Nurse Education Today 35 (2015) 562–567
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The effects of an HPV education program by gender among Korean university students Hae Won Kim a, Seungmi Park b,⁎, Hye Young Ahn c, Eun-Jun Park d a
The Research Institute of Nursing Science, College of Nursing, Seoul National University, Seoul, Republic of Korea Department of Nursing, Hoseo University, Asan-Si, Chungcheongnam-Do, Republic of Korea College of Nursing, Eulji University, Daejeon, Republic of Korea d Department of Nursing, Konkuk University, Chungju-si, Chungcheongbuk-do, Republic of Korea b c
a r t i c l e
i n f o
Article history: Accepted 16 December 2014 Keywords: Health education Sex education Sexual behavior Students Motivation Intention
s u m m a r y Purpose: This study compared the effects of an HPV education program by gender among Korean university students in terms of their knowledge of HPV, intention to prevent HPV, awareness of sexual rights, and perception of gender equality. Methods: A quasi-experimental pre–post design was employed. 31 male and 28 female university students participated in eight sessions of an HPV prevention program for four weeks and in a self-administrative survey. Results: At pre-test, the perception of gender equality and some of the intentions to prevent HPV, including the intention to make regular use of condoms, reduce the number of sexual partners, abstain from sex until marriage, and stop smoking or stay non-smoker, were lower among men than women. When these differences by gender at pre-test were taken into account using ANCOVA, education outcome measures at post-test did not differ by gender. After completing the HPV prevention program, both male and female students presented a significant increase in terms of HPV knowledge, awareness of sexual rights, and perception of gender equality. Among the intentions to prevent HPV, only male intention to recommend the Pap test to their partner and female intention to regularly seek the Pap test and pelvic examinations were significantly increased after the program. Conclusion: The HPV program was effective for both genders eliminating gender differences in attitudes and prevention intentions of HPV. However, the intentions to prevent HPV did not increase significantly, and future research is warranted to better understand students' perceived obstacles for practicing HPV prevention methods. © 2014 Elsevier Ltd. All rights reserved.
Introduction HPV-associated cancers, including cervical cancer, anal cancer, and oropharyngeal cancer, can be effectively prevented by avoiding HPV infection, which again can be avoided by practicing already known HPV prevention. As seen in the United States, the incidence of HPV-associated cervical cancer has decreased, but the incidence of the anal cancer or oropharyngeal cancer caused by HPV has increased and is likely to become higher than that of cervical cancers (Chaturvedi et al., 2011; Gillison et al., 2008), high-lighting the importance of continuous HPV prevention. In South Korea, HPV prevention is often left to individual women who want to avoid HPV-associated cervical cancer or to the pharmaceutical marketing of HPV vaccines. Although the vaccination is recommended for both females aged 9–26 and males aged 9–15 by the Korean Society of Obstetrics and Gynecology and Colposcopy (Kim et al., 2007), HPV vaccine has not been introduced ⁎ Corresponding author at: Department of Nursing, Hoseo University, 336-795, 20, Hoseo-ro, 79beon-gil, Baebang-Eup, Asan-Si, Chungcheongnam-Do, Republic of Korea. Tel.: +82 41 540 9533; fax: +82 41 540 9558. E-mail address: [email protected] (S. Park).
http://dx.doi.org/10.1016/j.nedt.2014.12.014 0260-6917/© 2014 Elsevier Ltd. All rights reserved.
