Promoting men’s awareness, self-examination, and help-seeking for testicular disorders: a systematic review of interventions

Objectives

The aim of this systematic review is to evaluate the effectiveness of experimental studies, and the findings of structured reviews of experimental studies promoting men’s knowledge and awareness of testicular disorders and/or self-examination, behaviours and/or intentions to examine their testes, and help-seeking behaviours and/or intentions for testicular symptoms. The primary outcomes of this review are presented below using the PICOS (participants, interventions, comparisons, outcomes, and study design) framework (http://handbook-5-1.cochrane.org/):

Primary outcomes:

1. The effect of intervention on men’s knowledge and awareness of testicular disorders and/or self-examination, compared to baseline and/or control conditions (i.e. alternative intervention or no intervention).

2. The effect of intervention on men’s behaviours and/or intentions to examine their testes, compared to baseline and/or control conditions (i.e. alternative intervention or no intervention).

3. The effect of intervention on men’s help-seeking behaviours and/or intentions for testicular symptoms.

Due to the anticipated dearth of literature on testicular disorders, secondary outcomes such as measures of benefits and/or harms, economic evaluations, and process evaluations were also considered.

Protocol and registration

This systematic review was guided by the Cochrane Handbook for Systematic Reviews of Interventions (http://handbook-5-1.cochrane.org/), and reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) checklist¹⁸ (Supplementary File 1). The review questions and methods were predetermined and were not amended during the review process. The review protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO) under the registration number CRD42018093671.

Eligibility criteria

Studies were eligible for inclusion if they used an experimental or structured review design and were conducted among men who did not have a diagnosis of a testicular disorder. Studies addressing primary and/or secondary outcomes and studies evaluating the effect of intervention(s) compared to baseline and/or control conditions were included. The full inclusion criteria are reported in Table 1 using the PICOS framework.

Men with a diagnosis of a testicular disorder, studies with women only, and studies where findings from men and women are indistinguishable were excluded. Additionally, quantitative descriptive studies, qualitative studies, opinion papers, and conference abstracts were not eligible for inclusion. Theses and dissertations were also excluded because the merit of their use in systematic reviews is questionable¹⁹.

Information sources and search strategy

The following electronic databases were searched on April 13^th 2018: Academic Search Complete, Medline, CINAHL, PsycINFO, ERIC, and The Cochrane Library. In addition, eligible studies were sought from trial registries including the World Health Organisation International Clinical Trials Registry Platform (ICTRP) and Clinicaltrials.gov. The grey literature (i.e. the Grey Literature Report and Open Grey) and reference lists of eligible papers were also reviewed for eligible papers. The search was limited to records published in English between November 1^st 2014 (the date of the last search in the review by Saab et al.¹⁶) and April 30^th 2018.

The following keywords were searched on title and abstract using Boolean operators “OR” and “AND”: “testicular disease*” OR “testicular disorder*” OR “testicular cancer” OR “testicular neoplas*” OR “testicular tumor*” OR “testicular tumour*” OR “testicular malignan*” OR “benign testicular disorder*” OR “benign testicular disease*” OR “testicular torsion” OR epididymitis OR orchitis OR epididymo-orchitis OR hydrocele OR varicocele OR spermatocele OR “testicular symptom*” OR “testicular pain” OR “testicular lump*” OR “testicular swelling” OR “scrot* symptom*” OR “scrot* pain” OR “scrot* lump*” OR “scrot* swelling” AND knowledge OR awareness OR practice* OR self-exam* OR “self exam*” OR feel* OR screen* OR “early detect*” OR help-seeking OR “help seeking” OR “help-seeking intention*” OR “help seeking intention*” OR “help-seeking behavior*” OR “help-seeking behaviour*” OR “help seeking behavior” OR “help seeking behaviour” AND intervention* OR inform* OR educat* OR “health education” OR “health promotion” OR trial* OR experiment* OR stud* OR program*.

Study selection and data extraction

Records identified from electronic databases, trial registries, and grey literature searches were exported to a software package for reference management (EndnoteX8). Duplicates were then deleted and the records were transferred to Covidence, an online service use by Cochrane reviewers to facilitate screening and data extraction.

