CLINICAL RESEARCH e-ISSN 1643-3750 © Med Sci Monit, 2017; 23: 4269-4277 DOI: 10.12659/MSM.903370
Knowledge and Awareness of Cervical Cancer, Human Papillomavirus (HPV), and HPV Vaccine Among HPV-Infected Chinese Women
Received: 2017.01.15 Accepted: 2017.02.20 Published: 2017.09.04
Authors’ Contribution: Study Design A Data Collection B Analysis C Statistical Data Interpretation D Manuscript Preparation E Literature Search F Funds Collection G
ABCDEF 1,2 CDE 1 BF 2 BF 1,2 BF 1,2 ABCG 3
BCDEFG 4
BCDEG 1,2
Zulqarnain Baloch Nafeesa Yasmeen Yuanyue Li Wenhui Zhang Hongyu Lu Xiaomei Wu Xueshan Xia Shihua Yang
1 College of Veterinary Medicine, South China Agricultural University, Guangzhou, Guangdong, P.R. China 2 Key Laboratory of Comprehensive Prevention and Control for Severe Clinical Animal Diseases of Guangdong Province, South China Agricultural University, Guangzhou, Guangdong, P.R. China 3 The 1st People’s Hospital of Yunnan Province, Kunming, Yunnan, P.R. China 4 The Research Center for Molecular Medicine, Faculty of Life Science and Technology, Kunming University of Science and Technology, Kunming, Yunnan, P.R. China
Corresponding Authors: Source of support:
Yang Shihua, e-mail: [email protected], Xueshan Xia, e-mail: [email protected] This study was supported by research grants from the Natural Science Foundation of China (81260248) and the Science and Technology Agency of Yunnan Province, China (2014FB090)
Background:
Material/Methods:
Results:
Conclusions:
It is important to understand the knowledge that various groups of a population have about cervical cancer and human papillomavirus (HPV) and their attitudes toward HPV vaccination, as it will ultimately influence their decision-making for or against the acceptability of vaccines and other preventive methods. This study was designed to determine the level of knowledge and awareness about cervical cancer, HPV, and the HPV vaccine among Chinese women in Yunnan province. A survey was conducted in Yunnan province by the Laboratory of Molecular Virology in collaboration with the Yunnan First People’s Hospital in Feb 2015. A total of 388 women were recruited and asked to participate in a questionnaire-based interview that collected information related to their awareness and knowledge about: (1) cervical cancer, (2) HPV and HPV vaccine and willingness to have their children receive vaccination, and (3) demographic characteristics. A total of 388 HPV-positive women were included; 300/388 (73.3%) were Han, and 88/388 (22.7%) were other ethnicities. Overall, 204/388 (52.6%) of the women were aware of cervical cancer, with a significant difference between Han women and women of other ethnic groups (168/388, 56.0% and 36/88, 40.9%; P=0.015). Overall, 26.5% of the women were aware of the role of HPV in cervical cancer; 29.0% of the Han women and 18.2% of women of other ethnic groups were aware of this role of HPV (P=0.05). The knowledge that HPV infection leads to cervical cancer was higher among Han women (29.0%) compared to women of other ethnicities (18.2%). Knowledge about the HPV vaccine was very low in all ethnic groups, but the Han women were more willing to allow their children to be vaccinated before they become sexually active. A similar difference has also been found in women from various regions. Although level of awareness and knowledge about cervical cancer was moderate, knowledge and awareness of HPV and the HPV vaccine was very low. Targeted communication is very important among populations in which knowledge gaps exist in order to promote dialogue about the vaccine among patients and their healthcare providers.
