knowledge of testicular self-examination and attitudes toward it

(1)

www.analesdepediatria.org

ORIGINAL ARTICLE

Impact of an educational intervention on the

knowledge of testicular self-examination and attitudes toward it

Juana Serret-Montoya

^a

, Sarait Nadja Rodríguez-Ibarra

^a

, Karla Denis Nava-Sánchez

^b

, Jessie Nallely Zurita-Cruz

^c,^∗

aDepartamentodeAdolescentes,HospitalInfantildeMéxicoFedericoGómez,CiudaddeMéxico,Mexico

bUniversidadJuárezAutónomadeTabasco,DivisiónAcadémicadeCienciasdelaSalud,Tabasco,Mexico

cFacultaddeMedicina,UniversidadNacionalAutónomadeMéxico,HospitalInfantildeMéxicoFedericoGómez,Ciudadde México,Mexico

Received25April2022;accepted14August2022 Availableonline5December2022

KEYWORDS Adolescents;

Testicularcancer;

Testicular self-examination

Abstract

Introduction:There isevidence thatthepercentage ofadolescentsthatpracticetesticular self-examinationislow.

Objective:Toassesstheshort-termandlong-term(6months)impactinmaleadolescentsofan educationalinterventionontheknowledgeoftesticularself-examinationandattitudetoward it.

Methods:Weconducted aquasi-experimental pre-testpost-test study inmaleadolescents.

A questionnairewas validated toassess knowledge ontesticular self-examination and atti- tudestowards it (awareness, intentions,and behaviour). The educational interventionwas group-basedandconsistedinaninstructionaltalkwiththeaidofdiagramsandbrochures.The questionnairewasadministeredbeforeandaftertheintervention.Afollow-upwasscheduled6 monthslater,andthetalkwasdeliveredagain,withadministrationofthequestionnairebefore andafter.

Results:The study included 139 adolescentswith a median age of14 years.We found an improvementinknowledge(18.3%vs78.9%;P=0.02)andattitude(5.6%vs53.5%;P=0.02) aftertheinitialintervention.Atthe6-monthfollow-up(n=98),therewasnochangeinknowl- edge(87.0%vs93.0%;P=0.671),butattitudeimprovedafterthesecondintervention(58.0%

vs78.0%;P=0.009).

∗Correspondingauthor.

E-mailaddress:[email protected](J.N.Zurita-Cruz).

(2)

Conclusion: Aneducationalinterventionontesticularself-examinationimprovedtheproportion ofadolescentswithanadequateattitude(5.6%vs53.5%)andadequateknowledge(18.3%vs 78.9%).Therepetitionoftheinterventionat6monthsincreasedtheproportionofadolescents withanadequateattitude(53.5%vs86.4%).

4.0/).

PALABRASCLAVE Adolescentes;

Cáncertesticular;

Autoexploración testicular

Impactodeunamaniobraeducativasobreelconocimientoyactituddela autoexploracióntesticular

Resumen

Introducción: Sehadescritoquelaautoexploracióntesticularserealizaenunbajoporcentaje delosadolescentes.

Objetivo: Evaluarelimpactodeunamaniobraeducativaacortoylargoplazo(6meses)sobre elconocimientoyactituddelosadolescentesvaronesenlaautoexploracióntesticular.

Métodos: Serealizóuncuasi-experimento,antesydespuésenadolescentesvarones.Sevalidó uncuestionarioparaevaluarelconocimientoylaactitud(conciencia,intencionesycompor- tamiento)sobrelaautoexploracióntesticular.Lamaniobraeducativaconsistióenunacharla informativa demaneragrupal incluyendoesquemasy folletos.Se lesaplicó elcuestionario antesy despuésdelamaniobra educativa.Secitaronalos6mesesposteriores yselesdio nuevamentelacharlaaplicándoseuncuestionarioantesydespuésdelamisma.

