Promoting self-examination behaviors in men: a touchy subject?

In the United States a man is more likely to be diagnosed with cancer during his lifetime than the typical American woman. Over a lifetime an American man has a 50% chance of developing cancer while an American woman has a 33% chance (American Cancer Society [ACS], 2006). Once cancer develops, the American man is more likely to die from the disease. Approximately 243 white men and 339 African-American men per 100,000 will die from cancer annually compared to 165 white women and 194 African-American women (ACS). Similar disparities among men and women in health have been documented in other disease conditions including cardiac and pulmonary diseases (Smith, Bonhomme, Semanio, & Fox, 2003). This article will address promotion of health seeking behaviors in men and will use testicular cancer as a model for early detection and treatment.

Health Seeking Behaviors and Cancer

Differences in health seeking behaviors among men and women have been proposed as a factor to the higher morbidity and mortality among American men (Smith et al. 2003). Men and women demonstrate different approaches to seeking care and health maintenance. First, women are more likely to seek preventive care, utilize health services, and share information related to their health status (Lantz, Fullerton, Harshburger, & Sadler, 2001, Nicholas, 1999, Tudiver & Talbot, 1999). Men typically seek health care for specific needs, such as a work-related physical or a sports-injury. Men are more likely to avoid discussing emotional feelings or health status (Good, Borst, & Wallace, 1994). This avoidance may inhibit both information-seeking and health promotion in men and may explain the higher incidences of morbidity and mortality among American men (Lantz et al.). When men do seek intervention for symptom-related health concerns they are more likely to present with more severe symptoms, and experience higher morbidity and mortality (Banks, 2001; Nicholas, 2000; Tudiver & Talbot, 1999).

Second, early detection of cancer in asymptomatic individuals has been identified as an effective tool to decrease the severity of disease, promote early stage treatment, prevent exacerbations, and decrease mortality. Survival rates in certain cancers, such as breast cancer in women, have increased since the advent of effective screening tools such as mammography and breast self-exam. Cancers such as breast, colon, prostate, and testicular cancers have excellent survival rates when detected early. Yet, the mortality rate for colon and rectal cancer remains approximately 41 to 45% higher in American men than women (ACS, 2006).

Testicular Cancer: A Model for Early Detection among Men

Testicular cancer, although relatively rare in comparison to all cancers, is the most common cancer among men between the ages of 15 and 35 (Armstrong & Jenkins, 2001; Brenner, Hergenroeder, Kozinetz, & Kelder, 2003; Brown, 2004; McCullagh & Lewis, 2005; Vaughn, Gignac, & Meadows, 2002). Testicular cancer (TC) is a highly treatable cancer with a five-year survivability rate of greater than 99% if detected in the early stages (Vaughn et al. 2002, ACS 2006). Incident rates of testicular cancer have risen in the last 50 years (Pharris-Ciurej, Cook, & Weiss, 1999), possibly related to 1) better reporting mechanisms and/or 2) increased exposure to carcinogens at an early age (Brenner et al.). Testicular cancer most typically occurs in young men, and may have significant impact on the individual's lifestyle and life expectancy. Late diagnosis may have significant societal impact due to loss of the individual's contribution to society and family (Pinkowish, 2000).

Recent advances in treatment of late stage TC have led to increased long-term survivability. Oliver (2001) reports up to 60% disease-free survival at five years in patients with diffuse metastasis. However, treatment of TC may lead to significant sequelae including chemotherapy side effects, risk of secondary leukemia, infertility, and body image changes due to orchiectomy (Dearnaley, Huddart, & Horwich, 2001).

Testicular self-examination (TSE) is a relatively simple procedure. It can be taught to the general public and performed in private. It is similar to breast self-examination in women. TSE is easily taught with simple education and demonstration during physical examinations. The value of TSE has been discussed in medical and educational literature since the 1970s; yet, studies show that few men actually practice TSE (Brenner et al. 2003; Nicholas 1999). As many as 88% present initially for treatment of TC with metastasis (Brenner et al. 2003). The effectiveness of TSE is unclear. Studies of young men in the age range most susceptible to TC are unaware of TSE and know very little about signs and symptoms of TC (Brenner et al., 2003; Brown, 2004; Nicholas 1999; Khadra & Oakeshott, 2002). Some authors postulate that emphasizing TSE and risk of TC may actually have a negative effect on early symptom reporting as young men may fear the results of treatment more than the initial symptoms of the disease (Buetow, 1996; Gasgcoigne, Mason, & Roberts, 1999; Morris, 1996). However, nurses must ask: Could the cancer mortality among American men be decreased by increasing health-seeking behaviors and promoting early detection?

