Awareness of cancer cervix and its prevention among students in Melaka, Malaysia
Somsubhra De1, Vigneshwari T Selvan2, James Tan2, Htoo Htoo Kyaw Soe3, Soumendra Sahoo4, Rashmirekha Sahoo5
1 Department of Obstetrics and Gynecology and MAHE-FIILIPE Fellow, Melaka Manipal Medical College (MAHE), Melaka, Malaysia
2 Department of Obstetrics and Gynecology, Melaka Manipal Medical College (MAHE), Melaka, Malaysia
3 Department of Community Medicine, Melaka Manipal Medical College (MAHE), Melaka, Malaysia
4 Department of Ophthalmology, Melaka Manipal Medical College (MAHE), Melaka, Malaysia
5 Foundation in Science, Melaka Manipal Medical College (MAHE), Melaka, Malaysia
|Date of Submission||01-Jul-2019|
|Date of Acceptance||27-Jul-2019|
|Date of Web Publication||29-Nov-2019|
Prof. Somsubhra De
Department of Obstetrics and Gynecology, Melaka Manipal Medical College (MAHE), Melaka
Source of Support: None, Conflict of Interest: None
BACKGROUND: Cancer cervix is caused by human papillomavirus (HPV), oncogenic virus and has vaccines and screening as its preventive measures. This study analyzes the change in awareness and attitudes of nonmedical students toward the condition following the use of an educational module.
METHODOLOGY: The study design was quasi-experimental. The interprofessional (IP) team implemented an educational module and analyzed the difference in awareness of young individuals toward the cancer cervix. A pretest and posttest written questionnaire, customized for both genders, was administered with the intervention of the educational module in between. The module consisted of a short educational presentation along with a group activity. A follow-up survey was also done after 2 months to check the attrition of awareness. The statistical analysis was done using MacNemar test using SPSS 12 IBM software and significance of differences were determined.
RESULTS: There was a significant improvement of knowledge and awareness on linkage between HPV and cervical cancer (P < 0.001). There was also significant change with regard to attitudes toward cervical cancer vaccination (P = 0.004). The knowledge of HPV linkage to the malignancy was maintained after 2 months of gap. The subjects also wished for more future awareness program.
CONCLUSIONS: There is improved awareness in the dental and foundation in science students, and this improved awareness will ensure favorable attitudes toward cervical cancer vaccines or will attend regular screening programs. Awareness program must be held at regular intervals at different locations to enhance the knowledge dissemination of this common yet preventable genital malignancy of females. The IP collaboration and practices will help in reducing the disease burden of the society in future.
Keywords: Awareness, cancer cervix, education, screening
|How to cite this article:|
De S, Selvan VT, Tan J, Soe HH, Sahoo S, Sahoo R. Awareness of cancer cervix and its prevention among students in Melaka, Malaysia. J Edu Health Promot 2019;8:231
|How to cite this URL:|
De S, Selvan VT, Tan J, Soe HH, Sahoo S, Sahoo R. Awareness of cancer cervix and its prevention among students in Melaka, Malaysia. J Edu Health Promot [serial online] 2019 [cited 2019 Dec 6];8:231. Available from: http://www.jehp.net/text.asp?2019/8/1/231/271926
| Introduction|| |
Cancer of cervix is the most common genital malignancy of the female population. Cancer cervix is caused by human papillomavirus (HPV), and there are vaccines against this oncogenic virus. Studies reveals that the community in general has a lack of awareness of the causative agent and preventive methods of this cancer which are HPV and vaccines or screening respectively. These vaccines can cover 70%–80% of all the HPV responsible for this malignancy. With vaccination and regular screening this malignancy can be controlled to a great extent. There are no credible side effects reported for these vaccines in the postmarket surveillance making it a relatively safe vaccine.,
Cancer cervix awareness is of prime importance among the general population. Studies conducted in Malaysian women suggest that there is partial awareness of cancer cervix. They are aware of its causative factor as multiple sexual partners and sexually transmitted disease and screening method like Pap smear More Details., The awareness amongst nursing students in Sudan appeared to be very poor with regards to cancer prevention., Dental students revealed poor knowledge with regard to causative factor and screening methodology. Sometimes, awareness about the disease process might be adequate, but poor practice in prevention methods  neutralizes the knowledge learned by the health workers. There is an awareness gap about other causative agents and also preventive methods for cancer cervix vaccines. This lacuna in awareness is addressed in the educational module to improve the wholesome awareness of cancer cervix. An effective educational module is a necessity for the various group of professionals who might come across women at high risk. The educational module will make them aware of the disease process and basic causative predisposition. They will also bring in an attitudinal change in the society by changing the practice whereby women will be aware of the preventive measures for cancer cervix and possibly incorporate them in their lifestyle. We believe with the help of interprofessional (IP) team, the practice of vaccinating and early detection of premalignant condition will be enhanced thereby improving the health of the society.
