Knowledge Level of Female Students of Kabul Medical University "Abu Ali Sina" About Cervical Cancer

Objective: The aim of this study was to find the knowledge of female students of Kabul University of Medical Sciences about Cervical cancer.

Methods: This cross-sectional descriptive study was conducted by non-probable sampling, or Sampling based on quota sampling in fall 2022 among female students of Kabul University of Medical Sciences.  Data using (SPSS 25) software have been analyzed.

Results:  337 out of 347 students participated in this study.   In this study, the average age of participants was 21 years, 89.91% participants were single.  83.9 % of participants had heard about cervical cancer, 54 % of whom were university professors. Students had no knowledge about Cervical cancer because 21.1% mistakenly identified old age as risk factors and 53.1% had Cervical swelling, 14.2% had fever and 19.6 % mistakenly chose itching as symptoms of Cervical cancer.   70.6% had knowledge that cervical cancer was preventable, but more than half of the students, i.e. 54.6%, did not know whether the vaccine was available to prevent Cervical cancer. In this study, only 10.4% of students correctly diagnosed that HPV vaccination can be given to boys.   As a result, the study showed that 84.9% of students had poor knowledge about Cervical cancer and the relationship between knowledge level and faculty proved statistically significant (P Value = 0,000) and 74.8% had poor knowledge about HPV vaccination and the relationship between knowledge level and faculty was statistically significant. (P Value = 0,03).

Conclusion: According to the results of this study, we found that the knowledge of cancer among female students of Kabul Medical University was weak.   That highlighted the importance of educational programs, various seminars on Cervical knowledge and HPV vaccination within universities and for participants.

Cancer is a non-normal and pathological view of the body's cells that disturbs the normal state of the same part or body. Normally, the cells reproduce and die in a regular manner, so that each new cell replaces a destroyed cell.  But sometimes the cells become abnormal and continue to grow.  These abnormal cells may become cancerous [1].

Cervical cancer is a cancer that starts from the cervical cells. And the cervix connects the uterus to the vagina. Cervical cancer usually slowly develops over time before Cervical cancer appears, and cervical cells change, known as dysphagia, in which abnormal cells are observed in cervical enclosures, and over time, if abnormal cells are not destroyed or removed, they may become cancerous cells and begin to grow deeper into the cervix and surrounding areas [2].

Cervical cancer is the fourth most common cancer among women worldwide, with about 604,000 new cases and 342,000 deaths in 2020. About 90% of new cases and deaths worldwide occurred in low- and middle-income countries in 2020. In 2012, 528,000 new cases of cervical cancer were diagnosed worldwide; of these, a large majority, about 85% occurred in less developed areas. In the same year, 266,000 women died of cervical cancer worldwide; almost 9 in 10 of these, or totally 2,310 women, live in low to middle countries. in contrast, 350, or just 1 in 10 of these women, living in high-income countries, died. The main reason for these differences is the relative lack of effective prevention and early diagnosis and treatment programs and lack of equal access to such programs. Without these interventions, cervical cancer is usually only diagnosed when it is at an advanced stage. so that it is too late for effective treatment [3].

Cervical cancer is a common cancer in women, with 270,000 women dying of the disease annually, 90% of whom live in developing countries.  By 2035, these numbers are expected to double unless effective public health interventions are introduced [4].

Cervical cancer is the second most common cancer among Afghan women. 3.3% of Afghan women are infected with this cancer. In 2018, 694 new cases of cancer were recorded. About 520 women died of this cancer in Afghanistan in 2017.  8 out of every 10 women with Cervical cancer die. In 2019, 540 women in Afghanistan died of Cervical cancer. In 2020, the prevalence of Cervical cancer was 6.3% [5].

Two types of human papillomavirus (HPV) 16 and 18 are responsible for approximately 50 percent of cervical cancers.  HPV is mainly transmitted through sexual contact and most people become infected with HPV shortly after sexual activity begins. More than 90% of them eventually eliminate infection. Women with HIV are six times more likely to develop cervical cancer compared to women without HPV.  Vaccination against HPV, screening and treatment of precancerous waste is a cost-effective way to prevent cervical cancer. If cervical cancer is diagnosed in the early stages and treated on time, it can be treated.  Comprehensive cervical cancer control includes primary prevention (vaccination against HPV), secondary prevention (screening and treatment of precancer waste), third prevention (diagnosis and treatment of invasive cervical cancer) and palliative care. In high-income countries, there are programs that allow girls to be vaccinated against HPV and women to be screened regularly and treated adequately.   Screening allows precancer waste to be detected in stages that are easily treatable [6].

