1

Integrative Review of the Literature

Alex Depew

Bon Secours Memorial College of Nursing

NUR 4322

Dr. Arlene Holowaychuk

April 24, 2021

Honor Code: “I pledge”

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Abstract

Purpose: The purpose of this literature review was to investigate methods of achieving

compliance with testicular self-exam (TSE), an evidence-based intervention to aid in the early

detection of testicular cancer (TC). Background: worldwide, incidences of TC are increasing.

Survivability is incredibly high when TC is detected at an early stage but declines dramatically if

the disease metastasizes. TSE is not widely practiced and there is a noted lack of research into

methods to motivate these checks. Design and Search Method: research presented here is

based on a search of literature from PubMed and OvidMEDLINE. A Boolean operator of

“testicular cancer exam” was employed and articles manually screened for inclusion. Five

articles were chosen: three cross-sectional observational studies, one quasi-experimental pre-

test/post-test article, and one mixed factorial experimental trial. Results and Findings:

participants have limited knowledge about TSE and the risks of TC. TSE compliance was nearly

universally low. There is evidence that providing education on the topic can increase

compliance. Findings show that helping patients believe that they can improve their health could

increase willingness to perform the checks. Limitations: most of the findings presented are

cross-sectional, observational studies which cannot investigate causality and in which

researchers could not manipulate variables. Implications for Practice: teaching patients about

how and why to perform TSE needs to be a focus. Recommendations for Future Research:

There is an ongoing need for research investigating how to influence health beliefs of patients to

help them do what is best for their health and feeling empowered.
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Integrative Review of the Literature

The purpose of the integrative review of the literature is to establish which methods of

communication are most effective in eliciting compliance with testicular self-examination (TSE)

from patients. Globally, the incidence of testicular cancer (TC) is on the rise and is the most

common form of cancer among males ages 15-45 (Roy & Casson, 2017). We know that

performing TSE regularly can help detect cancers at an early stage (Rovito et al., 2011) and in

cases of early detection there is a 100% survival rate in some countries (Roy & Casson, 2017).

However, in one study, 66% of respondents did not perform testicular self-exams monthly

(Brown et al., 2012).

The effects of TC can be wide-ranging and devastate the health of people who contract

this illness. As with most cancers, the sooner it can be detected, the better the outcomes for

recovery tend to be. TSE is an important tool in the detection of neoplasm but offers the most

benefit if it is done regularly and correctly. Unfortunately, there is a dearth of information

available to men in this country and around the world about the benefits of and need for such a

practice. The purpose of this review is to examine literature and findings related to the PICOT

question of: in males ages 15-45 (P), how does focused education about the practice of

testicular self-exam (I) compare to a lack of targeted teaching (C) in motivating compliance with

the practice (O) on a monthly schedule (T)?

Design and Search Methods

This research is designed as a literature review. A search of available resources was

conducted through two online resources for medical literature, Ovid MEDLINE and PubMed.

Search terms for each resource were ‘testicular cancer exam’. This search was intentionally

broad so that the maximum available number of articles were returned and could be considered

for inclusion within this review. PubMed returned a total of 49 articles, while Ovid returned 8019

titles. However, many these were duplicates of one another and because of the intentionally

broad search term many of these were unsuitable for inclusion in this paper.
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To be considered for inclusion, articles needed to be published in English within the last

10 years. A slight accommodation was made for inclusion of an article slightly older but which

was a landmark study within the field and cited by numerous contemporary authors. They

needed to contain original, peer-reviewed research; meta-analyses, expert opinions and opinion

articles were excluded. Finally, each article was screened for pertinence to the PICOT question

being asked. To be included, the research needed to address at least a portion of the question.

Specifically, articles were screened to ensure they focused on either establishing a trend of TSE

compliance or investigating methods that compliance could be increased. Articles were

excluded if they were focused exclusively on medical diagnosis and treatment of TC; to be

included, research needed to be focused on TSE practice and belief specifically. As there has

not been extensive research into this topic, some allowances were required for research that did

not entirely align with all aspects of the PICOT question. Ultimately, five articles were selected

for inclusion. Three were cross-sectional, observational studies (Peltzer & Pengpid, 2015;

Rovito et al., 2011; Roy & Casson, 2017). One was a quasi-experimental, pre-test/post-test

study (Brown et al., 2012). The fifth was a mixed factorial experimental study (Umeh &

Chadwick, 2010).