to the school mandatory vaccination program yet. The HPV vaccination rate is less than 10% of Korean women (Kang and Moneyham, 2010) and unknown for Korean men. The high cost of the vaccination (about US $400), which is not covered by national health insurance, may have some relevance in explaining the low HPV vaccination rate. Nevertheless, one of the primary reasons for inadequate prevention measures is low awareness and attitudes regarding HPV (Oh et al., 2010) and greater education is needed. Although school health education is recommended from primary school to high school by the School Health Law of South Korea (http://www.law.go.kr/main.html), HPV relevant information is rarely included in school health education (Yun et al., 2005). Accordingly, Korean university students often have insufficient information or misconceptions about HPV infection and methods of prevention (Kim and Park, 2009; Oh et al., 2010). In light of the limited opportunity to learn about HPV among university students, a comprehensive education program is needed in Korea. In Korea, the overall seroprevalence of HPV was not significantly different between male and female university students (Clifford et al., 2007). Nyitray et al. (2011) found that the prevalence of anal HPV infection ranges from 12.2% to 47.2% with no age-group predilection. In previous studies, men consistently presented less knowledge than
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women about HPV although both genders are equally responsible for its transmission (Klug et al., 2008). However, research on male HPV prevention is hardly found in South Korea except for a few (Oh et al., 2010; Park and Park, 2012). There is even a misconception that HPV vaccination and prevention are necessary only for women because of the link with cervical cancer or that men are not at risk from HPV-associated cancers. To effectively prevent HPV transmission it is essential for men to have a clear understanding of the HPV infection and to participate in prevention such as condom use, limiting the number of sexual partners, or getting HPV vaccination (Giuliano et al., 2011). Issues of sexual rights and gender equality are often recommended in sex education to promote individual responsibility in interpersonal relationships (Ahn et al., 2008; Kim et al., 2010; Levesque, 2000). An egalitarian perspective in sexuality and sexual health is included in school health education in primary schools in South Korea (Han and Seo, 2014). However, men are less likely to think about or take preventive action with regard to STDs than women even though they have had the same education (Ahn et al., 2008; Kim et al., 2010; Levesque, 2000). Sexual health cannot be achieved or maintained without sexual rights for all humans (World Association for Sexual Health, 2008). In addition, gender equality, rights of men and women to nondiscrimination, influences sexual attitudes and practices of both genders and thus it should be dealt with in sex education (Rogow and Haberland, 2005). In fact, men who accept gender equality were more likely to have desirable attitudes toward sexual behavior and contraceptive use (Lee, 2005; Pulerwitz and Barker, 2008). Although understanding of sexual rights and gender equality is considered crucial components of STD prevention education (Kim et al., 2010), few HPV prevention programs are found to include those issues so far. HPV can be prevented through a comprehensive approach to sexual health (Pollack et al., 2007) and inclusion of the issues of sexual rights and gender equality is expected to promote university students' respect for not only their own sexual health but also that of their partners in terms of HPV prevention. To develop and evaluate HPV prevention education, the information– motivation–behavioral skill (IMB) model was adopted as a theoretical framework. Information and motivation, as independent factors, are influencing behavior change like HPV prevention behaviors directly or indirectly through behavioral skills (Robertson et al., 2006). When the IMB model is applied to the HPV education program in this study, the information component includes knowledge on HPV facts, prevention methods, sexual rights, and gender equality. Motivation to stop HPV-risky behaviors and adopt prevention methods was stimulated through small-group discussions in the program and measured through behavioral intention for HPV prevention as a proxy for real behavior. Behavioral skills in performing specific HPV prevention behavior, such as sexually assertive communication skills and condom use, were taught in the program but not measured in this study. The purpose of this study was to evaluate effects of HPV prevention education by gender, considering a previously known gender difference in HPV knowledge and general attitudes for sexual health. The following two hypotheses were proposed: 1) the HPV prevention education enhances both male and female university students' knowledge of
