Effective strategies for testicular torsion education in adolescents: A qualitative study in educational environments

Abstract

Objective:

In the context of testicular torsion, research demonstrates a delay from the onset of testicular pain to attending hospital in adolescents, leading to high rates of testicular loss. This is due to a lack of knowledge about this condition. In this study, we aimed to investigate the methods adolescents and their parents felt would be effective in testicular torsion education.

Design:

Qualitative semi-structured interviews and focus group workshops were used to generate ideas and opinions regarding the ‘ideal’ education package for testicular torsion.

Setting:

One-to-one interviews with young men and a chosen chaperone recruited through purposive sampling from after-school clubs. Focus groups recruited from an active hospital youth forum.

Method:

Qualitative data analysis was undertaken to explore collective and normative views and to validate findings using a combination of thematic framework, and descriptive and content analysis.

Results:

In all, 16 young men aged 11–19 years with an attending chaperone were interviewed. Forty-four young people of both sexes participated in focus groups. Participants in all groups supported school-based teaching about testicular torsion, with focus group members mentioning Personal, Social, Health and Economic Education (PSHE) as the preferred setting. Members of all groups also advocated the use of video, but tone was a matter of debate. Reservations were expressed regarding the use of social and online media as primary means of dissemination but saw these as useful adjuncts to formal school lessons. Focus group members were supportive of teaching in a mixed sex environment and for repeat lessons at 11 and 13 years of age.

Conclusion:

Study findings support the development and use of PSHE teaching, using video methodology, to promote knowledge about testicular torsion in boys and young men. An evidence-based intervention to improve outcomes in testicular torsion for this cohort can now be developed.

Keywords

Adolescent education health testicle torsion

Introduction

Torsion of testis, more commonly known as testicular torsion, is a condition whereby the testicle rotates on its axis, around a suspending cord, which contains the blood supply. This leads to ischaemia, with rapid progression to organ death. Torsion is heralded by a sudden onset of excruciating testicular pain. Urgent surgery is required to untwist the testis. Testicular loss is 9% if surgery is undertaken within 6 hours of the onset of pain (Saxena et al., 2012). If there is a 24-hour delay, testicular loss rates are between 91% and 100 % (Lian et al., 2016; Tryfonas et al., 1994).

Testicular torsion is a worldwide phenomenon particularly affecting young men aged between 12 and 18 years (Williamson and Thomas, 1984). Rates of testicular loss in children are higher than in adults (Jones et al., 1986; Moslemi and Kamalimotlagh, 2014), due to a delay in the time from onset of severe testicular pain to presentation at hospital (MacDonald et al., 2018). To develop effective strategies to improve rates of testicular loss in adolescents, effective methods of behaviour change intervention need to be developed. Interventions with an evidence-based theoretical underpinning have been found to be more effective than those without (Cane et al., 2012; Michie et al., 2011).

To understand why boys and young men present late to hospital with testicular pain, a previous study utilised qualitative methodology to explore knowledge and attitudes to testicular health in young men aged 11–19 years and their families, asking the question ‘what would you do if you developed testicular pain?’ The authors found a total lack of knowledge about the urgency of testicular torsion, among both adolescents and their parents (MacDonald et al., 2021). Previous survey-based studies, in a paediatric population, agreed with these findings, showing poor knowledge of parents regarding testicular torsion (Burnand et al., 2011; Friedman et al., 2016). Other groups have explored testicular health awareness in young men (aged 18–50 years) and found, similarly, poor knowledge of what to do in the case of testicular pain (Clark et al., 2011; Congeni et al., 2005). Previous work has explored barriers to help-seeking behaviour for testicular health in adults and found the barriers to include lack of knowledge, symptom misappraisal, fear, denial, avoidance, embarrassment, not wanting to worry the family, being busy with life, and the social norms of masculinity, such as machoism, stoicism, optimism and the fear of being labelled a hypochondriac (Saab et al., 2017a).

In the adult male population, a framework to promote testicular awareness has been developed (Saab et al., 2018). Investigating adult men’s preferences for increasing awareness, it was suggested that television, Internet and print media information sources and campaigns through schools, colleges, sports clubs and the workplace were likely to be well received by men over 18 years of age (Saab et al., 2017b). Similar studies have not been performed among children and adolescents, nor has there been discussion in the context of the family. As 65% of torsion events happen in the adolescent population (Williamson and Thomas, 1984), we aimed to investigate the methods young men aged 11–19 years and their parent/guardians perceived as effective to educate adolescents and their families about testicular health issues, with a focus on testicular torsion.