Findings and Results

Education about the topic was shown repeatedly to be a significant factor in eliciting

compliance with TSE (Brown et al., 2012; Peltzer & Pengpid, 2015; Rovito et al., 2011). A

patient’s philosophical beliefs about health and health promotion were also found to have an

effect (Roy & Casson, 2017; Umeh & Chadwick, 2010). Research has been clustered into these

two primary themes for purposes of review. See Appendix I for a summary of each article listed

here.

Education as Key

In many cases, young men simply have not been taught about the importance of TSE.

Brown et al., (2012) report that only half the sample of 93 young male soldiers stationed on the
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East Coast in the US Army had ever been told about the importance of the practice by a

healthcare professional. This article was a quasi-experimental study with the purpose of

investigating whether simply putting TSE instruction cards in showers the soldiers used or

putting cards in their showers and additionally showing them a brief training video, created

increased compliance compared to offering them no education on the topic. Each condition was

applied to a company within the same Unit. Participants were then asked to fill out surveys

which asked them about their habits and beliefs concerning TSE. Results were compared

across participant conditions using ANOVA.

Ultimately, the most interesting finding for purposes of this review is that none of the

participants who received video training and cards in their showers reported that they had

‘never’ performed TSE. This finding proved to be statistically significant. While about 80% of

participants knew of the existence of TSE, about 74% of people who responded cited lack of

knowledge of how to properly perform TSE as a chief reason for not performing it. Therefore, it

follows that providing teaching about the proper technique would be useful in motivating

compliance. The study was limited by low participation rates which prevented the authors from

achieving statistical significance for some of the study questions.

For Peltzer & Pengpid (2015), knowledge about the existence of the procedure was

found to be needed more than knowledge about the exact methods to perform it. This study was

a cross-sectional, observational study. In total, a convenience sample of 2061 undergraduate

male participants at universities in 5 countries across Asia and Africa were asked to fill out a

simple survey after class. Surveys were administered in local languages as needed.

Researchers sought to examine potential relationships between socioeconomic status and

culture of a country regarding compliance with TSE.

Data underwent linear regression and computerized validation metrics. For the purposes

of this review, some of the most significant findings were that in the poorest countries polled (in

this case, Madagascar), the awareness of TSE was extremely low. Only about 12% of
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respondents in Madagascar reported that they knew what the term was. Even in middle-income

countries like South Africa and Singapore, rates of awareness hovered around the 20% range.

The authors are careful to note that these findings are not linked to causational factors based on

the study design so any attempt to assign these numbers implication is purely speculative.

However, it feels fair to say that within the populations sampled lack of knowledge about the

importance of TSE is a barrier to compliance that could cause negative health outcomes. Lack

of internal validity measures combined with some grammatical errors left some questions about

the professionalism of this research.

The study by Rovito et al., (2011) notes that while there is ample evidence that TSE

helps with the early detection of certain types of cancer, the American Cancer Society does not

officially endorse the practice due to a lack of evidence that it is effective. The authors feel that

this lack of evidence is not an indication that it is in fact not effective, but rather a reflection of

the fact that it is practiced so infrequently that it makes establishing definitive evidence difficult.

Their purpose therefore is to start an investigation into how to motivate young males to

compliance.

This cross-sectional observational study polled 300 undergraduate males ages 18-35 at

a university in the Northeastern US on their beliefs and practices concerning TSE. Data

collection processes were complex but involved the use of two assessment tools. Cronbach’s

alpha testing was applied to results and adequate reliability was established.

Overall, respondents rated their understanding of the topic of TC quite low. An aspect of

interest for the PICOT question in this review is the fact that participants were polled concerning

their preferred way to receive education about TSE. Educational handouts and private one-on-

one training opportunities received more favorable feedback than a group training class option,

indicating that participants may be more likely to follow through on training they receive privately

than training they receive in a group setting. This study was limited by the fact that the protocols
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were confusing and not simple to follow. This could detract from the credibility of findings

presented.

Health Beliefs as Key

Intellectual understanding of the existence of the need for TSE is an important factor in

compliance. However, equally as important is the belief that it makes a difference and that one

can do it. This was the focus of the research conducted by Umeh & Chadwick (2010). They

state a desire to investigate the role of self-efficacy, defined as the belief in one’s own ability to

effect a change, in the context of Rogers protection theory. Their mixed factorial experimental

study took place at a university in the UK. There were 128 participants, all undergraduate males

between the ages of 18 and 35. The only other inclusion criterion mentioned is that participants

must not have previously been diagnosed with testicular cancer.

