Assessment of Knowledge, Attitude and Practice regarding HPV Vaccination and Cervical cancer among Medical students of a Tertiary care hospital in
Chennai, Tamil Nadu.
1*Siddharth A R, 2 Dr.Shanthi E, 3 Dr.Jayashree K, 4 Dr.G Shiny Chrism Queen Nesan,
5 Dr. Srinivasan V
1Undergraduate, Saveetha Medical College and Hospital, Chennai, India.
2 Associate Professor, Department of Obstetrics and Gynecology, Saveetha Medical College and Hospital, Chennai, India.
3Professor and HOD,Department of Obstetrics and Gynecology,Saveetha Medical College and Hospital, Chennai, India.
4Assistant professor,Department of Community Medicine, Saveetha Medical College and Hospital, Chennai, India.
5Associate professor, Department of Pharmacology, Saveetha Medical College and Hospital, Chennai, India.
*Corresponding author Dr. Shanthi E
Associate Professor, Dept of Obstetrics and Gynecology Saveetha Medical College and Hospital, Chennai
Tamil Nadu, India
ABSTRACT
Background: Human Papilloma Virus (HPV) infection is one of the most common sexually transmissible diseases (STD) and believed to affect nearly 30-50% of the sexually active young women. Cervical cancer being one of the most common in the world and the second most common cause of cancer in India, 70% of which is caused by types 16 & 18. Two vaccines were developed and launched for primary prevention of HPV and both have shown good efficacy.
These vaccines were developed from the major capsid protein the L1 protein creating a VLP (Virus like Particle) which retains the immunogenicity but lacks infectivity due to absence of genetic material.
Objectives: This study aims at assessing the level of knowledge, attitude and practice regarding HPV Vaccination and cervical cancer among the Medical students and to evaluate the relationship between their socio-demographic details and their knowledge regarding HPV Vaccination.
Materials and Methods: A cross-sectional study was conducted among the Medical college students of a tertiary care hospital in Chennai. 204 students were studied by convenient sampling method. A pre-tested, validated, structured and self-administered questionnaire was given and the desired information was elicited. Chi square test was used to test the significance (p <0.05) Results: A total of 204 students were studied of which 65 (31.9%) were males and 139 (68.1%) were females. It is observed that year of study, place from where they come and socio-economic status have a statistically significant relationship with knowledge about KPV vaccination and cervical cancer.
Conclusion: A major portion of the medical students have only a poor or moderate knowledge about HPV vaccination. Hence it is highly essential to spread awareness about the benefits of HPV vaccination among the medical students to achieve a nationwide compliance to the vaccine.
Key words: HPV, Cervical cancer, Vaccination, HPV Vaccine, HPV infection, Medical students
INTRODUCTION
Human Papilloma Virus (HPV) infection is one of the most common sexually transmissible diseases (STD)[1-5] and believed to affect nearly 30-50% of the sexually active young women.
The infection may range from genital warts [6-8] caused by low-risk types 6 & 11 to HPV induced cancers like cervical, oropharyngeal, anus, rectum and penile cancers 9,10). Cervical cancer being one of the most common in the world [11]and the second most common cause of cancer in India, 70% of which is caused by types 16 & 18. About 80% of the cervical cancer cases occur in the developing countries which accounts for nearly 12% of female cancers [11].
About 70-80% of sexually active acquire infection with at least one type of HPV during their lifetime.
Two vaccines were developed and launched for primary prevention of HPV and both have shown good efficacy [12,13]. These vaccines were developed from the major capsid protein the L1 protein creating a VLP (Virus Like Particle) which retains the immunogenicity but lacks infectivity due to absence of genetic material [14].
The availability of an effective vaccine alone is not enough if it does not have an effective vaccination program [15]. Hence this study was targeted towards the medical students since they are going to become the future health care providers & the acceptance of the vaccine by a patient
& the society largely depends on the acceptance & advocation of the vaccine by the health care professionals. If they are properly trained and awareness regarding the vaccine is created, they will act as a first line information resource and can play a vital anchoring role in spreading awareness about the same to the larger sections of the society [15]. Hence the identification of knowledge gaps & the barriers of acceptance during medical education will help in proposal for improving the education provided to the students, reduce the ill beliefs and promote HPV
vaccine recommendation [16]. Hence it is important that medical students who are the budding practitioners be taught that like in other diseases, in HPV infection as well, prevention is better than cure.