MeSH Keywords:
Health Knowledge, Attitudes, Practice • Papillomavirus Vaccines • Uterine Cervical Neoplasms
Abbreviations: HPV – human papillomavirus; WHO – World Health Organization; CDC – Center for Disease Control and Prevention Full-text PDF:
https://www.medscimonit.com/abstract/index/idArt/903370
2988
5
This work is licensed under Creative Common AttributionNonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0)
—
4269
36
Indexed in: [Current Contents/Clinical Medicine] [SCI Expanded] [ISI Alerting System] [ISI Journals Master List] [Index Medicus/MEDLINE] [EMBASE/Excerpta Medica] [Chemical Abstracts/CAS] [Index Copernicus]
Baloch Z. et al.: Knowledge and awareness of cervical cancer, human papillomavirus (HPV)… © Med Sci Monit, 2017; 23: 4269-4277
CLINICAL RESEARCH
Background Cervical cancer is the 3rd most frequently detected cancer among females, with an estimated 530 000 new cases and 275 000 deaths in 2008 worldwide [1]. Developed countries have reduced the incidence and mortality rates of cervical cancer due to the wide application of cervical screening tests and vaccinations [2,3]. It is well established that infection with human papillomavirus (HPV) is a major cause (99.9%) of cervical cancer and is one of the most common sexually transmitted pathogens of the genital system. Approximately 85% of the infections and 88% of the deaths caused by cervical cancer occur in developing countries [4,5]. According to the World Health Organization (WHO) (2006) estimation, multiple factors contribute to higher cervical cancer prevalence and mortality in developing regions of the world, such as lack of awareness about cervical cancer among the people, health care workers, and policy makers, lack of cervical screening programs, and limited access to healthcare facilities [6]. It is also thought that women’s knowledge about HPV and cervical cancer is very low in many countries [7–10]. China is the largest developing country, and according to the National Health and Family Planning Commission of the People’s Republic of China, it is estimated that there are 130 000 new cervical cancer cases registered annually, and almost 30 000 women die due to disease progression [11]. However, these estimates likely underestimate the true incidence of the disease due to the low number of cervical screening facilities and the substantial number of women living in rural areas, particularly the ethnic populations, who are rarely screened for cervical cancer [12]. Furthermore, many women also fail to get cervical screening tests due to poverty, fatalistic attitude, and lack of knowledge. Although the knowledge and attitudes about cervical cancer and HPV vary among Chinese women from different regions, most women have a high level of willingness to have their children receive vaccination, with some exceptions [13,14]. Previously published studies documented findings in developed areas, but the large social and economic variations of those areas make the findings less applicable to the whole of Mainland China, particularly Yunnan province. It is important to understand the knowledge of different populations about cervical cancer and HPV and their attitudes toward HPV vaccination acceptability as it will ultimately influence their decision for or against receiving HPV vaccination. Additionally, it is also important to understand the role of socioeconomic and demographic factors because several factors, such as education and interaction with the healthcare system, greatly influence HPV knowledge and vaccine acceptability compared to other factors [15].
This work is licensed under Creative Common AttributionNonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0)
Yunnan, also called Dian, is located in southwest China. Since ancient times, Yunnan has served as China’s gateway to Southeast Asia and South Asia. Additionally, it is a meeting point for Eastern and Western cultures. With its distinct environmental and geographical characteristics, the social characteristics of Yunnan province are also varied. In particular, 26 state-certified ethnic populations are scattered across the remote and hilly region of Yunnan. A significant difference in HPV prevalence and its genotype distribution has already been described in various populations of Yunnan [16,17]. However, no data are currently available regarding knowledge and awareness about cervical cancer, HPV, and vaccine acceptability among Chinese women in Yunnan. Thus, this study was designed to evaluate knowledge and awareness of HPV, cervical cancer, and the HPV vaccine among various populations of women in Yunnan province.
Material and Methods Experimental ethics A questionnaire was developed for this study. The protocol used in this study was in accordance with the Declaration of Helsinki and was approved by the Ethics Committee at Kunming University of Science and Technology and the Center for Disease Control and Prevention (CDC) in the Yunnan province, China. Written consent was individually obtained from each participant. Participant recruiting A survey was conducted by the Research Center for Molecular Medicine, Kunming University of Science and Technology in collaboration with First Peoples Hospitals of Yunnan. Between January 2014 and March 2015, women who visited the outpatient department of the First People’s Hospital of Yunnan were recruited. The First People’s Hospital of Yunnan is located in the center of Kunming city, which is the largest city in Yunnan province. The population of Yunnan province is approximately 44 million people. Han are the predominant ethnic group in the Yunnan province, with a population of 29 million. In contrast, other ethnic groups are in the minority and are scattered throughout various parts of the Yunnan province with a combined population of 15 million. A copy of the questionnaire was sent to a gynecologist who worked at the Outpatient Department of the Yunnan First People’s Hospital. She consented to appoint the female doctors to collect data from each patient individually. Before starting the interview, a cover letter described the aim of the study, conveyed the guarantee of secrecy, and highlighted that the participant’s decision to participate or ignore the interview would not effect of her medical check-up.
