- Email: [email protected]
Attitudes and Intentions to Performing Testicular Self-Examination: Utilizing an Extended Theory of Planned Behavior
Journal of Adolescent Health 44 (2009) 404–406
Adolescent health brief
Attitudes and Intentions to Performing Testicular Self-Examination: Utilizing an Extended Theory of Planned Behavior Caroline McGilligan, B.Sc*, Carol McClenahan, Ph.D, and Gary Adamson, Ph.D University of Ulster, Magee Campus, Londonderry, Northern Ireland Manuscript received April 8, 2008; manuscript accepted August 27, 2008
Abstract
This study examined the ability of an extended theory of planned behavior (TPB) to predict 500, 17- to 35-year-old male students’ intentions to perform testicular self-examination (TSE). In a hierarchical regression analysis TPB components attitude, subjective norm and self-efficacy and the added constructs, past behavior, and anticipated regret all emerged as significant independent predictors of TSE intention. Overall, 64% of the variance in TSE intention was explained. Although prospective research is needed to confirm these preliminary findings, they suggest that an extended TPB might be a useful framework to guide interventions aimed at promoting TSE. Ó 2009 Society for Adolescent Medicine. All rights reserved.
Keywords:
Attitudes; Testicular self-examination; Theory of planned behavior; Young adult males; self-efficacy
Testicular Cancer (TC) is the most frequently occurring cancer and a leading cause of death among young adult males between the ages of 15 and 35 years, and it has increased by 60% in the last 25 years. TC has a survival rate of 95% when detected at an earlier stage; however, over half of the males are diagnosed after the tumor has spread [1]. Awareness of the symptoms of TC is believed to be important to early presentation, and hence, more effective treatment. Although TC is not preventable, in the United Kingdom it is recommended that young males examine their testicles at least once a month for unusual lumps or swellings [2]. Nevertheless, studies have shown that regular testicular self-examination (TSE) is rarely performed [3,4]. The present study describes the application of an extended theory of planned behavior (TPB) [5] to TSE intention. The TPB identifies intention as the precursor to behavior, and attitude, subjective norm (SN) (the influence of important others) and perceived behavioral control (PBC) as the sociocognitive determinants of intention. To date, only a few studies have focused on TSE intention using the TPB [3,6]. This study aims to evaluate the TPB as a framework for under*Address correspondence to: Caroline McGilligan, Department of Psychology, University of Ulster, Northland Road, Londonderry, Northern Ireland BT48 7JL. E-mail address: [email protected]
standing TSE intention among a sample of young males in the age range most affected by TC. It is hypothesized that the TPB will predict TSE intention. Self-efficacy (SE) has emerged as a highly significant predictor of health behavior and behavioral intention across many TPB-based studies, and there is empirical evidence to support a division of the PBC construct into two separate components, one based on control (PBC) and the other on confidence/ability (SE) [7–9]. The second hypothesis is that SE will contribute more to TSE intention than PBC. Other studies have extended the TPB with constructs such as past behavior (PB), and anticipated regret (AR). For example, Abraham and Sheeran [10] explained significantly more variance in exercise intention with the addition of both. The third hypothesis is that the addition of PB and AR will make a significant contribution to TSE intention over and above the TPB variables.
Method Participants, design and procedure The participants were a random sample of 500 male students (mean ¼ 25.67; SD ¼ 9.77; range ¼ 17–35 years) from the University of Ulster. A cross-sectional survey design was employed. This study was approved by the
1054-139X/09/$ – see front matter Ó 2009 Society for Adolescent Medicine. All rights reserved. doi:10.1016/j.jadohealth.2008.08.018
C. McGilligan et al. / Journal of Adolescent Health 44 (2009) 404–406
405
Table 1 Mean, standard deviations, and correlations (Pearson) among the TPB variables Variables
Mean
SD
Alpha
1
2
3
4
5
6
7
1. Intention 2. Attitude 3. Subjective norm 4. PBC 5. Self-efficacy 6. Past behavior 7. Anticipated regret
4.70 5.66 4.94 6.38 5.44 1.21 3.74
1.69 1.01 1.32 .95 1.54 1.74 1.50
0.90 0.73 0.76 0.58 0.87 0.86 0.81
— .659** .528*** .153** .584*** .494*** .611***
— .420*** .30*** .751*** .313*** .399***
— .219*** .526*** .302*** .439***
— .471*** 0.29 -.005
— .278*** .325***
— .412***
—
Response offered for TSE past behavior were: 0 ¼ never, 1 ¼ once in last month , 2 ¼ two or three times, 3 ¼ three or four times; 4 ¼ four or five times; 5 ¼ five or six times; 6 ¼ more than six times per month. *p < .05; ** p < .01; *** p < .001.
