Knowledge, Attitude, and Practices toward Skin Cancer Prevention and Detection among Students of Rawalpindi Medical University: A Cross- Sectional Study

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Despite the rising incidence, awareness of prevention and detection remains low in countries like Pakistan. Medical students, as future healthcare providers, have a significant role in promoting public education on skin cancer, yet data on their knowledge, attitudes, and practices (KAP) is limited. Objectives: This study evaluates the knowledge, attitudes, and practices regarding skin cancer prevention and detection among medical students at Rawalpindi Medical University (RMU) to identify educational gaps. Methods: A cross-sectional study was conducted at RMU with 260 participants, representing 15% of the student body. Data were collected from students aged 18–27 across all MBBS years using a validated 49-item structured questionnaire regarding Knowledge, Attitude, and Practices of Skin Cancer Prevention. Statistical analysis included descriptive statistics and inferential statistics such as the Kruskal-Wallis test and Tukey's post-hoc test to assess differences in knowledge scores between classes. Results: Among the participants, 70.8% were female, and 53.8% were aged 20–23. Most (96.9%) had no family history of skin cancer, and 63.5% claimed to have proper knowledge. The mean knowledge score was 9.89/24, with significant differences between class years (p < 0.001). The third year scored the highest (mean: 12.65), followed by first-year students (mean: 12.56). However, final-year students had the lowest (mean: 7.56) scores. Only 21.5% correctly identified basal cell carcinoma as the most common type. Additionally, 38% of students practiced regular sun protection, and 45.4% reported conducting self-examinations for early detection. Attitudinal analysis revealed that the majority of participants had a positive outlook toward prioritizing skin cancer prevention. Conclusion: This study underscores the need for enhanced educational strategies within the medical curriculum focusing on skin cancer prevention and early detection. Strengthening these areas can better prepare medical students to educate the public effectively and help mitigate the skin cancer burden in Pakistan. Skin Neoplasms Melanoma Students Medical Public Health Introduction Skin cancer is the fifth most prevalent cancer worldwide, posing a significant public health concern. ( 1 ) According to the World Health Organization, approximately 2–3 million non-melanoma skin cancers and 132,000 melanoma skin cancers are diagnosed annually across the globe. ( 2 ) The incidence of skin cancer has been steadily increasing, with studies indicating that 1 in every three diagnosed cases of cancer is a skin cancer. ( 3 ) The rising trend in skin cancer cases is attributed to various factors, including increased ultraviolet (UV) radiation exposure, fair skin color, and genetics. ( 4 ) Although national data on the prevalence of skin cancer is limited in Pakistan, the global rise in cancer trends points to a health challenge in the country. The Punjab Cancer Registry reports increasing cases, with significant geographic and ethnic differences. It showed that skin cancer is the most prevalent (7%) among females in Gilgit-Baltistan ( 5 ) . While in Karachi (Sindh) and Multan (Punjab), these rates are impacted by sun exposure, lifestyle, and lack of awareness about skin protection and early detection. ( 6 ) Dow Cancer Registry suggested NSMC as the fifth most common cancer in Karachi. ( 7 ) Despite rising numbers, awareness and understanding of skin cancer prevention and detection are low among the general population in Pakistan. A study from DUHS suggested a neglect of skin cancer-related research in Pakistan. ( 8 ) Report suggests that limiting the exposure to UV light prevents more than 5 million cases of skin cancer, and regularly applying sunscreen with adequate Sun Protection Factor (SPF) reduces the risk of melanoma by 50% and squamous cell carcinoma by 40%. ( 9 ) Suppose heredity plays a crucial role in the development of skin cancer. In that case, the environmental factors such as excessive sun exposure, poor skincare habits, and lack of sun protection turn out to be one of the most significant risk factors. It is important to reduce the health and economic burden of skin cancer in a developing country like Pakistan. Such strategies include sunscreen with a good sun protection factor (SPF), wearing hats with adequate protection to the entire head, along with tightly woven clothing that covers the arms, torso, and legs. ( 10 ) At the same time, secondary sun-protective behaviors include conducting regular self-examination and total body skin examinations by physicians. ( 11 ) Medical students, as future healthcare providers, play a crucial role in educating the public about skin cancer prevention and detection. ( 12 ) However, there is limited data on their awareness levels. A 2001 study by Agha Khan University Medical College found that while students had substantial knowledge about malignant melanoma (MM), there was a significant gap in practical application. Many students were unaware of key risk factors and the commonality of skin cancer, with inadequate sun protection practices reported. ( 13 ) Medical students, as future healthcare providers, play a pivotal role in promoting sun-protective behaviors and early skin cancer detection. However, there is limited data on the knowledge, attitudes, and practices (KAP) of medical students regarding skin cancer prevention and detection in Pakistan. This study aims to assess knowledge, attitudes, and practices regarding skin cancer prevention among medical students of Rawalpindi Medical University, Pakistan. Assessing the KAP of these students, targeted educational interventions may take place to enhance the preparedness of future healthcare professionals in addressing the rising burden of skin cancer. Methods Study Design This is a survey-based cross-sectional study conducted on medical students of Rawalpindi Medical University. Setting This study was conducted at Rawalpindi Medical University, Pakistan, from July to November 2024. Participants Data was collected using a Non-random Convenience Sampling Technique during July and November 2024. All the Medical students from the five years of Rawalpindi Medical University, between the ages of 18–25, were eligible to participate in the study. We excluded foreign nationality medical students, students who have been previously diagnosed with any form of skin cancer, and students who are currently undergoing treatment for skin cancer to prevent any potential bias in the results. Participation of students was entirely voluntary. Informed consent was taken from all the participants, and they were assured that they could withdraw from the questionnaire at any time. The approval was taken by the Institutional Review Board of Rawalpindi Medical University. Variables After obtaining informed consent from the participants, data were collected regarding Knowledge, Attitude, and Practices in skin cancer prevention and early detection. Data Sources and Measurement A structured, validated, and comprehensive 49-item questionnaire ( 14 ) was used to collect data physically from the students. Six questions gathered demographic details about the participants, such as age, gender, academic year, rank, and any personal or family history related to skin cancer. Thirty questions evaluated the students' general knowledge on topics such as types of skin cancer, risk factors, early signs and symptoms, and preventive measures. Five questions focused on their attitudes toward performing self-examinations for skin abnormalities. Additionally, eight questions assessed attitudes and behaviors concerning sun exposure, including protective measures like the use of sunscreen, protective clothing, and shade-seeking behaviors. Study Size The sample size of 260 was calculated by the OpenEpi sample size calculator with a confidence interval of 95% and an anticipated frequency of 83.5% taken from the study by Seetan et al ( 14 ) . Quantitative Variables Knowledge of risk factors of skin cancer was the quantitative variable. We assessed knowledge of the 24 most important risk factors of skin cancer on a Likert scale. The students who agreed on a particular risk factor were given 1 score. Statistical Methods Data analysis was conducted using Statistical Product and Service Solutions (SPSS) version 27. Descriptive statistics were applied to evaluate the data using mean ± SD for continuous variables; however, percentages and frequencies were used to evaluate categorical variables. Inferential statistical methods, such as the Kruskal-Wallis Test, were applied to assess the differences in mean knowledge of risk factors between different classes, and Mann Mann-Whitney U test was used to assess the difference in mean knowledge of risk factors among the students who practiced self-care against exposure and those who didn’t. Moreover, p-values less than 0.05 were considered statistically significant. Results Patient Demographics A total of 260 students met the above-given eligibility criteria and participated in our study. This makes up to 15% of the students at Rawalpindi Medical University. We had 184 females (70.8%) and 76 males (29.2%). The majority of our students belonged to the age group of 20-23 years old (n=140, 53.8%), followed by 104 (40%) being less than 20 years old, while only 16 (6.2%) belonged to the age group of 24-27 years old. The data was collected from MBBS students of the 1 st to final years. 