Humor-Based Messaging in Testicular Cancer Awareness Campaigns: A Comparative Critical Review

Abstract

Extensive research showcases the extent and efficacy of humor-based messaging in general health promotion. However, the work describing humor’s use within testicular cancer (TC) awareness is less developed. The aim of this comparative critical review was to determine the impact of using humor-based messaging in TC awareness campaigns to achieve a baseline assessment from which future research can be modeled. A literature search was conducted using seven databases to locate relevant literature. Three research questions guided this investigation: (1) To what extent has humor been used in TC awareness campaigns? (2) What does the literature reveal about the use of humor-based messaging on relevant health outcomes? (3) What are the limitations within current TC awareness strategies? Six studies were included in the review, of which three directly assessed the use of humor in TC awareness vis-à-vis intervention designs. Humor-based strategies were implemented to enhance knowledge of TC and testicular self-examination (TSE) procedures, reduce anxiety surrounding detection threat, and promote TSE. The rhetoric provided to men via various health interventions relied on humor and slang to promote TSE among males. Despite the small sample size of the included studies, this review determined that humor may be useful in reducing uncomfortable feelings surrounding TSE, increasing awareness of TC, and promoting TSE. When using humor-based messaging, however, the audience and type of humor implemented must be considered. Limited research exists assessing the long-term impact humor in TC promotion on health behavioral changes, easing anxieties related to detection, and increased self-efficacy surrounding TSE.

Background

Testicular Cancer Overview

Testicular cancer (TC) is the most common malignancy in males ages 20 to 34 (National Cancer Institute: Surveillance, Epidemiology and End Results Program [NCI], 2021). The American Cancer Society predicts 9,910 new cases and 460 deaths from TC in 2022 (ACS, 2022). Since 2021, there is a rising incidence of 0.7% a year and a stable worldwide mortality rate of TC among most male populations (NCI, 2021), although disparities exist, particularly among marginalized men and boys (Ghazarian & McGlynn, 2020). TC survival ranks among the highest of all cancers due to effective treatment, most notably platinum-based chemotherapy, radiotherapy, and surgery (Cheng et al., 2018). The 5-year survival rate at all stages is 95%, with local stage at 99%, regional stage at 96%, and distant stage at 73% (ACS, 2022).

Although an individual’s chance of dying from TC is very low (1 in 5,000), this does not necessarily mean health-related quality of life (HRQoL), defined as an individual’s overall satisfaction with life and sense of psychosocial, physical, and emotional well-being (Theofilou, 2013), will return to pre-operative levels. Many, if not most, men survive their struggle with TC, but they suffer from proximal, intermediate, and distal issues stemming from their treatment. Chemotherapy and radiation therapy, for example, have many short- and long-term side effects, which may require further treatment later during the lifespan. A significant share of TC survivors lives with chronic side effects, which ultimately influence HRQoL. These side effects include Raynaud phenomena, sexual and fertility issues, anxiety, fatigue, among others (Cappuccio et al., 2018; Ellingson & Borofka, 2018; Kim et al., 2011).

The median age of diagnosis (~33 years) must be considered in the discussion of post-treatment life. Not only do TC survivors have a longer proportion of their life to experience these side effects, which increase the post-treatment burden of TC, but also the side effects have ample time to reoccur or become more severe (Schepisi et al., 2019). For example, those treated with platinum-based chemotherapy are more likely to suffer adverse health outcomes, like vascular toxicity, cardiovascular issues, and hypertension than those without such treatment. This negatively influences HRQoL across the lifespan (Clasen et al., 2021).

Aside from the creation and implementation of more effective, less toxic treatments, the only other method to limit deleterious effects on HRQoL post-treatment is early detection. This is achieved vis-à-vis testicular examination, either with a health care provider, intimate partner, or oneself (i.e., testicular self-examination [TSE]) (ACS, 2018a, 2018b; Fadich et al., 2018). Although the survivability is of utmost importance, again, so too is post-treatment HRQoL. The most effective key to surviving and then thriving (i.e., high HRQoL), arguably, is the detection of TC in early stages of its development.

The most common risk factors for TC are cryptorchidism, family history, age, and/or previous diagnosis of TC (Fadich et al., 2018). Race and ethnicity have shown to play a significant part in development and discovery of the disease, evidenced by a large shift in incidence rates from White males to minority males (Ghazarian & McGlynn, 2020; Li et al., 2020). Mortality trends are highest among non-Hispanic Black Americans (Filippou et al., 2016). One possible cause for this disparity is access to care, as non-White race/ethnicity, low socioeconomic status, and underinsurance status are associated with decreased access to TC care (Macleod et al., 2018). Scientific evidence is too sparse, however, to gauge the magnitude of risk for each of these factors. A more focused approach at producing quality and abundant evidence is necessary for any type of conclusive statement to be made about causal factors of TC.

