Journal of Obstetrics and Gynaecology
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Knowledge of and attitude towards human papillomavirus infection and vaccines among nurses at a tertiary hospital in South Africa M. E. Hoque, S. Monokoane & G. Van Hal To cite this article: M. E. Hoque, S. Monokoane & G. Van Hal (2014) Knowledge of and attitude towards human papillomavirus infection and vaccines among nurses at a tertiary hospital in South Africa, Journal of Obstetrics and Gynaecology, 34:2, 182-186 To link to this article: http://dx.doi.org/10.3109/01443615.2013.861395
Published online: 23 Jan 2014.
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Journal of Obstetrics and Gynaecology, February 2014; 34: 182–186 © 2014 Informa UK, Ltd. ISSN 0144-3615 print/ISSN 1364-6893 online DOI: 10.3109/01443615.2013.861395
Knowledge of and attitude towards human papillomavirus infection and vaccines among nurses at a tertiary hospital in South Africa M. E. Hoque1, S. Monokoane2 & G. Van Hal3 1Graduate School of Business and Leadership, University of KwaZulu-Natal (Westville Campus), Durban, 2Department of Obstetrics
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and Gynaecology, University of Limpopo (Medunsa Campus), Pretoria, South Africa and 3Medical Sociology and Health Policy, University of Antwerp, Belgium
The purpose of this cross-sectional study was to determine factors contributing to recommending vaccination to patients, using a self-administered anonymous questionnaire given to 345 nurses working at a tertiary hospital in South Africa. The average age of the participants was 37.2 years. About three-quarters (73.3%) of the nurses were aware of HPV and among them, 38.3% knew that HPV is the most common sexually transmitted virus. Nurses had poor knowledge regarding HPV infection and the HPV vaccine. The majority (90.9%) of the nurses intended to recommend the vaccine to their patients. The nurses who mentioned that adolescents and young adults would accept HPV vaccination were more likely to recommend HPV vaccination to their patients (OR ⴝ 57.78, p ⴝ 0.031). Nurses had a low level of knowledge regarding HPV infection and vaccines but they were willing to recommend the vaccines to their patients. Nurses need to be educated before implementing HPV vaccinations nationwide. Keywords: Basic science, epidemiology, general gynaecology, gynaecological oncology, sexual health
Introduction Cervical cancer is considered a preventable disease. Globally however, it is the second most common cancer after breast cancer. More than 500,000 women are diagnosed with cervical cancer and 270,000 die of the disease. The majority (85.5%) of deaths occur in developing countries each year (Ferlay et al. 2010). In South Africa, the estimated mortality rate for cervical cancer is 12/100,000 resulting in 3,027 deaths per year (HPV Information Centre 2010). It is also projected that cervical cancer cases and cervical cancer deaths will increase to 7,329 and 4,177, respectively, by the year 2025 (HPV Information Centre 2010). The National Department of Health of South Africa developed a policy guideline for cervical cancer screening in the year 2000, to screen at least 70% of women over 30 years of age, nationally within 10 years of initiating the programme (National Department of Health 2000). Even though the screening was free of charge, the uptake was very low (Wellensiek et al. 2002; Hoque et al. 2008). Human papillomavirus (HPV) is the most common sexually transmitted infection and plays the most significant role in the development of cervical cancer (Baseman and Koutsky 2005; Moscicki et al. 2006). More than half of sexually active women
are exposed to at least one type of HPV in their lifetime and almost all cervical cancer cases are associated with genital infection with HPV (Baseman and Koutsky 2005). The majority of cervical cancer is caused by HPV types 16 and 18 (Seoud et al. 2011). In South Africa, HPV-16 and -18 contributes to 62.8% of the cervical cancer cases (HPV Information Centre 2010). Healthcare workers (HCWs) are the most trusted people to disseminate health-related information to the general population in a country (Hopkins and Wood 2013). In most countries in the world, patients first come into contact with nurses. Thus, nurses play a significant role in educating patients and their families, as well as in administering vaccines (Jakeway et al. 2008; WHO 2008; Nkowane et al. 2009). In many high-income countries, for example, the Netherlands, Canada and the UK, nurses are involved directly in implementing the HPV vaccine programmes (Kimman et al. 2006; Duval et al. 2009; Hopkins et al. 2009). Through health promotion and education, nurses can also influence parents to have their children vaccinated (Matin and LeBaron 2004; Dinh et al. 2007). After educating nurses and other health workers extensively, Rwanda is the only country in the African continent which has successfully completed a national HPV vaccination programme (Binagwaho et al. 2012). Nurses