 Cervical cancer, caused by the human papillomavirus (HPV), is the main cause of years of loss of life due to cancer in developing countries.  Cervical cancer has a disturbing effect on the well-being of families. Introducing a successful HPV vaccination program directly reduces complications and deaths from HPV types, improves women's health, increases health care costs. By introducing HPV testing as part of screening technology and, most importantly, by producing effective HPV preventive vaccines, it has been shown that well-organized cervical screening programs can reduce the incidence of cancer and mortality.  Screening programs, diagnostics for HPV waste are generally available in developed countries.  However, not all developing countries have a lack of public health policies, vocational and public education, financial resources and media knowledge, and the National Cancer Screening Program.  So, women's knowledge campaigns about cancer, mainly Cervical cancer, can have a significant impact on controlling Cervical cancer [7].

Cervical cancer is one of the cancers in which a precursor stage (precancer) lasts years before it becomes invasive cancer, but lack of proper strategies and policies has still disrupted the events of this disease. Unfortunately, although it is preventable, there are still many women who die from cervical cancer in many countries (this is because they lack access to services for prevention and treatment – a problem that may arise. There are many factors, such as barriers that limit their access to services (such as operation hours, distance, lack of transportation) as well as dominant cultural and gender barriers. For the most part, though, the cause is excessive poverty [8].

The aim of this study was to investigate the knowledge of Cervical cancer in female students of Kabul University because medical students play an basic role as health care providers to raise community awareness and improve population behavior.  This is the first time at Kabul Medical University that students' knowledge assessment of Cervical cancer is being examined.

Type of study

This research is a basic study from the practical point of view, a quantitative study from the question point of view, in term of obtaining information it is an elementary study and in term of objective it is a descriptive study and descriptive cross-sectional method has been done.

Research Location

The research has been done in one of Afghanistan’s governmental universities, Kabul University of Medical Science (Abu Ali Ibn Sina) located in the third district of Kabul city. According to the report of the department of product affairs, the owner of database the total number of male and female students (3467) including the number of female students (1752) and has 7 faculties (curative medicine, stomatology, public health, midwifery-nursing & complimentary health services).

Duration

This study was conducted in seven weeks which started from the third week of October 1401 and ended until the second week of December 1401.

Sample Technique

In this study non-probability, non- random and quota sampling method are used. The sample size by Epi-info (version 3.2.5.0) whereas the total papulation of 1752 people, 5% standard error, 50% frequency, 95% confidence interval 315 person were received and considering 10% (31 persons) of non-response the final sample size was 346 persons became. Then quotas have been set for each faculty as follows: curative medicine 31% (107 persons), stomatology 24% (83 persons), public health 9% (31 persons), nursing 10% (35 persons), medical technology 7% (24 persons), anesthesia 5% (17 persons) and midwifery 14% (48 persons) became. Then the number of samples from each faculty were classified to the number of classes (first, second, third, fourth and fifth) and the questionnaires were distributed to available sample in the classes.

Participants

The target population in this research includes all female students of Kabul University of Medical Science, the source population includes students from the 1th to the 5th classes of curative medicine, stomatology and 1th to 4th classes of public health, nursing, midwifery and complementary health science. The studied population was those who based on the quotes of the faculties and from the sample size accessible. The available sample consisted 346 persons of which 339 persons participated in the study.

Sample size

The sample size from the target population (1752) using Epi-info version 3.5.2.0 with comment expected 50% frequency, 95% confidence interval and 5% standard error 315 persons were selected but considering 10% (31% people) of non-response the sample size was 346 persons.

Data sources and measurement 

The tools and source of information were used to obtain knowledge about Cervical cancer, a related standard questionnaire derived from reviewing the works published in PubMed [9] [10].  Which includes 3 sections (demographic characteristics, knowledge questions about Cervical cancer, HPV vaccination knowledge).

Measurement of Cervical cancer knowledge

In the taker of 13 multi-choice questions with 34 statements related to the cause of the disease, risk factors, symptoms, screening recommendation and HPV. 1 score was given for each correct answer and 0 for each wrong answer, and in the questions that are (multi response), if you choose not to answer the wrong answer, a score was also given.  The total knowledge score for each participant was calculated from 34. Participants had poor, moderate and good knowledge if their scores were 0-17, 25-18 and 34-26, respectively [9].

Measurement of HPV Vaccination Knowledge

That includes 10 questions. For each correct answer, 3 scores were given and for each wrong answer 0 was scored. The total score for each participant was 30, if their score was 0_15, 22_15 and 30_23, respectively, they had low, moderate and good knowledge [10].

Measuring information sources about Cervical cancer

Receiving a percentage of information sources about Cervical cancer of all participants [10]. 

Statistical methods

After completing the data Total stage and completing the determined number of questionnaires, the related database in SPSS version 25.0 was arranged and data entry of all questionnaires was done in the software, descriptive statistics and chi-square were used for data analysis.

