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).

Method

Participants

The final sample consisted of 27 males between the ages of 18 and 43 (mean age = 23.41, SD = 6.02). Twenty-three participants (85.2%) were recruited from psychology courses at Teesside University; most of whom responded to an advertisement placed on the University’s managed research participation system. Additionally, four participants (14.8%) known to the researcher, namely friends, peers and colleagues, were recruited for the study via E-mail and in person. All participants were recruited for the study on a voluntary basis. In terms of demographics, 24 participants (88.9%) identified their ethnic background as being white British/Caucasian, one (3.7%) as black/black British, one (3.7%) as mixed race, and one (3.7%) as Chinese/Asian. Nineteen participants (70.4%) identified themselves as being single, whilst the remaining eight participants (29.6%) stated they were married or cohabiting. Ten of the males (37%) were in their first year of undergraduate study, four (14.8%) in their second year of study, seven (25.9%) in their final year of study, whilst two males in the sample (7.4%) identified themselves as being postgraduate students.

Development of the Q-sort pack

Statements for the Q-sort were derived from academic literature and published research, health education campaign materials, practical guides, online community resources, attitude instruments developed during past research (namely Rudberg et al., 2005), and through what is ‘sayable’ about TC and TSE more generally (Darwin & Campbell, 2009). Health education materials were sourced through cancer charity organisations Macmillan (2010b) and Orchid (2008; 2009a; 2009b). The guiding principle in selecting the statements for the study was to aim for a diverse representation of ideas, opinions and discourses on the subject, to allow participants to engage with a varied range of viewpoints (Shinebourne & Adams, 2007a). Eighty-three statements were initially chosen, which represented a diverse range of viewpoints on:

• Popular ideas about TC and TSE
• Factual statements concerning TC and TSE
• The causes of TC
• Emotional consequences of TC
• Common myths surrounding TC and TSE
• Education (i.e. whether TSE should be taught in school and sexual health clinics)

From the initial pool of 83 statements, 38 were systematically removed during standard piloting procedures to form a final Q-sort pack comprising 45 items (Appendix A). Duplicates/repetitions and ambiguities were removed, and statements were generally discarded if pilot participants found them difficult to understand. Statements which, by and large, yielded ‘no opinion’ were subsequently removed from the final Q-sort pack, as were any statements for which participants demonstrated complete agreement or disagreement. Moreover, the pilot study allowed individual statements to be checked for clarity, and appropriateness of wording or terminology. The final Q-sort pack of 45 statements contained roughly equal numbers of ‘positive’, ‘negative’ and ‘neutral’ statements representing the categories outlined above. A Q-sort pack of 45 statements is often considered satisfactory, and is consistent with prior reputable studies using such methodological techniques (Shinebourne & Adams, 2007b; Watts & Stenner, 2005).

Materials

Participants were provided with an A4 plastic wallet containing detailed instructions, 45 randomly numbered statement cards, one copy of the Q-sort response grid, one copy of a short demographic questionnaire, an additional comments sheet (which included the open-ended question ‘Where do you feel your attitudes towards testicular cancer and testicular self-examination have come from?’), and two copies of an informed consent document. The Q-sort response grid matrix contained spaces for 45 statements in columns below a scale with integers ranging from -5 (most strongly disagree) through to +5 (most strongly agree). On completion of the Q-sorting task, all participants were provided with debrief documentation.

Procedure

On providing informed consent, participants were instructed to familiarise themselves with each of the 45 Q-sort statements, and to arrange the cards into three piles according to the extent to which they agreed or disagreed with each statement. Participants were then requested to sort the 45 Q-sort statement cards along a continuum from -5 (strongly disagree) through to +5 (strongly agree) according to the shape of the Q-sort response grid matrix (forced normal distribution). Starting with the ‘agree’ pile, participants were advised to select the two statements which they tended to agree with most, and then to place the cards accordingly on the blank Q-sort response grid. Next, participants were asked to select the two statements which they most disagreed with from the ‘disagree’ pile, and to place these cards in the appropriate boxes on the response grid. This sorting process was repeated until all statement cards in the ‘agree’, ‘disagree’ and ‘neutral’ piles had been allocated onto the response grid. On completion of the Q-sorting task, participants were advised that they were free to make changes, prior to confirming their final arrangement.