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HPV, awareness of sexual rights, perception of gender equality, and intention to prevent HPV infection, and 2) the education reduces gender differences in terms of knowledge of HPV, awareness of sexual rights, perception of gender equality, and intention to prevent HPV infection. Methods Design and Participants The research protocol was approved by the Institutional Review Board. A pre–post test quasi-experimental design was employed. Using a convenience sampling method, university students were recruited through website and offline advertisements at the university from September 27 to October 8, 2010. Students were excluded if they 1) had been married with regular sexual activity, 2) majored health care fields such as nursing, medicine, or public health, and 3) were part of or completed an HPV vaccination program because they may be better informed about HPV and have more positive prevention attitudes than the other students (Kim and Park, 2009). To compare mean differences by gender, the number of subjects in each gender was estimated 26 for a statistical power of 0.80, significance of 0.05, and a large effect size of 0.79 based on a previous study (Kim, 2009) using G*Power 3.12. Assuming 20% withdrawal of subjects, a total of 59 students, 31 men and 28 women, participated in the study. Among the study applicants, 2 male students were not able to participate in the study because of their academic schedule, and 2 female students dropped out. Each participant was assured that their data would remain confidential and anonymous and signed an informed consent before the education. HPV Education Program The education program was based on the premise that HPV infection is common regardless of gender and that both men and women require equal perspective and responsibility for HPV prevention. The content was developed based on a previous HPV education program (Kim, 2009): a) the first four lectures about general HPV information, gender-specific HPV infection, genital warts, common approaches for HPV prevention, and sexual autonomy and sexual rights, and b) the following four small-group discussions about sexism and prejudice regarding sexuality, experiences and feeling of gender inequality, sexually assertive communication skills and condom use, and breaking prejudice about sexuality, STDs, and HPV (Table 1). Social factors like awareness of sexual rights and perception of gender equality are highly likely to influence interpersonal relations or negotiation in sexual behavior between men and women (De Meyer et al., 2014). Accordingly, the HPV program was designed to educate about gender equality and sexual rights in addition to HPV knowledge, expecting to improve gender-biased attitudes and strengthen HPV prevention intention for both males and females. The content and methodology of the education were validated by experts of women's health nursing, public health nursing, gynecology,
Table 1 Education contents of the HPV prevention program. Session
Contents
Instructional method
1 2
General HPV information: prevalence, pathology, types, and vaccines Gender-specific HPV infection: cervical, genital, and other types of cancers in males and females Genital warts as a common STDs among both males and females Common approaches for HPV prevention for both males and females: abstinence, regular condom use, fewer sexual partners, the cessation of smoking, HPV vaccination, and routine Pap smears Sexual autonomy and sexual rights for both males and females Sexism and prejudice regarding sexuality in Korean society Exploration of experiences and feelings of gender inequality in sexual health and interpersonal relationships Sexually assertive communication skills and condom use Breaking prejudices about sexuality, STDs, and HPV
Lecture with a handout Lecture with a handout
3 4 5 6 7 8
STDs = sexually transmitted diseases; HPV = human papilloma virus.
Lecture with a handout Lecture with a handout Small-group discussion Small-group discussion Small-group discussion and practice Small-group discussion
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and teaching engineering. The education consisting of eight 50-min sessions was delivered in a multimedia classroom for four weeks by the first author and two assistants. In a small-group discussion, 9 ~ 10 students per group with a similar number of males and females participated and a team leader was selected. A small-group discussion was adopted to allow the students to speak their mind and communicate actively with one another about topics including sexual rights and gender equality. The discussion was guided so that the students could exchange their different perspectives and experiences regarding the education contents among men and women with respect to the opposite gender. Two meetings were held for a week prior to the education to take a pre-test and to increase the participants' emotional closeness while they introduced themselves and were oriented about the program. After completing the eight sessions, the post-test was conducted.
