Health Education Research, Vol. 17, No. 1, 73-84,
February 2002
© 2002 Oxford University Press
Testicular self-examination (TSE) among Dutch young men aged 15–19: determinants of the intention to practice TSE
Department of Social Science, Open University The Netherlands, 6401 AT Heerlen and
1 Department of Health Education and Promotion, Maastricht University, 6200 MD Maastricht, The Netherlands
 |
Abstract |
|---|
 Top Abstract IntroductionMethodsResultsDiscussionReferences |
|---|
The present study analyzed what determinants are important to describe and explain the intention of testicular self-examination (TSE) for young men aged 15–19 attending senior high school (response rate 80%, n = 274). The questionnaire assessed determinants, including knowledge, attitude (positive and negative consequences, anticipated regret, and moral obligation), social influence (social norm, social support and modeling) and self-efficacy. Knowledge of testicular cancer and TSE was very low. Only 2% of the subjects reported regularly performing TSE. After hearing of TSE (through the questionnaire), 41% of all young men had a positive intention to start performing TSE regularly. The various intention groups (positive, neutral and negative) differed significantly on almost all of the determinants. Multiple regression analysis showed that young men who where anxious about TSE and those who were not anxious had different determinants explaining the variance in the intention to perform TSE regularly (R2 = 41–57%). Differences in determinants of intention between young men who are anxious about TSE and young men who are not can be used to design health education interventions that may therefore be more effective for these different subgroups.
|
Introduction |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
Unnecessary morbidity and mortality results from cancers that could have been prevented or could have been successfully treated, had they been detected earlier. For many cancer sites detection of the cancer early in the course of the disease, when treatment is more likely to be successful, improves survival (American Cancer Society, 1992
). Testicular cancer is eminently curable when detected in an early stage (Giwercman et al., 1996). Five-year relative survival rates of testicular cancer are high (99%) when detected early and, due to advances in treatment (chemotherapy), patients with metastatic disease have 5-year relative survival rates of 75% (Ries et al., 2000). Although survival rates of testicular cancer are still relatively high when the disease is detected at a later stage, the prognosis is not as favorable and the morbidity effects, like sterility or impotence, are much more extreme (Roth et al., 1993; Dutch Cancer Society, 1997). Hence, early diagnosis of testicular cancer is associated with a reduction in mortality, and is likely to be associated with a simpler and less toxic treatment (Austoker, 1994). So far, no randomized controlled trials have been conducted providing evidence of the long-term effectiveness of testicular self-examination (TSE). However, the very optimistic prognosis that results from early detection and treatment of testicular cancer stresses the importance of teaching young men techniques to self-detect early warning signs of testicular cancer.
The most relevant cancers that can be detected by regularly self-examination are breast cancer for women and testicular cancer for men. Although testicular cancer is far less prevalent than breast cancer, it is the most frequent cancer for men aged 15–44 in The Netherlands (Visser et al., 1997). In 1993, of all new cases of testicular cancer that were recorded in The Netherlands, 61% were found in the group of adult men younger than 35 (Visser et al., 1996). Adult men below the age of 35 are considered to be the main high-risk age group with respect to testicular cancer. Therefore, organizations such as the Dutch Cancer Society and the American Cancer Society recommend that adult men below 35 should examine their testicles every month (American Cancer Society, 1991; Dutch Cancer Society, 1996).
Unlike breast self-examination (BSE), which is more generally known among women in Europe, knowledge of TSE in Europe is reported to range from 0 to 31% among males in the high-risk age group (adult men below 35) and TSE performance rates in Europe range from 0 to 18% (Best et al., 1996). In The Netherlands, 93% of men in the high-risk age group (adult men below 35) reported that they never performed TSE, while only 2.5% of Dutch men reported that they performed TSE 10 times or more per year (Wardle et al., 1994). A recent study reported that 89% of the risk group (adult men below 35) had never performed TSE, while only 4% knew of the advice that men in the 15–35 age group should perform TSE every month (Lechner et al., 1998).
