand the many factors influencing men’s knowledge and awareness of TC and TSE, particularly with regards to social or peer support, and to formulate strategies or interventions that will promote practice of TSE in young adult males.

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Appendix A

Table 1. Factor A: Media Influenced

Table 2. Factor C: Knowledgeable

Table 3. Factor D: Cautious

Table 4. Factor E: Mislead