Methods

In this article, testicular self-examination (TSE) serves as a for a health-seeking behavior in men. The hypothesis is that, provided with exposure to information for making decisions about health care and access, men will implement health-seeking behaviors. To test this hypothesis, recent literature about TC and TSE was explored. The sample included five experimental or quasi-experimental studies with teen-age men completed in the past 10 years, and published in English. The five studies were conducted in the United States (3), United Kingdom (1), and the Netherlands (1). Authors included nurses, health educators, and psychologists.

A total of 2,634 men between the ages of 14 and 55 were included in the five studies. Study participants were recruited from high school classes (Best, Davis, Vaz, & Kaiser, 1997; Lechner, Oenema, & Noorijer, 2002), undergraduate psychology classes (Finney, West, & Friman, 1995), and work settings (McCullagh, Lewis, & Warlow, 2005; Wynd, 2002).

Convenience samples were used for all five studies. In three studies (Best et al., 1997, Finney et al., 1995, McCullagh et al., 2005) participants were randomized into treatment groups. Age, race/ ethnicity, and socioeconomic status (SES) were measured in some or all five studies.

Theoretical Framework

Only one study tested a theoretical model. Lechner and colleagues (2002) proposed the ASE Model for Health Related Behavior. In this model attitude (A), social influence (S), and self-efficacy (E) are precursors of intent to perform a health related behavior. The investigators tested attitude using three concepts: perceived positive or negative consequences of TC, the moral obligation to perform TSE to care for oneself or to meet others' expectations, and anticipatory regret about failure to perform TSE should cancer be found a late stage when it could have been detected earlier. Social influence included social support from significant others or awareness of peers or others who practice TSE. Self-efficacy measured the participant's belief in his capability to perform TSE and his perception of risk of developing TC. The concepts tested were derived from earlier work that assessed young men's concerns and perceptions about TC (Oenema, 1998, cited in Lechner et al).

Finney and colleagues (1996) found that social support did not influence performance of TSE. However, Lechner et al (2002) found that a sense of vulnerability (self-efficacy) was positively related to performance of TSE.

Interventions

A variety of interventions were used to teach men about TSE. These interventions included a) posting information about TSE and TC in changing rooms and shower stalls in fitness centers, b) peer training, c) videos of TSE, d) pamphlets with step-by-step TSE procedures outlined and pictures, e) health fair displays, and f) use of models with TC nodules. Most strategies required the learner to listen to a presentation or watch a film. Three studies required active learner engagement. In two of these studies the intervention materials were displayed and readily accessible. The participants could choose to bypass the displays or to view information at an exhibit during a health fair or to read waterproof stickers in the shower (McCullagh et al., 2005; Wynd, 2002). The third study required the participants to actually perform TSE (Finney et al., 1995).

Training was provided in group and individual sessions. High schools students typically were taught in class (Best et al., 1997; Lechner et al. 2002). Individual sessions were provided to undergraduate men. These sessions were the only ones to require a return demonstration of TSE which was recorded on video so that compliance with TSE training could be objectively evaluated by a panel of physicians. (Finney et al., 1995).

Only one of the five studies addressed correct teaching and measurement.. This study explored the use of peer versus adult trainers and used four different teaching delivery modalities All trainers participated in a 3-hour training session (Best et al., 1997).

Outcomes

Four outcomes were assessed in the five studies: knowledge of TC, TSE performance, satisfaction with training materials, and adherence to TSE over time.

Knowledge gains were identified through posttests and comparison to either participant baseline or a control group that had not yet received TSE training. All studies identified low levels of awareness of TC among participants (treatment and control) prior to the intervention. In most studies, knowledge was measured through objective questions that assessed the individual's knowledge of the incidence and risk of TC, early symptoms, treatment options, survival rates, and purpose of TSE. Construct validity was problematic in two investigations which noted that constructs and concepts were not effectively measured by the tools used(Wynd2002; Lechner et al, 2002).