It can be argued that if TSE is to be encouraged (Friman and Finney, 1990; Rosella, 1994), it should be stimulated at an early age. Since most young Dutch men aged 15–17 still attend senior high school, the school environment might provide the best setting for teaching young men about testicular cancer and the practice of TSE. In order for education to be effective, it should focus on possible misbeliefs, and it should be adjusted to existing beliefs and knowledge concerning testicular cancer and TSE. However, little is still known about the beliefs that these young men might have concerning TSE or about possible barriers that they experience to TSE. Therefore, in order to develop effective interventions to stimulate young men to start practicing TSE, it seemed highly relevant to gain insight into the knowledge, beliefs and barriers that these young men experience concerning TSE.
Theoretical framework
Several social psychology models suggest that a particular behavior is determined by the intention to perform this behavior (De Vries et al., 1988; Ajzen, 1991; Lechner and De Vries, 1995; Lechner, 1998). This intention is generally determined by three important factors: attitude, social influence and self-efficacy. These factors can be integrated in models such as the Theory of Planned Behavior (Ajzen, 1991) or the ASE model (Attitude–Social influence–self-Efficacy) (De Vries et al., 1988; Lechner and De Vries, 1995; Lechner, 1998). Both frameworks have been proven relevant for studying behavior regarding TSE, BSE or breast cancer screening (Brubaker and Wickersham, 1990; Murphy and Brubaker, 1990; Lechner et al., 1997; Moore et al., 1998; De Nooijer et al., submitted). For the present study, the ASE model was used.
According to the ASE model, the first possible determinant of behavioral intention is the attitude, which consists of the perceived advantages (pros) and disadvantages (cons) of a particular behavior. These expected outcomes (Bandura, 1986) may result from the behavior immediately or after a longer period. With respect to TSE, this period between behavior and possible outcomes seems particularly important: although long-term outcomes of TSE might be very positive (TSE could lengthen a healthy life), its short-term benefits may not be so obvious, since TSE might cause tension or fear of the results and might result in the detection of something one does not want to find (a lump). Several studies have found attitude to be an important determinant of the intention of performing TSE (Brubaker and Wickersham, 1990; Steffen, 1990; Steffen and Gruber, 1991; McCaul et al., 1993).
Another possible determinant of intention could be the personal norm that people experience about what would be the right thing to do. One aspect of the personal norm is anticipated regret (Van der Pligt and Richard, 1993; Lechner et al., 1997). Young men might think that failure to perform TSE, even though they realize its importance, might leave them with feelings of regret if at a later date testicular cancer should be detected. In addition to anticipated regret, young men may feel they are fulfilling a moral obligation by practicing TSE: by performing TSE you show responsibility toward yourself and others. There are several possibilities to situate the personal norm concept (anticipated regret, moral obligation) within the ASE determinant model. Personal norms could be seen as a separate new concept or as a concept within the attitude construct. As Eagly and Chaiken state, personal norms could be subsumed under attitude toward the behavior, because guilt, self-reinforcement and other outcomes of meeting or violating one's own standards are merely additional consequences of behavior (Eagly and Chaiken, 1993). For screening behavior, evidence was found for the importance of the personal norm as a predictor of behavior (Lechner et al., 1997).
A second factor, in addition to attitude, consists of the social influences people encounter. Such social influences can manifest themselves in several ways (Grube et al., 1986; Reno et al., 1993; De Vries et al., 1995). Some evidence was found for the importance of the social norm that men experience with respect to TSE (Brubaker and Wickersham, 1990; Steffen, 1990; Steffen and Gruber, 1991; McCaul et al., 1993; Moore et al., 1998). Furthermore, men may also experience direct social support or pressure to practice TSE. Men who feel encouraged by their family, friends or physician to perform TSE may be more likely to actually do so. In addition to direct support, the knowledge that other young men do so might also encourage men to perform TSE (modeling).
The third factor consists of self-efficacy expectations, which are a person's beliefs in his or her abilities to perform a particular behavior. Increased self-efficacy will result in improved performance of a healthy behavior. Research over the past decades has stressed the importance of self-efficacy for enacting new healthy behaviors in general (Bandura, 1986; Schwarzer, 1992; Lechner, 1998), as well as for TSE in particular (Brubaker and Wickersham, 1990; McCaul et al., 1993).
