Abstract
Background
Testicular cancer (TC) is a rare but curable malignancy that commonly affects men aged 15–45. Early diagnosis significantly increases the chance of survival, with five-year survival rates exceeding 95% in early stages. Testicular self-examination (TSE) is a simple and cost-effective method for early detection; However, awareness and practice remain low, especially in low-resource countries, highlighting the urgent need for educational interventions and culturally appropriate programs to improve TSE knowledge and uptake among young men. The aim of this study is to assess the knowledge, attitude, and practice regarding TC and TSE among medical students in Afghanistan.
Methods
A cross-sectional, questionnaire-based study was conducted among 319 male students at Kabul University of Medical Sciences from February to April 2025. Participants were selected using a stratified random sampling method. Statistical analysis was performed using SPSS version 27, applying chi-square tests, Spearman’s correlation, and logistic regression. A p-value < 0.05 was considered statistically significant.
Results
Among 319 male students (response rate: 96.4%), most (69.3%) were aged 21–25 years, and the majority were single (91.2%). Overall, 87.8% demonstrated good knowledge of testicular cancer (TC), and 97.2% showed a positive attitude toward TC and testicular self-examination (TSE). Despite this, Awareness of TSE was low (24.8%), and only 11% had ever performed it. TSE practice was significantly associated with age group (p = 0.037), family history of TC (p = 0.039), and testicular abnormalities (p = 0.005). In multivariable analysis, higher academic year was inversely associated with knowledge (AOR = 0.70; p = 0.034), while testicular abnormalities were positively associated with TSE practice (AOR = 2.72; p = 0.046). No significant correlations were observed between knowledge, attitude, and practice scores.
Conclusions
Despite positive attitudes, students demonstrated poor knowledge and low TSE practice. Our findings underscore the urgent need to enhance awareness and practice of testicular self-examination among Afghan medical students through culturally relevant educational interventions and awareness campaigns. Interventions such as curriculum-based education and culturally appropriate awareness programs are urgently needed to promote early detection of TC in Afghan male youth.
Supplementary Information
The online version contains supplementary material available at https://doi.org/10.1186/s12885-026-16693-w.
Keywords: Testicular cancer, Testicular self-examination, Knowledge, Attitude, Practice, Medical students, Afghanistan
Introduction
Testicular cancer (TC) is a malignant tumor primarily affecting young males, aged 15–45 years, and is the most common malignancy in this age group [1]. Despite its rarity, comprising only 1–2% of all male cancers globally [2, 3], it is one of the most important threats to a young man’s life [4] and has significant implications due to its impact on quality of life and psychological adjustment during a critical stage of life [5]. Early detection plays a crucial role in improving survival rates, with five-year survival rates exceeding 95% when diagnosed at an early stage [2, 3, 6].
The incidence of TC varies across geographical regions and socioeconomic groups [4, 7]. Western and Northern Europe, as well as Australia and New Zealand, report the highest incidence rates, while Africa and Asia exhibit much lower incidence rates but higher mortality, often attributed to limited diagnostic and treatment resources [7, 8]. Studies indicate that the incidence of TC has been increasing globally over the past four decades; however, the reasons for this rise remain poorly understood [4].
Testicular self-examination (TSE) is a critical and simple screening tool for the early detection of TC. It involves the inspection and palpation of the testes to identify any unusual lumps or changes, which could be the first signs of cancer [9]. TSE offers a non-invasive, cost-effective, and easy-to-learn method for men to monitor their health [10]. Despite these advantages, awareness and practice of TSE remain low among young men globally.
For instance, in Iran, among medical university students, only 5% had knowledge of TSE and 10% practiced it [11]. In Uganda, 14% of general undergraduate students reported performing TSE regularly [12]. Similarly, a large European study among university students (7,304 men, mostly non-medical students) reported that only 3% performed TSE monthly [13].
The delay in diagnosis and treatment of TC is often attributed to insufficient knowledge about the disease, its symptoms, and the importance of TSE, as well as cultural or psychological barriers such as guilt or fear of seeking medical help [14]. Additionally, risk factors such as cryptorchidism (undescended testicles), family history, and genetic predisposition further underscore the need for heightened awareness and proactive screening [3, 15]. While TC cannot be prevented, regular TSE offers a practical means for early detection, enabling timely intervention and improved outcomes [16].
Although previous studies in various countries have examined testicular cancer (TC) and testicular self-examination (TSE), most of these investigations have been conducted in high-income countries with well-developed healthcare systems. In contrast, there is a lack of localized data and empirical evidence from low-resource settings such as Afghanistan, where awareness and education on TC and TSE remain largely neglected. This gap is particularly significant in the Afghan context. To the best of our knowledge, this is the first study in Afghanistan to investigate knowledge, attitudes, and practices regarding testicular cancer and testicular self-examination among medical students, and no prior research has addressed this topic in any population or group in the country. It contributes novel empirical data and provides a foundation for culturally tailored, evidence-based educational interventions and public health strategies. Addressing this gap can meaningfully enhance male reproductive health awareness, encourage preventive behaviors, and reduce mortality from late detection of testicular cancer in the country.
Materials and methods
Study design, setting, and period
This cross-sectional, questionnaire-based study was conducted at Kabul University of Medical Sciences, the oldest and most prominent public medical university in Afghanistan. The study was carried out from February to April 2025.
Sample size and sampling method
In 2025, Kabul University of Medical Sciences had 1704 students. The sample size was determined using the Cochran formula and the Epi Info 7.2.6 program, with a 95% confidence interval, 5% absolute error, and a 0.5 population proportion. The calculated sample size was 314. To account for a 5% non-response rate, the final sample size was adjusted to 331.