TSE performance was measured in several different manners including:

* self-report of performance and frequency (Best et al., 1997; Finney et al., 1995; Lechner et al., 2002; McCullagh et al. 2005);

* intention to perform TSE (Finney et al.; Lechner et al.; Wynd, 2002); and

* -actual performance of TSE, observed via video (Finney et al.).

Authors expressed concern about self-reported data as such data may exaggerate or underestimate compliance (Best et al.; McCullagh et al). Finney and colleagues added a mail-back card for participants to report weekly adherence to the TSE protocol. In this instance, they noted that mail-back cards may actually underestimate adherence

Intent to perform TSE was measured using participant self-report in response to objective questions. Actual performance of TSE was only measured in one study that used both return demonstration and simulated exam of a testes model (Finney et al. 1995). Following a one-on-one session with a health educator, participants were asked to demonstrate TSE in a private room with a video camera.. The researchers found that despite detailed instructions, the participants frequently missed steps in the procedure as it had been taught (Finney et al., 1995).

Satisfaction with the teaching/training modality was measured in two studies. McCullagh and colleagues (2005) developed specific training conducive to remembering and performing TSE, such as men's changing rooms in work settings and locker rooms in fitness centers. In addition to displays using pamphlets and posters, reminders to perform TSE were posted on water-proof stickers in showers and on soaps. The authors of this study were interested in both the effectiveness of the teaching tools as measured by knowledge gains related to TC and self-report of TSE performance and by satisfaction with the method used. Participants reported a high awareness of the unique teaching tools and satisfaction with the quality and detail of the information. However, only 95 of the 252 men (38%) in the treatment group actually used the soaps with the slogans and reminders.

In the second study that addressed satisfaction with learning about TC and TSE, Best and colleagues (1997) were interested in the effectiveness of training for high school students. In this study, no difference was found in post-test TC/TSE attitudes of participants who received training from peers vs. professionals. Adherence to TSE protocols over time was assessed over three, six, and 18 month intervals in two studies. In the three months study participants were asked to mail in cards stating their continued adherence. At the end of the three months, participants returned for an interactive session with a researcher, provided a return demonstration of TSE, and verbally described their level of adherence and intent to continue TSE. While the participants did not consistently follow the steps taught in the TSE procedure, the majority reported that they had been continued to perform TSE during the interval (Finney et al, 1995).

Another study Best and colleagues (1997) assessed adherence to TSE in 524 high school men at six and 18 month intervals post-TSE training. They assessed another 276 participants at six months following training. In both samples, 48 percent of the participants reported continuing to perform TSE after 18 months.

Limitations

All studies had limitations due to sample selection, maturation and attrition, and/or novelty and testing bias. No study had a representative cross-section of the target population of men at risk for TC. Comparing the demographics of the participants to epidemiological reports of TC cases would have strengthened all the studies.

Discussion

Early detection of testicular cancer is associated with decreased mortality and morbidity (Brown, 2004; Dearnaley et al., 2001; McCullagh & Lewis, 2005; Oliver, 2001); there is some evidence about the usefulness of teaching TSE. The five studies analyzed in this article consistently found that men exposed to information about TC and TSE demonstrated increased knowledge of signs and symptoms as well as increased TSE performance. Two of the studies demonstrated adherence to TSE recommendations over 48 months.

Designs varied among the studies, all but one used variations of pre-test/post-test designs. Content validity of the tools was addressed while reliability and construct validity were inconsistently addressed. The theoretical basis of the studies was specified in only one study, The ASE Model for Health-Related Behavior (attitude, social influence and self-efficacy). In this review, the concepts of social support and perceived susceptibility to TC versus anxiety related to the diagnosis were found as themes or factors that influence TSE performance. While these were not presented as a theoretical framework by the authors, these concepts could form the basis for such a framework in future research.

Social Support: Participants who considered themselves likely to perform TSE were found to perceive high levels of social support (Lechner et al., 2002). A previous descriptive study had found this variable predict TSE (Barling & Lehman, 1999). The impact of this variable was support by Gascoigne and colleagues (1999) who interviewed six men with TC and found that significant other's expressions of concerns or reminders to see a physician exerted a positive effect in decreasing delays in seeking treatment for TC. These findings were substantiated a qualitative study in which 45 men diagnosed with TC were interviewed regarding their perceptions about treatment delays (Chapple, Ziebland, & McPherson, 2004).