Immediately following the Q-sorting task, participants completed the additional comments sheet - participants were asked to elaborate on their sorting choices, by commenting on the statements they had most agreed or disagreed with. Participants were also asked to comment on statements they had deemed confusing or particularly difficult to understand, and to provide an answer to the open-ended question. Finally, participants were asked to complete a short demographic questionnaire concerning age, marital status, ethnic origin and year of academic study (where appropriate). On completion of the study, all participants were thanked for their participation and provided with debrief documentation.

Findings

Statistical overview

The 27 completed Q-sorts were entered into the dedicated Q analysis programme PCQ (Stricklin & Almeida, 2010), and statistically analysed using centroid factor analysis. Eight factors emerged from the analysis (rotated using orthogonal varimax procedures), which explained 59% of the total variance and accounted for 16 of the 27 participants. Nine of the remaining 11 participants significantly loaded upon two or more factors (designated as confounded). Only factors presenting an Eigenvalue greater than unity (EV> 1.00) together with two or more factor exemplars (i.e. participants loading both significantly and exclusively onto the factor) were interpreted. Factor interpretation was based primarily on the positioning of statements in each factor, combined with the open-ended responses and comments of those participants loading significantly upon these factors, along with any biographical or voluntary information offered. Each interpreted factor was given a descriptive title, and a summary of each factor is presented below in narrative form. In order to maintain anonymity during data analysis, pseudonyms will be used when referring to individual participants.

Factor interpretations

Factor A: Media influenced.
Factor A explains 9% of the study variance, and has an Eigenvalue of 2.41. Two participants loaded significantly onto factor A, as did three other participants with confounding Q-sorts. The theoretical array and key statements can be found in table 1. The two participants who loaded significantly onto factor A demonstrate a positive view of health promotion, and they acknowledge the role that TSE plays in the early detection and treatment of TC. This was particularly evident in participant open-ended comments; both participants indicated that the media had influenced their attitude towards TC and TSE. Anthony specifically stated that he had formed his views on the back of “media adverts and warnings from the NHS”, whilst Duncan commented that the ‘Know Your Balls… Check ‘Em Out!’ campaign has been “well advertised”. This is perhaps further evidenced by the endorsement of statements 25: ‘With early diagnosis, testicular cancer can be successfully treated in 98% of cases’ (+4) and 9: ‘Testicular cancer is the highest risk cancer for men between the ages of 15 and 45’ (+3). The endorsement of factual statements indicates that TC might well be at the forefront of men’s minds, however this may also point towards an over-reliance on incidence statistics in awareness campaign materials, as participants were mildly dismissive of statements concerning ethnic and biological risk factors involved in TC. Despite this, participants who loaded onto factor A appear knowledgeable about the issue, or at the very least, demonstrate an understanding of the symptoms often associated with TC. Participants who share this perspective acknowledge that TC is highly treatable, and recognise that the majority of testicular lumps, bumps and swellings are not cancerous. Consistent with this, participants endorsed statements concerning testicular changes, and they strongly disagreed with the notion that TC often results in poor quality of life. Participants who share this view are generally dismissive of the common myths surrounding TC, yet they do not appreciate that TC is rare in comparison to other forms of cancer. Whilst participants asserted that the fear of being labelled a hypochondriac should not discourage men from consulting their doctor about any testicular changes, they reported only mild agreement (or disagreement) with statements concerning the psychological, psychosexual or emotional effects of cancer.