This study employed a stratified random sampling method to ensure proportional and representative participation of students across academic disciplines and academic years. The entire male student population at Kabul University of Medical Sciences was first stratified based on two variables: faculty (department) and academic year (first, second, and third year or above). All eligible male students were approached for participation, and a proportionate number of participants was selected from each stratum using simple random sampling. A higher number of students from junior years (first and second year) were included because these years constitute a larger proportion of the overall student population, reflecting the natural distribution rather than an intentional bias. Consequently, the results primarily represent the distribution of students across academic years, although awareness and practices among senior students may differ slightly. This approach ensured that students from all faculties and academic years were adequately represented in the final sample. No personally identifying information was collected, and confidentiality was strictly maintained throughout the study.
Data source and measurement
A structured questionnaire was developed specifically for this study by the authors, based on a review of previous similar studies [17–19], and adapted to the cultural and academic context of Afghanistan. The questionnaire consisted of 26 items divided into four sections to achieve the objectives of the research. The content validity of the questionnaire was reviewed by expert researchers, and their feedback was incorporated into the final design. The first section included 5 items about the participants’ demographic information. Testicular abnormalities were defined as any self-reported history of testicular conditions, including cryptorchidism (undescended testis), varicocele or previous varicocele repair, infertility related to testicular causes, or any other previously diagnosed testicular disorder. The second section assessed knowledge through 9 items, with 1 point awarded for each correct answer. Based on the total score, participants’ knowledge was categorized into two levels: Good knowledge (score ≥ 7) and Poor knowledge (score < 7). The third section assessed attitudes using 8 items on a 5-point Likert scale: Strongly agree (5 points), Agree (4 points), Not sure (3 points), Disagree (2 points), and Strongly disagree (1 point). Based on the total score, participants’ attitudes were categorized into two levels: Positive attitude (score of 20 or more) and Negative attitude (score less than 20). The fourth section included 4 questions assessing participants’ practice. Based on their responses, participants were classified into two categories: those who have performed testicular self-examination and those who have not.
The questionnaire was translated into the local language (Dari/Pashto) to ensure clarity and ease of understanding for participants. To ensure reliability and validity, a pilot study was conducted with 20 students who were excluded from the main sample. The questionnaire was designed with closed-ended, multiple-choice questions to facilitate ease of completion in less than ten minutes and to minimize recall bias. The English version of the questionnaire is available as Supplementary Material 1.
Statistical analysis
All statistical analyses were performed using IBM SPSS Statistics version 27. Descriptive statistics, including frequencies and percentages, were used to summarize categorical variables. Chi-square tests were conducted to assess associations between categorical variables. Spearman’s correlation analysis was used to evaluate the relationships between knowledge, attitude, and practice scores. Multivariate binary logistic regression analyses were performed to identify predictors of knowledge, attitude, and practice. P-values less than 0.05 were considered statistically significant. All statistical tests were two-tailed.
Results
Students’ sociodemographic characteristics
A total of 319 fully completed questionnaires were included in the analysis, out of 331 distributed (response rate: 96.37%). The demographic characteristics of the participants are presented in Table 1. The mean age of participants was 21.61 ± 1.89 years. Most participants 221 (69.3%) were aged between 21 and 25 years. Most respondents were first-year students 96 (30.1%) and the majority were single 291 (91.2%). A small proportion of participants 19 (6%) reported a family history of testicular cancer, and 30 (9.4%) reported having experienced testicular abnormalities.
Table 1.
Demographic characteristics of the participants (N = 319)
| Demographic characteristics | Category | frequency | Percentage |
|---|---|---|---|
| Age Group | 18–20 | 88 | 27.6% |
| 21–25 | 221 | 69.3% | |
| 26–30 | 10 | 3.1% | |
| Year of education | 1st year | 96 | 30.1% |
| 2nd year | 67 | 21% | |
| 3rd year | 75 | 23.5% | |
| 4th year | 56 | 17.6% | |
| Above | 25 | 7.8% | |
| Marital status | Single | 291 | 91.2% |
| Married | 28 | 8.8% | |
| Family History of Testicular Cancer | Yes | 19 | 6% |
| No | 300 | 94% | |
| Testicular Abnormalities | Yes | 30 | 9.4% |
| No | 289 | 90.6% |
All values are presented as frequency (n) and percentage (%)
Knowledge of participants regarding testicular cancer
The overall level of knowledge regarding testicular cancer among participants was high, with 280 (87.8%) demonstrating good knowledge and 39 (12.2%) exhibiting poor knowledge (Fig. 1).
Fig. 1.
Distribution of knowledge, attitude, and practice regarding testicular cancer and testicular self-examination among participants
Out of 319 participants, most 246 (77.1%) had heard about testicular cancer. The most frequently reported sources of information were books and articles, 156 (63.4%) and hospitals or clinics 119 (48.4%). Regarding the definition of testicular cancer, less than one-third of participants 87 (27.3%) correctly recognized it as a painless lump. A significant number 153 (48%) instead believed it to be a painful lump. Family history 206 (64.6%) and personal history 115 (36.1%) were the most commonly perceived risk factors. However, only 103 (32.3%) participants correctly identified the 15–40 years age group as being most at risk, while a majority 193 (60.5%) incorrectly believed it affects aged 40 years and above. The most frequently recognized symptoms included scrotal heaviness 132 (41.4%) and painful lumps 123 (36.6%). In terms of complications, metastasis 167 (52.4%) and infertility 131 (41.1%) were most frequently cited. Early diagnosis 208 (65.2%) and regular testicular self-examination 142 (44.5%) were commonly reported as effective preventive measures. When asked about their response to discovering a painless lump, the majority 236 (74%) indicated they would seek urgent medical care. Detailed data are presented in Table 2.