In addition to attitude, social influence and self-efficacy, the risk perception that people have of getting testicular cancer might also be an important determinant of the intention to perform TSE (Rogers, 1983; Strecher and Rosenstock, 1997). If the estimated severity of testicular cancer and the estimation of people's own risk of getting the disease are low, the intention to perform TSE is also likely to be low (Rogers, 1983; Strecher and Rosenstock, 1997).
The present study aimed to analyze what determinants are important to describe and explain the intention of performing TSE among young men attending high school. Since it was expected that knowledge and behavior with respect to TSE would be at a very low level among this age group, the present study focused on the intention to perform TSE, rather than on actual TSE behavior. This study is the first to systematically apply the ASE model to TSE behavior, including additional concepts into the model, like anticipated regret, moral obligation and risk perception. The study also analyzed possible interactions between determinants, in order to detect whether there were any subgroups with different determinants of intention.
|
Methods |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
Respondents and procedure
The target group for our study consisted of young men aged 15–20 who were still attending high school. Subjects were recruited by approaching several high schools and asking them if they were prepared to let the researcher administer the written questionnaire among their male high school students aged 15–20. A total of 14 high schools in the Northern part of The Netherlands were approached. All schools were of the same general Dutch type of high school (HAVO, VWO). Of these 14 schools, six were prepared to participate in the study. Of the six, only four schools were needed to get the needed sample for the study. These four schools were randomly selected from the available six schools. One school was selected for a qualitative study and three schools were selected for the quantitative study that is reported here.
The qualitative study (Oenema, 1998), which was done to obtain the information to develop the questionnaire for the quantitative study, consisted of two methods. First, two focus group interviews were held to gain insight into the ideas that young men have concerning testicular cancer and TSE. Second, qualitative questionnaires were administered to 26 young men. The questionnaire consisted of 20 open-ended questions to find out the relevant beliefs among the young men concerning testicular cancer and TSE. The results from both qualitative methods were used to formulate the specific items needed for the quantitative questionnaire.
The three schools that participated in the quantitative study were asked to allocate two or three classes for the study. In total, eight classes participated in the study: five classes (n = 228) in the 10th grade senior high school (age 15–16) and three classes (n = 116) in the 11th grade senior high school (age 16–17). Since there were less 11th grade classes than 10th grade classes available at the three schools, more 10th grade classes participated in the study.
For each class one lesson was allocated in which the researcher could administer the questionnaires. One week before the lesson, all male students were notified of the study and of the time of administration. All male students were asked to participate in the study. The written questionnaires were completed in the classroom, in the presence of their teacher and the researcher. Since we knew from the qualitative study (Oenema, 1998) that most students had little or no knowledge of TSE, the administration of the questionnaire was preceded by a short neutral introduction about testicular cancer. In addition, the questionnaire started with a brief instruction about what TSE actually involves. This was done so that the young men knew what the actual behavior was, in order to correctly assess the relevant beliefs. After completing the questionnaire, all subjects received a leaflet on testicular cancer and TSE. Of the 344 available male students, 274 were willing to fill in the questionnaire (response rate 80%). Response rates showed no difference between the 10th grade students (n = 181, response 79%) and the 11th grade students (n = 93, response 80%). Since no data were available of the non-response, a comparison of the response with the non-response could not be made.
Questionnaire
The questionnaire was based on the results of a qualitative study (Oenema, 1998), on the available literature and on the theoretical concepts described in the introduction. The questionnaire assessed several concepts (see Table I).
|
Attitude was measured using several concepts:
- Perceived positive consequences or outcomes (pros) of doing TSE were assessed by means of five items on four-point scales (Cronbach's
= 0.62). An example would be `Performing TSE results in much more–no more certainty of my health'.
- Perceived negative consequences or outcomes (cons) of TSE were assessed by means of eight items on four-point scales. Factor analysis showed that these cons could be divided into two constructs: cons related to negative emotions (affects) related to TSE (ConsI; = 0.63), and more practical cons of TSE (ConsII; = 0.52). An example of ConsI would be `How afraid would you be to detect cancer, if you should perform TSE', an example of ConsII would be `Performing TSE would cost me very much–not much time'.
- The moral norm or obligation that subjects feel to perform TSE was assessed by means of one item on a four-point scale: `Now that I know that TSE exists, I feel that by doing TSE I would fulfil a very great (3)–no obligation (0) to myself'.
