Received date: 21 March 2006; Accepted date: 31 July 2006
Background In Mexico, there has been a National Cervical Cancer Screening Program (NCCSP) since 1974. Undergraduate medical and nursing students are the most important healthcare providers in rural areas.Objective To evaluate knowledge about the aetiology andpreventio n of cervical cancer among undergraduate medical and nursing students during their social service placements in Yucatan, Mexico.Method A questionnaire survey was carriedout which included all the medicine and nursing students who had completed their credits and were doing their social service in a rural community of Yucatan. A 10-item questionnaire, validated previously by other researchers, was usedfor the evaluation. Each correctly answereditem was given a point. The maximum grade was 10 and theminimum 0, andfor optimum analysis the results were classifiedinto three levels of knowledge: low, from0 to 4 points; medium, from5 to 7 points; and high, from 8 to 10 points.Results One hundred and twenty-six subjects were included; the knowledge mean was 7.5 points. The optimum time interval between Pap smear and the ideal age range for Pap smear were the questions with the most incorrect answers. However, 97% of the students recognised Pap smear as the main methodof screening to prevent cervical cancer.Conclusion The students know theoretical concepts about cervical cancer; however, it seems that they do not receive the specific elements about the practice, or, if they did, they are not being adequately assimilated.
cervical cancer, Mexico, Pap smear
Cervical cancer (CC) is an important public health problem worldwide; every year 500 000 new cases and235 000 deaths are reported. Latin America has a high incidence of CC: 76 000 new cases and 30 000 deaths were reported in the year 2000, which represents 16% and13%, respectively, of all the cases worldwide.
In Mexico, CC has been the most common malignancy among women during the last few decades, and is the main cause of death in women aged over 35 years. More than 4000 women die from this condition in Mexico every year, andt he incidence is one of the highest in the world.[3–5] During the past 25 years, mortality due to CC among the Mexican population has remainedstable , with an average age of death of 48 years.[6,7] Studies carried out in Mexico have estimatedthat women living in rural areas have a higher risk of dying from CC than women living in urban areas. This is relatedto factors associatedwith poverty. Cervical cancer is more common in Yucatan, in the southeast of Mexico, since the mortality rate in women over 25 years oldfrom 1997 to 2001 was higher than the national average.
The NCCSP is regulatedby the Health Ministry:
The Pap test is offeredto women who both belong and do not belong to the social security system. Each medical institution carries out CC detection activities within the available infrastructure andhuman resources, within each of the 32 states of the Mexican Republic.
The actions of NCCSP are guided by an official technical CC standard. It is complex and involves a large number of elements in order to reach its objective: a reduction in the morbidity and mortality rate from CC. These elements can be divided into three categories: women at risk, healthcare providers, and healthcare service use.
In Mexico, undergraduate students must complete an activity called‘social service’. It is a short-term obligatory activity to consolidate their academic study, practise their acquiredknowle dge, help them become aware of national health problems (especially in the most unprotectedsectors of the country), andto extendto society the benefits of science, technique andculture .
Medical and nursing students work during their social service in rural clinics for one year. Promotion of the NCCSP is one of the most important activities during the year, and in many communities the students are the sole contact with the programme andbe come the principal healthcare providers. Their work is very important, andtheir knowledge about CC and of the official technical CC standard is fundamental for an adequate execution of the NCCSP.
In that context, the aimof this study was to evaluate knowledge about aetiology and prevention of CC among undergraduate medical and nursing students during their social service in Yucatan, Mexico.
From August 2003 to July 2004, a questionnaire survey was carried out that included all the medical and nursing students who had completed their credits andwere undertaking their social service in a rural community of Yucatan. One hundred and four medical students and 22 nursing students were included. The students had been studying at three different universities: 77% at the Universidad Autonoma de Yucatan (UADY), which is the public university of the state of Yucatan, 8.7% at the Universidad Autonoma de Mexico (UNAM), which is the largest public university in Mexico andis locatedin Mexico City, and 9.5% from the Universidad del Mayab, a private university foundin the city of Merida, in Yucatan, Mexico.
A 10-item questionnaire, validated and used previously by other researchers, was usedfor the evaluation (see Table 1).12 Each correctly answereditem was given a point, so that the maximum grade was 10 andthe minimum 0. For optimum analysis, the results were classifiedinto three levels of knowledge: low, from 0 to 4 points; medium, from 5 to 7 points; andhigh, from 8 to 10 points.
Prior permission was sought andgrantedfrom the schools andcorresp onding public health authorities, as well as from the participating students. The questionnaire was appliedandthe following complementary data gathered: sex, age, and home university. This activity was carriedout during the monthly meetings for students in specific locations designated by the supervisors of each area.
Data were enteredandanalysedusing EPI version 6.0. Univariate analysis and 2 test were done to compare high levels of knowledge between males and females, private andpublic university students, and medical andnursing students.
All the students agreed to participate in the study and responded to the questionnaire. Most of the participants were male medical students of a public university (see Table 2).