Prevention of TC

TC prevention can be organized into two broad categories: (1) primordial, primary, and secondary (i.e., awareness-raising and early detection efforts) and (2) tertiary (i.e., treatment). Regarding the former, there is little evidence on firmly established risk factors of TC beyond those mentioned previously (e.g., cryptorchidism and family history). Coupled with the fact that there is no widely agreed upon action on how to prevent either established risk factor, it is difficult to have well-coordinated efforts to preventing them from occurring (i.e., both primordial and primary prevention efforts). Most TC preventive services in this category would classify as secondary screening. Tertiary prevention, or treatment, has well-established protocols and is beyond the scope of this article.

Some key components in TC prevention outside of treatment are disease education and screening/detection awareness, instruction, and adherence. Although the predominant preventive measure for the early detection and treatment of TC is TSE, the United States Preventive Services Task Force (USPSTF, 2011) gave TSE a “D” grade, meaning they recommend against screening for TC in adolescent and adult men. However, there are numerous calls for a formal re-review of the evidence (e.g., Rovito et al., 2022) to establish a more methodologically sound decision than what exists.

Health promotion campaigns play an integral part in TC prevention as they serve as the conduit between message senders (health care providers, public health professionals, etc.) and receivers (at-risk males). There is a large amount of research that reports, in the short term at least, information and awareness promotions increase participant’s knowledge of TC and related screening procedures (Nwozichi, 2015). We have seen a near equal amount of evidence and formal theorizing that awareness and knowledge alone are not enough to prompt sustained health behaviors (Corace & Garber, 2014; Kim et al., 2011; Schwarzer, 2008).

Generally, TC promotional messages debatably catalog into one of three categories: (1) fact-based (strictly informative messages aiming to teach males about TC, TSE, and prevention methods through pictures, models, and evidence), (2) fear-based (severity of disease, probability of occurrence), or (3) humor-based (messages slanted with witty language, sarcasm, or puns). There has not been any assessment on which strategy is comparatively most effective. There have been, however, independent assessments on some of the techniques. Ruiter et al. (2014), for example, indicated that over many decades of research, fear appeal strategies have generally shown little significant impact upon human behaviors and that other alternative methods need to be pursued. Nabi (2016), further, stated that humor has the ability to grab individual’s attention and to sustain maintenance of certain behaviors, which suggests a need to explore this method more so than the others. Humor, generally, has been presented as an alternative option to the fear appeal method.

Due to the paucity of research revolving around TC messaging methods, however, and especially the effectiveness of humor-based messaging, this article provides a comparative critical review of the humor-based messaging observed in TC prevention efforts. We focus on humor-based communication as it appears to be the most prevalent method distributed among TC awareness-raising efforts.

Humor

Defining Humor

Humor is a complex phenomenon that involves behavioral, emotional, social, and cognitive dimensions (Martin, 2007). Humor functions to build support and group cohesiveness, clarify issues or positions, reinforce norms, and differentiate oneself from others (Meyer, 2000). Humor has an inherent duality (a uniting and dividing concept) that can allow rhetors to use it in a multitude of ways, rendering it a very powerful tool in the communication process (Meyer, 2000).

There are several categories of humor: (1) slapstick, (2) clownish, (3) surprise, (4) misunderstanding, (5) irony, (6) satire, and (7) parody (Buijzen & Valkenburg, 2004), which all vary in levels of complexity and cognitive demand. All are uniquely employed to achieve set goals but are highly contextualized due to the idiosyncrasies of the specific, highlighted health topic. Pertaining to type of humor used within healthy promotion, it is a variation, depending on the specific health topic, the audience, among other contextual factors.

Humor and its Effects on Learning and Health Promotion

Historical evidence showcases that fear and laughter influence physiological and psychological processes (Akhtar, 2021; Berk et al., 1989; Schwartz et al., 2012). Savage et al. (2017) reported that when used in instructional communication, humor has effective means of gaining attention, enhancing recall, aid learning, and promoting a positive classroom environment. The authors noted, however, that the appropriateness and relevance of the humor must be considered during the development (especially during the delivery) if the humor associated with the instructional material was relevant and appropriate.