in South Africa should also play a significant role in national cervical cancer initiatives, particularly in creating awareness and educating adolescents and their families. In South Africa, the two vaccines (Gardasil® and Cervarix®) have been introduced and are available in private health facilities but not in public health facilities. HPV vaccination is administered only to adolescent girls and has not been integrated into other vaccination programmes in South Africa. The effectiveness of vaccination programmes against HPV will largely depend on how health professionals such as nurses have been oriented, since there is a massive shortage of nurses in South Africa. Thus, it is important to know if the current nurses have accurate knowledge and beliefs regarding this public health problem. Therefore, the objective of this study was to determine the factors contributing to recommending vaccination among nurses in South Africa.
Materials and methods This was a cross-sectional study targeting nurses permanently employed at the Dr George Mukhari Hospital (DGMH). The
Correspondence: M. E. Hoque, Graduate School of Business and Leadership, University of KwaZulu-Natal, Durban, South Africa. E-mail: [email protected]
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HPV vaccination in South Africa 183 hospital is a tertiary hospital which has 39 wards with 1,400 beds. It is also a referral hospital for Polokwane and Northwest province. There are 1,200 nurses currently working in the hospital. The hospital is situated in the close proximity of the University of Limpopo (Medunsa Campus) and is used as an academic institution for medical students. Even though it is a referral hospital, it also offers outpatient treatment to its catchment population. It is situated about 35 km north of the capital city of South Africa in Pretoria, in Gauteng Province. The sample size for the study was calculated based on the following information: assuming 50% of nurses will have sufficient knowledge regarding HPV vaccination, with 95% confidence level and 80% power of the study, the study requires 297 nurses. We added 20% more to the sample size in case of incompleteness and thus, the final sample size was 357 nurses. All the study samples were selected using multistage sampling techniques. First, stratifying HCWs according to the department and then proportional probability was used to select the samples. HCWs who generally do not come in contact with female patients, e.g. HCWs in the paediatrics and intensive care unit department and laboratory workers, were excluded from the study. A self-administered questionnaire, which was developed by Walsh and McPhee (1992) was used in this study. This model considers health beliefs and attitudes as HCWs predisposing factors, knowledge as enabling factors and professional and social support as reinforcing factors. Additional factors were also considered, for example organisational factors, such as access, preventive activity factors and cues for action. The questionnaire consisted of four sections. Section 1 for assessing general information; Section 2 for assessing HPV infection and its prevention, consisting of 58 items; Section 3 considered HCWs practice-related characteristics (seven items); and the last section consisted of demographic characteristics. On average, the study questionnaire took about 20–25 min to complete. One research assistant collected the data from the different departments of the hospital. The research assistant was trained on data collection methods. Data were collected during the tea-time or lunch-time, so it did not affect their work. Before the data collection, the research assistant explained the aim and objective of the study to the nurses. It was also highlighted that participation in the study was voluntary and anonymity and confidentiality would be maintained at all times. From 12 knowledge items, a ‘True–False–Not Sure’ scale was used for nine items. One point was given for each correct answer. We used a 4-point Likert scale (1 point for strongly disagree and 4 points for strongly agree) for all other factors except demographic variables. The results were summarised using descriptive summary measures such as mean (standard deviation, SD) for continuous variables and percentages for categorical variables. Categorical variables were compared using χ2-test or Fisher’s exact test where necessary. Multivariate logistic regression models were carried out to determine variables that were significantly associated with the intention to recommend HPV vaccination. A p value of ⬍ 0.05 was considered statistically significant. An ethical clearance certificate was obtained from the Medunsa Research Ethics Committee of the University of Limpopo. The researchers also concurrently obtained permission to carry out the study from the hospital management team. All the participants were fully informed about the study. They signed the consent form before completing the questionnaire. Their confidentiality was maintained at all times.
