0506P - MEDICAL STUDENT KAP REGARDING CANCER PREVENTION

Omar Hasan Kasule[1]

 

ABSTRACT

Introduction: Study of student KAP is important because they are susceptible to health education and change of behavior.

Objectives: The study assesses KAP indicators among medical students and relates them to the year of study and gender.

Methodology: This is a cross-sectional questionnaire study involving undergraduate medical students. The 87 KAP variables covered knowledge (cancer sites, cancer symptoms and signs, cancer detection methods, and cancer treatment methods), cancer risk factors, and cancer prevention methods), opinions on and attitudes towards cancer, and practices regarding cancer prevention (health seeking behaviors, smoking and dietary habits).

Results: The respondents in this study displayed high KAP scores. A KAP score was defined as the percentage of respondents who gave a correct or appropriate response for the KAP variable. Scores were 91-100 for 30 variables, 81-90 for 21 variables, and 51-80 for 25 variables. Only 11 variables had scores below 50. Year of study and gender were significant independent predictors of KAP variables.

Discussion: The findings of the study support those of earlier studies showing variation of KAP indicators by year of study and gender. It is recommended to undertake further research into the impact of the undergraduate medical curriculum on specific KAP indicators.

Key words: KAP, students, medical

INTRODUCTION

This study is part of a series of KAP surveys of KAP regarding cancer among youths[i] [ii]. The first study investigated KAP among secondary school students. The second study investigated KAP regarding cancer in non-medical students in an international university. The present study is investigating KAP in medical students. The underlying motivation for these studies is the thesis that youths are in an impressionable age and that cancer education at that stage will have a lasting lifetime impact. Cancer education in older adults may not have the same impact because lifestyle opinions and attitudes are already fixed and are difficult to change. Several surveys have revealed low KAP indicators regarding cancer prevention among medical students[iii] [iv] [v] [vi].
Specific intervention programs were found to improve medical student KAP regarding cancer prevention[vii] [viii] [ix] [x]. These interventions could have even a bigger impact if they were integrated in the medical curriculum. This study assesses KAP indicators among medical students. A follow-up study will assess the impact of specific parts of the curriculum on KAP.

METHODS

A questionnaire used in 2 previous KAP studies^{1 2} involving the author was modified and was distributed to all students of the UIA Faculty of Medicine with a cover letter explaining the purpose of the study and measures taken to preserve confidentiality as well as requesting written informed consent. Questionnaires were collected, the data was entered in a PC, edited using EXCEL, and analyzed using SPSS version 12.0. The 87 KAP variables covered knowledge (cancer sites, cancer symptoms and signs, cancer detection methods, and cancer treatment methods), cancer risk factors, and cancer prevention methods), opinions on and attitudes towards cancer, and practices regarding cancer prevention (health seeking behaviors, smoking and dietary habits). Some of the KAP variables included were wrong or non-specific. Background variables with potential confounding effects were history of cancer in the several relatives and sources of cancer information. A KAP score for each KAP variable was defined as the percentage of respondents who gave a correct or appropriate response. Both KAP and background variables were tabulated by year of study and gender. Background variables with significant associations with year of study and/or gender as shown by Pearson chi square testing were included in several multivariate logistic regression models relating each KAP variable to year of study (Continuing students in Year 2 and Year 3 vs. New students in Year 1) and gender (female students vs. male students). Levels for the stepwise regression model were set as 0.05 for entry and 0.1 for removal. The maximum number of iterations was set at 20. The odds ratios were computed comparing year 2 and year 3 to year 1 and comparing female to male gender. Detailed raw responses for each KAP variable were tabulated to enable meta-analysis involving similar studies by the author and others.

RESULTS

Study sample

Table #1 shows response to the questionnaire by year of study and gender. Questionnaires were returned from year 1, year 2 and year 3 students.  Being a new medical school, there were no student from year 4 and year 5. The response from year 3 was lower due to the students being scattered in various clinical postings. More males in year 3 returned questionnaires. The overall response rate was 86.7%. Table #2 shows significant variation of gender by year as study among the 195 students who returned questionnaires. The proportion of females responding to the study decreases from year 1 through year 3 which did not correspond to the proportion of females in each year. The predominant majority, 193 (99.0%) were Muslims and 2 were Hindu. The Malay was the dominant ethnic group being out of   .  The age range was very narrow being 2x – 2x.  