Ethical Consideration

The proposal of research along with the questionnaire, was submitted to the public health faculty Institutional Review Board prior to the distribution and interview, and the IRB was obtained from the public health faculty research committee, an informed consent letter was obtained from each participant prior to their participation. We have never written the names of participants, the process of study conducted regarding the obtained IRB and university policies, and all the ethical issues have been considered according to the declaration of Helsinki.

Demographic profile of subscribers

In this study, the average age of the participants was 21 years and the standard deviation was 1, the lowest age of the participants was 17 and the highest age was 30. The highest participants were 23.7 (80) in the age range of 21 and 89.91% (303) of the participants were single. The study participants (337 people) were from all 7 faculties (medical medicine, stomatology, public health, nursing, midwifery, anesthesia, and technology). From the first grade to the fifth grade, students who related to the percentages shown in the table were included in the study.

Distribution of demographic characteristics of participants

Knowledge of Cervical Cancer

Out of the 337 participants, 83.9% of the participants had heard about cervical cancer, among the participants who had heard about Cervical cancer, 54% of the participants had received information from university professors. Among 337 participants, 97.3% of the students answered the question about the causal cause of cervical cancer. 45.4% of participants had chosen I don’t know about the causal cause of cervical cancer. 

Participant’s explanations based on the cause of cancer 

The results of this study show that 12.1% students mistakenly selected old age as cervical cancer risk factors. According to the results of this study, it is observed that students did not have enough knowledge of Cervical cancer symptoms because 53.1% of participants were mistakenly selected for Cervical cancer due to lack of sufficient knowledge, cervical swelling, 14.2% of students had fever and 19.6% of students had itching due to poor knowledge. The results of this study show that only 16% chose the right answer that women can do screening test between the ages of 25 and 65 years, and most participants had chosen the option I don't know.

Participant’s explanations based on the duration of screening for women

In this study, the most participants selected (46.6%) of the option to ask girls who were vaccinated whether they needed to attend cervical cancer screening, and only 35.3% (119) students had answered correctly.

Participants' explanations in accordance with the presence of screening for girls who have received vaccine

In this study, only 21.7% of students chose the right answer that women between the ages of 25 and 44 should take the screening test after 2 years. Similarly, only 8% of students had the knowledge that women between the ages of 45 and 60 should take the screening test every five years.

Participants' explanations are based on women aged 44-25 and 60-45 years with screening

The results of this study on HPV knowledge show that students had good knowledge that HPV is responsible for the caste range of diseases including Cervical cancer. More than half of the participants were (59.8%) that HPV causes a wide range of diseases, including Cervical cancer. In this study, 63.5% of participants had the knowledge that HPV virus can transmit. the most participants selected (32%) the pop smear examination for HPV diagnosis. Only 20.5 % have answered correctly that HPV 6 and HPV 11 cause genital progenitors, and 66.26% of students have answered that they do not know which type of HPV virus causes cancer of the uterus, only 18.4 The percentage of students answered correctly that HPV 16   and HPV 18 cause Cervical cancer. The above results show poor knowledge about HPV.

Participants ' explanations according to HPV types that cause papilloma and Cervical cancer

As a result of this study, 84.9% of students had poor knowledge, 14.2% of students had moderate knowledge and 0.9% (students had good knowledge of Cervical knowledge and the average knowledge score was 2.8%.

Participants ' Knowledge of Cervical Cancer

The results of this study show that knowledge about Cervical cancer is generally poor among other faculties, and there is no difference in knowledge between faculties and the relationship between knowledge level and faculty proved statistically significant (P Value = 0,000), according to P value, the results of this study are closer to the truth and less than chance. 

Distribution of Knowledge Levels Considering Faculty

Knowledge about HPV vaccination

In the present study, 32.3 percent thought that all cancers were predictable due to poor knowledge, and the highest participants had 70.6 percent knowledge that cervical cancer was predictable.

Participant’s explanations Is Cervical cancer can be preventble?

Only 25.2% of students had knowledge that Cervical cancer was vaccinated and 54.6% chose not to know the option due to lack of sufficient knowledge.

Participants' contents in terms of HPV vaccine 

According to the above results, 18.7% of students have correctly diagnosed that there is a Cervical cancer vaccine in Afghanistan and 10.4% of students have correctly diagnosed that HPV vaccination can be given to boys.  48.7% answered correctly that girls and women have screening for HPV before they are vaccinated, 27.3% of students mistakenly have the yes option to ask if we can vaccinate HPV to a woman currently having HPV virus has chosen and believed that those who currently have HPV virus in the body can receive HPV vaccination. As a result, it is observed that a small percentage of students have chosen the right answers, and most participants have chosen the wrong option due to lack of sufficient knowledge in this field or option.

