p
ISSN 2723-6927-e ISSN 2723-4339
Knowledge, Attitude, And Practice On
Cervical Cancer And HPV Vaccination Among Active Female Clinical Students In Faculty
Of Medicine And In Correlation With Obstetric And Gynecology Rotation
Julita D.L. Nainggolan1, Celine Chrystelle2,
Theodora Christine2, Chintya Marcellin2, Ongky Satria2
1Department of Obstetrics and Gynaecology, Faculty of Medicine,
Pelita Harapan University, Tangerang, Indonesia
2Faculty of Medicine, Pelita Harapan University, Tangerang, Indonesia
Email: dlaurentina@yahoo.com
ABSTRACT
In 2018, the
global prevalence of Human Papillomavirus (HPV) infections reached
approximately 43 million cases, with cervical cancer attributed to 75% of cases
in women. The HPV vaccine has shown efficacy in preventing up to 88% of
cervical cancer cases. To address the lack of awareness surrounding HPV and
cervical cancer prevention, this study aimed to assess the knowledge, attitude,
and practice among active female medical students at the Faculty of Medicine,
Universitas Pelita Harapan. In March 2023, this cross-sectional study utilized
a questionnaire developed and validated by Winarto et al., covering socio-demographic
information and questions related to cervical cancer. Out of 168 participants,
75.6% demonstrated good knowledge about cervical cancer, yet the practice of
raising awareness and HPV vaccination was notably low. Interestingly, students
who underwent obstetric and gynaecology rotations exhibited similar low
practice scores (87.5%) compared to those who had not. Furthermore, only 40% of
students had completed their HPV vaccination. The study suggests a disconnect
between knowledge, attitude, and practice among students, with no significant
influence observed from obstetric and gynaecology rotations.
Keywords: Cervical Cancer, HPV, Knowledge, Attitude,
Practice, Clinical Students.
INTRODUCTION
Cervical cancer is a preventable disease, and
the clinical and economic burdens of cervical cancer are still substantial
issues in Indonesia (Setiawan et
al., 2016). Cervical cancer ranks as the eighth
most common cancer affecting women across the country, with an annual incidence
of 358 new cases. One preventive measure against this disease involves
receiving vaccination against the human papillomavirus (HPV), which is
recognized as the primary culprit behind cervical cancer (Alherz et al.,
2024). Cervical cancer was the second most
common cancer in Indonesia and fourth worldwide among women by 2019, with the
number of cases continuing to increase up to 134.400 cases by 2020 and 834.000
deaths were reported worldwide (WHO INFODATIN) (Bookshelf,
2023).
Cervical cancer is one of the cancers that can
be prevented by vaccination. The Human papillomavirus (HPV) was found to cause
cervical cancer in 75% of women, and the administration of the HPV vaccine can
prevent the incidence of cervical cancer in up to 88% of women. Among
Indonesian women who have received HPV vaccination, it is not a given that 1 in
10 have received a full dose of vaccination (Lei et al.,
2020).
The World Health Organization (WHO)
Director-General announced a global cervical cancer elimination program and
launched a global strategy to accelerate elimination in 2020 (Jibat et al.,
2024). WHO estimates that if prevention and
control measures are not carried out properly, by 2030, at least 800,000 new
cases of cervical cancer will be diagnosed every year. The primary cause of
pre-cancerous and cancerous cervical lesions is infection with high-risk or
oncogenic HPV types. Most cases of cervical cancer occur as a result of infection
with HPV16 and 18. High-risk types, especially HPV16, are found to be highly
prevalent in human populations (Zhang, Xu, Zhang, & Qiao, 2020).
HPV
vaccination was introduced as one of the national immunization programs by WHO
in 2009 in terms of cervical cancer prevention measures. WHO's primary
prevention measure aims for girls aged 9-14 years to get the HPV vaccination.
Secondary prevention aims for adult women to screen and treat precancerous
lesions (Organization,
2016).