4270
Indexed in: [Current Contents/Clinical Medicine] [SCI Expanded] [ISI Alerting System] [ISI Journals Master List] [Index Medicus/MEDLINE] [EMBASE/Excerpta Medica] [Chemical Abstracts/CAS] [Index Copernicus]
Baloch Z. et al.: Knowledge and awareness of cervical cancer, human papillomavirus (HPV)… © Med Sci Monit, 2017; 23: 4269-4277
CLINICAL RESEARCH
For this study, we calculated that the sample size needed to estimate that the knowledge and awareness of HPV, cervical cancer, and the HPV vaccine among various populations of women in Yunnan province as high as 50% with an error rate of 5% was 384. We expected a low response rate, and the sample size was increased to 700 HPV-infected women. The overall response rate was approximately 74.4% (521/700).
Table 1. Demographic characteristics of study participants (n=388). Characteristics
Frequency
Percent
300
77.3
88
22.7
140
36.1
Ethnicity Han Others Region
Questionnaire data and process
Central
A 20-question questionnaire was prepared based on a review of the literature and a previously published questionnaire [14,18,19] and was designed in the Chinese language. Every participant appeared in an interview, in which a standardized questionnaire was used to collect information about socio-demographic factors, such as ethnicity, area, regional background, age, education, occupation, marital status, monthly income, their knowledge about cervical cancer, HPV, and the relationship between HPV and cervical cancer and the vaccine.
Northeast
49
12.6
Northwest
42
10.8
Southeast
40
10.3
Southwest
35
9.0
Others
82
21.1
Rural
110
28.3
Urban
278
71.7
Statistical analysis
Age 75
19.3
31–40
148
38.1
41–50
130
33.5
35
9.0
121
31.2
High school
94
24.2
Middle
78
20.1
Primary
53
13.6
Illiterate
42
10.8
Farmers
63
16.2
Government
30
7.7
Private
82
21.1
Self-employed
83
21.4
Teachers
32
8.2
Others
80
20.6
Unemployed
18
4.6
319
82.2
69
17.8
Knowledge and Awareness of Cervical Cancer, Human Papillomavirus (HPV), and HPV Vaccine Among HPV-Infected Chinese Women
Received: 2017.01.15 Accepted: 2017.02.20 Published: 2017.09.04
Authors’ Contribution: Study Design A Data Collection B Analysis C Statistical Data Interpretation D Manuscript Preparation E Literature Search F Funds Collection G
ABCDEF 1,2 CDE 1 BF 2 BF 1,2 BF 1,2 ABCG 3
BCDEFG 4
BCDEG 1,2
Zulqarnain Baloch Nafeesa Yasmeen Yuanyue Li Wenhui Zhang Hongyu Lu Xiaomei Wu Xueshan Xia Shihua Yang
1 College of Veterinary Medicine, South China Agricultural University, Guangzhou, Guangdong, P.R. China 2 Key Laboratory of Comprehensive Prevention and Control for Severe Clinical Animal Diseases of Guangdong Province, South China Agricultural University, Guangzhou, Guangdong, P.R. China 3 The 1st People’s Hospital of Yunnan Province, Kunming, Yunnan, P.R. China 4 The Research Center for Molecular Medicine, Faculty of Life Science and Technology, Kunming University of Science and Technology, Kunming, Yunnan, P.R. China
Corresponding Authors: Source of support:
Yang Shihua, e-mail: [email protected], Xueshan Xia, e-mail: [email protected] This study was supported by research grants from the Natural Science Foundation of China (81260248) and the Science and Technology Agency of Yunnan Province, China (2014FB090)
Background:
Material/Methods:
Results:
Conclusions:
It is important to understand the knowledge that various groups of a population have about cervical cancer and human papillomavirus (HPV) and their attitudes toward HPV vaccination, as it will ultimately influence their decision-making for or against the acceptability of vaccines and other preventive methods. This study was designed to determine the level of knowledge and awareness about cervical cancer, HPV, and the HPV vaccine among Chinese women in Yunnan province. A survey was conducted in Yunnan province by the Laboratory of Molecular Virology in collaboration with the Yunnan First People’s Hospital in Feb 2015. A total of 388 women were recruited and asked to participate in a questionnaire-based interview that collected information related to their awareness and knowledge about: (1) cervical cancer, (2) HPV and HPV vaccine and willingness to have their children receive vaccination, and (3) demographic characteristics. A total of 388 HPV-positive women were included; 300/388 (73.3%) were Han, and 88/388 (22.7%) were other ethnicities. Overall, 204/388 (52.6%) of the women were aware of cervical cancer, with a significant difference between Han women and women of other ethnic groups (168/388, 56.0% and 36/88, 