University’s Research Ethics Committee. Voluntary completion of the questionnaire indicated informed consent. Measures The questionnaire was structured in the TPB-format [5,11]. Items were developed from a variety of past TPBbased studies on both TSE and BSE (breast self-examination). Findings from a principal components analysis (PCA) with varimax rotation revealed that the six PBC items—three designed to measure TSE confidence/ability and three to measure control over TSE—clearly produced (based on Table 2 Hierarchical multiple regression of the extended theory of planned bhavior in the prediction of intention to perform TSE (N ¼ 500) Variable
Adj R2
DR2
DF
Standardized coefficients b
Step 1 .526*** Attitude Subjective norm PBC Self-efficacy
137.52 ***
.482 *** .283 *** .133*** .136 *
.523 Step 2 .059*** Attitude Subjective norm PBC Self-efficacy Past behavior
69.862 ***
.424 *** .230 *** .102 ** .120 * .262 ***
TPB. Three items measured intention (I intend/I will perform TSE—strongly disagree to strongly agree; how likely or unlikely is it that you will?—extremely unlikely to extremely likely. There were four attitude items (e.g., my performing TSE in the next month would be bad/good; foolish/wise; harmful/beneficial; unimportant/important), three SN items (e.g., most people who are important to me think I should/ would want me to/would approve of me—strongly disagree to strongly agree), three PBC items (e.g., whether or not I perform TSE is entirely up to me/I have complete control over whether or not I—strongly disagree to strongly agree/how much control do you have over whether you—no control to complete control; and three SE items (e.g., to what extent do you see yourself as being capable?—incapable to capable/I am confident I would be able /I believe I have the ability to—strongly disagree to strongly agree. PB and AR. PB was measured with three items (e.g., how frequently have you examined you testicles for cancer in the last month/6 months/year? and AR was also measured using three items. If I did not perform TSE in the next month, I would regret it/be upset/feel worried—strongly disagree to strongly agree. Scores for each of the constructs were based on the mean of the items. Results
.581 Step 3 .057*** At Attitude Subjective norm PBC Self-efficacy Past behavior Anticipated regret
eigenvalues and scree plot) two separate factors labeled SE and PBC, respectively. All variables were measured on seven-point Likert-scales, and all items referred to performing TSE in the next month.
39.067 ***
.350 *** .132 *** .060 .124 ** .184 *** .265 ***
.637 TSE¼ testicular self-examination. DF¼ F change; DR2 ¼ R squared changed. * p < .05; ** p < .01; *** p < .001.
The means, standard deviations, and correlations for all variables can be seen in Table 1. A three-step, hierarchical regression analysis (HRA) was performed consistent with the theoretical tenets of an extended TPB. TPB constructs (attitude, SN, PBC, and SE) were entered on Step 1. In line with Abraham and Sheeran’s [10] study on exercise intentions, PB was added on Step 2 and AR on Step 3. The three TPB components accounted for 52.3% (adjusted R2) of the variance in TSE intention, each making a significant contribution. PB and AR together added 11.4% (adjusted R2). In
406
C. McGilligan et al. / Journal of Adolescent Health 44 (2009) 404–406
total, 63.7% of the variance in TSE intention was explained (see Table 2).