Persistent Human Papillomavirus (HPV) infection
poses a significant risk for the development and progression of cervical cancer
and its precancerous conditions (Qiu et al.,
2023). In 2018, about 43 million HPV
infections were reported around the world. One of the reasons for this high
prevalence is due to a lack of knowledge regarding HPV and its potential to
cause cervical cancer, and even more, how the HPV vaccine can prevent cervical
cancer (Leclair &
Stenson, 2022).
Previous studies have shown a low level of
knowledge of HPV in some developing countries, including Indonesia, Vietnam,
and Turkey (Ver et al.,
2021). Indonesia has a program for early
detection of cervical cancer to be implemented in primary public health care
facilities, in which screening is done through visual inspection with acetic
acid (VIA) with easily accessible and affordable tools and materials (Winarto et
al., 2022). However, as stated in the Republic
of Indonesia Constitutional Law Number 36, 2009, healthcare facilities should
perform promotion, prevention, curative, and rehabilitative efforts therefore
for that matter HPV vaccination should be carried out nationwide and be easily
accessed by various members of the economic level to prevent and suppress the
prevalence of cervical cancer (Gizi, 2019).
Medical students were given knowledge and
exposure during their pre-clinical and clinical years to various cases seen in
daily clinical practices. Medical students were expected to have a better
understanding of this matter due to their direct exposure to patients (AkbariRad et
al., 2023). Clinical students/co-assistants were
also expected to carry out the task of promotion and prevention, to themselves
and the community, as they were considered to have higher concerns for health (Ayu &
Ramadhani, 2022). This study aims to have a better
understanding and assess the knowledge, attitude, and practice of active female
clinical students of the Faculty of Medicine Universitas Pelita Harapan towards
cervical cancer and HPV vaccination while also assessing their competence and
participation in cervical cancer prevention.
In the previous study, it was concluded that
cervical cancer and HPV vaccination were not included enough as important
topics in clinical year material, which caused poor awareness among students in
the clinical year (Wen et al.,
2014). Thus, this study also raises a topic
about the correlation between clinical year students who have or have not been
through obstetric and gynaecology rotation with their knowledge, attitude, and
practice towards cervical cancer and HPV vaccination (Winarto et
al., 2022).
RESEARCHED
METHODS
This study utilized an unpaired categorical
analysis method within a cross-sectional study design to investigate the knowledge,
attitudes, and behaviours related to cervical cancer among active female
clinical medical students at the Faculty of Medicine, Universitas Pelita
Harapan. Data collection was conducted through the administration of a
questionnaire distributed via Google Forms, following a comprehensive
explanation of the study's objectives and obtaining informed consent from the
respondents. The study population consisted of active female clinical medical
students enrolled at the Faculty of Medicine, Universitas Pelita Harapan. The
minimum required sample size was determined to be 157 participants. The
questionnaire utilized in this study was previously developed and validated by (Winarto et
al., 2022), covering socio-demographic
information along with inquiries of knowledge, attitudes, and behaviours
regarding cervical cancer.
Data collection took place throughout March
2023. Statistical analysis of the collected data was carried out utilizing
Pearson’s analysis and the Chi-square test facilitated by SPSS 25.0 software.
Through this methodological approach, the study aimed to provide insights into
the understanding, attitudes, and practices regarding cervical cancer among the
targeted population of female medical students, contributing to the body of
knowledge in this field.8
RESULTS AND DISCUSSION
Table 1. Demographic Profile of
Participants (N: 168)
|
|
N |
Percentage (%) |
|
Study Year |
|
|
|
First Second Third Fourth Other |
77 73 15 2 1 |
45,8 43,5 8,9 1,2 0,6 |
|
Students Who Have Gone Through Obstetric and
Gynecology Rotation |
||
|
Yes No |
51 117 |
30,4 69,6 |
|
Knowledge Score |
|
|
|
Good Poor |
127 41 |
75,6 24,4 |
|
Attitude Score |
|
|
|
Good Poor |
119 49 |
70,8 29,2 |
|
Practice Score |
|
|
|
Good Poor |
21 147 |
12,5 87,5 |
Students who have gone through the rotation
were thought to have better knowledge in this regard. However, the number of
students who have passed the rotation was not selected purposefully; thus,
there were only 51 (30,4%) students in this category. Most of the respondents were first and
second-year students. In an overall scoring, more than 70% of clinical year
students' knowledge and attitude scores were good (>60%). However, only
12,5% of students gained a good score in practice. It shows that even though
only 30.4% of students have been through obstetric and gynaecology rotations,
more than a third quarter of the respondents still manage to get a good score
in knowledge regarding these topics. We assume that all active clinical year
students are well taught regarding cervical cancer and HPV vaccinations during
their pre-clinical year. Nevertheless, from this result, there are some
concerns that even though most of them have a good knowledge regarding cervical
cancer and HPV vaccination, their practice towards HPV vaccination and raising
cervical awareness was poor.
