Awareness Regarding Cervical Cancer, Pap Smear Screening, HPV: Cross-Sectional Study in Lebanese Population

Cervical cancer is the fourth most common cancer in women and the seventh overall, with an estimated 528,000 new cases and 266,000 deaths in 2012 worldwide, accounting for 7.5% of all female cancer deaths [1]. Likewise, Human papillomavirus (HPV) infection is extremely common. Although genital HPV infection is difficult to estimate, current figures suggest that visible genital warts are present in approximately 1 % of sexually active adults in the united states and that at least 15% have subclinical infection as detected by HPV DNA assays [2].The correlation between the presence of this virus and the development of precancerous lesions that may lead to cervical cancer is clearly established [3].

practice screening due to the feeling of embarrassment, cost and accessibility [11]. In order to resolve this dilemma, we decided to conduct a study on a big mass of Lebanese college students to assess their actual awareness and what method is best used to improve their knowledge.

Methods
This is a cross-sectional survey conducted in multiple faculties of the Lebanese university across Lebanon, in June 2018.We extended the survey to areas of geographical proximity and socioeconomic/ religious equivalence, including Tripoli city in the North Governorate of Lebanon, the neighborhood of the capital [ Fanar, Roumyeh.] and the Capital Beirut. A 23-item, self-administered, anonymous, pretested, structured questionnaire with closed-ended questions was used to obtain data. The formation of our questionnaire was based on previously validated and reliable tools from the literature and adapted to our society culture [12][13][14].
Our tool written in English and Arabic and was tested on a sample of 30 university students to ensure clarity, appropriate wording, and ease of administration. Data of the pilot test were not included in this study.
Our questionnaire targeted the following information: a) The sociodemographic and socioeconomic features of students.
b) The awareness/knowledge of the students about cervical cancer, HPV mode of transmission, HPV vaccine (the questions related to awareness were asked if the person has ever heard of the issue) and Pap smear screening and importance. c) The source of information, which students mostly use.
In order to decrease the bias in our study as much as possible, we excluded a number of faculties that can interfere with the results of our study. In fact, we excluded the faculty of Medical Sciences, faculty of Dentistry, faculty of Pharmacy, faculty of Sciences and the faculty of public health.

Study Design and Ethical Permission
This cross-sectional study used a KAP survey based on validated and reliable tools from the literature [12][13][14] (Table 3) The two main source of information for cervical cancer were "family and friends" (36.4%) followed by "Internet/ Social media" (34%). The primary source of information for Pap smear was also "family and friends" (52.4%), succeeded by "medical staff" (19%) and "Internet/Social Media" (17%). Concerning HPV, the leading source of information was "internet/Social media" (50%) then "family/Friends" and "Medical staff" with a percentage of 23.9%

Source of Information
and 20.2% respectively. Overall, schools, universities and Lebanese media were the least to provide any source of knowledge to our young generations (Table 3).

Discussion
In our study, we included university students since they Less than one fifth of the students had ever heard of HPV infection. This is lower than what was observed in similar study done in Italy (23.3%) [15], Finland (33%) [16], Florida (78%) [17] and Malaysia (85%) [18]. Student's level in the university also had an association with the awareness. Similarly, a study in Brazil showed respondents with higher educational attainment were more likely to have a better knowledge [19]. Our study is the first in Lebanon to examine the source of information that students use most. In Fact, we demonstrated that the two main sources are "family and friends" and "The Internet/Social Media". The same as studies in Florida which showed similar results considering these methods commonly utilized for leisure by young adults and could also be used to disseminate information [15,19]. Unfortunately, an important issue is often neglected which is the essential quality of our society which is considered conservative, religious despite the recent westernization. In fact, the majority refuses pre-marital relationships and considers with HPV vaccine an access for these relationships. Hence the necessity of education which is of huge importance.

What are the Methods Required to Fix This Problem?
The lack of knowledge revealed in our study can be improved with few simple methods: All these methods and many more will have a tremendous effect not only on the prevalence of cervical cancer, but also on its early detection in the Lebanese population.

Limitations and Strengths
Our study is the first to study the knowledge of cervical cancer, Pap smear and HPV altogether in a considerable sample size of young college students, in different Lebanese districts. We are also the very first to study the source of information students used in order to improve their medical awareness. However, we have few limitations; first we did not ask about sexual activity of our students, since this can affect tremendously their knowledge.
Second, we should have separated Family from Friends in the source of information category, to have a more precise idea on the Family's role per so toward this topic. Additionally, a potential limitation that should be considered when interpreting this study is that the information obtained was collected using a self-administered questionnaire and so possibly exists that some respondents may have given incorrect information. Finally, we did not encounter their accessibility to Pap smear and HPV vaccine, and the obstacles preventing students with adequate knowledge from engaging in these preventive measurements.

Conclusion
The level of awareness about cervical cancer, Pap smear and HPV in our studied population was significantly low. The two main sources of information were "family and Friends" and "Internet/ Social media" whereas Lebanese media, schools and universities had no role in educating our students. Further studies are needed to monitor the amelioration in education and to shed more light on the numerous obstacles facing the Lebanese society preventing them from easy accessibility to Pap smear and HPV vaccine.