Factor C: Knowledgeable.
Factor C explains 12% of the variance, and has an Eigenvalue of 3.26. Factor C had four significantly loading participants, making this the strongest factor to emerge from the analysis. In addition, three participants with confounding Q-sorts loaded significantly on this factor. The theoretical array and key statements can be found in table 2. The four participants who exemplified factor C demonstrate having substantial prior knowledge of TC and TSE. Two participants (Kurt and Pedro) commented that they had learnt about TC during school health presentations, whilst Bradley commented that “having a father who had and was successfully treated for prostate cancer and a mother who died from pancreatic cancer makes one all the more aware of cancer, and early detection”. These particular comments are further evidenced by the endorsement of statements 22: ‘School is the most appropriate place to be taught testicular self-examination’ (+3) and 4: ‘Brothers or sons of men who have had testicular cancer have an increased risk of testicular cancer’ (+5). A key theme of this account is that TC is seen to be highly treatable, and participants recognise the potential benefits of early diagnosis and treatment. Consequently, participants strongly endorse TSE; however they acknowledge that the fear of being labelled a hypochondriac might prevent young males from alerting their GP to any testicular changes. Consistent with this, participants who share this perspective demonstrate a positive view of public education and awareness campaigns promoting TC and TSE, and they do not feel that such campaigns are likely to increase anxiety amongst young males. Moreover, participants rejected the notion that masculine values might inform the ways in which young males think about TC and TSE. Although the participants who loaded onto factor C appear knowledgeable about the common symptoms associated with TC, they demonstrate a limited understanding of the potential risk factors for TC. However, participants were completely dismissive of non–factual statements and myths concerning the cause of TC. This is perhaps further evidenced by Gareth’s open-ended comments in response to statement number 3: “It seems a bit harsh to say that if your pants are tight, you may get cancer. They might be associated, but as a direct cause…” – this comment was provided despite the fact that the participant stated he knew very little about TC or TSE.

Factor D: Cautious.
Factor D explains 7% of the study variance, and has an Eigenvalue of 1.95. Two participants loaded significantly onto factor D, as did one other participant with a confounding Q-sort. The theoretical array and key statements can be found in table 3. The participants who loaded significantly onto factor D appear somewhat fearful of TC, and for one of the participants his views are based on the personal experience of losing a family member to TC. In response to the open-ended question, Damian provided the following comment: “My dad’s uncle died from testicular cancer which has made me aware of the painful death he suffered, so I have strong views on looking after yourself and self-checking regularly - even at an early age”. This is further evidenced by the endorsement of statements 23: ‘In over 25% of cases the cancer has already spread by the time of diagnosis’ (+3) and 40: ‘Inherited genetic factors are important in testicular cancer’ (+4). Moreover, Damian kindly provided additional comments in relation to these particular statements:

People do not want to believe they will get it because their dad will get it, so they choose not to get checked. There should be screening done as soon as you are 40 to prevent early onset of testicular cancer. (S.40)

Most men do not check their testicles and signs are difficult to pick up on, so by the time the pain threshold has been reached and the men do not feel embarrassed to go to the doctors it has already spread widely. (S.23)

Taking the above comments into account, it would seem that the participants see TC as being a disease which affects men aged 40 years and above only. However, this view was not reflected in the positioning of certain statements within this specific factor. Nonetheless, the participants who share this view understand that TC is rare in comparison to other forms of cancer, and they acknowledge that successful treatment is heavily reliant upon early detection. Furthermore, the men who share this perspective are able to differentiate between the common symptoms of TC and the potential side effects of high-dose chemotherapy and radiotherapy, and they realise that not all testicular changes are the result of cancer. Interestingly, the participants who loaded onto factor D demonstrate a limited understanding of the causes and ethnic/biological risk factors associated with TC, and they strongly agree with the notion that mobile phones may potentially trigger TC. A key theme of this account is that participants recognise the importance of TSE, and they assert that masculine values should not prevent young men from discussing any testicular lumps, bumps or swellings with their GP. Despite indicating mild disagreement with statement 20: ‘Testicular self-examination reduces anxiety and encourages young men to take greater responsibility for their health’ (-2), participants consider schools and GUM clinics to be the most appropriate environment for learning TSE, and they would appear to be in favour of health education and awareness campaigns addressing TC and TSE.

Factor E: Mislead.
Factor E explains 8% of the variance, and has an Eigenvalue of 2.08. Two participants loaded significantly onto factor E, as did four other participants with confounding Q-sorts. The theoretical array and key statements can be found in table 4. The participants who exemplified factor E would appear to be somewhat misguided about the subject of TC and TSE, with participants indicating that they had formed their views as a result of conversations with parents and peers. This was most certainly evident in the open-ended comments of both participants. In response to the open-ended question, Jake provided the following comment:

Mostly from a little information handed out over the years, as well as rumours and word of mouth etc. I think it does cause a lot of anxiety to men because the majority do not have all the information about it.