Participants were sorted by a random number generator into a trial condition. There

were eight educational pamphlets created, each presenting factual but selective information

about the risk of developing testicular cancer, the severity of the disease if it does develop, and

the difficulty of performing testicular exam correctly. After the participants completed an

informed consent document they received one of the educational pamphlets. They were asked

to read it then complete a survey that queried their beliefs concerning the variables being

investigated. A one-month follow-up queried similar topics and whether participants had

performed TSE during the interim. The completion rate of the follow-up survey was 57.8%.

Data was analyzed through ANOVA to investigate the effects of variable manipulations.

Box’s M testing showed that each sample condition was appropriately randomized. Wilks

Lambda testing showed that there was significant multivariant correlation between the three

variables manipulated in the educational pamphlets. Although no mention of statistical

significance is apparent, there are findings which are pertinent to the PICOT question. The

researchers found a demonstrable link between TSE compliance after reading materials that

increase self-efficacy when it was tied to a high perception of vulnerability to TC. Materials that
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increase self-efficacy but do not instill a sense of vulnerability had a paradoxical effect of

reducing TSE compliance. These findings hold with the general ideas of Rogers protection

theory but are valuable because they are among the first to investigate TSE specifically under

this paradigm. Lack of mention of approval from an ethics committee or IRB is a glaring

omission from this study.

Roy & Casson (2017) set out to establish a baseline of understanding about attitudes

toward TSE for men in Northern Ireland after observing that such data had not previously been

investigated. The authors developed a cross-sectional observational study utilizing an online

survey. Their online survey tool was completed by a convenience sample of 150 men ages 18-

45 from across Northern Ireland. Participants were asked to identify risk factors and symptoms

of TC and whether they had been taught by a healthcare professional how to perform TSE.

Polling asking participants about their attitude toward the importance of TSE and other aspects

of testicular health was also performed. Finally, respondents were asked how often they

performed the exams and whether they felt comfortable in their ability to do so.

Kruskal-Wallis statistical testing was applied to investigate responses across age

groups. A p value of ≤.05 indicates that the authors set tight allowances for defining statistical

significance. The most valuable findings from this research are that men who had been shown

by a healthcare professional how to perform TSE were more likely to do it monthly and felt more

comfortable talking to their provider if an abnormality was detected. A lack of discussion about

power analysis is a limiting factor in the credibility of this research.

Discussion and Implications for Practice

In males ages 15-45 (P), how does focused education about the practice of testicular

self-exam (I) compare to a lack of targeted teaching (C) in motivating compliance with the

practice (O) on a monthly schedule (T)? The belief that TC is serious and that TSE is an

achievable goal clearly play a role in motivating compliance with the practice. Evidence to

support these claims is strongly present within the literature. Research founded on the health
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belief model and Rogers protection theory discussed within this review has universally

concluded that there is benefit to patients who hold these beliefs. That said, there remains the

fact that changing health beliefs is more complicated than simply providing education is.

Education about how to perform the procedure is easy to provide; convincing patients that it is

important is harder. Further research will be crucial to improving outcomes for patients.

Investigations about how health beliefs are cemented and how to help clients address

maladaptive thinking would be a useful adjuvant.

One primary obstacle to compliance with TSE is simple lack of information on the topic.

While some teaching methods are more effective than others based on the individual, it seems

clear that any information at all is more helpful than none would have been based on findings

discussed in this review including those by Brown et al., (2012). In practical terms, this means

that we need to be more diligent about teaching patients why TSE is important for their health.

As many of the authors note, research into the topic of TSE is limited. There is a chain of

articles cited in this review that built upon findings of other articles in the review. Umeh &

Chadwick (2010) appears to be a rather landmark study which is referenced by several of the

other authors. The thread of interconnectedness within these studies is worth mentioning

although implications for the observation could be minimal.

Some of the authors report that health issues affecting men may be less researched

than problems specifically affecting women. There are multiple reasons proposed for this

disparity, including the fact that this may be perceived as “unmasculine” to seek medical help.

Further research into this toxic mindset will be needed so that progress can be made on health

issues particular to males.

