Pilot Test of a Spanish Version of a Previously Validated HPV Survey that Evaluates Dental Students’ Knowledge, Perception and Clinical Practices in Latin America

Lilliam Pinzon University of Utah Alan Velazquez Universidad Autonoma de Baja California Holdunn Rutkoski Caring Health Center, United States Djin Tay University of Utah Laura Martel University of Utah Carmen Drury Huntsman Cancer Institute Shauna Ayres Huntsman Cancer Institute Barbara Dixon University of Utah James Winkler University of Utah Deanna Kepka (  deanna.kepka@hci.utah.edu ) University of Utah

reduce the HPV-OPC burden. In an effort to increase HPV vaccination coverage, the FDA has recently approved HPV vaccine Gardasil-9 for men and women aged 27 to 45 years old [10]. Acknowledging the increase of HPV-OPC incidence, the American Dental Association's (ADA) recently adopted policy stating that dentists need to be current with HPV-OPC knowledge and support HPV vaccine use and administration [11].
With su cient knowledge and adequate training on how to educate patients about HPV vaccination, dental providers have the potential to lead HPV-OPC prevention [12]. In fact, administering the HPV vaccine in the dental setting could be a viable option according to a multi-state study of United States (US) oral health students, where it was found that a majority of dental and dental hygiene students are open to be trained to administer the HPV vaccine [13]. Thus, it is crucial to evaluate dental professional's knowledge of, perceptions about, and clinical practices surrounding HPV and HPV vaccination. It is also important to understand what elements of dental school curriculum and clinical practices could improve HPV-OPC education and screening.
Globally, HPV knowledge and awareness has been reported to be low among the dental student, oral health student, and oral health professional populations; however, the construct validity of these instruments is questionable as many were study-speci c [14][15][16][17][18][19][20][21]. Likewise, studies that examine HPV knowledge and awareness in Latin American countries are limited, but point to suboptimal levels of knowledge and awareness of HPV in countries such as Brazil and Ecuador [22,23].
Validated instruments have been developed in the United States for HPV and HPV vaccine communication, advocacy, attitudes, and clinical practices among dental providers [24,25,18].
Researchers from the University of Minnesota utilized a validated 32-item survey instrument designed to measure head and neck surgeon's knowledge, attitudes, and practices regarding HPV communication and vaccine advocacy with dentists and dental hygienists, and found a lack of knowledge about HPV and HPV vaccination [18]. However, all of these scales were developed for English-speaking respondents, and to our knowledge, none have been tested for applicability to Latin America, a region with a high burden of emerging HPV-OPC and low HPV knowledge and awareness.
This study aimed to evaluate the applicability of a Latin American Spanish translation of a multi-scale survey evaluating Knowledge, Perceptions, and Clinical Practices (KPCP) regarding HPV and HPV-OPC originally developed for English-speaking US dental and dental hygiene student populations [25]. The primary aim of the study was to assess the reliability of the survey subscales using Cronbach alpha. The secondary aim of the study was to examine the translated survey for linguistic and cultural equivalency using qualitative open-ended questions and in-person discussions.
It is crucial that the next generation of Latin American dental professions have the tools needed to improve the health and well-being of their patients through increasing HPV vaccination coverage. This can be achieved through HPV-OPC patient education [26], HPV vaccination recommendation, and preventative OPC screening [27]. Having a validated Spanish instrument evaluating KPCP for HPV and HPV-OPC would help identify areas of where Latin American dental schools could improve curriculum and secondarily help improve HPV-OPC prevention among their populations.

Methods
This study was conducted by researchers from the University of Utah School of Dentistry in Salt Lake City, Utah in the US and the Autonomous University of Baja California's Faculty of Dentistry in Tijuana, Mexico. Huntsman Cancer Institute and University of Utah School of Medicine also supported this research.