In addition, Patrick commented that he had previously been “taught to look after himself” by his parents and teachers. These comments would indicate that there is a potential for young males to be provided with inaccurate healthcare information through informal conversation with family members, friends and school teachers. Consequently, this account is characterised by conflicting views and an acceptance of inaccurate or misleading information concerning the risk factors and potential symptoms involved in TC. For example, despite asserting that testicular changes are not always indicative of cancer, participants seem unaware that testicular lumps and bumps are often found to be non-cancerous, and they may not realise that certain warning signs are associated with TC. Unlike the participants who loaded onto factor D, the young males who share this view appear unable to differentiate between the common symptoms often associated with TC and the possible side effects of cancer therapy. Moreover, the participants who loaded onto factor E demonstrate a limited understanding of the risk factors involved in TC, and they reject all notions of TC being a rare disease. The following additional comments were provided in response to statements 38 and 33.

Testicular cancer is more common in men than breast cancer is in women. (Patrick, S.38)

I do not think testicular cancer is rare, in fact it is quite common in young males. (Jake, S.38)

I think it will be a lot higher than 2% as there seems to be a lot of information labelling it as one of the main cancer types for men. (Jake, S.33)

Interestingly, it is important to note that the positioning of statement 31: ‘More men die of testicular cancer than women do of breast cancer’ (-2) contradicts both the views being expressed in the open-ended comments and the positioning of statement number 38 within factor E (-5). Although participants were dismissive of particular myths and non-factual statements, notably those concerning rashes on the scrotum and sporting strains and/or injuries, they believe there to be an association between tight underpants and increased cancer risk. Furthermore, participants who loaded onto factor E mistakenly believe that TC often affects both testicles. In spite of these contradictory findings, participants acknowledge that young males are those most at risk of TC, and they recognise that TC is highly treatable in cases where the cancer is detected during the early stages. Moreover, participants hold a positive view of health education awareness campaigns, and they acknowledge the role that TSE plays in the early detection of TC.

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

Q-sort pack statements
1.	Health campaigns promoting testicular self-examination only increase anxiety amongst young men.
2.	There are no warning signs associated with testicular cancer.
3.	Tight underpants can cause testicular cancer.
4.	Brothers or sons of men who have had testicular cancer have an increased risk of testicular cancer.
5.	Testicular cancer is often terminal and leads to poor quality of life.
6.	There are a number of different types of testicular cancer.
7.	Testicular cancer often results in an ache or heavy feeling in the groin.
8.	Testicular cancer often results in hair loss.
9.	Testicular cancer is the highest risk cancer for men between the ages of 15 and 45.
10.	The majority of lumps and swellings found on the testicles are the result of testicular cancer.
11.	If testicular cancer occurs in one testicle, it is likely to occur in the other.
12.	Testicular cancer is more common in white men than African-Caribbean or Asian men.
13.	Men with fertility problems have an increased risk of testicular cancer.
14.	Testicular cancer adversely affects sexual performance.
15.	Testicular cancer is not routinely screened for in sexual health clinics.
16.	Each year around 2,000 young men in the UK are diagnosed with testicular cancer.
17.	The exact causes of testicular cancer are unknown.
18.	Testicular cancer leads to feelings of being overwhelmed.
19.	The majority of men with testicular cancer who undergo chemotherapy treatment become infertile.
20.	Testicular self-examination reduces anxiety and encourages young men to take greater responsibility for their health.
21.	Leukaemia is more common than testicular cancer in young men.
22.	School is the most appropriate place to be taught testicular self-examination.
23.	In over 25% of cases the cancer has already spread by the time of diagnosis.
24.	Testicular cancer is more common in men who have a testicle that has failed to descend.
25.	With early diagnosis, testicular cancer can be successfully treated in 98% of cases.
26.	Most men who have testicular discomfort do not have cancer.
27.	Testicular cancer is associated with injury and sporting strains.
28.	Keeping a mobile phone in your trouser pocket can trigger testicular cancer.
29.	The most straightforward and safest way of dealing with a cancerous lump is to remove the testicle.
30.	Testicular cancer leads to weight loss.
31.	More men die of testicular cancer than women do of breast cancer.
32.	Testicular cancer is highly treatable.
33.	Testicular cancer is responsible for approximately 2% of all male cancers.
34.	Testicular cancer results in a loss of masculinity.
35.	The fear of being labelled a hypochondriac prevents young men from consulting their doctor.
36.	Blood in the urine is a common symptom of testicular cancer.
37.	Testicular cancer only affects older age groups (men over the age of 55).
38.	Testicular cancer is relatively rare compared to cancers such as lung or breast cancer.
39.	Most lumps found on the testicles are benign.
40.	Inherited genetic factors are important in testicular cancer.
41.	The ‘Know Your Balls… Check ‘Em Out!’ campaign aims to promote awareness of testicular cancer and testicular self-examination.
42.	Vasectomy does not increase the risk of a man developing testicular cancer.
43.	Testicular cancer leads to feelings of isolation.
44.	Testicular cancer often results in unbearable pain.
45.	Testicular cancer is associated with a rash on the scrotum.

