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HPV Knowledge and Factors Associated with Intention to Use Condoms for Reducing HPV Infection Risk among Adolescent Women in Taiwan a
b
Yu-Ching Tu PhD, RN , Hsiu-Hung Wang PhD, RN, FAAN , Yi-Jung Lin c
d
MSN, RN & Te-Fu Chan MD a
Department of Nursing, Chung Hwa University of Medical Technology, Tainan, Taiwan b
College of Nursing, Kaohsiung Medical University, Kaohsiung, Taiwan
Click for updates
c
Department of Nursing, Shu-Zen College of Medicine and Management, Kaohsiung, Taiwan d
School of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan Published online: 16 Mar 2015.
To cite this article: Yu-Ching Tu PhD, RN, Hsiu-Hung Wang PhD, RN, FAAN, Yi-Jung Lin MSN, RN & Te-Fu Chan MD (2015) HPV Knowledge and Factors Associated with Intention to Use Condoms for Reducing HPV Infection Risk among Adolescent Women in Taiwan, Women & Health, 55:2, 187-202, DOI: 10.1080/03630242.2014.979970 To link to this article: http://dx.doi.org/10.1080/03630242.2014.979970
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content.
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Women & Health, 55:187–202, 2015 Copyright © Taylor & Francis Group, LLC ISSN: 0363-0242 print/1541-0331 online DOI: 10.1080/03630242.2014.979970
HPV Knowledge and Factors Associated with Intention to Use Condoms for Reducing HPV Infection Risk among Adolescent Women in Taiwan YU-CHING TU, PhD, RN Downloaded by [New York University] at 19:53 19 April 2015
Department of Nursing, Chung Hwa University of Medical Technology, Tainan, Taiwan
HSIU-HUNG WANG, PhD, RN, FAAN College of Nursing, Kaohsiung Medical University, Kaohsiung, Taiwan
YI-JUNG LIN, MSN, RN Department of Nursing, Shu-Zen College of Medicine and Management, Kaohsiung, Taiwan
TE-FU CHAN, MD School of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
Human papillomavirus (HPV) is a frequent cause of sexually transmitted infection worldwide, and has a key role in the etiology of cervical cancer. Young people are the most vulnerable age group for acquiring HPV infection, but this particular age group in Taiwan knows little about it. This study investigated Taiwanese adolescent women’s knowledge of HPV and factors associated with intention to use condoms for reducing HPV-related diseases among adolescent women. A descriptive cross-sectional design was used, and a convenience sample of 384 adolescent women aged 15 to 16 years in Southern Taiwan was recruited. Data were collected using a self-administered questionnaire and analyzed with descriptive statistics, t-test or ANOVA, and multiple regression analysis. Only 26.6% of the participants were aware of HPV. The percentage of correct answers for knowledge about HPV was 35.4%. Factors associated with intention to use condoms for HPV prevention were
Received November 1, 2013; revised March 28, 2014; accepted April 6, 2014. Address correspondence to Hsiu-Hung Wang, PhD, RN, FAAN, College of Nursing, Kaohsiung Medical University, No. 100, Shih-Chuan 1st Road, Kaohsiung 80708, Taiwan. E-mail: [email protected] 187
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discussion of sexual issues, attitude, subjective norm, perceived behavioral control, and HPV knowledge. These variables accounted for 55.8% of the variance in scores for intention to use condoms for HPV prevention. These findings could be used in future HPV prevention education and campaigns. Future intervention programs might be particularly focused on insufficient HPV knowledge among adolescent females. KEYWORDS
HPV, knowledge, puberty, risk factors
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INTRODUCTION Human papillomavirus (HPV) is the most frequent cause of sexually transmitted diseases (STDs). Ninety-nine percent of cervical cancer cases are associated with genital infection with high-risk HPV (types 16 and 18), and the most frequent viral infections of the reproductive tract are low-risk HPV (types 6 and 11) in men and women (World Health Organization [WHO] 2010). In Taiwan, cervical cancer is the fifth most prevalent form of cancer and the sixth highest cause of cancer-related death for women, with a death rate of 5.7 per 100,000 people (Health Promotion Administration of Taiwan [HPA] 2011). HPV infection typically occurs with the initiation of sexual activity, and approximately 74% of women aged 15 to 24 years are infected with HPV (Myers et al. 2000). The proportion having sexual intercourse among Taiwanese adolescents was 12.14%, and the average age of first sexual intercourse was around 16 years (Lin and Chu 2010). The Lin and Chu study reported overall an HPV prevalence rate of 15% in women at various ages, and the highest rate of HPV infection was 28.1%, found in women aged under 20 years old in Taiwan (Wang, Garvilles, and Chen 2010). Prophylactic HPV vaccine was approved by the Taiwan HPA for use in women aged 9–26 years, but the medical expense was not covered by National Health Insurance (NHI). Thus, Taiwan’s HPV vaccine inoculation rate has been less than 4% (Chow et al. 2010). Therefore, a variety of HPV prevention methods are worthy to be considered to reduce HPV infection risk for maintaining the sexual health of unvaccinated adolescent women. HPV transmission is via skin-to-skin contact. In women, practically no HPV has been found in the cervix from virgins; rather, acquisition of HPV is largely dependent on sexual intercourse (Kjaer et al. 2001). Previous studies have indicated that consistent condom use in every vaginal intercourse diminished the risk of HPV acquisition by 70% (Winer et al. 2006), lowered the prevalence of transmission of HPV infection from men to their sexual women partner (Nielson et al. 2010), accelerated the clearance of HPV infection, and promoted regression of cervical intraepithelial neoplasia (CIN) (Hogewoning et al. 2003; Munk et al. 2012). Though areas not covered
