Overall, 122 female physicians completed the questionnaire: 42 OB/GYN physicians ( residents – 18, attending physicians- 24) and 80 non-OB/GYN physicians (“non-OB/GYNs”, residents -48, attending physicians -32). The two groups comprised of similar proportions of resident and senior participents (p=0.0865). Professional characteristics of the study cohort are presented in Table 1, distribution of the study cohort according to specialty and seniority is presented in figure 1.
There were no significant differences in the demographic characteristics and professional experience between the two groups as presented in Table 1. There were no significant differences in the prevalence of most known risk factors for CC as well: 9.52% of the OB/GYNs were smoking vs. 16.25% of non-OB/GYNs (p=0.41), 95.24% of the OB/GYNs were sexually active vs. 90% of the non-OB/GYN (p=0.49) and the average age at initiation of sexual activity was 19.4±3.3 in the OB/GYNs group vs.19.01±2.52 in the non-OBGYNs group (p>0.99). All the above mentioned remained non-significant when participants were stratified based on seniority, as shown in Table 1. It is noteworthy that condom use was less prevalent in OB/GYN attending physicians compared to OB/GYN residents (0% vs 27.78%, p=0.01) and compared to non-OB/GYNs attending physicians (0% vs. 34.38%, p=0.0013), despite similar proportions of married and sexually active individuals in these groups (Table 1). The age at the performance of first Pap was younger in the non-OB/GYNs group (22.96±4.56 years vs. 26.03±4.57 years, p=0. 023) and significantly less OB/GYNs were in compliance with the recommendations of the Israeli Society of Obstetrics and Gynecology for first Pap testing at the age of 25 (48.38% vs. 75% ,p=0.01) 19 probably due to a trend in OB/GYN attending physicians (OB/GYN attending physicians - 33% non-OB/GYN attending physicians – 62.96%, p=0.07). Of note, this difference cannot be attributed to professional differences since the participants were still during their basic medical education at the time.
Table 1
Demographic characteristics and professional experience of the study cohort.
| OB-R | OB-AP | OB-A | NOB-R | NOB-AP | NOB-A | OB-A vs. NOB-A (p value) | OB-R vs. OB-AP (p value) | NOB-R vs. NOB-AP (p value) | OB-R vs. NOB-R (p value) | OB-AP vs. NOB-AP (p value) |
Age (yrs., mean±SD) | 34.5±3.45 | 44.47±7.6 | 40.09±7.87 | 33.29±3.11 | 44.54±7.53 | 37.76±7.71 | 0.605 | 0.0005*** | <0.0001**** | >0.99 | >0.99 |
Married (N, %) Yes No | 12 (66.67) 6 (33.33) | 21 (87.5) 3 (12.5) | 33 (78.57) 9 (21.43) | 33 (68.75) 15 (31.25) | 26 (81.25) 6 (18.75) | 59 (73.75) 21 (26.25) | 0.66 | 0.139 | 0.3 | >0.99 | 0.717 |
Smoking (N, %) Yes No | 2 (11.11) 16 (88.89) | 2 (8.33) 22 (91.67) | 4 (9.52) 38 (90.48) | 7 (14.58) 41 (85.42) | 6 (18.75) 26 (81.25) | 13 (16.25) 67 (83.75) | 0.413 | >0.999 | 0.758 | >0.99 | 0.44 |
Sexually active (N, %) Yes No | 18 (100) 0 (0) | 22 (91.67) 2 (8.33) | 40 (95.24) 2 (4.76) | 45 (93.75) 3 (6.25) | 27 (84.38) 5 (15.63) | 72 (90) 8 (10) | 0.49 | 0.498 | 0.255 | 0.556 | 0.686 |
Age at first sexual activity (yrs., mean ±SD) | 19.44±3.95 | 19.45±2.75 | 19.45±3.3 | 19.06±2.61 | 18.93±2.33 | 19.01±2.52 | >0.999 | >0.99 | >0.99 | >0.999 | >0.999 |
Condom use (N, %) Yes No | 5 (27.78) 13 (72.22) | 0 (0) 24 (100) | 5 (11.9) 37 (88.1) | 18 (37.5) 30 (62.5) | 11 (34.38) 21 (65.63) | 29 (36.25) 51 (63.75) | 0.0053** | 0.01* | 0.816 | 0.568 | 0.0013** |
Education (yrs., mean ±SD) | 20.11±1.76 | 19.74±1.63 | 19.9±1.67 | 19.2±2.11 | 19.08±3.91 | 19.16±2.88 | 0.329 | >0.99 | >0.99 | 0.854 | >0.999 |
