The present study performed the initial steps of a cross-cultural adaptation of a previously validated English version HPV survey, and aimed to evaluate internal consistency of the HPV-OPC Knowledge, Perceptions, and Clinical Practices (KPCP) subscales of the Spanish Version (SV) in a sample of Latin American dental students. The two schools that participated in the SV pretest were both good candidates to test the HPV-OPC-KPCP-SV instrument and measure internal consistency, since their HPV-OPC knowledge had not been evaluated before. The main findings indicate high internal consistency of most subscales in the instrument. Culturally, the survey also demonstrated strong practical relevance for students in Latin American countries, as participants expressed interest in acquiring knowledge related to the topic through open-ended questions. Feedback received from students suggest some minor orthographical and grammatical corrections.
In general, there was evidence of equivalence between the HPV-OPC-KPCP-SV and the English version.
Compared to the alpha coefficients of the English version in our previous work , HPV-OPC-KPCP-SV had a higher internal consistency in the following subscales: HPV Knowledge, HPV Vaccine Knowledge, and Scope of Practice. The English version had Cronbach’s alpha coefficient of 0.71 and 0.79 for HPV Knowledge, and HPV Vaccine Knowledge, respectively. These two categories in the English version had lower value of Cronbach’s alpha coefficient, which may due to differences in the sample population and not a characteristic of the instrument. The English version had two items for Scope of Practice and was analyzed using Spearman correlation, which resulted in an alpha coefficient of 0.71, while the SV was not directly comparable because the same questions were analyzed as part of the 24-item Barriers subscale using Cronbach’s alpha (0.93). The SV Scope of Practice four-item subscale (Cronbach’s alpha = 0.93) most similarly resembled the English version Willingness to discuss, recommend, or administer the HPV vaccines two-item subscale (Spearman Correlation Alpha = 0.85) and was not directly comparable due to item and calculation differences. There was no English version equivalent of the SV six-item Curriculum Evaluation subscale and the low internal consistency (Cronbach’s alpha = 0.23) may be due to differences in population characteristics, or differences in curriculum between dental schools in the two Latin American countries. To improve the internal consistency for an HPV Curriculum Evaluation subscale, senior dental students, with program curriculum experience, should be surveyed and analyzed separately by school and/or country. 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.
Previous researches in Latin America have evaluated different aspects related to HPV-OPC in dental students . Each research group developed a questionnaire regarding dental students’ demographic, sexual habits, sexual-related pre-existing pathologies, and HPV-OPC knowledge. Two studies claimed that their questionnaires were validated [34, 35]. Although, there are no statistical reports and references in these studies that allows us to evaluate and compare the validation process of their questionnaires with ours. The description provided by the researchers were as followed: Medina et al. reported that experts validated their questionnaire with high reliability; on the other hand, Lama-González’s group simply reported the administration of an HPV knowledge assessment and questionnaire among dental students of La Facultad de Odontología de la Universidad Autónoma de Yucatan. In both studies, no reports were found in the publications about Cronbach’s alpha coefficient or any statistical analysis used to validate their questionnaires [34, 35].
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 first to describe their validation methodology. Besides assessing dental students’ knowledge, perception, and clinical practice, the current survey also assessed the HPV-OPC curriculum in 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 identified 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.
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 pretesting of the HPV-OPC-KPCP-SV, the study was conducted in only two countries: Mexico and Colombia, thus findings may not generalize to other Latin American countries. Nevertheless, people from different cultural and demographic background were included in the present study and reliability was high suggesting that generalizability may be appropriate. Additional research is needed to support this claim.
The present study administered one survey in a cross-sectional design meaning Cronbach’s alpha was the only feasible reliability measure that could be assessed. Due to the research team’s limited access to the dental students, funding, and logistical constraints, the students were only asked to complete the survey once and the present study could not measure test–retest reliability. 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.
Religion and religiosity have been found to be important factors of HPV vaccination receipt, discussions, attitudes, and knowledge. HPV vaccination is often a health decision that is made on behalf of the patient by parents and/or caregivers, not considered required, and is ideally administered starting at age 9–11 years old, prior to sexual debut. HPV is often viewed as a sexually transmitted disease and that HPV vaccination is not needed for individuals who are in, or will only be in, monogamous relationships. Cronbach’s alpha can be considered as a characteristic of the sample and it is plausible that dimensionality of scales may vary by religion and/or religiosity and reported Cronbach’s alphas are under-estimated. Due to sample size, we were unable to effectively determine dimensionality of scales (via factor analysis), although a cursory examination of the HPV knowledge subscale did indicate the scale may not be unidimensional (13 dimensions indicated by the Guttman-Kaiser rule, Eigenvalues > 0)  and that the Cronbach’s alpha (0.83) is likely under-estimated (data not shown). A much larger sample size (3 to 20 times the number of variables in the subscale)  that allowed for factor analysis of the subscale by religiosity and/or different religious groups would provide insight into the scale dimensionality differences.
After the survey was administered, there was an in-person group discussion. This may have limited the ability of participants to confidently express and share their feedback. Also, it is possible that the participants’ responses could have been influenced by social desirability and conformity bias. Since participants 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 field 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.
We observed that participants answered an average (mean) of 44.76% (15.40 SD) of all HPV knowledge subscale questions correctly and 41.39% (18.18 SD) of HPV vaccination knowledge subscale questions correctly. Since the participants were first-year students, we expected knowledge scores to be low and that missingness would not be random as some students might feel uncomfortable answering some questions in this pretest due to the limited patient hours and the knowledge regarding cancer-related topics. Likewise, participants had not completed oral pathology curriculum prior to the pretest, meaning caution should be taken when interpreting the knowledge sections’ accuracy or internal consistency. This limitation of knowledge may also be the reason why the Curriculum Evaluation had a low alpha coefficient.
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.