The Validity and Reliability of Health Belief Scale for Testicular Cancer Self-Examination

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1 611226JMHXXX / American Journal of Men s HealthAvci and Altinel research-article2015 Article The Validity and Reliability of Health Belief Scale for Testicular Cancer Self-Examination American Journal of Men s Health 1 8 The Author(s) 2015 Reprints and permissions: sagepub.com/journalspermissions.nav DOI: / ajmh.sagepub.com Ilknur Aydin Avci, PhD 1, and Busra Altinel, MSc 2 Abstract This study aimed to create a measurement tool for the determination of university students health beliefs about testicular cancer (TC) and self-examination. This is a methodological and cross-sectional study. The study sample included 425 university students. Consents and approvals were obtained from the relevant institutions and the ethics committee prior to the research. The data were collected using an interview form that included questions about descriptive characteristics, family history of TC, and knowledge, beliefs, and practice of self-examination. The health belief model including 41 questions about self-examination and the interview form were administered to the students in their classrooms at a suitable time. Principal components analysis and varimax rotation were used for the examination of the structures of the factors. Accordingly, factor patterns, self-values, and the variance percentages they explained were evaluated. The average age of the participants is 22.2 ± 2.3 (min = 17; max = 40). Of them, 98.8% of the participants are single (n = 420). Of them, 56.2% have heard about TC before, and 18.4% said they were informed about TC. of the items in the first factor was 0.64 to 0.89, while it was 0.48 to 0.75 for the items in the second factor, 0.50 to 0.87 for the items in the third factor, 0.37 to 0.68 for the items in the fourth factor, 0.51 to 0.68 for the items in the fifth factor, and 0.65 to 0.79 for the items in the sixth factor. The health belief model scale may be used in TC screenings for males to measure susceptibility, seriousness, health motivation, barriers, benefits, and self-efficacy. Keywords validity, reliability, testicular self-examination, health belief model Introduction Urogenital system cancers are one of the most common cancer types among males. Although accounting for only 1% to 2% of male cancers, testicular cancer (TC) is the most commonly diagnosed cancer in men aged between 15 and 35 years in the United States and in most European populations. The American Cancer Society s estimates for TC in the United States for 2015 are that about 8,430 new cases of TC will be diagnosed and about 380 men will die of TC (American Cancer Society, 2015). Nigam, Aschebrook-Kilfoy, Shikanov, and Eggene (2015) reported that, between 1992 and 2009, TC incidence in the United States and Europe continued to increase. Urogenital system cancers account for 4.72% of all cancer cases in Turkey, while 1.3% of male neoplasms are TC (Aydın, 2007). Epidemiological risk factors for the development of testicular tumors are a history of cryptorchidism or undescended testicle, high maternal estrogen levels during fetal development, Klinefelter syndrome, family history, a tumor or testicular intraepithelial neoplasm in the other testicle, younger age (15-34 years), White race/ethnicity, and infertility (Albers et al., 2015; Dieckmann, Loy, & Buttner, 1993; Osterlind et al., 1991). While TC is a relatively rare type of cancer, it still has a very significant place in urological oncology because it serves as a model curable cancer in oncology. Thus, early diagnosis and treatment are very important in TC. It is possible to cure TC completely if it is diagnosed at an early stage. After an early diagnosis, there is a 99% possibility of 5 more years of life (Bahrami, Ro, & Ayala, 2007; Lechner, Oenema, & Nooijer, 2002). The primary 1 Ondokuz Mayis University, Samsun, Turkey 2 Selcuk University, Konya, Turkey Corresponding Author: Ilknur Aydin Avci, Ondokuz Mayis University, Samsun School of Health, Samsun, Turkey. ilknura@omu.edu.tr

2 2 American Journal of Men s Health methods of diagnosis are ultrasonography, some blood tests, and magnetic resonance imaging (American Cancer Society, 2015). To be able to make an early diagnosis, individuals should be conscious about this issue and be able to do self-examination (Ceylan, Yılmaz, Yıldız, Kuş, & Gönülalan, 2006). The reasons for the delays in diagnosis and treatment are young males lack of knowledge about the danger of TC and self-examination, which is very important for early diagnosis. Although the frequency of TC has increased, many studies have reported that young males are not informed about this tumor and its frequency in their age-group. Young men do not know about its general symptoms and their