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

Introduction

Testicular cancer (TC), despite being a relatively rare disease, is the most frequently occurring malignancy in males between the ages of 15 and 45 (NHS Choices, 2010). TC accounts for 1 to 2% of all cancers occurring in males, with approximately 2,000 new cases diagnosed in the UK each year (Cancer Research UK, 2010a). Cancer Research UK (2010b) estimate the lifetime risk of developing TC to be 1 in 210 (for men in the UK), whilst incidence rates have been shown to peak at around 17 per 100,000 for males in the 25 to 34 age category. Incidence rates have risen steadily over the course of the last 30 years; however the reason for this rise remains unclear (Holdstock, 2010). Similar increases in TC incidence rates have been reported in numerous industrialised European countries, notably Spain and Slovenia (estimated to be almost 6% per year on average), whilst overall rates of TC have remained exceptionally high, but stable, in Switzerland for several decades; although the underlying causes in these trends have not been identified (Bray et al., 2006). Similarly, incidence rates are reported to have risen by almost 5% in Poland and Germany, with rising trends more prominent in men aged 15 to 30 (Adami et al., 1994). In contrast, TC is practically unheard of in parts of Africa and Asia (NHS Choices, 2010). As before, the reasons behind these trends are at the present time unknown.

Many attempts have been made to increase public knowledge and awareness of TC and testicular self-examination (TSE) amongst male populations (Evans, Steptoe & Wardle, 2006). These efforts have included the publication of health education awareness leaflets and guides (Macmillan, 2010b; Orchid, 2009b), informational CD-ROMs and DVDs (Macmillan, 2007, 2010a; Orchid, 2007) and national media campaigns advocating TSE. For the most part, cancer support organisations encourage TSE practice, with advice to seek medical attention from GPs or Genito Urinary Medicine (GUM) clinics should any concerns or problems arise (Handy & Sankar, 2008). While TSE is often recommended, there is surprisingly little data available concerning the prevalence of TC/TSE knowledge and awareness among male populations. Still, research conducted since the mid-1980s has consistently demonstrated that young males are uninformed about their risk for TC, have poor knowledge of the common symptoms associated with TC, and rarely practice monthly TSE in line with recommendations.

In what is now one of the most frequently cited papers in the literature, researchers Goldenring and Purtell (1984) surveyed knowledge and practice of cancer self-screening techniques amongst a sample of US College athletes aged 18 to 23 years. Eighty-seven per cent of males in the sample were unaware of their risk for TC, whilst only 10% had been taught how to perform TSE. Rather worryingly, only 4% of males in the sample had been taught how to perform TSE by their GP, despite the fact that 97% had undergone a physical examination in the three years previous. Only 6% of male participants actually examined themselves on a regular basis. In direct contrast, 64% of females had received breast self-examination instruction (BSE) (79% by their GP), with 33% of females in the sample performing BSE on a regular basis. Similarly, Moore and Topping (1999) surveyed knowledge and awareness of TC and TSE in a sample of 203 male undergraduate and postgraduate students aged 18 to 45 years, reporting that 32% had prior knowledge of TSE, whilst only 23% claimed to practice TSE once per month as recommended. While 27% of participants correctly identified the many risk factors and causes associated with TC, 7% felt that sexually transmitted diseases increased TC risk, with a further 2% indicating that HIV was a casual factor in TC. Alarmingly, 2% of participants felt that TC was directly related to homosexual intercourse. Consistent with these findings, 27% of males in a sample of Swedish high school students indicated that sexual problems were the most common symptom of TC, whilst only 12% reported having performed TSE during the 12 months previous (Rudberg, Nilsson, Wikblad & Carlsson, 2005). Less than half of the male students in the Swedish sample (48%) knew that TC is the most common malignancy in their age group. Furthermore, 87% of participants considered TC to be a serious disease, whilst 72% claimed to be afraid of TC. More recently, the work of researchers Güleser and Unalan (2010) and Urgulu et al. (2010) has added further weight to the notion that young males are misinformed about their risk for TC, and do not understand the importance of periodic TSE.