Table 2. Demographic Characteristics
and Knowledge, Attitude, and Practice Score
|
|
Knowledge Score |
P-value Knowledge |
Attitude Score |
P-value Attitude |
Practice Score |
P-value Prac -tice |
|||
|
|
Good(%) |
Poor(%) |
Good(%) |
Poor(%) |
Good(%) |
Poor(%) |
|||
|
First Year Second Year Third Year Fourth Year Other |
66 (85,7) 67 (91,8) 14 (93,3) 2 (100) 1 (100) |
11 (14,3) 6 (8,2) 1 (6,7) 0 (0) 0 (0) |
0.714 |
49 (63,6) 54 (74,0) 14 (93,3) 1 (50) 1 (100) |
28 (36,7) 19 (26,0) 1 (6,7) 1 (50) 0 (0) |
0.148 |
5 (6,5) 9 (12,3) 5 (33,3) 1 (50) 0 (0) |
72 (93,5) 64 (87,7) 10 (66,7) 1 (50) 1 (100) |
0.020 |
In Table 2, the percentage of overall good
knowledge, attitude, and practice scores was lower in first-year students and
increased year by year.
Table 3. Responses to The Knowledge Related to
Cervical Cancer and Human Papillomavirus Vaccination
|
Knowledge
Score |
||
|
Questions |
Correct Answer, n (%) |
Wrong Answer, n (%) |
|
Have you heard about HPV
vaccination? Is the HPV vaccine intended for
cervical cancer prevention? Cervical cancer is at the ... place
on the most common cancer diagnosed in women What is the most common mode of
transmission? How does the infection of HPV-16 and
HPV-18 cause cervical cancer? What are the brand names of HPV
vaccines in Indonesia? How many HPV vaccine doses are needed
to be fully vaccinated? At what range of age does the HPV
vaccine if given work optimally? How many doses of HPV vaccine are
recommended for a person younger than 15 years old? How many doses of HPV vaccine are
recommended for an adult? |
166 (98,8) 165 (98,2)
35 (20,8) 148 (88,1) 131 (78,0) 95 (56,5) 72 (42,9) 117 (69,6) 123 (73,2) 88 (52.4) |
2 (1,2) 3 (1,8) 133 (79,2) 20 (11,9) 37 (22,0) 73 (43,5) 96 (57,1) 51 (30,4) 45 (26,8) 80 (47.6) |
In Table 3, more clinical year students answered
correctly in 8 out of 10 questions, and more clinical students answered
incorrectly in 2 out of 10 questions. Overall, respondents excelled in
knowledge questions.
Table 4. Responses to Attitudinal Statements Related
to Cervical Cancer and Human Papillomavirus Vaccination
|
Attitude |
|||
|
Questions |
Disagree, n (%) |
Don’t know, n (%) |
Agree, n (%) |
|
I agree to get the HPV vaccination. |
- |
1 (0,6) |
167 (99,4) |
|
I’d rather get an HPV vaccination
rather than a new gadget |
30 (17,8) |
30 (17,8) |
108 (64,2) |
|
I agree with HPV vaccination in men |
9 (5,4) |
37 (22,0) |
122 (72,6) |
|
I am planning to take a cervical
cancer early-detection test |
10 (6,0) |
50 (29,8) |
108 (64,2) |
In Table 4, about 99,4% of respondents agree
with getting an HPV vaccination. About 64,2% of respondents would rather get an
HPV vaccination rather than a new gadget. About 72,6% of respondents agree on
HPV vaccination in men. A total of 64,2% of respondents planned to take a
cervical cancer early detection test.