Yeo et al. (2020) reported the effect humor had in relaying scientific information on social media, deeming it an effective way of reaching audiences, but noted that an individual’s knowledge is a key moderator in humor’s effects. Meaning, for someone to “get the joke,” they must have some sort of base knowledge that the pun or joke is referring to. The possibility of the audience misunderstanding the humor or not finding the approach to be humorous, may limit the utility of the information within the message. Therefore, “knowing the audience” and using the appropriate type of humor for each health topic is critical for effective and efficient communication.

It appears that content and context are both important for the successful delivery of humor-based messages in health promotion efforts, which forces communicators to pay homage to the idiosyncratic nature of health communication within select populations. These tactics would help increase motivation and ability to process information among the message recipients. If the humor was irrelevant or inappropriate, for example, it may be counterproductive and distract from the instructional message.

Even with humor’s impact on promoting a learning environment and increasing attention of the learners, there remains mixed research on the impact of humor on actual learning, and with that, human behaviors. Although evidence indicates health promotion techniques’ ability to enable increased control over health-based decisions and behaviors vis-à-vis utilizing social and personal resources (Iannarino, 2017; Miller et al., 2021), such evidence is rare considering how widespread its use is, at least from the men’s health promotion perspective. In fact, systematic reviews exploring the relationship of humor with attention and information retention are predominantly within non–health-related fields (Miller et al., 2021). This presents a need to explore humor’s effectiveness within human health behaviors, particularly within select demographic subpopulations.

Humor-based messaging in health promotion

The evidence that does exist indicates that humor-based messaging influences health attitudes and behaviors, elicits favorable audience responses, and promotes discussion about health issues, even ones that may be more sensitive or stigmatized in nature (Campo et al., 2013; Miller et al., 2021). Numerous health promotion campaigns, from sexually transmitted infection prevention to suicide prevention, have instead utilized humor-based messaging in its programming (Ahrens et al., 2006; Cernerud & Olsson, 2004; Newman, 2012). Other evidence demonstrates a mixed effect of humor in health promotion messaging as it can enhance favorable thoughts about the message being promoted yet simultaneously reduce favorable thoughts about the messenger (Eisend, 2022).

Rather than surmounting the anxiety surrounding self-examination through fear-evoking messages, humor-based messaging attempts at reducing the anxiety (Nabi, 2016). Essentially, stressors are moderated by humor through a reframing process that creates an alternative perspective to a stressful situation (Martin, 2007). However, as an aside, Nabi (2016) does suggest that fear-based messaging motivates individuals to perform select health-promoting behaviors and overcome anxieties associated with detection threat.

Given that not all humor is received equally (Campo et al., 2013), coupled with the potential adverse outcomes associated with some health topics, the unintended effects of humor-based messaging need to be addressed. There are a few considerations to be made when using humor in health promotion messaging. Using sarcasm, jokes, and innuendos can detract from the perceived credibility of the topic at hand (Nabi, 2016), making light of diseases and disorders that are grave and life-threatening to many. Past research has identified humor to be effective in garnering attention and enhancing recall (Blanc & Brigaud, 2014; Savage et al., 2017), but these authors argue that there are few studies that have reported humor to promote further understanding of the topic and subsequent health-promoting behavior change as a result.

Men’s health promotion messaging

The field of men’s health has grown tremendously over the past three decades and continues to evolve through a multidisciplinary approach (Houman et al., 2020). With that expansion came an increase in accessibility of services, coordinated political advocacy, among other achievements. Every year brings about new and existing organizations aiming to address the gender health disparity (Elterman & Pelman, 2014). Some fascinating work is indeed being conducted and new findings are emerging.

It appears, however, that despite the expansion of research and increased volume of outreach, the state of men’s health is, in the aggregate, improving little. Some male subpopulations report a lower quality of life than generations before (Amutah et al., 2016). While all males continue to have higher cancer incidence rates compared with females, their life expectancy is 5+ years less than their female counterparts, they live sicker, and are at enormously higher risks of violent death, injury, suicide, and homicide (ACS, 2018a; Baker & Shand, 2017; Leone et al., 2017).

Sustained funding is an issue, of course—many great ideas whither on the proverbial vine due to lack of resources and interest to sustain them (Lefkowich et al., 2017; Oliffe et al., 2010). There may be another reason why initiatives fail to make the impact intended. Addis and Mahalik (2003) and Rovito and Rovito (2015), for example, discuss the normalization of males living sicker, acting more aloof, becoming more detached, and dying younger than their female counterparts. Oliffe et al. (2020) indicate that a general lack of men’s health literacy can serve as a barrier to achieving effective health promotional messaging and that more attention is needed to remedy the continuing concern.