- Anticipated regret about failure to perform TSE was assessed by means of two items on four-point scales (r = 0.26). For example: `Now that I know that TSE exists, I expect that I would feel very much regret (3)–no regret at all (0) if I did not do TSE'.
Social influence was assessed by means of three concepts:
- The social norm that subjects experience with regard to TSE was assessed by means of two items on five-point scales (r = 0.60)
- Social support from significant others was assessed by means of two items on five-point scales (r = 0.53).
- Modeling was assessed by means of one item on a five-point scale `How many men do you know who do TSE?'.
Self-efficacy was assessed using eight items on five-point scales ( = 0.87). All items proposed various situations and respondents were asked if they would feel able to keep performing TSE under these circumstances, e.g. `If after a few months of TSE, you would have found no irregularities, would you be able to keep performing TSE?'.
Risk perception was measured by assessing the subjects' views on the severity of testicular cancer and on the susceptibility of getting the disease. Estimated severity of testicular cancer was assessed by means of one question on a four-point scale, ranging from very severe to not severe. Susceptibility of getting testicular cancer was assessed by asking subjects how they estimated their own risk of getting testicular cancer, using one question on a five-point scale, ranging from very high to very low risk.
Intention was assessed by asking the students if they intended to perform TSE on a monthly basis from now on, using a five-point scale. Furthermore, knowledge was assessed by asking subjects if they had ever heard of testicular cancer or TSE. In addition to the determinants and the intention, questions were asked about the demographic factors of age and educational level.
Statistical analysis
Data analysis included basic descriptive statistics of the respondents. Statistical differences between the various intention groups were analyzed using one-way ANOVA with Scheffé's multicomparison tests. Linear regression analysis was used to assess the predictive value of the determinants for the intention to perform TSE. The assumptions for the applicability of regression analysis were satisfied: none of the independent variables showed high colinearity, the residuals of intention were approximately normally distributed, there were no outliers or influential cases, and examination of scatterplots showed that intention was linearly related to the independent variables. All analyses were performed using the SPSS-X statistical program (SPSS Inc., 1988) (differences were significant at P < 0.05).
|
Results |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
A total of 274 students participated in the study. Their average age was 16.6 years (SD = 0.91), ranging from 15 to 19 years. Most of the students (n = 181; 66%) were in the 10th grade senior high school (age 15–16), while a minority (n = 93; 34%) were in the 11th grade senior high school (age 16–17). Knowledge or awareness of testicular cancer was poor: 74% had never heard of testicular cancer and only 3% of all students had ever heard of TSE. Of all subjects, only 2% (n = 5) reported that they regularly performed TSE. Since knowledge and behavior levels were so low, they showed no significant correlation with intention or any of the other determinants related to TSE. Of all students, 41% had a positive intention to perform TSE (32% positive, 9% very positive), while 27% had a negative intention to do TSE (20% negative, 7% very negative). The rest of the subjects had not yet formed an intention.
Correlations between the various determinants and the intention to perform TSE
Table II presents the correlations between the various determinants and the intention to perform TSE. The highest correlations with intention were found for the moral obligation that subjects experienced to perform TSE, their self-efficacy expectations, the expected positive consequences of TSE, the social norm that subjects experienced and the regret they expected to feel if they did not perform TSE. Except for the modeling concept, all determinants were significantly related to the intention to perform TSE. All of the significant correlations with intention were positive, except for the correlation with the negative emotional consequences of behavior (ConsI). This concept of negative emotional consequences was also negatively correlated with most of the other determinants, suggesting that more negative emotions experienced by the subjects lead to more positive determinants and intention toward TSE. The attitude concepts of pros, moral obligation and anticipated regret had high intercorrelations, ranging from 0.42 to 0.51, showing that these concepts were inter-related. The social influence concepts of social norm and social support were highly correlated (0.51).
|
Differences in determinants between the intention groups
In order to analyze whether students with a positive, neutral or negative intention differed with respect to the various determinants, potential differences between determinants were calculated; the results are presented in Table III
. There were no differences among the three intention groups with respect to knowledge, age and level of education.
|
With the exception of the determinants of modeling and negative emotional consequences (ConsI), students with positive intentions to perform TSE had significantly higher scores on all determinants than those with negative intentions. Subjects who had no clear intention (neutral intention) to perform TSE had lower determinant scores on most determinants than subjects with positive intentions, but scored higher on most determinants than subjects with a negative intention to perform TSE. As regards the negative emotional consequences, students with a negative intention toward TSE expected fewer negative emotional consequences than those who had a positive intention.