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by a condom can be infected with the virus, the studies mentioned above reasoned that consistent condom use is a risk reduction strategy to prevent the consequences of HPV in terms of cervical cancer. One Taiwanese study indicated that 61.5% of people who had their first sexual encounter did not use a condom, and among people with sexual experience the proportion who used condoms less frequently was 52.21%, and the percentage of those who consistently used condoms was only 25.71% (Lin and Chu 2010). Thus, condom use prevalence among adolescents is unsatisfactory. The studies specifically focused on HPV prevention have identified that attitudes toward HPV vaccination and significant others may influence the intention of HPV vaccination (Geshnizjani, Jozkowski, and Middlestadt 2013; Hsu et al. 2009; Kahn et al. 2003). As for HPV prevention, studies have also pointed out that perceived susceptibility (Hsu et al. 2009; Marlow et al. 2009) and perceived disease severity (Cox et al. 2010; Hsu et al. 2009) can significantly influence a person’s intention to receive HPV vaccination. Perceived risk may be an important motivator of health-related behaviors. Additionally, studies have suggested that greater knowledge of HPV is associated with greater HPV vaccine acceptability (Gerend and Magloire 2008) and uptake (Licht et al. 2010), and HIV knowledge is associated with greater condom use (Sun et al. 2013). This study aimed to assess HPV knowledge and to identify factors related to intention to use condoms for HPV prevention among adolescent women to develop tailored and effective education programs about HPV and HPV prevention for adolescent women’s health.
METHODS Participants and Procures This study used a cross-sectional and descriptive design. Participants were recruited from the first-year students of three five-year junior nursing colleges in Southern Taiwan by convenience sampling. These students had not yet taken any medicine or nursing courses, which could have affected the scores for HPV-related knowledge. Eligibility criteria were students who: (1) were adolescent women aged 15 to 16 years, (2) were unmarried, (3) provided permission from their parents to participate, and (4) were willing to participate in this study. The Institutional Review Board of a University approved all study procedures before the research was conducted. Prior to data collection, a meeting with the administrators of the participating schools was arranged to present the study. After obtaining the agreements of homeroom teachers, the principal investigator explained the study in first-year classes and contacted parents of the participants by letter to explain the study purpose and process. All participants were recruited on a voluntary basis and were also made aware that they could withdraw from the study at any point.
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Informed consent was signed by both participants and parents prior to data collection. The total numbers of students who attended classes on the designated days and times of recruitment was 592. Among these 592, 62 were men who were excluded and 112 of the remaining 530 (27.7%) were adolescent women who did not return the consent form. Thus, 418 (70.6%) who met inclusion criteria participated in this study. The questionnaires were delivered to the participants in their classrooms and were completed at the time of distribution. Only those who met eligibility criteria could stay in classrooms to fill out the questionnaires. Among the 418 eligible participants, a total of 384 (92%) completed the questionnaires. Using G∗ power analysis (Faul et al. 2009), the calculated necessary sample size was 196 for regression analysis, F-tests with fourteen of tested factors to detect a small effect size of .15, with two-sided alpha = 0.05, and a power of 95%. Therefore, the sample size of this study was enough to attain adequate statistical power. Data were collected from September to November of 2012.
Measures A self-administered questionnaire, including demographic and sexually relevant questions, a HPV-related Knowledge Questionnaire, an Attitude toward Condom Use Scale (ACUS), a Subjective norm Scale (SNS), a Perceived Behavioral Control Scale (PBCS), a Behavioral Intention Scale (BIS), and the Perceived Risk Scale (PRS) were developed. Questionnaires used previous relevant published studies and survey instruments (Gerend and Magloire 2008; Gerend and Shepherd 2011; Hsu et al. 2011; Kang and Kim 2011) as references. Content validity was verified by six experts in nursing, public health, obstetrics (ob) and gynecology (gyn), and education. The questionnaire was pre-tested on six adolescent women for clarity and ease of reading to evaluate face validity. Forty-two participants were invited to examine the test-retest reliability of the questionnaire after a two-week interval. The intraclass correlation coefficient for the ACUS, PSNS, PBCS, PRS, and BIS were 0.87, 0.75, 0.78, 0.77, and 0.80, and Cronbach’s alpha coefficients of internal consistency were 0.92, 0.82, 0.80, 0.79, and 0.91, respectively. Demographic and sexually relevant questions assessed participants’ demographic data, sexual experience, religious beliefs, parents’ educational levels, relationship with parents, history of ob/gyn visits, and whether they discussed sexual issues with adult family members. The six-item HPV-related Knowledge Questionnaire used a yes/no answer to assess the awareness of HPV. The item “Have you ever heard of HPV?” was not scored. Two single-choice items were used to assess the targets of HPV infection and main transmission route of HPV infection, and three multiple response items were used to assess knowledge of HPV, including HPV-related diseases, HPV prevention strategies, and risk factors for HPV infection. The responses were coded so that each correct answer received
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a score of 1. The knowledge score was the accumulation of the score of correct answers and the multiple response items got multiple scores of correct answers. The possible score ranged from 0 to 14, and the higher scores indicated higher levels of knowledge of HPV. Kuder-Richardson’s coefficient (K-R 20) of the HPV-related Knowledge Questionnaire was 0.82. The seven-item ACUS was used to assess participants’ perception of the value of condom use for HPV prevention, including safety, importance, effectiveness, necessity, acceptance, convenience, and appropriateness. Participants rated all items using a six-point Likert-type scale, ranging from 1 (strongly disagree) to 6 (strongly agree), with a higher score indicating that the respondent positively valued condom use for HPV prevention. Cronbach’s alpha coefficient of the ACUS was 0.92. The six-item SNS was used to assess adolescent women’s perception of people who could encourage them to use condoms for HPV