Knowledge and Views of Secondary School Students in Kuala Lumpur on Cervical Cancer and its Prevention

Cervical cancer is the third most common cancer in women worldwide and the leading cause of cancer deaths in women of developing countries (Ferlay et al., 2010). In Peninsular Malaysia, according to the report of the National Cancer Registry for 2007, cervical cancer is the third most common cancer, contributing 8.4% of all cancers in Malaysian women. Indian woman have the highest rate, followed by Chinese and Malays (Zainal Ariffin and Nor Saleha, 2011). Persistent infection with human papillomavirus (HPV) is the essential cause of cervical cancer with HPV types 16 and 18 causing around 70% of the cancers (Munoz et al., 2004; Catellsague et al., 2006). Some of the factors that may increase the risk to get cervical cancer are sexual behavior (Herrero et al., 2004) and smoking (Appleby et al., 2006). The incidence and problems associated with sexualy transmitted diseases (STDs) are of great concern, especially among adolescents and young adults. In America, 48% of STDs occur in people aged 15-24 years old and the three most common ones are HPV infection, Chlamydia and Herpes (Weinstock et al., 2004). However, because most of the HPV infections do not show any


Introduction
Cervical cancer is the third most common cancer in women worldwide and the leading cause of cancer deaths in women of developing countries (Ferlay et al., 2010). In Peninsular Malaysia, according to the report of the National Cancer Registry for 2007, cervical cancer is the third most common cancer, contributing 8.4% of all cancers in Malaysian women. Indian woman have the highest rate, followed by Chinese and Malays (Zainal Ariffin and Nor Saleha, 2011).
Persistent infection with human papillomavirus (HPV) is the essential cause of cervical cancer with HPV types 16 and 18 causing around 70% of the cancers (Munoz et al., 2004;Catellsague et al., 2006). Some of the factors that may increase the risk to get cervical cancer are sexual behavior (Herrero et al., 2004) and smoking (Appleby et al., 2006).
The incidence and problems associated with sexualy transmitted diseases (STDs) are of great concern, especially among adolescents and young adults. In America, 48% of STDs occur in people aged 15-24 years old and the three most common ones are HPV infection, Chlamydia and Herpes (Weinstock et al., 2004). However, because most of the HPV infections do not show any 1 RESEARCH ARTICLE

Knowledge and Views of Secondary School Students in Kuala Lumpur on Cervical Cancer and its Prevention
Hesham Rashwan 1 *, Ismarulyusda Ishak 2 , Nurhidayah Sawalludin 3 symptoms, most adolescents would not realize it until they become pre-cancerous (Moscicki, 2005).
Studies have shown that adolescents lack knowledge about cervical cancer and HPV. In a study done in China, only 7.8% of women under 20 years old had heard about HPV (Li et al., 2009) while in Canada, only 13% of high school adolescents had heard about HPV, sexually transmitted diseases and pap test (Dell et al., 2000).
For adolescent girls aged 15-20 years old, the most effective preventive method against cervical cancer would be the primary prevention by the HPV vaccination (Villa et al., 2005). The vaccines are highly effective in preventing cervical cancer caused by high risk oncogenic HPV types 16 and 18 when used before exposure to these types. Many countries including Malaysia have already started a cervical cancer vaccination program for school students (The Star Online, 2009).
It is important to assess the knowledge and views of the students on the prevention of cervical cancer inorder to develop appropriate educational and awareness programs targeting young Malaysian girls. The objectives of this study were to assess the level of knowledge and views of upper secondary school students in Kuala Lumpur towards cervical cancer and its preventive measures and to determine their acceptance of HPV vaccination.

Study design
This cross-sectional survey was carried out in 8 government schools in Kuala Lumpur. Participating schools were recruited from a list of all government secondary schools in Kuala Lumpur. The sample frame consisted of 94 secondary schools. Only female students from form 4 and lower form 6 participated in this study, with age range from 15-20 years old. This study was approved by the Education Planning and Research Division of Ministry of Education and Education Department of Kuala Lumpur. The 8 schools which participated in the study were SMK (P) Jalan Ipoh, SMK Puteri Titiwangsa, SMK Wangsa Melawati, SMK Seri Sentosa, SMK Raja Abdullah, SMK Puteri Wilayah, SMK Desa Tun Hussein Onn and SMK Setapak Indah. The study was carried out from April to September 2009 using pre-tested and validated self-adminstred questionnaire. The sample size was calculated according to Krejcie et al. (1970).

