Knowledge Gaps and Low Screening Uptake Among Bulgarian Female Medical Students

Female students training for careers in medicine, nursing, midwifery, and allied health professions in Bulgaria know a great deal about cervical cancer, but that knowledge does not reliably translate into protective action. A cross-sectional study conducted in 2025 at the Medical University of Sofia surveyed 277 female students from 11 different specialties and found that while roughly two-thirds described themselves as fully informed about cervical cancer, substantial gaps remained in their understanding of how human papillomavirus (HPV) spreads, how to interpret Pap smear results, and how often they actually underwent screening or vaccination. The proportions of students who had been tested for HPV or received the HPV vaccine were relatively low across the sample, ranging from 0 to 37 percent depending on the specialty, and the differences between groups were statistically significant.

The findings matter because cervical cancer remains a major public health problem worldwide. According to the World Health Organization, it ranks fourth in both incidence and mortality among cancers affecting women, with more than 600,000 new cases and more than 340,000 deaths recorded annually. The primary cause is persistent infection with high-risk HPV types, most notably HPV-16 and HPV-18. Risk factors for acquiring the virus include a higher number of sexual partners, younger age at first intercourse, sexual activity before the age of 19, and higher parity. In Bulgaria, the disease predominantly affects women of working age, imposing economic, psychosocial, and quality-of-life costs, and the country still lacks an effective national screening program.

Prevention operates at three levels: HPV immunization as primary prevention, screening with Pap and HPV tests as secondary prevention, and early treatment of precancerous lesions as tertiary prevention. In many countries, successfully implemented national screening programs have been associated with reductions in cervical cancer incidence and mortality. Bulgaria lags considerably behind: screening coverage stood at 45 percent in 2023, compared with 60 to 70 percent in developed countries, and only 8 percent of eligible girls had received the first dose of the HPV vaccine in 2021, with coverage particularly low among high-risk groups. Young women are considered a priority group for health education because of earlier sexual activity, and medical university students occupy a dual role as both beneficiaries of preventive services and future healthcare workers who will motivate their own patients.

The study, described by its authors as the first in Bulgaria to investigate barriers and opportunities in cervical cancer prevention among students from many different university training programs, used an anonymous online questionnaire. Respondents answered questions on awareness of cervical cancer, HPV, and screening; attitudes toward preventive care; health-related behaviors including Pap testing, HPV testing, and HPV vaccination; and motivations and barriers to screening. Sociodemographic data covered age, specialty, year of study, place of residence, and parental education. Specialty served as the independent variable in the statistical model, with age, place of residence, parental education, and year of study treated as confounders. The researchers used descriptive analysis, Pearson’s chi-square and Kruskal-Wallis tests with significance set at P ≤ 0.05, and multinomial logistic regression to identify factors influencing knowledge, attitudes, and practices.

Most respondents were nursing students (24.2 percent), medical students (17.2 percent), or public health and health management students (14.7 percent), and most were in their second or third year of study. Just over half (52.9 percent) were aged 20 to 30 years, and more than 90 percent lived in urban areas. Medical students more often came from highly educated families than nursing and midwifery students. Awareness of cervical cancer differed significantly across specialties (χ2 = 28.840, N = 272, P = 0.012): 76.0 percent of health care management students, 71.1 percent of midwifery students, and 68.1 percent of medical students reported being fully informed, compared with only 42.4 percent of dental medicine students and 13.3 percent of students in other specialties.

Knowledge of HPV transmission showed sharper deficits. Respondents were classified as fully informed only if they correctly identified that HPV spreads through skin-to-skin contact during vaginal, oral, and anal sexual activity. Medical students (58.7 percent) and midwifery students (42.1 percent) were the best informed, but 23.1 percent of dental medicine students were not informed at all about HPV transmission, a statistically significant difference (χ2 = 44.326, N = 271, P = 0.001). When asked an open-ended question about risk factors for cervical cancer, respondents mentioned most of the recognized factors, including HPV infection, early sexual activity, smoking, weakened immunity, long-term oral contraceptive use, multiple pregnancies, family history, socioeconomic status, obesity, nutritional factors, and age. The median number of correctly named risk factors was highest among health care management students at 3 out of a possible 10, but the differences between groups were not statistically significant.