rate of doing selfexamination is very low (Ceylan et al., 2006; Lechner et al., 2002; Rudberg, Nilsson, Wikblad, & Carlsson, 2005). A study conducted with 7,304 university students in Europe revealed that only 3% of students did selfexamination regularly every month (Wardle et al., 1994). A study conducted in Iran reported that only 7.9% of students did self-examination (Ramim, Mousavi, Rosatmnia, Bazyar, & Ghanbari, 2014). TC is not a preventable disease; however, a regular examination of testicles for swelling can lead to an early diagnosis. Thus, all males between 15 and 35 years of age should do this examination every month and identify the symptoms of TC. The only way to diagnose TC at an early stage is to do regular self-examination. Although self-examination creates a 90% possibility of early diagnosis (Cronholm, Mao, Nguyen, & Paris, 2009; Göçgeldi & Koçak, 2010; Rudberg et al., 2005), it is not effective in diagnosing early stage TC on its own. It definitely requires examination by a physician and the administration of radiological and pathological tests. Selfexamination is still an important health promotion behavior, like breast self-examination in diagnosing breast cancer. If young males are trained about selfexamination, this will create awareness about the early diagnosis of TC. Individuals doing self-examination will exhibit a health promoting behavior by taking care of themselves. It is commonly believed that cancer incidence increases in direct proportion with age. This leads young people to have lower levels of learning and adopting behaviors related to early diagnosis. Teaching and acquiring health protective behaviors at a young age will have a positive influence on attaining individual responsibility of protecting one s self from cancer and other preventable or curable diseases. Beliefs influence the health behaviors that determine the efficiency of the methods used for the early diagnosis of TC. The health belief model (HBM) is a useful theoretical basis for self-examination practices (Levi, Lucchini, Negri, Boyle, & La Vecchia, 2004). The HBM explains the relationship between a person s beliefs and behaviors and the effect of personal motivation on health behaviors (Cummings, Jette, & Rosenstock, 1978). The HBM defines the motivation for an individual s health behaviors, and particularly the conditions that affect protective behaviors. According to the HBM, health behavior, which is an integration of individual perceptions and values that leads a person to a specific end, is directly related to the formation of diseases (Janz & Becker, 1987). The HBM was created by Hochbaum, Kegeles, Leventhal, and Rosenstock in Some concepts thought to influence health beliefs and behaviors were added to this model later. The HBM claims that individuals health behaviors are affected by their beliefs, values, and attitudes. Identifying problematic beliefs and attitudes will make it possible to decide on health training or therapies more correctly. The factors that determine the possibility of health protective behaviors emerging in the HBM are the following: (1) perception of susceptibility or sensitivity: individuals perception of personal risks or sensitivities regarding a disease or health issues; (2) seriousness and caring: taking the outcomes of a disease seriously; (3) benefit: individuals belief in the benefit of protective behavior suggested to mitigate symptoms or prevent a disease; (4) barriers: perceived barriers to adopting new behaviors and adapting to situations. Selfefficacy and motivation perception were incorporated into the model later: (5) self-efficacy: individuals belief in their capability of successfully taking an initiative; (6) health motivation: individual beliefs and behaviors required for holistic health (Gözüm & Capik, 2014; Strecher & Rosenstock, 1997). The HBM has been used by many researchers to explain health protective behaviors in diseases such as breast cancer, cervical cancer, colorectal cancer, osteoporosis, and diabetes (Champion & Scott, 1997; Guvenc, Akyuz, & Açikel, 2011; Hurley, 1990; Kim, Horan, Gendler, & Patel, 1991; Rawl et al., 2001). Champion used the HBM in breast cancer screenings (Champion & Scott, 1997). Self-examination is a health promotion behavior that creates awareness and can guide the early diagnosis of TC. Nurses play a significant role in teaching the early symptoms of cancer and the ways to identify these symptoms. Nurses can also research patient attitudes and health behaviors, and nursing initiatives can be developed to change these attitudes and increase beneficial health behaviors (Champion, 1987; Clemen, Mcguire, & Eigsti, 2002). TC starts at an early age, and the risk group mainly consists of adolescents. This indicates that nurses should be informed about self-examination and related health beliefs in school nursing practices. Male health is too frequently disregarded. Health nursing staff should develop male health implementations for all age-groups and pay attention to this issue. This will lead to an increase in