Table 1. Factor A: Media Influenced

					6
					18
			3	4	19	1	7
		2	12	13	24	15	8	9
	5	10	21	14	30	17	16	20	25
11	27	35	38	23	31	34	22	33	26	41
29	28	37	40	45	44	43	36	39	32	42

No.	Statement.	Array position
Nine highest ranked statements (mostly agree)
41.	The ‘Know Your Balls… Check ‘Em Out!’ campaign aims to promote awareness of testicular cancer and testicular self-examination.	+5
42.	Vasectomy does not increase the risk of a man developing testicular cancer.	+5
25.	With early diagnosis, testicular cancer can be successfully treated in 98% of cases.	+4
26.	Most men who have testicular discomfort do not have cancer.	+4
32.	Testicular cancer is highly treatable.	+4
9.	Testicular cancer is the highest risk cancer for men between the ages of 15 and 45.	+3
20.	Testicular self-examination reduces anxiety and encourages young men to take greater responsibility for their health.	+3
33.	Testicular cancer is responsible for approximately 2% of all male cancers.	+3
39.	Most lumps found on the testicles are benign.	+3
Nine lowest ranked statements (mostly disagree)
11.	If testicular cancer occurs in one testicle, it is likely to occur in the other.	-5
29.	The most straightforward and safest way of dealing with a cancerous lump is to remove the testicle.	-5
5.	Testicular cancer is often terminal and leads to poor quality of life.	-4
27.	Testicular cancer is associated with injury and sporting strains.	-4
28.	Keeping a mobile phone in your trouser pocket can trigger testicular cancer.	-4
2.	There are no warning signs associated with testicular cancer.	-3
10.	The majority of lumps and swellings found on the testicles are the result of testicular cancer.	-3
35.	The fear of being labelled a hypochondriac prevents young men from consulting their doctor.	-3
37.	Testicular cancer only affects older age groups (men over the age of 55).	-3

Table 2. Factor C: Knowledgeable

					15
					18
			8	5	19	11	16
		1	9	10	21	14	26	7
	34	2	13	12	38	33	29	17	6
27	37	3	30	23	43	40	32	22	25	4
28	45	24	31	36	44	42	39	35	41	20

No.	Statement.	Array position
Nine highest ranked statements (mostly agree)
4.	Brothers or sons of men who have had testicular cancer have an increased risk of testicular cancer.	+5
20.	Testicular self-examination reduces anxiety and encourages young men to take greater responsibility for their health.	+5
6.	There are a number of different types of testicular cancer.	+4
25.	With early diagnosis, testicular cancer can be successfully treated in 98% of cases.	+4
41.	The ‘Know Your Balls… Check ‘Em Out!’ campaign aims to promote awareness of testicular cancer and testicular self-examination.	+4
7.	Testicular cancer often results in an ache or heavy feeling in the groin.	+3
17.	The exact causes of testicular cancer are unknown.	+3
22.	School is the most appropriate place to be taught testicular self-examination.	+3
35.	The fear of being labelled a hypochondriac prevents young men from consulting their doctor.	+3
Nine lowest ranked statements (mostly disagree)
27.	Testicular cancer is associated with injury and sporting strains.	-5
28.	Keeping a mobile phone in your trouser pocket can trigger testicular cancer.	-5
34.	Testicular cancer results in a loss of masculinity.	-4
37.	Testicular cancer only affects older age groups (men over the age of 55).	-4
45.	Testicular cancer is associated with a rash on the scrotum.	-4
1.	Health campaigns promoting testicular self-examination only increase anxiety amongst young men.	-3
2.	There are no warning signs associated with testicular cancer.	-3
3.	Tight underpants can cause testicular cancer.	-3
24.	Testicular cancer is more common in men who have a testicle that has failed to descend.	-3