40.9%; P=0.015). Overall, 26.5% of the women were aware of the role of HPV in cervical cancer; 29.0% of the Han women and 18.2% of women of other ethnic groups were aware of this role of HPV (P=0.05). The knowledge that HPV infection leads to cervical cancer was higher among Han women (29.0%) compared to women of other ethnicities (18.2%). Knowledge about the HPV vaccine was very low in all ethnic groups, but the Han women were more willing to allow their children to be vaccinated before they become sexually active. A similar difference has also been found in women from various regions. Although level of awareness and knowledge about cervical cancer was moderate, knowledge and awareness of HPV and the HPV vaccine was very low. Targeted communication is very important among populations in which knowledge gaps exist in order to promote dialogue about the vaccine among patients and their healthcare providers.
MeSH Keywords:
Health Knowledge, Attitudes, Practice • Papillomavirus Vaccines • Uterine Cervical Neoplasms
Abbreviations: HPV – human papillomavirus; WHO – World Health Organization; CDC – Center for Disease Control and Prevention Full-text PDF:
https://www.medscimonit.com/abstract/index/idArt/903370
2988
5
This work is licensed under Creative Common AttributionNonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0)
—
4269
36
Indexed in: [Current Contents/Clinical Medicine] [SCI Expanded] [ISI Alerting System] [ISI Journals Master List] [Index Medicus/MEDLINE] [EMBASE/Excerpta Medica] [Chemical Abstracts/CAS] [Index Copernicus]
Baloch Z. et al.: Knowledge and awareness of cervical cancer, human papillomavirus (HPV)… © Med Sci Monit, 2017; 23: 4269-4277
CLINICAL RESEARCH
Background Cervical cancer is the 3rd most frequently detected cancer among females, with an estimated 530 000 new cases and 275 000 deaths in 2008 worldwide [1]. Developed countries have reduced the incidence and mortality rates of cervical cancer due to the wide application of cervical screening tests and vaccinations [2,3]. It is well established that infection with human papillomavirus (HPV) is a major cause (99.9%) of cervical cancer and is one of the most common sexually transmitted pathogens of the genital system. Approximately 85% of the infections and 88% of the deaths caused by cervical cancer occur in developing countries [4,5]. According to the World Health Organization (WHO) (2006) estimation, multiple factors contribute to higher cervical cancer prevalence and mortality in developing regions of the world, such as lack of awareness about cervical cancer among the people, health care workers, and policy makers, lack of cervical screening programs, and limited access to healthcare facilities [6]. It is also thought that women’s knowledge about HPV and cervical cancer is very low in many countries [7–10]. China is the largest developing country, and according to the National Health and Family Planning Commission of the People’s Republic of China, it is estimated that there are 130 000 new cervical cancer cases registered annually, and almost 30 000 women die due to disease progression [11]. However, these estimates likely underestimate the true incidence of the disease due to the low number of cervical screening facilities and the substantial number of women living in rural areas, particularly the ethnic populations, who are rarely screened for cervical cancer [12]. Furthermore, many women also fail to get cervical screening tests due to poverty, fatalistic attitude, and lack of knowledge. Although the knowledge and attitudes about cervical cancer and HPV vary among Chinese women from different regions, most women have a high level of willingness to have their children receive vaccination, with some exceptions [13,14]. Previously published studies documented findings in developed areas, but the large social and economic variations of those areas make the findings less applicable to the whole of Mainland China, particularly Yunnan province. It is important to understand the knowledge of different populations about cervical cancer and HPV and their attitudes toward HPV vaccination acceptability as it will ultimately influence their decision for or against receiving HPV vaccination. Additionally, it is also important to understand the role of socioeconomic and demographic factors because several factors, such as education and interaction with the healthcare system, greatly influence HPV knowledge and vaccine acceptability compared to other factors [15].
