Faculty of Medicine University of Malaya

MBBS Phase IIIA Elective Report

NAME MATRIC NO. SUPERVISOR

: AJRINA BT CHE DAUD : MEM 070009 : DR. RAHMAH BT. SAAID

ABSTRACT

A cross-sectional study was conducted among 200 Malaysian women in the gynecology outpatient clinic in University of Malaya Medical Centre, Kuala Lumpur to determine the level of knowledge and awareness of cervical cancer screening and HPV vaccine. A hundred and eighty six women (93%) had heard about the cervical cancer screening and 85 about HPV vaccines (42.5%). Marital status was associated significantly with awareness of Pap smear and HPV vaccine (p=<0.001, p=<0.001; respectively), in addition to level of education (p=0.005). This study found a satisfactory level of awareness of Pap smear and a very low level of knowledge of HPV vaccine. Education of population is highly recommended and barriers to being vaccinated should be dealt with seriously.

Keywords: Knowledge Pap smear - HPV vaccination - Malaysian women

INTRODUCTION Cancer of the cervix remains as the second most common cancer among females in Malaysia after breast cancer. It is estimated that approximately 440,000 new cases of cervical cancers occur worldwide annually, and 80% of these cancers occur in developing and undeveloped countries. In Malaysia, the overall incidence rate is 19.7 per 100,000 women, however differs by ethnic group. Ethnic Chinese women have the highest ASR (age-standardized incidence rate) of 28.8 per 100,000, followed by ethnic Indians with 22.4 and ethnic Malays (includes Peninsular Malaysia but not East Malaysia) with 10.5 per 100,000 women. It is a known fact that one of the risk factors for cervical carcinoma is due to human papilloma virus infection. Over 100 different human papilloma virus (HPV) subtypes have been identified. Of these, 15 are classified as high-risk types (16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68, 73, and 82), 3 as probable high-risk (26, 53 and 66), and 12 as low risk (6, 11, 40, 42, 43, 44, 54, 61, 70, 72, and 81), but even those may cause cancer. Cancer of the cervix is preventable. The precursor cancer cells can be easily detected provided the women do regular screening tests called Pap smear (Papanicolau smear). Uptake of screening remains low in all regions and is further compounded by the lack of basic knowledge women have regarding screening as an opportunity for the prevention of cervical cancer. In Malaysia, the cervical cancer screening programme was established in 1969 to ensure early detection of cervical cancer among the target group of women aged 20-65 years (Wong et al., 2009) and many action plans and cancer awareness campaigns have been launched over the years (Lim et al., 2004).

Subsequently in 2006, the Malaysian government provided regulatory approval of the vaccine (Wong, 2008). Barriers to vaccination include costs, limited vaccine availability, and lack of vaccine awareness (Herzog et al., 2008). A little is known about the level of knowledge about HPV vaccine in Malaysian women. Therefore this study aimed to address three research questions (1) level of awareness of cervical cancer screening, (2) level of awareness and knowledge of HPV vaccine (3) factors associated with awareness and knowledge of Pap smear and HPV vaccine among Malaysian women.

MATERIALS AND METHODOLOGY Participants This cross-sectional study was conducted among 200 women in the gynecology outpatient clinic in University of Malaya Medical Centre during the period from October 2010 until November 2010. Written consent was obtained from the participants. Women aged less than 20 or more than 59 years and/or unable to communicate either in Bahasa Malaysia or English were excluded from this study.

Research instruments The questionnaire consisted of four parts: A) A questionnaire was developed for this study to obtain socio-demographic factors. It included questions ethnicity, age, marital status, and number of children. B) Two questions to assess the participants level of education. C) Knowledge of the participants on cervical cancer screening (Pap smear) was assessed by five questions. D) The participants awareness and knowledge about HPV vaccination was assessed with eight questions. The questionnaire was given in English and Bahasa Malaysia.

Data analysing Data analysis was performed using Statistical Package for Social Sciences (SPSS) version 16. Data generated was then coded, entered in the computer and analyzed. Chi square test was performed to explore the relation between socio-demographic and the study outcome variables (awareness and knowledge).

Results Socio-demographic characteristics Participants of this study were 200 women with mean age of 34.5 year-old. Thirty seven (18.5%) were in the age group 20-29 years old and thirty one (15.5%) were in the age group of 50-59 years old. Majority of the participants were Malay (52%) and married (77.5%) (Table 1).