Whilst the results of these studies are enlightening, they should be viewed with caution. In light of the fact that participants were drawn from academic institutions, the low levels of TC and TSE knowledge and awareness demonstrated throughout these studies is particularly worrying, especially when one considers that males in academia are arguably better educated than peers in other sections of society (Moore & Topping, 1999). Nonetheless, it could be argued that participant samples were specific to the male population most at risk of developing TC, namely well-educated males between the ages of 15 and 45 (Moore & Topping, 1999). In addition, these particular studies are not without their methodological shortcomings. Firstly, the method of data collection chosen by Goldenring and Purtell (1984) leaves a number of critical questions unanswered; only those participants responding correctly to the question ‘What is the most common form of testicular cancer in a young male your age?’ were asked where they had obtained their knowledge. It would have perhaps been beneficial to learn how misinformed participants had formed their views on the subject. In the same way, only participants providing confirmatory responses to questions 2 ‘Have you been taught to examine your testicles for cancer?’, and 3 ‘Do you examine your testicles for cancer?’ were asked to provide additional information. Moreover, results lend themselves to a number of reporting biases due to the fact that multiple-choice (Likert scale) forms of data collection were used. Moore and Topping (1999) report that 74% of participants correctly indicated that lumps were associated with TC, whilst 53% of male students in the Swedish sample expressed similar views. This could lead to erroneous assumptions being made regarding the level of TC knowledge held amongst these male samples; lumps are associated with cancers in general and it could well be argued that participants were simply attempting to guess the correct answer (Moore & Topping, 1999).

Unfortunately, these findings are not limited to participants in academic populations. In one of the first studies of this kind, Thornhill et al. (1986) surveyed public attitudes towards the disease in a sample of men of higher socioeconomic status. Ninety-two per cent of participants had never heard of TSE, whilst only five males (1%) claimed to examine themselves on a regular basis. These particular findings are echoed by the work of Wynd (2002), who discovered that 64% of adult employees attending occupational health fairs in the United States rarely, or never, practiced TSE. Interestingly, Wynd (2002) reported that demographic and socioeconomic variables were significantly related to TSE knowledge and performance, with Caucasian males and/or those of higher educational attainment more likely to practice TSE. In much the same way, de Nooijer, Lechner and de Vries (2002) reported that 64% of males in a sample of Dutch adults had never previously heard of TSE, although demographic and socioeconomic variables could not be factored in due to small participant numbers. Conversely, 34% of females in the Dutch sample reported that they practiced BSE once per month or more, with 29% performing BSE once or twice every three months, and 37% performing BSE no more than twice every six months (de Nooijer et al., 2002). Lastly, research carried out in British healthcare settings, notably GP surgeries and GUM clinics, has confirmed that such attitudes towards TC and TSE are not merely those representative of higher socioeconomic populations (Handy & Sankar, 2008; Khadra & Oakeshott, 2002).

The studies summarised above are affected by various limitations and therefore results should be interpreted with caution. Firstly, selection bias forms a common theme in past research. By and large, males belonging to higher socioeconomic classes are not representative of the wider population as a whole. There can be marked differences or health inequalities between males living in different social environments (Robertson, Douglas, Ludbrook, Reid & van Teijlingen, 2008) and one would expect males of higher socioeconomic status to be better educated, and perhaps more health conscious, than males in the wider population (Whiteford & Wordley, 2003). Consequently, the results reported in the studies cited above may not necessarily reflect general population trends, attitudes or beliefs. In addition, the mean ages reported in some studies are reasonably high, ranging from 32 to 46 years, and do not necessarily represent the group of males at highest risk of developing TC (de Nooijer et al., 2002; Khadra & Oakeshott, 2002). Nonetheless, these findings constitute a significant concern for the prevention, diagnosis and management of TC (Wynd, 2002).