prevention, for example, “parents could encourage you to use condoms for HPV prevention” as well as friends, sexual partners, teachers, healthcare providers, and mass media. Participants rated all items using a six-point Likert-type scale, ranging from 1 (strongly disagree) to 6 (strongly agree), with a higher score indicating that stronger social encouragement prompted adolescent women to engage in condom use for HPV prevention. Cronbach’s alpha coefficient of the PSNS was 0.93. The 15-item PBCS was used to assess adolescent women’s perceived ability to use condoms appropriately for HPV prevention. Example questions were: “If you have intercourse, would you (a) feel you could easily use a condom for HPV prevention, (b) feel confident in your ability to use a condom for HPV prevention, and (c) actively ask to use a condom for HPV prevention?” The scale comprised three reverse-scored items, including worrying about their partner refusing to use a condom for HPV prevention, embarrassing to ask to use a condom for HPV prevention, and submitting to your partner’s requests without using a condom for HPV prevention. Participants rated all items using a six-point Likert-type scale, ranging from 1 (strongly disagree) to 6 (strongly agree). A higher score indicated stronger or higher perceived condom use control for HPV prevention. Cronbach’s alpha coefficient of the PBCS was 0.88. The three-item PRS combined perceived susceptibility (two items) to, and perceived disease severity (one item) of, HPV infection. The two items of perceived susceptibility to HPV infection included “I think I am susceptible to have the HPV infection,” and “I am worried about whether I am susceptible to get HPV.” The item of perceived disease severity of HPV infection was “An awful consequence would happen to me if I have the HPV infection.” Participants rated all items using a six-point Likert-type scale, ranging from 1 (strongly disagree) to 6 (strongly agree). If individuals had the perception of severe consequences of infection and also considered themselves highly vulnerable to infection, they had higher perceived risk. In contrast, they
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had lower perceived risk if they believed that they were less vulnerable to infection and they also had the perception of minor consequences of infection. Cronbach’s alpha coefficient of the PRS was 0.79. The four-item BIS was used to assess the intention of condom use to prevent HPV infection, including “When having sexual intercourse, do you (a) consider using condoms for HPV prevention, (b) feel inclined to use condoms for HPV prevention, (c) feel strongly willing to use condoms for HPV prevention, and (d) definitely use condoms to protect against HPV infection?” Participants rated all items using a six-point Likert-type scale, ranging from 1 (strongly disagree) to 6 (strongly agree). The four items were averaged to create a score representing intention to use condom for HPV prevention. Cronbach’s alpha coefficient of the BIS was 0.92.
Data Analysis The Statistical Package for SPSS version 19.0 for Windows was used for data analysis. The participants’ demographic data and knowledge of HPV were analyzed by using chi square tests for categorical variables and t-tests for continuous variables. Differences in intention of condoms use for HPV prevention were analyzed by the participants’ demographics using t-tests or one-way analysis of variance (ANOVA). Multiple linear regression analysis was used to identify factors associated with condoms use intention for HPV prevention. The confounding variables included in the multiple regression were demographic variables, heard of HPV and discussed sexual issues, which had significant difference in intention to use condom for HPV prevention. The attitude, subjective norm, perceived behavioral control, perceived risk, and HPV knowledge scores were significantly correlated with intention to use a condom for HPV prevention and were also included in the model. Standardized Residual Covariance between −2.21 and 2.25 and Cook’s D < 1 were considered the model fit. Interactions were examined for each confounding variable with each independent variable separately. No changes were observed in the relationships or significant differences of variables between the separate and the whole model. The collinearity diagnostics were examined by testing the variance inflation factors (1.052 to 1.796) and showed no significant multicollinearity. In all tests, p values < .05 were interpreted as statistically significant.
RESULTS Characteristics of Participants The ages of the 384 participants were from 15 to 16 years. The majority of participants were unvaccinated against HPV-related disease (97.7%, n = 375). Ninety-five percent (n = 367) of the participants were sexually inexperienced, and 55.7% (n = 214) had discussed sexual issues with an adult
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TABLE 1 Demographic Data of Participants and ANOVA of Their Intention to Use Condoms for HPV Prevention (N = 384) Intention to use condoms for HPV prevention
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Variable Mean score (total possible range = 1–6) Have you ever heard of the HPV No Yes Have HPV vaccinated No Yes Sexual experience No Yes Have you ever discussed sexual issues with adult family members No Yes History of obstetrics-gynecology visits No Yesa Religious beliefs Buddhist/Taoist Christian/Catholic None Relationship with parents Harmonious Ordinary Standoffish/conflicting Father’s educational level Junior high school and lower High school College and above Mother’s educational level Junior high school and lower High school College and above a
n (%)
Mean (SD)
F/t value
p
2.180
.030
0.938
.392
0.460
.489
9.630
.002
0.521
.471
0.538
.584
1.616
.200
1.395
.213
1.115
.329
4.97 (0.78) 282 (73.4) 102 (26.6)
4.81 (0.76) 4.98 (0.72)
375 (97.7) 9 (2.3)
4.84 (0.72) 5.17 (0.72)
367 (95.6) 15 (3.9)
4.97 (0.78) 4.83 (0.86)
165 (43.0) 214 (55.7)
4.83 (0.84) 5.08 (0.72)
250 (65.1) 134 (34.9)
4.95 (0.80) 5.01 (0.75)
254 (66.1) 29 (7.6) 98 (25.5)
5.00 (0.80) 4.95 (0.82) 4.90 (0.72)
211 (54.9) 147 (38.3) 24 (6.3)
4.95 (0.73) 4.96 (0.73) 5.08 (0.71)
82 (21.4) 197 (51.3) 94 (24.5)
4.81 (0.83) 4.96 (0.77) 5.05 (0.73)
72 (18.8) 235 (61.2) 69 (18.0)
4.87 (0.73) 4.82 (0.73) 5.08 (0.71)
Integrated dysmenorrhea, menstrual disorder, vaginal excretion, pruritus, and others.