Perceived susceptibility to TC as well as negative and positive perceptions of the consequences of performing TSE were also measured (Lechner et al., 2002). The group of students who exhibited negative emotions related to TC was more likely to perform TSE because they perceived a "moral obligation" to perform TSE to meet either their personal or their families' expectations. Best et al (1997) used physician utilization and perceived susceptibility to measure the degree of anxiety related to TC. They found no difference in these measures when compared to the control group. These studies demonstrate no overt increase in anxiety about cancer and suggest that a heightened sense of susceptibility may actually increase the likelihood of TSE adherence. These findings are in direct contrast to Buetow's assertion that teaching TSE will likely lead to "unnecessary patient anxiety and inefficient use of scarce resources" (1996, p. 5).

Reflections on the Research

The focus of the interventions used in these studies evolved during the time period analyzed (1995-2005). During the mid-1990s TSE was commonly viewed as an effective tool to reduce cancer mortality. The literature no longer recommends rigid adherence to self-examination protocols. Instead, individuals are encouraged to become familiar with their bodies, be aware of risks and treatment options, and to seek advice from a healthcare provider if a variance from one's "normal" is noted (National Cancer Institute, 2006a, 2006b).

The earliest studies were prescriptive and focused on teaching a step-by-step method to perform TSE, measuring the learners' knowledge of TSE steps and procedures (Best et al., 1997; Finney et al., 1995).

In the late 1990's the literature began to emphasize awareness of the individual's normal genitalia, recognition of early signs and symptoms of TC including changes in the shape and feel of a testicle ,low back pain, and risk factors related to TC (age, undescended testicle, family history, and being Caucasian) (Brott, 2006; Oliver, 2001). The studies reported since 2000 present interventions that focus more on identifying normal, recognizing differences, and increasing knowledge of TC (Lechner et al., 2002; McCullagh et al., 2005). This change reflects current recommendations regarding not only TSE, but other forms of self-examination.

Summary

The purpose of this article was to explore TSE as a model for interventions to promote health-seeking behaviors in men. While the men demonstrated a baseline lack of knowledge about TC and TSE, they demonstrated knowledge gains and health behavior changes after interventions. This finding is substantiated by the large number of descriptive studies that reveal extremely low levels of knowledge about TC (Barling & Lehmann, 1999; Brenner et al., 2003; Khadra & Oakeshott, 2002; Moore & Topping, 1999). The knowledge gains and adoption of healthy practices reported in the studies support the view that men are interested in certain health issues e.g. TC and TSE, but experience barriers to healthy behaviors (Banks, 2001; Nicholas, 2000). Research is needed to identify lack of baseline knowledge about TC and TSE and to determine if this lack of knowledge is representative of other health promotion behaviors among men.

Both Wynd (2002) and McCullagh et al (2005) identified that minority men and men from lower socioeconomic backgrounds were less likely to know about TC and practice TSE. The overall lack of knowledge about health practices and disparity in adopting healthy practices among minorities and individuals from lower SES raise concerns that should be addressed with further research. Unfortunately no other studies addressed discrepancies in knowledge of or practice of TSE among participants from differing ethnic groups or socioeconomic status. Further, only three of the studies provided demographic data related to race/ethnicity and SES and one of these studies (Best et al. 1997), used race and SES to normalize their samples, but did not explore differences in learning and performance related to these important variables. The low levels of adoption of health-seeking behaviors among minorities and individuals of lower SES reported by Wynd and McCullagh et al. represent a disturbing trend that needs further exploration.

Overall, the analysis of these five research studies supports the premise that, given exposure to information for making decisions about health care, men will implement health-seeking behaviors. However, these studies cannot be generalized to all men and other health conditions because of their design and measurement limitations. The low level of baseline knowledge about health practices found in all studies which used a pre-test give credence to concerns about health promotion behaviors in men. Further research is needed into barriers to health promotion among men with specific focus on minorities and levels of SES. This analysis demonstrates that specific positive health promotion behaviors can be effectively taught to men and men will adhere to these recommendations.

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Ann Strong Anthony RN, MSN 

Associate Dean, Nursing Program

Tulsa Community College