An in-depth analysis of the different scales was conducted to determine which items were responsible for the differences in the scales (see Table IV). As the results show, the differences at concept level were caused by differences on several items. Most items that presented positive consequences of TSE led to different scores for the intention groups. With respect to the negative emotional consequences, only one item differed significantly between the intention groups: subjects with a positive intention experienced more fear of detecting cancer than subjects with a negative intention toward TSE. This means that the ConsI scale is predominantly an anxiety scale. For the more practical consequences of TSE (ConsII), only the expectation that TSE would be time-consuming and awkward was more obvious among subjects with a negative intention to perform TSE. The differences between the intention groups as regards the concepts of anticipated regret, social norm, social support and self-efficacy were brought about by differences in almost all the items of the various scales.
|
Determinants of intention to perform TSE
A stepwise multiple regression analysis was conducted to assess the predictive value of the various determinants toward the intention to perform TSE (Table V
). The regression analysis involved two steps. First, all determinant concept variables were entered, resulting in 46% explained variance of the intention to perform TSE. Four determinants proved to be significant predictors of the intention to perform TSE. Self-efficacy was the most important predictor of the intention, followed by the moral obligation that the students experienced with respect to TSE, the social norm they experienced and the regret they anticipated if they did not perform TSE. The other concepts were not significant predictors of intention.
|
In the second step, possibly relevant interaction terms between the determinants were entered. Since the negative emotional consequences (ConsI: anxiety) showed such different relations with the intention and the other determinants, it was tested whether there were possible interactions between the negative emotional consequences and the other determinants of the intention to perform TSE. Several interactions between the negative emotional consequences and other determinants were found. Since these interactions with the negative emotional consequences resulted in a significant unique contribution (R2 changed to 0.49), separate multiple regression analyses were performed for subjects who expected many negative emotional consequences and subjects who expected few negative emotional consequences (Table V
). Among subjects who did expect negative emotional consequences, the model proved predictive of intention (F = 8.70; P < 0.001; R2 = 0.41). Three predictors remained in the model for subjects scoring high on the emotional items: anticipated regret was the strongest predictor, followed by moral obligation and the expected social norm. Among subjects who did not expect negative emotional consequences, the model also proved predictive of intention (F = 15.44; P < 0.001; R2 = 0.57). Four predictors remained in the model for subjects scoring low on anxiety: expected self-efficacy was the strongest predictor, followed by the expected positive outcomes of TSE, the expected social norm and the estimated susceptibility of getting testicular cancer.
|
Discussion |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
Levels of knowledge and behavior with respect to testicular cancer and TSE were very low among the young men in this study. Before this study, only 3% had ever heard of TSE. This indicates that there is still a considerable task for health education with respect to TSE. In spite of the very low knowledge or awareness of TSE before the study, a large proportion (42%) of the young men said that now that they knew of the existence of TSE, they intended to start performing it regularly. This result suggests that the questionnaire, with the accompanying brief introduction, focused on increasing students' knowledge of testicular cancer and TSE, may be regarded as a powerful intervention. However, since almost 60% of the subjects still did not show a positive intention to perform TSE, it can also be concluded that for the majority of young men, simply increasing their knowledge of TSE will not be enough to change their intention and, subsequently, behavior. This finding is consistent with other research on early detection of cancer and TSE (Katz et al., 1995
; De Nooijer et al., submitted), showing that knowledge is an important prerequisite for a positive intention and behavior, but in itself is often not ground enough for a positive intention toward early detection behavior.
In this study we used the ASE model as the theoretical framework to explain TSE intention. The questionnaire used to assess the concepts of this framework was self-developed, based on a thorough qualitative study (Oenema, 1998) and a systematic literature review. As the results show, the framework proved to be relevant for explaining TSE intention. However, reliability analysis showed that the assessment of some concepts still has room for improvement. Furthermore, there is still limited insight in the validity of the concepts assessed. Therefore, further research is needed in order to get more insight in the validity of the concepts assessed and to find out whether the assessments of the different concepts of the model can still be improved.