Methods

A qualitative methodology was used to investigate the phenomenon. Initially, one-to-one semi-structured interviews were conducted with young men and their parents to generate hypotheses about effective and acceptable educational methods for testicular health in the family setting. Subsequently, adolescent peer focus groups were presented with suggestions from families, along with methods gathered from the literature review, and asked to create the ideal educational resource in a workshop environment.

Young men – family semi-structured interview

Semi-structured interviews were undertaken with young men aged 11–19 years who had not experienced testicular torsion. Those who had experienced testicular health issues or who had had frequent visits to hospital were excluded. Purposive sampling was used, with young men being recruited through sports and out-of-school clubs. Young men were asked to choose a chaperone prior to interview and given a gift voucher as an incentive to take part. Age-appropriate consent and assent were obtained from all young men and their legal guardians.

While the intention had been to interview the young men solely, we found the interviews evolved to include family members. Young men and their parents or guardians were asked the question ‘what do you feel are effective methods to raise awareness in young men and their families about testicular torsion’. Additional attitudes and opinions were then explored using interview technique as described by Brinkmann and Kvale (2014).

Interviews were undertaken sequentially by C.M.M. until data saturation was achieved (Turner-Bowker et al., 2018). Interviews were recorded on an electronic device and transferred to an encrypted hard drive kept on National Health Service (NHS) property. Transcriptions were anonymised. The project received ethical review with the Yorkshire and Humber Health Authority (REC number 15/YH/0299, HRA registration 167713).

Young people – focus groups

Young people were recruited for the focus groups from a hospital youth group forum, who provided a single session of their weekend activities to the investigators (N.M. and C.M.M., a female urologist and a female paediatric urologist, respectively). Individual consent was not obtained, but the forum publicised the event and described the nature of the project in advance. Young people not willing to be involved were invited to a parallel event on the day, and the option of not being recorded was given to young people in the focus group. Ideas from the initial semi-structured interviews were used to create a toolbox of interactive resources. Table 1 shows the core areas of exploration during focus group sessions. Young people were provided with work sheets, quiz sheets, links to videos, and an interactive plasticine model to create a testicle containing a mass to mimic the feeling of a testicular lump. The forum was divided into two age groups (<15 years and those ⩾15 years), and within these groups young people worked in groups of 5. The two investigators took young people through the resources relevant to the topic and asking them to present back to the whole group an ‘ideal’ education campaign to raise awareness of testicular health.

Table 1.

Domains for discussion within focus groups and suggestions within domain to develop the ideal testicular health education package.

Domain	Suggestions within domain
Environment/Setting	School Internet Social media via general practitioner (GP) via hospital Community Parents Podcast
Audience	Mixed sex Single sex Age Parents included
Resources	Fact sheet Work sheet Video Leaflets to take home Quiz / test of knowledge (online or paper) Plasticine modelling Model of a testicle Celebrity to camera
Content	Longer or shorter Funny or serious Real people or cartoon characters Focus on anatomy and torsion Focus on how to react and what to do with health problems

Data analysis

Semi-structured interviews were audio recorded and transcribed verbatim. C.M.M. listened to the recordings and coded the transcripts using NVivo software (NVivo 11^©). Themes and a conceptual pathway were developed using a framework approach (Gale et al., 2013), with dual coding and theme development being supported by academic supervisors. The data generated from the focus group workshop event included audio transcripts, reflective notes, and written outcomes. These were analysed by C.M.M. and N.M. using thematic, descriptive and content analysis.

Trustworthiness was maximised through reflective practice, keeping close to the transcripts, representing the young people with authenticity and advocacy, providing a deep description of the context of the study and by colleague triangulation. The findings were interpreted within the context of the researchers being women doctors, the young people being with their parents and recruitment being from a hospital environment for the focus groups.

Results

Family interview findings

Interviews took place with 16 young men aged 11–18 years (median, 13) between December 2015 and December 2017. Interviews were performed in two locations: Sheffield and Glasgow. The participants were recruited from a running club, three football clubs and a charity for weight loss. The population recruited represented a broad group socioeconomically but was limited in terms of Black and minority ethnic diversity. Seven young men chose their mother as chaperone, five chose both parents, three their father and one their grandmother who was a guardian.

Table 2 shows the seven methods that participants in the interview felt would be effective in improving knowledge about testicular torsion at first response. In 11 of the interviews, the young men or family members replied that they thought lessons at school would be the most effective education method. When this was reflected to the other four families, they all agreed this would be an effective route. It was felt school was an environment in which topics were taken seriously, and no one was excluded:

Interviewer (Int):

Do you think doing it in school is a good place to teach you about testicular health?