Since there is a gap in the literature in India in this fast-growing problem, this study was intended to explore more about it to identify, assess the level of knowledge regarding the HPV vaccination and to curb the disbeliefs and provide them with health education to come out of it.
METHODOLOGY:
Aims and Objectives:
To determine the level of knowledge regarding HPV Vaccination and Cervical cancer; to evaluate the attitude of medical students towards HPV Vaccination and to assess the practice towards HPV vaccination among medical students of a Tertiary care hospital.
A cross sectional study was conducted in a Medical College among MBBS students in Chennai, Tamil Nadu. Based on a study done by Pandey et.al [15], it was seen that 84.8% of subjects had awareness regarding the preventable nature of cervical cancer. Using formula 4pq/d2 and considering 5% allowable error the sample size was calculated as 204. All the subjects studying in 2nd, 3rd and final year MBBS who were willing to participate in the study were included in the study by convenient sampling method. Informed written consent was obtained from all the study participants before eliciting the desired information. A Pre-tested, validated, structured and self - administered questionnaire consisting of their socio demographic details, knowledge scale[8] which consists of 30-point likert scale questionnaire, where the scores are 0-15: Low knowledge, 15-22: Moderate knowledge, 23-30: good knowledge and a structured questionnaire on attitude and practice towards HPV vaccination and cervical cancer was used as study tools for the study. The data was then entered in the excel sheet and analyzed by using SPSS Software version 22. The frequencies and percentages were calculated. Chi square test was used to find the association and p value <0.05 was considered significant. This study had obtained the ethical clearance approval from the Institutional Ethical Committee of Saveetha Medical College and Hospital, Chennai.
RESULTS:
From Table 1 it is observed that a total of 204 students were studied of which 65 (31.86%) were males and 139 (68.13%) were females. Majority (44.6%) were in the age group of 21 years.
Majority (83.8%) were Hindus by religion. 8.3% were from 2nd year, 25% and 66.7% were from 3rd and final years respectively. Majority (81.9%) lived in a nuclear family. The socio-economic status of maximum students (76%) fell in the category of Class I (Upper Class). 78.9% of the students lived in urban areas. 48.5% of the students stayed in their homes, whereas 33.3%,
11.3%, 2.9% and 3.9% stayed in the hostel, relative’s house, friend’s house or alone in apartments respectively.
Table 1: Gender based distribution of study participants Variables
Gender
Total N (%)
Male Female
N (%) N (%)
Age:
19 Years 20 Years 21 Years 22 Years 23 Years 24 Years
5 (2.5%) 17 (8.3%) 27 (13.2%)
16 (7.8%) 0(0.0%) 0(0.0%)
16 (7.8%) 42 (20.6%) 64 (31.4%) 13(6.4%)
3 (1.5%) 1 (0.5%)
21 (10.3%) 59 (28.9%) 91 (44.6%) 29 (14.2%) 3 (1.5%) 1 (0.5%) Religion:
Hindu Christian Muslim Others
53 (26.0%) 6 (2.9%) 3 (1.5%) 3 (1.5%)
118 (57.8%) 13 (6.4%)
6 (2.9%) 2 (1.0%)
171 (83.8%) 19 (9.3%)
9 (4.4%) 5 (2.5%) Year of study:
2nd Year 3rd Year 4th Year
4 (2.0%) 13 (6.4%) 48(23.5%)
13 (6.4%) 38 (18.6%) 88 (43.1%)
17 (8.3%) 51 (25.0%) 136 (66.7%) Type of family:
Nuclear family Joint family
56 (27.5%) 9 (4.4%)
111 (54.4%) 28 (13.7%)
167 (81.9%) 37 (18.1%) Socio Economic Status:
Class I: Upper Class
Class II: Upper Middle Class Class III: Middle Class
Class IV: Lower Middle Class Class V: Lower Class
51 (25.0%) 7 (3.4%) 4 (2.0%) 3 (1.5%) 0 (0.0%)
104 (51.0%) 19 (9.3%)
9 (4.4%) 4 (2.0%) 3 (1.5%)
155 (76.0%) 26 (12.7%)
13 (6.4%) 7 (3.4%) 3 (1.5%) Place of stay?