1Participants' explanations of HPV vaccine

54.6% of the participants answered correctly that HPV vaccination is not harmful to health and 13.6% of participants have responded because of lack of knowledge that pregnant women can get HPV vaccination.    In general, the students did not have good knowledge about HPV vaccination.

Participants Knowledge of HPV vaccine

The results show that 74.8% had poor knowledge, 24.3% had moderate knowledge and 0.9% had good knowledge of Cervical cancer vaccination and the average knowledge score was 2.7.

Distribution of Knowledge Levels of HPV vaccine Considering Faculty

The results of this study show that knowledge about HPV vaccination was poor among all faculties and there is no difference in knowledge between faculties.  The relationship between knowledge and faculty level was statistically significant (P Worth = 0.03).

As a result of analysis and analysis of the figures obtained from this study, 84.9% of students had poor knowledge of Cervical cancer and 74.8% of participants had low knowledge of HPV vaccination. The highest knowledge of the participants about the symptoms and risk factors of Cervical cancer was weak because the most participants mistakenly selected cervical swelling (53.1%), fever (14.1%) and itching (19.8%) as symptoms of Cervical cancer.   And as a result of poor knowledge, 12.1% of older students mistakenly considered it as one of the risk factors for Cervical cancer, which is similar to the results of the study that was conducted in Jordan regarding knowledge about Cervical cancer and HPV vaccination among medical students. In this study, only 17.2% of students had the right answer that women who were in the age range of 45-25 should take screening tests every 3 years, and only 8% of students had the right answer that women aged 60-45 should take screening tests every 5 years, similar to the results of the study. In Jordan, knowledge about Cervical cancer and HPV vaccination was carried out among medical students [9].

In this study, despite poor knowledge about Cervical cancer vaccination, the majority of students knew that Cervical cancer was preventable, similar to the results of the study conducted at Nora Bent Abdul Rahman Medical University in Saudi Arabia, in which the majority of students knew that Cervical cancer was preventable with poor knowledge [11]. In a cross-sectional study conducted  among medical students of an extraordinary care hospital in Chennai, India, they also found poor knowledge and 23.5% that Cervical cancer is predictable [10], and a cross-sectional study  conducted at King Saud University in Saudi Arabia with good knowledge about Cervical cancer and vaccination of the most students is 96.5 percent [12] More than half of the students (54.6%) did not know that HPV vaccination causes Cervical cancer, but in studies conducted in southwestern China [13], 48.4% and the study conducted in Chennai, India [10] , 37.7% were aware that HPV vaccination  prevents Cervical cancer. 52.8% of students responded that the vaccine should not be injected into boys. These results were similar to the study conducted in Chennai, India, in which 69.1% responded that boys should not be vaccinated   with HPV. Half of the students have responded that HPV vaccination should also be given to boys. The source of information of most students is 54% of university professors, which is similar to King Saud studies [12] and the study conducted in southwestern China [13], in which the source of information studies of the majority of students are 96.5% and 66.4% of university professors, respectively.

Half of the students did not know whether HPV vaccination was available in Afghanistan, and in the Chennai study in India 37.7 percent [10], in the King Saud Saudi study [12] did not know whether HPV vaccination was available in their country. 59.8% of the study found that HPV causes Cervical cancer, similar to the research conducted among medical university students in Serbia [14]. In the study conducted at Jordan Medical University [9] and King Saud University in Saudi Arabia [12], the majority of students did not know the symptoms and risk factors of Cervical cancer, which is similar to the present study conducted among female students of Kabul University of Medical Sciences. In this study, more than 33% of students selected Pop smear as a technique for diagnosis of HPV, which is similar to the results of the study of Nora Bent Abdul Rahman University, in which 30% of pop smear students were selected as techniques for diagnosis of HPV.

The study was conducted to get the knowledge of female students of Kabul University of Medical Sciences about the knowledge of Cervical cancer, the average age of the 21 participants was the most single participants in this study, the majority of participants had heard about cervical cancer and the source of information was more than the participants of university professors. A number of students have mistakenly selected old age as the cause of Cervical cancer. The majority of students had mistakenly symptoms of Cervical cancer due to poor knowledge of cervical swelling, fever, and itching and did not have the knowledge that anemia and pelvic pain are the most common symptoms of Cervical cancer. In this study, students had low dash about screening, HPV and HPV vaccination, but despite the low knowledge of the high number of students, the majority of  students did not know about access to HPV vaccination in Afghanistan.   They have poor knowledge and it was also found by the separation of faculties that the knowledge of Cervical cancer and HPV vaccination was generally poor among other faculties.