The above points reinforce the historical claim that clinicians, providers, and public health experts must be wary of how they construct and implement outreach efforts, including messaging strategies, among male populations (Butler, 1996). Men and boys are usually aggregated into synonymy with a “one size fits all” approach to becoming healthier, which has reported ineffective results (Hammer et al., 2013). It is clear that how we present the message is of utmost importance in men’s health; nearly as important to what we are communicating.

Pertaining to humor, Conway and Dubé (2002) suggested a correlation between conformity to masculine norms and the tendency to respond favorably to humor-based messaging, with a subsequent increased intent to take part in the recommended behaviors. Branney et al. (2014) stated that humor allows males to make light of their condition and foster relationships with health care providers. Oliffe et al. (2009) indicated how humor can promote inclusiveness, establish guidelines for providing and receiving mutual help, and create normative beliefs about sexuality. However, much of the male health promotional work in the literature and media is many times written through the humorous lens of the despondent male where helplessness and ignorance are the commonly addressed barriers for males to achieve optimal health (Rovito & Rovito, 2015). It uses humor in a more pathogenic instead of salutogenic (i.e., strengths-based) manner. In fact, Oliffe et al. (2009) stated that besides some benefits discovered from humor’s use “there were also some instances when well-intended banter caused discomfort for attendees.” (p. 916)

Humor in TC awareness and its related self-screening behaviors

Humor-based messaging, fraught with puns and innuendos about the penis and/or testicles, appears to be the default method for mass communicated TC awareness campaigns and initiatives. From “Gentlemen, Touch Yourself Tonight” videos featuring Deadpool (20th Century Studios UK, 2016) to “Check Yo Nutz” (Wanzer et al., 2014) Twitter campaigns promoting TSE, these campaigns attempt to alleviate the stress and stigma surrounding TC vis-à-vis humor. Another example includes the Feeling Nuts challenge (Cheshire, 2014), which is a social media trend where participants recorded themselves grabbing their genitals in support of TSE. In fact, the Feeling Nuts campaign had a Feeling Nuts Comedy Special aired on the British Channel 4 (IMDb, 2014), which starred the likes of Harry Styles, Jimmy Carr, James Cordon, and Cara Delevingne. “A Ballsy Sense of Humor’s” (2022) TSE campaign, called #Takea2nd4theboys, encourages men to examine their testicles every second day of every month. As the organization’s name indicates, this effort is squarely rooted in witticisms and satire.

It goes without saying that the above efforts are some of the most visible TC-related awareness campaigns and each is squarely rooted in humor about the penis and/or testicles. From the authors’ perspectives, one would be extremely hard-pressed to find a TC awareness-raising program without the use of comedy. This fact alone is not a significant issue. However, a concern is that messages rooted in off-color humor about penises and/or testes may only speak to a certain type of male, not all. This style of humor-based communication could blur the lines between cheeky/comfortable/effective and absurd/uncomfortable/ineffective. These authors understand that that the line may be hard to locate. We acknowledge that not every message is meant to affect everyone similarly. However, we hypothesize that the existing humor-based TSE and TC promotion speaks to only a very narrow audience, which may alter its overall effectiveness.

The Current Study

Further inquiry about the extent to which humor has been used in TC awareness campaigns, its related health promotion, and the impact of using such strategies is needed. As research surrounding humor-based messaging in TC awareness and prevention is sparse, the need to conduct a comparative critical review presented itself. We aimed through this review to provide insight on male health promotion efforts to spur some deeper conversation about what humor-based health promotional strategies have been used in the past and present, and ultimately, suggestions on what strategies should be used in the future. Specifically, this piece queries how health professionals conduct their practice and how this inclination may be antithetical to promoting the best outcomes for men and boys pertaining to TC.

To address the overall aim of this comparative critical review, four research questions were examined: (1) To what extent has humor been used in TC awareness campaigns and its related health promotion strategies? (2) What does the literature reveal about the use of humor-based messaging on relevant health outcomes, including TSEs, cognitive and behavioral changes? (3) What are the methodological limitations within current TC awareness strategies? and (4) What recommendations can be made for future research?