Background factors

Reports of cancer in the family were low. The proportions reporting cancer in family members were: father 2.1%, mother 5.2%, brother 0.5%, sister 0%, grandfather 3.1%, grandmother 8.9%, uncle 6.3%, and aunt 2.6%. There was no significant variation of report of cancer in the family with either gender or year of study. Reported sources of cancer information were: doctor 73.3%, nurse at a health centre 19.2%, nurse in a hospital 19.9%, other health staff 30.9%, volunteer non-health staff 25.6%, national television 92.1%, foreign television (satellite/cable) 41.8%, radio 74.9%, primary school classes 32.2%, newspaper 97.9%, magazines 96.9%, books (academic) 95.8%, books (general and popular) 80.7%, pamphlets & newsletters 92.7%, family members 69.5%, secondary school teachers 70.7%, neighbors 23.8%, friends 86.9%, religious leaders 26.7%, matriculation teachers 75.8%, internet 77.5%, political leaders or govt. officials 22.5%, university lecturers 95.8%, social clubs or social gatherings 28.9%, and exhibitions/advertisements (posters) 94.8%. Female students relied on friends for cancer information 86.9% than males 80.7% p = 0.02. The rest of information sources did not show significant variation by gender. Four information sources showed significant variation by year of study. Year 2 (54.7%) and year 3 (41.8%) students relied on foreign satellite TV more than year 1 students (31.6%) p = 0.01. Year 1 students (81.8%) relied on secondary school teachers for cancer information more than year 2 (62.7%) and year 3 (62.5%) students p = 0.02. Year 1 students (36.5%) relied on religious leaders for cancer information more than year 2 (22.7%) and year 3 (12.9%) students p = 0.03. Year 2 students (32.4%) relied on political government officials for cancer information more than year 1 (18.1%) and year 3 (9.4%) students p = 0.02. Year 2 (100%) and year 3 (100%) relied on university lecturers for cancer information more than year 1 (89.9%) p = 0.00

Overview of responses on KAP Variables

The respondents in this study displayed high KAP scores as shown in Table 3. A KAP score was defined as the percentage of respondents who gave a correct or appropriate response for the KAP variable. Scores were 91-100 for 30 variables, 81-90 for 21 variables, and 51-80 for 25 variables. Only 11 variables had scores below 50.

Knowledge of cancer sites (Table 4)

Knowledge of 9 out of 14 cancer sites was significantly higher in continuing than in new students. Significant gender differences were found in the knowledge of only 2 sites out of 14. A higher proportion of females (92.2%) knew cervical cancer than males (84.6%) p = 0.00. A higher proportion of females (93.3%) knew brain cancer than males (87.9%) p = 0.03.

Knowledge of cancer symptoms and signs (Table 5)

The questionnaire had a mixture of specific and non-specific signs as well as common and uncommon ones. Student responses were mostly appropriate with higher proportions of knowledge found for specific and common signs and symptoms: non-healing ulcer, abnormal secretion, swelling, chronic cough, bloody cough, difficulty in swallowing, and frequent bone pains. Significant differences were found between continuing and new students for 6 out of 15 signs/symptoms and these tended to be the more non-specific ones. Gender differences were found only for 2 signs/symptoms: (balding and frequent bone pains) for which females had significantly higher proportions of knowledge.

Knowledge of cancer detection and treatment methods (Table 6)

Continuing students significantly knew more about Pap smear, mammography, chemotherapy, and hormone therapy than new students. There were no significant gender differences.

Knowledge of cancer risk factors and methods of prevention (Table 7)

Overall knowledge of risk factors and prevention methods was good. Knowledge of continuing students was significantly better for 6 out of 10 risk factors and for 5 out of 11 prevention methods. Females had significantly knowledge of one risk factor (multiple sexual partners) out of 10 and 2 prevention methods (avoid drinking alcohol and avoid sex with multiple partners) out of 11.

Opinions and attitudes about cancer (Table 8)

A higher proportion of continuing students knew that cancer was not contagious. Continuing students and female students did not agree that cancer was a rare disease affecting only the unlucky. There were no other significant differences on opinions and attitudes based on year of study or gender.

Health-seeking behavior: (Table 9)

The proportions reporting specific health-seeking behaviors were low in this young population with little and distant worry about cancer. There were no significant differences between continuing and new students however female students showed a highly significant difference from male students with regard to breast self examination.