| Methodology|| |
The study design was quasi-experimental. The objectives of the study was to assess the baseline awareness of etiology of cancer cervix and knowledge of its vaccination and to evaluate the improvement in the awareness of etiology of cancer cervix and knowledge of its vaccination with the intervention of educational module conducted by IP collaboration. This was done in reputed private college from October 2017 to January 2018. This project was focused on students who were not taught about cancer of cervix as part of their curriculum. Therefore the students were chosen from the Foundation in Science (FiS) and dentistry students. These students were invited for a half day workshop. The students were between 18 and 23 years old. At the onset, they were given a pretest questionnaire. This questionnaire was validated by the IP team, which included the subject expert. It had 19 questions for girls with answers in either multiple options or Likert rating. For boys the number of questions were 14 in number. The questionnaire was given to the cohort of participants in the group who attended the educational module. Consent was taken by a signature in the questionnaire. After pretest, the participants were subjected to a short educational presentation followed by group activity. The educational presentation along with the group activity constituted the aforementioned educational module. At the end of the entire session, a posttest was administered. Two months later, the same cohort was administered the questionnaire which was given during pretest and posttest. The knowledge and attitude were assessed and compared between the pretest versus posttest, pretest versus follow-up (F/up), and posttest versus F/up. F/up group consists of participants who attended the educational module and also answered the questionnaire after 2 months following the intervention of educational module. The analysis of the students who attended pretest, posttest and F/up were done. The attrited students from F/up were excluded from the final analysis. The statistical analysis was done using MacNemar test using SPSS 12 IBM software (SPSS Inc, Chicago, IL, USA) and significance of differences were determined.
The IP team was formed in the initial phase which included medical personnel and faculty members, FiS and dental faculty members, dental clerk, FiS clerk, MBBS graduates, statistician, and faculty from community medicine department. The Institutional Ethical Committee (IEC) clearance was obtained before conducting this study. The IEC ethical approval number is MMMC/FOM/Research Ethics Committee - 1/2017.
| Results|| |
[Table 1] shows the demographic characteristics of the participants. The mean age of the participants was 20.8 years (standard deviation 1.4 years). Most of the participants were female (77.6%). 58.2% of the participants were Chinese, 28.4% were Indian, 9% were Malay, while 4.5% were other ethnicity [Table 1].
[Table 2] shows the knowledge toward cervical cancer, HPV vaccination, and opinion about awareness program between pre- and post-intervention. There were significant differences about knowledge on link between HPV and cervical cancer, heard of cervical cancer screening, heard of vaccination and opinion on its effectiveness, and attitudes toward cervical cancer vaccination between preintervention and postintervention. At preintervention, 97.0% of the students had heard of cervical cancer, 72.3% of them had knowledge on link between HPV and cervical cancer, 68.7% had heard of cervical cancer screening, and 75.8% had heard of cervical cancer vaccination. At postintervention, all students (100%) had heard of cervical cancer, had knowledge on link between HPV and cervical cancer, and had heard of cervical cancer vaccination. With regard to the opinion toward awareness program, there was no significant difference between preintervention and postintervention (P = 0.082); however, 89.2% of the students mentioned that it is needed at preintervention, but it was increased to 96.9% [Table 2].
|Table 2: Comparison of knowledge towards cervical cancer, HPV vaccination and opinion about awareness program between pre and post intervention|
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[Table 3] shows attitudes toward HPV vaccination between pre- and post-intervention. At preintervention, 53.8% mentioned that the cervical cancer vaccines were effective while 40% were not sure about it. There was also significant difference in regard to attitudes toward effectiveness of cervical cancer vaccination between pre- and post-intervention (P = 0.004). At preintervention, 59.7% of the students agreed, 4.5% disagreed, and 10.4% were not sure that if a woman is vaccinated with cervical cancer vaccine, then she does not need any further screening test; however, it was increased to 74.6% of at postintervention [Table 3].