Professional experience (yrs., mean±SD) | 2.63±1.62 | 10.52±7.86 | 6.93±7.06 | 2.58±1.67 | 11.53±8.46 | 6.43±7.27 | >0.999 | 0.0077** | <0.0001**** | >0.999 | >0.999 |
Age at first Pap (yrs., mean±SD) <25 yrs. (N, %) >25 yrs. (N, %) | 24.77±3.46 9 (69.23) 4 (30.77) | 26.94±5.12 6 (33) 12 (66.67) | 26.03±4.57 15 (48.39) 16 (51.61) | 21.83±3.59 31 (83.78) 6 (16.22) | 24.51±5.17 17 (62.96%) 10 (37.04%) | 22.96±4.56 48 (75) 16 (25) | 0.0239* 0.019* | >0.999 0.073 | 0.40 0.08 | 0.400 0.42 | >0.999 0.07 |
OB-R – OB/GYN residents. OB-AP – OB/GYN attending physicians. NOB-R – non-OB/GYN residents. NOB-AP – non-OB/GYN attending physicians. OB-A – OB/GYN all. NOB-A – non-OBGYN all. Pap – Papanicolaou. yrs. – years (of age). SD- Standard deviation. *- p<0.05. **- p<0.01. *** -p<0.001. **** p<0.0001
Table 2 summarizes the differences in general knowledge regarding CC and Pap testing between the groups. A significantly higher proportion of OB/GYNs answered correctly each of the 6 questions asked (question 1 - p=0.0006 questions 2, 4-6 - P<0.001, question 10 -P=0.0018, Supplementary file 2). Notably, less OB/GYN residents knew about the Israeli Society of Obstetrics and Gynecology’s recommendations for upper age limit for Pap testing (50% vs. 83%, P=0.04) and for upper age limit for vaccination (11% vs 50%, p=0.01). Even so, when asked whether they would recommend HPV vaccination to their patients, the majority of physicians, both OB/GYNs and non-OB/GYNs and in all levels of seniority, answered positively (OB/GYNs – 93%, non-OB/GYNs 86%, p=0.37). Physicians in the OB/GYNs group also demonstrated greater knowledge regarding risk factors for CC as seen by significantly higher calculated risk factor awareness indices (5.78 vs 4.48, p<0.001), with no difference between residents and attending physicians (Table 2).
Table 2
Knowledge of Pap testing and HPV vaccination among OB/GYN and non-OB/GYN female physicians.
| OB-R | OB-AP | OB-A | NOB-R | NOB-AP | NOB-A | OB-A vs. NOB-A (p value) | OB-R vs. OB-AP (p value) | NOB-R vs. NOB-AP (p value) | OB-R vs. NOB-R (p value) | OB-AP vs. NOB-AP (p value) |
Goal of Pap smear (N, %) Right answer Wrong answer | 18 (100) 0 (0) | 24 (100) 0 (0) | 42 (100) 0 (0) | 38 (79) 10 (21) | 24 (77) 7 (23) | 62 (77) 17 (23) | 0.0006*** | >0.99 | >0.99 | 0.051 | 0.014* |
Recommended Pap frequency (N, %) Right answer Wrong answer | 16 (89) 2 (11) | 21 (87) 3 (13) | 37 (88) 5 (12) | 18 (38) 30 (62) | 10 (32) 21 (68) | 28 (35) 51 (65) | <0.0001**** | >0.99 | 0.81 | 0.0002*** | <0.0001**** |
Recommended age first Pap (N, %) Right answer Wrong answer | 11 (61) 7 (39) | 19 (79) 5 (21) | 30 (71) 12 (29) | 6 (12) 42 (88) | 4 (13) 27 (87) | 10 (12) 69 (88) | <0.0001**** | 0.302 | >0.99 | 0.0002*** | <0.0001**** |
Recommended age last Pap (N, %) Right answer Wrong answer | 9 (50) 9 (50) | 20 (83) 4 (17) | 29 (69) 13 (31) | 5 (10) 43 (90) | 3 (10) 28 (90) | 8 (10) 71 (90) | <0.0001**** | 0.04* | >0.99 | 0.0012** | <0.0001**** |
Aware of vaccine type (N, %) Right answer Wrong answer | 12 (67) 6 (33) | 17 (71) 7 (29) | 29 (69) 13 (31) | 13 (27) 35 (73) | 9 (29) 22 (71) | 22 (28) 57 (72) | <0.0001**** | >0.99 | >0.99 | 0.0046** | 0.0029** |
Upper age of vaccine (N, %) Right answer Wrong answer | 2 (11) 16 (89) | 12 (50) 12 (50) | 14 (33) 28 (67) | 3 (6) 45 (94) | 4 (13) 27 (87) | 7 (9) 72 (91) | 0.0018** | 0.01* | 0.423 | 0.608 | 0.006** |
Recommends vaccination (N, %) 1 Yes 2 No | 16 (89) 2 (11) | 23 (96) 1 (4) | 39 (93) 3 (7) | 44 (92) 4 (8) | 24 (77) 7 (23) | 68 (86) 11 (14) | 0.374 | 0.567 | 0.099 | 0.66 | 0.119 |
Risk factor awareness index (out of 7±SD) | 5.55±1.15 | 5.95±0.8 | 5.78±0.97 | 4.43±1.08 | 4.56±0.95 | 4.48±1.03 | <0.0001**** | >0.99 | >0.99 | 0.006** | <0.0001**** |