Smoking and diet behavior (Table 10)

There were no significant differences in smoking and dietary habits between continuing and new students. Female students reported significantly higher fruit intake and lower meat intake.

DISCUSSION

The data shows high levels of knowledge as well as appropriate opinions, attitudes and practices regarding cancer prevention. The respondents get cancer information from a diverse range of sources with mass media playing the major role. New students’ sources of information reflected general community sources of information and differed from those of continuing students who having been in the medical school tended to get more information from academic sources. KAP variables showed better scores for continuing than new students. There were some interesting gender differences. Female students relied more on friends than male students as a source of cancer information. This can be explained by the more close social relations and communication. They also had a higher proportion of knowing that the cervix was a cancer site which would be expected. Also expected was their higher knowledge of alcohol and multiple sexual partners as risk factors. What was unexplainable is their higher proportion of knowing that the brain was a cancer site. The variation of KAP with year of study and gender is similar to the finding of a Massachusetts study of medical students³. The generally low levels of health seeking behaviors can be explained by the relative youth of the study participants and their not worrying about cancer at this stage. The impact of the medical curriculum on cancer KAP will be explored in a subsequent study that will identify components of the curriculum that have the bigger impact on cancer KAP.

TABLE 1: RESPONSE PROPORTIONS BY GENDER and YEAR OF STUDY

	Year 1			Year 2			Year 3			All Years Combined
Gender	No.	Total	% Response	No.	Total	% Response	No.	Total	% Response	No.	Total	% Response
Male	26	27	96.3%	39	42	92.9%	26	37	70.3%	91	106	85.8%
Female	56	60	93.3%	37*	35	105.7%	11	24	45.8%	104	119	87.4%
All	82	87	94.3%	76	77	98.7%	37	61	60.7%	195	225	86.7%

* The 2 extra students were repeating the year

TABLE 2: STUDY SAMPLE BY GENDER AND YEAR OF STUDY

	OVERALL	YEAR 1	YEAR 2	YEAR 3	Chi	P
Male	91 (46.7%)	26 (31.3%)	39 (51.3%)	26 (70.3%)	16.3 (2 df)	0.000
Female	104 (53.3%)	56 (68.3%)	37 (48.7%)	11 (29.7%)
Total	195	82	76	37

TABLE 3: NUMBER OF KAP VARIABLES IN EACH of 10 GROUPS BY CORRESPONDING KAP SCORE

	KAP SCORE (% OF RESPONDENTS GIVING AN APPROPRIATE RESPONSE)
	91-100	81-90	51-80	<50	Total
1. Cancer sites	5 (35.7%)	5 (35.7%)	3 (21.4%)	1 (7.1%)	14 (100%)
2. Cancer signs and symptoms	2 (13.3%)	4 (26.7%)	8 (53.3%)	1 (6.7%)	15 (100%)
3. Cancer detection methods known	1 (16.7%)	2 (33.3%)	2 (33.3%)	1 (16.7%)	6   (100%)
4. Cancer treatment methods	2 (50.0%)	1 (25.0%)	1 (25.0%)	0 (0.0%)	4   (100%)
5. Cancer risk factors	3 (27.3%)	3 (27.3%)	5 (45.5%)	0 (0.0%)	11 (100%)
6. Cancer prevention methods	2 (18.2%)	4 (36.4%)	5 (45.5%)	0 (0.0%)	11 (100%)
7. Opinions on cancer	9 (90.0%)	1 (10.0%)	0 (0.0%)	0 (0.0%)	10 (100%)
8. Attitudes to cancer	5 (83.3%)	1 (16.7%)	0 (0.0%)	0 (0.0%)	6   (100%)
9. Health seeking behaviors	0 (0.0%)	0 (0.0%)	0 (0.0%)	6 (100%)	6   (100%)
10. Smoking and dietary habits	1 (25.0%)	0 (0.0%)	1 (25.0%)	2 (50.0%)	4   (100%)
Total	30 (34.5%)	21 (24.1%)	25 (28.7%)	11 (12.6%)	87 (100%)