Discussion The results of the present study indicate that the TPB is a useful model for understanding TSE intention among young adult males and may be a useful framework to guide interventions aimed at promoting TSE. Attitude, SN, and self-efficacy significantly contributed to intention to perform TSE (see Table 2), supporting previous research [6]. The additional constructs PB and AR increased the variance in intention scores substantially (5.9% and 5.7%, respectively; see Table 2). In descending order of importance, attitude, AR, PB, SN, and SE were all significantly associated with TSE intention, suggesting that these might be the factors to focus on in a TPB-based, TSE intervention. Although the cross-sectional nature of the present study is a limitation, this is the first study to investigate the determinants of TSE intention extending the TPB model with PB and AR. Another major strength of the study is that its 500 young adult male participants represent those from the highest risk age group for TC. However, prospective research is needed to confirm these preliminary findings.
References [1] Institute of Cancer Research. Available at: http://www.icr.ac.uk. Accessed January 2, 2007. [2] Cancer Research, UK. Available at: http//cancerresearchuk.org. Accessed January 2, 2007. [3] Brubaker RG, Wickersham D. Encouraging the practice of testicular self-examination: a field application of the theory of reasoned action. J Health Psychol 1990;9:154–63. [4] Rudberg L, Nilsson S, Wikblad K, et al. Health-related quality of life in survivors of testicular cancer, 3 to 13 years after treatment. J Psychosoc Oncol 2000;18:19–31. [5] Ajzen I. The theory of planned behavior, organizational behavior and human decision processes. Organizational Behavior and Human Decision Processes 1991;50:179–211. [6] McClenahan C, Shevlin M, Adamson G, et al. Testicular self-examination: a test of the health belief model and the theory of planned behaviour. Health Educ Res 2007;22:272–84. [7] Armitage CJ, Conner M. Social cognitive determinants of blood donation. J Appl Soc Psychol 2001;31:1431–57. [8] Giles M, McClenahan C, Cairns E, et al. An application of the theory of planned behaviour to blood donation: the importance of self-efficacy. Health Educ Res 2004;19:380–91. [9] Norman P, Hoyle S. The theory of planned behavior and breast self-examination: distinguishing between perceived control and self-efficacy. Appl Soc Psychol 2004;34:694–708. [10] Abraham C, Sheeran P. Deciding to exercise: the role of anticipated regret. Br J Health Psychol 2004;9:209–78. [11] Ajzen I. Aavailable at: http//people.umass.edu/aizen/index.html. Accessed January 2, 2007.
Adolescent health brief
Attitudes and Intentions to Performing Testicular Self-Examination: Utilizing an Extended Theory of Planned Behavior Caroline McGilligan, B.Sc*, Carol McClenahan, Ph.D, and Gary Adamson, Ph.D University of Ulster, Magee Campus, Londonderry, Northern Ireland Manuscript received April 8, 2008; manuscript accepted August 27, 2008
Abstract
This study examined the ability of an extended theory of planned behavior (TPB) to predict 500, 17- to 35-year-old male students’ intentions to perform testicular self-examination (TSE). In a hierarchical regression analysis TPB components attitude, subjective norm and self-efficacy and the added constructs, past behavior, and anticipated regret all emerged as significant independent predictors of TSE intention. Overall, 64% of the variance in TSE intention was explained. Although prospective research is needed to confirm these preliminary findings, they suggest that an extended TPB might be a useful framework to guide interventions aimed at promoting TSE. Ó 2009 Society for Adolescent Medicine. All rights reserved.
