Integrated Medical Education Resources: 0903P - KNOWLEDGE, ATTITUDES, AND PRACTICES (KAP) REGARDING CANCER PREVENTION AMONG STUDENTS OF THE INSTITUTE OF MEDICINE, UNIVERSITI BRUNEI DARUSSALAM

Paper by Prof. Omar Hasan Kasule Sr.

Institute of Medicine, Universiti Brunei Darussalam

Abstract (383 words)

The paper reports results of a cross-sectional questionnaire study of cancer knowledge, attitudes, and practices (KAP) among students of the Institute of Medicine, Universiti Brunei Darussalam. An extensive questionnaire of cancer KAP profiles designed and used previously by the author was employed in the study [1]. The self administered self coding questionnaire was distributed after explaining the aims of the study and obtaining student consent. Data was coded and was analyzed using the SPSS and STATA packages. The data was summarized as proportions. Contingency 2 x 2 tables were generated and bivariate relations were tested using Fisher’s exact test. The response rates by year of study were: 1^st year 17/17 (100%), 2^nd year 12/13 (92.3%), and third year 9/15 (60%). There were 18 males and 20 females. There was no statistically significant variation of gender distribution by year of study. The age range was very narrow 2-3 years in the early twenties. Results of data analysis revealed high KAP scores on most indicators. The following are the proportions of students with appropriate knowledge: cancer sites 39.5-100%, cancer detection methods 42.1-92.1%, cancer treatment methods 42.1-97.4%, and cancer risk factors was: 42.1-97.4%. Opinions about cancer were: cancer can be cured if detected early 86.8%, most cancers are life-threatening 57.9%, some cancers can be detected early 63.2%, all cancers can be detected early 23.7%, and some cancers are hereditary 92.1%. Attitudes towards cancer were: I would like to detect cancer early in order to save my life 92.1%, all individuals are at risk of getting cancer 92.1%, I prefer traditional treatment if I have breast cancer 2.6%, I will not see a doctor even if I have early signs of cancer 2.6%, I do not like to sit next to someone smoking 81.6%, and I am not concerned about what I eat 26.3%. Practices regarding cancer prevention were: Hepatitis B vaccination 73.3%, breast examination by a doctor or a nurse 47.4%, mammography 31.5%, breast self-examination 60.5%, pap smear 36.8%, and annual physical examination 52.5%. The scores also corresponded with what would be expected from epidemiological data for example all respondents knew lung cancer which is common but only 39.5% knew eye cancer that is rare. Some of the opinions were unexpected like 26.3% of the respondents saying that they were not concerned about what they ate.

Key words: cancer prevention, knowledge, attitudes, practices

INTRODUCTION

Cross sectional

METHODS

RESULTS

Cancer KAP

Response: Yr 1 17/17 (100%), Yr 2 12/13 (92.3%), Yr 3 9/15 (60%)

18 males, 20 females

No significant gender variation by year of study

KNOWLEDGE OF CANCER SITES

Lung 100%

Breast 97.4%

Cervix 89.5%

Mouth 76.3%

Uterus 76.3%

Blood 81.6%

Intestine 78.9%

Stomach 86.8%

Bone 78.9%

Skin 97.4%

Eyes 39.5%

Bladder 44.7%

Kidney 57.9%

Brain 94.7%.

KNOWLEDGE OF CANCER DETECTION METHODS

PAP smear 92.1%

Mammography 86.8%

Breast self-examination 94.7%

Chest x-ray 73.7%

Physician regular check-up 76.3%

Stool examination for blood 44.7%.

KNOWLEDGE OF CANCER TREATMENT METHODS

Chemotherapy 97.4%

Radiotherapy 86.8%

Surgery 97.4%

Hormone therapy 42.1%.

KNOWLEDGE OF CANCER RISK FACTORS

Cigarette smoking 97.4%

Tobacco chewing 68.4%

Betel nut chewing 47.4%

Diet high lipid content 47.4%

Diet Low in vegetables & Fruits 57.9%

Diet Low in fiber 50.5%

Viral infections 65.8%

Multiple sexual partners 42.1%

Alcohol 86.8%

Occupational Exposure 84.2%

Chemicals and Drugs 89.5%.