3 Avci and Altinel 3 public health. The identification of health beliefs about TC and self-examination, which are included in early diagnosis, will create a significant awareness about male health and enable further research to improve it. This study aimed to create a measurement tool for the determination of university students health beliefs about TC and self-examination. The research questions are the following: What is the validity and reliability of Health Belief Scale that measures university students beliefs and attitudes? Do students self-examination habits influence their health beliefs? Method This is a methodological and cross-sectional study. It was conducted in collaboration with male university students in Eskisehir, Turkey, in Study Sample The study sample included 459 of 542 university students. The students were invited to participate in the study, informed about the subject, and volunteers were chosen using improbable sampling. The aim of this research was described to these students in their class. They participated as voluntary at this research. In this research, 34 of the students made errors on their data collection forms. These students were excluded from the study, and thus 425 students participated in the research. The participants were informed that they could withdraw at any time and that their responses would be anonymous and confidential. Consents and approvals were obtained from the relevant institutions and the ethics committee prior to the research (Ethics Committee Decision No. 672). Data Collection Tools The data were collected using an interview form that included questions about descriptive characteristics, family history of TC, and knowledge and practice of self-examination. Selection This study analyzed the research that created measurement tools for breast cancer, cervical cancer, osteoporosis, diabetes, and colorectal cancer based on the Health Belief Scale (Çapık & Gözüm, 2011; Champion & Scott, 1997; Guvenc et al., 2011; Hurley, 1990; Kim et al., 1991; Rawl et al., 2001). The studies in the relevant literature mainly evaluated six basic concepts of HBM: susceptibility, caring, benefit, barriers, self-efficacy, and health motivation. Based on these concepts, the authors created an item pool including 51 items about health beliefs about TC and self-examination. The interview form was assessed by six specialists, two urologists, two public nurses, one physiologist, and one psychologist. Some items were excluded from the form after consulting experts, and two items were added TC would end my sex life and TC causes infertility at the suggestion of the urologists. These two items had never before been used in scales. The final version of the form included 41 questions. Instruments The HBM includes six subscales: (1) susceptibility, (2) seriousness, (3) benefit, (4) barriers, (5) self-efficacy in self-examination practices, and (6) health motivation. This is a 5-point Likert-type scale with the following responses: 5 = Strongly agree, 4 = Agree, 3 = Undecided, 2 = Disagree, and 1 = Strongly disagree. Higher scores on the susceptibility, seriousness, health motivation, benefits, and self-efficacy subscales indicate a positive situation, while higher scores on the barriers subscale indicate a negative situation since those with a high level of perceived barriers would not do TC screening. There is no total score on the scale; the scores for each subdimension are calculated and assessed separately. The necessary permission to use the Champion Health Belief Model Scale was obtained from Victoria Champion in Data Collection Procedure The final version of the interview form was administered to a group of 20 students as a pilot test. The data collected from this group were evaluated separately. After the pilot test, the authors decided that the form did not require any changes. The HBM including 41 questions about selfexamination and the interview form were administered to the students in their classrooms at a suitable time. The scale takes approximately 15 minutes to complete. Data Analysis The IBM SPSS 21.0 program was used to analyze the data. The author made psychometric measurements using explanatory factor analysis and Cronbach s alpha reliability analysis. Reliability was also assessed by interpreting the subscale correlations between all items. s with less than r =.30 correlation among subscale items were excluded. Principal components analysis and varimax rotation were used for the examination of the structures of the factors. Accordingly, factor patterns, self-values, and the variance percentages they explained were evaluated.