Limitations

Limitations within literature cited should be addressed. Brown et al., (2012) failed to

achieve statistical significance for most findings due to a failure to recruit enough responses.

They also note that there is a weakness in their study design that prevents them from knowing
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whether differences existed between groups prior to the research being performed. Peltzer &

Pengpid (2015) do not report on any internal validity measures being undertaken and make

some typographical errors that may undercut the credibility of research findings. Reading Rovito

et al., (2011) it is not immediately clear exactly how the study was performed. The authors

acknowledge that a convenience sampling can never be a true probability sample despite their

efforts to maximize randomization within the constraints of the study design. It is also observed

that there may be an educational bias present in the sampling group considering all the

participants were college students. Umeh & Chadwick (2010) do not report any sort of power

analysis and it is therefore not apparent whether the findings are statistically significant. It is also

worrisome that there is no mention of review by any form of IRB considering this is the one

article cited that operated on a truly experimental design, manipulating variables in a way that

could conceivably create negative health outcomes for participants. A high attrition rate was

reported in this study which the authors themselves acknowledge as deleterious for the

outcomes. Roy & Casson (2017) operated on a convenience sampling model which may have

introduced a bias into the findings. They note that the incentive for people to complete their

survey may have been low.

A plurality of the studies cited in this review are cross-sectional observational studies.

Some of the formats were slightly more intricate than others, but many of the data collected

across these studies are fundamentally just responses to surveys in one form or another. While

this research design is helpful, it does not establish a causality for findings. These publications

should largely be viewed as preliminary findings.

None of the publications cited is without some negative aspect. The conclusions of this

review must be seen as subject to the same shortcomings. However, the overarching

agreement of findings by the various authors provides reassurance that research was soundly

conducted. There are no significant outliers within the studies cited. Generalizability of the
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findings seems to be high when considering that researchers from all over the world returned

results that are essentially the same.

Conclusions

In conclusion, two overarching themes emerged from research as valuable methods to

increase compliance with TSE: knowledge about how to do it, and the belief that doing it may be

valuable for health. Patients who received more personalized and consistent teaching were

more likely to perform self-exams on a monthly basis. This effect persisted across cultures and

countries, although there does appear to be a component of culture in predicting whether

patients will be compliant. These findings shed light onto the PICOT question of “In males ages

15-45 (P), how does focused education about the practice of testicular self-exam (I) compare to

a lack of targeted teaching (C) in motivating compliance with the practice (O) on a monthly

schedule (T)?” There is strong evidence that offering appropriate instruction to patients will

result in improved compliance which could lead to better health outcomes as compared to

offering no instruction to these patients. Future research aimed at investigating the outcomes of

specific teaching tools should be paired with research investigating how to change patients’

health beliefs to offer them a sense of self-efficacy.

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References

Brown, C. G., Patrician, P. A., & Brosch, L. R. (2012). Increasing testicular self-examination in

active duty soldiers: An intervention study. Medsurg nursing: Official journal of the

Academy of Medical-Surgical Nurses, 21(2), 97–103.

Peltzer, K., & Pengpid, S. (2015). Knowledge, attitudes and practice of testicular self-

examination among male university students from Bangladesh, Madagascar, Singapore,

South Africa and Turkey. Asian Pacific Journal of Cancer Prevention: APJCP, 16(11),

4741–4743. https://doi.org/10.7314/apjcp.2015.16.11.4741

Rovito, M. J., Gordon, T. F., Bass, S. B., & Ducette, J. (2011). Perceptions of testicular cancer

and testicular self-examination among college men: A report on intention, vulnerability,

and promotional material preferences. American Journal of Men's Health, 5(6), 500–507.

https://doi.org/10.1177/1557988311409023

Roy, R. K., & Casson, K. (2017). Attitudes toward testicular cancer and self-examination among

Northern Irish males. American Journal of Men's Health, 11(2), 253–261.

https://doi.org/10.1177/1557988316668131

Umeh, K., & Chadwick, R. (2010). Early detection of testicular cancer: Revisiting the role of self-

efficacy in testicular self-examination among young asymptomatic males. Journal of

Behavioral Medicine, 39(1), 151–160. https://doi.org/10.1007/s10865-010-9262-z

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Appendix I: Summary of the Literature Tables

APA Citation and Brown, C. G., Patrician, P. A., & Brosch, L. R. (2012). Increasing
Author Qualifications
testicular self-examination in active duty soldiers: An

intervention study. Medsurg nursing: Official journal of the

Academy of Medical-Surgical Nurses, 21(2), 97–103.