Data Collection and Measures Both a pre-test and a post-test were conducted using a selfadministered questionnaire in October and November 2010, respectively, assessing HPV knowledge, awareness of sexual rights, perception of gender equality, and intention to prevent HPV infection. The content of the structured questionnaire was validated by three HPV experts, and its applicability was verified by a pilot test with 10 female nursing students and 10 male engineering students. The participants' sociodemographic characteristics were asked in a pretest, which included age, grade, major, living conditions, sexual experience, the number of sexual partners, a history of STD examinations, previous condom use, smoking experience, alcohol consumption, and having heard of HPV and genital warts. Smoking and alcohol use were assessed because the regular use of cigarettes or alcohol is likely to increase the prevalence of HPV infection (National Cancer Institute, 2012; Shin et al., 2003). At both the pretest and posttest, knowledge of HPV, awareness of sexual rights, perception of gender equality, and intention to prevent HPV infection were measured as short-term education outcomes. Characteristics of these measures are summarized in Table 2 with the relevant references, the number of items, scales, and a reliability index. The HPV knowledge questionnaire was modified by eliminating three items after examining a reliability index in the pilot study, and the final five items were validated by two HPV experts: a) HPV can be asymptomatic, b) HPV can disappear without treatment, c) the HPV vaccine prevents HPV infection, d) condoms prevent HPV, and e) HPV can affect men. Perception of gender equality was measured with five items: a) control of sexuality is more difficult for males than for females, b) sex education is needed more by female students than by male students, c) an obscene portrayal of women's bodies in commercial advertising is not sexual discrimination but just marketing, d) sex outside of marriage is more morally serious for women than for men,
and e) sexual harassment is caused by body over-exposure. The answers to these items were reversely coded for scoring so that always the higher score refers to better outcomes in this study. Intention to prevent HPV infection was measured with six items: a) intention to make regular use of condoms, b) intention to reduce the number of sexual partners, c) intention to abstain from sex until marriage, d) intention to be vaccinated for HPV, e) intention to regularly undergo the Pap test or pelvic examinations even before marriage (females only) or to recommend seeking the Pap test or pelvic examinations regularly to sexual partners (males only), and f) intention to stop smoking or to stay a non-smoker.
Data Analysis SPSS Statistics version 20.0 was used. The homogeneity of sociodemographic factors and having heard of HPV was compared by gender using t-test, χ2, and Fisher's exact test. Gender comparison in the outcome variables, that is, HPV knowledge, awareness of sexual rights, perception of gender equality, and intention to prevent HPV, were analyzed using the Mann–Whitney U test in the pretest. In the posttest, the outcome measures were compared by gender using Wilcoxon signed-rank test after adjusting any gender differences found in the pretest with the ANCOVA.
Results Sociodemographic factors and having heard about HPV were not significantly different by gender except more males having sexual experience (χ2 = 7.55, p = .023) and smoking (χ2 = 18.82, p b .001) than females (Table 3). The average ages of male and female students were 20.57 ± 1.98 years and 19.70 ± 1.20 years, respectively. A majority of them were freshmen or sophomore, living in a university dormitory. A small number of the students had heard of HPV (7% of males, 14% of females) or genital warts (13% of males, 11% of females). At the pretest, the students' HPV knowledge was very low with a mean score of 0.80 ± 1.19 out of 5 for males and 1.46 ± 1.64 for females without a significant difference (Table 4). The awareness scores of sexual rights (score 17–68) were 53.67 ± 7.38 for males and 55.82 ± 6.67 for females without a significant difference. Gender differences were found from consistently low scores of males in terms of perception of gender equality (Z = − 2.40, p = .016) and four intentions of HPV prevention methods such as making regular use of condoms (Z = − 2.13, p = .033), reducing the number of sexual partners (Z = − 3.61, p b .001), practicing abstinence from sex until marriage (Z = − 3.55, p b .001), and stopping smoking or staying a non-smoker (Z = − 2.20, p = .028). An intention to get HPV vaccination was 3.52 ± 1.00 for males and 3.71 ± 0.90 for females, which was not high enough without a significant gender