Keywords:
Attitudes; Testicular self-examination; Theory of planned behavior; Young adult males; self-efficacy
Testicular Cancer (TC) is the most frequently occurring cancer and a leading cause of death among young adult males between the ages of 15 and 35 years, and it has increased by 60% in the last 25 years. TC has a survival rate of 95% when detected at an earlier stage; however, over half of the males are diagnosed after the tumor has spread [1]. Awareness of the symptoms of TC is believed to be important to early presentation, and hence, more effective treatment. Although TC is not preventable, in the United Kingdom it is recommended that young males examine their testicles at least once a month for unusual lumps or swellings [2]. Nevertheless, studies have shown that regular testicular self-examination (TSE) is rarely performed [3,4]. The present study describes the application of an extended theory of planned behavior (TPB) [5] to TSE intention. The TPB identifies intention as the precursor to behavior, and attitude, subjective norm (SN) (the influence of important others) and perceived behavioral control (PBC) as the sociocognitive determinants of intention. To date, only a few studies have focused on TSE intention using the TPB [3,6]. This study aims to evaluate the TPB as a framework for under*Address correspondence to: Caroline McGilligan, Department of Psychology, University of Ulster, Northland Road, Londonderry, Northern Ireland BT48 7JL. E-mail address: [email protected]
standing TSE intention among a sample of young males in the age range most affected by TC. It is hypothesized that the TPB will predict TSE intention. Self-efficacy (SE) has emerged as a highly significant predictor of health behavior and behavioral intention across many TPB-based studies, and there is empirical evidence to support a division of the PBC construct into two separate components, one based on control (PBC) and the other on confidence/ability (SE) [7–9]. The second hypothesis is that SE will contribute more to TSE intention than PBC. Other studies have extended the TPB with constructs such as past behavior (PB), and anticipated regret (AR). For example, Abraham and Sheeran [10] explained significantly more variance in exercise intention with the addition of both. The third hypothesis is that the addition of PB and AR will make a significant contribution to TSE intention over and above the TPB variables.
Method Participants, design and procedure The participants were a random sample of 500 male students (mean ¼ 25.67; SD ¼ 9.77; range ¼ 17–35 years) from the University of Ulster. A cross-sectional survey design was employed. This study was approved by the
1054-139X/09/$ – see front matter Ó 2009 Society for Adolescent Medicine. All rights reserved. doi:10.1016/j.jadohealth.2008.08.018
C. McGilligan et al. / Journal of Adolescent Health 44 (2009) 404–406
405
Table 1 Mean, standard deviations, and correlations (Pearson) among the TPB variables Variables
Mean
SD
Alpha
1
2
3
4
5
6
7
1. Intention 2. Attitude 3. Subjective norm 4. PBC 5. Self-efficacy 6. Past behavior 7. Anticipated regret
4.70 5.66 4.94 6.38 5.44 1.21 3.74
1.69 1.01 1.32 .95 1.54 1.74 1.50
0.90 0.73 0.76 0.58 0.87 0.86 0.81
— .659** .528*** .153** .584*** .494*** .611***
— .420*** .30*** .751*** .313*** .399***
— .219*** .526*** .302*** .439***
— .471*** 0.29 -.005
— .278*** .325***
— .412***
—
Response offered for TSE past behavior were: 0 ¼ never, 1 ¼ once in last month , 2 ¼ two or three times, 3 ¼ three or four times; 4 ¼ four or five times; 5 ¼ five or six times; 6 ¼ more than six times per month. *p < .05; ** p < .01; *** p < .001.
University’s Research Ethics Committee. Voluntary completion of the questionnaire indicated informed consent. Measures The questionnaire was structured in the TPB-format [5,11]. Items were developed from a variety of past TPBbased studies on both TSE and BSE (breast self-examination). Findings from a principal components analysis (PCA) with varimax rotation revealed that the six PBC items—three designed to measure TSE confidence/ability and three to measure control over TSE—clearly produced (based on Table 2 Hierarchical multiple regression of the extended theory of planned bhavior in the prediction of intention to perform TSE (N ¼ 500) Variable
Adj R2
DR2
DF
Standardized coefficients b
Step 1 .526*** Attitude Subjective norm PBC Self-efficacy
137.52 ***
.482 *** .283 *** .133*** .136 *
.523 Step 2 .059*** Attitude Subjective norm PBC Self-efficacy Past behavior
69.862 ***
.424 *** .230 *** .102 ** .120 * .262 ***
TPB. Three items measured intention (I intend/I will perform TSE—strongly disagree to strongly agree; how likely or unlikely is it that you will?—extremely unlikely to extremely likely. There were four attitude items (e.g., my performing TSE in the next month would be bad/good; foolish/wise; harmful/beneficial; unimportant/important), three SN items (e.g., most people who are important to me think I should/ would want me to/would approve of me—strongly disagree to strongly agree), three PBC items (e.g., whether or not I perform TSE is entirely up to me/I have complete control over whether or not I—strongly disagree to strongly agree/how much control do you have over whether you—no control to complete control; and three SE items (e.g., to what extent do you see yourself as being capable?—incapable to capable/I am confident I would be able /I believe I have the ability to—strongly disagree to strongly agree. PB and AR. PB was measured with three items (e.g., how frequently have you examined you testicles for cancer in the last month/6 months/year? and AR was also measured using three items. If I did not perform TSE in the next month, I would regret it/be upset/feel worried—strongly disagree to strongly agree. Scores for each of the constructs were based on the mean of the items. Results
.581 Step 3 .057*** At Attitude Subjective norm PBC Self-efficacy Past behavior Anticipated regret
eigenvalues and scree plot) two separate factors labeled SE and PBC, respectively. All variables were measured on seven-point Likert-scales, and all items referred to performing TSE in the next month.
