Enhancing Men’s Awareness of Testicular Disease

Testicular cancer is rare, but it’s the most common cancer in young men aged between 15 and 44. About 170 men are diagnosed with testicular cancer every year in Ireland.

Just this year, a new initiative has been launched in Ireland – ‘On the Ball’ which is an inclusive community-based campaign to promote testicular awareness.

We spoke with Dr Mohamad Saab who led the campaign to find out more.

Dr Mohamad Saab is Senior Lecturer and Vice Dean of Graduate Studies in the School of Nursing and Midwifery, University College Cork (UCC). He holds a PhD in Nursing from UCC, a PGDip and Cert in Teaching and Learning in Higher Education from UCC, MSc in Advanced Practice Nursing and BSc in Nursing from the American University of Beirut. Mohamad has over 100 research outputs and around ¤11 million in research funding.

His research is primarily focused on the use of virtual reality in several contexts, including raising young men’s awareness of testicular diseases, teaching simulation to nursing students, and teaching nursing and medical students about difficult conversations. Mohamad teaches across several interdisciplinary oncology, palliative care, research, and communication modules and supervises a number of MSc and PhD students.

What are the key considerations in evaluating the long-term impact of the “On The Ball” campaign, particularly regarding early detection of testicular diseases?

“On the Ball” is an inclusive community-based campaign aimed to raise young men’s awareness of testicular diseases including testicular cancer. Funded by the Health Research Board (HRB), “On the Ball” was co-designed and refined with 20 representatives of various community organisations. A soft launch of “On the Ball” took place with 411 students engaging with the campaign stand and receiving various campaign merchandise.

The projected long-term impact of “On the Ball” is increased “testicular awareness” which involves men being aware of the normal look and feel of their own testes and seeking help for symptoms of concern. This would lead to early detection, less aggressive treatment, and improved survival and survivorship.

How do you anticipate the combination of online and offline media (e.g., social media, games, place-based advertising) will evolve in future health campaigns to address stigma around men’s health topics like testicular cancer?

Participants in the co-design and refinement of “On the Ball” discussed the importance of being inclusive. To this end, they recommended delivering “On the Ball” both, offline and online. Offline delivery would target men who do not necessarily use social media while online delivery, primarily using social media, would reach age groups at risk of testicular disease (i.e., young men and boys aged 15-39 years) who are the primary users of social media. The effect of multimodal campaigning is well documented in the wider literature and the recommendation to deliver “On the Ball” both online and offline ties in with existing literature on cancer awareness campaigns.

As for addressing stigma, indeed, in the past we found that men and boys with suspected testicular diseases delay medical help-seeking for symptoms of concern primarily due to the inherent limited contact with the healthcare system, embarrassment due to the sensitive nature of testicular diseases, and perceived threats to masculinity. We believe that the use of light-hearted messages and easy and accessible language in “On the Ball” would help overcome some of these barriers, leading to early detection and treatment of testicular diseases.

Given the higher engagement and satisfaction with the VR component of E-MAT, how do you see VR’s role in future health interventions for younger male populations? What are its limitations?

E-MAT stands for “Enhancing Men’s Awareness of Testicular Diseases.” This intervention, also funded by the HRB, uses VR gaming to engage young men with information on testicular diseases, improving their knowledge of what could go wrong with their testes and highlighting the importance of early help-seeking for symptoms of concern. We have successfully tested E-MAT with young GAA players in Co. Cork who are at high risk of testicular injury. We hope to seek future funding in order to test E-MAT in a larger population across Ireland.

VR is one of the most rapidly growing technologies in healthcare. Adolescents and young adults aged 15-39 years, including Millennials and Generation Z, are prominent users of VR. This population is increasingly using VR for educational purposes. Therefore, the use of VR technology in the context of raising awareness of testicular diseases is appropriate and timely.

As for limitations, there are no major adverse effects from VR and since E-MAT does not involve sudden movement or jumping. However, it is not advisable for individuals with severe motion sickness and/or uncontrolled seizures to use VR. Just to note that only 1 of the 142 participants in the three studies testing E-MAT reported mild nausea that subsided immediately after taking off the VR headset. Another limitation could be the cost of equipment. Having said that, the rapid growth and adoption of VR has led to significant price drops and the development of user friendly, wireless, light, and affordable devices.

What factors do you believe contributed to the sustained knowledge of testicular diseases among participants three months after the intervention, and how do you plan to address potential drop-offs in awareness over longer periods?