Results A total of 357 questionnaires were distributed and 350 received. Five questionnaires were incomplete, thus excluded from the analysis. Table I summarises the sociodemographic information of the participants. The average age of the participants was 37.2 years with two-thirds (71.6%) between 30 and 49 years. Regarding gender, females were predominant (78.6%). Results indicate that more than half of the participants were professional nurses (60%) and had been providing care for less than 10 years (55.1%). The majority of the nurses (78.3%) were working less than 7 h in outpatient care per week. Nurses were initially asked if they were aware of HPV. Those who were not aware of HPV were not included for further analysis. About three-quarters (73.3%, n ⫽ 252) of the nurses were aware of HPV. Table II shows the nurses’ answers regarding HPV infections and the HPV vaccine. Over a third (38.3%) of the nurses knew that HPV is the most common sexually transmitted virus. The majority correctly indicated that ⬎ 80% of the population harbours HPV (84%) and persistent HPV infection is a necessary cause of cervical cancer (92.1%). None of the nurses knew that a regular Pap test with a frequency of ⱕ 3 years reduces the risk of cervical cancer between 71% and 90%. Only one nurse knew that more than 80% of cervical cancer is caused by HPV-16 and -18. All the nurses knew that there is a vaccine for HPV but only 42.7% could name both the vaccines. Regarding effectiveness of the vaccines, about a third (30.0%) mentioned that vaccines were very effective. Overall, nurses had poor knowledge regarding HPV and HPV vaccination. Table III summarises the nurses’ attitudes concerning HPV immunisation, perceived support, expected benefits and intention to recommend vaccination. Almost all the nurses disagreed that the vaccines should be given to girls before the onset of sexual activity and less than half (44.3%) reported that the best age for a universal immunisation programme would be 14 years of age. A significant difference was observed regarding the best age for a universal immunisation programme among the nurse cadres (p ⫽ 0.016).
Table I. Provider and practice characteristics of the participants. Variables Age (years) ⬍ 30 30–39 40–49 ⱖ 50 Age (years) (means ⫾ SD) Gender Female Male Profession Professional nurse Enrolled nurse Assistant nurse Years providing care ⬍ 10 10–19 20–29 ⱖ 30 Time spent in outpatient care per week (h) (n ⫽ 253) ⬍7 7–21 ⬎ 21
55 164 83 43 37.2 ⫾ 9.4
15.9 47.5 24.1 12.5
207 104 34
60.0 30.1 9.9
190 98 47 10
55.1 28.4 13.6 2.9
198 49 6
78.3 19.4 2.4
M. E. Hoque et al.
Table II. Nurse’s knowledge on HPV infection and HPV vaccination (%).
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Statement HPV is the most common sexually transmitted infection ⬎ 80% of the population is infected with HPV at some point in their life Persistent HPV infection is a necessary cause of cervical cancer Conventional screening Pap tests have a sensitivity of ⬎ 75% In south Africa, less than 20% women have had a Pap smear test There are 13–17 HPV types HPV-6 and -11 are responsible for ⬎ 90% of anogenital warts Anogenital warts induced by HPV-6 and -11 are cervical cancer precursors A regular Pap test with a frequency of ⱕ 3 years reduces the lifetime risk of cervical cancer by 71–90% The proportion of cervical cancer related to HPV-16 and -18 types is: 61–80% Is there any vaccine for HPV? (Yes) Which one/s is/are the vaccine/s? Gardasil® Cervarix® Gardasil® and Cervarix® None of them How eﬀective are the vaccines? Very eﬀective Somewhat eﬀective Not sure Aggregate mean score (SD)
Almost all (⬎ 95%) of the nurses indicated that obstetricians/ gynaecologists will recommend HPV vaccination; parents will accept HPV vaccination for their children; adolescents and young adults will accept HPV vaccination; and parents will prefer HPV vaccination to be given at school. More than 90% of the nurses reported that a vaccination programme will reduce the frequency of screening in vaccinated women, and it will also reduce the number of post-screening follow-up interventions. Overall, the majority (90.9%) of the nurses intended recommending the vaccine to their patients. Factors that contribute in recommending HPV vaccination are shown in Table IV. Nurses who mentioned that adolescents and young adults will accept HPV vaccination were more likely to recommend HPV vaccine to their patients (OR ⫽ 57.78, p ⫽ 0.031).