151 (58.1%) students were from the first year, 31 (11.9%) from the second year, 16 (6.2%) from the third year, 23 (8.8%) from the fourth year, and 39 (15%) from the final year. Only 11 (4.2%) students reported having scored excellent marks in their last academic exams. 62 (23.8%) reported very good marks, 175 (67.3%) reported good, and 12 (4.6%) reported to have performed weak. ( Table 1 ) Outcomes Knowledge of Skin Cancer Before testing the students' knowledge, we inquired whether any students had a family history of skin cancer. 252 (96.9%) students reported having no such family history, while only 8 (3.1%) students reported that they had a positive family history of skin cancer. We inquired how the students themselves would describe their knowledge. 165 (63.5%) students exclaimed they had proper knowledge regarding skin cancer, while 95 (36.5%) students reported improper knowledge. 99 (38.1%) students reported having gained their knowledge from medical school. 56 (21.5%0 of the students correctly chose basal cell carcinoma as the most common type of skin cancer. 60 (23.1%) students identified melanoma as a mole with a symmetrical border, while 67 (25.8%) students reported not knowing the characteristics of melanoma. ( Table 2 ) Knowledge of Risk Factors We tested the students' general knowledge regarding the risk factors for skin cancer. The mean score of our students was 9.89 out of 24, with a maximum score of 23. The mean score of first-year students was 12.56. The mean score of second-year students was 9.03. Third-year students had the highest mean score of 12.65. Fourth-year students had 9.8, and the final year scored lowest at 7.56. The mean scores were not normally distributed, so the Kruskal-Wallis test was applied to find whether the difference between classes was statistically significant. A significance of <0.001 was shown. Tukey’s test revealed that the differences between the 1st, the 3rd, and 4th years were not statistically significant, while the second and final years had scored significantly lower . ( Table 3 ) Attitude Regarding Protection from Skin Cancer We determined the students' attitudes toward skin cancer by asking whether they had a habit of doing skin self-examination. 142 (54.6%) reported no such practice, while the remaining 118 (45.4%) did practice. Out of the 142 who did not practice, 123 (86.6%), we have concluded that they never thought about it. Among the students who reported performing the self-examination, 44 (37.3%) used to look for a new lesion. 66 (55.9%) reported that it gives them peace of mind. The majority (25, 29.7%) of the students reported that the Internet was the main source of learning about the self-examination procedure. We determined the difference in knowledge regarding risk factors between the students who practiced self-examination and those who didn’t. We found a statistically significant difference (P=0.01) with the Mann-Whitney U test. The mean score of practicing students was 10.8, while those who did not perform scored 9.1. ( Table 4 ) The Practices of Protection Measures from Skin Cancer Lastly, we asked questions about the students' sun exposure practices. Only 15 (5.8%) of the students exclaimed that they sometimes tried to avoid the Sun from 10 a.m. to 4 p.m. 18 (6.9%) of students reported wearing a hat when going outside, while 91 (35%) never wore a hat. Only 9 (3.5%) of students always used sunglasses, while 59 (22.7%) always used sunscreen at least with an SPF of 15. The majority, i.e., 96 (36.9%) of students reported that they don’t go swimming . ( Table 5 ) Discussion Cancers are the second leading cause of mortality globally, surpassed only by cardiovascular diseases. ( 14 ) Skin cancer is the fifth most common cancer globally, accounting for approximately 5.8% of cases, with melanoma comprising 1.6% and an overall mortality rate of 0.6–0.7%. (8) Its incidence continues to rise, particularly in areas with high ultraviolet (UV) radiation exposure, such as Pakistan. In Pakistan, where there is no national cancer registry, regional sources such as the Punjab Cancer Registry (PCR) have reported a higher incidence of skin cancer compared to the Globocan 2018 report, which ranked non-melanoma skin cancers (NMSC) as the 18th and melanoma as the 32nd most common cancers. ( 8 ) The PCR indicated that in 2017, skin cancer was the eighth and ninth most common cancer among females and males, respectively. ( 8 ) Higher incidence rates have been reported in Karachi and Larkana compared to regions like Hazara, supporting the inverse relationship between skin cancer incidence and distance from the equator. ( 8 ) These findings highlight an increasing burden of skin cancer in Pakistan, underscoring the need for targeted research efforts. ( 8 ) Although skin cancer is among the most prevalent cancers in Pakistan, there is a concerning lack of research and public awareness regarding the disease. ( 8 ) Skin cancer, in particular, is largely preventable due to the identification of numerous risk factors. In response, the World Health Organization (WHO) has established strategies aimed at controlling skin cancer by enhancing public awareness through health education, thereby fostering improved attitudes and preventive practices. ( 14 ) The early detection and prevention of skin cancer are crucial in reducing its morbidity and mortality rates. ( 15 ) However, knowledge gaps and inadequate preventive practices are widespread among the general public. Medical students, as future healthcare professionals, play an essential role in raising awareness, early detection, and promoting prevention. Therefore, it is vital to assess the knowledge, attitudes, and practices (KAP) of medical students regarding skin cancer, particularly in an educational setting. General Knowledge of Skin Cancer Our study aimed to evaluate the KAP of students of Rawalpindi Medical University regarding skin cancer prevention and detection. The results revealed that while many students had some awareness of skin cancer, their overall knowledge was far from comprehensive. A majority of the students (63.5%) self-reported some knowledge about skin cancer; however, when examined in more detail, it was found that their knowledge was limited, particularly regarding the types of skin cancer and their risk factors. Approximately only 21.5% of the students correctly identified basal cell carcinoma as the most common type of skin cancer, while a lesser proportion (32.3%) correctly identified melanoma as a highly dangerous form. This is concerning, as melanoma, although less common, accounts for a larger number of deaths due to its aggressive nature. ( 16 ) This knowledge gap aligns with findings from other studies conducted in similar academic settings. ( 17 ) For instance, a study at Agha Khan University found that although students had substantial knowledge of malignant melanoma, there was a lack of practical knowledge, particularly regarding preventive measures. Many were unaware of key risk factors, such as new moles, and the commonality of skin cancer. A significant portion (73%) reported childhood sunburns, indicating insufficient sun protection. ( 13 ) This trend appears to persist over time, as similar findings have been reported in studies from various countries. In Turkey, for example, a study conducted among students demonstrated that although basic knowledge of skin cancer was high, knowledge about specific preventive practices and self-examination was relatively low. ( 18 ) Comparable trends were also found in a Canadian study, where medical students exhibited adequate knowledge about melanoma characteristics but limited awareness of non-melanoma skin cancers and their prevention. Several factors may contribute to this discrepancy in knowledge, including curriculum design, varying emphasis on skin cancer across different years of study, and limited practical exposure to dermatological health issues. Studies from Australia and New Zealand, regions with high rates of skin cancer, emphasize the importance of continuous reinforcement in the curriculum to ensure sustained knowledge retention among the general population and students. ( 19 ) A study published in the AAMC journal of Teaching and Learning Resources highlighted the importance of integrating skin cancer education into the medical