Table 3. Factor D: Cautious

					1
					4
			8	3	6	7	9
		10	20	5	14	13	16	23
	2	15	21	12	18	19	33	25	32
11	34	17	24	29	38	30	39	26	40	22
27	37	31	44	45	42	36	43	28	41	35

No.	Statement.	Array position
Nine highest ranked statements (mostly agree)
22.	School is the most appropriate place to be taught testicular self-examination.	+5
35.	The fear of being labelled a hypochondriac prevents young men from consulting their doctor.	+5
32.	Testicular cancer is highly treatable.	+4
40.	Inherited genetic factors are important in testicular cancer.	+4
41.	The ‘Know Your Balls… Check ‘Em Out!’ campaign aims to promote awareness of testicular cancer and testicular self-examination.	+4
23.	In over 25% of cases the cancer has already spread by the time of diagnosis.	+3
25.	With early diagnosis, testicular cancer can be successfully treated in 98% of cases.	+3
26.	Most men who have testicular discomfort do not have cancer.	+3
28.	Keeping a mobile phone in your trouser pocket can trigger testicular cancer.	+3
Nine lowest ranked statements (mostly disagree)
11.	If testicular cancer occurs in one testicle, it is likely to occur in the other.	-5
27.	Testicular cancer is associated with injury and sporting strains.	-5
2.	There are no warning signs associated with testicular cancer.	-4
34.	Testicular cancer results in a loss of masculinity.	-4
37.	Testicular cancer only affects older age groups (men over the age of 55).	-4
10.	The majority of lumps and swellings found on the testicles are the result of testicular cancer.	-3
15.	Testicular cancer is not routinely screened for in sexual health clinics.	-3
17.	The exact causes of testicular cancer are unknown.	-3
31.	More men die of testicular cancer than women do of breast cancer.	-3

Table 4. Factor E: Mislead

					6
					14
			10	4	22	1	3
		2	12	7	34	5	18	11
	33	8	13	16	40	29	19	15	20
37	39	21	28	23	42	36	24	17	25	9
38	45	27	31	30	43	44	41	35	32	26

No.	Statement.	Array position
Nine highest ranked statements (mostly agree)
9.	Testicular cancer is the highest risk cancer for men between the ages of 15 and 45.	+5
26.	Most men who have testicular discomfort do not have cancer.	+5
20.	Testicular self-examination reduces anxiety and encourages young men to take greater responsibility for their health.	+4
25.	With early diagnosis, testicular cancer can be successfully treated in 98% of cases.	+4
32.	Testicular cancer is highly treatable.	+4
11.	If testicular cancer occurs in one testicle, it is likely to occur in the other.	+3
15.	Testicular cancer is not routinely screened for in sexual health clinics.	+3
17.	The exact causes of testicular cancer are unknown.	+3
35.	The fear of being labelled a hypochondriac prevents young men from consulting their doctor.	+3
Nine lowest ranked statements (mostly disagree)
37.	Testicular cancer only affects older age groups (men over the age of 55).	-5
38.	Testicular cancer is relatively rare compared to cancers such as lung or breast cancer.	-5
33.	Testicular cancer is responsible for approximately 2% of all male cancers.	-4
39.	Most lumps found on the testicles are benign.	-4
45.	Testicular cancer is associated with a rash on the scrotum.	-4
2.	There are no warning signs associated with testicular cancer.	-3
8.	Testicular cancer often results in hair loss.	-3
21.	Leukaemia is more common than testicular cancer in young men.	-3
27.	Testicular cancer is associated with injury and sporting strains.	-3