OPINIONS ABOUT CANCER

cancer can be cured if detected early 86.8%

cancer is a serious problem 84.2%

cancer is a punishment for sins and should not be treated 2.6%

most cancers are life-threatening 57.9%

only smokers will get cancer 2.6%

some cancers can be detected early 63.2%

all cancers can be detected early 23.7%

cancer is very rare and affects only those who are unlucky 2.6%

some cancers are hereditary 92.1%, and cancer is contagious 7.9%.

ATTITUDES TOWARDS CANCER

I would like to detect cancer early in order to save my life 92.1%

all individuals are at risk of getting cancer 92.1%

I prefer traditional treatment if I have breast cancer 2.6%

I will not see a doctor even if I have early signs of cancer 2.6%

I do not like to sit next to someone smoking 81.6%

I am not concerned about what I eat 26.3%.

PRACTICES REGARDING CANCER PREVENTION

Hepatitis B vaccination 73.3%

breast examination by a doctor or a nurse 47.4%

mammography 31.5%

breast self-examination 60.5%

pap smear 36.8%

annual physical examination 52.5%

never smoked 2.6%

DISCUSSION

REFERENCES

1. Omar Hasan Kasule Sr, MD Tahir MD Azhar, Syed Hassan al-Mashor, Hooi Lai Ngoh, Zarihad Md. Zain, Gerald Lim, Aziz Baba, Fuad Ismail, impact of school-based health intervention on cancer KAP. International Medical Journal Vol 1 No. 1 (www.e-imj.com)

Geller AC, Prout M, Sun T, Lew RA, Culbert AL, Koh HK. Medical students' knowledge, attitudes, skills, and practices of cancer prevention and detection. 1: J Cancer Educ. 1999 Summer;14(2):72-7

BACKGROUND: Surveys of U.S. physicians show deficiencies in cancer detection and counseling skills. Thus, there is a compelling need to provide skills teaching during medical school for cancers with preventable mortality and for counseling techniques for smoking prevention and cessation. METHODS: In advance of the integration of initiatives for cancer education into the medical school curriculum, the authors conducted a baseline survey of students' knowledge, attitudes, skills, practices, observation, and training (KASPOT) related to cancer education. Eighty-one percent of Boston University School of Medicine students (n = 499) completed surveys. RESULTS: The students reported higher levels of KASPOT for breast and cervical cancers, compared with skin cancer examination or tobacco use cessation or prevention counseling. More than half of third- and fourth-year students reported that too little emphasis was given to cancer control education. CONCLUSIONS: It appears that students' practice and skills for detection of the most common cancer (skin cancer), and for cancers with the greatest mortality (tobacco-related cancers) are deficient. Revisions in medical students' curricula should seek to address these shortcomings.

Post-White J, Carter M, Anglim MA. Cancer prevention and early detection: nursing students' knowledge, attitudes, personal practices, and teaching. Oncol Nurs Forum. 1993 Jun;20(5):743-9..

This study evaluated the impact of an educational workshop on nursing students' knowledge, attitudes, and personal practices regarding cancer prevention and early detection (CP&ED), as well as the effect that it had on their teaching of CP&ED recommendations. Four one-day workshops--which included lectures, small group discussions, and practice of early detection skills--were held in three cities in Minnesota. Students from baccalaureate, associate-degree, and practical nursing programs participated (N = 220). Preworkshop, postworkshop, and six-month follow-up surveys were used to evaluate the knowledge, attitudes, and self-practice of the participants, as well as their teaching of clients, family, friends, and peers. Data were analyzed with matched paired t-tests, chi-square, correlation, and analysis of variance. The postworkshop and six-month follow-up surveys showed improvement in the students' knowledge and attitudes; however, the only self-practice behaviors that changed within six months of the workshop were breast/testicular self-examinations. The results also showed that the students felt more confident and subsequently taught more clients, family, friends, and peers about the CP&ED recommendations. These findings indicate that educating students early in their careers may increase the number of people practicing CP&ED recommendations

Geller AC, Prout MN, Miller DR, Siegel B, Sun T, Ockene J, Koh HK. Evaluation of a cancer prevention and detection curriculum for medical students. Prev Med. 2002 Jul;35(1):78-86.