From the 126 subjects queried, the knowledge mean was 7.5 points out of a maximum grade of 10. Thirtythree students (26.2%) were classified as having a low level of knowledge, 67 (53.2%) had a medium level, and26 (20.6%) hada high level.
With regardto sex, 51/126 (40.5%) were female and 75/126 (59.5%) were male. The level of knowledge among both groups was very similar: 23% of females and19% of males hadhigh level, 51% of females and 54% of males hada medium score, while 26% of females and27% of males hada low level. A high level of knowledge was most different between the groups, but this was not significant by 2 test (P = 0.50).
Medical students obtained higher scores than those studying nursing. Twenty-two percent of medical students and 14% of nursing students had high knowledge scores (8–10 points); 36% of nursing students and 24% of medical students had a low score, 0–4 points (P = 0.28).
With regard to university attended, 111/126 (88%) studied in a public university and 15/126 (12%) in a private university. All nursing students were from public universities. The levels of knowledge were high in 22.5% and7% of students from public andpriv ate universities, respectively, medium in 52.2% and 60%, andlow 25.2% and 33% (P = 0.13).
With regard to the knowledge of each itemincluded in the questionnaire, only 58.7% identified CC as an important health problem in Mexico; however, 81.7% identified CC as a preventable cause of deaths among Mexican women. Human papillomavirus (HPV) was recognisedas the main aetiological agent for CC by 91.3% of the students; 96.8% mentioned the Pap smear as the main methodof diagnosis of CC.
The last five items on the questionnaire relatedto the NCCSP. The results were as follows: less than 25% of all the students knew the time interval between Pap smear tests andthe appropriate age range for Pap smears, andonly 50% knew what to do with women who were HPV positive, without a precancerous cervical lesion. The factors that couldinterfere with sampling of a Pap smear was the item with the most correct answers (63.5%).
Doctors andnurse s working in rural areas are fundamental to successful reduction in mortality from CC, since when living in the communities, their work as health educators and promoters of the NCCSP is well received. This was why we considered it important to carry out an evaluation of the knowledge of CC and its prevention in medical and nursing students.
This work was realisedwith the collaboration of one of the medical students during his social service. He personally explainedandasked his peers for their collaboration which couldexpl ain the 100% response rate in our study, higher than that reported by other authors. Aldrich et al completeda study among Mexican general practitioners (GPs) and obstetrician-gynaecologists, reporting a 76% response rate.
CC was recognisedas an important health problem by most of the students interviewed (58.2%), a rate which is similar to that reportedby Lazcano-Ponce et al.
For decades, the Pap smear has been used as the principal tool for CC screening in many countries aroundthe world. That the Pap smear is the main methodfor early CC diagnosis was the answer of 96.8% of the interviewers in our study. Many studies in Mexico, Nigeria, Australia andUgan da reported similar results.[12,14–16]
The majority of respondents in our study correctly identified HPV infection as the main aetiological factor, whereas other authors have evaluatedkno wledge about HPV and CC among graduated doctors andnurse s to be lower.[12,14–16]
The official technicalCC standard is not included in either medical or nursing school programmes. Students are introduced to theNCCSP during a conference they receive before initiating their social service programme, which is reflectedin the results of this study. The first four items, referring to knowledge acquired in the classroom, were appropriately assimilated; however, this did not occur with information that was acquired outside the context of a curricular course, meaning that the concepts relatedto the NCCSP were less well known. These results can be explainedin light of learning theories, including conductive and cognitive theories. The conductive theory indicates that any behaviour is guided by stimulus–answer relations and is justified by its immediate consequences. According to the cognitive theory, the behaviour is the result of mental processes for which a value is assignedto the consequences of an action, andhenc e the probability that the action wouldpro duce the expectedresults .
In this study we can clearly observe that when the acquisition of knowledge is framed in a stimulus– answer system (acquisition of knowledge equals good grades), there was a positive response on the part of the students. Furthermore, knowledge provided outside a curricular programme, in which learning did not represent an immediate benefit for students was not assimilatedproperly.
More than five decades ago, academics of the Department of Health Behaviour andHealth Education of The University North Carolina at Chapel Hill, concernedabout health education, presented a model of health beliefs to explain the participation andad hesion to disease-prevention programmes. According to the model, the concurrence of the following factors promotes positive behaviours for health prevention: the belief or perception that a certain problem is sufficiently serious to be worthy of consideration; the belief or perception that one is vulnerable to that problem; andthe belief or perception that the action taken will produce a personal benefit.[17,18]
Although the Health Belief Model was originally thought to describe health education in the general population, it can also be appliedto acquisition of knowledge and behaviour among healthcare workers. It is necessary to work hardwith this group of health professionals to make them conscious that their function in rural communities was much more than just attending patients. Their real role lies in health promotion, andin this context they must be instructed clearly andefficient ly not only about NCCSP, but also in all the other primary health programmes that can improve the health of the most vulnerable individuals.