Resultados: Se incluyeron 139 adolescentes con una mediana para la edad de 14 a˜nos. El conocimiento(18.3%vs78.9%p=0.02)yla actitud(5.6%vs53.5% p=0.02) mejoróposterior alaprimeracharlainformativa.Alos6mesesdeseguimiento(n=98)elconocimientonose modificó(87.0%vs93.0%p=0.671);sinembargo,laactitudsuperóposterioralasegundacharla (58.0%vs78.0%p=0.009).

Conclusión: Unamaniobraeducativasobrelaautoexploracióntesticularmejorólaproporción deunaadecuadaactitud(5.6%vs53.5%)yconocimiento(18.3%vs78.9%)enlosadolescentes.El reforzamientodelamaniobraa6mesesmejoralaproporcióndeunaadecuadaactitud(53.5%

vs86.4%).

Introduction

Testicularcanceristhemostfrequenttypeofcancerinmen aged 15---40 years,with detection of 9 cases per 100 000 maleindividualsperyearinEurope¹.Themainriskfactors described in the literature are cryptorchidism, genitouri- naryanomaliesandendocrinedysfunction,amongothers². Theincidenceoftesticularcancerislowcomparedtoother forms of cancer affecting male individuals, but it contin- ues togrow worldwide, as the main problem is the lack of dissemination of information regarding its prevention, detectionandtreatment,contributingtoinsufficientaware- nessand implementationof behavioural measures^1,3.This is concerning, given that early detection has a substan- tial impact on survival and the cure rate for testicular cancer is approximately96% if it is detected in the early stages^2,4.

The American Cancer Society recommends testicular self-examinationasan effectiveandcost-free measureto preventlate-stagediagnosis^5,6.Inlightofthis,themaingoal ofpromotingtesticularself-examinationistoimprovethe

efficacyofdoctor-patientcommunication,therebyimprov- ingthequalityandefficiencyofhealtheducation⁷.

Studiesinyoungadultshave evincedlackofknowledge regardingtesticularself-examinationandwhattodowhen a mass is detected, with only 10% of study participants reportingperformingtesticularself-examinations^3,8,9.Other studieshavebeenconductedtoassesstheeffectivenessof comprehensivetesticularcancercampaignswithadvertising insocialnetworksandmassmedia,flyersandeducational talksthatanalyseddataonage,riskgroups,symptoms,per- formanceofself-exams,curabilityratesandtheimportance ofearlydetection^10---14,andstatisticallysignificantchanges inbehaviour(performance,monthlyself-examination,discussion of testicular cancer with a physician, friend or relativeand searchofinformation) havebeen foundafter educationalcampaings^5,15,16.

There is evidence that performance of testicular self- examination is influenced by attitudes and emotional factors,andanxietyandshame maypose barrierstoself- examination^17,18;ontheotherhand,informationaltalkson testicularself-examinationreducedanxietyinyoung men,

20

(3)

increasing the probability of having performed testicular self-examinationinthepastmonth^15,16.

Interventional studies on testicular self-examination have mostly focused on young adults, whereas few prevention campaigns targetthe maleadolescent population andtesticularself-examinationisrarelyexplainedinroutine medicalcheckupsinthisagegroup,whichposesabarrierto adolescentsseekinginformationonthesubject⁷.

The aim of our study was toassess the impactin the short and long term (6 months after) of an educational intervention on the knowledge and attitude of testicular self-examinationinmaleadolescents.

Material and methods

The study wasconductedbetween January2019 andJan- uary2020intheDepartmentofAdolescentCareofatertiary carechildren’shospital.Weconsecutivelyrecruitedallado- lescentsvisitingtheoutpatientclinicoftheDepartmentof adolescentcarefor theinitialevaluationorfor follow-up.