All records were screened on title and abstract. Following the exclusion of irrelevant records, the full-text of potentially eligible studies was obtained for further screening. Title, abstract, and full-text screenings were conducted by two independent reviewers (M.M.S. and J.H.). Screening conflicts were resolved either by consensus or a third reviewer.

A standardised extraction table was used to extract data from experimental studies^16,17. Data were extracted by one reviewer (M.M.S.) and cross-checked for accuracy by a second reviewer (J.H.). The following data were extracted: author(s) and year; aim(s); country, setting and funding; participants; design and theoretical underpinning; intervention(s); outcome(s) and data collection; and findings presented according to the review questions. As for structured reviews, a separate data extraction table was designed by two experienced reviewers (M.M.S. and J.H.) to include the following: author(s), year, and country; aim(s); review type and funding; eligibility criteria; data sources; study selection and data extraction; quality appraisal; and study characteristics and findings.

Quality and level of evidence assessment

The Quality Assessment Tool (QAT), developed by the Effective Public Health Practice Project (EPHPP), was used to appraise the methodological quality of experimental studies (http://www.nccmt.ca/knowledge-repositories/search/14). This tool is recommended in the Cochrane Handbook for Systematic Reviews of Interventions (http://handbook-5-1.cochrane.org/). The quality of the studies was judged as either Strong, Moderate, or Weak based on the following criteria: selection bias; study design; confounders; blinding; data collection methods; withdrawal and dropouts; intervention integrity; and analyses.

The Grading of Recommendations Assessment, Development and Evaluation (GRADE) tool was then used to assess the level of evidence per outcome²⁰. “The quality of the evidence was assessed in terms of methodological limitations, heterogeneity and/or inconsistency of findings, indirectness of evidence, imprecision of results, and publication bias” (p. 475)¹⁶. Eligible studies were included regardless of their methodological quality in order to minimise the risk of reporting bias.

The AMSTAR 2 measurement tool was used to assess the methodological quality of structured reviews²¹. The domains within this tool address 16 key questions in relation to: using PICO to guide the review question and eligibility criteria; reporting on the review methods; explaining the choice of study designs; conducting the literature search; selecting and extracting data in duplicate; justifying and describing study inclusion and exclusion; assessing the risk of bias; reporting on sources of funding; conducting a meta-analysis; discussing study heterogeneity; and reporting conflict(s) of interest²¹.

Data synthesis

A meta-analysis with summary measures of treatment effect using weighted/standard mean difference, risk/odds ratios, and 95% confidence was planned using RevMan 5, if the included studies were sufficiently homogenous. However, the included studies were heterogeneous in terms of intervention format, data collection, and participant allocation; therefore, findings from the reviewed studies were synthesised meta-narratively.

Study selection

A total of 405 records were identified from electronic databases, clinical trial registries, and grey literature searches. No additional records were identified from reference list checks. Following the exclusion of duplicates, 242 records were screened on title and abstract. Of those, 15 full-text articles were assessed for eligibility and 10 were excluded, with the majority being cross-sectional studies (n=6). As a result, five papers were included in the present review; two were experimental studies and three were structured reviews. The full study selection process and reasons for exclusion are presented in Figure 1.

Figure 1. Flow diagram detailing study identification, screening, and selection process.

Study characteristics

The two experimental studies were conducted in Turkey and were underpinned by the Health Belief Model^22,23. Both studies explored the awareness of TC and TSE, TSE behaviours, and perceived susceptibility, severity, benefits of TSE, barriers to TSE, and self-efficacy^22,23. Sample sizes were n=96²² and n=174²³. Data were collected from patient care personnel (i.e. care assistants)²² and university students²³. Akar and Bebiş used a prospective, randomized, controlled intervention design²², whereas Pour et al. conducted a quasi-experimental follow-up study²³.

Of the three structured reviews, two were systematic reviews^16,24, and one was an integrative review¹⁷. The review by Rovito et al. included 10 studies²⁴, and the reviews by Saab et al. included 11 and 4 studies, respectively^16,17. Rovito et al. addressed TSE behaviours only²⁴, Saab et al. explored TC and TSE awareness and TSE intentions and behaviours¹⁶, and Saab et al. explored awareness of BTDs¹⁷.