All three authors are PhD level nurses with past military
experience. Two are professors at state run nursing schools
and the third is a director at a military medical research body.
These qualifications seem appropriately robust to perform
this research.
Background/Problem Aside from humanitarian concerns, military readiness is the
Statement primary motivator of these authors. They report that about
80% of male soldiers are between the ages of 18 and 35, the
primary population of concern for testicular cancer.
Incidences of the neoplasm are rising, but one study found
that about 2/3 of male soldiers never perform self-
examinations and only about half ever received any
education on the topic at all. Improving these metrics will
result in earlier disease detection and improve military
readiness by reducing illness among troops.
Conceptual/theoretical Health Belief model, which has been in widespread use for
Framework decades and draws upon the Rogers protection theory
utilized in another article.
Design/ Quasi-experimental pre-test post-test design that was
Method/Philosophical truncated into a post-test-only design to account for low
Underpinnings participation. Group A was provided with cards attached to
showerheads detailing how and when to perform testicular
self-exam, Group B received shower cards and viewed an
instructional video, and control Group C received training
about how to avoid injury while running but no direct
information about testicular self-exam. Data about knowledge
and health beliefs relating to testicular cancer and self-exam
were collected from each group.
Sample/ Each sample group was a single company within the same
Setting/Ethical Army Unit stationed on the East Coast of the US. Participants
Considerations were between 18 and 36. Officers were excluded to prevent
the introduction of perceptions of coercion of their
subordinates. Chi-square testing to achieve an alpha of 0.05
and 80% power indicated that 65 participants were needed
for each group, however as a company contains 150 soldiers
and interventions were offered to the entire company the
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potential sample was considerably higher. In total, however,

only 93 participants complete the post-testing.
Major Variables Barriers to testicular self-examination (lack of knowledge
Studied (and their being a highly reported barrier among participants) were
definition), if examined. Researchers also investigated health beliefs about
appropriate susceptibility to and severity of testicular cancer, as well as
potential benefits of self-exams.
Measurement A four-part data assessment tool was employed that allowed
Tool/Data Collection researchers to examine each variable separately. This
Method instrument has been previously employed by at least three
other research studies indicating reliability.
Data Analysis ANOVA was employed to examine responses between
different demographic groups within the study. Data are
presented in graphical format with various demographic
breakdowns for race, rank, education and marital or paternity
status. Analysis is robust and detailed clearly.
Findings/Discussion There was a statistically significant decrease in the group
who both watched the training video and received the
information card in reporting that they had “never” performed
self-exam. The group who received training and the
information cards also reported a higher percentage of
participants who performed monthly self-exam but this result
was not statistically significant. Knowledge of the existence of
self-exams was roughly equal among all three groups, as
was knowledge about testicular cancer and age groups most
at risk. Statistically significant differences were found
between the control group and highest intervention group
about their perceptions of barriers to performing self-exams.
Appraisal/Worth to This is a well-conducted study that avoids pitfalls. It rests on
practice well-established principles, the methods are clear, and data
analysis is robust. The value to practice is evidenced by the
fact that men who received a brief training and information
card are less likely to report having never performed
testicular self-exam at a statistically significant rate. Clearly,
some evidence-based intervention is more effective than no
training at all. The one issue with this study is failure to
capture enough responses to elicit statistical significance for
some metrics.
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APA Citation and Peltzer, K., & Pengpid, S. (2015). Knowledge, attitudes and
Author Qualifications
practice of testicular self- examination among male

university students from Bangladesh, Madagascar,

Singapore, South Africa and Turkey. Asian Pacific Journal

of Cancer Prevention: APJCP, 16(11), 4741–4743.