Questionnaire
The questionnaire was divided into 4 parts. Part A: demographic data of respondents, part B: knowledge of cervical cancer, part C: knowledge of prevention of cervical cancer and part D were the questions about vaccination. After the questionnaires were completed and given back, each student was given a pamphlet about cervical cancer and its preventive measures. All pamphlets were provided by Glaxosmithklein pharmaceutical company (GSK SDN BHD) .

Data analysis
Data was analyzed using Statistical Package for Social Sciences (SPSS) version 12.0. The analysis results of respondent's demographics variables were summarized using descriptive summary measures; expressed as percent for categorical variables. The chi-square test was used to find association between categorical variables. All statistical tests were performed using 0.05 level of significance.
The level of knowledge about cervical cancer and the knowledge about the prevention of cervical cancer were classified into three different levels; low, intermediate and high. Every question that was correctly answered by students was be given one mark. Table 1 shows the score for level of knowledge of cervical cancer and knowledge of prevention of cervical cancer (Razaei et al., 2004).

Demographic data
A total of 550 completed questionnaires, out of 610 that were distributed, were returned by the students with a 90% response rate. The average age of respondents was 16.6. Most of the respondents were Malay (54.0%), followed by Chinese (33.8%) and Indian and others (12.2%). More form 4 students (74.9%) participated in the study compared to lower form 6 students (25.1%). More than   half of the respondents were art students (60.0%) ( Table  2.)

Knowledge of cervical cancer and its prevention
Most respondents (80.4%) had heard about cervical cancer with a strong significant relationship (p<0.001) with form and race. For race, more Malay students (86.9%) had heard about cervical cancer, followed by Indian (80.6%) and Chinese students (69.9%). More students of lower Form 6 (92.8%) had heard about cervical cancer compared to form 4 students (76.2%).
Most of the respondents (74.4%) had low knowledge about cervical cancer while (70.4%) had a low knowledge about the preventive measures of cervical cancer. The level of knowledge about cervical cancer and its prevention was significantly higher among students from science stream (p<0.001) compared to students from art stream.
However, the differences were not significant among different races (p=0.259) or different forms (p=0.617). Details of the data are shown in Table 3.

Views on vaccination
Most of the students (68.9%) were interested to find out more information about vaccines to prevent cervical cancer if such vaccines existed. Their first choice for a source of information was the internet (64.4%) followed by books and magazines (54.0%) and also healthcare professionals (52.9%).
On the question of whether they would take the vaccine if it is available in schools, 69.3% of respondents accepted to take the vaccine. There were significant differences (p<0.05) between races and forms. More Malay students (75.1%) would take the vaccine, followed by Indian students (67.2%) and Chinese students (60.8%). More lower Form 6 students (77.5%) would accept vaccination compared to Form 4 (66.5%) students.
The main reason to take the vaccine was because they were aware about the risk of getting the cancer (51.1%). For students who refused to take the vaccine, the main reason was because they believed that they were not prone to get cervical cancer (12.4%). Other reasons were fear of adverse events (11.1%) and did not know the importance of vaccination (8.7%).
Also the majority of respondents (82.2%) agreed that vaccination should be compulsory for school students in Malaysia. There was significant difference between races (p<0.05). More Malay students (87.5%) agreed to make the vaccination compulsory, followed by Indian students (76.1%) and Chinese students (75.8%). Details of the data are shown in Tables 4 and 5.