curriculum to ensure that future healthcare professionals are equipped with the knowledge required for early detection. ( 20 ) If medical students are not sufficiently knowledgeable about melanoma’s characteristics, they may struggle to educate their future patients effectively. Medical schools must prioritize educating students about melanoma’s signs, including asymmetry, irregular borders, multiple colors, and larger diameters (the ABCD rule), which are essential for early detection. ( 21 ) Our study also found that a significant number of students relied on internet sources (33.5%) for information about skin cancer, while 38.1% reported obtaining most of their knowledge from their formal education. The increasing reliance on online sources, including websites and social media, for medical knowledge highlights the importance of integrating credible and accurate information about skin cancer into these platforms to ensure that students are equipped with reliable facts. ( 22 ) Knowledge of Risk Factors for Skin Cancer Our study also evaluated the knowledge of students regarding the risk factors for skin cancer. The average score for knowledge about risk factors was relatively low, with a mean score of 9.89 out of 24. Notably, first-year students scored higher than students in later years, with first-year students averaging 12.56 out of 24. This could suggest that the initial years of medical education offer more foundational information about skin cancer, but as students’ progress in their studies, the focus may shift to other, more prevalent medical conditions. This trend highlights the need for ongoing education on skin cancer prevention, even in advanced years of medical training. A common gap in students' knowledge was related to the influence of environmental factors, such as UV radiation, on skin cancer development. Many students were unaware of the full range of risk factors, including the role of family history, fair skin, and certain genetic conditions. These findings align with similar research conducted in other countries, where medical students exhibited limited awareness about the complexities of risk factors for skin cancer, particularly in terms of genetics and environmental exposures. ( 18 ) Importantly, a lack of awareness of these risk factors may contribute to ineffective prevention practices and an inability to educate patients on proper sun protection behaviors. ( 10 ) Understanding and being able to recognize risk factors, such as prolonged sun exposure, tanning bed use, and family history, is essential for early detection and prevention efforts. Attitudes toward Prevention and Detection The attitudes toward skin cancer prevention and detection were mixed. In this study, 45.4% of students reported regularly performing skin self-examinations, a practice that is critical for early detection of melanoma and other forms of skin cancer. However, this also means that more than half of the students (54.6%) did not regularly engage in self-examination, which is concerning for medical professionals who should model health-promoting behaviors for the general public. Of the students who did perform self-examinations, the main motivation was to check for new lesions, while others indicated that they engaged in this practice to alleviate anxiety about potential skin cancer. However, many students who did not perform self-examinations cited a lack of awareness or simply never considered doing so. This highlights a significant barrier to preventive health practices, even among future healthcare professionals. A study has found that healthcare professionals themselves often fall short of adopting recommended preventive behaviors. ( 23 ) This calls into question the extent to which medical students are being trained to prioritize personal health practices, including regular self-examinations. A critical finding in our study was the limited use of sun protection measures, such as sunscreen application, wearing hats, and avoiding excessive sun exposure during peak UV hours. Only a small number of students regularly practiced these preventive measures. This finding is consistent with studies conducted elsewhere, where medical students and even healthcare professionals exhibited poor sun protection behaviors despite knowing the risks associated with UV radiation. ( 17 ) The lack of adherence to sun protection recommendations among medical students may indicate that preventive behaviors need to be instilled as part of medical education. Medical schools could play a pivotal role in shaping students' attitudes toward skin cancer prevention by incorporating sun safety practices and self-examination training into the curriculum. Practical Implications for Medical Education Sun exposure practices among RMU students revealed notable gaps in preventive measures. Only a few students indicated that they occasionally avoided peak sun hours from 10 a.m. to 4 p.m., and a limited number wore hats when outdoors, while a significant portion did not use hats at all. The consistent use of sunglasses was rare, and only a minority reported regularly applying sunscreen with a minimum SPF of 15. Additionally, most students did not engage in swimming, possibly indicating limited exposure to situations requiring sun protection awareness. The findings from this study underscore the need to improve the education and awareness of medical students regarding skin cancer prevention, detection, and risk factors. Medical curricula must include detailed and updated information on skin cancer, particularly focusing on the types of skin cancer, risk factors, and prevention measures. Furthermore, enhancing practical training in recognizing early signs of skin cancer, such as melanoma, and encouraging regular self-examinations would better prepare students to not only protect their health but also advise patients effectively. In addition, medical schools should prioritize health promotion and disease prevention, both within their curricula and through extracurricular activities. Public health initiatives that target medical students, as well as the general population, are essential for raising awareness about skin cancer. These initiatives should focus on promoting sun safety and the importance of self-examination for early detection. Digital platforms, particularly social media, can be valuable tools in disseminating this information widely, given the high reliance on the internet for health information. Limitations and Future Directions This study's limitations include the use of convenience sampling and self-reported measures, which could introduce selection and response biases. Additionally, this study’s cross-sectional design does not allow for assessment of changes in knowledge and behaviors over time. Given the significance of skin cancer as a public health issue, further research is recommended to explore similar KAP assessments in other regions of Pakistan. Comparative studies involving medical students from different institutions or regions could provide a broader understanding of the educational needs and potential solutions for improving skin cancer awareness in the country. Conclusion This study found that medical students at RMU demonstrate an unsatisfactory level of knowledge regarding skin cancer, and significant gaps remain in their attitudes and practices related to prevention and detection. These findings reflect trends observed in other regions and underscore the need for a more integrated approach to teaching skin cancer prevention in medical curricula. Enhancing awareness and preventive behaviors among future healthcare providers could contribute to broader public health efforts in reducing the incidence and impact of skin cancer. Declarations Author contribution Statement B.S: Conceptualization, Methodology, Software, Data curation, Writing Original draft preparation, M.B : Data curation, Writing- Original draft preparation. F.A: Visualization, Investigation, Data Curation, M.B : Software, Validation. H.M.M: Writing Reviewing and Editing, E.H: Data Curation, Manuscript writing, T.A: Data Curation, Manuscript writing, Writing-Original Draft Preparation, A.K: Supervision, Writing-Original Draft Preparation; M.N.S : Writing-Original Draft Preparation Acknowledgement None Declaration of Use of Artificial Intelligence (AI) During the preparation of this work, AI was used as an assistance for refining language and structure, but the authors have reviewed the work and take full responsibility for the content. Disclosure of Potential Conflicts of Interest The authors have declared no conflict of interest. Funding Declaration: The author received no funding from any individual, organization, or authority. Ethical Approval: Ethical approval was taken from the Institutional Review Board (IRB) of Rawalpindi Medical University, Rawalpindi, Pakistan. Reference Number: 1012/IREF/RMU/2024. The study was conducted following the STROBE checklist for cross-sectional studies. