Young men's awareness, attitudes and practice of testicular self-examination: a health action process approach

One-hundred-and-one Australian university students aged 18-25 years, with a mean age of 22. 9 years (SD = 1.62) completed a survey assessing testicular self-examination, and knowledge of testicular cancer, d statistically significant difference was found in knowledge scores between performers and non-performers. The factors influencing performance of testicular self-examination were examined using Schwarzer's (1992) Health Action Process Approach as the theoretical framework. Results showed that the majority of men were uninformed or misinformed about testicular cancer and testicular self-examination. Eighty-three per cent of respondents did not perform testicular selfexamination once per month as recommended. Intention, outcome expectancies and selfefficacy were the best predictors of testicular self-examination performance. Findings provided some support for the Health Action Process Approach. Testicular cancer, relative to other cancers in men, is not a prevalent cancer. In 1985 there were 5,000 new cases reported in the USA and 500 deaths (Neef et al., 1991). The best estimate available was that there would be 7,600 new cases of testicular cancer, and 400 deaths in the USA by 1998 (American Cancer Society, 1998). In Australia, 400 new cases were reported in 1990 (Jelfs et al., 1991). This number increased to 514 in 1994 (Australian Institute of Health and Welfare, 1998). Moreover, the incidence of testicular cancer when examined over a longer period is on the rise. In Australia, a study reported a threeto fourfold increase since the 1940s (Stone et al., 1990). The apparent paradox surrounding testicular cancer is that while it can lead to death, early diagnosis indicates that it is one of the most curable cancers (Queensland Cancer Fund, 1997). Further, an analysis of data reporting incidence and subsequent deaths indicates that the number of deaths had decreased by 50% since 1974 (American Cancer Society, 1998). While the number of deaths from testicular cancer is decreasing, it is still a leading cause of death in American and Australian men aged between 15 and 44 years (Friman & Finney, 1990). The significance of this general statement is apparent when testicular cancer is compared with other cancers, and when deaths are analyzed in `years of potential life loss'. Because testicular cancer principally attacks young males, it has the highest male mortality statistics in terms of `years of potential life loss' for male cancer victims (Friman & Finney, 1990). As with many forms of cancer, the aetiology of testicular cancer is unknown. The only major recognized risk factor is cryptorchidism (undescended testicle), which occurs in 10 to 12% of cases, leaving the risk factors for approximately 90% of cases unknown (Stone et al., 1991). The majority of cases report previous presenting symptoms, with the most common being a painless lump or swelling on the testicle (Raghavan, 1990). Early detection of testicular cancer is of paramount importance. The survival rate for early stage testicular cancer approaches 100%; however, the prognosis is poor for individuals with an advanced stage of the disease, with cure rates as low as 44% (Nikzas et al., 1991). Population screening as a method of early detection of testicular cancer is not justified due to the low incidence and low mortality rates (Buetow, 1996; Smart, 1990). However, Testicular Self-Examination (TSE) is a cost-effective alternative, which is simple to perform and effective in detecting abnormalities (Thornhill et al., 1987; Meffan et al., 1991). Cancer groups recommend that men perform TSE once per month from the onset of puberty through to 40 years of age (Queensland Cancer Fund, 1997). Research indicates that despite the value of TSE, the majority of men do not perform it (Cummings et al., 1983; Katz et al., Meyers, & Walls, 1995; Neef et al., 1991; Reno, 1988; Thornhill et al., 1986; Wardle et al., 1994). Unfortunately, Australian research into TSE is deficient, with the only data being an unpublished pilot study conducted by Ross and colleagues at Charles Sturt University. They surveyed 37 young mean aged 15 to 34 years of age and found that only 49% knew how to perform testicular self-examination and 43.2% had never examined their testes (Ross, personal communication). Knowledge about testicular cancer and TSE is necessary to perform TSE effectively, and research indicates that most men are uninformed, about both (Cummings et al., 1983; Ganong & Markovitz, 1987; Klein et al., 1990; Thornhill et al., 1986; Vaz et al., 1988). Again, Australian research is limited, with the only available data being a survey conducted by Raghavan (1990), a leading oncologist at the Royal Prince Alfred Hospital in Sydney. He surveyed 80 patients presenting at his practice and reported that less than 15% of presenting patients had heard of testicular cancer and only 10% were aware that young men were in the greatest at risk age group for developing testicular cancer. It is evident that further research needs to be undertaken to determine awareness and practices in the Australian context. Interestingly, studies have shown that increases in knowledge about testicular cancer and TSE do not produce concomitant increases in performance (Dach et al., 1989). These findings suggest that although knowledge is necessary to perform testicular self-examination, it is not sufficient, and other influencing factors need to be considered. Researchers have developed theories and models, such as the Self-Efficacy Theory (Bandura, 1977; 1986), the Theory of Reasoned Action (Ajzen & Fishbein, 1980; Fishbein & Ajzen, 1975), and the Health Belief Model (Becker, 1979; Becker & Maiman, 1975; Rosenstock, 1974) to investigate the factors influencing health behaviours. A variety of health behaviours have been investigated using health behaviour models (Brubaker et al., 1987; Fishbein, 1982; Maddux, 1993; Sutton, 1989). However, research using these models to identify the factors influencing performance of TSE has been limited in number (Brubaker & Wickersham, 1990; Katz et al., 1995; Reno, 1988). The Health Action Process Approach model was evolved by Schwarzer (1992), and was developed to address the inadequacies of earlier conceptualizations (Figure 1). The Health Action Process Approach (HAPA) includes components of previous models, which have been shown to be significant predictors of health behaviours. An investigation of the factors influencing TSE using this model as the theoretical framework may enrich the current understanding of why some men practice TSE and others do not. The present study will investigate testicular self-examination practices in young Australian men. It will also identify the factors influencing performance of testicular self-examination using the HAPA as the theoretical framework. It is hypothesized that most men will be uninformed about testicular cancer, and testicular self-examination (TSE). Most men will not be performing TSE, and the factors operationalized as components of the Health Action Process Approach will be significant predictors of TSE performance.