Discussion
Knowledge of cervical cancer and its prevention, most students (80.4%) had heard about cervical cancer. This is similar to results of a study done In Trinidad where 71% of students aged 14-19 years old had heard about cervical cancer or cervical smear testing (Orett et al., 1996) and another study among Malaysian University students (Tan et al., 2010). The awareness among our respondents from Kuala Lumpur was higher than that among East Malaysian students from Sarawak (Hesham et al., 2011). This is because of the less publicity about cervical cancer and its prevention in rural states such as Sarawak compared to Kuala Lumpur. Higher percentage of Malay students had heard about cervical cancer followed by Indian and Chinese students although Chinese Malaysian women have the highest incidence rate of cervical cancer compared to other races (Lim et al., 2008). The main source of information for the respondents about cervical cancer was mass media such as television, movies and magazines. Public media was also the main source of information of cervical cancer among adolescents in other studies16 (L'Engle et al., 2006). Therefore mass media can play an important role in educating adolescents about the effective methods to prevent cervical cancer if they provide them with accurate and simple information. Government health authorities in collaboration with non-government organizations and/or pharmaceutical companies should make use of popular mass media to raise the awareness of adolescents about cervical cancer and its prevention.
Another important source of information for students was education. It was shown earlier that there was a significant increase of respondents' knowledge after one-hour curriculum about cervical cancer (Tejeda et al., 2006). Hence, introduction of a cervical cancer curriculum into the school syllabus and during awareness programs at schools as well as community centers can effectively increase the knowledge of students toward prevention of the disease. Only 15.2% of students got the information from healthcare providers. An earlier study concluded that although 61% of adolescents wanted to discuss about sexually transmitted diseases with the health care provider, as many as two-thirds of them have not had the opportunity to do so (Klein and Wilson, 2002). It is important to encourage students to seek information about the prevention of cervical cancer from healthcare providers perhaps through the involvement of these professionals in regular awareness programs at schools.
Most students had low knowledge of cervical cancer and its prevention. This result was expected as an earlier study had shown that Malaysian women lacked knowledge of cervical cancer and pap smear (Wong et al., 2009). Students from science stream had significantly higher knowledge compared to students from art stream. This finding suggests that the difference in curriculum content that they learn at school might affect the students' knowledge about cervical cancer. Science students might also find it easier to search for information about diseases.
Almost half of respondents knew that the main cause of cervical cancer is virus infection. However, only 24% knew that HPV is the main cause of cervical cancer. These findings were different from a survey done among students of Mangosuthu University where almost half of the undergraduate female students knew that HPV is the main cause of cervical cancer (Hoque and Hoque, 2009). However students in our study were younger and only in secondary schools.
The majority of the students (88.2%) did not know that there was a vaccine to prevent cervical cancer. This is similar to an ealier report where only 10% of Malaysian females aged thirteen to twenty-seven years old had ever heard about the cervical cancer vaccines (Wong, 2008). The vaccines for cervical cancer prevention received regulatory approval in Malaysia only in recent years that is the reason not many females knew about them. Besides, not many campaigns were done by the government or non-governmental organizations to promot cervical cancer vaccination among teenagers at schools or in community centers.
There were no significant differences between different races and forms on the knowledge of methods to prevent cervical cancer. Only 30% of students correctly answered questions about pap smear. Even after vaccination, females still need to do pap smear screening because the HPV vaccines do not protect against all types of HPV (Bosch and Harper, 2006). Thus, it is important for the students to be aware of the pap smear test and information should be provided to encourage them to practice pap smear test even after they get vaccinated.
Views on vaccination, most of the respondents were very interested to find information about the vaccines to prevent cervical. Their source of choice for information was the internet. This is because internet is a convenient tool to find information and most teenagers nowadays are familiar with the use of internet as a source of information and it is widely available. However, students must be guided to find the correct information from reliable internet sources. This can be provided to students by simple brochures and during health talks.
The respondents also showed positive attitude toward taking the vaccination if it were available in schools and they agreed that the vaccination should be compulsory to school students. Malaysian University students had also shown positive attitude toward HPV vaccination (Tan et al., 2010;Hesham et al., 2012). Vaccination was significantly more accepted by Malay students compared to Chinese students. This is interesting as we expected Chinese students to show more interest in vaccination because they are more susceptible to get cervical cancer than Malay (Zainal and Nor, 2011). It is not clear why less Chinese students accepted the HPV vaccination and this should be investigated in future studies. Most students did not have a problem with the vaccine being compulsory at schools because they are used to the practice of taking different vaccines at schools.
The main reason for refusal of vaccination was not prone to get cervical cancer, which was similar to Malaysian University students (Hesham et al., 2012). This might be due to the low knowledge of students on cervical cancer. In addition, the belief in Malaysia was that school students were not sexually active due to the religious and cultural guidance. Similarly a study done among Malaysian women showed that for those who were not sexually active, they thought they did not need the vaccine and preferred to wait before they were vaccinated (Wong, 2008). However, earlier studies carried out abroad showed that the cumulative prevalence for HPV infection among adolescents is as high as 82% (Brown et al., 2005). Thus, vaccination in younger age would provide the effective protection against cervical cancer before the adolescents are exposed to HPV infection. Anothe reason for refusal of the vaccine was being afraid of the adverse events that they might get from the vaccine. However, the adverse effects of cervical cancer vaccines are transient and minor such as fever, redness, swelling and fatigue (Einstein et al., 2009). Therefore, providing the students and their parents with accurate and simple information about the reasons for the need to vaccinate adolescents with the effective and safe HPV vaccines can increase the acceptance of HPV vaccination among the students.
In conclusion, the respondents had low knowledge about cervical cancer and its prevention but showed positive attitude toward vaccination and agreed that the vaccine should be compulsory for school students. They were also willing to search for information about the vaccines to prevent cervical cancer with the internet being their first choice. It is important to educate the students about the effective methods to prevent cervical cancer through educational and awareness programs at schools as well as usimg the internet and mass media to raise awareness of adolescents and their families about the disease.