Quality and level of evidence assessment

Both experimental studies had a “Weak” overall quality rating since both failed to address confounders and blinding^22,23. Items in relation to selection bias, study design, and withdrawal and dropout were rated as “Poor” in the study by Pour et al.²³ (Table 2).

The quality of evidence was “Very Low” for two outcomes, namely TC and TSE awareness and TSE behaviours, and “Low” for health belief in relation to TC and TSE. These ratings were attributed to a number of limitations including the lack of blinding and allocation concealment, lack of sample size calculation and power analysis, and lack of effect size and magnitude of effect measures (Table 3).

As for the structured reviews, none mentioned using PICO to guide the research questions or inclusion criteria and none reported whether methods were established prior to conducting the reviews. In addition, none of the three reviews reported on the sources of funding for the included studies^16,17,24. Rovito et al. did not list the search terms, justify study exclusion, or report on heterogeneity in the results²⁴ (Table 4).

Synthesis of results

Results of experimental studies and structured reviews are presented in Table 5 and Table 6, respectively.

Awareness of testicular disorders and self-examination

Three of the reviewed papers addressed men’s awareness of TC and TSE^16,22,23. However, interventions promoting awareness of BTDs were lacking.

Akar and Bebiş conducted a prospective randomised controlled trial comparing the effect of two interventions (45-minute interactive PowerPoint presentation (Group 1) and pamphlets (Group 2)) on men’s (n=96) awareness of TC and TSE and assessing their health beliefs in relation to TSE²². Approximately half of the participants (54.1%, n=52) were unaware of TC and TSE at pre-test. However, knowledge increased significantly at 3 months post-test for both groups (p=0.001), but was significantly higher among Group 1 than in Group 2 (p=0.005). Similarly, Pour et al. conducted a quasi-experimental follow-up study to evaluate the effectiveness of TC and TSE education (i.e. PowerPoint, video, pamphlet, and question and answer sessions) on men’s (n=174) knowledge of TC and TSE, TSE behaviours, and health belief in relation to TSE²³. Of note, data in relation to TC and TSE awareness were collected at pre-test only. The majority of the participants (82.8%, n=144) reported that they have heard of TC; however, only 40.8% (n=71) were informed about this malignancy. Likewise, almost half of the participants were unaware of TSE (54.5%, n=95) and 72.4% (n=126) were not educated about this practice²³.

Saab et al. reviewed evidence from 11 experimental studies promoting men’s knowledge and awareness of TC and TSE and increasing their TSE behaviours and intentions¹⁶. Some of the interventions addressed knowledge of TC and TSE at pre-test only. Baseline knowledge of TC risk factors ranged between 7.75%²⁵ and 50.6%²⁶. Similarly, knowledge of TSE ranged between 4%²⁷ and 53.2%²⁶.

The majority of the studies reviewed by Saab et al. were successful in increasing knowledge and awareness of TC and/or TSE¹⁶. For instance, TC knowledge increased significantly as a result of a video on TC filmed in the American Sign Language (p<0.05)²⁸; shower gel sachets, waterproof stickers, and posters (p=0.014)²⁹; a TC educational video (p<0.001)³⁰; and a TC university campaign (p<0.001)³¹. Furthermore, awareness of TSE increased significantly following a multimodal intervention comprising lectures, discussions, role-plays, posters, pamphlets, booklets, and screening sessions (p<0.001)²⁷. Interventions that significantly increased men’s awareness of both TC and TSE included: a television show featuring a celebrity with TC (p<0.001)³²; TC and TSE factsheets and testimonies from fictitious patients (p<0.001)³³; and TC facts and TSE advice (p=0.004)³⁴. On the other hand, a three-armed intervention comparing the effect of print material and shower cards versus video on TSE and shower cards versus no information, did not identify a significant difference in increase in knowledge of TC and TSE (p=0.7)³⁵.