Interestingly, none of the studies cited above address the question of how masculine behaviours, norms and values might inform the ways in which young males understand TC and their TSE practices. From a social constructionist perspective, gender is practiced in social interactions and is signified by beliefs and behaviours; many men are socialised into believing that they are ‘hard’ or ‘strong’, and by reporting emotional and physical symptoms or discomfort they display signs of weakness (Moynihan, 1998). Consequently, learning to endure emotional or physical pain is simply part of being male (Nicholas, 2000). In their social relationships, males interact socially around external matters, namely sports, business, politics or personal interests; emotional feelings and health concerns are considered personal or private matters, and are therefore not discussed in public (Murphy, 1998). Should men ascribe to these socially constructed gender roles, both information-seeking and health-promoting behaviours may be inhibited (Lantz, Fullerton, Harshburger & Robins Sadler, 2001). This general reluctance to discuss personal concerns or health issues may extend into the doctor-patient relationship; men are often less forthcoming when seeking medical attention and less likely to provide specific details regarding their health concerns (Kroenke & Spitzer, 1998). Moreover, whilst females often rely on their GP for sources of healthcare information, males are more likely to use family, friends and electronic media as sources of health information (Meissner, Potosky & Convissor, 1992). Men who take this passive role when seeking healthcare information are often less informed about health and the many screening options available (Meissner et al., 1992).

For Wynd (2002), social support is a factor of increasing interest in helping young men to understand the importance of periodic TSE, and the need to seek medical attention should symptoms ever be detected. Research indicates that a lack of social support differentiates those who rarely (or never) practice TSE from those who perform TSE on a monthly basis (Wynd, 2002). Moreover, Gascoigne and Whitear (1999) have previously identified social and emotional support as being factors which contribute to a man’s decision to seek medical attention; wives who supported their husbands emotionally were instrumental in persuading their husband to seek medical attention in cases where testicular abnormalities were found. In examining the applicability of the theory of reasoned action (TRA) (Ajzen & Madden, 1986) in relation to TSE performance, Brubaker and Wickersham (1990) reported that subjective norms (i.e. the perception of support or approval from significant others) may in fact enhance a man’s intention to perform TSE. However, Finney, Weist and Friman (1995) subsequently examined the efficacy of social support as a means of TSE adherence. On this occasion, social support (i.e. reminders to practice TSE provided by significant others) was found to have no effect on TSE adherence, or frequency of performance (Finney et al., 1995). Nevertheless, the intention to practice TSE is considered by many to be a key component in men’s testicular health practices (Lechner, Oenema & de Nooijer, 2002; McGilligan, McClenahan & Adamson, 2009). Whilst the provision of healthcare information (or interventions designed to increase uptake of TSE) can increase men’s intentions to practice TSE, attitudinal factors have been shown to mediate the relationship between knowledge and TSE practice (Lechner et al., 2002). Summarising past research, Poljski, Andrews, Holden and de Kretser (2003) identify a number of attitudinal barriers to performing TSE and include; perceptions of being immune to TC; the belief that TSE is not important to health; perceived embarrassment or difficulty in performing TSE; expectations of TSE becoming an awkward (or time consuming) process; concerns about the general reliability of TSE; and fears about what the TSE procedure may reveal.

The consensus prevails that young males have poor knowledge and awareness of TC, and do not recognise the importance of periodic TSE. Given that health professionals and cancer registries often recommend monthly TSE, and the fact that few researchers have previously assessed male attitudes towards TC and TSE, the next step would be to determine the current level of TC/TSE knowledge amongst young adult males using qualitative forms of data collection. A thorough review of the literature revealed that past research has relied heavily on quantitative measures including self-report questionnaires and health risk appraisals; methods which, by and large, lend themselves to a number of biases. To date, no previous studies have explored male attitudes towards TC and TSE using Q-methodology. To tackle these gaps in the literature the present study uses Q-methodology to address the research question: What attitudes do young males currently hold towards testicular cancer and testicular self-examination? Q-methodology enables these research gaps to be tackled through exploring the diverse range of meanings and understandings that young males construct regarding TC and TSE. Q-methodology was devised by British physicist William Stephenson in the 1930s, and provides a means of exploring subjectivity in a range of situations, from the standpoint of the persons lived experience (Cross, 2005).