Thesamplingmethodwasnonprobabilistic.Itwasaquasi- experimental,pre-testpost-teststudyinasampleofmale adolescents.Weexcludedpatientswhorefusedtopartici- pate,whodidnotknowhowtoreadorwrite,whodidnot filloutthequestionnairecompletelyorwhodidnotundergo the educationalintervention.We interviewedparticipants tocollectdataontheirage,schoolenrolment,occupation andprovinceofresidence.

Educationalintervention

An informational talk was given, explaining the anatomy ofthemalereproductivesystemandillustrating thesteps involvedinperformingatesticularself-examination,inaddi- tion toitsusefulness, importance,howand howoften to performit, warningsignsthat meritrequesting amedical evaluation and risk factors for development of testicular cancer. We distributedflyers totheadolescents andhung posters intheoutpatientclinic thatremainedinplacefor the duration ofthe study (8 months).The talk wasgiven by apaediatrician withspecialisedtrainingon adolescent medicine,andlastedapproximately20min.Afterthetalk, thepaediatricianansweredquestionsposedbythepartici- pants.

Questionnairetomeasuretheresultsofthe intervention

We assessed knowledge and attitudes on testicular self- examination by means of a questionnaire previously used intheUnitedKingdominmenaged18---45years^16,19.

Acompanyspecialisedinmedicalwriting(LATAM-ENAGO Academy)didthebackandforwardtranslationoftheitems ofthequestionnaire.

The questionnaire comprised 16 items, with answers given on a Likert scale ranging from 1 (totally disagree) to5(totallyagree).Thequestionnaireassessedknowledge andattitudesontesticularcancerandself-examination.The attitudessectionwasdividedintocomponentsofawareness, behaviouralintentandbehaviour:

Knowledge

The knowledge section assessed knowledge of signs and symptomsoftesticularcancer.Thisincludedriskfactorsfor thepresenceoftesticularcancerandtheearlydetectionof testicularabnormalities.Alltheinformationfortheitemsof thequestionnairewasobtainedfromtheAmericanCancer Society⁶(items11---16,withthelevelofknowledgeconsid- eredgoodwithascoreof24---30,fairwithascoreof18---23 andpoorwithascore≤17).Theknowledgescalehasshown adequatereliability(validationoftranslation:␣=0.81).

Attitudes

Weevaluatedattitudesthrough3components:awareness, behaviouralintentandbehaviour.

Awarenesswasassessedinitems1---4,andratedgoodfor scoresof16---20points,fairfor scoresof12---15pointsand poorforscoresof11orfewerpoints.Theawarenesssubscale has shown adequate reliability (validation of translation:

␣=0.77).

Behaviouralintent wasassessed in items 5 and 6,and rated good for scores of 8---10 pints, fair for scores of 6---7 pointsand poor for scores of 5 or fewer points. The behaviouralintentsubscalehasshown adequatereliability (validationoftranslation:␣=0.84).

Self-reportedbehaviourrelatedtotesticularcancerwas assessedwithitems7---10,andratedgoodforscoresof16---20 points,fair forscores of12---15 pointsandpoorfor scores of 11 or fewer points. The behaviour subscale has shown adequatereliability(validationoftranslation:␣=0.81).

The knowledgeandattitudes questionnairewasadmin- isteredtomaleadolescentsaged10---18 yearsmanagedin theoutpatientclinicoftheDepartmentofAdolescentCare oftheHospitalInfantildeMéxicobetweenJanuaryandMay 2019.In thefirstvalidationround,it wasadministeredto 20maleadolescents;adjustmentsweremadebasedonthe results,and second andthird validationrounds wereper- formedwithadministrationto20adolescentsineach.Atthe endofthethirdround,thereliabilityofthequestionnaire wasadequate,withaCronbach␣greaterthan0.80.

Short-termimpact

Once the questionnaire had been validated, we imple- mentedthegroupeducationalinterventionintheoutpatient clinicoftheDepartmentofAdolescentCareoftheHospital InfantildeMéxicofromJunetoAugust2019,administering thequestionnairebeforeandaftertheintervention.