Table 2.
Participants’ knowledge about testicular cancer
| Variables | Category | Frequency | Percentage |
|---|---|---|---|
| Ever heard about testicular cancer? | Yes | 246 | 77.1% |
| No | 73 | 22.9% | |
| Source of information about testicular cancer? | Family | 43 | 17.5% |
| Friends | 87 | 35.4% | |
| Hospital/Clinic | 119 | 48.4% | |
| Books and Articles | 156 | 63.4% | |
| Recognized definitions of testicular cancer? | Painful lump | 153 | 48% |
| Painless lump | 87 | 27.3% | |
| Swelling/redness | 107 | 33.5% | |
| Enlargement of testicle | 98 | 30.7% | |
| Perceived risk factors? | Family history | 206 | 64.6% |
| Having many children | 25 | 7.8% | |
| Personal history | 115 | 36.1% | |
| Undescended testicle (cryptorchidism) | 78 | 24.5% | |
| Most at-risk age group for testicular cancer? | 1–15 years | 23 | 7.2% |
| 15–40 years | 103 | 32.3% | |
| 40 years and above | 193 | 60.5% | |
| Recognized signs and symptoms | Pain during urination | 89 | 27.9% |
| Abdominal bloating/cramps | 33 | 10.3% | |
| Scrotal heaviness | 132 | 41.4% | |
| Painful lump | 123 | 36.6% | |
| Painless lump | 89 | 27.9% | |
| Swelling/redness | 115 | 36.1% | |
| Weight loss | 83 | 26% | |
| Sudden scrotal fluid | 92 | 28.8% | |
| Perceived complications | Urinary incontinence | 83 | 26% |
| Cancer spread (metastasis) | 167 | 52.4% | |
| Erectile dysfunction | 107 | 33.5% | |
| Infertility | 131 | 41.1% | |
| Best methods of prevention | Regular monitoring | 111 | 34.8% |
| Watchful waiting | 34 | 10.7% | |
| Early diagnosis | 208 | 65.2% | |
| Regular testicular self-examination | 142 | 44.5% | |
| Action if a painless lump is noticed | Delay until symptoms | 33 | 10.3% |
| Wait and see | 41 | 12.9% | |
| Seek urgent medical care | 236 | 74% | |
| Consult traditional medicine | 61 | 19.1% |
Data are presented as frequency (n) and percentage (%). Multiple responses were allowed for selected items; therefore, percentages may exceed 100%
Attitude of participants toward testicular cancer and testicular self-examination
Participants generally demonstrated a positive attitude toward testicular cancer and testicular self-examination, with 310 (97.2%) showing a positive attitude and 9 (2.8%) exhibiting a negative attitude (Fig. 1).
A majority of participants either agreed 102 (32%) or strongly agreed 139 (43.6%) that testicular self-examination (TSE) helps in early detection of testicular cancer. Similarly, most participants 113 (35.4%) agreed and 53 (16.6%) strongly agreed that TSE should be performed monthly. However, only 110 (34.5%) remained neutral, and a smaller proportion disagreed 38 (11.9%) with this practice. Awareness regarding the best time to perform TSE was moderate, with just 74 (23.2%) agreeing and 36 (11.3%) strongly agreeing that it should be done during or after a warm shower. Some misconceptions were observed: 132 (41.4%) participants were neutral about the belief that testicular cancer is untreatable, while 91 (28.5%) disagreed. Similarly, 152 (47.6%) participants were neutral about the misconception that all men diagnosed with testicular cancer become completely infertile, though 61 (19.1%) disagreed. Regarding perceived risk, 143 (44.8%) participants were neutral on whether testicular cancer mostly affects men of their age, and 115 (36.1%) agreed that male relatives of affected individuals are at higher risk. Comprehensive responses are detailed in Table 3.
Table 3.
Participants’ attitudes toward testicular cancer and testicular self-examination
| Variables | SD (n/%) | D (n/%) | N (n/%) | A (n/%) | SA (n/%) |
|---|---|---|---|---|---|
| Testicular self-examination helps in early detection of testicular cancer. | 6 (1.9%) | 9 (2.8%) | 63 (19.7%) | 102 (32%) | 139 (43.6%) |
| Testicular cancer is untreatable. | 39 (12.2%) | 91 (28.5%) | 132 (41.4%) | 36 (11.3%) | 21 (6.6%) |
| All men diagnosed with testicular cancer are completely infertile. | 11 (3.4%) | 59 (18.5%) | 152 (47.6%) | 61 (19.1%) | 36 (11.3%) |
| Testicular cancer mostly affects men of my age. | 14 (4.4%) | 59 (18.5%) | 143 (44.8%) | 69 (21.6%) | 34 (10.7%) |
| Testicular self-examination should be done regularly once a month. | 5 (1.6%) | 38 (11.9%) | 110 (34.5%) | 113 (35.4%) | 53 (16.6%) |
| Testicular self-examination should be performed during or right after a warm shower. | 10 (3.1%) | 37 (11.6%) | 162 (50.8%) | 74 (23.2%) | 36 (11.3%) |
| Testicular cancer is common and many men experience it. | 12 (3.8%) | 80 (25.1%) | 112 (35.1%) | 82 (25.7%) | 33 (10.3%) |
| Male relatives of men with testicular cancer are at higher risk of developing the disease. | 13 (4.1%) | 41 (12.9%) | 104 (32.6%) | 115 (36.1%) | 46 (14.4%) |
Responses were measured using a 5-point Likert scale: SD Strongly Disagree, D Disagree, N Neutral, A Agree, and SA Strongly Agree
Practice of participants regarding testicular cancer and testicular self-examination
The majority of participants reported not performing testicular self-examination, with 284 (89%) indicating that they had never performed it, while only 35 (11%) reported performing it (Fig. 1).