Table 5. Responses to Practice Related to Cervical
Cancer and Human Papillomavirus Vaccination
|
Practice |
|||
|
Questions |
No, n (%) |
Maybe, n (%) |
Yes, n (%) |
|
I have educated
others about the need for cervical cancer screening |
22 (13,1) |
34 (20,2) |
112 (66,7) |
|
I have advised
the people closest to me to carry out early detection of cervical cancer on a
regular basis |
33 (19,6) |
22 (13,1) |
113 (67,3) |
|
I have watched
cervical cancer screening or detection |
53 (31,54) |
26 (15,47) |
89 (52,9) |
|
I have
participated in a cervical cancer screening program |
113 (67,3) |
12 (7,1) |
43 (25,6) |
|
I have
completed the HPV vaccination |
100 (59,5) |
- |
68 (40,5) |
In Table 5, about 66,7% of respondents have
educated others about the need for cervical cancer screening, and about 67,3%
of respondents have advised people close to them to carry out early detection
of cervical cancer on a regular basis. About 52,9% of respondents have watched
cervical cancer screening or detection, and about 25,59% of respondents have
participated in a cervical cancer screening program. Only 40.5% of respondents
have completed HPV vaccination.
Table 6. Correlation Between Obstetric
and Gynecology Rotation and Knowledge Score
|
|
Knowledge Score |
|
|
|
|
|
|
|
Good |
Poor |
Total |
P-Value |
Odd Ratio |
CI (95%) |
|
Have been through |
49 |
2 |
51 |
0.108 |
0.258 |
0.057-1.165 |
|
Have not been through Total |
101 150 |
16 18 |
117 168 |
|||
Table 6-8
shows the number of students who have gone through the Obstetric and Gynecology
rotation and its correlation to their knowledge, attitude, and practice on HPV
vaccination. A total of 101 students who have not been through the rotation
were shown to have good knowledge of HPV vaccination. Meanwhile, 16 students
had poor knowledge. 49 of 51 students who
went through the rotation were shown to have a good knowledge of HPV
vaccination and cervical cancer. Table 6 shows a p-value of 0,108 (OR 0,258,
CI: 0,057-1,165), indicating that there was no significant correlation between
students who have passed the rotation with their knowledge. However, it must
also be kept in mind that the sample selection was not purposefully done to
have equal numbers of students in the two categories, which might have caused
the insignificant result in this study.
Table 7. Correlation Between Obstetric
and Gynecology Rotation and Attitude Score
|
|
Attitude Score |
|
|
|
|
|
|
|
Good |
Poor |
Total |
P-Value |
Odd Ratio |
CI (95%) |
|
Have been through |
41 |
10 |
51 |
0.106 |
0.488 |
0.221-1.076 |
|
Have not been through Total |
78 119 |
39 49 |
117 168 |
|||
A total of 41 Students who have been through
the rotation were shown to have a good attitude towards HPV vaccination, while
the other 10 students were shown to have a poor attitude. There were 78 and 39
students who had not been through the rotation who were showing good and poor
attitude, respectively. A p-value of 0.106 was obtained with OR 0.488 and
CI of 0.221-1.076. These results implied that there was no significant
relationship between having been through the rotation with students' positive
attitudes towards HPV vaccination.