Long-termimpact(6monthsafter)

Six months after the initial educational intervention, we contactedtheadolescentstoinvitethemtoattendasec- ondgroup-basededucationaltalkintheoutpatientclinicof theDepartmentofAdolescentCareoftheHospitalInfantil deMéxicobetweenDecember2019andFebruary2020.The questionnaire was administered again before(third time) andafter(fourthtime)thesecondtalk.

(4)

The research protocol was approved by the research ethicscommitteeofthehospitalunderfileR-2017-21.The parentsofparticipantssignedtheirinformedconsent,and theadolescentsthemselvestheirinformedassent,inadher- encewiththeprinciplesoftheDeclarationofHelsinki.

Statisticalanalysis

Forquantitativedata,we usedtheShapiro-Wilk test, and sincewefound thatthe datadidnotfollow anormaldis- tribution,wesummarisedthemwiththemedian,minimum andmaximumvalues.

To assess differences between questionnaire scores beforeandaftertheeducationalinterventionand6months later,weusedtheWilcoxonsigntestforrepeatedmeasures.

To assess differencesin theproportions of participants thatexhibitedgoodattitudesandgoodknowledgeregarding testicularself-examination beforeandafter theinterven- tion,weusedtheFisherexacttest.

WeconsideredPvaluesoflessthan0.05statisticallysig- nificant.

The analyses wereperformedwiththesoftwareSTATA, version12.

Results

Short-termimpactoftheeducationalintervention Weidentified148patientsaspotentialcandidates,ofwho only139wereincluded;5wereexcluded duetoanestab- lisheddiagnosisofmalegenitaldisease,2duetoincomplete datainthequestionnaireand2due tomissingtheeduca- tionalinterventionduetotimeconstraints(Fig.1).

In the resultingsample, the medianage was14 years;

mostparticipantswerecurrentlyenrolledinsecondaryedu- cation(Table1).

Table 2 shows that when it came to attitudes (further dividedintoawareness,intentandbehaviour),participants generallyexhibitedapoor attitudetowardtesticularself- examinationinthepre-interventiontest(medianscalescore of 29), and only 5.6% (n=4) exhibited a good attitude, whereaswhenitcametoknowledgeabout testicularself- examination, they generally had fair knowledge (median scalescoreof21),and18.3%(n=13)hadadequateknowl- edgeatbaseline(Table2).

After the intervention, there was improvement in the attitudescore(29vs40;P< 0.001)andtheknowledgescore (21vs27;P< 0.000),inadditiontoanincreasedproportion ofadolescentswithagoodattitude(5.6%vs53.5%;P= 0.02) andadequateknowledge(18.3%vs78.9%;P= 0.02)(Table2 andFig.2).

Long-termimpactoftheeducationalintervention (6monthsafter)

In the third phase, there were only 98 participants (out of the139thatcompleted thesecond phase);35 patients reported not being ableattend the following talk due to school,and6patientsrefusedonthegroundsthattheydid

notneed a second talk,asa singleonewassufficient for them(Fig.1).

Thecharacteristicsofthegroupof98patientswhopar- ticipatedintheassessmentofthelong-termimpactofthe intervention(phase3)wereamedianageof14years,with anagerangeof10---18years;with18patients(60%)residing inMexicoCityandtherestoutsidethecitylimits(Table1).

The results of the third test (6 months after the ini- tialtalk)evincedadecreasing trendintheawarenessand behaviourscorescomparedtothesecondtest,althoughit wasnotstatisticallysignificant(Table3).However,whenwe comparedtheproportionofadolescentswithagoodattitude score in the post-test after the initial educational intervention(talk)comparedtothetest performedbeforethe secondtalk6monthsafterthefirst(thirdtest), wefound thattheproportionhaddecreased(53.5%vs30.1%;P=0.02) (Fig.2).