Methods

Search Strategy and Study Selection

The search strategy involved using Ovid Medline (1950 to present), Cumulative Index to Nursing and Allied Health Literature (CINAHL; 1982 to present), PsycINFO (1806 to present), All EBM Reviews (2022), Ovid Healthstar (1966 to present), the Education Resources Information Center (ERIC; 1966 to present), and Google Scholar (2022) databases to locate relevant literature. The review also conducted ancestry (citation tracking) and gray literature (e.g., unpublished reports, PhD theses, etc.) searches to ensure full capture of relevant research.

Electronic databases were searched using the combination of the following terms: “humor” or “comedy” or “testicular cancer” or “health outcomes” or “testicular self-examination” or “men’s health.” The search aimed to identify studies that evaluated the extent and efficacy of humor-based messaging in TC health promotion and its outcomes on people at any age, published in English after 2000, to capture the latest methods for addressing contemporary men’s health issues. All searches were carried out between April and August 2022.

Inclusion and Exclusion Criteria

Selected studies were assessed in comparison with the inclusion and exclusion criteria presented in Table 1. Studies had to meet the following inclusion criteria to undergo critical review. The articles were screened and described in the below sections.

Table 1.

Inclusion and Exclusion Criteria

Category	Included	Excluded
Research design	Quantitative and qualitative methods, including randomized control trials, quasi-experimental, systematic literature reviews; unpublished reports and dissertations	N/A
Research setting	Any	N/A
Program type	Program, intervention, strategy that explicitly used humor-based promotion strategies; program may include other components in combination with humor component	N/A
Dependent variable	Testicular self-examination rates; at least one behavioral, cognitive, or health outcome was assessed following the intervention	Did not report health outcomes post-intervention
Publication status	Published in English after 2000	Articles published in languages other than English; articles published prior to 2000

Primary Screening

Titles and abstracts were screened for relevance. Articles were moved forward if they discussed TC and humor.

Secondary Screening

Full articles were screened for relevance. Articles discussing humor-based messaging, as well as TC awareness and health promotion among all populations of males were moved forward.

Tertiary Screening

The third assessment further eliminated articles that did not use interventional methods in their design. Articles were also screened out if they did not discuss health outcomes or cognitive and behavioral changes post-intervention of humor-based messaging.

Review Procedures and Data Abstraction

The search (see Figure 1) identified 12 articles that discussed the use of humor within the context of a TC-focused study. The identified articles’ titles and abstracts were then independently screened and read by each author, resulting in the elimination of three articles due to the lack of minimum criteria for inclusion (Seymour-Smith, 2013; Semino & Demjen, 2017; Pietrzyk et al., 2020). A total of nine papers were read in full. Three articles were then screened out as they did not utilize analytical intervention methods in their study design (Chapple & Ziebland, 2004; Miller et al., 2021; Schumacher, 2017). Six articles were ultimately included in this comparative critical review.

Figure 1.

PRISMA Flowchart

Relevant data, including type of intervention, research setting, behavioral change outcomes, and health outcomes, were extracted from each study and summarized. Due to the heterogeneity in study design and outcome measures, coupled with the lower numbers of identified qualifying articles a systematic review or meta-analysis was not appropriate for this research topic.

Results

Summary of Included Literature

Characteristics of the six studies included in this review are summarized in Table 2. A total of three studies (studies 1, 3, and 6) directly assessed via intervention design the use of humor-based messaging via TC promotion on outcomes, such as information retention and health behavior change. The remaining three studies (studies 2, 4, and 5) were a mix of non-experimental studies aiming to highlight humor as part of their observational research design or discussed the phenomenon tangentially from their primary study aim.

Table 2.

Characteristics of Included Studies Table

Study	First author (year), country	Study aim	Design	Intervention	n	Setting	Program length
1	Dobmeier (2020), USA	To examine the mechanisms through which humor facilitates or impedes (1) anxiety reduction, (2) information processing, (3) memorability, and (4) behavior change	Longitudinal, experimental design	Humor-based testicular self-examination video	181 males: (Singapore, n = 53; United States, n = 128)	University	2 weeks
2	Engelberg et al. (2019), USA	To evaluate the degree to which the pairing of health messages with humor could facilitate (1) an increase in cancer knowledge, (2) retention of that newly acquired knowledge, (3) person-to-person promotion of the deaf-friendly educational website, and (4) repeat visits to the website	Feasibility study	Health promotion video paired with humor message	32 women, 30 men	Deaf community	2 weeks
3	Nabi (2016), USA	To examine the possible benefit of using humor to reduce anxiety associated with performing beast and testicular cancer self-examination behaviors	Experimental	Humorous public service announcement encouraging breast or testicular self-examination behavior	S1: 187 university students; S2: 267 university students	University	2 weeks
4	Saab et al. (2019), USA	To describe the development, feasibility, and usability of a virtual reality (VR) intervention designed to enhance men’s awareness of testicular disorders (E-MAT)	Feasibility study	VR-based intervention familiarizing men with the normal testes and common testicular symptoms and disorders	15 males	University	-
5	Trumbo (2004), USA	To assess the effects of a youth-targeted national cable broadcast that promoted testicular self-examination (TSE)	Survey	Exposure to the “Tom Green Show” promoting testicular self-examination	524 university students	University	-
6	Wanzer et al. (2014), USA	To examine the effects of a humor-based testicular cancer awareness campaign on intended knowledge, attitudinal, and behavioral outcomes	Longitudinal, experimental design	Check Yo Nutz testicular cancer awareness campaign using print media, events, social media, and websites	272 university students	University	2 weeks