Participant 7:

I think it’s good because everybody goes to school so the message will reach everyone. If you, did it at a sports place or a football club, they’re optional so . . . (14 years)

Table 2.

Frequency of initial response during one-to-one interviews for each methodology felt to be effective in educating adolescents and their families about torsion of testis.

Methodology felt to be effective	Frequency of spontaneous response
School-based Education	11
Social media	4
Talks and seminars	2
One-on-one teaching	2
Posters in schools	1
TV campaign	1
Celebrity endorsement	1

With respect to age at which education should take place, two sets of parents stated the subject would be appropriate for younger children, with one parent saying it would be best at ages 9 or 10 years. In the school environment, families mentioned video and PowerPoint presentations as good ways of delivering the teaching.

There were conflicting feelings about whether teaching should occur in single or mixed sex classes. Some participants noted that both girls and boys may have children in the future so that the lessons would be of use to all. Others felt that young men would find it easier to discuss the subject in single sex groups or classes. Overall, the responses were balanced on the issue of mixed or single sex classes:

Int:

Do you think girls need to know about the problem too?

Participant 14:

They’re friends or whatever, so yes. (11 years)

Three of the young men said they felt teaching about testicular health should occur in PSHE (Personal, Social, Health and Economic Education) classes rather than in science, as they felt they had more opportunities to ask questions and discuss the issue in depth in PSHE:

Int:

How would you like to learn about that most?

Participant 8:

I think PSHE. Rather than biology, you get opportunity to chat about it (12 years)

Another family discussed school teaching versus the use of social media and felt the former was better as

I don’t think you take things in on social media so much though, do you? And there is time for the teachers to give to the kids in school. (Participant 3, 11 years)

When asked by the investigators whether they felt Internet-based education resources would be effective, most parents expressed about the quality of the information provided that way. Young men said they would prefer to talk to their parents rather than do an Internet search for testicular health information. When asked whether social media would be a good way of letting people know about the problem, most participants expressed reservations:

Int:

Do you use a phone do you use Twitter or Facebook?

Participant 1:

No not really,

Int:

So that wouldn’t be a particularly useful way of telling?

Participant 1:

No, No. (12 years)

One family suggested a television campaign with a celebrity who had been through the experience of torsion to promote the issue. One interviewee felt posters in sports changing rooms would be good. These comments were shared with other families, generating mixed responses. One participant felt no one really paid attention to posters and another thought having a poster about testicles would make boys laugh:

Int:

What about posters in the boys changing rooms at school – do you think you’d pay attention?

Participant 1:

Normally we just want to get to the lessons. (12 years)

One young man mentioned conveying information via a leaflet, but two other families pointed out that young people are unlikely to attend a General Practitioner and pick up leaflets and might disadvantage those with language and learning difficulties:

[He] has problems with his reading and writing, he’s a wee bit dyslexic . . .. There’s a few of his friends are dyslexic as well, so maybe that’s a problem with leaflets. (Mother of Participant 5b)

The use of talks and seminars from doctors was mentioned by two families, who felt a doctor teaching people about the problem would be effective.

Opinions about the tone of the educational content varied. Some felt it should not be too serious, but others warned against trying to make the issue funny. One family suggested using cartoons to get attention and another mentioned using pictures to get the message across.

Focus group findings

Two focus groups were undertaken in February 2020 as indicated above. Most of the participants had links to a London hospital due to health or sibling health issues. The groups were of mixed sex, and their members were aged 11–14 and 15–21 years, with 18 participants in the younger group and 26 in the older group. The groups were equally split between girls/young women and boys/young men and of mixed racial and disability demographics as observed by the research team.

The groups unanimously identified PSHE as the most effective platform from which to deliver education, with a smaller number choosing social media (see Figure 1 as an example of this). Members preferred to be taught about testicular torsion by a teacher and not just be given resources to work through. All wanted their teacher to have knowledge about the topic and wanted there to be interactive teaching methods. Participants felt they should be taught directly and not through their parents, but their parents should be informed of the lesson content by letter or email.

Figure 1.

Example worksheet from focus group identifying platform for campaign.