After the second intervention, we found a substan- tialincrease inthe proportionofadolescentswitha good attitude toward testicular self-exploration (second intervention:30.1%inpre-testvs86.4%inpost-test;P= 0.001), andthisproportionwasalsogreatercomparedtothepro- portionafterthefirsttalk(testafterfirsttalk,53.5%vstest aftersecondtalk,86.4%;P= 0.003)(Fig.2).

Ononehand,whenwecomparedtheproportionofado- lescentswithadequate knowledgeamongthe adolescents whoattended1 talk and thosewhoattended 2 talks,we foundthatthedifferencewasnotsignificant(1talk,87.0%

vs 2 talks,93.0%; P= 0.671), but on the other, when we comparedtheproportionwithagoodattitude,wefounda significantlygreaterproportioninthegroupofadolescents thatattended2 talks(1 talk,58.0% vs2 talks,78.0%; P= 0.009)(Fig.3).

Discussion

Mainfindings

Overall, we found a very low proportion of adolescents withafavourableattitude(5.6%)andadequateknowledge (18.3%)abouttesticularself-examination.

The delivery of an educational talk on testicular self- examination to male adolescents significantly improved knowledgeonthesubject,however,wefoundthatimprove- mentsinfavourableattitudeswanedsignificantly6months aftertheinitialtalk.

Although our goal was to assess the impact of an educationalintervention on testicularself-examination in adolescents,itisimportanttomentionthatatbaseline,we foundalowproportionofadolescentswithfavourableatti- tudesandadequateknowledgeregardingself-examination, inagreementwiththefindingsof otherstudiesconducted inmaleadolescentsandyoungadults^3,8,10,11,whichreflects howlittle this subject is discussed in the population and thescarceeffortsmadetopromoteroutineself-examination andawarenessofthewarningsignsoftesticulardisease.

Inourstudy,deliveryoftheeducationalinterventionwas associatedwithasubstantialimprovementinknowledgeon thesubject,withshort-termimprovementsinattitudeand knowledgeof53.5% and78.9%,respectively,evincingthat themainproblemisthelackofdisseminationontesticular

(5)

Figure1 Flowchartofdatacollection.

Table1 Characteristicsofmaleadolescentswhocompletedthesecondphaseofthestudy.

Shortterm Longterm

n=138 n=98

n(%) P

Age^a 14(10−18%) 14(10−18%)

Educationcycle Primary 1(1.4%) 1(3.33%) 0.050

Secondary 48(67.6%) 24(80%)

Preparatory 22(31%) 5(16.66%)

Occupation Student 68(95.8%) 27(90%) 0.039

None 3(4.2%) 3(10%)

Residence MexicoCity 63(88.7%) 29(96.7%) 0.330

Province 8(11.3%) 1(3.3%)

a Median(range).

Figure2 Proportionofadolescentswithadequateattitudesandknowledgebeforeandaftertheeducationalintervention(phases 1and2).

(6)

J.Serret-Montoya,S.N.Rodríguez-Ibarra,K.D.Nava-Sánchezetal.

thestudy(shortterm).

Pre-intervention Total Post-intervention Total P

Median(range) Awareness Ihavebeenexposedtoinformationregarding

testicularcancer

3(1−5) 11(4−20) 5(1−5) 18(4−20) 0.000

Iknowthewarningsignsandsymptomsof testicularcancer

2(1−5) 4(1−5)

Iknowwheretogotofindaccurate informationabouttesticularcancer

4(1−5) 4(1−5)

Iknowhowtoperformaself-examfor testicularcancertocheckthateverythingis fine

3(1−5) 5(1−5)

Intent Iamreadytoperformaself-examfor

testicularcancerinthenextmonth

3(1−5) 7(2−10) 5(1−5) 9(2−10) 0.000

Iplantotalkwithmydoctorabouttherisks, signsandsymptomsoftesticularcancer

4(1−5) 4(1−5)