Description of Humor-Based Health Promotion Strategies in TC

Humor in testicular health promotion was utilized in a multitude of mediums (see Table 3): video messages (studies 1, 2, and 6), television shows (study 5), public service announcements (study 3), virtual reality (study 4), and social media (study 6). Humor-based strategies were implemented to assist with: (1) enhancing awareness, knowledge, and understanding of TC and TSE procedures, (2) reducing uncomfortable feelings surrounding detection threat, and (3) increasing self-examination behavior.

Table 3.

Key Findings of Included Studies

Study	First author (year), country	Intervention	Key findings
1	Dobmeier (2020), USA	Humor-based testicular self-examination video	In the context of TSE, humorous messaging was not as effective as informational messaging. Informational TSE messaging yielded deeper information processing, significantly better message recall of the steps to perform TSE, and greater TSE uptake. There was no significant difference in TSE performance between the humorous TSE and informational TSE conditions
2	Engelberg et al. (2019), USA	Health promotion video paired with humor message	Humor-based messaging had significant improvements in health knowledge, both immediately and post-intervention, in nearly all topics tested. Humor increased ’participants’ motivation to seek more information and to share it with others. Thus, the interweaving of humor and health messages appears to have the potential to raise cancer knowledge, while also contributing to the retention of that knowledge
3	Nabi (2016), USA	Humorous public service announcement encouraging breast or testicular self-examination behavior	Humorous and serious messages did not generate differences in subsequent self-exam behavior, though the intention–behavior relationship was stronger and significant for those exposed to the humorous versus the serious messages
4	Saab et al. (2019), USA	VR-based intervention familiarizing men with the normal testes and common testicular symptoms and disorders	The feasibility and usability of the intervention were established. Participants were satisfied with the intervention and perceived it as user-friendly and interactive and enjoyed its different elements, including the voiceover, haptic feedback, and light humor. Recommended use of innovative and stimulating strategies and to move away from print media
5	Trumbo (2004), USA	Exposure to the “Tom Green Show” promoting testicular self-examination	Perceived humor from the episode on testicular self-examination was not significantly associated with self-examination intention
6	Wanzer et al. (2014), USA	Check Yo Nutz testicular cancer awareness campaign using print media, events, social media, and websites	Participants’ knowledge of testicular cancer and likelihood of conducting a testicular self-exam increased significantly after being exposed to the campaign information. Men who were exposed to testicular cancer messages were more knowledgeable about testicular cancer and were more likely to conduct testicular self-examinations than were men in the control group

Discussion

Extent to Which Humor has Been Used in TC Health Promotion Strategies

The primary aims of this comparative critical review were to determine: (1) the extent of humor-based messaging in TC-focused campaigns, (2) the scope of their usage, and (3) any limitations present in the designs. Although the settings and populations were homogeneous in most of the literature, the methods of humor implementation and assessed outcomes varied. This heterogeneity impaired meaningful comparison between studies.

Of the six studies included, only three directly assessed the implementation of humor-based messaging in TC awareness and/or TSE. One such study was a Master’s Thesis (study 1) that examined the mechanisms through which humor-based TSE video facilitated anxiety reduction, information processing, memorability, and behavior change. Another study (study 3) directly assessed humor-based messaging and TC-related health outcomes where university students read humorous or fact-based, more emotional and/or serious public service announcements on breast self-examinations or TSEs. For example, the humorous TSE message included males adjusting/scratching their testicles in public with the quote, “While you’re down there, check for lumps.” Participants were then assessed on anxiety levels surrounding performing TSE. The third study (study 6) implemented a humorous TC awareness campaign with a mascot (Sammy the Squirrel) holding two acorns serving as the primary conduit of TC-related promotional information in a university setting. The investigators examined the effects of such message strategies on information retention and changes in attitude and behavior.