4 4 American Journal of Men s Health Results Descriptive Features The average age of the participants was 22.2 ± 2.3 years (minimum = 17; maximum = 40). Of them, 98.8% of the participants are single (n = 420). Of them, 56.2% have heard about TC before, and 18.4% said they were informed about TC. Of them, 2.8% knew about self-examination, and 1.9% did self-examinations. Only 59.3% of the students said that they thought self-examination was important for early diagnosis of TC. Validity and Reliability The Kaiser Meyer Olkin and Barlett tests were done before the explanatory factor analysis. The Kaiser Meyer Olkin measurement of sampling adequacy was 0.84, and the Barlett test results were quite significant (χ 2 = , df = 780, p =.000). The factor analysis of the 41-item HBM Self-examination Scale reported that six factors were important. 11 (I can live 5 more years at most if I have TC.), 24 (Doing self-examination means doing something good for myself.), 25 (Doing self-examination every month will help me find any lumps at an early stage.), and 32 (I am afraid of doing self-examination incorrectly.) were excluded from the scale since the correlation between each item and the entire scale was under The other items had appropriate correlations with the entire scale. After these items were excluded, the final form of the scale consisted of 37 items (Table 1). Cronbach s alpha reliability coefficient was calculated for each subdimension. Cronbach s alpha value was.88 in the susceptibility subdimension,.86 in seriousness,.87 in the benefit and health motivation subdimension,.82 in the barriers subdimension, and.68 in self-efficacy subdimension, and.64 in the health motivation subdimension (Table 1). The key components analysis of the scale revealed that six factors had self-values above 1. Of the factors revealed by varimax rotation, the first one explained 6% of the total variance, the second explained 18.7%, the third explained 12.8%, the fourth explained 7.2%, the fifth explained 4.8%, and the sixth explained 4.5%. The variance explained by all six factors is 53.8%. The factor analysis identified that the first factor included 5 items, the second factor had 10, the third 6, the fourth 9, the fifth 4, and the sixth factor had 3 items. load of the items in the first factor was 0.64 to 0.89, while it was 0.48 to 0.75 for the items in the second factor, 0.50 to 0.87 for the items in the third factor, 0.37 to 0.68 for the items in the fourth factor, 0.51 to 0.68 for the items in the fifth factor, and 0.65 to 0.79 for the items in the sixth factor (Table 2). The study reported that students doing self-examination affected their self-efficacy. Students who do self-examination had higher self-efficacy perceptions than those who did not (p <.001; Table 3). There was no correlation between students knowledge on self-examination and their health beliefs (p >.05). Discussion The HBM has been used in many studies to create measurement tools to determine health protective and promotive behaviors. The final version of the scale includes 37 items and 6 factors. The authors reviewed the relevant literature to develop the items on the scale. Champion adapted the Health Belief Scale to breast cancer studies, and this scale is the structural reproduction of this study (Champion & Scott, 1997). Explanatory factor analysis indicated that the form created for TC screenings was valid and reliable. Cronbach s alpha value for each subscale varies between.64 and.88. These results are in accordance with Champion s belief scale, and the results of the studies that are based on this scale (Çapık & Gözüm, 2011; Champion & Scott, 1997; Gözüm & Aydin, 2004; Kim et al., 1991). s with coefficient values lower than 0.30 are recommended to be excluded from the scale due to their statistical significance (Polit & Beck, 2003). In this study, the total item correlation values for all items are statistically significant (factor minimum = 37; maximum = 89). The authors added two more items about sexuality and reproductive health, which is a different quality from other similar studies. The inclusion of these items points to the importance attached to the change in the perception of seriousness. It is an important point that factor loads are above 0.30, and the alpha reliability coefficient of seriousness subdimension is high. TC is closely related to sexuality and reproduction. The statements about sexuality and reproductive health in this scale were carefully evaluated by the participants. Thus, it is important that these items were included in the scale because they reflect concerns about TC. This study reported that students do not have sufficient information about TC, and they rarely do self-examination. In their study, Kuzgunbay et al. (2013) reported that 11.1% of 799 students were informed about TC, and only 2.5% of them did self-examination. Ugboma and Aburoma (2011) reported that 88.6% of their participants had not heard of TC, and 63% had not learned about selfexamination. The results of this study are similar. Selfexamination protects and improves health. For this reason, this behavior should be adopted and used by individuals. Like earlier studies, this study also reported that male students rarely did self-examination.