Table 2 Measures and variables used to evaluate the HPV prevention education. Measures
Reference of original scales
Number of items
Scale
Cronbach's α
HPV knowledge
HPV knowledge scale Kim (2011) Kim et al. (2010)
5 out of original 8 items
1 (right) or 0 (wrong)
.82
17 items under 5 domains: sex education, free from prejudices and biases, sexual satisfaction, safe and equal sexuality, and sexual autonomy 5 items of sexuality subscale
1 (not at all important) to 4 (very important) Likert-type
.84
1 (very much agree) to 5 (never agree) Likert-type
.62
1 (not at all) to 5 (very much) Likert-type
.80
Awareness of sexual rights
Perception of gender equality Intention to prevent HPV infection
Korean gender egalitarianism scale Korean Women's Development Institute (1999) Kim (2009, 2012) Centers for Disease Prevention and Control for HPV prevention (CDCP, 2011)
6 items
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Table 3 Homogeneity of general sociodemographics between male and female students (N = 59). Characteristics
Categories
Male (n = 31)
1 2 3 4 With parents Alone, sublets Dormitory None Irregular Regular
20.57 ± 1.98 18 (58.1) 10 (32.2) 2 (6.5) 1 (3.2) 2 (6.5) 11 (35.5) 18 (58.1) 15 (50.0) 9 (30.0) 6 (20.0) 5.38 ± 7.71
19.70 ± 1.20 14 (50.0) 5 (17.9) 5 (17.9) 4 (14.3) 1 (4.6) 9 (32.1) 18 (64.3) 21 (80.8) 1 (3.8) 4 (15.4) 1.33 ± 0.51
27 (96.4) 1 (3.6) 15 (53.6) 7 (25.0) 6 (21.4) 12 (38.7) 19 (61.3) 1 (3.2) 14 (45.2) 8 (25.8) 8 (25.8) 29 (93.5) 2 (6.5) 27 (87.1) 4 (12.9)
24 (100.0) 0 (0.0) 18 (81.8) 2 (9.1) 2 (9.1) 26 (92.9) 2 (7.1) 6 (21.4) 12 (42.9) 5 (17.9) 5 (17.9) 23 (82.1) 5 (14.3) 25 (89.3) 3 (10.7)
χ2 or t (p)
Female (n = 28)
n (%) or M ± SD Age (years) Grade
Living condition
Sexual experience (n = 56)
Numbers of sexual partners (n: men = 13, women = 6) STDs examination (n = 52)
No Yes Never Rarely Often No Yes Never 1–2/month 1/week 2–3/week No Yes No Yes
Condom use (n = 50)
Smoking experience Frequency of alcohol consumption
Heard of HPV… Heard of genital warts…
3.86 (.055) 5.11 (.164)
0.38 (.826)
7.55 (.023)
1.85 (.191) (1.00)a 4.39 (.111)
18.82 (b.001) 4.97 (.174)
(.240)a (1.00)a
STDs = sexually transmitted diseases; HPV = human papilloma virus. a Fisher's exact test.
difference. An intention to undergo or recommend the Pap test was 3.87 ± 0.92 for males and 4.14 ± 0.71 for females. By completing the HPV education, male students showed a significant increase in their HPV knowledge (Z = −3.80, p b .001), awareness of sexual rights (Z = − 2.78, p = .005), perception of gender equality (Z = − 2.53, p = .012), and an intention to recommend the Pap test to the partner (Z = − 2.49, p = 0.013, Table 4). Female students presented very similar findings with a significant increase in HPV knowledge (Z = − 3.16, p = 0.002), awareness of sexual rights (Z = − 2.83, p = 0.005), perception of gender equality (Z = − 2.13, p = 0.033), and an intention to undergo the Pap test and pelvic examinations regularly (Z = −2.36, p = 0.018). Therefore, the HPV education was found to be effective for both male and female university students. However, the education outcomes were not achieved at satisfying high level; for example, the HPV knowledge
score was lower than 3 out of 5 points, and perception of gender equality was lower than 18 out of 25 points. To compare the effects of the HPV education by gender at the posttest, the gender differences in perception of gender equality and some intentions of HPV prevention methods found at the pretest were taken into account using ANCOVA. As a result, there were no significant gender differences in HPV knowledge, awareness of sexual rights, perception of gender equality, and intentions to prevent HPV (Table 4), which demonstrates that comprehensive HPV education can eliminate gender differences in attitudes and prevention intentions of HPV. Discussion This study evaluated short-term effects of a four-week HPV education program in which both genders participated and attitudes toward sexual