The other three studies (studies 2, 4, and 5) tangentially studied humor-based health promotion and TC awareness. One study (study 4) primarily assessed the feasibility of a virtual reality intervention on men’s awareness of testicular disorders, specifically familiarizing men to the normal testes and common testicular disorders, using humor and lighthearted messages at certain points. In one aspect of the intervention, for example, the testes were represented in 3D space as walnuts, where participants could move them around and “touch” abnormalities, which triggered humorous responses from the voiceover and haptic feedback. The walnuts were then replaced by a 3D model of real testes, where participants could again look for abnormalities and familiarize themselves with testicular structures. So, there was humor infused within the study, but it played a more minor role in the design, and therefore, did not factor into the primary analyses as a standalone variable.

Another study (study 2) utilized humor in health promotion videos, with aims to increase cancer knowledge and retention, person-to-person promotion of the hearing impaired-friendly educational website, and repeated visits to the website. The video content in American Sign Language included information for breast, cervical, colorectal, ovarian, prostate, testicular, skin, and uterine cancers, as well as videos to promote healthy lifestyle changes. It was impossible, however, to tease out the effects humor played upon TC-related outcome within the analyses.

A 2004 study (study 5) surveyed 524 university students after they watched MTV’s 2000 “Tom Green Cancer Special,” featuring the character’s own surgical treatment for TC, with hints of seriousness and humor. The author indicated that this show was not designed as an intervention but posed as an opportunity to evaluate the mass-dissemination of prompting TSE behaviors.

There is a significant lack of peer-reviewed, interventional, and longitudinal studies specifically assessing humor-based messaging within TC awareness promotion (including TSE). These authors collectively support the notion of expanding work in this area as what evidence that does exist is very limited, making it impossible to determine which delivery method is most effective.

Use of Humor-Based Messaging in Improving TC Health Outcomes and Cognitive or Behavioral Changes

The second aim of this review was to assess the impact of humor-based messaging in TC promotion, of which are summarized in Table 3. In one interventional study (study 1), humorous messaging was identified to not be as effective as fact-based messaging and showed no significant difference in subsequent TSE performance. Fact-based messaging yielded deeper information processing and better recall of TSE steps. The second interventional study (study 3) also discovered no significant differences in TSE behavior between the humorous and serious messages. However, the intention–behavior relationship was stronger in the humorous condition. The third interventional study (study 6) noted participants’ knowledge and likelihood of conducting TSE showed a significant moderate increase in the group exposed to humorous messaging. However, the intention to talk to a physician about TC was not statistically significant compared with the control group.

The study involving virtual reality (study 4) noted that participants found the intervention to be enjoyable and user-friendly and claimed the use of light humor to be an effective aspect of the intervention, at least in the aggregate sense of the entire presentation. The feasibility study on humorous cancer education videos (study 2) noted the potential for increased cancer knowledge and retention as well as the repeated visits to the educational website. Finally, the study surveying university students (study 5) reported that perceived humor from the episode on TSE was not significantly associated with intention to perform TSE.

Overall, it appears that humor-based messaging can aid in coping with challenging situations, like cancer discovery, fostering connectivity with other males on the topic (i.e., TC), and positively disrupting maladaptive viewpoints about TC. However, in the context of information processing and the intention–behavior process, humor-based messaging fared worse, or no better than, informational-based TC promotional messaging.

Because humor is more open to misinterpretation than other emotional appeals, it may be seen as offensive to some with the disease or may be perceived as making light of serious conditions (Nabi, 2016). In a 2004 study, 45 men who had a diagnosis of TC were interviewed and asked about their experiences with TC, including the role that humor can have in easing difficult situations and expressing camaraderie (Chapple & Ziebland, 2004). When used inappropriately, humor was said to “dig a bit too deep” and insensitive to those who have had drastic changes in their quality of life (Chapple & Ziebland, 2004), which relates to Oliffe et al.’s (2009) findings. When used appropriately, light humor can help facilitate an easier conversation, help perhaps relax participants, and aid in message retention, but in terms of long-term affective change with agency (i.e., increased TSE performance and other health-promoting behaviors), the existing evidence does not exist to support such claims.