This work is licensed under Creative Common AttributionNonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0)
Yunnan, also called Dian, is located in southwest China. Since ancient times, Yunnan has served as China’s gateway to Southeast Asia and South Asia. Additionally, it is a meeting point for Eastern and Western cultures. With its distinct environmental and geographical characteristics, the social characteristics of Yunnan province are also varied. In particular, 26 state-certified ethnic populations are scattered across the remote and hilly region of Yunnan. A significant difference in HPV prevalence and its genotype distribution has already been described in various populations of Yunnan [16,17]. However, no data are currently available regarding knowledge and awareness about cervical cancer, HPV, and vaccine acceptability among Chinese women in Yunnan. Thus, this study was designed to evaluate knowledge and awareness of HPV, cervical cancer, and the HPV vaccine among various populations of women in Yunnan province.
Material and Methods Experimental ethics A questionnaire was developed for this study. The protocol used in this study was in accordance with the Declaration of Helsinki and was approved by the Ethics Committee at Kunming University of Science and Technology and the Center for Disease Control and Prevention (CDC) in the Yunnan province, China. Written consent was individually obtained from each participant. Participant recruiting A survey was conducted by the Research Center for Molecular Medicine, Kunming University of Science and Technology in collaboration with First Peoples Hospitals of Yunnan. Between January 2014 and March 2015, women who visited the outpatient department of the First People’s Hospital of Yunnan were recruited. The First People’s Hospital of Yunnan is located in the center of Kunming city, which is the largest city in Yunnan province. The population of Yunnan province is approximately 44 million people. Han are the predominant ethnic group in the Yunnan province, with a population of 29 million. In contrast, other ethnic groups are in the minority and are scattered throughout various parts of the Yunnan province with a combined population of 15 million. A copy of the questionnaire was sent to a gynecologist who worked at the Outpatient Department of the Yunnan First People’s Hospital. She consented to appoint the female doctors to collect data from each patient individually. Before starting the interview, a cover letter described the aim of the study, conveyed the guarantee of secrecy, and highlighted that the participant’s decision to participate or ignore the interview would not effect of her medical check-up.
4270
Indexed in: [Current Contents/Clinical Medicine] [SCI Expanded] [ISI Alerting System] [ISI Journals Master List] [Index Medicus/MEDLINE] [EMBASE/Excerpta Medica] [Chemical Abstracts/CAS] [Index Copernicus]
Baloch Z. et al.: Knowledge and awareness of cervical cancer, human papillomavirus (HPV)… © Med Sci Monit, 2017; 23: 4269-4277
CLINICAL RESEARCH
For this study, we calculated that the sample size needed to estimate that the knowledge and awareness of HPV, cervical cancer, and the HPV vaccine among various populations of women in Yunnan province as high as 50% with an error rate of 5% was 384. We expected a low response rate, and the sample size was increased to 700 HPV-infected women. The overall response rate was approximately 74.4% (521/700).
Table 1. Demographic characteristics of study participants (n=388). Characteristics
Frequency
Percent
300
77.3
88
22.7
140
36.1
Ethnicity Han Others Region
Questionnaire data and process
Central
A 20-question questionnaire was prepared based on a review of the literature and a previously published questionnaire [14,18,19] and was designed in the Chinese language. Every participant appeared in an interview, in which a standardized questionnaire was used to collect information about socio-demographic factors, such as ethnicity, area, regional background, age, education, occupation, marital status, monthly income, their knowledge about cervical cancer, HPV, and the relationship between HPV and cervical cancer and the vaccine.
Northeast
49
12.6
Northwest
42
10.8
Southeast
40
10.3
Southwest
35
9.0
Others
82
21.1
Rural
110
28.3
Urban
278
71.7
Statistical analysis
Age 75
19.3
31–40
148
38.1
41–50
130
33.5
35
9.0
121
31.2
High school
94
24.2
Middle
78
20.1
Primary
53
13.6
Illiterate
42
10.8
Farmers
63
16.2
Government
30
7.7
Private
82
21.1
Self-employed
83
21.4
Teachers
32
8.2
Others
80
20.6
Unemployed
18
4.6
319
82.2
69
17.8