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6949812","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":475155872,"identity":"f48db4b6-dfc8-46b9-a42a-1997e7634e90","order_by":0,"name":"Beenish Sabir","email":"","orcid":"","institution":"Rawalpindi Medical University","correspondingAuthor":false,"prefix":"","firstName":"Beenish","middleName":"","lastName":"Sabir","suffix":""},{"id":475155873,"identity":"8f1ed5f9-280d-4f86-803c-940419e9c97e","order_by":1,"name":"Mahnoor Bajwa","email":"","orcid":"","institution":"Rawalpindi Medical 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University","correspondingAuthor":false,"prefix":"","firstName":"Haris","middleName":"Mumtaz","lastName":"Malik","suffix":""},{"id":475155877,"identity":"8dad4a66-f00d-4f5b-84c0-e557f28d0974","order_by":5,"name":"Talha Amin","email":"","orcid":"","institution":"Rawalpindi Medical University","correspondingAuthor":false,"prefix":"","firstName":"Talha","middleName":"","lastName":"Amin","suffix":""},{"id":475155878,"identity":"b7a33871-bf44-472a-9e64-d4fc277df964","order_by":6,"name":"Erum Habib","email":"","orcid":"","institution":"Dow University of Health Sciences","correspondingAuthor":false,"prefix":"","firstName":"Erum","middleName":"","lastName":"Habib","suffix":""},{"id":475155879,"identity":"02c18c95-2c5a-4e38-a27d-10ec733264d1","order_by":7,"name":"Afifa Kulsoom","email":"","orcid":"","institution":"Rawalpindi Medical University","correspondingAuthor":false,"prefix":"","firstName":"Afifa","middleName":"","lastName":"Kulsoom","suffix":""},{"id":475155880,"identity":"8e88fe13-0f68-4999-9b20-4bfa96bb12fa","order_by":8,"name":"Muhammad Nabeel Saddique","email":"data:image/png;base64,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","orcid":"","institution":"King Edward Medical University","correspondingAuthor":true,"prefix":"","firstName":"Muhammad","middleName":"Nabeel","lastName":"Saddique","suffix":""}],"badges":[],"createdAt":"2025-06-22 13:38:22","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6949812/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6949812/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":85303980,"identity":"bcc9468b-1716-4a8c-9d7d-04b270b27f8a","added_by":"auto","created_at":"2025-06-24 12:32:09","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":775464,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6949812/v1/e1adf1e2-55f5-429b-bd0e-55dd40c8d3f1.pdf"},{"id":85263802,"identity":"1be6a0ff-3006-428f-beb7-686714358965","added_by":"auto","created_at":"2025-06-24 04:38:50","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":13927,"visible":true,"origin":"","legend":"","description":"","filename":"Table1.docx","url":"https://assets-eu.researchsquare.com/files/rs-6949812/v1/321eaf70d53f55ba1c9d483f.docx"},{"id":85263805,"identity":"518dcbd2-d4e8-4d1f-9ac9-535a484b8a5e","added_by":"auto","created_at":"2025-06-24 04:38:51","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":14912,"visible":true,"origin":"","legend":"","description":"","filename":"Table2.docx","url":"https://assets-eu.researchsquare.com/files/rs-6949812/v1/0cca7bb1628564d442a01de3.docx"},{"id":85264083,"identity":"84e01a98-34e4-46d6-b8d9-cd171db5a651","added_by":"auto","created_at":"2025-06-24 04:46:51","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":13242,"visible":true,"origin":"","legend":"","description":"","filename":"Table3.docx","url":"https://assets-eu.researchsquare.com/files/rs-6949812/v1/61cf31620986622b6e195f56.docx"},{"id":85263810,"identity":"7f5a3866-6edd-45f2-b4f3-b99e8090d610","added_by":"auto","created_at":"2025-06-24 04:38:51","extension":"docx","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":14679,"visible":true,"origin":"","legend":"","description":"","filename":"Table4.docx","url":"https://assets-eu.researchsquare.com/files/rs-6949812/v1/5bf5b357cd9ed07768c3d997.docx"},{"id":85264489,"identity":"4304973f-ff70-4d27-9765-ddccc2e3f724","added_by":"auto","created_at":"2025-06-24 04:54:51","extension":"docx","order_by":5,"title":"","display":"","copyAsset":false,"role":"supplement","size":14228,"visible":true,"origin":"","legend":"","description":"","filename":"Table5.docx","url":"https://assets-eu.researchsquare.com/files/rs-6949812/v1/926f816d7e1fe2b76d338702.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Knowledge, Attitude, and Practices toward Skin Cancer Prevention and Detection among Students of Rawalpindi Medical University: A Cross- Sectional Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eSkin cancer is the fifth most prevalent cancer worldwide, posing a significant public health concern. \u003csup\u003e(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/sup\u003e According to the World Health Organization, approximately 2\u0026ndash;3\u0026nbsp;million non-melanoma skin cancers and 132,000 melanoma skin cancers are diagnosed annually across the globe. \u003csup\u003e(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/sup\u003e The incidence of skin cancer has been steadily increasing, with studies indicating that 1 in every three diagnosed cases of cancer is a skin cancer. \u003csup\u003e(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/sup\u003e The rising trend in skin cancer cases is attributed to various factors, including increased ultraviolet (UV) radiation exposure, fair skin color, and genetics. \u003csup\u003e(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eAlthough national data on the prevalence of skin cancer is limited in Pakistan, the global rise in cancer trends points to a health challenge in the country. The Punjab Cancer Registry reports increasing cases, with significant geographic and ethnic differences. It showed that skin cancer is the most prevalent (7%) among females in Gilgit-Baltistan \u003csup\u003e(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/sup\u003e. While in Karachi (Sindh) and Multan (Punjab), these rates are impacted by sun exposure, lifestyle, and lack of awareness about skin protection and early detection. \u003csup\u003e(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/sup\u003e Dow Cancer Registry suggested NSMC as the fifth most common cancer in Karachi. \u003csup\u003e(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)\u003c/sup\u003e Despite rising numbers, awareness and understanding of skin cancer prevention and detection are low among the general population in Pakistan. A study from DUHS suggested a neglect of skin cancer-related research in Pakistan. \u003csup\u003e(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/sup\u003e Report suggests that limiting the exposure to UV light prevents more than 5\u0026nbsp;million cases of skin cancer, and regularly applying sunscreen with adequate Sun Protection Factor (SPF) reduces the risk of melanoma by 50% and squamous cell carcinoma by 40%. \u003csup\u003e(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e)\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eSuppose heredity plays a crucial role in the development of skin cancer. In that case, the environmental factors such as excessive sun exposure, poor skincare habits, and lack of sun protection turn out to be one of the most significant risk factors.\u003c/p\u003e \u003cp\u003eIt is important to reduce the health and economic burden of skin cancer in a developing country like Pakistan. Such strategies include sunscreen with a good sun protection factor (SPF), wearing hats with adequate protection to the entire head, along with tightly woven clothing that covers the arms, torso, and legs. \u003csup\u003e(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e)\u003c/sup\u003e At the same time, secondary sun-protective behaviors include conducting regular self-examination and total body skin examinations by physicians. \u003csup\u003e(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e)\u003c/sup\u003e Medical students, as future healthcare providers, play a crucial role in educating the public about skin cancer prevention and detection. \u003csup\u003e(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e)\u003c/sup\u003e However, there is limited data on their awareness levels. A 2001 study by Agha Khan University Medical College found that while students had substantial knowledge about malignant melanoma (MM), there was a significant gap in practical application. Many students were unaware of key risk factors and the commonality of skin cancer, with inadequate sun protection practices reported. \u003csup\u003e(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e)\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eMedical students, as future healthcare providers, play a pivotal role in promoting sun-protective behaviors and early skin cancer detection. However, there is limited data on the knowledge, attitudes, and practices (KAP) of medical students regarding skin cancer prevention and detection in Pakistan. This study aims to assess knowledge, attitudes, and practices regarding skin cancer prevention among medical students of Rawalpindi Medical University, Pakistan. Assessing the KAP of these students, targeted educational interventions may take place to enhance the preparedness of future healthcare professionals in addressing the rising burden of skin cancer.