Download Participants and Methods

Final Presentation
28th May‘10
Introdução à Medicina II
Class 16 - 2009/2010
I. Background
II. Research Question and Aims
III. Participants and Methods
IV. Results
V. Discussion
VI. References
Why are we developing this study?
 Cervical cancer has a high incidence and mortality.
 A lack of knowledge about the disease is shown in
articles previously consulted.
 Knowledge is a key first step to health education
intervention and appropriate decision-making.
 Medical students will play a major role in the future
public healthcare and education.
 We believe there is potential for better results on
prevention of cervical cancer.
What is cervical cancer?
 A slow developing malignant cancer that starts in the
tissues of the cervix.
 Human papillomavirus (HPV) is implicated in more than
99% of these cancers. (Kaplan-Myrth N, 2007, Family Physicians of Canada)
Normal
Cervix
HPV Infection
HPV Clearance
Infected
Cervix
HPV infection
must persist for
more than one year
Progression
Regression
CIN
Invasion
Cancer
How aware are people of cervical cancer?
 1st grade college students’ knowledge was uncertain
about forms of HPV transmission. There were no major
differences between genders, except for the
knowledge about the link between HPV and genital
warts (4,2%-males; 11,6%-females). (Baer H. et al, 2000, J
Community Health)
Awareness among young university students is low.
How aware are people of cervical cancer?
 “Health professionals and women had better
knowledge about HPV than other participants (…)
Overall, the knowledge of the general public about
HPV infection is poor.” (Klug SJ et al, 2008, Prev. Med.)
 “In a population sample of British women (…) only
2.5% cited HPV as the cause of cervical cancer
without prompting (…) Public education is urgently
needed.” (Marlow LA et al, 2007, Br J Cancer)
How common is cervical cancer?
 Portugal is the
country with the
greatest incidence
of cervical cancer
among the Western
Europe.
 It is also one of
the countries with
higher
mortality
rate.
I.
Background
II. Research Question and Aims
III. Participants and Methods
IV. Results
V. Discussion
VI. References
Major and minor aims
Are medical students well informed about
cervical cancer? And how do they behave?
Major aim:
•
To assess medical students’ knowledge on
cervical cancer...
•
Link between cervical cancer and HPV infection
•
Methods of prevention and detection
•
(...)
Major and minor aims
... and their behaviour in regard to this problem.
•
•
•
•
Number of sexual partners
Age of sexual activity initiation
Vaccine
Others
Secondary aims:
• To compare the results between male and female medical
students’.
• To confront differences involving basic and clinical grades.
• To associate the students’ behaviour with the level of
knowledge shown.
I.
Background
II. Research Question and Aims
III. Participants and Methods
IV. Results
V. Discussion
VI. References
Study design
•
Observational
•
Analytic
•
Cross sectional
•
Unit of analysis: individual
Inclusion & exclusion criteria
Inclusion Criteria:
•
FMUP’s student, available population of the 1st and
5th grades
Exclusion criteria:
•
No questionnaire obtained (no response or no
contact with the subject, after two attempts);
•
Classes 10, 15 and 16 of the 1stgrade
Study participants & sampling methods
Target Population:
•
Medical students
Sampling Methods:
1. Stratification of the sample, according to the
students’ grades
2. Questionnaire’s application to all students of 1st
and 5th grades.
Study participants & sampling methods
Questionnaire’s application method
Selection of date and schedule
to apply the questionnaire to
each class
Selection of other date
and schedule to apply the
questionnaire to the
missing students
Application of the
questionnaire to the students
of the class
no
All the students
are present?
yes
End
Data collection methods. Questionnaire.
Main objectives in the design (Leung WC, 2001, StudentBMJ)
•
•
To maximize the response rate
•
Simplicity, shortness and clearness
•
Close-ended questions only
•
Sensitive questions last
To obtain accurate and relevant information for our survey
•
Different types of questions
•
Reversed coded questions
•
Good question quality
Data collection methods. Questionnaire.
Characteristics of the questionnaire:
•
Self-administered, 4-pages; to be applied in groups
(classes), during obligatory practical sessions.