We thought school PSHE lessons would be the best way. But for the teachers to be more educated themselves about the topic. Because a lot of teachers don’t really know what they are talking about, or they get things wrong, and it makes other people feel uncomfortable. (Participant 1, Group 2, younger focus group)

Neither group selected podcasts, online forums, leaflets or radio as a means of education. These media were felt unsuitable as young people do not listen to podcasts, do not feel comfortable in chat rooms, are unlikely to read a leaflet and do not listen to live radio. Television campaigns too were felt to be unhelpful as ‘people don’t watch [live] TV anymore’, and watching an advert on testicular health might make young people feel uncomfortable in front of their parents. Online adverts on social media platforms could be of greater interest and might grab attention. The effectiveness of social media was, however, questioned: ‘are people really going to look at it?’ and the topic was felt ‘too personal’ to share that way. All were keen on the use of video:

’coz people would rather like our age listen to it than have to read like lots of stuff on it. (Participant 2, Group 3, younger focus group)

The groups felt using a celebrity or a doctor in the video could be effective alongside the presence of high-profile celebrities. The reputability of the celebrity was stressed by both groups:

We thought athletes and actors, household names like David Beckham, . . . Even people like Prince Harry have done a lot for charities. People like him would definitely be great on at spreading the message. (Participant 2, Group 1, older focus group)

Both sub-group and main group discussions highlighted the importance of online resources being endorsed by the National Health Service (NHS) and having the NHS logo as a mark of quality and validity. Other professional groups were mentioned by the investigators, but because they were not recognised by group participants, they were not felt to be credible:

So, if something has a NHS logo or something, you would be like, ok that’s more reliable. Because you don’t to look up some dodgy website, do you? Like about ‘oh I’ve got ball pain and you can find all kinds of websites out there? (Interviewer N.M.; interviewer reflection on group discussion, all group in agreement)

Many described utilising an information sheet, either paper or online, giving them something to take away and read or use a time of concern as back-up for the school lesson. Fact sheets needed to be simple and not have too much text, but some participants felt other kinds of media were better:

Fact sheets and worksheets but they can get a bit boring. And like if you’re watching a video, I don’t know for me it’s more interesting watching a video than doing a factsheet. (Participant 1, Group 3, younger focus group)

Participants were not keen on a plasticine model which they thought was immature and distracting. None of them identified a quiz as an effective method of education spontaneously but acknowledged it could be a useful marker of knowledge gained.

All felt it good if education in school could be provided at two time points in time: the topic could be introduced around 11 years and repeated at ages 13–14 years in more detail. Following discussion, it was agreed that mixed sex classes were most appropriate since they would allow the topic to be taken more seriously. Girls too should know about the subject, both in relationships and as the future parents to young boys:

And we said mixed groups because later on in life in relationships boys are going to have to talk about it with their partners and it breaks down the barriers in a relationship. (Participant 3, Group 1, older focus group)

The content groups wanted from the lesson was the following: the normal anatomy and function of the testicles; what is torsion; how to recognise it; what are the symptoms; who gets it; how many people get it; what to do if you think you have it; what to do if symptoms go away; what else could it be; and does it affect your fertility. Both groups felt that the information provided was interesting, important for them to know about, and was missing in the current curriculum.

Of the resources provided, the younger group preferred the cartoon graphics, while the older group liked the anatomical or graphical videos and wanted the tone to be more serious. The younger group similarly thought the presentation of the subject should not be too funny, but it should not be ‘boring’ either.

Discussion

To decrease rates of adolescent testicular loss, a major change in young men’s behaviour is necessary. Effective approaches to behaviour change are well researched and consensus approaches within the field of public health have been developed (Michie et al., 2011).

The capability, opportunity, motivation-behaviour (COM-B) model of behaviour change, for example, suggests that the route to understanding behaviour change lies in capability, motivation and opportunity, and lists a number of effective interventions for behaviour change including teaching, training, incentivisation, coercion, persuasion and environmental restructuring. This approach has been appraised and found to be effective (Cane et al., 2012; French et al., 2012).

In this study, the importance of beginning from a sound evidence base was highlighted. As knowledge about testicular torsion is poor (MacDonald et al., 2021), education is required to influence behavioural change in young men with a painful testis. This study sought to identify acceptable and effective ways of educating young people and parents about testicular health, and from our results, we can describe the optimum methodology for this in terms of platform, target audience, resources, and tone and content

Platform

PSHE lessons were felt by both groups to provide the optimal context for delivery of testicular torsion education. School-based education has been found to be effective for a range of issues, including teenage pregnancy (Department for Education, 2015; Kirby, 2001), obesity, fitness, diet, tobacco use, and bullying and socio-emotional health (Langford et al., 2014; Sklad et al., 2012), and has been shown to increase rates of breast examination in young women (Ludwick and Gaczkowski, 2001).