Behaviours and intentions to perform testicular self-examination

TSE behaviours and/or intentions were explored in four of the reviewed papers^16,22–24. Pour et al. measured TSE behaviours at pre-test only and found that 50.5% (n=88) of participants did not know how to perform TSE and 76.5% (n=126) did not perform TSE²³. However, 81% (n=141) believed that TSE should be done²³. Only 5.2% (n=5) of participants in the study by Akar and Bebiş reported performing TSE at pre-test²². This increased significantly to 83.3% (n=40) among Group 1 (45-minute interactive PowerPoint presentation) and 54.2% (n=26) among Group 2 (pamphlets) three months post-test (p=0.002)²².

Of the 11 studies reviewed by Saab et al., six explored TSE intentions and/or behaviours¹⁶. The following four interventions significantly increased men’s intentions to perform TSE: a television show featuring a celebrity with TC (p<0.001)³²; TC and TSE factsheets and testimonies from fictitious patients (p<0.001)³³; TC facts and TSE advice (p=0.002)³⁴; and a TC university campaign (p<0.001)³¹. Briefing sessions by a physician increased the acceptability of clinical testicular examination but failed to increase men’s willingness to get their testes examined by a clinician²⁵. Moreover, messages written using implementation intentions statements did not significantly increase men’s intentions to perform TSE but significantly increased TSE behaviours²⁶. Other studies that significantly increased TSE behaviours include: shower gel sachets, waterproof stickers, and posters (p=0.006)²⁹; multimodal intervention comprising lectures, discussions, role-plays, posters, pamphlets, booklets, and screening sessions (p<0.001)²⁷; TC and TSE factsheets and testimonies from fictitious patients (p<0.05)³³; and a university campaign (p<0.001)³¹.

In terms of significant TSE reporting, Rovito et al. found that 3 out of the 10 reviewed studies did not significantly increase TSE behaviours²⁴. These included: an intervention comparing the effect of print material and shower cards versus video on TSE and shower cards versus no information³⁵; TSE information on shower gel sachets and waterproof stickers and posters versus no information²⁹; and a brochure and checklist to perform TSE versus film with information³⁶.

Help-seeking behaviours and intentions for testicular symptoms

None of the reviewed experimental studies explored help-seeking for testicular symptoms. In addition, only two of the four cross-sectional studies reviewed by Saab et al.¹⁷ addressed help-seeking for testicular symptoms^37,38.

Health behaviours in relation to testicular cancer and self-examination

The reviewed experimental studies addressed men’s health beliefs at pre- and post-test using the five sub-dimensions of the Champion Health Belief Model (i.e. perceived susceptibility, severity, benefits of TSE, barriers to TSE, and self-efficacy)^22,23. Perceived susceptibility, severity, benefits of TSE, and confidence increased (p=0.001) and perceived barriers decreased significantly (p=0.001) 3 months following exposure to a 45-min presentation (Group 1) and pamphlet (Group 2)²². Exposure to TC and TSE education using a PowerPoint presentation, video, pamphlet, and question-answer interaction led to a significant decrease in perceived susceptibility (p=0.001) and an increase in perceived benefits of TSE at 3 months post-test²³. By contrast, perceived severity, barriers to TSE, and self-efficacy did not vary significantly²³.

Summary of evidence

A total of five papers were included in the present review. Two were experimental studies and three were structured literature reviews. Overall, the reviewed literature showed that there was an increase in men’s awareness of TC and TSE and behaviours and intentions to perform TSE in response to various interventions. By contrast, help-seeking behaviours and intentions for testicular symptoms were not explored and interventions aimed at raising men’s awareness of BTDs were also lacking.

Examples of interventions that successfully increased men’s awareness of TC and TSE included: a university campaign that involved the use of TC “flyers, brochures, posters, shower cards, bulletin boards, social networking sites, videos, newspaper advertisements, a website, and mass media” (p.305)³¹; a television show featuring a celebrity with TC³²; and TC and TSE factsheets and testimonies from fictitious patients³³. By contrast, none of the reviewed interventions aimed to raise men’s awareness of BTDs. Of note, BTDs are more common than TC and a delay in help-seeking for benign testicular symptoms is also linked to negative health outcomes. For instance, a delay of more than 6 hours for pain caused by testicular torsion significantly reduces the chances of salvaging an ischemic testis⁷. Likewise, untreated epididymitis can lead to severe orchitis, sepsis, and in some cases irreversible infertility^5,6.