|Table 3: Comparison of attitudes towards HPV vaccination between pre and post intervention|
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[Table 4] shows that there was significant difference about knowledge on link between HPV and cervical cancer, heard of cervical cancer screening, and heard of vaccination between preintervention and F/up. However, there was no significant difference about heard of cervical cancer between preintervention and F/up (P = 0.500). With regard to the opinion toward awareness program, there was significant difference (P = 0.030) as 89.6% of the students mentioned that it is needed at preintervention, but it was increased to 100% during F/up [Table 4].
|Table 4: Comparison of knowledge towards cervical cancer, HPV vaccination and opinion about awareness program between pre and follow-up intervention|
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[Table 5] shows that there was significant difference about opinion on its effectiveness between preintervention and F/up. At preintervention, only 49.2% of the students agreed that HPV vaccines are effective, but 92.3% of them stated that HPV vaccines are effective at F/up intervention. However, there was no significant difference about attitudes toward cervical cancer vaccination between preintervention and F/up [Table 5].
|Table 5: Comparison of attitudes towards HPV vaccination between pre and follow-up intervention|
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[Table 6] and [Table 7] show the knowledge toward cervical cancer and attitudes toward HPV vaccination between postintervention and F/up. There was no significant difference about heard of cancer cervix, knowledge on link between HPV and cervical cancer, heard of cervical cancer screening, heard of vaccination and opinion on its effectiveness, attitudes toward cervical cancer vaccination, and opinion toward awareness program between postintervention and F/up [Table 6] and [Table 7].
|Table 6: Comparison of knowledge towards cervical cancer, HPV vaccination and opinion about awareness program between post and follow-up intervention|
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|Table 7: Comparison of attitudes towards HPV vaccination between post and follow-up intervention|
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| Discussion|| |
The incidence of cancer cervix in Malaysia is 7.7 out of 100,000. This makes this cancer one of the common genital cancers affecting the women population and warrants measures to curb it or prevent it. The government administers free vaccination for girls for only 13 years of age; however, there is a considerable lack of awareness of these vaccines and there is significant ethnic variations noted when it comes to acceptability. The project was conducted among subjects who are of an impressionable age and with the right training and knowledge can be molded for better outcomes. Among them, majority were females which is even better as this malignancy happens in the female population. Social media played an important role in the source of knowledge for screening test and vaccines for this malignancy. HPV is proven to be a causative organism for cancer cervix in 70% of cases. HPV vaccines are relatively a newer concept for most young girls. HPV vaccines are effective and they do not cause any major side effects. They are immunogenic and have a very good seroconversion, and hence, it can play an important role in primary prevention of cancer cervix.,, Awareness in certain communities might be low; however, once the awareness is increased, the willingness to use screening method and vaccination is very high. There are many educational modules on cancer cervix prevention for health personnel such as general practitioners, nurses, gynecologists, and sexual health physicians; however, there are no uniform structured educational modules for the community. Most of the educational sessions are limited to an educational presentation on the disease and its prevention method. An educational presentation has also shown to have profound benefit on the awareness of people and their outlook on screening for cancer cervix. A similar study done in Haiti consolidates that if proper awareness is given to women about HPV and screening, there is improvement of willingness to practice the screening methods. Study in Korea found that mother played an important role in educating their daughters and to enforce education mother and daughters would definitely go a long way toward cancer cervix prevention. Choosing the target population to spread the awareness is of paramount importance, as that will determine the sustainability of the awareness. Usually, since this a malignancy of women, most often women population will be chosen. The women should be educated about the mortality and morbidity of the disease and more importantly the modes of prevention, namely primary prevention by usage of vaccines and secondary prevention by screening of the premalignant conditions for cancer of cervix. The secondary schools should come under the awareness program, as vaccination is most applicable at that age before exposure to sexual intercourse. Furthermore, formation of an effective team, which is the foundation stone for an IP project, will go a long way in disseminating the knowledge and awareness of cancer cervix and its prevention. This study showed us that with proper educational module, the awareness of the disease process got enhanced even among students of science-related subjects.
| Conclusions|| |
The educational module used in the study significantly improved the awareness of the malignancy per se and knowledge of availability of its prevention such as screening methods and vaccines among the students of dentistry and FiS. The module also led to a change of attitude toward an increase need for awareness program and modules in future. The findings revealed that the knowledge of linkage of HPV and cancer cervix improved significantly after the execution of the module and it was maintained even during F/up. With an IP team approach, it is possible to improve the awareness and acceptability about the vaccines and screening in the general population. The improved awareness of the disease process, screening techniques, and acceptability of the vaccines will definitely impact on the lifestyle of the female population and in turn reduce the cancer load in the society and improve the community health status.