Hostel With parents With relatives With friends
Alone in an apartment
28 (13.7%) 20 (9.8%)
9 (4.4%) 3 (1.5%) 5 (2.5%)
40 (19.6%) 79 (38.7%) 14 (6.9%)
3 (1.5%) 3 (1.5%)
68 (33.3%) 99 (48.5%) 23 (11.3%) 6 (2.9%) 8 (3.9%) Place:
Rural Urban
17 (8.3%) 48 (23.5%)
26 (12.7%) 113 (55.4%)
43 (21.1%) 161 (78.9%)
From Table 2, it is observed that year of study, socio-economic status and place of stay (Rural/Urban) have statistically significant relationship with HPV vaccination and cervical cancer knowledge, whereas age, gender, religion, type of family and place of stay were not statistically significant. Good knowledge was observed in final year students. Students who belonged to the higher socio-economic status had a better knowledge compared to the students of the lower socio-economic status. Maximum number of students from the urban area (26.1%) had a better knowledge compared to students from the rural areas (4.7%)
Table 2: Association between HPV Vaccination and Cervical Cancer Knowledge and Socio-demographic characteristics
Variables
HPV Vaccination and Cervical Cancer Knowledge Scale
*P Value (<0.05)
Low Moderate Good
N (% within demographic characteristic)
N (% within demographic characteristic)
N (% within demographic characteristic) Age:
19 Years 20 Years 21 Years 22 Years 23 Years 24 Years
9 (42.9%) 18 (30.5%) 22 (24.2%) 7 (24.1%)
0 (0%) 0 (0%)
9 (42.9%) 30 (50.8%) 48 (52.7%) 14 (48.3%) 2 (66.7%)
1 (100%)
3 (14.3%) 11 (18.6%) 21 (23.1%) 8 (27.6%) 1 (33.3%) 0 (0%)
0.788
Gender:
Male Female
20 (30.8%) 36 (25.9%)
29 (44.6%) 75 (54.0%)
16 (24.6%) 28 (20.1%)
0.460 Religion:
Hindu Christian Muslim Others
45 26.3%) 8 (42.1%) 3 (33.3%) 0 (0%)
90 (52.6%) 6 (31.6%) 4 (44.4%) 4 (80.0%)
36 (21.1 %) 5 (26.3%) 2 (22.2%) 1 (20.0%)
0.461
Year of study:
2nd Year 3rd Year 4th Year
5 (29.4%) 22 (43.1%) 29 (21.3%)
9 (52.9%) 23 (45.1%)
72(52.9%)
3 (17.6%) 6 (11.8%) 35 (25.7%)
0.034
Type of family:
Nuclear family Joint family
46 (27.5%) 10 (27.0%)
83 (49.7%) 21 (56.8%)
38 (22.8%) 6 (16.2%)
0.638
Socio Economic Status:
Class I: Upper Class
Class II: Upper Middle Class Class III: Middle Class
Class IV: Lower Middle Class Class V: Lower Class
31 (20.0%) 13 (50.0%) 7 (53.8%) 4 (57.1%) 1 (33.3%)
85 (54.8%) 11 (42.3%) 5 (38.5%) 2 (28.6%) 1 (33.3%)
39 (25.2%) 2 (7.7%) 1 (7.7%) 1 (14.3%) 1 (33.3%)
0.009 Place:
Rural Urban
18 (41.9%) 38 (23.6%)
23 (53.5%) 81 (50.3%)
2 (4.7%)
42 (26.1%) 0.003
Place of stay?