Since hardly any of the young men in this study performed TSE regularly, the determinants of behavior were not assessed. Instead, the determinants of intention were analyzed. Several interesting results were found. Firstly, several determinants proved to be of little or no importance in predicting the intention to perform TSE. Although the knowledge of what TSE actually is has proved to be an important predictor in other studies (Steffen, 1990; Rosella, 1994), it was found to be of no practical importance in the present study, since hardly any of the subjects had this knowledge. This lack of knowledge may be related to the age of the subjects (below 20). These very young men may not be very conscious of cancer; it could be that in their perception cancer is associated only with older people. This is consistent with other studies, which found that knowledge and behavior with respect to TSE were more highly developed in The Netherlands and other countries if the study group also included older men, aged up to 35 (Rosella, 1994; Wardle et al., 1994; Lechner et al., 1998). The lack of knowledge (and therefore behavior) with respect to TSE found in the present study may also explain the very limited importance of the determinant of modeling. Since most subjects had never heard of TSE, they obviously had no knowledge of other men's behavior with respect to TSE.
On almost all other determinants, the intention groups differed substantially in their scores. The positive intention group had the most positive score on all determinants. Only the concept of negative emotional consequences, in which the item on fear of detecting cancer proved to be the only relevant item, had a different relation with intention. If subjects were more fearful of detecting cancer by performing TSE, they were more likely to have a positive intention to perform TSE. A possible explanation for this relation could be that the men who said they had a positive intention felt more involved in the subject, and therefore experienced more fear. Furthermore, the fear of (detecting) cancer is actually one of the reasons for performing TSE. If subjects have no fears or worries about cancer, they are not likely to use detection techniques. This fear of detecting cancer also proved to be interactively related to the relation between other determinants and intention. The multiple regression analysis to explain intention showed that there were interactions between the anxiety determinant and other determinants. Separate regression analysis for subjects high and low in anxiety revealed that the determinants that explained intention were substantially different for the two groups. The proportion of variance in the intention explained by the determinants (41–57%) was high and partly comparable to percentages found in other studies (Steffen, 1990; Steffen and Gruber, 1991). However, ours was the first study to focus on differences in determinants between young men (below 20) showing considerable fear of detecting testicular cancer and young men showing little fear.
As the results show, the level of intention among subjects showing fear of detecting cancer was determined by the personal norm, which consists of anticipated regret and moral obligation, and by the expected social norm. The experienced personal norm might be such an important predictor of behavior for this group because the personal norm reflects the emotions that these young men experience about TSE, just as this group is also emotionally more concerned about TSE. For the group who experienced little fear of detecting cancer, and who were therefore probably less emotional about the subject, the determinants of intention were also of a more cognitive nature. In this more `rational' group, the relevant determinants were expected self-efficacy, expected positive outcomes of performing TSE, the social norm and the estimated risk of getting testicular cancer themselves.
The differences in determinants found in the present study have practical consequences for designing effective health education interventions for stimulating regular TSE performance. The results indicate that a different approach is needed for young men who experience few negative emotions concerning TSE and those experiencing major negative emotions. Providing straightforward cognitive health education techniques might prove to be very effective among those young men with limited negative emotional feelings about testicular cancer or TSE. This group of men will probably respond best to objective information that emphasizes the pros of TSE, to education that gives useful tips that help them to keep up regular TSE and to education providing objective information on the risk of getting testicular cancer. Young men who are fearful of finding testicular cancer by performing TSE probably need a different health education approach. They will probably respond better to health education focusing on their personal responsibility to perform TSE regularly and on the importance of behaving in accordance with their own personal standards or norms with respect to health behavior.
|
Acknowledgments |
|---|
The authors wish to thank Professor Hein de Vries and Professor Bart van den Borne for their contribution in the project. This study was financially supported by a grant from the Dutch Cancer Society.
|
References |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
Ajzen, I. (1991) The theory of planned behavior. Organizational Behavior Human Decision Processes, 50, 179–211.