TABLE 4: KNOWLEDGE OF CANCER SITES

CANCER SITE	ALL YEARS COMBINED			year 2 and Year 3 vs. Year 1		Gender: Female vs. male
	n	N	%	OR (95% CI)	p	OR (95% CI)	P
Lung	182	192	94.8	5.2 (1.0 – 27.7)	0.06	1.0 (0.24, 4.4)	1.0
Breast	195	195	100	Na	na	na	na
Cervix	172	194	88.7	24.3 (4.4, 133.8)	0.00	7.6 (1.9, 30.3)	0.00
Mouth	159	194	82.0	4.0 (1.3, 11.6)	0.01	1.8 (0.70, 4.6)	0.22
Uterus	178	194	91.8	8.3 (2.1, 33.6)	0.00	1.7 )0.5, 5.2)	0.43
Blood	166	191	86.9	59.0 (8.7, 400)	0.00	3.0 (1.0, 9.4)	0.06
Intestine	150	194	77.3	16.9 (5.3, 53.7)	0.00	0.94 (0.4, 2.4)	0.90
Stomach	169	194	87.1	3.0 (1.0, 8.6)	0.05	1.2 (0.5, 3.3)	0.68
Bone	169	194	87.1	6.4 (1.8, 22.3)	0.00	2.6 (0.9, 7.8)	0.08
Skin	181	195	92.8	1.4 (0.36, 7.2)	0.72	3.7 (0.7, 19.0)	0.12
Eyes	95	191	49.7	5.6 (2.5, 12.2)	0.00	1.0 (0.5, 1.9)	0.90
Bladder	127	190	66.8	19.6 (7.1, 53.8)	0.00	1.2 (0.5, 3.0)	0.63
Kidney	117	191	61.3	12.6 (5.2, 30.7)	0.00	1.4 (0.7, 3.2)	0.37
Brain	181	194	93.3	2.3 (0.5, 10.1)	0.29	6.0 (1.2, 30.8)	0.03

TABLE 5: KNOWLEDGE OF CANCER SYMPTOMS and SIGNS

SYMPTOM / SIGN	ALL YEARS COMBINED			year 2 and Year 3 vs. Year 1		Gender: Female vs. male
	n	N	%	OR (95 % CI)	p	OR (95% CI)	p
Non-healing Ulcer	134	168	79.8	1.7 (0.7, 4.3)	0.27	1.1 (0.5, 2.5)	0.90
Inability to fall asleep (insomnia)	49	149	33.1	1.8 (0.8, 4.5)	0.19	1.2 (0.6, 2.6)	0.67
Abnormal secretion or bleeding	167	179	93.3	1.4 (0.3, 7.2)	0.71	4.9 (0.9, 28.9)	0.07
Increased appetite	16	155	10.3	0.4 (0.1, 1.3)	0.13	0.6 (0.2, 2.1)	0.46
Gradual hair loss (balding)	126	178	70.8	07. (0.3, 1.7)	0.46	2.9 (1.3, 6.2)	0.01
Swelling or thickening of any part of the  body	165	182	90.7	2.5 (0.7, 9.0)	0.16	2.0 (0.6, 6.6)	0.25
Frequently passing urine at night in a young person	54	152	35.5	3.4 (1.3, 8.8)	0.01	1.1 (0.5, 2.5)	0.80
Chronic cough	158	177	89.3	2.8 (0.8, 9.5)	0.11	1.5 (0.5, 4.5)	0.46
Prolonged diarrhea (at least 2 weeks)	76	154	49.4	3.3 (1.4, 7.8)	0.01	0.9 (0.4, 1.9)	0.79
Bloody cough	164	184	89.1	2.9 (0.9, 9.7)	0.08	0.5 (0.2, 1.6)	0.25
Sudden chest pain	71	158	44.9	0.5 (0.3, 1.2)	0.12	2.0 (1.0, 4.0)	0.06
Swelling of the breast during menstrual period	59	163	36.2	0.7 (0.3, 1.6)	0.40	0.5 (0.3, 1.1)	0.08
Difficulty in swallowing	115	163	70.6	7.7 (3.0, 20.3)	0.00	0.8 (0.4, 1.9)	0.65
Difficulty in passing motion (constipation) for more than 2 weeks	92	155	59.4	7.3 (3.0, 17.9)	0.00	0.6 (0.3, 1.3)	0.17
Frequent Bone Pains	139	154	84.8	6.9 (2.1, 22.5)	0.00	3.3 (1.1, 9.6)	0.03