Among the 319 participants, only a minority 79 (24.8%) reported having heard about testicular self-examination (TSE). Even fewer 35 (11%) had ever performed TSE. Among those who reported performing TSE, most did so irregularly only 9 (25.7%) participants practiced it monthly, while 17 (48.6%) did it only when experiencing discomfort. The most commonly cited reasons for not performing TSE included lack of knowledge about how to perform it 14 (4.9%), feelings of inappropriateness or guilt 11 (3.9%), and fear of discovering serious results 6 (2.1%). Detailed results are shown in Table 4.
Table 4.
Practice of testicular self-examination (TSE) among participants
| Variables | Category | Frequency | Percentage |
|---|---|---|---|
| Have you heard about TSE? | Yes | 79 | 24.8% |
| No | 240 | 75.2% | |
| Have you ever performed TSE? | Yes | 35 | 11% |
| No | 284 | 89% | |
| If performed TSE, how often? | Monthly (Regularly) | 9 | 25.7% |
| Every 3 months | 3 | 8.6% | |
| Every 6 months | 6 | 17.1% | |
| Only when feeling discomfort | 17 | 48.6% | |
| If not performed TSE, why? | Lack of interest in performing TSE | 8 | 2.8% |
| Fear of serious or bad results after TSE | 6 | 2.1% | |
| Feelings of guilt or belief that TSE is inappropriate | 11 | 3.9% | |
| Lack of knowledge about how to perform TSE | 14 | 4.9% | |
| No symptoms or discomfort | 5 | 1.8% |
Percentages are based on subgroup totals. Multiple responses were allowed for reasons for not performing TSE (n = 284)
Statistical associations and predictors of knowledge, attitude, and practice regarding testicular cancer and testicular self-examination
A significant association was found between age group and both attitude (χ² = 6.233, p = 0.044) and practice (χ² = 10.188, p = 0.037). Specifically, students aged 21–25 years demonstrated the highest proportion of positive attitudes toward TSE (98.6%), while the oldest age group 26–30 years reported the highest proportion of TSE practice (20%), indicating a clear age-related difference in preventive behavior. Participants aged 21–25 years demonstrated the higher proportion of positive attitudes toward TSE 218 (98.6%) and a moderate level of TSE practice 23 (10.4%). The oldest group (26–30) had the highest rate of TSE practice 2 (20%). Regarding family history of testicular cancer, it was significantly associated with TSE practice (χ² = 6.479, p = 0.039). Among those with a family history, 5 (26.3%) participants reported having performed TSE. A statistically significant association was also found between presence of testicular abnormalities and TSE practice (χ² = 10.471, p = 0.005). Participants who had experienced testicular abnormalities were more likely to have performed TSE 8 (26.7%) compared to those without abnormalities 27 (9.3%). No significant associations were observed between demographic variables and knowledge level (p > 0.05). Marital status and year of education were not significantly related to knowledge, attitude, or practice. Details of the statistical associations are presented in Table 5.
Table 5.
Association between demographic characteristics and levels of knowledge, attitude, and practice
| Variables | Knowledge level | Attitude level | Practice level | |||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Good | Poor | Chi-square | P-value | Positive | Negative | Chi-square | P-value | performed | Not performed | Chi-square | P-value | |
| Age Group | ||||||||||||
| 18–20 | 76 (86.4%) | 12 (13.6%) | 0.253 | 0.881 | 83 (94.3%) | 5 (5.7%) | 6.233 | 0.044 | 10 (11.4%) | 7 (8%) | 10.188 | 0.037 |
| 21–25 | 195 (88.2%) | 26 (11.8%) | 218 (98.6%) | 3 (1.4%) | 23 (10.4%) | 33 (14.9%) | ||||||
| 26–30 | 9 (90%) | 1 (10%) | 9 (90%) | 1 (10%) | 2 (20%) | 4 (40%) | ||||||
| Year of Education | ||||||||||||
| 1st year | 81 (84.4%) | 15 (15.6%) | 5.260 | 0.262 | 91 (94.8%) | 5 (5.2%) | 5.623 | 0.229 | 10 (10.4%) | 13 (13.5%) | 5.487 | 0.704 |
| 2nd year | 58 (86.6%) | 9 (13.4%) | 64 (95.5%) | 3 (4.5%) | 7 (10.4%) | 8 (11.9%) | ||||||
| 3rd year | 65 (86.7%) | 10 (13.3%) | 74 (98.7%) | 1 (1.3%) | 8 (10.7%) | 7 (9.3%) | ||||||
| 4th year | 51 (91.1%) | 5 (8.9%) | 56 (100%) | 0 | 8 (14.3%) | 10 (17.9%) | ||||||
| Above | 25 (100%) | 0 | 25 (100%) | 0 | 2 (8%) | 6 (24%) | ||||||
| Marital Status | ||||||||||||
| Single | 255 (87.6%) | 36 (12.4%) | 0.065 | 0.789 | 283 (97.3%) | 8 (2.7%) | 0.063 | 0.802 | 29 (10%) | 38 (13.1%) | 5.692 | 0.058 |
| Married | 25 (89.3%) | 3 (10.7%) | 27 (96.4%) | 1 (3.6%) | 6 (21.4%) | 6 (21.4%) | ||||||
| Family History of TC | ||||||||||||
| Yes | 17 (89.5%) | 2 (10.5%) | 0.054 | 0.816 | 19 (100%) | 0 | 0.587 | 0.444 | 5 (26.3%) | 4 (21.1%) | 6.479 | 0.039 |
| No | 263 (87.7%) | 37 (12.3%) | 291 (97%) | 9 (3%) | 30 (10%) | 40 (13.3%) | ||||||
| Testicular Abnormalities | ||||||||||||
| Yes | 27 (90%) | 3 (10%) | 0.153 | 0.696 | 29 (96.7%) | 1 (3.3%) | 0.032 | 0.859 | 8 (26.7%) | 6 (20%) | 10.471 | 0.005 |
| No | 253 (87.5%) | 36 (12.5%) | 281 (97.2%) | 8 (2.8%) | 27 (9.3%) | 38 (13.1%) | ||||||
Chi-square test was used to determine the association between sociodemographic variables and levels of knowledge, attitude, and practice. p < 0.05 was considered statistically significant
Spearman’s rank correlation analysis did not reveal any statistically significant relationships between the scores of knowledge, attitude, and practice. The observed correlations were weak and failed to reach statistical significance, indicating limited alignment between what students know, how they feel, and what they do regarding testicular cancer and TSE. A detailed summary of correlation coefficients is provided in Table 6.