Questionnaire Development
This pilot study adapted a previously developed questionnaire for English-speaking oral health students.
The translation of the pilot test questionnaire was done by two native Spanish-speaking members of the research team (LMP & AV) who are also uent in the source language. Forward translation was done by a researcher who is a certi ed bilingual translator (LMP). The initial version was evaluated for sematic equivalence by the appointed in-country investigator (AV), who also served as an editor and highlighted grammatical and typographic errors. Reconciliation of forward translation concerns was made via a discussion between the members of the research team and a nal version of the translated survey was made when all concerns were resolved. The resulting translated version was tested in this pilot study.
The HPV-OPC Knowledge, Perceptions, and Clinical Practices (KPCP) Spanish Version (SV) consisted of 147 items, of which 106 items were included in the nal analysis. Items made up seven subscales: 1) HPV knowledge, 2) HPV-OPC knowledge, 3) HPV vaccine knowledge, 4) Barriers, 5) Clinical Procedures, 6) Scope of Practice, and 7) Curriculum Evaluation. The questionnaire also included demographic questions. The questions had a variety of response types, including true/false/don't-know, multiple choice, check all that apply, yes/no, and Likert scale. The pilot test survey questionnaire took between 30-40 minutes to complete. Approval from University of Utah's and Institutional Review Board (IRB), also known at the university's ethics committee, was obtained prior to this study (IRB_00087209).

Questionnaire Pilot Testing
Throughout Latin America, email invitations were sent to eight universities to participate in this pilot study, from which two agreed to participate; one program was located in Colombia (Facultad de Odontología de la Universidad de Antioquia) and the other, in Mexico (Facultad de Odontología de la Universidad Autónoma de Baja California, Tijuana campus). The two schools selected for this study are located in geographical regions where dental student's HPV-OPC knowledge has not been evaluated before. Thus, they were both good candidates to pilot test the HPV-OPC-KPCP-SV instrument and measure internal consistency. Eligible participants were rst year dental (D1) students as they perform oral health educational duties as part of their program requirements. Since D1 student participants had not completed oral pathology curriculum prior to the pilot, the investigators were cautious in interpreting the knowledge section's accuracy and focuses on internal consistency. Study procedures were conducted by two of the study investigators (Colombia-LMP; Mexico-AV) according to the IRB-approved study protocol in both sites to ensure consistency. First, study investigators gave a short oral presentation about the research project to D1 students. Students were then instructed on how to properly answer the questions and then completed the questionnaire at their own pace. The questionnaire was administered in pencil-and-paper format, and then study investigators manually entered the data into Vanderbilt University's Research Electronic Data Capture (REDCap) program for data management.
Students took between 30 to 40 minutes to complete the questionnaire, after which, they participated in an in-person discussion for about 30 minutes. During the in-person discussion, issues related to the survey questions were reviewed to gain additional feedback. Participants also provided their overall impressions of the instrument, suggested changes, shared what they liked or disliked about the instrument, and provided feedback on the order of questions. D1 students were incentivized to participate in the study by holding three ra es per University with the opportunity to win clinical dental instruments. Ra es were done immediately after participants nished the questionnaire and discussion. Analyses were conducted using SAS software, Version 9.4.