OB-R – OB/GYN residents. OB-AP – OB/GYN attending physicians. NOB-R – non-OB/GYN residents. NOB-AP – non-OB/GYN attending physicians. OB-A – OB/GYN all. NOB-A – non-OBGYN all. Pap – Papanicolaou. HPV - Human Papillomavirus. SD- Standard deviation. *- p<0.05. **- p<0.01. *** -p<0.001. **** p<0.0001 |
Data regarding Pap performance status is presented in Table 3. In average, longer time has passed since the last Pap smear in the OB/GYNs group compared with the non-OBGYNs group (3.305 years vs 2.26 years, respectively, p=0.0099) but a similar proportion of physicians had performed a Pap smear in the last 3 years (OB/GYN – 75% non-OB/GYN – 83%, p=0.3). Of note, a higher percentage of residents, both OB/GYNs and non- OBGYNs were vaccinated against HPV compared to their senior counterparts (OB/GYNs -38.89% vs. 4.76%, p=0.0149, non-OB/GYNs 51.06% vs. 15.38%, p=0.0028). Excluded from these calculations were 3 OB/GYN attending physicians, 1 non-OB/GYN resident and 6 non-OB/GYN attending physicians who were older than 45 yr. at the time HPV vaccination was available in Israel. About half of the unvaccinated physicians agreed to reveal their motives. Interestingly, 60% of OB/GYN resident and attending physicians as well as of non-OB/GYN attending physicians did not vaccinate because they had a regular sex partner. The remaining 40% did not vaccinate because of their age. Out of the unvaccinated non-OB/GYN attending physicians who revealed their motives, 16.66% justified their choice in having a regular sex partner and 83.34% stated their reason was age related. Only half of OB/GYNs (residents – 50%, attending physicians – 66.67%, p=0.348) initiated their own Pap testing, similar to non-OB/GYNs. Among non-OB/GYNs, residents showed a higher initiative towards undergoing Pap test compared to attending physicians, although not significant (47.92% vs 37.5%, p=0.49). Overall, OBGYNs tend to initiate the test more than non – OBGYNs although also not significant (59.52% vs 43.75%, p=0.127).
Table 3
Pap testing and HPV vaccination compliance in OB/GYN and non-OB/GYN female physicians.
| OB-R | OB-AP | OB-A | NOB-R | NOB-AP | NOB-A | OB-A vs. NOB-A (p value) | OB-R vs. OB-AP (p value) | NOB-R vs. NOB-AP (p value) | OB-R vs. NOB-R (p value) | OB-AP vs. NOB-AP (p value) |
Time from last Pap (yrs., mean±SD) <3 years (N, %) >3 years (N, %) | 3.625±3.217 13 (81.25) 3 (18.75) | 3.05±1.385 14 (70) 6 (30) | 3.305±2.358 27 (75) 9 (25) | 2.2073±1.588 35 (85.37) 6 (14.63) | 2.351±2.02 22 (81.48) 5 (18.52) | 2.264±1.79 57 (83.82) 11 (16.18) | 0.0099** 0.3 | >0.99 0.7 | >0.99 0.742 | 0.31 0.7 | 0.208 0.489 |
Time between last Pap and previous one (yrs., mean±SD) | 3.687±3.177 | 3±1.414 | 3.305±2.352 | 2.5±1.325 | 3.41±4.125 | 2.904±2.980 | 0.691 | >0.99 | >0.99 | >0.99 | >0.99 |
Pap initiator Patient (N, %) Physician (N, %) | 9 (50) 9 (50) | 16 (66.67) 8 (33.33) | 25 (59.52) 17 (40.48) | 23 (47.92) 25 (52.08) | 12 (37.5) 20 (62.5) | 35 (43.75) 45 (56.25) | 0.127 | 0.348 | 0.49 | >0.99 | 0.057 |
HPV vaccination status ^ Positive (N, %) Negative (N, %) | 7 (38.89) 11 (61.11) | 1 (4.76) 20 (95.24) | 8 (20.51) 31 (79.49) | 24 (51.06) 23 (48.94) | 4 (15.38) 22 (84.62) | 28 (38.36) 45 (61.64) | 0.059 | 0.0149* | 0.0028** | 0.418 | 0.362 |
^ Excluding cases over vaccination age limit.
OB-R – OB/GYN residents. OB-S – OB/GYN attending physicians. NOB-R – non-OB/GYN residents. NOB-AP – non-OB/GYN attending physicians. OB-A – OB/GYN all. NOB-A – non-OBGYN all. Pap – Papanicolaou. HPV - Human Papillomavirus. yrs. – years (of age). SD- Standard deviation. *- p<0.05. **- p<0.01. *** -p<0.001. **** p<0.0001