Table 6.
Correlation between knowledge, attitude, and practice scores
| Variable | Correlation Coefficient (ρ) | P-value |
|---|---|---|
| Knowledge-Attitude | 0.064 | 0.257 |
| Knowledge-Practice | 0.004 | 0.950 |
| Attitude-Practice | 0.041 | 0.469 |
Correlation between continuous scores was assessed using Spearman’s rank correlation coefficient (ρ). P < 0.05 was considered statistically significant
Multivariate logistic regression analysis was conducted to examine the independent effect of sociodemographic factors on knowledge, attitude, and practice related to testicular cancer and TSE. The analysis showed that year of education was significantly associated with knowledge, with each additional year of education associated with a decrease in the odds of having good knowledge (AOR = 0.70; 95% CI: 0.50–0.97; p = 0.034), indicating that students in higher years of study were slightly less likely to demonstrate good knowledge. Regarding practice, students with testicular abnormalities had significantly higher odds of performing TSE (AOR = 2.72; 95% CI: 1.02–7.28; p = 0.046). Other variables, including age group, marital status, and family history of testicular cancer, did not show significant associations with knowledge, attitude, or practice. Full results including adjusted odds ratios, confidence intervals, and p-values are presented in Table 7.
Table 7.
Multivariate logistic regression analysis of sociodemographic predictors of knowledge, attitude and practice regarding testicular cancer and testicular self-examination
| Demographic characteristics | Knowledge | Attitude | Practice | |||
|---|---|---|---|---|---|---|
| AOR (95% CI) | P-value | AOR (95% CI) | P-value | AOR (95% CI) | P-value | |
| Age Group | 1.384 (0.628–3.051) | 0.421 | 1.001 (0.247–4.057) | 0.999 | 1.345 (0.583–3.105) | 0.487 |
| Year of Education | 0.700 (0.503–0.973) | 0.034 | 2.226 (0.967–5.121) | 0.060 | 0.931 (0.672–1.290) | 0.668 |
| Marital Status | 0.859 (0.224–3.302) | 0.825 | 0.567 (0.055–5.810) | 0.632 | 0.533 (0.178–1.599) | 0.262 |
| Family History of Testicular Cancer | 0.929 (0.185–4.677) | 0.929 | – | 0.998 | 2.043 (0.621–6.715) | 0.239 |
| Testicular Abnormalities | 1.365 (0.353–5.280) | 0.652 | 1.375 (0.142–13.323) | 0.784 | 2.723 (1.019–7.280) | 0.046 |
Multivariate logistic regression analyses were conducted to determine the associations between sociodemographic characteristics and knowledge, attitude, and practice. AOR Adjusted Odds Ratio, CI Confidence Interval. P < 0.05 was considered statistically significant
Discussion
This is the first study in Afghanistan that examines the knowledge, attitude, and practice (KAP) of university students regarding testicular cancer (TC) and testicular self-examination (TSE) among medical students, providing insights that can guide future educational programs and inform further research on male health awareness in similar settings. The findings revealed that most participants had good knowledge and positive attitudes, but demonstrated poor practices concerning TC and TSE. This discrepancy highlights a critical gap between awareness and preventive behavior, which is a key concern in cancer prevention efforts. No significant correlations were observed between knowledge, attitude, and practice scores, suggesting that awareness alone may not translate into behavior. Statistically significant associations were observed between selected sociodemographic variables and the levels of knowledge, attitude, and practice. Age was significantly associated with attitude (p = 0.044) and practice (p = 0.037), suggesting that older students are more aware and exhibit more positive attitudes toward preventive behaviors. Additionally, a family history of testicular cancer (p = 0.039) and the presence of testicular abnormalities (p = 0.005) were significantly associated with the practice of TSE. These findings align with studies among medical students in Northwest Ethiopia [20] and Nigeria [21], as well as among general university students in Turkey [22]. This alignment may be attributed to the fact that individuals who are older or have personal or family experiences with cancer tend to have a greater understanding of the importance of early detection and are thus more inclined to perform TSE.