•
Two sections:
•
Section A – Knowledge
•
Section B – Personal data and behaviour
•
Each question has a “Comments” area.
•
We piloted for clarity in class 10, which resulted in changing
some of the questions, and gave us an idea of its duration.
•
Questions are coded for an easier analysis.
Data collection methods. Questionnaire.
‘Introduction’
Title and logo
Objective
Anonymity
Confidentiality
Instructions
Data collection methods. Questionnaire.
‘Questions’
Variables description
•
Each question generates one or more variables.
•
Analysed variables:
•
Global knowledge of cervical cancer (using a scale); degree of preoccupation
of being infected; degree of self-evaluated knowledge; frequency of pap
smearing  ordinal variables; outcomes in scales
•
Knowledge of specific subjects – questions 2 to 5 (e.g, of the causal link
between HPV and cervical cancer)  nominal variables; outcomes: yes/no
•
Age; age of initiation of sexual activity; number of sexual partners in lifetime
and in the last 12 months  quantitative variables; outcomes will be
categorized
•
Having started sexual activity; use of condom; being vaccinated; having done
a pap smear  nominal variables; outcomes : yes/no
Planned statistical analysis
•
Analysis of each question according to their
previously determined codes.
•
Treatment of the results will be made in SPSS ©
(Statistical Package for Social Sciences).
•
Descriptive statistics
•
Comparative statistics, according to several
interest groups: gender, grade, having or not
started sexual activity, using or not using
condom, etc.
•
Results in tables and graphs.
I.
Background
II. Research Question and Aims
III. Participants and Methods
IV.Results
V. Discussion
VI. References
Answers’ Rate
Gender
Total of
Female
Male
Answers
1st grade
5th grade
126
92
76
42
202
(72,03%)
139
(69,15%)
Total of
Students
286
201
Section A – Knowledge : Question 1 & 2
Table 1. Results of the section A
1st year
n=206
Response rate: 72,03%
5th year
n=139
Response rate: 69,15%
Yes and know what it is
96,6%
99,3%
Yes but don’t know what it is
3,4%
0,7%
Yes
92,6%
99,3%
No
4%
0%
3,4%
0,7%
Variables
Section A
1. Have heard of cervical cancer
2. Know that the main cause of cervical cancer is HPV infection
No opinion

No statistically significant differences were found between grade, age
gender and sexual activity groups (χ2 tests)
Section A – Knowledge: Question 3 (True/False)
Percentage of correct answers in group 3
*
*
*
*
5th Grade
*
1st Grade
*
*
*
*
*
*
* p<0,05 (Chi*
* square test)
*
*
*
*
*
*
"HPV is transmitted through skin." (True)
"HPV types 6 and 11 are oncogenic." (False)
"HPV infection has no known impact in pregnancy." (True)
"HPV infection affects mainly women." (False)
"Some HPV infections frequently disappear without treatment." (True)
"The incidence of cervical cancer in Portugal is the highest in Western Europe." (True)
"Condoms are the most effective way to prevent HPV infection." (False)
"The Papanicolaou smear is used to detect the presence of HPV." (False)
"The HPV types 16 and 18 are the highest-risk types for cervical cancer." (True)
"Some types of HPV cause genital warts." (True)
"There is a virological HPV test that identifies an infection through detection of viral DNA." (True)
"Cervical cancer is more frequently diagnosed in women between 35 and 55 years old." (True)
"An abnormal cytological smear indicates cervical cancer."(False)
"The mortality rate by cervical cancer in Portugal is very low." (False)
"Not all HPV types are potentially oncogenic." (True)
"HPV infection is always symptomatic." (False)
"Vaccination is especially recommended for women who have already started sexual activity."