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design\u003c/h2\u003e \u003cp\u003eThis is a survey-based cross-sectional study conducted on medical students of Rawalpindi Medical University.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSetting\u003c/h3\u003e\n\u003cp\u003eThis study was conducted at Rawalpindi Medical University, Pakistan, from July to November 2024.\u003c/p\u003e\n\u003ch3\u003eParticipants\u003c/h3\u003e\n\u003cp\u003eData was collected using a Non-random Convenience Sampling Technique during July and November 2024. All the Medical students from the five years of Rawalpindi Medical University, between the ages of 18\u0026ndash;25, were eligible to participate in the study. We excluded foreign nationality medical students, students who have been previously diagnosed with any form of skin cancer, and students who are currently undergoing treatment for skin cancer to prevent any potential bias in the results. Participation of students was entirely voluntary. Informed consent was taken from all the participants, and they were assured that they could withdraw from the questionnaire at any time. The approval was taken by the Institutional Review Board of Rawalpindi Medical University.\u003c/p\u003e\n\u003ch3\u003eVariables\u003c/h3\u003e\n\u003cp\u003e After obtaining informed consent from the participants, data were collected regarding Knowledge, Attitude, and Practices in skin cancer prevention and early detection.\u003c/p\u003e\n\u003ch3\u003eData Sources and Measurement\u003c/h3\u003e\n\u003cp\u003eA structured, validated, and comprehensive 49-item questionnaire\u003csup\u003e(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e)\u003c/sup\u003e was used to collect data physically from the students. Six questions gathered demographic details about the participants, such as age, gender, academic year, rank, and any personal or family history related to skin cancer. Thirty questions evaluated the students' general knowledge on topics such as types of skin cancer, risk factors, early signs and symptoms, and preventive measures. Five questions focused on their attitudes toward performing self-examinations for skin abnormalities. Additionally, eight questions assessed attitudes and behaviors concerning sun exposure, including protective measures like the use of sunscreen, protective clothing, and shade-seeking behaviors.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStudy Size\u003c/h2\u003e \u003cp\u003eThe sample size of 260 was calculated by the OpenEpi sample size calculator with a confidence interval of 95% and an anticipated frequency of 83.5% taken from the study by \u003cem\u003eSeetan et al\u003c/em\u003e\u003csup\u003e(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e)\u003c/sup\u003e.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eQuantitative Variables\u003c/h3\u003e\n\u003cp\u003eKnowledge of risk factors of skin cancer was the quantitative variable. We assessed knowledge of the 24 most important risk factors of skin cancer on a Likert scale. The students who agreed on a particular risk factor were given 1 score.\u003c/p\u003e\n\u003ch3\u003eStatistical Methods\u003c/h3\u003e\n\u003cp\u003eData analysis was conducted using Statistical Product and Service Solutions (SPSS) version 27. Descriptive statistics were applied to evaluate the data using mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD for continuous variables; however, percentages and frequencies were used to evaluate categorical variables. Inferential statistical methods, such as the Kruskal-Wallis Test, were applied to assess the differences in mean knowledge of risk factors between different classes, and Mann Mann-Whitney U test was used to assess the difference in mean knowledge of risk factors among the students who practiced self-care against exposure and those who didn\u0026rsquo;t. Moreover, p-values less than 0.05 were considered statistically significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003ePatient Demographics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 260 students met the above-given eligibility criteria and participated in our study. This makes up to 15% of the students at Rawalpindi Medical University. We had 184 females (70.8%) and 76 males (29.2%). The majority of our students belonged to the age group of 20-23 years old (n=140, 53.8%), followed by 104 (40%) being less than 20 years old, while only 16 (6.2%) belonged to the age group of 24-27 years old. The data was collected from MBBS students of the 1\u003csup\u003est\u003c/sup\u003e to final years. 151 (58.1%) students were from the first year, 31 (11.9%) from the second year, 16 (6.2%) from the third year, 23 (8.8%) from the fourth year, and 39 (15%) from the final year. Only 11 (4.2%) students reported having scored excellent marks in their last academic exams. 62 (23.8%) reported very good marks, 175 (67.3%) reported good, and 12 (4.6%) reported to have performed weak. (\u003cstrong\u003eTable 1\u003c/strong\u003e\u003cstrong\u003e)\u003c/strong\u003e\u003c/p\u003e\n\u003ch2\u003eOutcomes\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003e\u003cstrong\u003eKnowledge of Skin Cancer\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBefore testing the students\u0026apos; knowledge, we inquired whether any students had a family history of skin cancer. 252 (96.9%) students reported having no such family history, while only 8 (3.1%) students reported that they had a positive family history of skin cancer. We inquired how the students themselves would describe their knowledge. 165 (63.5%) students exclaimed they had proper knowledge regarding skin cancer, while 95 (36.5%) students reported improper knowledge. 99 (38.1%) students reported having gained their knowledge from medical school. 56 (21.5%0 of the students correctly chose basal cell carcinoma as the most common type of skin cancer. 60 (23.1%) students identified melanoma as a mole with a symmetrical border, while 67 (25.8%) students reported not knowing the characteristics of melanoma. (\u003cstrong\u003eTable 2\u003c/strong\u003e\u003cstrong\u003e)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eKnowledge of Risk Factors\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe tested the students\u0026apos; general knowledge regarding the risk factors for skin cancer. The mean score of our students was 9.89 out of 24, with a maximum score of 23. The mean score of first-year students was 12.56. The mean score of second-year students was 9.03. Third-year students had the highest mean score of 12.65. Fourth-year students had 9.8, and the final year scored lowest at 7.56. The mean scores were not normally distributed, so the Kruskal-Wallis test was applied to find whether the difference between classes was statistically significant. A significance of \u0026lt;0.001 was shown. Tukey\u0026rsquo;s test revealed that the differences between the 1st, the 3rd, and 4th years were not statistically significant, while the second and final years had scored significantly lower\u003cstrong\u003e. (\u003c/strong\u003e\u003cstrong\u003eTable 3\u003c/strong\u003e\u003cstrong\u003e)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAttitude Regarding Protection from Skin Cancer\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe determined the students\u0026apos; attitudes toward skin cancer by asking whether they had a habit of doing skin self-examination. 142 (54.6%) reported no such practice, while the remaining 118 (45.4%) did practice. Out of the 142 who did not practice, 123 (86.6%), we have concluded that they never thought about it. Among the students who reported performing the self-examination, 44 (37.3%) used to look for a new lesion. 66 (55.9%) reported that it gives them peace of mind. The majority (25, 29.7%) of the students reported that the Internet was the main source of learning about the self-examination procedure. We determined the difference in knowledge regarding risk factors between the students who practiced self-examination and those who didn\u0026rsquo;t. We found a statistically significant difference (P=0.01) with the Mann-Whitney U test. The mean score of practicing students was 10.8, while those who did not perform scored 9.1. (\u003cstrong\u003eTable 4\u003c/strong\u003e\u003cstrong\u003e)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThe Practices of Protection Measures from Skin Cancer\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLastly, we asked questions about the students\u0026apos; sun exposure practices. Only 15 (5.8%) of the students exclaimed that they sometimes tried to avoid the Sun from 10 a.m. to 4 p.m. 18 (6.9%) of students reported wearing a hat when going outside, while 91 (35%) never wore a hat. Only 9 (3.5%) of students always used sunglasses, while 59 (22.7%) always used sunscreen at least with an SPF of 15. The majority, i.e., 96 (36.9%) of students reported that they don\u0026rsquo;t go swimming\u003cstrong\u003e. (\u003c/strong\u003e\u003cstrong\u003eTable 5\u003c/strong\u003e\u003cstrong\u003e)\u003c/strong\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eCancers are the second leading cause of mortality globally, surpassed only by cardiovascular diseases.