E-MAT is underpinned by the Preconscious Awareness to Action theoretical framework that I have developed. This framework highlights the role of various types of memories in knowledge retention. Episodic memory involves recalling events of interest in specific spatial and temporal contexts (e.g., weddings and concerts). In the context of E-MAT, experiencing VR technology, particularly for first-time VR users, would create a long-lasting memorable episode of the intervention. Semantic memory pertains to factual knowledge and general information, such as scientific concepts learned through education. In E-MAT, the use of clear and accessible information to educate young men about testicular diseases would facilitate the retention of scientific facts. Procedural memory is acquired through practice and repetition (e.g., riding a bicycle or typing). Engaging with VR technology including headsets and handheld devices would aid in developing procedural skills and memory. All these factors could have contributed to the sustained increase in knowledge of testicular diseases.

Drop-offs in awareness and knowledge over longer periods are inevitable, especially in interventions delivered once. This phenomenon is at times referred to as “knowledge decay.” We are constantly bombarded by information and more important life events tend to take precedence over information acquired within health promoting interventions. This is one of the reasons why several organisations and researchers involved in health promotion tend to design new health promotion interventions periodically. VR is still a novel and evolving technology and its use in the context of raising awareness of testicular diseases is warranted. The VR market is growing, and VR devices are evolving. This would require iterations of the E-MAT intervention.

What specific lessons were learned from the SWAT about recruiting male participants in sports organisations, and how might these inform future recruitment strategies for health trials targeting young men?

The E-MAT intervention was accompanied by a Study Within A Trial (SWAT). The purpose of the SWAT was to determine which recruitment method (X, [formerly Twitter], Facebook, or quick response [QR] codes via posters) was more efficient and cost effective for recruiting participants in E-MAT from various GAA clubs. We also aimed to determine if the recruitment method influenced retention in E-MAT.

We found that participants mainly heard about the study through friends, with some engagement via social media platforms Facebook and X, and little to no engagement with the QR code. Primary outcomes were hindered by the inability to disaggregate data by GAA club. Economic outcomes revealed QR code as the costliest strategy, and while X was cheaper than Facebook in terms of the number of clicks, Facebook demonstrated better recruitment and retention and thus reduced the costs per participant.

The SWAT had some limitations (or lessons learned!) in evaluating recruitment strategies for GAA clubs due to the use of a single Facebook link, X link, and QR code for all clubs, hindering the ability to analyse data at the club level and understand the impact of individual characteristics on recruitment. Researchers lacked direct administrative access to club accounts, making it difficult to separate participant data from general club data. Also, many participants learned about the study through friends, complicating the tracking of recruitment sources. The analysis revealed that some individuals accessed links via text or WhatsApp, further obscuring the effectiveness of recruitment methods. Insights into optimal posting times indicated that X usage peaks at noon, 6 PM, and 9 PM on Tuesdays and Thursdays, while Facebook peaks at 8 AM and 8 PM on Fridays. All these lessons will be taken into consideration while planning wider testing of E-MAT.

The study found no significant difference in knowledge outcomes between VR and tablet-based interventions. Do you believe future iterations of E-MAT should focus more on enhancing interactivity, or should the emphasis shift toward accessibility and cost-effectiveness?

We compared the effect of E-MAT delivered using VR (E-MATVR) to E-MAT delivered electronically as plain text using a tablet (E-MATE) and found that, while knowledge improved in both E-MATVR and E-MATE groups, knowledge did not differ when E-MATVR was compared to E-MATE. This can be explained by the fact that the with only 74 participants. A full trial with a larger sample size powered to detect the efficacy of E-MATVR is needed to establish efficacy.

As part of the E-MAT feasibility trial, we conducted a process evaluation to determine how to best deliver E-MAT in the future. Overall, participants were highly satisfied with E-MATVR. They made valuable recommendations to enhance interactivity, reduce cost, and improve access to VR. All these recommendations will be taken into consideration when developing and testing E-MAT in the future.

Dr Saab can be contacted on msaab@ucc.ie

• Saab, M. M., McCarthy, M., Davoren, M. P., Shiely, F., Harrington, J. M., Shorter, G. W., … & Dahly, D. (2024). Enhancing Men’s Awareness of Testicular Diseases (E-MAT) using Virtual reality: A randomised pilot feasibility study and mixed method process evaluation. PLOS ONE, 19(7), e0307426. https:// doi.org/10.1371/journal. pone.0307426
• Saab, M. M., Shetty, V. N., McCarthy, M., Davoren, M. P., Flynn, A., Kirby, A., … & Hegarty, J. (2024). Codesign and Launch of ‘On the Ball’: An Inclusive Community-Based ‘Testicular Awareness’ Campaign. Health Expectations, 27(3), e14100. https://doi. org/10.1111/ hex.14100

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