In this study, a high proportion of participants (87.8%) demonstrated good knowledge, which is higher than that reported in secondary school students in Uganda (41.1%) [9], and general university students in Nepal (56.7%) [17]. This difference might be due to increased health awareness campaigns, better internet access, or educational programs available to university students in Afghanistan, particularly within medical institutions. Furthermore, 77.1% of respondents had heard of TC, which is higher than the findings from general university students in Nepal (39.3%) [17] and medical students in Northwest Ethiopia (44%) [20]. This could be attributed to the inclusion of more health sciences students in our sample or increased exposure to health-related topics through media and academic curricula.
Regarding awareness of risk factors, 64.6% correctly identified family history, and 36.1% identified personal history as risk factors. These results contrast with findings from a study conducted among general university students in Nepal [17], possibly due to differences in health education systems or public health awareness levels in the respective countries. Our study showed that only 32.3% of participants correctly identified the age group at risk (15–40 years), which is similar to findings from medical students in Nigeria (32.7%) [21] and general university students in Nepal (38.3%) [17], but lower than that reported among the general male population in the USA (68.5%) [23], and higher than that reported among medical students in Northwest Ethiopia (28.8%) [20]. This discrepancy may stem from differences in awareness campaigns and educational outreach across countries.
A remarkable 97.2% of respondents expressed a positive attitude toward TC and TSE, surpassing reports from general university students in Nigeria (30.8%) [24], medical students in Northwest Ethiopia (51.2%) [20], and general university students in Nepal (67.2%) [17]. This positive attitude may reflect increased health awareness among Afghan students and growing understanding of male-specific health issues. Furthermore, 43.6% of participants strongly agreed that TSE is useful for early detection of TC, consistent with the findings from healthcare workers in Turkey (42.7%) [25] and general university students in Nepal (47%) [17]. Conversely, 28.5% of respondents disagreed with the belief that TC is untreatable, which is lower than figures from general university students in Nepal (33.8%) [17]. Awareness of testicular cancer treatability among participants may be influenced by local healthcare capacity. While early-stage testicular cancer is highly treatable globally, reliable national data on cure rates in Afghanistan are limited, which may affect participants’ perception of disease treatability. A total of 47.6% were neutral regarding the belief that TC causes infertility, which is higher than that reported among general university students in Nepal (39.1%) [17], while 19.1% agreed with this belief, which is lower than the rate among the general adult male population (primary care attenders) in London (58.9%) [26]. This might suggest either a lack of sufficient information or persistent misconceptions regarding the consequences of TC among the participants.
Regarding participants’ attitude toward testicular self-examination (TSE), 34.5% were neutral about performing monthly TSE, similar to general university students in Nepal (32.8%) [17] and lower than healthcare workers in Turkey (55.7%) [25]. Additionally, 50.8% were neutral about performing TSE during or after a shower, which is higher than general university students in Nepal (43.5%) [17] but lower than healthcare workers in Turkey (55.7%) [25]. This neutrality may indicate uncertainty or limited confidence in performing TSE correctly. Only 11% of respondents reported ever performing TSE, consistent with findings from general university students in Nepal (11.4%) [17], but higher than the general adult male population in Bahrain (5.8%) [27], and lower than general university students in Uganda (23.6%) [16] and the general adult population in Malaysia (66.7%) [28]. The low rate of TSE performance in our study might reflect a lack of education on the proper technique or cultural sensitivity surrounding this practice.
The low rate of TSE performance in our study can be explained by several factors. Cultural beliefs and social norms in Afghanistan may make students hesitant to perform self-examination, as male-specific health topics are often considered sensitive or taboo. Additionally, insufficient practical training on TSE during university courses, lack of confidence in performing the examination correctly, and limited awareness campaigns specifically targeting young men likely contributed to the poor practice. These barriers indicate that while knowledge and attitude are high, behavioral and systemic constraints impede translation into regular practice.
International awareness initiatives, such as the “Movember” campaign, have demonstrated effectiveness in improving awareness and preventive practices related to testicular cancer in various settings. Implementing culturally appropriate and context-specific awareness initiatives in Afghanistan could help bridge the gap between knowledge and practice among young men and provide guidance for national public health strategies, including mass media campaigns, community outreach, and integration into primary healthcare for young males.
Furthermore, only 2.8% of participants performed TSE monthly, which is lower than general university students in Turkey (15.3%) [22], medical students in Northwest Ethiopia (26.5%) [20], and the general adult male population in Bahrain (6%) [27]. Cultural stigma, lack of awareness, or inadequate training may contribute to this low rate. Notably, 3.9% of participants believed that TSE is inappropriate or sinful, which aligns with findings from medical students in Northwest Ethiopia (3.3%) [20], general university students in Nepal (5.9%) [17], and general male population in the USA (6.1%) [23]. Moreover, 4.9% stated they did not know how to perform TSE correctly. This rate is much lower than that reported among general male population in the USA (83.4%) [23], general adult male population in Bahrain (73%) [27], and general university students in Uganda (31.5%) [16], possibly indicating some baseline education or familiarity with the concept among Afghan students.
Additionally, we acknowledge that clinical tools such as tumor markers and ultrasonography (USG) play a significant role in the early detection and assessment of testicular cancer. Although our study focused on knowledge, attitude, and practice among students, incorporating these diagnostic methods in future studies could provide a more comprehensive understanding of testicular cancer detection and complement educational interventions. Moreover, although the study was conducted among medical students, the findings offer valuable insights for public health authorities and policymakers in Afghanistan, highlighting the urgent need for population-level awareness campaigns, health education initiatives, and culturally tailored strategies targeting young men outside medical schools.