Hostel With parents With relatives With friends
Alone in an apartment
13 (19.1%) 36 (36.4%) 4 (17.4%) 2 (33.3%) 1 (12.5%)
41 (60.3%) 43 (43.4%) 13 (56.5%) 2 (33.3%) 5 (62.5%)
14 (20.6%) 20 (20.2%) 6 (26.1%) 2 (33.3%) 2 (25.0%)
0.272
*Chi square test
From Table 3, it is observed that 23.52% of the students did not know that cervical cancer was preventable. 77 students (37.74%) of the students did not know that there was vaccine available for cervical cancer and only 54.41% of the students knew that the HPV vaccine is available in India. 69.11% of the students did not know that HPV vaccine could be given to boys and 37.24%
of the students did not know if HPV vaccination could be given to sexually active girls.
Table 3: Knowledge About HPV Vaccination and Cervical Cancer Among the Study Participants
Questions
Responses
Yes: N (%) No: N (%) Don’t Know: N (%) 1. All cancers are preventable 35 (17.15%) 145 (71.07%) 24 (11.76%) 2. Cervical cancer is preventable 156 (76.47%) 18 (8.82%) 30 (14.70%) 3. Is there any vaccine available for
cervical cancer?
127 (62.25%) 0 (0%) 77 (37.74%)
4. Is the cervical cancer vaccine available in India?
111 (54.41%) 22 (10.78%) 71 (34.80%)
5. Can it be given to boys? 63 (30.88%) 68 (33.33%) 73 (35.78%) 6. Can it be given to a sexually
active girl? 128 (62.74%) 49 (24.01%) 27 (13.23%)
7. Do girls/women need to be screened for HPV before getting vaccinated?
98 (48.03%) 38 (18.62%) 68 (33.33%)
8. Can it be given to a woman already having HPV infection?
44 (21.56%) 66 (32.35%) 94 (46.07%)
9. Is it safe to have multiple sexual partners after full course of HPV vaccine?
19 (9.31%) 65 (31.86%) 120 (58.82%)
10. Is it safe to have sex without
condoms after HPV vaccine? 16 (7.84%) 58 (28.43%) 130 (63.72%) 11. Do girls/women who have
already been vaccinated, require cervical cancer screening?
116 (56.8%) 72 (35.29%) 16 (7.84%)
146 students (71.56%) knew that cervical cancer was caused by a virus, whereas 9.8%, 2.94%
and 15.68% of the students thought that it was caused by bacteria, fungi and none of the above respectively. Only 28.43% of the students knew the correct number of vaccine doses to be taken.
Only 35.78% of the students knew that the efficacy of the vaccine was around 70%.
About 123 (60.29%) of the students were willing to receive/advice HPV vaccination. 84 (41.17%) of the students felt that inadequate information was the main obstacle preventing them from receiving/advising HPV vaccination, whereas 50 (24.50%), 39 (19.11%) and 31 (15.19%) of the students felt that the worry about complications, worry about vaccine efficacy and high respectively were the main obstacles. 159 (77.94%) of the students said that their friends or family members had not sought their opinion regarding HPV vaccination whereas opinion was sought from the remaining 45 (22.05%) students. Finally, 178 (87.25%) of the students wanted themselves to be educated by experts regarding HPV vaccination.
Figure 1: Knowledge Score About HPV Vaccination and Cervical Cancer Among the Study Population
Low 56 (27.5%)
Moderate 104 (51%) Good
(21.6%)44
Knowledge about HPV Vaccination and Cervical Cancer
Low
Moderate
Good
From Figure 1, it is observed that only 44 (21.6%) of the students had a good knowledge regarding HPV Vaccination and cervical cancer while 104 (51%) and 56 (27.5%) of the students had a moderate and low knowledge respectively.
Figure 2: Source of Knowledge Regarding HPV Vaccination Among the Study Population
From Figure 2, it is observed that medical school teaching was the source of knowledge of most of the students (49.5%) and newspaper (0.5%) served as a least source of knowledge.
DISCUSSION
In our study, 71.56% of the participants knew that cervical cancer was mainly caused by HPV in comparison to the study done by Ying Wen et al [11] where 68.30% of the study participants knew the causal association between HPV & cervical cancer. The variation in the levels of knowledge could probably be due to the fact that the study done by Ying Wen et al was conducted in 2014 in China and the knowledge among the students could have increased in this 7-year period with the advent of rapid growth of technology making more information readily available to the students.