family member. About 34.9% (n = 134) reported previous ob/gyn visits for gynecologic problems. Participants who had heard of HPV (t = 2.180, p = .030) and had discussed sexual issues with an adult family member (t = 9.630, p = .002) had a significantly higher behavioral intention score for condom use than those who had not (Table 1).
HPV Awareness and Knowledge The majority of participants were unaware of HPV (n = 282, 73.4%). The HPV knowledge overall correct mean score was 4.96 (SD = 3.61), showing that the overall correct knowledge score percentage was 35.4% out of a
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total possible score of 14. Of those participants aware of HPV (n = 102), the HPV knowledge mean score was 6.93 (SD = 3.40), showing that the correct knowledge score percentage was 49.5% out of a total possible score of 14. The HPV knowledge correct mean score among participants aware of HPV was significantly higher than among those who were unaware of HPV (t = 6.803, p < .001). Among the participants who were aware of HPV, 40.2% (n = 41) responded that both men and women could suffer from HPV infection, and 73.5% (n = 75) responded that sexual contact was the primary transmission route of HPV infection. Only 30.4% (n = 31) and 65.7% (n = 67) of the participants responded that genital warts and cervical cancer might occur if women have an HPV infection. The most frequent strategies for preventing HPV infection were HPV vaccination (79.4%, n = 81), monogamy (52.0%, n = 53), and condom use (39.2%, n = 40). When asked about the risk factors for HPV infection, 43.1% (n = 44) responded infrequent use of condoms. Surprisingly, the proportion of incorrect answers was significantly higher from the participants who were aware of HPV than from those who were unaware of HPV (Table 2).
Correlations With Intention to Use Condom for HPV Prevention Several variables were significantly correlated with intention to use condoms for HPV prevention. The mean score of behavioral intention was 4.97 out of a total possible score of 6 (SD = 0.78) (Table 1). The mean scores for attitude, subjective norm, perceived behavioral control, perceived risk, and HPV knowledge were 5.00, 5.15, 4.41, 3.98, and 4.96 out of a total possible score of 6 for each measure. This indicated that participants rated relatively high in subjective norms of condom use for HPV prevention and relatively low in perceived risk of HPV infection. Attitude (r = 0.56, p < .001), subjective norm (r = 0.59, p < .001), perceived behavioral control (r = 0.56, p < .001), perceived risk (r = 0.10, p < .05), and HPV knowledge (r = 0.15, p < .01) were significantly positively correlated with intention of condom use for HPV prevention (Table 3).
Factors Associated With Intention to Use Condom for HPV Prevention A multiple linear regression analysis was used to examine the factors associated with intention to use condoms for HPV prevention. Heard about HPV, discussed sexual issues, attitude, subjective norm, perceived behavioral control, perceived risk, and knowledge of HPV as independent variables were all entered into the regression model. The results of the multiple linear regression analysis showed that discussed sexual issues, attitude, subjective norm, perceived behavioral control, and HPV knowledge were significantly associated with intention to use condoms for HPV prevention. These findings accounted for 55.8% (p < .001) of the overall variance of intention to use
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HPV Prevention among Adolescent Women TABLE 2 Participants’ Responses to HPV Knowledge (N = 384) Heard of the Not heard of the HPV (n = 102) HPV (n = 282)
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Knowledge items Who are the targets of HPV infection? Both men and womena Women only Men only Do not know What is the main transmitted route of HPV infection? Sexual contacta Public spring Swimming pool Toilet seat Do not know What problem might occur if women have an HPV infection? Cervical cancera Genital wartsa AIDS Vaginitis Intercourse pain Syphilis Gonorrhea Sterility Menstrual disorder Do not know What strategies can be used to prevent HPV infection? HPV vaccinea Monogamya Condom usea Regular hours and exercisea No smokinga Pap testa Do not know What are the risk factors for HPV infection? High number of sexual partnersa Partner with high number of partnersa Infrequent use of condomsa Earlier intercoursea Do not know Correct mean scores [SD] Answer correctly (%) Overall correct mean score [SD] Overall answer correctly (%)
n (%)
n (%)
X 2 /t
p
41 55 3 4
(40.2) (53.9) (2.9) (3.9)
149 (52.8) 58 (20.6) 2 (0.7) 74 (26.2)
4.79 40.13 2.90 23.05
.029
Women & Health Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/wwah20
HPV Knowledge and Factors Associated with Intention to Use Condoms for Reducing HPV Infection Risk among Adolescent Women in Taiwan a
b
Yu-Ching Tu PhD, RN , Hsiu-Hung Wang PhD, RN, FAAN , Yi-Jung Lin c
d
MSN, RN & Te-Fu Chan MD a
Department of Nursing, Chung Hwa University of Medical Technology, Tainan, Taiwan b
College of Nursing, Kaohsiung Medical University, Kaohsiung, Taiwan
Click for updates
c
Department of Nursing, Shu-Zen College of Medicine and Management, Kaohsiung, Taiwan d
School of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan Published online: 16 Mar 2015.
