HEALTH EDUCATION RESEARCH Vol.17 no.1 2002
Theory & Practice Pages 73–84
Testicular self-examination (TSE) among Dutch young
men aged 15–19: determinants of the intention to
practice TSE latest update
Lilian Lechner, Anke Oenema1 and Jascha de Nooijer1
Abstract Introduction
The present study analyzed what determinants Unnecessary morbidity and mortality results from
are important to describe and explain the inten- cancers that could have been prevented or could
tion of testicular self-examination (TSE) for have been successfully treated, had they been
young men aged 15–19 attending senior high detected earlier. For many cancer sites detection
school (response rate 80%, n = 274). The ques- of the cancer early in the course of the disease,
tionnaire assessed determinants, including when treatment is more likely to be successful,
knowledge, attitude (positive and negative improves survival (American Cancer Society,
consequences, anticipated regret, and moral 1992). Testicular cancer is eminently curable when
obligation), social influence (social norm, social detected in an early stage (Giwercman et al., 1996).
support and modeling) and self-efficacy. Know- Five-year relative survival rates of testicular cancer
ledge of testicular cancer and TSE was very are high (99%) when detected early and, due to
low. Only 2% of the subjects reported regularly advances in treatment (chemotherapy), patients
performing TSE. After hearing of TSE (through with metastatic disease have 5-year relative sur-
the questionnaire), 41% of all young men had vival rates of 75% (Ries et al., 2000). Although
a positive intention to start performing TSE survival rates of testicular cancer are still relatively
regularly. The various intention groups (posi- high when the disease is detected at a later stage,
tive, neutral and negative) differed significantly the prognosis is not as favorable and the morbidity
on almost all of the determinants. Multiple effects, like sterility or impotence, are much more
regression analysis showed that young men who extreme (Roth et al., 1993; Dutch Cancer Society,
where anxious about TSE and those who were 1997). Hence, early diagnosis of testicular cancer
not anxious had different determinants is associated with a reduction in mortality, and is
explaining the variance in the intention to per- likely to be associated with a simpler and less toxic
form TSE regularly (R2 = 41–57%). Differences treatment (Austoker, 1994). So far, no randomized
in determinants of intention between young men controlled trials have been conducted providing
who are anxious about TSE and young men evidence of the long-term effectiveness of testicular
who are not can be used to design health self-examination (TSE). However, the very optim-
education interventions that may therefore be istic prognosis that results from early detection
more effective for these different subgroups. and treatment of testicular cancer stresses the
importance of teaching young men techniques to
self-detect early warning signs of testicular cancer.
The most relevant cancers that can be detected
Department of Social Science, Open University The
Netherlands, 6401 AT Heerlen and 1Department of Health by regularly self-examination are breast cancer for
Education and Promotion, Maastricht University, 6200 women and testicular cancer for men. Although
MD Maastricht, The Netherlands testicular cancer is far less prevalent than breast
cancer, it is the most frequent cancer for men aged and barriers that these young men experience
15–44 in The Netherlands (Visser et al., 1997). In concerning TSE.
1993, of all new cases of testicular cancer that
were recorded in The Netherlands, 61% were found Theoretical framework
in the group of adult men younger than 35 (Visser Several social psychology models suggest that a
et al., 1996). Adult men below the age of 35 are particular behavior is determined by the intention
considered to be the main high-risk age group with to perform this behavior (De Vries et al., 1988;
respect to testicular cancer. Therefore, organiza- Ajzen, 1991; Lechner and De Vries, 1995; Lechner,
tions such as the Dutch Cancer Society and the 1998). This intention is generally determined by
American Cancer Society recommend that adult three important factors: attitude, social influence
men below 35 should examine their testicles every and self-efficacy. These factors can be integrated
month (American Cancer Society, 1991; Dutch in models such as the Theory of Planned Behavior
Cancer Society, 1996). (Ajzen, 1991) or the ASE model (Attitude–Social
Unlike breast self-examination (BSE), which is influence–self-Efficacy) (De Vries et al., 1988;
more generally known among women in Europe, Lechner and De Vries, 1995; Lechner, 1998). Both
knowledge of TSE in Europe is reported to range frameworks have been proven relevant for studying
from 0 to 31% among males in the high-risk age behavior regarding TSE, BSE or breast cancer
group (adult men below 35) and TSE performance screening (Brubaker and Wickersham, 1990;
rates in Europe range from 0 to 18% (Best et al., Murphy and Brubaker, 1990; Lechner et al., 1997;
1996). In The Netherlands, 93% of men in the Moore et al., 1998; De Nooijer et al., submitted).
high-risk age group (adult men below 35) reported For the present study, the ASE model was used.
that they never performed TSE, while only 2.5% According to the ASE model, the first possible
of Dutch men reported that they performed TSE determinant of behavioral intention is the attitude,
10 times or more per year (Wardle et al., 1994). which consists of the perceived advantages (pros)
A recent study reported that 89% of the risk group and disadvantages (cons) of a particular behavior.
(adult men below 35) had never performed TSE, These expected outcomes (Bandura, 1986) may
while only 4% knew of the advice that men in the result from the behavior immediately or after a
15–35 age group should perform TSE every month longer period. With respect to TSE, this period
(Lechner et al., 1998). between behavior and possible outcomes seems
It can be argued that if TSE is to be encouraged particularly important: although long-term out-
(Friman and Finney, 1990; Rosella, 1994), it should comes of TSE might be very positive (TSE could
be stimulated at an early age. Since most young lengthen a healthy life), its short-term benefits may
Dutch men aged 15–17 still attend senior high not be so obvious, since TSE might cause tension
school, the school environment might provide the or fear of the results and might result in the
best setting for teaching young men about testicular detection of something one does not want to find
cancer and the practice of TSE. In order for (a lump). Several studies have found attitude to
education to be effective, it should focus on pos- be an important determinant of the intention of
sible misbeliefs, and it should be adjusted to performing TSE (Brubaker and Wickersham, 1990;
existing beliefs and knowledge concerning testicu- Steffen, 1990; Steffen and Gruber, 1991; McCaul
lar cancer and TSE. However, little is still known et al., 1993).
about the beliefs that these young men might have Another possible determinant of intention could
concerning TSE or about possible barriers that be the personal norm that people experience about
they experience to TSE. Therefore, in order to what would be the right thing to do. One aspect
develop effective interventions to stimulate young of the personal norm is anticipated regret (Van der
men to start practicing TSE, it seemed highly Pligt and Richard, 1993; Lechner et al., 1997).
relevant to gain insight into the knowledge, beliefs Young men might think that failure to perform
74
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