J Canc Educ DOI 10.1007/s13187-014-0703-1
Human Papillomavirus Vaccines and Cervical Cancer: Awareness, Knowledge, and Risk Perception Among Turkish Undergraduate Students Gülay Rathfisch & İlkay Güngör & Ece Uzun & Özlem Keskin & Zeliha Tencere
# Springer Science+Business Media New York 2014
Abstract The aim of this study was to evaluate awareness, knowledge, and risk perception about human papillomavirus (HPV), cervical cancer, and HPV vaccines among undergraduate students in Turkey. The convenience sample of this descriptive cross-sectional study consisted of 605 undergraduate students in Istanbul University during a semester. Demographic characteristics of students, their reproductive health and lifestyle behaviors, and knowledge of HPV and HPV vaccine were questioned using self-administered forms. The overall proportion of students who had heard about HPV infection was 48.8 %, while the proportion of students who had heard of the HPV vaccine was 44.5 %. Forty eight percent of females and 60 % of males reported never having heard of the HPV. Only 45.7 % of females had knowledge about HPV as a cause of genital warts, and 58.1 % correctly indicated that HPV caused cervical cancer. The majority of students in both genders (>80 %) knew that the infection is primarily G. Rathfisch : İ. Güngör (*) Florence Nightingale Faculty of Nursing, Department of Women’s Health and Diseases Nursing, Istanbul University, Abide-i Hurriyet cad., 34381 Sisli, Istanbul, Turkey e-mail: [email protected] G. Rathfisch e-mail: [email protected] E. Uzun : Ö. Keskin Medipol University Hospital, TEM Avrupa Otoyolu Goztepe Cikisi No: 1, Bagcılar 34214, Istanbul, Turkey E. Uzun e-mail: [email protected] Ö. Keskin e-mail: [email protected] Z. Tencere Johns Hopkins Medicine Anatolian Health Center, Cumhuriyet mahallesi 2255 sokak no:3, Gebze 41400, Kocaeli, Turkey e-mail: [email protected]
transmitted through sexual intercourse. Females were more concerned than males about having cervical/penile cancer associated with HPV in the future. Only 46.4 % of females and 39 % of males reported having heard of the HPV vaccine. The majority of the female and male students did not know who should get the HPV vaccine and when to get vaccinated. Among males, 25.8 % reported that they would consider getting vaccinated (if available) and 38.4 % intended to vaccinate their children. Turkish undergraduate students had a low to moderate level of knowledge regarding HPV infection and HPV vaccine. In order to increase awareness about HPV and develop positive behaviors, young people should be provided with accurate information through educational activities in the community and health care services. Keywords Human papillomavirus . HPV vaccine . Awareness . Risk perception
Introduction Cervical cancer is the most common gynecologic cancer and the fourth common cancer in women. There were an estimated 528,000 new cases and 266,000 deaths from cervical cancer worldwide in 2012, and almost nine out of ten (87 %) cervical cancer deaths occur in the less developed regions [1]. In Turkey, cervical cancer has been reported to be the third most common gynecologic cancer after corpus and ovarian cancer and it has been the tenth most common cancer in women [2]. HPV is a sexually transmitted disease (STD), and the most common viral disease of the reproductive system. Almost 99 % of the cases of cervical cancer are HPV related. The virus has 40 different types that cause cancer (penis, vulva, intravaginal walls, cervix, anus, and rectum) among men and women. Among these, genotypes, 16 and 18 have the strongest potential of causing cervical, vaginal, vulvar, and penile
J Canc Educ
cancers. Low-risk genotypes HPV 6 and HPV 11 are known to be the reason behind the considerable number of low-level cervical dysplasia cases, as well as 90 % of genital warts [3, 4]. HPV is the most common infection. The lifetime risk of HPV infection among sexually active men and women has been reported as 50 % at the very least [5]. Every woman has the lifelong risk of HPV infection, independently of sociocultural and economic status. Adolescents and young adults at the age of high school and university constitute the highest risk groups [4, 6–8]. Discovery of the virus as the main agent behind endemic cervical cancer has paved the way for vaccines as a preventive measure [9]. Worldwide, young girls from ages 9 to 26 are recommended to get prophylactic vaccination, preferably before they have their first sexual contact. Regarding that the HPV infection can also be encountered in men, there is an ongoing debate of whether if it is enough for girls to receive vaccination or men of the same age group should receive it as well. In recent years, men of the same age group are recommended to get vaccination, as there is a high number of carriers among them and as a preventive measure against penile cancer [9–13]. Following the long-term studies, HPV vaccine was approved and made accessible to the public in year 2006. The vaccination was