Table 1. Socio-Demographic Characteristics of the Participants (n=200)

N Variable Age 20-29 30-39 40-49 50-59 Race Malay Chinese Indian Others Education level Primary Secondary Diploma University Marital Status Single Married Divorced Widowed No of Children No children 1-3 >3 5 84 81 2.9 49.4 47.7 30 155 1 14 15 77.5 0.5 15 19 100 51 30 9.5 50 25.5 15.5 104 49 37 10 52 24.5 18.5 5 37 65 67 31 18.5 32.5 33.5 15.5 %

Level of education A mere nineteen participants (9.5%) only completed up until primary level and thirty three (15%) received education up to tertiary level. However, majority of the participants completed until secondary level (50%).

Knowledge on cervical cancer screening Participants were asked if they had heard about cervical cancer screening (Pap smear). Majority of participants (186, 93%) were aware about the cervical cancer screening. Most of them (121, 60.5%) acquired the information from the health personnel. They were also asked about the frequency one should go for Pap smear. Only twelve (6%) answered that one should go for cervical cancer screening every three years after two consecutive normal Pap results. Most of the participants (103, 51.5%) answered yearly. The only factors that have significant association with awareness of Pap smear screening were age, marital status, and level of education (p=<0.001, p=<0.001, p=0.005 respectively)(Table 2).

Awareness of HPV vaccines Participants were also asked if they had heard about HPV vaccine. Eighty five out of 200 women (42.5%) have heard about HPV vaccine. Only age, marital status and working professions were found to be significantly associated with awareness on HPV vaccination (p=<0.001, p=<0.001, p=0.013 respectively)(Table 2).

Table 2. Factors Associated with Awareness of Pap smear and HPV Vaccine

HEARD ABOUT PAP SMEAR YES N(%) NO N(%) Variable Age 20-29 30-39 40-49 50-59 Race Malay Chinese Indian Others Marital status Single Married Widowed Divorced Education level Primary Secondary Diploma University Profession Professionals Technician Clerk Services Operators Number of children No children 1 to 3 More than 3

P value

HEARD ABOUT HPV VACCINE YES N(%) NO N(%)

P value

29 (78.3) 63 (96.9) 27 (100) 67 (94.4) 97 (93.3) 48 (98.0) 32 (86.5) 9 (90.0) 22 (73.3) 149 (96.1) 14 (100) 1 (100)

8 (21.7) 2 (3.1) 0 (0.0) 4 (5.6) 7 (6.7) 1 (2.0) 5 (13.5) 1 (10.0) 8 (26.7) 6 (3.9) 0 (0.0) 0 (0.0)

<0.001

12 (32.4) 26 (40.0) 47 (70.1) 0 (0.0) 62 (59.6) 24 (49.0) 23 (62.2) 6 (60.0) 6 (20.0) 77 (49.7) 1 (7.1) 1 (100)

25 (67.6) 39 (60.0) 20 (29.9) 31 (100) 42 (40.4) 25 (51.0) 14 (37.8) 4 (40.0) 24 (80.0) 78 (50.3) 13 (92.9) 0 (0.0)

<0.001

0.220

0.572

<0.001

<0.001

14 (73.7) 94 (94.0) 50 (98.0) 28 (93.3) 15 (93.8) 22 (95.7) 37 (100) 37 (97.4) 8 (100)

5 (26.3) 6 (6.0) 1 (2.0) 2 (6.7) 1 (6.2) 1 (4.3) 0 (0.0) 1 (2.6) 0 (0.0)

0.005

10 (52.6) 40 (40.0) 22 (43.1) 13 (43.3) 8 (50.0) 8 (34.8) 20 (54.1) 22 (57.9) 5 (62.5)

9 (47.4) 60 (60.0) 29 (56.9) 17 (56.7) 8 (50.0) 15 (65.2) 17 (45.9) 16 (42.1) 3 (37.5)

0.784

0.055

0.013

5 (100) 81 (96.4) 78 (96.3)

0 (0.0) 3 (3.6) 3 (3.7)

0.761

2 (40.0) 42 (50.0) 35 (43.2)

3 (60.0) 42 (50.0) 46 (56.8)

