KNOWLEDGE OF SAUDI FEMAL UNIVERSITY STUDENTS REGARDING

CERVICAL CANCER AND ACCEPTANCE OF THE HPV VACCINE

Ghadeer K. Al-Shaikh

MD, FRCSCAssociate professor , King Saud UniversityDean College of MedicinePrinces Nourah bint Abdulrahman UniversityRiyadh Kingdom Of Saudi Arabia

Background• Cervical cancer is an important global public health

problem, and a leading cause of mortality all over the world.

• There are approx. 500,000 new cases of Ca Cx. worldwide and 250,000 Ca Cx related deaths each year

• Higher incidence rates have been reported from sub-Saharan Africa, Central and South America, Southeast Asia and Brazil. In contrast the incidence rates were the lowest in Middle East, particularly among Muslims and Jews

• In KSA, Ca Cx. accounts for 2.6% of female cancers and is ranked 9th among all carcinomas affecting Saudi females

Background –cont.• Among all known risk factors, persistent infection with

high-risk human papillomavirus (HPV) plays a considerable role in the pathogenesis of Ca Cx.

• The worldwide HPV prevalence in cervical cancer was estimated to be between 85-99%.

• HPV are a diverse group of DNA viruses, which cause infection without triggering a strong immune response and natural infection provides only limited protection against reinfection

Background-cont.

• To date more than 200 genotypes of HPV have been identified; but there are 13 to 17 types that can cause Ca Cx.

• HPV 16 is the most frequent type detected in positive samples, followed by 18 in more than 70% positive samples

• The HPVs are grouped according to their genomic sequence into oncogenic high, probable high, and non-oncogenic low-risk.

Background-cont.

• The strong association of oncogenic HPV infection with the development of Ca Cx. provides an opportunity for primary prevention through prophylactic vaccination.

• Two highly effective and safe HPV vaccines are currently available; a bivalent vaccine targeting HPV 16 & 18 and a quadrivalent vaccine additionally targeting HPV 6 and 11.

• Cytological screening based on Pap smear plays a major role in reducing both incidence and mortality of invasive cervical cancer; but lack of awareness and access to the test leads to increased incidence in developing countries

Rationale

• Appropriate level of knowledge, attitude and beliefs are key elements for adopting healthy life style, influencing human behaviors and accepting newly-introduced preventive measures.

• The gap of knowledge about clinical presentation, risk factors, primary and secondary prevention of Ca Cx. has been documented in several studies both in developed and developing countries.

• However, fewer studies have been reported from Saudi Arabia.

Objectives of the Study

1. To assess the level of knowledge of healthcare students about Clinical Presentation & Primary and Secondary Prevention of Cervical Cancer

2. To determine the extent of Acceptance of HPV vaccine

Subjects and Methods

Study design Cross-sectional with convenient sampling

Sample size 1258 students

Study setting Health Colleges at Princess Nourah bintAbdulrahman University, Riyadh, KSA

Duration December 2013 to February 2014

Study tool Self-administrated questionnaires consisting of 48 questions in 4 sections

Reliability of Questionnaire as tested by Cronbach’s alpha was 0.82.

Data Collection

Included

1. Socio-demographic data 2. Knowledge about cervical cancer risk factors3. Clinical presentation 4. Pap smear and 5. HPV vaccine acceptance

Response rate was 89.9%

Statistical Analysis

• Data was analyzed using SPSS version 20. • The knowledge score represents the sum of the correct

answers of the 27 questions. The value ‘1’ was given for the correct & ‘0’ for wrong answers & “don’t know” responses.

• The cutoff for a poor knowledge score was set at values below 60% of the total score.

• Mann-Whitney and Kruskal-Wallis tests were used to compare knowledge scores among different subgroups.

• P-value of less than 0.05 was considered as statistically significant.

• Multivariate linear regression analysis was adopted to adjust the effect of independent variables on the knowledge score.