BACKGROUND: Undergraduate medical education needs revision to ensure that medical students graduate with the skills necessary to assist their patients in cancer prevention and detection. We sought to implement and incorporate a cancer education curriculum into the students' core curriculum and to assess their skill levels prior to (1996), during (1997), and at the peak (1998-1999) of the incorporation of new hours. METHODS: We conducted pretest and posttest surveys of students at Boston University School of Medicine (medical student years 1-4) enrolled in each of the four study years (1996-1999). A total of 1,956 surveys (response rate, 82%) were completed. The primary outcome measure was the student's self-reported skill level (with responses ranging from 1 (very unskilled) to 5 (very skilled)) for counseling for tobacco cessation, tobacco prevention, and sun protection and for the early detection of breast, skin, and cervical cancer. Mean scores were computed for each chronological year of the study and medical school year. Differences and trends over time in mean scores of students in each medical school year were evaluated using multiple regression analysis. RESULTS: The number of hours of cancer education increased from 6 in 1996 to 15 in 1999. Strong improvements in self-rated skill levels were recorded for four of the six measures. In particular, tobacco cessation counseling skill rose from 2.16 (1996) to 3.13 (1999) for second year students (P < 0.001) and from 3.27 (1996) to 4.17 (1999) for fourth year students (P < 0.001). Among fourth year students, the percentage reporting that cancer prevention was given too little emphasis declined from 62% (1996) to 26% (1999) (P < 0.001), suggesting that the expanded curriculum reflected the students' preferences. CONCLUSIONS: Cancer education can be interwoven into the existing medical school curriculum and produce improvements in students' skill levels for counseling and examinations. Strategies to enhance prevention teaching can use this model.

Reed SG, Duffy NG, Walters KC, Day TA1: Oral cancer knowledge and experience: a survey of South Carolina medical students in 2002.

J Cancer Educ. 2005 Fall;20(3):136-42.

BACKGROUND: Compared to the U.S. states and District of Columbia, the adult population in South Carolina ranks in the high five in oral cavity and pharynx cancer mortality rate and top ten for incidence rate. Previous studies revealed a lack of knowledge related to the diagnosis of oral cancer among health professionals in the USA. This study assessed the oral cancer knowledge and experience of medical students in an academic setting. METHODS: This IRB approved cross-sectional survey used a self-administered pilot-tested questionnaire and the census of the Medical University of South Carolina medical students. Data were summarized by frequencies and chi-square comparisons of pre-clinical (first and second year) and clinical (third and fourth year) students. RESULTS: The overall response rate was 79% (450/571 students), range 61-91% by year. Significant (p < 0.001) differences were found between pre-clinical and clinical students for knowledge of risk factors, signs and symptoms of oral cancer, and tobacco cessation techniques; with clinical students more knowledgeable but at less than 78% accuracy. All students were in high agreement of the role and responsibility of physicians in tobacco cessation, and in medical history taking. Four students had seen or been instructed on how to perform an oral biopsy. Most (75%) of fourth year students felt adequately trained to palpate neck lymph nodes. However, less than 7% of all students perceived they were adequately trained to examine patients for oral cancers. CONCLUSIONS: Results suggest that these students may not receive adequate exposure to oral cancer prevention and detection knowledge and practices. Additional training to increase knowledge of risk factors and cessation counseling, and knowledge of signs and symptoms and examination skills may improve oral cancer prevention and detection. The implication is that additional education for the medical students in prevention and detection may lead to improvements in South Carolina oral cavity and pharyngeal cancer incidence and mortality rates.

Springer CM, Tannert Niang KM, Matte TD, Miller N, Bassett MT, Frieden TR. Do medical students know enough about smoking to help their future patients? Assessment of New York City fourth-year medical students' knowledge of tobacco cessation and treatment for nicotine addiction. Acad Med. 2008 Oct;83(10):982-9.