(False)
"HPV is mainly sexually transmitted." (True)
"HPV infection is uncommon in young women." (False)
"After vaccination, there's no need to continue with Papanicolaou smear screening." (False)
0%
20%
40%
60%
80%
100%
Section A – Knowledge: Question 3 (True/False)
Percentage of correct answers in group 3
"HPV infection has no known impact in pregnancy." (True)
"HPV infection affects mainly women." (False)
"HPV is transmitted through skin." (True)
"Condoms are the most effective way to prevent HPV infection." (False)
*
"Some HPV infections frequently disappear without treatment." (True)
Males
Females
"HPV types 6 and 11 are oncogenic." (False)
*
"The incidence of cervical cancer in Portugal is the highest in Western Europe." (True)
"The Papanicolaou smear is used to detect the presence of HPV." (False)
"The HPV types 16 and 18 are the highest-risk types for cervical cancer." (True)
*
"Vaccination is especially recommended for women who have already started sexual activity." (False)
*
"An abnormal cytological smear indicates cervical cancer."(False)
"Cervical cancer is more frequently diagnosed in women between 35 and 55 years old." (True)
* p<0,05 (Chi-
"There is a virological HPV test that identifies an infection through detection of viral DNA." (True)
square test)
"Some types of HPV cause genital warts." (True)
"The mortality rate by cervical cancer in Portugal is very low." (False)
"Not all HPV types are potentially oncogenic." (True)
*
"HPV is mainly sexually transmitted." (True)
"HPV infection is always symptomatic." (False)
"After vaccination, there's no need to continue with Papanicolaou smear screening." (False)
"HPV infection is uncommon in young women." (False)
0%
20%
40%
60%
80%
100%
Section A – Knowledge: Question 4: Likert scale
No statistically significant
differences were found
between grades. (p=0,428))
Self-assessed degree of preocupation
of getting infected by HPV
5th Grade
High
Medium
Low
1st Grade
0.00%
20.00%
40.00%
60.00%
80.00%
Self-assessed degree of knowledge
about cervical cancer
100.00%
5th Grade
Statistically significant
differences were found
between grades (p<0,001)
High
Medium
Low
1st Grade
0%
20%
40%
60%
80%
100%
Section A – Knowledge: Question 4: Likert scale
Statistically significant
differences were found
between genders. (p<0,001))
Self-assessed degree of preocupation
of getting infected by HPV
Males
High
Females
Medium
Low
High
0%
20%
Medium
40%
60%
Low
80%
100%
Self-assessed degree of knowledge
about cervical cancer
Males
Statistically significant
differences were found
between genders (p=0,034)
High
Females
Medium
High
0%
20%
Low
Medium
40%
60%
Low
80%
100%
Section A – Knowledge: Question 5
Percentage of correct selection of risk
factors in question 5
Extended use of oral contraception is a risk factor
Multiparity is a risk factor
Chlamydia infection is a risk factor
Smoking is a risk factor
*
Treatment with immunodepressive drugs is a risk factor
*
1st grade
Race or ethnicity isn’t a risk factor
HIV infection is a risk factor
5th grade
*
Intake of alcoholic drinks isn’t a risk factor
Having multiple sexual partners is a risk factor
Having a sexual partner with multiple sexual partners is a risk
factor
* p<0,05 (Chi-
*
square test)
*
0%
20%
40%
60%
80%
100%
Section A – Knowledge: Question 5
Percentage of correct selection of risk
factors in question 5
Extended use of oral contraception is a risk factor
Multiparity is a risk factor
Chlamydia infection is a risk factor
Smoking is a risk factor
*
Treatment with immunodepressive drugs is a risk factor
HIV infection is a risk factor
Males
Females
Having multiple sexual partners is a risk factor
Having a sexual partner with multiple sexual partners is a risk
factor
Race or ethnicity isn’t a risk factor
*
* p<0,05 (Chisquare test)
Intake of alcoholic drinks isn’t a risk factor
0%
20%
40%
60%
80%
100%
Section B – Personal and behavioral knowledge
Table 2. Results of the section B
1st year
n=206
5th year
n=139
Female
62,4%
68,7%
Male
37,6%
31,3%
Yes
49,5%
83,2%
No
50,5%
16,8%
Yes
63,7%
41,7%
No
36,3%
58,3%
Variables
Section B
6. Gender
8. Have already started sexual activity
12. Always use condom during sexual activity
Section B – Personal and behavioral knowledge
Table 2. Results of the section B
1st year
n=206
5th year
n=73
Yes
22,9%
18,3%
No
77,1%
81,7%
13,7%
48,9%
86,3%
51,1%
Only did it once
46,6%
48,9%
Annually
46,6%
34,9%
Every 2 or 3 years
6,8%
13,9%
0%
2,3%
Variables
Section B
13. Vaccination against HPV infection
14. Have done a Papanicolaou smear
Yes
No
14.1 Papanicolaou smear frequency
Every 4 years or more
I.