American Cancer Society (1992) Cancer Facts and Figures (1992). American Cancer Society, Inc., Atlanta, GA.
Bandura, A. (1986) Social Foundations of Thought and Action. Prentice-Hall, Englewood Cliffs, NJ.
Austoker, J. (1994) Cancer prevention in primary care: screening for ovarian, prostatic, and testicular cancers. British Medical Journal, 309, 315–320
Best, D. L., Davis, S. W., Vaz, R. M. and Kaiser, M. (1996) Testicular cancer education: a comparison of teaching methods. American Journal of Health Behavior, 20, 229–241.
Brubaker, R. G. and Wickersham, D. (1990) Encouraging the practice of testicular self-examination: a field application of the theory of reasoned action. Health Psychology, 9, 154–163.[Web of Science][Medline]
De Vries, H., Dijkstra, M. and Kuhlman, P. (1988) Self-efficacy: the third factor besides attitude and subjective norm as a predictor of behavioral intentions. Health Education Research, 3, 273–282.
De Vries, H., Backbier, E., Kok, G. J. and Dijkstra, M. (1995) Measuring the impact of social influences on smoking onset in a longitudinal study: an integration of social psychological approaches. Journal of Applied Social Psychology, 25, 237–257
Dutch Cancer Society (1997) Zaadbalkanker [Testicular Cancer]. De Nederlandse Kankerbestrijding/KWF, Amsterdam.
Eagly, A. H. and Chaiken, S. (1993) The Psychology of Attitudes. Harcourt, Fort Worth, TX.
Friman, P. C. and Finney, J. W. (1990) Health education for testicular cancer. Health Education Quarterly, 17, 443–453.[Web of Science][Medline]
Giwercman, A., Rajpert-De Meyts, E. and Skakkebaek, N. E. (1996) Carcinoma in situ of the testis: a new biological concept of urologic relevance and implications for detection and management. In Vogelzang, N. J., Scardino, P., Shipley, W. U. and Coffey, D. (eds), Comprehensive Textbook of Genitourinary Oncology. Williams & Wilkins, Baltimore, MD, pp. 941–952.
Grube, J. W., Morgan, M. and McGee, S. T. (1986) Attitudes and normative beliefs as predictors of smoking intentions and behaviours: a test of three models. British Journal of Social Psychology, 25, 81–93.
Katz, R. C., Meyers, K. and Walls, J. (1995) Cancer awareness and self-examination practices in young men and women. Journal of Behavioral Medicine, 18, 377–384.[Web of Science][Medline]
Lechner, L. and De Vries, H. (1995) Starting participation in an employee fitness program: attitudes, social influence and self-efficacy. Preventive Medicine, 24, 627–633.[Web of Science][Medline]
Lechner, L., De Nooijer, J. and De Vries, H. (1998) Vroege ontdekking van kanker: een gedrags- en determinanten analyse onder de Nederlandse bevolking [Early detection of cancer: a behavioral and determinants analysis among the Dutch population]. Maastricht University, Maastricht.
Lechner, L. (1998) Social psychological determinants of health risk behaviors related to cancer and CVD: applications and elaborations of the ASE model. Dissertation, Unigraphic, Maastricht.
Lechner, L., De Vries, H. and Offermans, N. (1997) Participation in a breast cancer screening program: influence of past behavior and determinants on future screening participation. Preventive Medicine, 26, 473–482.[Web of Science][Medline]
McCaul, K. D., Sandgren, A. K., O'Neill, H. K. and Hinsz, V. B. (1993) The value of the theory of planned behavior, perceived control, and self-efficacy expectations for predicting health-protective behaviors. Basic and Applied Social Psychology, 14, 321–352.
Moore, S. M., Barling, N. R. and Hood, B. (1998) Predicting testicular and breast self-examination behaviour: a test of the Theory of Reasoned Action. Behaviour Change, 15, 41–49.
Murphy, W. G. and Brubaker, R. G. (1990) Effects of a brief theory-based intervention on the practice of testicular self-examination by high school males. Journal of School Health, 60, 459–462.
Oenema, A. (1998) Opvattingen over zaadbalzelfonderzoek: een kwalitatieve studie [Beliefs about testicular self-examination: a qualitative study]. Maastricht University, Maastricht.