5 Avci and Altinel 5 Table 1. Analysis and Internal Consistency of HBM Self-Examination. Scale mean SD Corrected item total correlation Cronbach s alpha Susceptibility 1. The possibility that I have testicular cancer is very high The possibility that I will have testicular cancer in a few years is very high. 3. I feel that I will have testicular cancer in some part of my life I fear dying of testicular cancer In comparison to a male peer, the possibility that I have testicular cancer is very high. Seriousness 6. The thought of testicular cancer scares me My heartbeat gets faster when I think of testicular cancer I will suffer from various problems for a long period of time if I have testicular cancer. 9. Having testicular cancer will threaten my relationship with my wife/ partner. 10. If I have testicular cancer, my whole life will change Testicular cancer is a hopeless disease Having testicular cancer would put my financial security in danger Testicular cancer would put my future professional life in danger Testicular cancer would end my sexual life If I have testicular cancer, I will be infertile Benefits and health motivation 16. I search for new information to improve my health Finding out my health problems at an early stage is important to me Staying healthy is very important to me I think it is important to do things that benefit my health If I do self-examination every month, I will be less likely to die of testicular cancer. 21. I would have a successful testicular cancer treatment if I find a lump by TSE at an early stage. Barriers 25. I find it boring to do TSE every month It takes a long time to do TSE Testicular self-examination is painful If I do TSE, my family will make fun of me It is difficult to remember to do TSE I do not have the privacy required to do TSE If I have a health professional do my testicular examination, I will not need to do self-examination. 32. I do not do self-examination since I am afraid of finding something (a lump). 33. I have more important problems than doing self-examination Self-efficacy 34. I know how to do self-examination I can do TSE correctly I can find a lump in my testicles by doing self-examination I can say that I have a problem in my testicles by doing selfexamination Health motivation 22. I eat a balanced diet I exercise at least three times a week I have medical checkups regularly even if I am not ill Note. HBM = health behavior model; TSE = testicular self-examination.

6 6 American Journal of Men s Health Table 2. Rotated Analysis of Adapted Champion s Health Belief Model Scale for Testicular Cancer and Testicular Self- Examination. 1: Susceptibility (SUS) 2: Seriousness (SER) 3: Benefits and health motivation (BEN) 4: Barriers (BAR) 5: Selfefficacy (SEF) 6: Health motivation (MOT) SUS SER BEN BAR SEF MOT SUS SER BEN BAR SEF MOT SUS SER BAR SEF MOT SUS SER MOT BAR SEF SUS SER MOT BAR SER MOT BAR SER MOT BAR SER BAR SER BAR SER Explained Explained. variance = 6.0% variance = 18.7% Total explained variance = 53.8% Explained variance = 12.8% Explained variance = 7.2% Explained variance = 4.8% Explained variance = 4.5% Table 3. Relationship Between Health Beliefs With Performing TSE. Performing TSE Not performing TSE Subscales x SD x SD Statistic p Susceptibility Seriousness Health motivation Benefits and health motivation Barriers Self-efficacy Note. TSE = testicular self-examination. p<0.001 The self-efficacy levels of students who did selfexaminations were higher than those who did not (p <.001). Self-efficacy indicates persons perceptions of their ability to succeed in a certain kind of behavior. Past studies have reported that the self-efficacy of people who know about and apply health protective behaviors are higher than those who do not (Avci, Kumcagiz, Altinel, & Caloglu, 2014; Çapık & Gözüm, 2011; Gözüm & Aydin, 2004). Self-examination is a health protective behavior. If students do it, both their participation in TC screenings and their possibilities of adopting and performing other similar behaviors will be increased. The scale created in this study was determined to be valid and reliable for TC screenings. This new scale will help health professionals to determine the benefits, barriers, susceptibilities, seriousness, health motivation, and self-efficacy perceptions of young males. The scale will also contribute to the research on this subject. Conclusion The HBM scale may be used in TC screenings for males to measure susceptibility, seriousness, health motivation, barriers, benefits, and self-efficacy. Male health, particularly that of young males, can be described as a subject that is generally disregarded. Thus, the identification of young males health beliefs about TC and selfexamination will help organize future educational practices and plan more effective initiatives. The measurement of men s health beliefs regarding cancer screenings will create awareness and lead young men to adopt health protective behaviors.

7 Avci and Altinel 7 Suggestions Health professionals working in health protection and promotion can research young males beliefs about TC and self-examination using this study s valid and reliable HBM scale. They can use this scale to learn about the health beliefs of males between 20 and 34 years of age who have cryptorchidism or TC in their family history, which is the high-risk group. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Funding The author(s) received no financial support for the research, authorship, and/or publication of this article. References Albers, P., Albrecht, W., Algaba, F., Bokemeyer, C., Cohn- Cedermark, G., Fizazi, K.,... Laguna, M. P. (2015). Guidelines on testicular cancer. Arnhem, Netherlands: European Association of Urology. Retrieved from uroweb.org/wp-content/uploads/testicular-cancer pdf American Cancer Society. (2015). 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