Table 8. Correlation Between Obstetric
and Gynecology Rotation and Practice Score
|
|
Practice Score |
|
|
|
|
|
|
|
Good |
Poor |
Total |
P-Value |
Odd Ratio |
CI (95%) |
|
Have been through |
10 |
41 |
51 |
0.076 |
0.383 |
0.149-0.988 |
|
Have not been through Total |
10 20 |
107 148 |
117 168 |
|||
Analysis
of Table 8 showed a significant correlation between having been through the
rotation and students practising HPV vaccination. There were fewer students with
good practice in both categories, showing that even if the students have passed
the rotation, it does not simply increase students' participation and practice
towards HPV vaccination. The p-value was 0,076, which was above 0,05, which
shows the correlation between the two topics is not significant.
Poor practice scores might result from a lack
of health promotion events. Therefore, students don't have a lot of
opportunities to be involved in educating and screening others about cervical
cancer. The opportunities that each student gets are also not the same; this
could also be due to some students undergoing obstetric and gynaecology
rotation when it is a cervical health awareness month, but some others don’t.
Although most of the students have little practice regarding cervical cancer
and HPV vaccination, they have a good attitude related to cervical cancer and
HPV vaccination. A study conducted by Winarto in 2022 said that some poor
practices regarding cervical cancer and HPV vaccination may be influenced by
activities held by universities. Some universities have more variant kinds of
activity related to cervical cancer, while others don’t.
In this study, we also investigate the Correlation Between Obstetric and Gynecology
Rotation and Knowledge Score, attitude score, and practice score. None of them
show a significant result. This result isn’t in line with the study conducted
by Hariyono Winarto in Jakarta in 2021 on the urban communities, which found
that there was an inter-association between knowledge, attitude, and practice
to push a successful HPV vaccine program. Hariyono Winarto also conducted the
same study in 2022 among medical students in Jakarta, which, in line with this
study, the result showed that the score of knowledge and attitude did not
reflect on the student’s practice on cervical cancer and its prevention (HPV
Vaccination), the research encourages efforts to raise awareness of the
importance of prevention, in this case HPV vaccination, through the university
curriculum and public health policy.
The insignificant results in this study can
also be influenced by the sample selection method. The sample selection method
in this study is purposive sampling, where the sampling is determined or
adjusted to the research objective so that the sample may not represent the
general population (Winarto et
al., 2022). There were several
limitations in this study. This study was limited to females only, study year,
and university. Further studies should also assess other socio-demographic
characteristics. Another limitation of this study was that this study did not
investigate the factors that can affect low practice in educating, screening,
and vaccination regarding cervical cancer.
CONCLUSION
The knowledge or attitude that students have is not necessarily in
line with their practice. Even though most of the clinical year students have a
good knowledge and attitude regarding cervical cancer and its prevention, they
have poor practice towards this topic. This study also shows that a student's
knowledge, attitude, and practice are not influenced by whether or not they
have been through obstetric and gynaecology rotations.
REFERENCES
AkbariRad, Mina, Khadem-Rezaiyan, Majid, Ravanshad, Sahar,
Rafiee, Mahdi, Firoozi, Abdollah, Zolfaghari, Seyed Ali, Aghaei, Hamid Reza,
Zadehahmad, Reyhaneh, Azarkar, Setareh, & Moodi Ghalibaf, AmirAli. (2023).
Early clinical exposure as a highly interesting educational program for
undergraduate medical students: an interventional study. BMC Medical
Education, 23(1), 292.
Alherz, Fatemah A., Alamri, Amjaad A., Aljbreen, Aseel, &
Alwallan, Naifah. (2024). Knowledge of cervical cancer, human papillomavirus
(HPV), and acceptance of the HPV vaccine among parents of daughters in Riyadh,
Saudi Arabia. Journal of Infection and Public Health, 17(5),
789–794. https://doi.org/https://doi.org/10.1016/j.jiph.2024.03.014
Ayu, Mayang Sari, & Ramadhani, Mayasari. (2022). Impact
of Corona Virus Disease-19 Pandemic on Co-Assistant Mental Health. Review of
Primary Care Practice and Education (Kajian Praktik Dan Pendidikan Layanan
Primer), 5(2), 67–71.
Bookshelf, NCBI. (2023). Cervical Cancer - Statpearls.