PURPOSE: Practicing physicians underutilize U.S. Department of Health and Human Services evidence-based approaches to nicotine addiction and treatment. Few studies have assessed medical student knowledge in this area. This study examined New York City fourth-year medical students' knowledge of tobacco cessation and treatment of nicotine addiction. METHOD: The authors conducted a Web-based survey, comprising 27 closed- and open-ended questions, of six of seven New York City medical schools in the spring of 2004. They drew questions from international, national, and local surveys on tobacco and health, U.S. Department of Health and Human Services tobacco treatment guidelines, and prior studies. Primary outcome measures were knowledge of the epidemiology of smoking, benefits of cessation and treatment of nicotine addiction, clinical cessation practices, and students' use of tobacco and intentions to stop smoking. RESULTS: Of 943 fourth-year medical students, 469 (50%) completed an online survey. Students had good knowledge of the epidemiology of smoking, including its prevalence and health effects, with most responding correctly to relevant questions (mean correct response 79%; SD = 9.4). Students demonstrated a fair understanding of the benefits of cessation (mean correct response, 67%; SD = 19.2) and treatment of nicotine addiction (mean correct response, 61%; SD = 13.2). Three hundred students (64%) rated their own preparation to assist patients to quit as less than adequate. CONCLUSIONS: Fourth-year medical students at the participating schools in New York City understood the harms of smoking but needed more information on the benefits of stopping smoking and treatment of nicotine addiction.

Schkrohowsky JG, Kalesan B, Alberg AJ. Tobacco awareness in three U.S. medical schools. 1: J Addict Dis. 2007;26(3):101-6.

PURPOSE: To evaluate the attitudes, knowledge, and beliefs of future physicians regarding smoking cessation and tobacco-related issues and the development of these attributes during the course of medical education. METHODS: In a cross-sectional survey, questionnaires were completed by 298 first- and fourth-year medical students at three medical schools from 2003 through 2004. The primary outcomes were knowledge of the health effects of tobacco and smoking cessation strategies, attitudes toward smoking cessation, and anticipated clinical behavior with respect to addressing smoking behavior and cessation with future patients. RESULTS: Fourth-year medical students had knowledge scores that were 13% higher than first-year students for smoking-caused morbidity and mortality and understanding the physician's /role in smoking cessation. The average proportion of correct responses for specific knowledge of smoking cessation was only 64% and did not differ significantly between fourth- and first-year medical students. Three-quarters of fourth-year students felt they needed further training in counseling patients to stop smoking. CONCLUSION: In this study, medical students had not received adequate education to provide effective and appropriate smoking cessation counseling to their patients. In general, this indicates a need for medical schools to place greater emphasis on developing the knowledge-base and skills required for future physicians to effectively guide their nicotine-dependent patients to stop smoking.

Daudt AW, Alberg AJ, Prola JC, Fialho L, Petracco A, Wilhelms A, Weiss A, Estery C1: A first step incorporating smoking education into a Brazilian medical school curriculum: results of a survey to assess the cigarette smoking knowledge, attitudes, behaviour, and clinical practices of medical students. J Addict Dis. 1999;18(1):19-29.

Smoking-related illnesses are the leading causes of morbidity and mortality in Brazil. Despite a smoking prevalence of approximately 40%, there is limited national effort to reduce tobacco use in Brazil by means of public education and training of health care professionals to promote smoking education. In particular, the need for information about tobacco warrants increased emphasis in undergraduate medical education. An educational program on nicotine addiction during medical school could facilitate the incorporation of smoking cessation interventions into routine medical practice. As a preliminary step toward implementing a tobacco education and intervention program, this study was designed to assess knowledge and attitudes about smoking among Brazilian medical students. Five hundred thirteen (N = 513) medical students from the Federal University of Rio Grande do Sul, the southernmost state of Brazil, completed a self-reported questionnaire during the 1995-1996 academic school year. Most students recognize the adverse health effects of smoking and the importance of their professional role in promoting smoking cessation. In contradiction, however, few medical students currently provide their patients who smoke with even minimal intervention. This discrepancy supports the idea that training in nicotine addiction and smoking cessation techniques will help medical students to develop the skills and confidence needed to successfully intervene with their current and future patients.