Discussion To the authors’ knowledge, this is the first study in South Africa investigating nurses’ knowledge, opinions and recommending
36.3 84.2 91.2 1.2 90.1 21.1 85.4 0.6 0.0
38.3 85.0 93.3 0.0 83.3 18.3 88.3 0.0 0.0
54.5 81.8 95.5 0.0 86.4 31.8 86.4 0.0 0.0
39.8 19.3 40.4 0.6
43.3 8.3 48.3 0.0
36.4 18.2 45.5 0.0
33.3 64.3 2.3 5.35
21.7 70.0 8.3 5.19
27.3 54.5 18.2 5.68
HPV vaccination. This study found that a majority of the nurses correctly indicated persistent HPV infection is a cause of cervical cancer (92.1%). A similar finding was reported from a study among nurses in Cameroon, where 90.8% of the nurses acknowledged that cervical cancer is directly linked to HPV infection (Wamai et al. 2013). A Nigerian study conducted among nurses working in a tertiary institution found that 70.1% knew about the association between HPV infection and cervical cancer (Makwe and Anorlu 2011). Other studies conducted among nurses from Thailand, Greece and New Zealand reported that percentages of nurses knowing about this association were 78.5%, 71% and 81.8%, respectively (Nganwai et al. 2008; Dinas et al. 2009; Henninger 2009). Consistent with other studies, this study indicates low levels of knowledge about HPV infection, and HPV vaccination among nurses (Ali et al. 2010; Urasa and Darj 2011). All the nurses in this study knew that sexual intercourse is the mode of HPV transmission. A Tanzanian study found that two-thirds of the
Table III. Nurses’ attitudes concerning HPV immunisation, perceived support, expected beneﬁts, and intention to recommend vaccination. Statements HPV vaccine should be given To girls before the beginning of sexually active lifestyles The best age for an eventual universal immunisation program would be: ⬍ 14 years In your opinion most Physicians will recommend HPV vaccination to their patients Parents will accept HPV vaccination for their children ⬍ 14 years of age Parents will prefer HPV vaccination to be given at school Adolescents and young adults will accept HPV vaccination Adolescents and young adults will seek HPV vaccination Your patients will comply with the counsel regarding Safe sexual behaviour Regular screening for cervical cancer HPV vaccination A vaccination program would eventually permit The beginning of screening later in life The reduction of the frequency of screening interventions in vaccinated females The reduction of the number of post-screenings The abolishment of screening
99.4 96.5 99.4 98.9 94.2
100.0 100.0 100.0 100.0 96.6
100.0 100.0 100.0 100.0 100.0
62.0 72.5 95.9
36.7 58.4 91.7
0.0 18.2 77.3
98.7 96.5 88.9 85.9
100.0 98.3 93.3 91.7
100.0 100.0 100.0 100.0
HPV vaccination in South Africa 185 Table IV. Backward stepwise (likelihood ratio) logistic regression output for recommending HPV vaccine. Variables∗ Adolescents and young adults will accept HPV vaccination Suﬃcient Information received about HPV vaccination ⱖ 7 h spent in outpatient care per week
95% CI for OR
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∗Variable(s) entered on step 1:age, profession, years of service provided, The reduction of the number of post-screening follow-up interventions, Obstetricians-gynecologists will recommend HPV vaccination, Parents will accept HPV vaccination for their children, Adolescents and young adults will accept HPV vaccination, will recommend HPV vaccination if it reduces the number of abnormal Pap results by at least 50%, Patients will comply if I counsel them about HPV vaccination, Information received about HPV vaccination is suﬃcient, and Hours spent in outpatient care per week, ⱖ 7 h.