Behaviour Iperformatesticularself-exameverymonth 2(1−5) 11(4−20) 3(1−5) 13(4−20) 0.000

Ihavediscussedtesticularcancerwithmy doctor

2(1−5) 4(1−5)

Isearchforinformationontesticularcanceron theInternet

4(1−5) 4(1−5)

Ihavediscussedtesticularcancerwithfriends orfamily

2(1−5) 2(1−5)

Assessmentofprovided information-knowledge

Testicularcancermainlyoccursinyoungand middle-agedmen

4(1−5) 21(6−28) 5(1−5) 27(6−30) 0.000

Cryptorchidismandafamilyhistoryof testicularcancerareamongtheriskfactorsfor testicularcancer

3(1−5) 4(1−5)

Testicularcancercanbedetectedearly throughtesticularself-examination

4(1−5) 5(1−5)

Thebesttimetoperformatesticular self-examisduringorafterawarmbathor shower,whentheskinofthescrotumisrelaxed

4(1−5) 5(1−5)

Itisnormalforonetesticletobeslightly largerorhanglowerthantheother

3(1−5) 4(1−5)

Alumporswellinginthetesticle,painora feelingofheavinessaresomeofthesignsand symptomsoftesticularcancer

3(1−5) 5(1−5)

24

(7)

AnalesdePediatría98(2023)19---27 thestudy(longterm).

Scoreafterfirsttalk Total Score6months afterfirsttalk

Total P

Median(range) Awareness Ihavebeenexposedtoinformationregarding

testicularcancer

5(1−5) 17(4−20) 5(2−5) 16(6−20) 0.07

Iknowthewarningsignsandsymptomsof testicularcancer

4(1−5) 4(2−5)

Iknowwheretogotofindaccurate informationabouttesticularcancer

4(1−5) 4(1−5)

Iknowhowtoperformaself-examfor testicularcancertocheckthateverythingis fine

5(1−5) 4(1−5)

Intent Iamreadytoperformaself-examfor testicularcancerinthenextmonth

5(1−5) 8(2−10) 4(1−5) 9(2−10) 0.81

Iplantotalkwithmydoctorabouttherisks, signsandsymptomsoftesticularcancer

4(1−5) 4(1−5)

Behaviour Iperformatesticularself-exameverymonth 3(1−5) 13(4−20) 4(1−5) 12(4−19) 0.52

Ihavediscussedtesticularcancerwithmy doctor

4(1−5) 3(1−5)

Isearchforinformationontesticularcanceron theInternet

4(1−5) 3(1−5)

Ihavediscussedtesticularcancerwithfriends orfamily

2(1−5) 2(1−5)

Assessmentofprovided information- knowledge

Testicularcancermainlyoccursinyoungand middle-agedmen

5(1−5) 25(6−30) 2(1−5) 25(6−30) 0.75

Cryptorchidismandafamilyhistoryof testicularcancerareamongtheriskfactorsfor testicularcancer

4(1−5) 4(1−5)

Testicularcancercanbedetectedearly throughtesticularself-examination

5(1−5) 4(1−5)

Thebesttimetoperformatesticular self-examisduringorafterawarmbathor shower,whentheskinofthescrotumisrelaxed

5(1−5) 5(1−5)

Itisnormalforonetesticletobeslightly largerorhanglowerthantheother

4(1−5) 4(1−5)

Alumporswellinginthetesticle,painora feelingofheavinessaresomeofthesignsand symptomsoftesticularcancer

5(1−5) 4(1−5)

25

(8)

Figure3 Comparisonoftheproportionofadolescentswithadequateattitudesandknowledgeinthegroupexposedto1inter- ventionversusthegroupexposedto2interventions(educationaltalks).

self-examination, which contributestoinadequateknowl- edge and behaviour. Along the same lines, Wanzer et al.