\u003csup\u003e(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e)\u003c/sup\u003e Skin cancer is the fifth most common cancer globally, accounting for approximately 5.8% of cases, with melanoma comprising 1.6% and an overall mortality rate of 0.6\u0026ndash;0.7%.\u003csup\u003e(8)\u003c/sup\u003e Its incidence continues to rise, particularly in areas with high ultraviolet (UV) radiation exposure, such as Pakistan. In Pakistan, where there is no national cancer registry, regional sources such as the Punjab Cancer Registry (PCR) have reported a higher incidence of skin cancer compared to the Globocan 2018 report, which ranked non-melanoma skin cancers (NMSC) as the 18th and melanoma as the 32nd most common cancers. \u003csup\u003e(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/sup\u003e The PCR indicated that in 2017, skin cancer was the eighth and ninth most common cancer among females and males, respectively. \u003csup\u003e(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eHigher incidence rates have been reported in Karachi and Larkana compared to regions like Hazara, supporting the inverse relationship between skin cancer incidence and distance from the equator. \u003csup\u003e(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/sup\u003e These findings highlight an increasing burden of skin cancer in Pakistan, underscoring the need for targeted research efforts. \u003csup\u003e(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/sup\u003e Although skin cancer is among the most prevalent cancers in Pakistan, there is a concerning lack of research and public awareness regarding the disease. \u003csup\u003e(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eSkin cancer, in particular, is largely preventable due to the identification of numerous risk factors. In response, the World Health Organization (WHO) has established strategies aimed at controlling skin cancer by enhancing public awareness through health education, thereby fostering improved attitudes and preventive practices. \u003csup\u003e(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e)\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe early detection and prevention of skin cancer are crucial in reducing its morbidity and mortality rates. \u003csup\u003e(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e)\u003c/sup\u003e However, knowledge gaps and inadequate preventive practices are widespread among the general public. Medical students, as future healthcare professionals, play an essential role in raising awareness, early detection, and promoting prevention. Therefore, it is vital to assess the knowledge, attitudes, and practices (KAP) of medical students regarding skin cancer, particularly in an educational setting.\u003c/p\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eGeneral Knowledge of Skin Cancer\u003c/h2\u003e \u003cp\u003eOur study aimed to evaluate the KAP of students of Rawalpindi Medical University regarding skin cancer prevention and detection. The results revealed that while many students had some awareness of skin cancer, their overall knowledge was far from comprehensive. A majority of the students (63.5%) self-reported some knowledge about skin cancer; however, when examined in more detail, it was found that their knowledge was limited, particularly regarding the types of skin cancer and their risk factors. Approximately only 21.5% of the students correctly identified basal cell carcinoma as the most common type of skin cancer, while a lesser proportion (32.3%) correctly identified melanoma as a highly dangerous form. This is concerning, as melanoma, although less common, accounts for a larger number of deaths due to its aggressive nature. \u003csup\u003e(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e)\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThis knowledge gap aligns with findings from other studies conducted in similar academic settings.\u003csup\u003e(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e)\u003c/sup\u003e For instance, a study at Agha Khan University found that although students had substantial knowledge of malignant melanoma, there was a lack of practical knowledge, particularly regarding preventive measures. Many were unaware of key risk factors, such as new moles, and the commonality of skin cancer. A significant portion (73%) reported childhood sunburns, indicating insufficient sun protection.\u003csup\u003e(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e)\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThis trend appears to persist over time, as similar findings have been reported in studies from various countries. In Turkey, for example, a study conducted among students demonstrated that although basic knowledge of skin cancer was high, knowledge about specific preventive practices and self-examination was relatively low.\u003csup\u003e(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e)\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eComparable trends were also found in a Canadian study, where medical students exhibited adequate knowledge about melanoma characteristics but limited awareness of non-melanoma skin cancers and their prevention. Several factors may contribute to this discrepancy in knowledge, including curriculum design, varying emphasis on skin cancer across different years of study, and limited practical exposure to dermatological health issues. Studies from Australia and New Zealand, regions with high rates of skin cancer, emphasize the importance of continuous reinforcement in the curriculum to ensure sustained knowledge retention among the general population and students.\u003csup\u003e(\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e)\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eA study published in the AAMC journal of Teaching and Learning Resources highlighted the importance of integrating skin cancer education into the medical curriculum to ensure that future healthcare professionals are equipped with the knowledge required for early detection.\u003csup\u003e(\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e)\u003c/sup\u003e If medical students are not sufficiently knowledgeable about melanoma\u0026rsquo;s characteristics, they may struggle to educate their future patients effectively. Medical schools must prioritize educating students about melanoma\u0026rsquo;s signs, including asymmetry, irregular borders, multiple colors, and larger diameters (the ABCD rule), which are essential for early detection.\u003csup\u003e(\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e)\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eOur study also found that a significant number of students relied on internet sources (33.5%) for information about skin cancer, while 38.1% reported obtaining most of their knowledge from their formal education. The increasing reliance on online sources, including websites and social media, for medical knowledge highlights the importance of integrating credible and accurate information about skin cancer into these platforms to ensure that students are equipped with reliable facts.\u003csup\u003e(\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e)\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eKnowledge of Risk Factors for Skin Cancer\u003c/h2\u003e \u003cp\u003eOur study also evaluated the knowledge of students regarding the risk factors for skin cancer. The average score for knowledge about risk factors was relatively low, with a mean score of 9.89 out of 24. Notably, first-year students scored higher than students in later years, with first-year students averaging 12.56 out of 24. This could suggest that the initial years of medical education offer more foundational information about skin cancer, but as students\u0026rsquo; progress in their studies, the focus may shift to other, more prevalent medical conditions. This trend highlights the need for ongoing education on skin cancer prevention, even in advanced years of medical training.