Mostafa SR, Shokeir NF. Smoking-related behaviour and attitudes among medical students in Alexandria. 1: J Egypt Public Health Assoc. 2002;77(1-2):1-28.

As a preliminary step toward incorporating a tobacco education and intervention program into our undergraduate medical curriculum, this study was designed to assess students' smoking-related behaviour, knowledge and attitudes towards tobacco, and perceptions of their future role as doctors in smoking intervention. A cross-sectional, study was conducted in the university year 2001/2002 on a representative sample of male medical students enrolled in 4th and 5th years at Alexandria University. A total of 320 students across the 2 years completed the survey. The smoking rate among medical students was 17.5% (10.9% smoked daily and 6.6% occasionally). The awareness of harmful effects of smoking and knowledge about the causal role of tobacco in the development of specific diseases were deficient. The intention to perform smoking intervention in the future as doctors seemed unsatisfactory. About 85% of the students thought that doctors should carry out smoking cessation advice depending on the disease, while the rate of those who thought so irrespective of the disease did not reach 44%. Current smokers thought less actively about smoking intervention than non-smokers. Nearly two-thirds of students (65.3%) felt they were not sufficiently prepared for caring or counseling smokers, and only 31.9% of students were convinced of the effectiveness of the doctor's advice to stop smoking. Seventy-seven and half percent of them desired specific training in smoking intervention. Non-smokers were more in favour of legislative actions to discourage tobacco use than current smokers. These findings suggest that medical school authorities should design and implement an appropriate basic training aimed at better preparing medical students for their future role in prevention of smoking. Specific teaching of medical students about smoking-related diseases and a patient-centered smoking cessation intervention is required to provide future medical practitioners with the knowledge and skills they need to effectively intervene with smokers

Richmond RL, Kehoe L.1: Med Educ. 1997 May;31(3):169-76. Links

Smoking behaviour and attitudes among Australian medical students.

Teaching about tobacco and related diseases is essential in the undergraduate medical course in order for students to gain knowledge about smoking and how to intervene with patients who smoke. The objective of the study was to assess students' smoking-related behaviour, knowledge and attitudes towards tobacco, and perceptions of their future role as doctors. Data were collected from two consecutive years of year 1 and year 5 medical students at the University of New South Wales, Sydney. A total of 594 (79%) of students across the 2 years completed the survey: 90% of year 1 students, and 69% of year 5 students. The daily smoking rate among the total medical students was 2.9%: 11.8% in year 1 (2.3% daily, 9.5% occasional) and 13.7% in year 5 (3.3% daily, 10.4% occasional). There were significantly more male than female smokers in year 5 (P < 0.05). The overall smoking rates for males in years 1 and 5 were 12.4% and 19.3%, and the smoking rates for females were 11.2% and 8%. Knowledge about the causal role of tobacco in the development of specific diseases improved significantly from year 1 to year 5 (P < 0.001). Nevertheless, in year 5 there remained a lack of knowledge about the relationship of smoking and some diseases. Fifty-seven per cent of students thought that their current knowledge was sufficient to counsel smokers, with year 5 students (89%) being far more positive than year 1 students (34%) (P < 0.001). Teaching medical students about smoking-related diseases and a patient-centred smoking cessation intervention results in an increase in knowledge, as well as positive perceptions about their future role in intervening with smokers

Kawakami M.1: Awareness of the harmful effects of smoking and views on smoking cessation intervention among Japanese medical students. Intern Med. 2000 Sep;39(9):720-6.