carriedoutastudyinNewYorkthroughacomprehensivetes- ticularcancerandself-examinationcampaignin220college studentswhocompletedmeasuresbeforeandafterthecam- paignsandinacontrolgroupof52studentswhowerenot exposedtothecampaignmessages.Thestudyfoundanover- allimprovementinknowledgeandawareness.Thecampaign included similarstrategies, deliveringinformationthrough flyers,posters,showercardsandonlineplatforms,andthe authorsfoundthattheknowledgeontesticularcancerand self-examinationofthestudentsimprovedby12%afterthe campaign,andthatexposuretospecificmaterials(shower cards)wasassociatedwithaself-reportedimprovementin awarenesscomparedtostudentsnotexposedtothem,with a5%change¹⁶.

Several past studies have evinced that informational talks substantially improve knowledge on testicular self- examination in male adolescents and young adults, with improvementsrangingfrom10.3%to68.3%^3,10,14.Thisiscon- sistentwithourresults,aswefoundastatisticallysignificant improvementinawarenessandbehaviour,correspondingto a53.5%change,intheshortterm.

When itcomestothefactorsthatmayhave animpact ontesticularself-examinationinadolescents,Shepherdand Wattidentifiedacollectionofemotionalfactorsthatcould promote or discourage self-examination (anxiety, shame, anticipated regret and relief),evincing that these social- cognitiveandemotionalfactorscouldhaveanegativeeffect ontheimprovementofawarenessandbehaviourof 10%¹⁸. Althoughwedidnotassessfactorsassociatedwiththepro- motion or deterrence of testicular self-examination, we found thatadolescentsin ahighereducationallevel were lesslikelytoreturnforasecondeducationalintervention.

As regardstheeducationalintervention,thestudy con- ductedinNewYorkshowedthatreinforcementat2different timeswithmultipleinformationalstrategiesandtheuseof pre-aandpost-interventionmeasuressignificantlyincreased knowledgeacquisitionbetweenbaselineandtheendofthe intervention¹⁶; this wasalsothe case in ourstudy, where wefoundthattheproportionofadolescentswithadequate knowledgewasmaintainedintheshortandlongterm(78.9%

and76.6%).

We found that maintaining good attitudes (53.5%) required reinforcement of what had been learned (6 months), as a second educational intervention improved behavioural intent, which had not changed with a single talk,andpromoted adherenceofadolescentstotesticular self-examination,while theproportionofgoodknowledge of self-examinationremained constant(78.9% vs76.0%) 6 months after receiving the informational talk. This was similartothefindingsofastudybyRoyandCassoninNorth- ern Ireland, which included 150 men aged 18---45 years, seeking to determine the level of awareness, knowledge andattitudestowardtesticularcancerandself-examination throughaneducationalintervention,reportinga50%decline inattitudeovertime,evincingtheneedofreinforcement, however,acquiredknowledgewasmaintainedin70%after 6months⁹.

Overall,thefindingsofourstudy,supportedbythepre- viousliterature,clearlyevincedtheneedofspecificefforts todisseminate information ontesticular cancer targeting youth in orderto increase the efficacy of testicular self- examination¹¹.

Weproposedeliveringthistypeofeducationalinterven- tionintheschool setting,which studentshave toattend, withaminimumof1talksufficingtosubstantiallyimprove attitudesandknowledge;however,sinceattitudesdecline overtime,reinforcementoftheeducationalinterventionat leastevery6monthsisrequiredtomaintaingoodattitudes.

Conclusion

Afterdeliveringaneducationalinterventioninapaediatric hospital,we concludethattherewassubstantialimprove- mentintheproportionofadolescentswithagoodattitude (5.6%vs53.5%) andadequate knowledge(18.3% vs78.9%) aftertheinterventionintheshortterm(testingbeforeand aftertheintervention).

Wefoundthattheproportionofadolescentswithagood attitude decreased when we assessed the results of the intervention6 months afterits delivery (53.5% vs30.5%), whilethe proportionof adolescentswithadequate knowledgewasmaintainedintheshortandlongterm(78.9%vs 76.6%).