https://doi.org/10.7314/apjcp.2015.16.11.4741

Both authors are affiliated with the ASEAN Institute for Health
Development as well as a university in South Africa. The
primary author is also associated with a human research
counsel in South Africa. These qualifications are listed on the
abstract page.
Background/Problem This study seeks to determine differences in attitude and
Statement practice regarding testicular self-exam across five different
countries. The countries are spread across Africa and Asia
with differing levels of income and development. Overall,
awareness of men around the world of the need for self-exam
is shown to be low. The authors hope to compare findings
across several different regions of the globe to determine
trends and establish guidance for policy and ongoing
research.
Conceptual/theoretical None is noted
Framework
Design/ This is a cross-sectional study. Participants were chosen
Method/Philosophical from a major university in each of the five countries with
Underpinnings preference given to a university located in that country’s
capital. Participants were simply asked whether they knew
about testicular self-exam, how often they did it, and if they
believed it to be important to health. Students were asked to
complete the brief survey at the end of an undergraduate
level lecture class. When needed the questions were asked
in a language commonly used in that specific area.
Sample/ A total of 2061 men aged 16-30 were recruited across the
Setting/Ethical five different countries with a roughly equal distribution
Considerations between the locations. The setting was in a classroom of
each respective university. Ethical considerations included
approval from ethics boards of each participating university
and solicitation of informed consent from participants.
Major Variables Variables were not manipulated in this study, but researchers
Studied (and their were investigating simple questions of whether participants
definition), if knew about testicular exam, how often they did it, and how
appropriate important they perceived it to be.
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Measurement The data collection tool was very simple and consisted of
Tool/Data Collection only three questions. There was a yes/no binary question
Method about whether participants knew how to perform self-exam.
Those who answered yes were then asked on a scale of 1-4
how often they did it, 1 being never and 4 being more than 10
times a year. They then were asked on a scale of 1-10 how
important to health they believed the practice to be.
Data Analysis Means and standard deviations were calculated for each
metric before logistic regression was performed to determine
at 95% confidence intervals the associations between health
beliefs and compliance with self-exams in each population.
No metrics for measuring internal validity were reported.
Findings/Discussion Overall, only about 17% of respondents reported knowing
how to perform testicular self-exams. Young men from
Singapore tended to view the practice as much more
important than young men from Turkey did. Even so, only
about 3% of respondents reported monthly compliance with
checks while 86% of respondents reported they had never
performed a self-exam. The authors acknowledge that this
study design in inadequate to determine causal relationships
but feel strongly that interventions need to be implemented to
improve compliance.
Appraisal/Worth to This study has positive and negative aspects. The large
practice sample size increases confidence in the findings. It is a
significant task to sample participants on two continents and
in five nations, so the results that are reported are clearly
hard-fought. However, lack of internal validity measures is
problematic for this study. Also, there are several places
where the authors mention “BSE” as opposed to “TSE” in an
apparently inadvertent manner. Such simple editing errors
should not have made it through the approval process and
detract from the credibility of the study. However, there is still
useful implication for value to practice. Being aware of
cultural differences, socioeconomic status, and other factors
which may influence how receptive a patient is to teaching is
critical to success. The authors highlight some of these
considerations in this research and while there are no direct
suggestions for next steps it is still a worthwhile reminder that
not every patient will respond to teaching the same way.
 17

APA Citation and Rovito, M. J., Gordon, T. F., Bass, S. B., & Ducette, J. (2011).
Author Qualifications
Perceptions of testicular cancer and testicular self-

examination among college men: A report on intention,

vulnerability, and promotional material

preferences. American Journal of Men's Health, 5(6), 500–

507. https://doi.org/10.1177/1557988311409023

All of the researchers listed hold PhDs and are affiliated with
a well-regarded university in Pennsylvania. These facts are
found on the abstract page.
Background/Problem The authors report that most young men are not aware of
Statement their risk for testicular cancer. The American Cancer Society
does not recommend testicular self-exams because there is a
lack of evidence they reduce mortality. In the authors’ view
this is not because they are not an effective tool but because
compliance is so low that demonstrating a causal link is
difficult. The authors feel that if compliance were higher the
link between testicular self-exams and increase cancer
survival would become clear. Therefore, they undertook this
research to investigate methods for increasing compliance
among the target population.
Conceptual/theoretical The authors draw on the planned behavior theory to frame
Framework this study. They also mention a more amorphous and
unnamed idea of “tailored messaging” which underpins the
findings.
Design/ It is not stated directly, but this is a cross-sectional
Method/Philosophical observational study. Interestingly, participants took a pre-
Underpinnings survey before completing the actual study with the intention
of sorting them into cohorts based on their beliefs about
health promotion and health control beliefs. Then, further
investigations were performed within these cohorts about
beliefs relating to health locus of control. Participants were
polled about their preference of health promotion material. It
is not fully clear how testing was performed and in what
order.
Sample/ The sample contained 300 males enrolled in a Northeastern
Setting/Ethical university. All were between 18 and 35. Subjects were
Considerations recruited by convenience following the end of a lecture class.
A university classroom was the primary setting for
investigations. Participants were informed of the voluntary
nature of the study, no identifying information was collected,
and the university IRB approved all the survey protocols.
 18