The majority of the studies reviewed by Rovito et al.²⁴ and Saab et al.¹⁶ were successful in increasing men’s awareness of TSE and behaviours and intentions to perform TSE. A Cochrane review conducted by Ilic and Misso³⁹ found no definitive evidence regarding the risks and benefits of regular TSE; therefore it was recommended that at-risk groups, such as men with a family history of TC, undescended testis, or testicular atrophy, ought to be advised by their physician regarding the risks (e.g. false positives and concomitant anxiety) and benefits (e.g. early detection) of TSE. As a result, whether to conduct monthly TSE has been polarised into two competing positions. The U.S. Preventive Services Task Force “recommends against screening for testicular cancer in adolescent or adult men”⁴⁰. Proponents of monthly TSE, however, argue that such recommendations are not based on definitive evidence⁴¹. Saab et al. called for a middle ground, whereby men are taught how to feel their testes and establish a baseline of what is normal for them without necessarily promoting “scheduled” TSE⁸.

As stated, help-seeking was not addressed in the reviewed literature. A number of quantitative and qualitative descriptive studies found that men’s intentions to seek help for testicular symptoms (e.g. lumpiness, swelling, and pain) are low^37,38,42. Saab et al. conducted a qualitative descriptive study to explore men’s (n=29) awareness of testicular disorders and intentions to seek help for testicular symptoms⁴². It was found that a number of men lacked awareness of testicular disorders in general and BTDs in particular, as a result many reported that they would most likely delay help-seeking. In addition to lack of awareness, the following were identified as barriers to help-seeking: lack of familiarity with own testes, symptom misappraisal, low perceived risk of TC, embarrassment, fear, denial, false optimism, fatalism, machoism, stoicism, false reassurance by others, and healthcare system barriers such as access, cost and waiting time⁴². By contrast, the following were identified as facilitators to help-seeking: personal or family history of a testicular disease, inherent health-seeking drive, and access to support⁴².

Contradictory evidence in relation to health beliefs (i.e. perceived susceptibility, severity, benefits of TSE, barriers to TSE, and self-efficacy) was found in the reviewed literature. For instance, perceived susceptibility increased following TC and TSE education in the study by Akar and Bebiş²², and decreased following a similar educational approach in the study by Pour et al.²³. These findings echo findings from studies conducted in different cultural contexts. Muliira et al. found that perceived risk of TC was low among Ugandan men⁴³, whereas participants in a study conducted by Rovito et al. in the USA scored high on perceived TC vulnerability⁴⁴. Of note, low perceived TC risk was identified as one of the barriers to seeking help for testicular symptoms⁴².

None of the reviewed studies reported on whether men’s preferred learning strategies were taken into account during intervention design and delivery. Saab et al. interviewed 29 men about their preferred strategies for learning about testicular disorders⁴⁵. Overall, participants were open to learning about testicular disorders and recommended interventions that are brief, interactive, simple, and light-hearted rather than funny/cheeky⁴⁵. Thornton warned against the use of “cheeky” humour and puns as these can be potentially offensive and ineffective⁴⁶. Another factor that should be considered in the design and delivery of health promotion interventions is the literacy and health literacy levels of men. A meta-narrative systematic review of 31 studies exploring men’s information-seeking behaviours in relation to cancer prevention found that younger men and those with high literacy and health literacy levels were more likely to engage with information delivered using technological means. By contrast, men who were older, belonged to ethnic minorities, and had low literacy and health literacy levels were more likely to engage with health information delivered by peers, physicians, and churches⁴⁷.

Strengths and limitations

Rigour was ensured by following the guidance of the Cochrane Handbook for Systematic Reviews of Interventions (http://handbook-5-1.cochrane.org/) and systematically reporting this review using the PRISMA checklist. Moreover, a thorough search of electronic databases, trial registries, grey literature, and reference lists was conducted, and records were independently screened by more than one reviewer to avoid omitting important records. However, the search was limited to records published in English between 2014 and 2018, which increases the risk of study selection bias, and only findings that were relevant to the review outcomes were discussed, which increases the risk of reporting bias.