Results
A total of N = 122 Latin American dental students participated in this study. The majority of participants were female (58%), aged 18 to 29 years old (93%), Hispanic/Latino(a)/Spanish (87%), and had at least an undergraduate associate or bachelor's degree prior to entering their dental program (95%). Table 1 contains a complete breakdown of participant demographics.  however this is likely due to the differences in curriculum between dental schools and differences in geographical regions (U.S. vs Mexico and Colombia). The questions used for these analyses are shown in Table 3. Qualitative comments from students were also concurrently reviewed. Overall, discussion feedback was positive, with some suggestions for improvement regarding missing accents and minor rewording of certain items.  In the dental o ce, how often should a patient receive an oral, head, and neck cancer examination?
Which age group(s) should an oral, head, and neck cancer examination be performed on?
Which ethnic/racial background has the highest rate of oropharyngeal cancer? ¿En cuál grupo de edades se tiene la tasa más alta de cáncer orofaríngeo?
Which age group has the highest rate of oropharyngeal cancer?
Which sex/gender has the highest rate of oropharyngeal cancer?
While age group has the highest rate of HPV infections?
What percentage of oropharyngeal cancer is attributed to HPV?
Over the last ten years, which of the following oral locations had the most increase in rate for HPV related oropharyngeal cancer?
Over the last ten years, which age group has shown the most increase in rate for HPV related oropharyngeal cancer?
Which of the following professionals are the most reliable clinical sources of HPV and oropharyngeal cancer information?
Discutir la asociación entre cáncer orofaríngeo y el VPH es parte del rol del odontólogo Discussing the link between HPV and oropharyngeal cancer falls within the scope and role of a dental professional.
Recomendar a un paciente la vacuna del VPH es parte del rol profesional del odontólogo Recommending HPV vaccination falls within the scope and role of a dental professional.
La administración de la vacuna del VPH en el consultorio odontológico es parte del rol profesional del odontólogo Administering the HPV vaccines inside the dental o ce falls within the scope and role of a dental professional. When is HPV vaccination ideally recommended?
¿Cuál es la edad optima para administrar la vacuna del VPH a las mujeres?
What is the optimal age for HPV vaccination in females?
¿Cuál es la edad optima para administrar la vacuna del VPH a los hombres?
What is the optimal age for HPV vaccination in males?
Based on your experience, how di cult or easy is it to discuss the following topics with your patients? Which of the following describes your typical approach in communicating with patients about the purpose and the results of their oral, head, and neck cancer examination?
If you were to discuss the relationship between HPV and oropharyngeal cancer with your patients, which of the following do you think would best facilitate this conversation?
Which statement best describes how you communicate with patients about the HPV vaccines?
¿Cuál frase describe mejor como usted comunica a sus pacientes la conexión de la salud oral y sistémica?
Which statement best describes how you communicate with patients about their oral/systemic health?
¿Cuál frase describe mejor como usted se comunica con pacientes acerca de su historia sexual?
Which statement best describes how you communicate with patients about the HPV vaccines?
Which statement best describes how you communicate with patients about their sexual history?
How willing would you be to participate in a training to administer the HPV vaccines in your dental practice?
How willing would you be to participate in a training to administer the u vaccines in your dental practice?
If trained, how willing would you be to administer the HPV vaccines in your dental o ce?
If properly trained, how willing would you be to administer the u vaccine in your dental o ce?
Which structure(s) do you visually examine during an oral, head, and neck cancer examination?
Which structure(s) do you palpate during an oral, head, and neck cancer examination?
How well has your dental education prepared you to perform an oral, head, and neck cancer examination? ¿Qué tanta con anza tiene en su habilidad para hacer una evaluación de cáncer oral y de cabeza y cuello?
How con dent are you in your ability to perform an oral, head, and neck cancer examination?
How frequently has HPV or HPV related oropharyngeal cancer been discussed during your dental education? ¿Hasta que punto está de acuerdo con la siguiente declaración: "mi plan de estudios odontológicos debería haber tenido más énfasis sobre la asociación del VPH con el cáncer orofaríngeo?
What is your level of agreement with the following statement: "More emphasis should have been placed on HPV related oropharyngeal cancer education during my dental curriculum." ¿Cuál de las siguientes metodologías fueron utilizadas por su facultad de odontología para educarlos en el tema del VPH?
Which of the following methodologies were used for HPV education by your dental institution?
During your formal dental education training, where did you learn about the link between HPV and oropharyngeal cancer?
What are the probable risk factors for HPV oropharyngeal cancer?
Where is the most common location for a HPV related oropharyngeal cancer biopsy?
Existen estándares o pruebas de rutina para el cáncer orofaríngeo especí camente There are standards or routine screening tests for oropharyngeal cancer, speci cally. However, ndings also showed lower internal consistency of the Curriculum Evaluation subscale. This could be due to the curriculum differences between dental schools in the U.S. and in Latin America. To improve the internal consistency for Curriculum Evaluation, analysis and comparison between American and Latin American curriculum should be conducted. This analysis would assist researchers in understanding which questions in Curriculum Evaluation must be revised and adapted to the dental schools where the survey will be administered. Even though the previous studies listed above were valuable in assessing dental students' knowledge regarding HPV-OPC, they did not demonstrate any methodological steps needed to claim validity of their new scales. HPV-OPC-KPCP-SV is the rst to describe their validation methodology. Besides assessing dental students' knowledge, perception, and clinical practice, the current survey also assessed the HPV-OPC curriculum in Latin American dental schools. The study results reveal a great opportunity for curriculum evaluation and development among Latin American dental schools and can be used to further implement research in Latin American countries regarding HPV-OPC. By comprehensively evaluating dental students' knowledge, perception, curriculum, and clinical practice, the barriers that prevent or limit the discussion of HPV-OPC and HPV vaccination with patients can be identi ed and mitigated. Knowing these barriers provides the foundation to propose a guide and/or intervention that would aim to increase HPV-OPC education among patients and increase HPV vaccination rates in Latin America.