found to be 65–76 % effective against HPV infections, depending on the prevalence of oncogenic subtypes of HPV in the society. On the other hand, the vaccination is 100 % effective in preventing precancerous cervical lesions caused by HPV types 16 and 18 [3]. Randomized controlled studies have also shown that the HPV vaccination is indeed quite safe and effective [14]. However, the studies have also shown that the worldwide demand for vaccination depends on the information level of individuals’ on HPV and cervical cancer, their attitudes regarding vaccination, as well as parents’ and partners’ approval [7, 8, 15, 16]. In the previous studies, the awareness among young population was determined to be increasing, despite misinformation and concerns towards HPV and vaccination [7, 8, 15, 16]. Further studies are recommended to address the knowledge and attitudes about HPV and to raise awareness among youth by means of education [15, 14]. HPV vaccines are available in Turkey but are not yet included in national routine immunization schedule. Currently, HPV vaccine is paid and at the discretion of the family [17, 18]. In Turkey, limited numbers of small-scale studies have demonstrated that the majority of young people do not have adequate knowledge about HPV and vaccines and they had concerns about being vaccinated [19]. Therefore, there has been a growing need for further research on young people about HPV knowledge and vaccination in Turkey. In conclusion, the evaluation of information and attitudes towards the prevention of HPV among young adults is of
critical importance to assess their needs and encourage positive behaviors.
Method Objectives The aim of this study was to evaluate awareness, knowledge, and risk perception about human papillomavirus (HPV), cervical cancer, and HPV vaccines among undergraduate students in Turkey. Design A descriptive cross-sectional study Sample The population of the study consisted of undergraduate students at the faculties of science, health sciences, and social sciences in Istanbul University during an academic semester. The convenience sample of the study consisted of 605 undergraduate students who were available and agreed to participate in the study. Almost all of the available students who were invited to the study agreed to participate. Since some of the students were out of the faculty buildings because of their practical training in other institutions, students after the third year were not available and they were represented less in the sample especially in the faculties of health sciences. Written ethical approval were obtained from Istanbul University and related faculties prior to the study. Data Collection Data were collected using a selfadministered questionnaire prepared in line with the literature. The questionnaire included questions about demographic characteristics of students, their reproductive health and lifestyle behaviors, knowledge of HPV, genital warts, cervical cancer, and HPV vaccine. Following the informed verbal consent, questionnaires were given to each participant by nursing students (two of the authors) during the breaks in the classrooms or cafeterias at university buildings. In addition, after the students returned the filled questionnaires, researchers (two nursing students) have given information on this subject and answered their questions. Data Analysis The data were analyzed using a statistical program on computer. Percentage calculation was used to present the characteristics of students and the distribution of their answers to questions about HPV knowledge. Chi-square analysis was used to evaluate the differences between genders and faculties.
Results Out of the 605 participant students, 446 (73.7 %) were females and 159 (26.3 %) were males. The mean age for female and
J Canc Educ
male students was 20 years (SD 2.1) (range 17–33 years) and 21.5 years (SD 3.6) (range 17–37 years), respectively. Overall, 42.3 % of the students were studying for a degree in social sciences, 33.4 % were in science, and 24.3 % were in health sciences. Almost all (98.5 %) were single; the majority was in their first or second year in the university, staying in dorms, and had middle income. The data about the demographical characteristics of the students are presented in Table 1. Male students (52.2 %) were significantly more likely than female students (6.1 %) to report being sexually active (p11 years) Father’s education Uneducated (illiterate or not graduated a school) Primary school (5–8 years) High school and over (>11 years)
Female
Male
n
n
%
%
172 38.6 154 34.5 120 26.9
84 52.8 48 30.2 27 17.0
191 139 60 56
61 34 36 28
42.8 31.2 13.5 12.6
38.4 21.4 22.6 17.6
262 58.7 138 30.9 46 10.3
90 56.6 23 14.5 46 28.9
91 20.4 241 54.0 114 25.6
43 27.0 89 56.0 27 17.0
357 80.0 120 75.5 50 11.2 26 16.4 39 8.7 13 8.2 34
7.6
26 16.4
242 54.3 170 38.1
76 47.8 57 35.8
10
2.2
180 40.4 256 57.4
13
8.2
56 35.2 90 56.6
for females and 17 (SD 2.2) for males. Condom use among sexual active students was found to be significantly lower (p