Background
II. Research Question and Aims
III. Participants and Methods
IV. Results
V. Discussion
VI. References
Limitations
•
Low response rate, which leads to a decreased
power of the inference tests, due to:
•
Low willingness of 5th graders to participate
•
Some students simply ran away with the questionnaire.
•
Retained and/or working students attend less to classes
and may not have all subjects
Limitations
•
Treatment of the results, due to:
•
We obtained an enormous amount of data, which
required recoding and treatment.
•
Too much comparisons to do, according to several
interest groups, such as: gender, grade, having or not
started sexual activity, using or not using condom, etc.
Main findings
•
The students of the 5th grade know more about
cervical cancer, in general, than 1st graders:
•
In general, 5th graders have a knowledge rate of 77,6%,
compared to the 1st graders’ 43,8%.
•
The lessons during graduation seems to successfully
instruct them on this subject, which reflects in their
higher self-assessed degree of knowledge.
•
Nevertheless, the self-degree of preoccupation of
getting infected by HPV is similar between the grades:
the higher level of knowledge seems to not affect this
variable.
Main findings
•
Behaviour:
•
The 5th graders have a lower rate of condom use, which
may indicate to their long term duration relationships
when compared to 1st graders.
•
There’s more female students in the 5th grade doing
Papanicolaou smear than female 1st graders.
•
Even though it’s not statistically different, there’s a
tendency for the 1st graders (younger students) to have a
higher vaccination rate.
I.
Background
II. Research Question and Aims
III. Participants and Methods
IV. Results
V. Discussion
VI.References
Baer H, Allen S, Braun L. Knowledge of human papillomavirus infection among young adult men and
women: implications for health education and research. J Community Health. 2000 Feb;25(1):67-78.
Gerhardt CA, Pong K, Kollar LM, Hillard PJ, Rosenthal SL. Adolescents’ Knowledge of Human
Papillomavirus and Cervical Dysplasia. J Pediatr Adolesc Gynecol. 2000 Feb;13(1):15-20.
Holcomb B, Bailey JM, Crawford K, Ruffin MT 4th. Adults' knowledge and behaviors related to human
papillomavirus infection. J Am Board Fam Pract. 2004 Jan-Feb;17(1):26-31.
Kaplan-Myrth N, Dollin J. Cervical cancer awareness and HPV prevention in Canada. Can Fam
Physician. 2007 Apr;53(4):693-6, 697.
Klug SJ, Hukelmann M, Blettner M. Knowledge about infection with human papillomavirus: a
systematic review. Prev Med. 2008 Feb;46(2):87-98. Epub 2007 Sep 14.
Lambert EC. College students' knowledge of human papillomavirus and effectiveness of a brief
educational intervention. J Am Board Fam Pract. 2001 May-Jun;14(3):178-83.
Leung WC. How to design a questionnaire. studentBMJ (2001);09:171-216
Marlow LA, Waller J, Wardle J. Public awareness that HPV is a risk factor for cervical cancer.
Br J Cancer. 2007 Sep 3;97(5):691-4. Epub 2007 Aug 7.
Pitts M, Clarke T. Human papillomavirus infections and risks of cervical cancer: what do
women know? Health Educ Res. 2002 Dec;17(6):706-14.
Tiro JA, Meissner HI, Kobrin S, Chollette V. What do women in the U.S. know about human
papillomavirus and cervical cancer? Cancer Epidemiol Biomarkers Prev. 2007 Feb;16(2):28894.
Yacobi E, Tennant C, Ferrante J, Pal N, Roetzheim R. University students' knowledge and
awareness of HPV. Prev Med. 1999 Jun;28(6):535-41.