Major Variables The authors were not manipulating variables in this case, but
Studied (and their they grouped their survey into sections intended to
definition), if investigate overall awareness, perceived health control
appropriate beliefs, perceived vulnerability, perceived value of health
promotion and preference for educational material about
testicular self-exam.
Measurement Two different survey tools were employed by researchers.
Tool/Data Collection The initial 41-item survey was their original creation, while the
Method secondary tool has a basis in research from 1981. The level
of detail with which the survey tools are explained is not
extensive.
Data Analysis Internal validity was measured using Cronbach’s alpha.
“Composite variables” were constructed by linking responses
from various fields into a single scored value. Some insight is
provided into how survey responses were interpreted and
scored, but this information is not extensive.
Findings/Discussion In general, participants understand that testicular cancer can
be severe, but do not report very much specific knowledge on
the topic. The unique finding for this study compared to
others is that they inquired how participants would be most
receptive to receiving teaching about the topic of testicular
self-exam, with educational materials and private education
sessions scoring much higher than group teaching sessions.
Their conclusion is that men who feel the most vulnerable to
harm may benefit the most from a personally tailored
education plan.
Appraisal/Worth to There are some limitations to this study. The fact that it is not
practice totally transparent how the surveys were performed is
worrisome. The metrics for measuring results could benefit
from a more extensive explanation. However, the valuable
part of this study for my research question has to do with
directly investigating methods that men would be receptive to
receiving education about testicular self-exam. The portions
of this research relating specifically to that component are
easily understood and fully explained. Both for the research
question and clinical practice, this paper is worthwhile even if
nothing but this is taken from it. Overall, this is not the
strongest paper appraised but it does offer useful ideas.
 19

APA Citation and Roy, R. K., & Casson, K. (2017). Attitudes toward testicular cancer
Author Qualifications
and self-examination among Northern Irish

males. American Journal of Men's Health, 11(2), 253–261.

https://doi.org/10.1177/1557988316668131

Both authors hold graduate degrees within the nursing field.

Both are affiliated with a university in Northern Ireland. This
information is provided on the abstract page of the text. No
other mention of qualifications is forthcoming.
Background/Problem The authors report that despite a worldwide increase in
Statement incidence of testicular cancer, there has been very little
investigation into awareness of the problem among men in
Northern Ireland. They also note that attention to health
problems specific to men may not receive the same level of
attention as problems specific to women around the world.
Survival rates in the UK for testicular cancer detected in
Stage I are close to 100% but decline as the disease
progresses. Research into techniques that increase early
detection will have a positive impact on patient outcomes.
Conceptual/theoretical Authors drew upon the health belief model when framing this
Framework study. This is in keeping with other authors cited during this
review of literature and seems appropriate.
Design/ A cross-sectional, observational study was used based on a
Method/Philosophical 20 question online survey. The authors acknowledge that this
Underpinnings may not be the most comprehensive sampling technique but
that there is a concern about forthrightness when a female
researcher is interviewing a male subject about sensitive
topics. An initial pilot study was conducted to increase
confidence that the assessment tool functioned as intended.
Reliability was also investigated through a test-retest method.
Expert opinions were solicited. Validity and reliability were felt
to be achieved with these measures.
Sample/ A convenience sample of 150 men were recruited through an
Setting/Ethical email chain maintained by a healthcare charity in Northern
Considerations Ireland. The sample therefore represents a diverse range of
ages and backgrounds. A plurality of respondents were
between 26 and 35. Setting would have varied depending
upon participant as the survey tool was an online format.
Ethical considerations are addressed, including a
recommendation that participants seek professional guidance
if they are unsure about any component of their health. An
oversight committee found the study to be ethical.
Major Variables Variables were not fully controlled by researchers in this case
Studied (and their as this was a questionnaire rather than a true experiment.
 20