\u003c/p\u003e \u003cp\u003eA common gap in students' knowledge was related to the influence of environmental factors, such as UV radiation, on skin cancer development. Many students were unaware of the full range of risk factors, including the role of family history, fair skin, and certain genetic conditions. These findings align with similar research conducted in other countries, where medical students exhibited limited awareness about the complexities of risk factors for skin cancer, particularly in terms of genetics and environmental exposures. \u003csup\u003e(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e)\u003c/sup\u003e Importantly, a lack of awareness of these risk factors may contribute to ineffective prevention practices and an inability to educate patients on proper sun protection behaviors. \u003csup\u003e(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e)\u003c/sup\u003e Understanding and being able to recognize risk factors, such as prolonged sun exposure, tanning bed use, and family history, is essential for early detection and prevention efforts.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eAttitudes toward Prevention and Detection\u003c/h2\u003e \u003cp\u003eThe attitudes toward skin cancer prevention and detection were mixed. In this study, 45.4% of students reported regularly performing skin self-examinations, a practice that is critical for early detection of melanoma and other forms of skin cancer. However, this also means that more than half of the students (54.6%) did not regularly engage in self-examination, which is concerning for medical professionals who should model health-promoting behaviors for the general public.\u003c/p\u003e \u003cp\u003eOf the students who did perform self-examinations, the main motivation was to check for new lesions, while others indicated that they engaged in this practice to alleviate anxiety about potential skin cancer. However, many students who did not perform self-examinations cited a lack of awareness or simply never considered doing so. This highlights a significant barrier to preventive health practices, even among future healthcare professionals. A study has found that healthcare professionals themselves often fall short of adopting recommended preventive behaviors. \u003csup\u003e(\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e)\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThis calls into question the extent to which medical students are being trained to prioritize personal health practices, including regular self-examinations.\u003c/p\u003e \u003cp\u003eA critical finding in our study was the limited use of sun protection measures, such as sunscreen application, wearing hats, and avoiding excessive sun exposure during peak UV hours. Only a small number of students regularly practiced these preventive measures. This finding is consistent with studies conducted elsewhere, where medical students and even healthcare professionals exhibited poor sun protection behaviors despite knowing the risks associated with UV radiation.\u003csup\u003e(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e)\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe lack of adherence to sun protection recommendations among medical students may indicate that preventive behaviors need to be instilled as part of medical education. Medical schools could play a pivotal role in shaping students' attitudes toward skin cancer prevention by incorporating sun safety practices and self-examination training into the curriculum.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003ePractical Implications for Medical Education\u003c/h2\u003e \u003cp\u003eSun exposure practices among RMU students revealed notable gaps in preventive measures. Only a few students indicated that they occasionally avoided peak sun hours from 10 a.m. to 4 p.m., and a limited number wore hats when outdoors, while a significant portion did not use hats at all. The consistent use of sunglasses was rare, and only a minority reported regularly applying sunscreen with a minimum SPF of 15. Additionally, most students did not engage in swimming, possibly indicating limited exposure to situations requiring sun protection awareness.\u003c/p\u003e \u003cp\u003eThe findings from this study underscore the need to improve the education and awareness of medical students regarding skin cancer prevention, detection, and risk factors. Medical curricula must include detailed and updated information on skin cancer, particularly focusing on the types of skin cancer, risk factors, and prevention measures. Furthermore, enhancing practical training in recognizing early signs of skin cancer, such as melanoma, and encouraging regular self-examinations would better prepare students to not only protect their health but also advise patients effectively.\u003c/p\u003e \u003cp\u003eIn addition, medical schools should prioritize health promotion and disease prevention, both within their curricula and through extracurricular activities. Public health initiatives that target medical students, as well as the general population, are essential for raising awareness about skin cancer. These initiatives should focus on promoting sun safety and the importance of self-examination for early detection. Digital platforms, particularly social media, can be valuable tools in disseminating this information widely, given the high reliance on the internet for health information.\u003c/p\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003eLimitations and Future Directions\u003c/h2\u003e \u003cp\u003eThis study's limitations include the use of convenience sampling and self-reported measures, which could introduce selection and response biases. Additionally, this study\u0026rsquo;s cross-sectional design does not allow for assessment of changes in knowledge and behaviors over time. Given the significance of skin cancer as a public health issue, further research is recommended to explore similar KAP assessments in other regions of Pakistan. Comparative studies involving medical students from different institutions or regions could provide a broader understanding of the educational needs and potential solutions for improving skin cancer awareness in the country.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study found that medical students at RMU demonstrate an unsatisfactory level of knowledge regarding skin cancer, and significant gaps remain in their attitudes and practices related to prevention and detection. These findings reflect trends observed in other regions and underscore the need for a more integrated approach to teaching skin cancer prevention in medical curricula. Enhancing awareness and preventive behaviors among future healthcare providers could contribute to broader public health efforts in reducing the incidence and impact of skin cancer.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthor contribution Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eB.S:\u0026nbsp;\u003c/strong\u003eConceptualization, Methodology, Software, Data curation, Writing Original draft preparation, \u003cstrong\u003eM.B\u003c/strong\u003e: Data curation, Writing- Original draft preparation. \u003cstrong\u003eF.A:\u0026nbsp;\u003c/strong\u003eVisualization, Investigation, Data Curation, \u003cstrong\u003eM.B\u003c/strong\u003e: Software, Validation. \u003cstrong\u003eH.M.M:\u0026nbsp;\u003c/strong\u003eWriting Reviewing and Editing, \u003cstrong\u003eE.H:\u0026nbsp;\u003c/strong\u003eData Curation, Manuscript writing,\u003cstrong\u003e\u0026nbsp;T.A:\u0026nbsp;\u003c/strong\u003eData Curation, Manuscript writing, Writing-Original Draft Preparation, \u003cstrong\u003eA.K:\u0026nbsp;\u003c/strong\u003eSupervision, Writing-Original Draft Preparation; \u003cstrong\u003eM.N.S\u003c/strong\u003e: Writing-Original Draft Preparation\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of Use of Artificial Intelligence (AI)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDuring the\u0026nbsp;preparation of this work, AI was used as an assistance for refining language and structure, but the authors have reviewed the work and take full responsibility for the content.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDisclosure of Potential Conflicts of Interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have declared no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding Declaration:\u0026nbsp;\u003cbr\u003e\u003c/strong\u003eThe author received no funding from any individual, organization, or authority.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Approval:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was taken from the Institutional Review Board (IRB) of Rawalpindi Medical University, Rawalpindi, Pakistan. Reference Number: 1012/IREF/RMU/2024. The study was conducted following the STROBE checklist for cross-sectional studies.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to Participate Declaration:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent was obtained from the students and their participation was voluntary basis.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to Publish Declaration:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConsent to publish their information was taken from the participants, ensuring that anonymity would be maintained.