Our findings emphasize the critical need to improve awareness and practice of testicular self-examination among Afghan medical students. Implementing culturally tailored educational interventions and structured awareness campaigns is essential to promote early detection of testicular cancer and enhance men’s health outcomes.
Despite the fact that a majority of participants demonstrated good knowledge and a highly positive attitude toward testicular cancer and testicular self-examination, their actual practice of TSE was notably poor. This discrepancy highlights that knowledge and attitude alone are insufficient to change behavior, and context-specific cultural barriers must be addressed to improve practice. Future research should focus on identifying the specific behavioral and systemic barriers that prevent young men from performing TSE despite being well-informed and having a positive outlook. Designing culturally appropriate, evidence-based strategies to overcome these barriers is essential to promote early detection of testicular cancer and improve men’s health outcomes in Afghanistan.
Strengths and limitations
One of the main strengths of this study is that it is the first to explore the knowledge, attitude, and practice regarding testicular cancer and testicular self-examination among medical students in Kabul, Afghanistan. This provides important preliminary baseline data that can inform future public health strategies and educational interventions. Additionally, the use of a stratified random sampling method enhanced the representativeness of the sample and reduced selection bias by ensuring adequate representation of students from different academic years.
However, this study also has several limitations. First, as the research was conducted solely among medical students, the findings may not be generalizable to the broader population of young men in Afghanistan, including non-medical students or those not enrolled in higher education. Second, although self-administered questionnaires promote anonymity and may encourage honest responses, they are susceptible to recall bias and social desirability bias, particularly when addressing sensitive issues such as self-examination behaviors. Third, the study did not assess the medical curriculum or the timing and content of formal teaching related to testicular cancer or testicular self-examination. Therefore, although students in higher academic years demonstrated better knowledge and practice, it was not possible to determine whether these differences were attributable to structured coursework, clinical exposure, or individual learning experiences. Moreover, no pre- and post-instructional comparison were performed, which limits conclusions regarding the causal impact of educational exposure on students’ awareness and practices.
Conclusion
This study revealed suboptimal and uneven levels of knowledge, attitude, and practice regarding testicular cancer and testicular self-examination among male students at Kabul University of Medical Sciences. Although the majority of participants had heard about testicular cancer, misconceptions about its symptoms, risk factors, and treatability were common. Only a small proportion of students reported having heard about or ever performed TSE, with lack of knowledge and discomfort cited as key barriers.
Despite a generally positive attitude toward early detection and TSE, actual practice rates were notably low. While statistically Significant associations were observed between age, family history of testicular cancer, and prior testicular abnormalities and a higher likelihood of practicing TSE. Multivariate analysis further identified testicular abnormalities as an independent predictor of TSE practice, while year of education was significantly associated with knowledge level. Importantly, no statistically significant correlations were observed between knowledge, attitude, and practice scores, indicating a clear gap between students’ awareness, perceptions, and actual preventive behaviors related to testicular cancer and TSE. These findings underscore the need for targeted and culturally sensitive educational interventions, rather than solely information-based approaches, aimed at improving testicular health awareness and encouraging regular self-examination among young men in Afghanistan.
Supplementary Information
Acknowledgements
Not applicable.
Abbreviations
- KAP
Knowledge, Attitude and Practice
- TC
Testicular Cancer
- TSE
Testicular Self-Examination
- WHO
World Health Organization
- SPSS
Statistical Package for Social Sciences
Authors’ contributions
All authors (NN, BAQ, FAM, RS and SAQ) contributed significantly to the work reported, whether in study design, execution, data acquisition, analysis, interpretation, or all of these areas; they participated in the article’s drafting, revision, or critical review; they approved the final version for publication; they agreed on the journal to which the article was submitted; and they agreed to take responsibility for every aspect of the work.
Funding
No financial support has been received from any source for conducting this research.
Data availability
Data cannot be shared publicly for reasons of ethical restriction and anonymity. Data are available upon request from Dr. Bashir Ahmad Qudrati, Kabul University of Medical Sciences, Kabul, Afghanistan, via email: [bashirqudrati786@gmail.com](mailto: bashirqudrati786@gmail.com) .
Declarations
Ethics approval and consent to participate
This study received ethical approval from the Institutional Review Board (IRB) of the Faculty of Public Health, Kabul University of Medical Sciences (Approval ID: 19/2025). The study protocols adhered to the ethical standards of the IRB and were conducted in accordance with the principles of the Declaration of Helsinki. Informed consent was obtained from all participants, and confidentiality and anonymity were strictly maintained throughout the research process.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Naweedullah Noori and Bashir Ahmad Qudrati contributed equally to this work.
References
- 1.Gaddam S, Chesnut G. Testicle Cancer. StatPearls. 2023, StatPearls Publishing, Treasure Island (FL).