0.063

Discussion Results of this study revealed that awareness of cervical cancer screening was 93% among the participants. It is found out that majority of them who had heard about Pap smear screening, obtain the information from health care personnels (65%, p=<0.001). It is a higher rate compared to a previous study which reported 70.8% (Jamsiah, 2009). This is a good figure in which it signifies that the Pap smear screening and cervical cancer campaign had been done tremendously well in healthcare centres. However, we must take into consideration that this study was done in a tertiary centre where most of the patients are well-educated. It is reported in a previous study (Rushdan, 2008) that the total number of Pap smear taken in Malaysia from 1996 until 2005, ranged from 350,000 to 400,000 annually (Figure 1) and there was no significant increase in the numbers over the years. However, the actual Pap smear coverage in the recent years is unknown as there is no Pap smear registry in Malaysia. The insignificant increase in the number of Pap smear taken may be due to the patients lack of understanding about the Pap screening. It has been reported in a study (Wong, 2009) that many women perceive Pap smear as a diagnostic tool rather than screening. Thus they chose not to take Pap smear as they did not have any symptoms. Other factors such as embarrassment, lack of Pap smear availability, and own-perceive low susceptibility also play a significant role.

Figure 1: Number of Pap smear slide taken from 1994 - 2005 (source: Information and Documentation System Unit (IDS) Family Health Development Division) MOH, Malaysia 2005

This study also found that awareness of HPV vaccine (42.5%) was high in comparison to a previous study which reported higher rate of awareness 21.7% (Sami et al., 2009). Even though some of the participants claimed that they are aware of the vaccine, 21.2% of them still not sure of the target group who should go for vaccination (Table 3). It is crucial to address this problem as many women who have heard about the vaccine still refuse to go for screening because of misunderstanding and lack of knowledge. For instance, a study conducted and reported by Wong (2008) found that many young women felt that they did not need the vaccine or would prefer to wait because they were not sexually active; this highlights the failure to educate women of the importance of vaccination before exposure to HPV. Young women must be made aware that the

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vaccine is most effective if administered before initiation of sexual activity (Goldie et al., 2004; Zimet, 2005) so they should not delay vaccination.

Table 3. Association of HPV vaccine awareness and knowledge of the vaccination

Target group for HPV vaccination Sexually active Not sexually active Not sure HPV vaccine awareness YES N (%) NO N (%) p=<0.001 27 (31.8) 26 (22.6) 40 (47.0) 3 (2.6) 18 (21.2) 86 (74.8)

Total 85 115

In this study the age was found to be significantly associated with awareness of Pap smear. It shows a totally different finding from a previous local study where there is a converse relation between age and level of Pap smear awareness (Jamsiah, 2009). However there is a study done in other country (Breitkopf et al) which reveals a similar finding as to this current study. Marital status and level of education also plays a major role in the level of knowledge about Pap screening among the participants. Jamsiah (2009) also reported that higher education was associated with higher cervical cancer screening awareness. Thus educational materials should be developed to provide comprehensive, detailed information about cervical cancer and its prevention with an emphasis given to women from minority groups and those with lower education (Calloway et al., 2006; Sherris et al., 2006).

The level of knowledge regarding HPV vaccination also significantly associated with the age and marital status of the participants. In contrast, a previous study showed that not being married is associated factor with initiation of the HPV vaccine series among women (Jain et al., 2009). This may due to those unmarried women may perceive themselves are at a greater risk for
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HPV infection and therefore may be more interested in vaccination. Apart from that, the working profession also was found to be one of the contributing factors affecting the awareness of HPV vaccination. It is different from a previous study conducted in Malaysia, Vietnam, and United States of America which reported there is no significant association between work profession and level of knowledge of HPV vaccine. This may be due to the fact that this study was conducted in a tertiary healthcare centre situated in the heart of Kuala Lumpur where most of the patients are working modern-women.

There is evidence that increased knowledge of a particular disease and its associated vaccine have proven to be important determinants of peoples health beliefs and practices (Bodenheimer et al., 1986). Thus, rising public awareness and knowledge on HPV, Pap smear screening, and HPV vaccine are important determinant of heath and health promotion programs implemented by the government. Without communication vaccines may have little impact on disease burden. It is important to raise awareness among population on HPV and its link to cervical cancer. Education on HPV vaccine should also include information about its safety and its benefit to prevent cervical cancer. Therefore, public health campaign and patient education is required to increase the acceptance of the HPV vaccine among the population.

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Conclusion It is found that the level of awareness regarding Pap smear screening is up to satisfactory level. However, a Pap smear registry should be initiated to monitor the progress of Pap smear uptake to correlates and improve the government actions for future benefits. On the other hand, the level of knowledge concerning HPV vaccine is still at the lower level. The main question is, why does this scenario happens despite all the governments actions and initiative to do campaigns about HPV vaccine since 5 years ago? Thus, certain issues affecting the vaccines uptake should be addressed and dealt with to improve the womens health in terms of cervical cancer prevention.

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