definition), if However, some of the metrics they were investigating include

appropriate whether participants could correctly identify risk factors and
signs of testicular cancer. Participants were asked about how
important they thought self-exams were and whether a
healthcare professional had discussed this with them in the
past. Attitudes about speaking to a provider concerning
testicular health were investigated.
Measurement The online survey tool was based upon tools implemented by
Tool/Data Collection previous researchers. This is felt to have added to the validity
Method of the tool. It was provided via a secure portal and the only
identifying detail collected from participants was their postal
code. The less formal, self-directed online setting is thought
to have increased candid responses.
Data Analysis Levels of statistical significance for all factors being
investigated was set to p less than or equal to 0.05. A variety
of analytical methods were employed to examine differences
between respondent cohorts on the basis of age. The authors
mention a variety of tools used to compare findings between
these cohorts.
Findings/Discussion Men over the age of 25 were more likely to know about
testicular self-exams, feel confident they can perform them,
and do so more regularly. Men over 35 are more likely to
believe this is important for their health. Overall, only 11% of
participants felt they were at risk for testicular cancer despite
the fact that all participants were within the age range of
concern for developing the disease. Almost half of
respondents incorrectly believe that being overweight
contributes to testicular cancer. Most importantly for this
purpose, those found to have high self-efficacy for performing
exams were more likely to do it regularly.
Appraisal/Worth to This paper is highly valuable to the research question. It
practice contains a huge number of findings that offer additional areas
for investigation. Statistically significant findings abound.
There are numerous actionable findings to incorporate into
clinical practice. The paper is well-written, densely
informational, avoids ethical dilemmas and answers
questions not even thought to pose. No discussion of power
analysis is observed but that is the only major drawback.
 21

APA Citation and Umeh, K., & Chadwick, R. (2010). Early detection of testicular
Author Qualifications
cancer: Revisiting the role of self-efficacy in testicular self-

examination among young asymptomatic males. Journal of

Behavioral Medicine, 39(1), 151–160.

https://doi.org/10.1007/s10865-010-9262-z

Qualifications not immediately apparent, although one

researcher works for the NHS and one at a prominent
university in the UK. No conflicts of interest are reported.
Background/Problem Observation that while a lot of research has been devoted to
Statement various health motivations, there is a relative dearth of
investigations into factors that specifically serve to motivate
compliance with testicular self-examinations. A hypothesis is
offered with a basis in generalized findings in this field and
the assumption that similar outcomes are likely when the
specific topic of testicular self-examination is tested.
Conceptual/theoretical Rogers protection theory, a well-defined idea within research
Framework about the psychology of risk assessment and motivation to
act in the face of a threat.
Design/ 2x2x2 mixed factorial experimental design which is not
Method/Philosophical uncommon in experiments intended to measure
Underpinnings psychological variables. Pamphlets were produced that
contained information intended to portray each experimental
condition in either a high or low level of importance.
Participants were sorted into a condition randomly, received
education, then asked to report back immediately and at one
month about their attitudes toward and compliance with
testicular self-examinations.
Sample/ The sample was of undergraduate males at a university in
Setting/Ethical the UK. There were initially 128 participants. They received
Considerations education and provided feedback in the setting of the
university. The glaring ethical consideration is that there is no
reference to any sort of IRB oversight which is problematic
because the manipulation of variables could conceivably
result in negative health outcomes for participants.
Major Variables The three major variables examined were the effects of
Studied (and their vulnerability to the threat of testicular cancer, severity of the
definition), if condition if they did develop it, and self-efficacy which is
appropriate defined as the ability to effect an outcome within one’s own
life.
Measurement Data was collected after interventions by surveys distributed
Tool/Data Collection to participants. Metrics for measuring outcomes are
Method exhaustively defined.
 22

Data Analysis Data analysis is explained in a technical and extensive

fashion. Internal validity was examined using multiple
analytical tools. The authors make no reference to power
analysis and it is not immediately clear whether the sample
size is appropriately robust.
Findings/Discussion Findings generally align with existing thinking about the topic
at large. The research question appears to largely be
answered. The authors discuss some limitations of the study,
including the fact that there may be a self-selection bias
among people who would choose to participate in this study.
Significance to clinical practice is addressed and ideas for
ongoing research to further this line of thinking are offered.
No mention is made of adverse events.
Appraisal/Worth to This article is appraised to have reasonable applicability to
practice practice. The lack of power analysis and apparent lack of IRB
oversight are concerning, but results seem to have
generalizability to other populations and internal validity is
very high within the study. The fact that specific messaging
suggestions are offered makes implementing the findings
easier.