OBJECTIVE: To clarify attitudes toward smoking, and views on smoking intervention among medical students, as well as to teach them the harmful effects of smoking. SUBJECTS AND METHODS: We carried out an anonymous questionnaire among 2nd and 5th year Japanese medical students and 1,137 of them responded. RESULTS: Smoking prevalence was 25.1% in men and 8.8% in women in the 2nd year and 43.1% and 9.3%, respectively, in the 5th year. Most respondents thought smoking is harmful to health, but smokers were more likely to think it is not so harmful. In both groups, 97% of the respondents knew lung cancer was related to smoking. Apart from this, knowledge of smoking-related diseases (pulmonary emphysema, coronary heart disease, peptic ulcer, and neonatal death) increased by the 5th year but the rates of recognition were generally less than 50%. Many of them learned about the deleterious effects mainly at places other than medical class (80.2% in the 2nd, 44.9% in the 5th year). About 90% intended to perform smoking intervention in the future, but only one-third were actively interested. More than 70% of the respondents thought that doctors should carry out smoking cessation advice depending on the disease, while the rate of those who thought so irrespective of the disease did not reach 20%. Smokers thought less actively about smoking intervention than current nonsmokers. CONCLUSION: The awareness of the harmful effects of smoking and intention to perform smoking intervention in the future as doctors seemed unsatisfactory among Japanese medical students.

Fakhfakh R, Hsairi M, Ben Romdhane H, Achour N, Ben Ammar R, Zouari B, Nacef T.1: Smoking among medical students in Tunisia: trends in behavior and attitudes (French) Sante. 1996 Jan-Feb;6(1):37-42.

We report a cross sectional survey to analyze the effects of medical training on the smoking habits of Tunisian medical students, and their attitudes and knowledge about smoking. Two groups of medical students were studied. One group was 257 first year students at the Medical Faculties of Tunis and Sfax, in 1987, the other 211 final year students at the same Faculties in 1994 and who had been in the first year in 1987. A questionnaire bases on that of the WHO and International Union against Lung Disease for health professionals was administered. It was completed by 95% of the students. Fifty-four % were men and 46% women, and 70.2% lived in an urban area before attending university (table 1). Nonsmokers were defined as those who had never smoked. Exsmokers were those who had formerly smoked but no longer did so. Smokers were divided into those who smoked occasionally and those who smoked daily. The prevalence of smoking was higher among the final year students than the first year students. Combined daily and occasional smoking was 24.1% among first year students and 37.1% among final year students (table 2). The rates among men for daily smoking were 19.2% in the first year and 38.9% in the final year, whereas for women the corresponding rates were 1.8% and 2% (table 3). The prevalence of occasional smoking among men was 17.8% for the first year and 17.7% in the final year. Among women, this behavior increased from 5.5% to 16.8%. Men exsmokers increased from 6.2% to 16.8% and women from 4.6% to 13.4% from the first to the final year. The proportion of first year smokers who reported a serious attempt to stop was 64.8% and that of final year students was 50%. Protected personal health was the most common reason (table 4). In the final year, 94.1% of te students agreed strongly with the view that smoking is harmful to health (table 5). However, there was substantial underestimation of the contribution of tobacco to causing serious diseases including bladder cancer, coronary artery disease, peripheral vascular disease, emphysema and neonatal morality (table 6). The study evidences insufficient awareness of medical students about their responsibility for health education and prevention. There was little interest in preventive action for patients. Only 4.5% of the final year students felt that they were equipped to advise patients about smoking. Similarly, 65.7% would not advise patients to stop smoking if they had no smoking-related symptoms and did not raise the question themselves (table 7). There were major deficiences in knowledge of preventive measures. Only 45.5% of final year students considered that they had adequate knowledge to advise patients about smoking (table 8) and 72.5% thought that they should have received more specific training about counseling (table 9). This work shows that, like in Africa, Asia and Europe, Tunisian medical students have an unsatisfactory knowledge of tobacco and its effects. There were no substantial changes in the students' knowledge of, or attitude to, smoking between the first and final year of training. Simply stimulating the interest of these future doctors in the problem of smoking is insufficient

Mostafa SR, Shokeir NF1: Smoking-related behaviour and attitudes among medical students in Alexandria. J Egypt Public Health Assoc. 2002;77(1-2):1-28.

Daudt AW, Alberg AJ, Prola JC, Fialho L, Petracco A, Wilhelms A, Weiss A, Estery C.A first step incorporating smoking education into a Brazilian medical school curriculum: results of a survey to assess the cigarette smoking knowledge, attitudes, behaviour, and clinical practices of medical students. 1: J Addict Dis. 1999;18(1):19-29.