TABLE 6: KNOWLEDGE OF CANCER DETECTION and TREATMENT METHODS

METHOD	ALL YEARS COMBINED			year 2 and Year 3 vs. Year 1		Gender: Female vs. male
CANCER DETECTION	n	N	%	OR (95% CI)	p	OR (95% CI)	p
Pap smear	154	182	84.6	1.2? (8.8, 750)	0.00	1.4 (0.4, 4.3)	0.58
Mammography	139	179	77.7	7.4 (2.7, 19.8)	0.00	1.6 (0.7, 4.1)	0.30
Breast Self-examination	190	193	98.4	10.6 (0.4, 31.8?)	0.17	1.1 (0.1, 18.5)	0.97
Chest X-ray	137	177	77.4	1.2 (0.5, 2.8)	0.75	0.7 (0.3, 1.7)	0.48
Physician Regular Check-up	150	182	82.4	1.8 (0.7, 4.5)	0.22	1.3 (0.6, 3.1)	0.52
Stool Examination for blood	74	172	43.0	2.0 (0.9, 4.3)	0.08	1.2 (0.6, 2.5)	0.55
CANCER TREATMENT
Chemotherapy	183	194	94.3	20.7 (1.6, 268)	0.02	5.1 (0.8, 33.1)	0.09
Radiotherapy	158	189	83.6	30.3 (6.1, 150)	0.00	0.4 (0.1, 1.3)	0.14
Surgery	185	191	96.9	8.4 (0.7, 108)	0.10	0.9 (0.1, 6.4)	0.89
Hormone therapy	92	179	51.4	3.4 (1.6, 7.4)	0.00	0.8 (0.4, 1.6)	0.59

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[1] Professor Faculty of Medicine UIA Kuantan Malaysia

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[i] Prof Omar Hasan Kasule Sr,, Prof MD Tahir MD Azhar,, Prof Dr Syed Hassan al-Mashor, Dr Hooi Lai Ngoh, Dr Zarihad Md. Zain, Dr Gerald Lim, Dr Aziz Baba, Dr Fuad Ismail,: Impact of School-based Intervention on Cancer KAP. International Medical Journal. Vol. 1 No. 1  June 2002

[ii] Omar Hasan Kasule. Knowledge and Attitudes About Cancer Prevention: A Perspective Of A Multi- National Islamic University Community. International Medical Journal  Vol. 1 No. 2  December 2002

[iii] Zapka JG, Luckmann R, Sulsky SI, Goins KV, Bigelow C, Mazor K, Quirk M.
Cancer control knowledge, attitudes, and perceived skills among medical students. J Cancer Educ. 2000 Summer;15(2):73-8

[iv] Geller AC, Prout M, Sun T, Lew RA, Culbert AL, Koh HK. Medical students' knowledge, attitudes, skills, and practices of cancer prevention and detection. J Cancer Educ. 1999 Summer;14(2):72-7

[v] Crofton JW, Freour PP, Tessier JF. Medical education on tobacco: implications of a worldwide survey. Tobacco and Health Committee of the International Union against Tuberculosis and Lung Disease (IUATLD). Med Educ. 1994 May;28(3):187-96

[vi] Tessier JF, Freour P, Belougne D, Crofton J. Smoking habits and attitudes of medical students towards smoking and antismoking campaigns in nine Asian countries. The Tobacco and Health Committee of the International Union Against Tuberculosis and Lung Diseases. Int J Epidemiol. 1992 Apr;21(2):298-304

[vii] (Gooderham MJ, Guenther L. Impact of a sun awareness curriculum on medical students' knowledge, attitudes, and behaviour. J Cutan Med Surg. 1999 Apr;3(4):182-7

[viii] Liu KE, Barankin B, Howard J, Guenther LC.One-year followup on the impact of a sun awareness curriculum on medical students' knowledge, attitudes, and behavior. J Cutan Med Surg. 2001 May-Jun;5(3):193-200

[ix] Kolasa KM, Jobe AC, Miller MG, Clay MC. Teaching medical students cancer risk reduction nutrition counseling using a multimedia program. Fam Med. 1999 Mar;31(3):200-4

[x] Gooderham MJ, Guenther L. Impact of a sun awareness curriculum on medical students' knowledge, attitudes, and behaviour. J Cutan Med Surg. 1999 Apr;3(4):182-7