39.067 ***
.350 *** .132 *** .060 .124 ** .184 *** .265 ***
.637 TSE¼ testicular self-examination. DF¼ F change; DR2 ¼ R squared changed. * p < .05; ** p < .01; *** p < .001.
The means, standard deviations, and correlations for all variables can be seen in Table 1. A three-step, hierarchical regression analysis (HRA) was performed consistent with the theoretical tenets of an extended TPB. TPB constructs (attitude, SN, PBC, and SE) were entered on Step 1. In line with Abraham and Sheeran’s [10] study on exercise intentions, PB was added on Step 2 and AR on Step 3. The three TPB components accounted for 52.3% (adjusted R2) of the variance in TSE intention, each making a significant contribution. PB and AR together added 11.4% (adjusted R2). In
406
C. McGilligan et al. / Journal of Adolescent Health 44 (2009) 404–406
total, 63.7% of the variance in TSE intention was explained (see Table 2).
Discussion The results of the present study indicate that the TPB is a useful model for understanding TSE intention among young adult males and may be a useful framework to guide interventions aimed at promoting TSE. Attitude, SN, and self-efficacy significantly contributed to intention to perform TSE (see Table 2), supporting previous research [6]. The additional constructs PB and AR increased the variance in intention scores substantially (5.9% and 5.7%, respectively; see Table 2). In descending order of importance, attitude, AR, PB, SN, and SE were all significantly associated with TSE intention, suggesting that these might be the factors to focus on in a TPB-based, TSE intervention. Although the cross-sectional nature of the present study is a limitation, this is the first study to investigate the determinants of TSE intention extending the TPB model with PB and AR. Another major strength of the study is that its 500 young adult male participants represent those from the highest risk age group for TC. However, prospective research is needed to confirm these preliminary findings.
References [1] Institute of Cancer Research. Available at: http://www.icr.ac.uk. Accessed January 2, 2007. [2] Cancer Research, UK. Available at: http//cancerresearchuk.org. Accessed January 2, 2007. [3] Brubaker RG, Wickersham D. Encouraging the practice of testicular self-examination: a field application of the theory of reasoned action. J Health Psychol 1990;9:154–63. [4] Rudberg L, Nilsson S, Wikblad K, et al. Health-related quality of life in survivors of testicular cancer, 3 to 13 years after treatment. J Psychosoc Oncol 2000;18:19–31. [5] Ajzen I. The theory of planned behavior, organizational behavior and human decision processes. Organizational Behavior and Human Decision Processes 1991;50:179–211. [6] McClenahan C, Shevlin M, Adamson G, et al. Testicular self-examination: a test of the health belief model and the theory of planned behaviour. Health Educ Res 2007;22:272–84. [7] Armitage CJ, Conner M. Social cognitive determinants of blood donation. J Appl Soc Psychol 2001;31:1431–57. [8] Giles M, McClenahan C, Cairns E, et al. An application of the theory of planned behaviour to blood donation: the importance of self-efficacy. Health Educ Res 2004;19:380–91. [9] Norman P, Hoyle S. The theory of planned behavior and breast self-examination: distinguishing between perceived control and self-efficacy. Appl Soc Psychol 2004;34:694–708. [10] Abraham C, Sheeran P. Deciding to exercise: the role of anticipated regret. Br J Health Psychol 2004;9:209–78. [11] Ajzen I. Aavailable at: http//people.umass.edu/aizen/index.html. Accessed January 2, 2007.