(9)

Conflicts of interest

Theauthorshavenoconflictsofinteresttodeclare.

References

1.WolduSL,BagrodiaA.Updateonepidemiologicconsiderations and treatment trends in testicular cancer. Curr Opin Urol.

2018;28:440---7.

2.ChengL,AlbersP,BerneyDM,FeldmanDR,DaugaardG,Gilligan T,etal.Testicularcancer.NatRevDisPrim.2018;4:29.

3.WardKD,VanderWegMW,ReadMC,SellMA,BeechBM.Testic- ularcancerawarenessandself-examinationamongadolescent males in a community-based youth organization. Prev Med.

2005;41:386---98.

4.Neef N, Scutchfield FD, Elder J, Bender SJ. Testicular self- examination by young men: an analysis of characteristics associatedwithpractice.JAmCollHeal.1991;39:187---90.

5.AsgarPourH,KunterD,NorouzzadehR,HeidariMR.Theeffect oftesticular self-examinationeducation on knowledge, performance,andhealthbeliefsofTurkishmen.JCancerEduc.

2018;33:398---403.

6.American Cancer Society [Internet]; 2016 [Accessed 02 October 2019]. Available from: https://www.cancer.

org/es/cancer/cancer-de-testiculo.html

7.SaabMM, LandersM,HegartyJ. Promotingtesticular cancer awarenessandscreening:asystematicreviewofinterventions.

CancerNurs.2016;39:473---87.

8.CronholmPF,MaoJJ,NguyenGT,ParisRT.Adilemmainmale engagementinpreventiveservices:adolescentmales’knowledge and attitudes toward testicular cancer and testicular self-exam.AmJMensHeal.2009;3:134---40.

9.RoyRK,CassonK.Attitudestowardtesticularcancerandself- examination among northern Irish males. Am J Mens Heal.

2017;11:253---61.

10.LechnerL,OenemaA,deNooijerJ.Testicularself-examination (TSE)amongDutchyoungmenaged15-19:determinantsofthe intentiontopracticeTSE.HealEducRes.2002;17:73---84.

11.Trumbo CW. Mass-mediated information effects on testicularself-examinationamongcollegestudents.JAmCollHeal.

2004;52:257---61.

12.RovitoMJ,GordonTF,BassSB,DuCetteJ,TierneyAM,Coles N.Developingthe‘‘controlidentity’’typologytocreatemore effectivetesticularhealthpromotionalmessaging.AmJMens Heal.2018;12:546---55.

13.RovitoMJ,LeoneJE,CavayeroCT.‘‘Off-label’’usageoftestic- ularself-examination(TSE):benefitsbeyondcancerdetection.

AmJMensHeal.2018;12:505---13.

14.McCullaghJ,LewisG,WarlowC.Promotingawarenessandprac- ticeoftesticularself-examination.NursStand.2005;19:41---9.

15.Daley CM. College men’s knowledge, attitudes, and beliefs abouttesticularcancer.AmJMensHeal.2007;1:173---82.

16.WanzerMB,FosterSC,ServossT,LaBelleS.Educatingyoungmen abouttesticularcancer:supportforacomprehensivetesticular cancercampaign.JHealCommun.2014;19:303---20.

17.GascoigneP,MasonMD,RobertsE.Factorsaffectingpresenta- tionanddelayinpatientswithtesticularcancer:resultsofa qualitativestudy.Psychooncology.1999;8:144---54.

18.ShepherdL,WattC,LovellB.Theroleofsocial-cognitiveand emotionalfactorsontesticularself-examination.Psychooncol- ogy.2017;26:53---9.

19.BarlingNR,LehmannM.Youngmen’sawareness,attitudesand practiceoftesticularself-examination:ahealthactionprocess approach.PsycholHealMed.1999;4:255---63.