To cite this article: Yu-Ching Tu PhD, RN, Hsiu-Hung Wang PhD, RN, FAAN, Yi-Jung Lin MSN, RN & Te-Fu Chan MD (2015) HPV Knowledge and Factors Associated with Intention to Use Condoms for Reducing HPV Infection Risk among Adolescent Women in Taiwan, Women & Health, 55:2, 187-202, DOI: 10.1080/03630242.2014.979970 To link to this article: http://dx.doi.org/10.1080/03630242.2014.979970
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content.
Downloaded by [New York University] at 19:53 19 April 2015
This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
Women & Health, 55:187–202, 2015 Copyright © Taylor & Francis Group, LLC ISSN: 0363-0242 print/1541-0331 online DOI: 10.1080/03630242.2014.979970
HPV Knowledge and Factors Associated with Intention to Use Condoms for Reducing HPV Infection Risk among Adolescent Women in Taiwan YU-CHING TU, PhD, RN Downloaded by [New York University] at 19:53 19 April 2015
Department of Nursing, Chung Hwa University of Medical Technology, Tainan, Taiwan
HSIU-HUNG WANG, PhD, RN, FAAN College of Nursing, Kaohsiung Medical University, Kaohsiung, Taiwan
YI-JUNG LIN, MSN, RN Department of Nursing, Shu-Zen College of Medicine and Management, Kaohsiung, Taiwan
TE-FU CHAN, MD School of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
Human papillomavirus (HPV) is a frequent cause of sexually transmitted infection worldwide, and has a key role in the etiology of cervical cancer. Young people are the most vulnerable age group for acquiring HPV infection, but this particular age group in Taiwan knows little about it. This study investigated Taiwanese adolescent women’s knowledge of HPV and factors associated with intention to use condoms for reducing HPV-related diseases among adolescent women. A descriptive cross-sectional design was used, and a convenience sample of 384 adolescent women aged 15 to 16 years in Southern Taiwan was recruited. Data were collected using a self-administered questionnaire and analyzed with descriptive statistics, t-test or ANOVA, and multiple regression analysis. Only 26.6% of the participants were aware of HPV. The percentage of correct answers for knowledge about HPV was 35.4%. Factors associated with intention to use condoms for HPV prevention were
Received November 1, 2013; revised March 28, 2014; accepted April 6, 2014. Address correspondence to Hsiu-Hung Wang, PhD, RN, FAAN, College of Nursing, Kaohsiung Medical University, No. 100, Shih-Chuan 1st Road, Kaohsiung 80708, Taiwan. E-mail: [email protected] 187
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Y.-C. Tu et al.
discussion of sexual issues, attitude, subjective norm, perceived behavioral control, and HPV knowledge. These variables accounted for 55.8% of the variance in scores for intention to use condoms for HPV prevention. These findings could be used in future HPV prevention education and campaigns. Future intervention programs might be particularly focused on insufficient HPV knowledge among adolescent females. KEYWORDS
HPV, knowledge, puberty, risk factors
Downloaded by [New York University] at 19:53 19 April 2015
INTRODUCTION Human papillomavirus (HPV) is the most frequent cause of sexually transmitted diseases (STDs). Ninety-nine percent of cervical cancer cases are associated with genital infection with high-risk HPV (types 16 and 18), and the most frequent viral infections of the reproductive tract are low-risk HPV (types 6 and 11) in men and women (World Health Organization [WHO] 2010). In Taiwan, cervical cancer is the fifth most prevalent form of cancer and the sixth highest cause of cancer-related death for women, with a death rate of 5.7 per 100,000 people (Health Promotion Administration of Taiwan [HPA] 2011). HPV infection typically occurs with the initiation of sexual activity, and approximately 74% of women aged 15 to 24 years are infected with HPV (Myers et al. 2000). The proportion having sexual intercourse among Taiwanese adolescents was 12.14%, and the average age of first sexual intercourse was around 16 years (Lin and Chu 2010). The Lin and Chu study reported overall an HPV prevalence rate of 15% in women at various ages, and the highest rate of HPV infection was 28.1%, found in women aged under 20 years old in Taiwan (Wang, Garvilles, and Chen 2010). Prophylactic HPV vaccine was approved by the Taiwan HPA for use in women aged 9–26 years, but the medical expense was not covered by National Health Insurance (NHI). Thus, Taiwan’s HPV vaccine inoculation rate has been less than 4% (Chow et al. 2010). Therefore, a variety of HPV prevention methods are worthy to be considered to reduce HPV infection risk for maintaining the sexual health of unvaccinated adolescent women. HPV transmission is via skin-to-skin contact. In women, practically no HPV has been found in the cervix from virgins; rather, acquisition of HPV is largely dependent on sexual intercourse (Kjaer et al. 2001). Previous studies have indicated that consistent condom use in every vaginal intercourse diminished the risk of HPV acquisition by 70% (Winer et al. 2006), lowered the prevalence of transmission of HPV infection from men to their sexual women partner (Nielson et al. 2010), accelerated the clearance of HPV infection, and promoted regression of cervical intraepithelial neoplasia (CIN) (Hogewoning et al. 2003; Munk et al. 2012). Though areas not covered