TABLE.1: DISTRIBUTION OF STUDENTS ACCORDING TO SOCIO-DEMOGRAPHIC CHARACTERISTICS

College N (%)

Medicine 122 (9.7)

Dental 67 (5.3) lowest

Pharmacy 416 (33.1)

Nursing 215 (17.1)

Health and rehabilitation 438 (34.8) highest

Father’s occupation

Health Professional 89 (7.1)

Mother’s occupation

Health Professional 37 (2.9)

Monthly Income

More than 15,000 SR/month 612 (48.6)

24.1

34.6

48.9

33.7

22.626.5

59.6

48.8

25.9

0

10

20

30

40

50

60

70

80

90

100

% o

f co

rrec

t an

swer

s

FIG.1: KNOWLEDGE ABOUT RISK FACTORS

Fig.2:KNOWLEDGE ABOUT THE CLINICAL PRESENTATION OF Ca Cx

79.5

51.154.8

31.9

21.8

39.3

22.3

6.3

Breast canceris the mostcommon

female cancer

Cervical canceris preventable

Irregularvaginal

bleeding

Vaginaldischarges

Post coitalbleeding

Pelvic pains Weight loss Asymptomatic

% o

f cor

rect

an

swer

s

46.7

30.8

15.7

38

28.7

17.8 18

0

10

20

30

40

50

60

70

80

90

100

Heared aboutPap smear

Pap smear asensitive way

to earlydiagnose

cancercervix?

Pap smearpainful

One papsmear

enough

Pap smearhave serious

complications

Appropriatetime to havepap smear

Frequency ofpap smear

% O

f co

rrec

t an

swer

s

FIG.3: KNOWLEDGE ABOUT PAP SMEAR

10.9

6.1

8.1

0

5

10

15

20

25

30

Vaccine against cervicalcancer contains Human

Papilloma Virus

The vaccine is protectiveagainst genital warts

Appropriate age to get thevaccine is 12-25 years

% o

f cor

rect

an

swer

s

FIG.4: KNOWLEDGE ABOUT HPV VACCINE

TABLE.2: ACCEPTANCE AND BARRIERS FOR HPV VACCINE

Questions N (%)

Acceptable vaccine cost*

Less than 100 SR 481 (38.2)

100-300 SR 511 (40.6)

Up to 500 SR 114 (11. 4%)

More than 500 SR 57 (4.5)

Reasons for refusal to be vaccinated

Being afraid of the vaccine injection 333 (26.5)

Being worried about side effects 652 (51.9)

The cervical cancer is rare, is not worth vaccination

116 (9.2)

The vaccine might be unaffordable 168 (13.3)

She might have no time 257 (20.4)

Family refusal 106 (8.4)

She does not believe in the effect of vaccination 82 (6.5)

Good4%

Poor96%

FIG.5: DISTRIBUTION OF STUDENTS ACCORDING TO THE LEVEL OF TOTAL SCORE

OF KNOWLEDGE

However senior and Medical students had a significantly higher knowledge score

Limitations of the Study

• The dissimilar proportions of the numbers of respondents in different colleges

• Males and students from non-health colleges are not represented.

Conclusion

This study indicates:

1. Poor level of knowledge about cervical cancer and 2. Misinformation about primary and secondary preventive measures.

▫ The data provides a benchmark about the level of knowledge which can be used to formulate effective awareness program in future.

References • GLOBOCAN, 2013. cervical cancer incidence, mortality & prevalence

world wide in 2011. International agency or research on cancer. WHO. • Saudi Cancer Registry. Cancer Incidence and Survival Report: Saudi

Arabia 2007. In Special Edition. Riyadh (KSA): Ministry of Health: 2011• World Health Organization. Cervical cancer, human papillomavirus (HPV)

and HPV vaccines. Geneva:WHO:2008• Navarro-Illana P, etal 2014. Ethical considerations of universal

vaccination against human papilloma virus. BMC Med Ethics;15: 29• Zaridah S, 2014. A Review of cervical Cancer Research in Malaysia. Med J

Malaysia; 69(sup A): 33-41• Pelucchi C, etal, 2010. Knowledge of human papillomavirus infection and

its prevention among adolescents and parents in the greater Milan area, Northern Italy. BMC Public health; 10:378

• Carozzi etal, 2014. Age and geographic variability of HPV high-risk genotype distribution in a large unvaccinated population and of vaccination impact on HPV prevalence. J. of Clinical virology;60: 257-63