Screening behavior revealed further disparities. Dental medicine students (32 percent) and pharmacy students (21.1 percent) reported never having been screened for cervical cancer, compared with roughly 70 percent of students from other specialties who had been screened within the last 12 months (χ2 = 35.281, N = 271, P = 0.026). The ability to interpret Pap smear results also differed significantly (χ2 = 15.240, N = 269, P = 0.033): 48.0 percent of dental medicine students could not understand Pap smear results, compared with 9.5 percent of health care management students. On HPV testing, which offers better predictive values than cytology-based screening for detecting high-risk oncogenic infections and early cervical changes, the proportion never tested was significantly higher among dental medicine students (80.8 percent), midwifery students (68.4 percent), and medical students (68.1 percent) (χ2 = 18.384, N = 272, P = 0.010). HPV vaccination uptake was low in most groups, with the exception of medical students at 37.0 percent, and the differences between groups were again statistically significant.

The multinomial logistic regression models identified several prognostic markers. Specialty was the only variable inversely associated with awareness of cervical cancer: medical, nursing, midwifery, public health and health management, and health care management students were all significantly less likely to be only partially informed than fully informed. For the Pap test, younger students—those under 20 years (Exp(B) = 84.255, P = 0.050) and those aged 20 to 30 years (Exp(B) = 45.338, P = 0.018)—and students whose mothers had secondary rather than higher education (Exp(B) = 12.002, P = 0.013) were more likely to report never having had a Pap test. Conversely, lower paternal education (Exp(B) = 0.073, P = 0.007) and the ability to interpret Pap smear results (Exp(B) = 0.011, P = 0.001) were inversely associated with never having been screened. Dental medicine students (Exp(B) = 5.946, P = 0.034) and students from lower socioeconomic backgrounds, indicated by maternal primary education, were more likely to report not having undergone HPV testing.

Across all specialties, the most common barriers to cytological screening were lack of time, insufficient information, and psychological factors such as shame, discomfort, and fear, with no statistically significant differences between groups. Early detection of cervical cancer and a sense of individual health responsibility emerged as the leading motives for proactive behavior, although again without significant between-group differences. The authors note that these personal and sociocultural barriers often coincide with early-onset sexual activity and increasing sexual experience among university students, and that the decision to participate in screening is also shaped by gender roles, religious norms, education, self-care behavior, symptoms, prior experience, family history of cancer, the opinions of partners and peers, and acculturation.

The study’s conclusions come with important caveats. The cross-sectional design cannot establish causal relationships, the single-university sample limits generalizability to other institutions or the wider population, and self-administered online questionnaires are vulnerable to recall and social desirability bias. Participant numbers also varied between analyses because of missing responses. Even so, the central message is clear: awareness of cervical cancer among future healthcare professionals should not be considered equivalent to effective preventive behavior. The authors argue that comprehensive and targeted education on HPV transmission, screening recommendations, interpretation of screening results, and HPV vaccination should be systematically integrated into the curricula of all medical specialties, strengthening both students’ personal preventive practices and their future capacity to promote cervical cancer prevention among their patients.

Subject of Research: Knowledge, attitudes, and barriers to cervical cancer screening and prevention among female medical university students in Bulgaria

Article Title: Cervical cancer: A cross-sectional study of knowledge, attitudes, perceptions, and barriers to screening and prevention among female university students

Article References: Vlaykov, Z., Simeonova, J., & Kirkov, V. (2026). Cervical cancer: A cross-sectional study of knowledge, attitudes, perceptions, and barriers to screening and prevention among female university students. Pharmacia, 73, Article e217216. https://doi.org/10.3897/pharmacia.73.e217216

Image Credits: AI Generated

DOI: 10.3897/pharmacia.73.e217216

Keywords: cervical cancer, HPV, Pap test, HPV vaccination, screening, medical students, Bulgaria, health literacy, cross-sectional study, preventive medicine, public health, Medical University of Sofia