Retrieved March 21, 2023, from NCBI Bookshelf website:
https://www.ncbi.nlm.nih.gov/books/NBK431093/
Gizi, Angka Kecukupan. (2019). Peraturan Kementerian
Kesehatan Republik Indonesia Nomor 28 tahun 2019. Kemenkes RI. Jakarta.
Jibat, Nega, Ali, Rahma, Adissu, Wondimagegn, Buruh,
Gerezgiher, Abdissa, Alemseged, Goba, Gelila K., Garland, Suzanne M.,
Mulholland, Nigisti, Mulholland, Kim, & Amenu, Demisew. (2024). Less known
but greatly feared: Cervical cancer in Ethiopia, community awareness. Heliyon,
10(7), e28328.
https://doi.org/https://doi.org/10.1016/j.heliyon.2024.e28328
Leclair, Catherine, & Stenson, Amy. (2022). Common causes
of vaginitis. JAMA, 327(22), 2238–2239.
Lei, Jiayao, Ploner, Alexander, Elfström, K. Miriam, Wang,
Jiangrong, Roth, Adam, Fang, Fang, Sundström, Karin, Dillner, Joakim, &
Sparén, Pär. (2020). HPV Vaccination and the Risk of Invasive Cervical Cancer. New
England Journal of Medicine, 383(14), 1340–1348. https://doi.org/10.1056/NEJMoa1917338
Organization, World Health. (2016). Guide to introducing
HPV vaccine into national immunization programmes. World Health
Organization.
Qiu, Lin, Chen, Ying, Wang, Jue, Yu, Lili, Wu, Qibiao, &
Mo, Hui. (2023). Efficacy and safety of Simiao decoction in the treatment of
cervical HPV infection: A systematic review and meta-analysis of randomized
clinical trials. Heliyon, 9(11), e21840.
https://doi.org/https://doi.org/10.1016/j.heliyon.2023.e21840
Setiawan, Didik, Dolk, Franklin Christiaan, Suwantika, Auliya
A., Westra, Tjalke Arend, WIlschut, Jan C., & Postma, Maarten Jacobus.
(2016). Cost-Utility Analysis of Human Papillomavirus Vaccination and Cervical
Screening on Cervical Cancer Patient in Indonesia. Value in Health Regional
Issues, 9, 84–92.
https://doi.org/https://doi.org/10.1016/j.vhri.2015.10.010
Ver, Abbygail Therese, Notarte, Kin Israel, Velasco,
Jacqueline Veronica, Buac, Kevin Miko, Nazareno III, John, Lozañes, J. Alfred,
Antonio, Dominic, & Bacorro, Warren. (2021). A systematic review of the
barriers to implementing human papillomavirus vaccination programs in low‐and
middle‐income countries in the Asia‐Pacific. Asia‐Pacific
Journal of Clinical Oncology, 17(6), 530–545.
Wen, Ying, Pan, Xiong Fei, Zhao, Zhi Mei, Chen, Feng, Fu,
Chun Jing, Li, Si Qi, Zhao, Yun, Chang, Hong, Xue, Qing Ping, & Yang, Chun
Xia. (2014). Knowledge of human papillomavirus (HPV) infection, cervical
cancer, and HPV vaccine and its correlates among medical students in Southwest
China: a multi-centre cross-sectional survey. Asian Pacific Journal of
Cancer Prevention, 15(14), 5773–5779.
Winarto, Hariyono, Habiburrahman, Muhammad, Dorothea, Maya,
Wijaya, Andrew, Nuryanto, Kartiwa Hadi, Kusuma, Fitriyadi, Utami, Tofan Widya,
& Anggraeni, Tricia Dewi. (2022). Knowledge, attitudes, and practices among
Indonesian urban communities regarding HPV infection, cervical cancer, and HPV
vaccination. PloS One, 17(5), e0266139.
Zhang, Shaokai, Xu, Huifang, Zhang, Luyao, & Qiao, Youlin.
(2020). Cervical cancer: Epidemiology, risk factors and screening. Chinese
Journal of Cancer Research, 32(6), 720.