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by a condom can be infected with the virus, the studies mentioned above reasoned that consistent condom use is a risk reduction strategy to prevent the consequences of HPV in terms of cervical cancer. One Taiwanese study indicated that 61.5% of people who had their first sexual encounter did not use a condom, and among people with sexual experience the proportion who used condoms less frequently was 52.21%, and the percentage of those who consistently used condoms was only 25.71% (Lin and Chu 2010). Thus, condom use prevalence among adolescents is unsatisfactory. The studies specifically focused on HPV prevention have identified that attitudes toward HPV vaccination and significant others may influence the intention of HPV vaccination (Geshnizjani, Jozkowski, and Middlestadt 2013; Hsu et al. 2009; Kahn et al. 2003). As for HPV prevention, studies have also pointed out that perceived susceptibility (Hsu et al. 2009; Marlow et al. 2009) and perceived disease severity (Cox et al. 2010; Hsu et al. 2009) can significantly influence a person’s intention to receive HPV vaccination. Perceived risk may be an important motivator of health-related behaviors. Additionally, studies have suggested that greater knowledge of HPV is associated with greater HPV vaccine acceptability (Gerend and Magloire 2008) and uptake (Licht et al. 2010), and HIV knowledge is associated with greater condom use (Sun et al. 2013). This study aimed to assess HPV knowledge and to identify factors related to intention to use condoms for HPV prevention among adolescent women to develop tailored and effective education programs about HPV and HPV prevention for adolescent women’s health.
METHODS Participants and Procures This study used a cross-sectional and descriptive design. Participants were recruited from the first-year students of three five-year junior nursing colleges in Southern Taiwan by convenience sampling. These students had not yet taken any medicine or nursing courses, which could have affected the scores for HPV-related knowledge. Eligibility criteria were students who: (1) were adolescent women aged 15 to 16 years, (2) were unmarried, (3) provided permission from their parents to participate, and (4) were willing to participate in this study. The Institutional Review Board of a University approved all study procedures before the research was conducted. Prior to data collection, a meeting with the administrators of the participating schools was arranged to present the study. After obtaining the agreements of homeroom teachers, the principal investigator explained the study in first-year classes and contacted parents of the participants by letter to explain the study purpose and process. All participants were recruited on a voluntary basis and were also made aware that they could withdraw from the study at any point.
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Informed consent was signed by both participants and parents prior to data collection. The total numbers of students who attended classes on the designated days and times of recruitment was 592. Among these 592, 62 were men who were excluded and 112 of the remaining 530 (27.7%) were adolescent women who did not return the consent form. Thus, 418 (70.6%) who met inclusion criteria participated in this study. The questionnaires were delivered to the participants in their classrooms and were completed at the time of distribution. Only those who met eligibility criteria could stay in classrooms to fill out the questionnaires. Among the 418 eligible participants, a total of 384 (92%) completed the questionnaires. Using G∗ power analysis (Faul et al. 2009), the calculated necessary sample size was 196 for regression analysis, F-tests with fourteen of tested factors to detect a small effect size of .15, with two-sided alpha = 0.05, and a power of 95%. Therefore, the sample size of this study was enough to attain adequate statistical power. Data were collected from September to November of 2012.
Measures A self-administered questionnaire, including demographic and sexually relevant questions, a HPV-related Knowledge Questionnaire, an Attitude toward Condom Use Scale (ACUS), a Subjective norm Scale (SNS), a Perceived Behavioral Control Scale (PBCS), a Behavioral Intention Scale (BIS), and the Perceived Risk Scale (PRS) were developed. Questionnaires used previous relevant published studies and survey instruments (Gerend and Magloire 2008; Gerend and Shepherd 2011; Hsu et al. 2011; Kang and Kim 2011) as references. Content validity was verified by six experts in nursing, public health, obstetrics (ob) and gynecology (gyn), and education. The questionnaire was pre-tested on six adolescent women for clarity and ease of reading to evaluate face validity. Forty-two participants were invited to examine the test-retest reliability of the questionnaire after a two-week interval. The intraclass correlation coefficient for the ACUS, PSNS, PBCS, PRS, and BIS were 0.87, 0.75, 0.78, 0.77, and 0.80, and Cronbach’s alpha coefficients of internal consistency were 0.92, 0.82, 0.80, 0.79, and 0.91, respectively. Demographic and sexually relevant questions assessed participants’ demographic data, sexual experience, religious beliefs, parents’ educational levels, relationship with parents, history of ob/gyn visits, and whether they discussed sexual issues with adult family members. The six-item HPV-related Knowledge Questionnaire used a yes/no answer to assess the awareness of HPV. The item “Have you ever heard of HPV?” was not scored. Two single-choice items were used to assess the targets of HPV infection and main transmission route of HPV infection, and three multiple response items were used to assess knowledge of HPV, including HPV-related diseases, HPV prevention strategies, and risk factors for HPV infection. The responses were coded so that each correct answer received