nurses identified sexual intercourse as a mode of transmission of HPV (Urasa and Darj 2011). Studies among nurses conducted in Uganda, Pakistan and Tanzania, found a similar low level of knowledge regarding the symptoms associated with HPV infections, and the mode of transmission of HPV (Katahoire et al. 2008; Ali et al. 2010; Urasa and Darj 2011). Other studies also found that knowledge about HPV among healthcare providers was highly associated with recommending the vaccine to families (Duval et al. 2009; Hopkins et al. 2009). The general knowledge of the HPV vaccines such as more than 80% of cervical cancer is caused by HPV-16 and -18, name of the vaccines and effectiveness of vaccines were low among the nurses in this study. This might be due to the lack of HPV and cervical cancer education programmes in South Africa. Also, the nursing staff who participated in the study had not undergone any training on cervical cancer, HPV or HPV vaccination. The vaccines have not yet been launched in South Africa. The majority of nurses did not want the vaccines to be given to girls before the onset of sexual activity. Similar findings were also reported from a study conducted among nurses in Nigeria (Makwe and Anorlu 2011). A study conducted among physicians reported that only 39% mentioned not vaccinating girls before their first sexual intercourse (Chow et al. 2010). A possible reason for this could be that our study nurses did not have enough knowledge regarding the efficacy and safety of the vaccines. An Indian study highlights that vaccine implementation is negatively affected because of healthcare workers’ doubt and suspicions about vaccine safety (Larson et al. 2010). Other studies found that this is a barrier to effective immunisation (Black et al. 2009; Reiter et al. 2009). The opinions about the universal immunisation age for HPV vaccination varies among healthcare workers. Our study reported that less than half of the nurses mentioned an age less than 14 years. Studies conducted among doctors in the USA and UK reported that as the vaccinating age increases, doctors’ willingness to vaccinate also increases (Daley et al. 2010; Hopkins et al. 2009; Lutringer-Magnin et al. 2011). This is a cause for concern, as this suggests that nurses do not appreciate the benefits of early vaccination before HPV exposure. This will have a negative effect on future national campaigns of HPV vaccination. The effectiveness of vaccination programmes largely depends on how healthcare workers accept the vaccine. Recommendation from healthcare providers is the most significant predictor for a girl or parent to accept the vaccination (Dempsey et al. 2010; Rosenthal et al. 2011; Trim et al. 2012). This present study showed a high level of intention to recommend HPV vaccination among nurses to their patients, even though they had poor knowledge
regarding the HPV vaccination. Studies conducted among nurses in Nigeria and Cameroon reported similar findings (Ugwu et al. 2013; Wamai et al. 2013). Nurses in Rwanda played a significant role in successful implementation of an HPV vaccination programme (Binagwaho et al. 2012). This study had some limitations. First, it was a cross-sectional study which only considered one institution, thus generalisation of results is not possible. Also, the self-reported data are subject to bias but anonymity might have reduced this bias. Nevertheless, this study has shown nurses’ knowledge and opinions regarding HPV infections and HPV vaccination. These study findings should hopefully motivate further studies. Also, these findings will be helpful for programme and policy development on HPV immunisation and prevention of cervical cancer in South Africa.
Conclusion Overall knowledge regarding HPV infection and vaccines among nurses working in a tertiary hospital is South Africa was poor. But the nurses were willing to recommend the vaccines to their patients. This highlights the need to further integrate nurses into the discussion and training surrounding HPV infection and HPV vaccination, as a part of the planning process for HPV vaccination programmes in the future.
Acknowledgements The authors wish to thank all the nurses who participated in the study. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
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