Human Papillomavirus Vaccines and Cervical Cancer: Awareness, Knowledge, and Risk Perception Among Turkish Undergraduate Students Gülay Rathfisch & İlkay Güngör & Ece Uzun & Özlem Keskin & Zeliha Tencere
# Springer Science+Business Media New York 2014
Abstract The aim of this study was to evaluate awareness, knowledge, and risk perception about human papillomavirus (HPV), cervical cancer, and HPV vaccines among undergraduate students in Turkey. The convenience sample of this descriptive cross-sectional study consisted of 605 undergraduate students in Istanbul University during a semester. Demographic characteristics of students, their reproductive health and lifestyle behaviors, and knowledge of HPV and HPV vaccine were questioned using self-administered forms. The overall proportion of students who had heard about HPV infection was 48.8 %, while the proportion of students who had heard of the HPV vaccine was 44.5 %. Forty eight percent of females and 60 % of males reported never having heard of the HPV. Only 45.7 % of females had knowledge about HPV as a cause of genital warts, and 58.1 % correctly indicated that HPV caused cervical cancer. The majority of students in both genders (>80 %) knew that the infection is primarily G. Rathfisch : İ. Güngör (*) Florence Nightingale Faculty of Nursing, Department of Women’s Health and Diseases Nursing, Istanbul University, Abide-i Hurriyet cad., 34381 Sisli, Istanbul, Turkey e-mail: [email protected] G. Rathfisch e-mail: [email protected] E. Uzun : Ö. Keskin Medipol University Hospital, TEM Avrupa Otoyolu Goztepe Cikisi No: 1, Bagcılar 34214, Istanbul, Turkey E. Uzun e-mail: [email protected] Ö. Keskin e-mail: [email protected] Z. Tencere Johns Hopkins Medicine Anatolian Health Center, Cumhuriyet mahallesi 2255 sokak no:3, Gebze 41400, Kocaeli, Turkey e-mail: [email protected]
transmitted through sexual intercourse. Females were more concerned than males about having cervical/penile cancer associated with HPV in the future. Only 46.4 % of females and 39 % of males reported having heard of the HPV vaccine. The majority of the female and male students did not know who should get the HPV vaccine and when to get vaccinated. Among males, 25.8 % reported that they would consider getting vaccinated (if available) and 38.4 % intended to vaccinate their children. Turkish undergraduate students had a low to moderate level of knowledge regarding HPV infection and HPV vaccine. In order to increase awareness about HPV and develop positive behaviors, young people should be provided with accurate information through educational activities in the community and health care services. Keywords Human papillomavirus . HPV vaccine . Awareness . Risk perception
Introduction Cervical cancer is the most common gynecologic cancer and the fourth common cancer in women. There were an estimated 528,000 new cases and 266,000 deaths from cervical cancer worldwide in 2012, and almost nine out of ten (87 %) cervical cancer deaths occur in the less developed regions [1]. In Turkey, cervical cancer has been reported to be the third most common gynecologic cancer after corpus and ovarian cancer and it has been the tenth most common cancer in women [2]. HPV is a sexually transmitted disease (STD), and the most common viral disease of the reproductive system. Almost 99 % of the cases of cervical cancer are HPV related. The virus has 40 different types that cause cancer (penis, vulva, intravaginal walls, cervix, anus, and rectum) among men and women. Among these, genotypes, 16 and 18 have the strongest potential of causing cervical, vaginal, vulvar, and penile
J Canc Educ
cancers. Low-risk genotypes HPV 6 and HPV 11 are known to be the reason behind the considerable number of low-level cervical dysplasia cases, as well as 90 % of genital warts [3, 4]. HPV is the most common infection. The lifetime risk of HPV infection among sexually active men and women has been reported as 50 % at the very least [5]. Every woman has the lifelong risk of HPV infection, independently of sociocultural and economic status. Adolescents and young adults at the age of high school and university constitute the highest risk groups [4, 6–8]. Discovery of the virus as the main agent behind endemic cervical cancer has paved the way for vaccines as a preventive measure [9]. Worldwide, young girls from ages 9 to 26 are recommended to get prophylactic vaccination, preferably before they have their first sexual contact. Regarding that the HPV infection can also be encountered in men, there is an ongoing debate of whether if it is enough for girls to receive vaccination or men of the same age group should receive it as well. In recent years, men of the same age group are recommended to get vaccination, as there is a high number of carriers among them and as a preventive measure against penile cancer [9–13]. Following the long-term studies, HPV vaccine was approved and made accessible to the public in year 2006. The vaccination was found to be 65–76 % effective against HPV infections, depending on the prevalence of oncogenic subtypes of HPV in the society. On the other hand, the vaccination is 100 % effective in preventing precancerous cervical lesions caused by HPV types 16 and 18 [3]. Randomized controlled studies have also shown that the HPV vaccination is indeed quite safe and effective [14]. However, the studies have also shown that the worldwide demand for vaccination depends on the information level of individuals’ on HPV and cervical cancer, their attitudes regarding vaccination, as well as parents’ and partners’ approval [7, 8, 15, 16]. In the previous studies, the awareness among young population was determined to be increasing, despite misinformation and concerns towards HPV and vaccination [7, 8, 15, 16]. Further studies are recommended to address the knowledge and attitudes about HPV and to raise awareness among youth by means of education [15, 14]. HPV vaccines are available in Turkey but are not yet included in national routine immunization schedule. Currently, HPV vaccine is paid and at the discretion of the family [17, 18]. In Turkey, limited numbers of small-scale studies have demonstrated that the majority of young people do not have adequate knowledge about HPV and vaccines and they had concerns about being vaccinated [19]. Therefore, there has been a growing need for further research on young people about HPV knowledge and vaccination in Turkey. In conclusion, the evaluation of information and attitudes towards the prevention of HPV among young adults is of
critical importance to assess their needs and encourage positive behaviors.
Method Objectives The aim of this study was to evaluate awareness, knowledge, and risk perception about human papillomavirus (HPV), cervical cancer, and HPV vaccines among undergraduate students in Turkey. Design A descriptive cross-sectional study Sample The population of the study consisted of undergraduate students at the faculties of science, health sciences, and social sciences in Istanbul University during an academic semester. The convenience sample of the study consisted of 605 undergraduate students who were available and agreed to participate in the study. Almost all of the available students who were invited to the study agreed to participate. Since some of the students were out of the faculty buildings because of their practical training in other institutions, students after the third year were not available and they were represented less in the sample especially in the faculties of health sciences. Written ethical approval were obtained from Istanbul University and related faculties prior to the study. Data Collection Data were collected using a selfadministered questionnaire prepared in line with the literature. The questionnaire included questions about demographic characteristics of students, their reproductive health and lifestyle behaviors, knowledge of HPV, genital warts, cervical cancer, and HPV vaccine. Following the informed verbal consent, questionnaires were given to each participant by nursing students (two of the authors) during the breaks in the classrooms or cafeterias at university buildings. In addition, after the students returned the filled questionnaires, researchers (two nursing students) have given information on this subject and answered their questions. Data Analysis The data were analyzed using a statistical program on computer. Percentage calculation was used to present the characteristics of students and the distribution of their answers to questions about HPV knowledge. Chi-square analysis was used to evaluate the differences between genders and faculties.
Results Out of the 605 participant students, 446 (73.7 %) were females and 159 (26.3 %) were males. The mean age for female and
J Canc Educ
male students was 20 years (SD 2.1) (range 17–33 years) and 21.5 years (SD 3.6) (range 17–37 years), respectively. Overall, 42.3 % of the students were studying for a degree in social sciences, 33.4 % were in science, and 24.3 % were in health sciences. Almost all (98.5 %) were single; the majority was in their first or second year in the university, staying in dorms, and had middle income. The data about the demographical characteristics of the students are presented in Table 1. Male students (52.2 %) were significantly more likely than female students (6.1 %) to report being sexually active (p11 years) Father’s education Uneducated (illiterate or not graduated a school) Primary school (5–8 years) High school and over (>11 years)
Female
Male
n
n
%
%
172 38.6 154 34.5 120 26.9
84 52.8 48 30.2 27 17.0
191 139 60 56
61 34 36 28
42.8 31.2 13.5 12.6
38.4 21.4 22.6 17.6
262 58.7 138 30.9 46 10.3
90 56.6 23 14.5 46 28.9
91 20.4 241 54.0 114 25.6
43 27.0 89 56.0 27 17.0
357 80.0 120 75.5 50 11.2 26 16.4 39 8.7 13 8.2 34
7.6
26 16.4
242 54.3 170 38.1
76 47.8 57 35.8
10
2.2
180 40.4 256 57.4
13
8.2
56 35.2 90 56.6
for females and 17 (SD 2.2) for males. Condom use among sexual active students was found to be significantly lower (p