In the study done by Ying Wen et al [11] it was found that though the students had heard about HPV, the students had a poor knowledge regarding minute details regarding HPV infection and cervical cancer which is consistent with our study where only 21.6% of the study participants had good knowledge regarding HPV vaccination & cervical cancer owing to the poor levels of health education about these topics among medical students. Hence more focus on increasing the detailed knowledge through education programs, so as to reduce the gaps and misconceptions, should be given.
0 20 40 60 80 100 120
101 (49.5%)
17 (8.3%)
1 (0.5%)
16 (7.8%)
39 (19.1%)
4 (2%)
26 (12.7%)
Source of Knowledge regarding HPV
Vaccination
In the study done by Deeksha Pandey et al [15] 84.8% of the study participants were aware about the preventable nature of cervical cancer whereas in our study, only 76.47% were aware about the same. In the study done by Deeksha Pandey et al [15] it was found that the major obstacle for implementation as stated by most of the study participants (56.7%) was inadequate information which is similar to our study in which majority of the participants (41.17%) stated the same reason. Followed by this reason, our study participants stated other reasons like worry about complications, worry about vaccine efficacy and high cost which was similar to the results of the study done by Bharadwaj et al [17].
In our study a variability in the level of knowledge was found between the students coming from the Rural and Urban areas, where the students from the urban areas had a better knowledge compared to their counterparts probably due to better reach of resources and its utilization in the urban area and the vice versa in the rural area. It is therefore essential to ensure an equitable distribution of knowledge and resources to overcome this hurdle.
In our study, it was found that the students belonging to lower socio-economic status had less knowledge compared to the students of higher socio-economic status which is similar to many international studies (19-25) which have shown a similar result probably because of reduced availability of resources, family situations and misconception being more common at that level.
Hence more concentration has to be given to the lower strata of the population to nullify this ill effect.
Our study did not show much of difference in the level of knowledge between the female study participants and their male counterparts since both the sexes are exposed to the same number of theoretical concepts during medical education.
In the study done by Ahhlelson de Souza Costa et al [18] thefirst-year students had a greater knowledge gap than the final year students. Our study shows a similar result where the final year students had a better knowledge than their junior counterparts due to more clinical exposure.
Vertical integration will help to tide over this difficulty and will lay a strong foundation at the grass root level.
In our study, only 28.43% of the students knew that 3 doses of vaccine were required for full vaccination which was similar to the results of the study done by Ahhlelson de Souza Costa et al [18].
Even though the topic is already a part of the curriculum, 178 (87.5%) of the students wanted to be educated by experts regarding the topic which is similar to the study done by Deeksha Pandey et al [15] where 86.2% of the students wanted to get educated which shows the potential area where vertical and horizontal integrations can be done.
Our study reveals a moderate level of acceptability of HPV vaccination of 60.29% compared to 79.7% acceptability in the study done by Newton Sergio de carvalho et al [5] in Brazil. This
could be due to no nationwide campaigns or planned vaccination programmes. This issue can be addressed by nationwide vaccine awareness campaigns.
The entire students have not participated in the study and only a small number of students were sampled which is a limitation. Students from only one medical college have been included which might not reflect the overall awareness of medical students in India. Inclusion of other health care workers in the future studies might increase the impact.
CONCLUSION
A majority of the study participants had only a low or moderate level of knowledge regarding HPV vaccination and cervical cancer. There are still a few important knowledge gaps and continued efforts and widespread dissemination of information is essential. Public knowledge regarding HPV vaccination and cervical cancer can only be achieved if we augment the knowledge among the medical students, who will in turn influence the decisions of the public.
Vertical and horizontal integration health education sessions can be arranged in all the colleges and widespread health education campaigns nationwide will help in achieving our goal.
ACKNOWLEDGEMENTS
I would like to thank the Director of Saveetha Medical College Dr.Saveetha Rajesh, Dean Dr.J.Damodharan, Dr. Jayashree K,HOD of Obsterics and Gynecology for giving me this opportunity to conduct a research. I would also like to thank all the study participants who participated in my study.
SOURCE OF FUNDING: Nil
CONFLICT OF INTEREST: None declared REFERENCES
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