Reno, R. R., Cialdini, R. B. and Kallgren, C. A. (1993) The transsituational influence of social norms. Journal of Personality and Social Psychology, 64, 104–112.
Ries, L. A., Wingo, P. A., Miller, D. S., Howe, H. L., Weir, H. K., Rosenberg, H. M., Vernon, S. W., Cronin, K. and Edwards, B. K. (2000) The annual report to the nation on the status of cancer, 1973–1997, with a special section on colorectal cancer. Cancer, 88, 2398–2424.[Web of Science][Medline]
Rogers, R. W. (1983) Cognitive and physiological processes in fear appeals and attitude change: a revised theory of protection motivation. In Cacioppo, J. T. and Petty, P. E. (eds), Social Psychophysiology: A Sourcebook. Guilford Press, New York, pp. 153–176.
Rosella, J. D. (1994) Testicular cancer health education: an integrative review. Journal of Advanced Nursing, 20, 666–671.[Web of Science][Medline]
Roth, B. J., Nichols, C. R. and Einhorn, L. H. (1993) Neoplasms of the testis. In Holland, J. F., Frei E., III, Bast, R. C., Jr, Kufe, D. W., Morton, D. L. and Weichselbaum R. R. (eds), Cancer Medicine. Lea & Febiger, Philadelphia, PA, pp. 1592–1619.
Schwarzer, R. (ed. ) (1992) Self-efficacy, Thought Control of Action. Hemisphere, Washington, DC.
SPSS Inc. (1988) SPSS-X User's Guide. SPSS Inc., Chicago, IL.
Steffen, V. J. and Gruber, V. A. (1991) Direct experience with a cancer self-exam: effects on cognitions and behavior. Journal of Social Psychology, 131, 167–177.
Steffen, V. J. (1990) Effects of prior knowledge and an educational brochure. Journal of Applied Social Psychology, 20, 681–702.
Strecher, V. J. and Rosenstock, R. (1997) The Health Belief Model. In Glanz, K., Lewis, F. M. and Rimer, B. (eds), Health Behavior and Health Education: Theory, Research and Practice. Jossey Bass, San Francisco, CA, pp. 41–59.
Van der Pligt, J. and Richard, R. (1993) Changing adolescent's sexual behaviour: perceived risk, self-efficacy and anticipated regret. Patient Education and Counseling, 23, 187–196.
Visser, O., Coebergh, J. W. W. and Schouten, L. J. (1996) Netherlands Cancer Registry 1993: Incidence of cancer in the Netherlands. Comprehensive Cancer Centres, Utrecht.
Wardle, J., Steptoe, A., Burckhardt, R., Vögele, C., Vila, J. and Zarczynski, Z. (1994) Testicular self-examination: attitudes and practices among young men in Europe. Preventive Medicine, 23, 206–210.[Web of Science][Medline]
Received on July 12, 2000; accepted on May 8, 2001
CiteULike 
Connotea 
Del.icio.us What's this?
This article has been cited by other articles:
|
|
 |
|
  G. A. J. Fransen, I. Mesters, M. J. R. Janssen, J. A. Knottnerus, and J. W. M. Muris Which patient-related factors determine self-perceived patient adherence to prescribed dyspepsia medication? Health Educ. Res., October 1, 2009; 24(5): 788 - 798. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 P. F. Cronholm, J. J. Mao, G. T. Nguyen, and R. T. Paris A Dilemma in Male Engagement in Preventive Services: Adolescent Males' Knowledge and Attitudes Toward Testicular Cancer and Testicular Self-Exam American Journal of Men's Health, June 1, 2009; 3(2): 134 - 140. [Abstract] [PDF]
|
|
|
|
|
|
C. McClenahan, M. Shevlin, G. Adamson, C. Bennett, and B. O'Neill Testicular self-examination: a test of the health belief model and the theory of planned behaviour Health Educ. Res., April 1, 2007; 22(2): 272 - 284. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 L. Rudberg, S. Nilsson, K. Wikblad, and M. Carlsson Barriers Identified by Swedish School Nurses in Giving Information about Testicular Cancer and Testicular Self-Examination to Adolescent Males The Journal of School Nursing, February 1, 2005; 21(1): 17 - 22. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||