We would like to acknowledge Prof. Jaspal Singh, Chief Executive of MMMC, for his immense support; Department of FiS and Dentistry for arranging and scheduling their sessions to facilitate the educational module; Prof. Ciraj AM, Course Director, M-FIILIPE, and all the faculty members of M-FIILIPE, MAHE, Manipal, India, for providing guidance to enable the completion of the project. This study was done as a project work toward the Fellowship Program held in Manipal, India.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
De S, Kanagasabai S. Review article human papilloma virus vaccine – An update. Eur J Sci Res 2010;43:256 -264
De S, Kanagasabai S, Barua A. Awareness of human papilloma virus and acceptability of its vaccination amongst female medical students. Int J Health Sci Res 2014;4:82-90.
De Carvalho N, Teixeira J, Roteli-Martins CM, Naud P, De Borba P, Zahaf T, et al.
Sustained efficacy and immunogenicity of the HPV-16/18 AS04-adjuvanted vaccine up to 7.3 years in young adult women. Vaccine 2010;28:6247-55.
Sam IC, Wong LP, Rampal S, Leong YH, Pang CF, Tai YT, et al.
Maternal acceptance of human papillomavirus vaccine in Malaysia. J Adolesc Health 2009;44:610-2.
Seng LM, Rosman AN, Khan A, Haris NM, Mustapha NA, Husaini NS, et al.
Awareness of cervical cancer among women in Malaysia. Int J Health Sci (Qassim) 2018;12:42-8.
Abd Allah AA, Hummeida ME, Elmula IM. Awareness and attitudes of nursing students towards prevention of cervical cancer. Cervical Cancer 2016;1:1.
Rashwan HH, Saat NZ, Abd Manan DN. Knowledge, attitude and practice of Malaysian medical and pharmacy students towards human papillomavirus vaccination. Asian Pac J Cancer Prev 2012;13:2279-83.
Doshi D, Reddy BS, Karunakar P, Deshpande K. HPV, cervical cancer and Pap test related knowledge among a sample of female dental students in India. Asian Pac J Cancer Prev 2015;16:5415-20.
Dulla D, Daka D, Wakgari N. Knowledge about cervical cancer screening and its practice among female health care workers in Southern Ethiopia: A cross-sectional study. Int J Womens Health 2017;9:365-72.
Azizah Ab M, Nor Saleha I.T, Noor Hashimah A, Asmah Z.A, Mastulu W. Malaysian National Cancer Registry Report 2007-2011: National Cancer Registry, June 2015; 13-14
De Vuyst H, Clifford GM, Nascimento MC, Madeleine MM, Franceschi S. Prevalence and type distribution of human papillomavirus in carcinoma and intraepithelial neoplasia of the vulva, vagina and anus: A meta-analysis. Int J Cancer 2009;124:1626-36.
Reisinger KS, Block SL, Lazcano-Ponce E, Samakoses R, Esser MT, Erick J, et al.
Safety and persistent immunogenicity of a quadrivalent human papillomavirus types 6, 11, 16, 18 L1 virus-like particle vaccine in preadolescents and adolescents: A randomized controlled trial. Pediatr Infect Dis J 2007;26:201-9.
Kang S, Kim KH, Kim YT, Kim YT, Kim JH, Song YS, et al.
Safety and immunogenicity of a vaccine targeting human papillomavirus types 6, 11, 16 and 18: A randomized, placebo-controlled trial in 176 Korean subjects. Int J Gynecol Cancer 2008;18:1013-9.
Olubodun T, Odukoya OO, Balogun MR. Knowledge, attitude and practice of cervical cancer prevention, among women residing in an urban slum in Lagos, South West, Nigeria. Pan Afr Med J 2019;32:130.
Coronado Interis E, Anakwenze CP, Aung M, Jolly PE. Increasing cervical cancer awareness and screening in Jamaica: Effectiveness of a theory-based educational intervention. Int J Environ Res Public Health 2015 Dec 22; 13 (1):ijerph 13010053. doi: 10.3390/ijerph 13010053. [Journal name is International Journal of Environmental Research and Public Health]
McCarthy SH, Walmer KA, Boggan JC, Gichane MW, Calo WA, Beauvais HA, et al.
Awareness of cervical cancer causes and predeterminants of likelihood to screen among women in Haiti. J Low Genit Tract Dis 2017;21:37-41.
Kim HW, Kim DH. Awareness of cervical cancer prevention among mothers of adolescent daughters in Korea: Qualitative research. BMJ Open 2015;5:e006915.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]