Methodological Limitations Within the Current Literature Base

Our final claim was to examine the methodological limitations of existing research on humor-based messaging in TC awareness campaigns and to propose suggestions for future research. The available body of evidence limited the breadth of this current assessment, as most of the included literature did not directly assess humor in TC messaging and related health outcomes. Rather, all but three studies included humor as an indirect component of their study, therefore making such an analysis difficult to execute appropriately. Because of the included studies’ variety in setting, intervention method, and population characteristics, a meaningful between-subjects comparison was not appropriate.

Humor, just as in informal settings, can be a difficult tool to make use of in health promotion contexts and has the potential to backfire, which, in relation to health behavior, could be detrimental to promoting health among participants. Unfortunately, given the lack of rigorous research into the use of humor for TC-related health promotion, those seeking to incorporate it into their intervention or campaign have little more than their own personal perceptions upon which to base these decisions. This leads to the findings laid out in this study, where humor can have positive effects, but can also have little to no effect, or even deleterious effects on post-intervention outcomes.

Our findings suggest a need for more original research directly assessing the impact of humor-based messaging on associated TC-related outcomes (e.g., health-related behaviors, like TSE) before and after exposure to humor-based health promotion. These authors suggest randomized control studies that assess the efficacy of humor in health behavioral change, not just behavioral intention. Because most previous research has focused on one-time exposure to humor, future research should also investigate the long-term effects of repeated humor-based messaging over a longer period. Perhaps, future research can investigate the different modalities of health promotion and its impact on a variety of health outcomes and health behavior, yielding a myriad of homogeneous studies that are able to be meaningfully compared.

Conclusion/Future Recommendations

Male genitalia innuendos are very commonly used in a joking manner, making light of, usually, testicular disorders, particularly TC. Most mass-mediated TC awareness campaigns, for example, use the word “balls,” “nuts,” “nads,” or some other slang term to reference testicles (A Ballsy Sense of Tumor [ABST], 2022; IMDb, 2014; Wanzer et al., 2014). The repeated use of this kind of rhetoric highlights the fact that male health has catered to a very specific audience. Furthermore, it may highlight how health professionals may be oversimplifying the social aspect of male health by almost exclusively using this deleterious approach of masculinity and may be indirectly putting pressure on teen boys to present themselves as tough and indestructible (Thornton, 2016).

Current methods of using humor within TC-focused interventions may entertain, educate, or provide a sort of comic relief to a serious situation, which is welcomed to a certain degree. If not done tactfully, however, it falls directly into a daft, sexualized stereotype of more maladaptive forms of masculinity, or even worse, discredits medical information. Within the context of humor-based messaging in TC-related research, it appears most messaging speaks to the lowest form of low-brow comedy, which may ultimately prove to be ineffective as it only connects to a very small percentage of individuals. The salutogenic doctrine of positive masculinity must be incorporated into the lexicon of male health promotion and TC awareness.

Promoting wellness among males must be born from a strengths-based perspective, free of performative stereotypes, to develop effective and efficient programming and counsel. This, these authors believe, will lead to better quality of life for all males and their loved ones. The idea of a male must be one of a caring, astute, engaged being instead of the aloof, brawny, “high-five-er” that is so readily incubated and catered to in the media and within humor-based TC awareness promotional materials. Messages should be provided in an interactive and professional format (Thornton, 2016) with cheeky humor or puns, and carefully crafted to promote positive behavioral change. There are multitudes of personalities that aspire for messages different ways. We need to diversify our messages accordingly, within reason and within our capabilities. We need to steer clear of the absurdities of the performative, stereotyped male and his testicles. Low-brow, crass humor may turn males off to the message.

This article provided an overview of the extent to which humor has been used in TC awareness and TSE promotion strategies. Although limited, research has indicated that humor in TC messaging may alleviate tension, reduce detection anxiety, and enable information retention, however, its effects on genuine health behavior changes are mixed. Humorous messages must be carefully crafted with intention and professionalism, noting that content and context matter. Providers and public health advocates have the ability to make long-lasting impacts on the behavior of adolescent and young men, which is why the ways in which promote cancer education and health behavior change is so crucial to TC prevention. These authors encourage the expansion of communication interventions with emphases on different types of message delivery to expand the evidence base to determine best practices.

Limitations of the Current Study

This study is not without its own set of limitations. The study’s inclusionary criteria limited the review to just handful of studies, which limits its generalizability and potential impact upon the field. These strict set of criteria were implemented, however, to limit selection bias. Due to the low numbers of included studies into the review, the provided future recommendations are not provided on a set of overwhelmingly robust data.