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a score of 1. The knowledge score was the accumulation of the score of correct answers and the multiple response items got multiple scores of correct answers. The possible score ranged from 0 to 14, and the higher scores indicated higher levels of knowledge of HPV. Kuder-Richardson’s coefficient (K-R 20) of the HPV-related Knowledge Questionnaire was 0.82. The seven-item ACUS was used to assess participants’ perception of the value of condom use for HPV prevention, including safety, importance, effectiveness, necessity, acceptance, convenience, and appropriateness. Participants rated all items using a six-point Likert-type scale, ranging from 1 (strongly disagree) to 6 (strongly agree), with a higher score indicating that the respondent positively valued condom use for HPV prevention. Cronbach’s alpha coefficient of the ACUS was 0.92. The six-item SNS was used to assess adolescent women’s perception of people who could encourage them to use condoms for HPV prevention, for example, “parents could encourage you to use condoms for HPV prevention” as well as friends, sexual partners, teachers, healthcare providers, and mass media. Participants rated all items using a six-point Likert-type scale, ranging from 1 (strongly disagree) to 6 (strongly agree), with a higher score indicating that stronger social encouragement prompted adolescent women to engage in condom use for HPV prevention. Cronbach’s alpha coefficient of the PSNS was 0.93. The 15-item PBCS was used to assess adolescent women’s perceived ability to use condoms appropriately for HPV prevention. Example questions were: “If you have intercourse, would you (a) feel you could easily use a condom for HPV prevention, (b) feel confident in your ability to use a condom for HPV prevention, and (c) actively ask to use a condom for HPV prevention?” The scale comprised three reverse-scored items, including worrying about their partner refusing to use a condom for HPV prevention, embarrassing to ask to use a condom for HPV prevention, and submitting to your partner’s requests without using a condom for HPV prevention. Participants rated all items using a six-point Likert-type scale, ranging from 1 (strongly disagree) to 6 (strongly agree). A higher score indicated stronger or higher perceived condom use control for HPV prevention. Cronbach’s alpha coefficient of the PBCS was 0.88. The three-item PRS combined perceived susceptibility (two items) to, and perceived disease severity (one item) of, HPV infection. The two items of perceived susceptibility to HPV infection included “I think I am susceptible to have the HPV infection,” and “I am worried about whether I am susceptible to get HPV.” The item of perceived disease severity of HPV infection was “An awful consequence would happen to me if I have the HPV infection.” Participants rated all items using a six-point Likert-type scale, ranging from 1 (strongly disagree) to 6 (strongly agree). If individuals had the perception of severe consequences of infection and also considered themselves highly vulnerable to infection, they had higher perceived risk. In contrast, they
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had lower perceived risk if they believed that they were less vulnerable to infection and they also had the perception of minor consequences of infection. Cronbach’s alpha coefficient of the PRS was 0.79. The four-item BIS was used to assess the intention of condom use to prevent HPV infection, including “When having sexual intercourse, do you (a) consider using condoms for HPV prevention, (b) feel inclined to use condoms for HPV prevention, (c) feel strongly willing to use condoms for HPV prevention, and (d) definitely use condoms to protect against HPV infection?” Participants rated all items using a six-point Likert-type scale, ranging from 1 (strongly disagree) to 6 (strongly agree). The four items were averaged to create a score representing intention to use condom for HPV prevention. Cronbach’s alpha coefficient of the BIS was 0.92.
Data Analysis The Statistical Package for SPSS version 19.0 for Windows was used for data analysis. The participants’ demographic data and knowledge of HPV were analyzed by using chi square tests for categorical variables and t-tests for continuous variables. Differences in intention of condoms use for HPV prevention were analyzed by the participants’ demographics using t-tests or one-way analysis of variance (ANOVA). Multiple linear regression analysis was used to identify factors associated with condoms use intention for HPV prevention. The confounding variables included in the multiple regression were demographic variables, heard of HPV and discussed sexual issues, which had significant difference in intention to use condom for HPV prevention. The attitude, subjective norm, perceived behavioral control, perceived risk, and HPV knowledge scores were significantly correlated with intention to use a condom for HPV prevention and were also included in the model. Standardized Residual Covariance between −2.21 and 2.25 and Cook’s D < 1 were considered the model fit. Interactions were examined for each confounding variable with each independent variable separately. No changes were observed in the relationships or significant differences of variables between the separate and the whole model. The collinearity diagnostics were examined by testing the variance inflation factors (1.052 to 1.796) and showed no significant multicollinearity. In all tests, p values < .05 were interpreted as statistically significant.