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eLi J, Yan H (2018) Skin toxicity with anti-EGFR monoclonal antibody in cancer patients: a meta-analysis of 65 randomized controlled trials. Cancer Chemother Pharmacol 82(4):571\u0026ndash;583\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRadiation Ultravoilet [Internet] Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/news-room/questions-and-answers/item/radiation-ultraviolet-(uv)-radiation-and-skin-cancer\u003c/span\u003e\u003cspan address=\"https://www.who.int/news-room/questions-and-answers/item/radiation-ultraviolet-(uv)-radiation-and-skin-cancer\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUrban K, Mehrmal S, Uppal P, Giesey RL, Delost GR (2021) The global burden of skin cancer: A longitudinal analysis from the Global Burden of Disease Study, 1990\u0026ndash;2017. 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Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://pjms.org.pk/index.php/pjms/article/view/2889\u003c/span\u003e\u003cspan address=\"http://pjms.org.pk/index.php/pjms/article/view/2889\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGreen A, Williams G, N\u0026egrave;ale R, Hart V, Leslie D, Parsons P et al (1999) Daily sunscreen application and betacarotene supplementation in prevention of basal-cell and squamous-cell carcinomas of the skin: a randomised controlled trial. Lancet 354(9180):723\u0026ndash;729\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUS Department of Health and Human Services The Surgeon General\u0026rsquo;s Call to Action to Prevent Skin Cancer [Internet]. Washington (DC): Office of the Surgeon General (US); 2014 [cited 2025 May 28]. (Reports of the Surgeon General). Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://www.ncbi.nlm.nih.gov/books/NBK247172/\u003c/span\u003e\u003cspan address=\"http://www.ncbi.nlm.nih.gov/books/NBK247172/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLee T, Diao D (2013) Sun-protective behaviors in populations at high risk for skin cancer. Psychol Res Behav Manag. ;9\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGooderham MJ, Guenther L (1999) Impact of a Sun Awareness Curriculum on Medical Students\u0026rsquo; Knowledge, Attitudes, and Behaviour. J Cutan Med Surg 3(4):182\u0026ndash;187\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGillani F, Rashid A, Anis A, Arif S, Jamall A, Iqbal N et al (2001) The skin we are in\u0026ndash;knowledge and practices regarding skin cancer in pre-clinical medical students. JPMA J Pak Med Assoc 51(10):373\u0026ndash;378\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSeetan K, Khamees A, Migdadi A, Abu Shqeer M, Hasan MJ, Shatnawi LA et al (2022) Knowledge, Attitude, and Practice toward Skin Cancer Prevention and Detection among Jordanian Medical Students: A Cross-Sectional Study. Kimyai Asadi A, editor. J Skin Cancer 2022:1\u0026ndash;8\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHenrikson NB, Ivlev I, Blasi PR, Nguyen MB, Senger CA, Perdue LA et al (2023) Skin Cancer Screening: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA 329(15):1296\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDepartment of Dermatology, The Warren Alpert Medical School, University B, Providence RI, Matthews USA, Li NH, Ward WQ, Farma WH et al (2017) JM, Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia,PA, USA, editors. Cutaneous Melanoma: Etiology and Therapy [Internet]. Codon Publications; [cited 2025 May 28]. pp. 3\u0026ndash;22. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://exonpublications.com/index.php/exon/article/view/168\u003c/span\u003e\u003cspan address=\"https://exonpublications.com/index.php/exon/article/view/168\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNahar VK, Wilkerson AH, Ghafari G, Martin B, Black WH, Boyas JF et al (2018) Skin cancer knowledge, attitudes, beliefs, and prevention practices among medical students: A systematic search and literature review. Int J Womens Dermatol 4(3):139\u0026ndash;149\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUgurlu Z, Işık SA, Balanuye B, Budak E, Elbaş N\u0026Ouml;, Kav S (2016) Awareness of Skin Cancer, Prevention, and Early Detection among Turkish University Students. Asia-Pac J Oncol Nurs 3(1):93\u0026ndash;97\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eScott JJ, Johnston RS, Darby J, Blane S, Strickland M, McNoe BM (2023) A novel skin cancer prevention strategy: Preservice teachers\u0026rsquo; perceptions of a sun safety intervention and experiences in schools. Health Promot J Austr 34(1):255\u0026ndash;263\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCompres E, Holzem K, Ibler E, Bierman JA, Rademaker AW, Kundu RV (2020) A Brief Dermatology Curriculum in Skin Cancer Detection and Prevention to Improve Medical Student Knowledge and Confidence. MedEdPORTAL. ;11049\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDuarte AF, Sousa-Pinto B, Azevedo LF, Barros AM, Puig S, Malvehy J et al (2021) Clinical ABCDE rule for early melanoma detection. Eur J Dermatol 31(6):771\u0026ndash;778\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDe La Garza H, Maymone MBC, Vashi NA (2021) Impact of Social Media on Skin Cancer Prevention. Int J Environ Res Public Health 18(9):5002\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRamot S, Tal O, Rosenbloom T (2024) Comparison of Health Behaviors of Healthcare Workers and the General Public in Israel: A Cross-Sectional Survey. Int J Environ Res Public Health 21(3):268\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1 to 5 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Skin Neoplasms, Melanoma, Students, Medical, Public Health","lastPublishedDoi":"10.21203/rs.3.rs-6949812/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6949812/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e \u003cp\u003eSkin cancer is the fifth most prevalent cancer globally, with approximately 2\u0026ndash;3\u0026nbsp;million non-melanoma and 132,000 melanoma cases diagnosed annually. Despite the rising incidence, awareness of prevention and detection remains low in countries like Pakistan. Medical students, as future healthcare providers, have a significant role in promoting public education on skin cancer, yet data on their knowledge, attitudes, and practices (KAP) is limited.\u003c/p\u003e\u003ch2\u003eObjectives:\u003c/h2\u003e \u003cp\u003eThis study evaluates the knowledge, attitudes, and practices regarding skin cancer prevention and detection among medical students at Rawalpindi Medical University (RMU) to identify educational gaps.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e \u003cp\u003eA cross-sectional study was conducted at RMU with 260 participants, representing 15% of the student body. Data were collected from students aged 18\u0026ndash;27 across all MBBS years using a validated 49-item structured questionnaire regarding Knowledge, Attitude, and Practices of Skin Cancer Prevention. Statistical analysis included descriptive statistics and inferential statistics such as the Kruskal-Wallis test and Tukey's post-hoc test to assess differences in knowledge scores between classes.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e \u003cp\u003eAmong the participants, 70.8% were female, and 53.8% were aged 20\u0026ndash;23. Most (96.9%) had no family history of skin cancer, and 63.5% claimed to have proper knowledge. The mean knowledge score was 9.89/24, with significant differences between class years (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The third year scored the highest (mean: 12.65), followed by first-year students (mean: 12.56). However, final-year students had the lowest (mean: 7.56) scores. Only 21.5% correctly identified basal cell carcinoma as the most common type. Additionally, 38% of students practiced regular sun protection, and 45.4% reported conducting self-examinations for early detection. Attitudinal analysis revealed that the majority of participants had a positive outlook toward prioritizing skin cancer prevention.\u003c/p\u003e\u003ch2\u003eConclusion:\u003c/h2\u003e \u003cp\u003eThis study underscores the need for enhanced educational strategies within the medical curriculum focusing on skin cancer prevention and early detection. Strengthening these areas can better prepare medical students to educate the public effectively and help mitigate the skin cancer burden in Pakistan.\u003c/p\u003e","manuscriptTitle":"Knowledge, Attitude, and Practices toward Skin Cancer Prevention and Detection among Students of Rawalpindi Medical University: A Cross- Sectional Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-24 04:38:46","doi":"10.21203/rs.3.rs-6949812/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ab430356-9030-4c7b-921d-ef4222e05c62","owner":[],"postedDate":"June 24th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-06-24T12:23:54+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-24 04:38:46","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6949812","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6949812","identity":"rs-6949812","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}