- 2.Cheng L, et al. Testicular cancer. Nat Reviews Disease Primers. 2018;4(1):29. [DOI] [PubMed] [Google Scholar]
- 3.Stonier T, Coscione A. Testicular cancer. Men’s Health. 2021;4e:30–8. [Google Scholar]
- 4.Cotton R. Like it or lump it: getting boys to self-examine. Br J School Nurs. 2009;4(5):245–8. [Google Scholar]
- 5.Ward KD, et al. Testicular cancer awareness and self-examination among adolescent males in a community-based youth organization. Prev Med. 2005;41(2):386–98. [DOI] [PubMed] [Google Scholar]
- 6.Albers P, et al. Guidelines on testicular cancer: 2015 update. Eur Urol. 2015;68(6):1054–68. [DOI] [PubMed] [Google Scholar]
- 7.Rosen A, et al. Global trends in testicular cancer incidence and mortality. Eur Urol. 2011;60(2):374–9. [DOI] [PubMed] [Google Scholar]
- 8.Park JS, et al. Recent global trends in testicular cancer incidence and mortality. Medicine. 2018;97(37):e12390. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Atuhaire C et al. Knowledge and practice of testicular self-examination among secondary students at Ntare School in Mbarara District, South western Uganda. Pan Afr Med J. 2019;33:85. 10.11604/pamj.2019.33.85.15150. [DOI] [PMC free article] [PubMed]
- 10.Znaor A, et al. International variations and trends in testicular cancer incidence and mortality. Eur Urol. 2014;65(6):1095–106. [DOI] [PubMed] [Google Scholar]
- 11.Ramim T, et al. Student knowledge of testicular cancer and self-examination in a medical sciences university in Iran. Basic Clin Cancer Res. 2014;6(3):7–11. [Google Scholar]
- 12.Zeleke S, Argaw Z, Kefale D. Knowledge, attitude and practice towards testicular self-examination among regular undergraduate non-health sciences university students, Debre Tabor, Amhara Regional State, North West Ethiopia. J Cancer Prev Curr Res. 2019;10(2):35–41. [Google Scholar]
- 13.Wardle J, et al. Testicular self-examination: attitudes and practices among young men in Europe. Prev Med. 1994;23(2):206–10. [DOI] [PubMed] [Google Scholar]
- 14.Bresciani M, et al. Awareness of testicular cancer among young men: A literature review. Int J Urol Nurs. 2021;15(1):5–11. [Google Scholar]
- 15.Singh D, Singh P, Mandal A. Epidemiology and treatment outcomes of testicular germ cell tumor at tertiary care center in Patna, India: A retrospective analysis. Asian Pac J Cancer Care. 2020;5(1):45–50. [Google Scholar]
- 16.Ugurlu Z, et al. Testicular cancer awareness and testicular self-examination among university students. Asian Pac J Cancer Prev. 2011;12(3):695–8. [PubMed] [Google Scholar]
- 17.Dhakal R, Paudel S, Paudel D. Knowledge, Attitude, and Practice regarding Testicular Cancer and Testicular Self-Examination among Male Students Pursuing Bachelor’s Degree in Bharatpur Metropolitan City, Chitwan, Nepal. Volume 2021. BioMed Research International; 2021. p. 1802031. 1. [DOI] [PMC free article] [PubMed]
- 18.Altowaijri K et al. A Survey on the Knowledge and Awareness of Testicular Cancer and Testicular Self-Examination Among Men in Saudi Arabia. Cureus, 2024;16(3):e55778. 10.7759/cureus.55778. [DOI] [PMC free article] [PubMed]
- 19.Adekunle AJ, Eboseremen OG. KNOWLEDGE, ATTITUDE AND PRACTICE OF TESTICULAR SELF-EXAMINATION AMONG MALE UNDERGRADUATE STUDENTS OF COMPUTING AND ENGINEERING SCIENCES IN BABCOCK UNIVERSITY, ILISHAN-REMO, OGUN STATE. Midwifery. 2023;6(3):149–71. [Google Scholar]
- 20.Alemu BW, Baih SZ. Awareness and practice of testicular self-examination among regular undergraduate male health sciences university students, Debre Tabor, Northwest Ethiopia. J Clin Sci. 2019;16(2):61–7. [Google Scholar]
- 21.Ugwumba FO, Ekwueme OEC, Okoh AD. Testicular cancer and testicular self-examination; knowledge, attitudes and practice in final year medical students in Nigeria. Asian Pac J cancer prevention: APJCP. 2016;17(11):4999. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Guven S. The knowledge, attitudes, and behaviors of university students regarding testicular cancer and testicular self-examination: a descriptive study from Turkey. Innovative J Med Health Sci. 2020;10(2):828–34. [Google Scholar]
- 23.Cronholm PF, et al. A dilemma in male engagement in preventive services: adolescent males’ knowledge and attitudes toward testicular cancer and testicular self-exam. Am J Men’s Health. 2009;3(2):134–40. [DOI] [PubMed] [Google Scholar]
- 24.Etita ER, et al. Knowledge, attitude and practice of testicular self-examination among male undergraduate students in a tertiary institution in Calabar, Cross River State Nigeria. J Nurs Health Sci. 2017;6(3):48–54. [Google Scholar]
- 25.Ozturk A, Unalan D, Guleser GN. Knowledge, attitude and practices of technicians working at hospitals towards testicular cancer and self-examination of testicles in Turkey. Asian Pac J Cancer Prev. 2014;15(23):10095–9. [DOI] [PubMed] [Google Scholar]
- 26.Khadra A, Oakeshott P. Pilot study of testicular cancer awareness and testicular self-examination in men attending two South London general practices. Fam Pract. 2002;19(3):294–6. [DOI] [PubMed] [Google Scholar]
- 27.Alaradi M, Almuqamam A. Awareness of testicular cancer and testicular self-examination among men in Bahrain. Asian Pac J Cancer Care. 2020;5(4):259–63. [Google Scholar]
- 28.Azha F, et al. The KAP study on TSE in Salak Tinggi, Sepang, Selangor. Int J Sci Healthc Res. 2017;2(2):59–63. [Google Scholar]
Associated Data
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Supplementary Materials
Data Availability Statement
Data cannot be shared publicly for reasons of ethical restriction and anonymity. Data are available upon request from Dr. Bashir Ahmad Qudrati, Kabul University of Medical Sciences, Kabul, Afghanistan, via email: [bashirqudrati786@gmail.com](mailto: bashirqudrati786@gmail.com) .