RESULTS Characteristics of Participants The ages of the 384 participants were from 15 to 16 years. The majority of participants were unvaccinated against HPV-related disease (97.7%, n = 375). Ninety-five percent (n = 367) of the participants were sexually inexperienced, and 55.7% (n = 214) had discussed sexual issues with an adult
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TABLE 1 Demographic Data of Participants and ANOVA of Their Intention to Use Condoms for HPV Prevention (N = 384) Intention to use condoms for HPV prevention
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Variable Mean score (total possible range = 1–6) Have you ever heard of the HPV No Yes Have HPV vaccinated No Yes Sexual experience No Yes Have you ever discussed sexual issues with adult family members No Yes History of obstetrics-gynecology visits No Yesa Religious beliefs Buddhist/Taoist Christian/Catholic None Relationship with parents Harmonious Ordinary Standoffish/conflicting Father’s educational level Junior high school and lower High school College and above Mother’s educational level Junior high school and lower High school College and above a
n (%)
Mean (SD)
F/t value
p
2.180
.030
0.938
.392
0.460
.489
9.630
.002
0.521
.471
0.538
.584
1.616
.200
1.395
.213
1.115
.329
4.97 (0.78) 282 (73.4) 102 (26.6)
4.81 (0.76) 4.98 (0.72)
375 (97.7) 9 (2.3)
4.84 (0.72) 5.17 (0.72)
367 (95.6) 15 (3.9)
4.97 (0.78) 4.83 (0.86)
165 (43.0) 214 (55.7)
4.83 (0.84) 5.08 (0.72)
250 (65.1) 134 (34.9)
4.95 (0.80) 5.01 (0.75)
254 (66.1) 29 (7.6) 98 (25.5)
5.00 (0.80) 4.95 (0.82) 4.90 (0.72)
211 (54.9) 147 (38.3) 24 (6.3)
4.95 (0.73) 4.96 (0.73) 5.08 (0.71)
82 (21.4) 197 (51.3) 94 (24.5)
4.81 (0.83) 4.96 (0.77) 5.05 (0.73)
72 (18.8) 235 (61.2) 69 (18.0)
4.87 (0.73) 4.82 (0.73) 5.08 (0.71)
Integrated dysmenorrhea, menstrual disorder, vaginal excretion, pruritus, and others.
family member. About 34.9% (n = 134) reported previous ob/gyn visits for gynecologic problems. Participants who had heard of HPV (t = 2.180, p = .030) and had discussed sexual issues with an adult family member (t = 9.630, p = .002) had a significantly higher behavioral intention score for condom use than those who had not (Table 1).
HPV Awareness and Knowledge The majority of participants were unaware of HPV (n = 282, 73.4%). The HPV knowledge overall correct mean score was 4.96 (SD = 3.61), showing that the overall correct knowledge score percentage was 35.4% out of a
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total possible score of 14. Of those participants aware of HPV (n = 102), the HPV knowledge mean score was 6.93 (SD = 3.40), showing that the correct knowledge score percentage was 49.5% out of a total possible score of 14. The HPV knowledge correct mean score among participants aware of HPV was significantly higher than among those who were unaware of HPV (t = 6.803, p < .001). Among the participants who were aware of HPV, 40.2% (n = 41) responded that both men and women could suffer from HPV infection, and 73.5% (n = 75) responded that sexual contact was the primary transmission route of HPV infection. Only 30.4% (n = 31) and 65.7% (n = 67) of the participants responded that genital warts and cervical cancer might occur if women have an HPV infection. The most frequent strategies for preventing HPV infection were HPV vaccination (79.4%, n = 81), monogamy (52.0%, n = 53), and condom use (39.2%, n = 40). When asked about the risk factors for HPV infection, 43.1% (n = 44) responded infrequent use of condoms. Surprisingly, the proportion of incorrect answers was significantly higher from the participants who were aware of HPV than from those who were unaware of HPV (Table 2).
Correlations With Intention to Use Condom for HPV Prevention Several variables were significantly correlated with intention to use condoms for HPV prevention. The mean score of behavioral intention was 4.97 out of a total possible score of 6 (SD = 0.78) (Table 1). The mean scores for attitude, subjective norm, perceived behavioral control, perceived risk, and HPV knowledge were 5.00, 5.15, 4.41, 3.98, and 4.96 out of a total possible score of 6 for each measure. This indicated that participants rated relatively high in subjective norms of condom use for HPV prevention and relatively low in perceived risk of HPV infection. Attitude (r = 0.56, p < .001), subjective norm (r = 0.59, p < .001), perceived behavioral control (r = 0.56, p < .001), perceived risk (r = 0.10, p < .05), and HPV knowledge (r = 0.15, p < .01) were significantly positively correlated with intention of condom use for HPV prevention (Table 3).
Factors Associated With Intention to Use Condom for HPV Prevention A multiple linear regression analysis was used to examine the factors associated with intention to use condoms for HPV prevention. Heard about HPV, discussed sexual issues, attitude, subjective norm, perceived behavioral control, perceived risk, and knowledge of HPV as independent variables were all entered into the regression model. The results of the multiple linear regression analysis showed that discussed sexual issues, attitude, subjective norm, perceived behavioral control, and HPV knowledge were significantly associated with intention to use condoms for HPV prevention. These findings accounted for 55.8% (p < .001) of the overall variance of intention to use
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HPV Prevention among Adolescent Women TABLE 2 Participants’ Responses to HPV Knowledge (N = 384) Heard of the Not heard of the HPV (n = 102) HPV (n = 282)
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Knowledge items Who are the targets of HPV infection? Both men and womena Women only Men only Do not know What is the main transmitted route of HPV infection? Sexual contacta Public spring Swimming pool Toilet seat Do not know What problem might occur if women have an HPV infection? Cervical cancera Genital wartsa AIDS Vaginitis Intercourse pain Syphilis Gonorrhea Sterility Menstrual disorder Do not know What strategies can be used to prevent HPV infection? HPV vaccinea Monogamya Condom usea Regular hours and exercisea No smokinga Pap testa Do not know What are the risk factors for HPV infection? High number of sexual partnersa Partner with high number of partnersa Infrequent use of condomsa Earlier intercoursea Do not know Correct mean scores [SD] Answer correctly (%) Overall correct mean score [SD] Overall answer correctly (%)
n (%)
n (%)
X 2 /t
p
41 55 3 4
(40.2) (53.9) (2.9) (3.9)
149 (52.8) 58 (20.6) 2 (0.7) 74 (26.2)
4.79 40.13 2.90 23.05
.029