It has been shown PSHE has increased effectiveness with parental consultation and engagement, which was supported by the youth participants in this study (Willis et al., 2013). Disadvantages of school-based teaching are few but revolve around the difficulty of asking teachers without specialist knowledge to deliver the lessons. This can be ameliorated by clinician–pedagogue partnership to develop a lesson able to be run with no need of specialist knowledge at the point of delivery (Jourdan, 2011).

Despite studies showing engagement with sexual health messages in social media can improve condom use and excitement about digital intervention methods (Michie et al., 2017; Stevens et al., 2017), this study suggests that young men in the UK will not engage with testicular health messages online. Male adolescents have been shown to predominantly use the Internet as a resource for maintaining and establishing friendships or following large corporations (Moorhead et al., 2013). There have been other descriptions of poor response to social media campaigns (Thornton, 2016), and young men in this study felt that some topics can be too personal to engage with on social media. There were concerns from some participants that encountering videos on YouTube® could lead to anxiety concerning the issue of testicular health, a finding supported in the literature where it has been shown YouTube® can contain misleading information (Madathil et al., 2015).

Target audience

Findings from individual and focus group interviews support the relevance and acceptability of teaching mixed sex groups of young people at around age 11 and again around age 13 about the torsion of testis.

Resources

The resources felt to be most effective in doing this work were video and validated online content. Video resources have been shown to increase attention and recall in health education programmes and activities compared to traditional didactic methods (Adam et al., 2019). None of the participants in this study mentioned classroom or online gaming as an effective means of education. Studies have found game-based learning and gamification to improve engagement (Haruna et al., 2018). Posters were not felt to be effective as young men felt they might not see them and, if they did, they would not take the messages seriously. Talks by doctors to individual families or groups were supported by the interview and focus group data, as well as the literature, to educate families about testicular health (Thornton, 2016), but this method is resource-heavy and unlikely to be effective for mass reach community education. Previous methods of television campaign and radio adverts are likely obsolete as families no longer engage with live media, which is a new finding in a rapidly evolving environment.

Tone and content

The tone of the education provided (including any video) was a matter of debate in family interviews, with some participants suggesting not making the content too serious but others cautioning against the use of humour. Focus groups felt the tone should be serious but not ‘boring’. Both of these findings align with previous research highlighting that humour is not effective in educating about testicular issues (Thornton, 2016). Focus groups revealed that young people wanted to know the basic facts (e.g. function, anatomy) about torsion of testis but were also interested in wider issues such as ‘how many people get it’ and ‘why does it happen’. This reflects previous findings that young people are particularly sensitive to context (Ciranka and van den Bos, 2019). Focus group members asked questions about the long-term effects of torsion, indicating an interest in future consequences which is at odds with the dominant portrayal of adolescents in the literature (Sawyer et al., 2018) and reveals a mature approach to engaging with the topic in the classroom.

Strengths and limitations

This is one of a very few studies to have explored perceived effective means of educating young people about a health topic with the target population themselves. Combining interviews and focus groups enhanced the richness of the findings and aided triangulation and validation (Lambert and Loiselle, 2008).

A key strength of the study was to capture, in a naturalistic light, perspectives from young men themselves, family and peers. All groups were free from the potential bias of recruitment arising from selection within a school environment. Throughout the study, interactions within the focus groups flowed easily with close adherence to the topic and few disagreements, supporting the validity of the findings. The presence of the parents was not a major disruptor, affecting the views expressed by individual young men.

Despite efforts, we struggled to recruit from Black and minority ethnic and marginalised communities for one-on-one interviews. However, we achieved broader ethnic diversity within the focus groups, enhancing the potential relevance of findings to a broad social demographic.

The interviews being undertaken by women doctors with a background in surgery may have made some young people reticent to participate fully due to power imbalances or embarrassment. However, free flowing discussion with candid replies suggested the effect of the research team was minimal.

Conclusion

This study is the first to explore the platform, content, resources and setting young people and their families feel will be effective for testicular health education with the target populations themselves. The study investigated these issues in two youth health education settings: with young men and their parents, and in a mixed sex peer group. Study findings signal support for school-based lessons taught as part of PSHE using interactive and video methodology. Given this understanding, practitioners are better placed to design resources for the education of young people and their families regarding testicular health, using a unique clinician–pedagogue–adolescent alliance.

Footnotes

Acknowledgements

We acknowledge the advice and contribution of Vicky Stubbs, the Highgate Group and Shabnam Undre at Lister Hospital Stevenage, UK.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship and/or publication of this article. This work received funding from The Children’s Hospital Charity (grant number CA14013).

ORCID iD

Nadine McCauley

Data availability

Raw data available for review are available as a Mendeley Dataset: DOI: 10.17632/cvfxm2j3w8.2.

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