Limitations
The HPV-OPC-KPCP-SV survey appears to have been successfully translated from English to Spanish. Moreover, the reliability and cross-cultural applicability is appropriate to be implemented in dental students from Latin America countries. However, in interpreting the results, it is important to take the study's limitations into account. Despite the success of the pilot testing of the HPV-OPC-KPCP-SV, the results could not be generalizable, as the study was not randomized. The study was conducted in only two countries: Mexico and Colombia, thus ndings may not generalize to other Latin American countries. Nevertheless, people from different cultural and demographic background were included in this study and reliability was high suggesting that generalizability may be appropriate yet additional research is needed to support this claim.
This study administered one survey in a cross-sectional design meaning Cronbach's alpha was the only feasible reliability measure that could be assessed. The study could not measure test-retest reliability because the students were only asked to complete the survey once. Concurrent validity or discriminant reliability measures were not possible as the students were only asked to complete one survey. Floor and ceiling effects are also possible limitations in surveys of this type. Administering this survey to a wider range of other dental students and professionals, both in experience and knowledge, and at multiple time points would reduce these limitations.
After the survey was administered, there was an in-person group discussion. This may have limited the ability of participants to con dently express and share their feedback. Also, it is possible that the participants' responses could have been in uenced by social desirability and conformity bias. Since participatns were relatively new to the dental school academic environment, they may have been knowingly or unknowingly responding to items while taking into consideration their peers or the researchers' perceptions of their responses. This was mitigated by an anonymous comment eld that allowed the participants, who may feel uncomfortable to discus in the in-person group discussion, opportunities to provide their feedback. However, these biases could still exist.
Since the participants were rst-year students, they might feel uncomfortable answering some questions in this pilot due to the limited patient hours and the knowledge regarding cancer-related topics. This limitation of knowledge may be the reason why the Curriculum Evaluation had a low alpha coe cient.
Future research should focus on the evaluation of knowledge that senior dental students (D4 and D5) as well as dentists and dental hygienists have about HPV Knowledge, HPV-OPC Knowledge, HPV Vaccine Knowledge, Barriers, Clinical Procedures, Scope of Practice, and Curriculum Evaluation in order to identify and overcome real or perceived barriers. This could take the form of offering continuing education courses, workshops, or changes in dental school curriculums. Subsequent studies should focus on further validation of the HPV-OPC-KPCP-SV and include assessment of additional reliably measures.

Conclusions
This study aimed to evaluate the applicability of a Spanish translation of an English survey developed for the US dental and dental hygiene student population in dental students from Latin America.