Table 4 Knowledge and attitudes for HPV prevention by gender. Characteristics (min–max)
Pre-test Male
Post-test Female
Z (p)
M ± SD
Male
Pre–post difference Female
Z (p)
M ± SD
Male
Female
Z (p)
HPV knowledge (0–5) Awareness of sexual rights (17–68) Perception of gender equality (5–25)
0.80 ± 1.19 53.67 ± 7.38 13.76 ± 3.27
1.46 ± 1.64 55.82 ± 6.67 15.93 ± 3.22
−1.30 (.194) 1.35 (.250) −2.40 (.016)
2.68 ± 1.25 58.57 ± 6.25 14.93 ± 3.48
2.84 ± 1.03 60.50 ± 6.25 17.62 ± 3.66
−0.55 (.580) −1.17 (.241) 1.19 (.281)a
−3.80 (b.001) −2.78 (.005) −2.53 (.012)
−3.16 (.002) −2.83 (.005) −2.13 (.033)
Intention to prevent HPV (1–5) Make a regular use of condoms Reduce the number of sexual partners Practice abstinence from sex until marriage Get HPV vaccination Stop smoking or remain a non-smoker Regularly undergo the Pap test and pelvic exams Recommend the Pap test to the partner
4.00 ± 1.10 3.45 ± 1.36 2.52 ± 1.29 3.52 ± 1.00 4.20 ± 1.24 NA 3.87 ± 0.92
4.54 ± 0.79 4.64 ± 0.62 3.71 ± 0.90 3.71 ± 0.90 4.75 ± 0.75 4.14 ± 0.71 NA
−2.13 (.033) −3.61 (b.001) −3.55 (b.001) −0.78 (.438) −2.20 (0.28) – –
3.90 ± 1.12 4.00 ± 1.17 2.72 ± 1.31 3.69 ± 0.81 4.07 ± 1.19 NA 4.36 ± 0.49
4.42 ± 0.86 4.54 ± 0.81 4.00 ± 1.26 4.04 ± 0.72 4.54 ± 0.86 4.58 ± 0.50 NA
1.27 (.266)a 0.95 (.334)a 1.84 (.180)a −1.75 (.081) 0.61 (.440)a – –
−0.48 (.632) −1.86 (.063) −1.37 (.170) −0.69 (.488) −0.79 (.431) – −2.49 (0.013)
−0.58 (.564) −0.54 (.589) −1.19 (.235) −1.62 (.104) −0.84 (.399) −2.36 (.018) –
NA = not applicable; HPV = human papilloma virus. a Being adjusted for pretest differences using ANCOVA.
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rights and gender equality in addition to HPV-related content were dealt with. The education improved HPV knowledge, awareness of sexual rights, perception of gender equality for both genders but room for improvement remained, partially supporting hypothesis 1. Unfortunately many prevention intentions, except Pap smear testing, were not significantly improved in spite of completing the education in both genders. Significantly lower levels of gender equality perception and of most prevention intentions were found among men at the beginning, but these gender differences disappeared after taking the HPV education, supporting hypothesis 2. This study suggests that men should participate in efforts to prevent HPV infection considering their low perception of gender equality and low motivation for HPV prevention. Men showed consistently lower knowledge of HPV than females in previous studies (Kim, 2011; Klug et al., 2008; Oh et al., 2010). Though, often only women were targeted in HPV prevention programs because of the well-known fact that almost all cervical cancers are caused by HPV infection (Schiffman et al., 2007), in spite of that the inclusion of men in HPV programs was beneficial for both men and women. As seen in this study, male students who had taken part in the education program showed a strong intention to recommend the Pap test to their partner, which increases the likelihood of men playing an active role in preventing HPV infection and HPV-associated cancers. Unlike HPV education programs in general, the education content in this study taught awareness of sexual rights and perception of gender equality in HPV prevention. South Korea ranks 15th in the Human Development Index but 85th in the Gender Development Index, reflecting disparity in human development achievements between women and men in health, education and living standards, among the world nations (The United Nations Development Programme, 2014). This gender disparity issue in Korea was again found in a lower perception of gender equality of males in this study. Awareness of sexual rights and the gender equality perception scores were improved after the education but were not high enough. A small-group discussion in this study seems to contribute to reducing gender differences found at the pretest regarding knowledge and attitudes toward HPV and sexual health. Considering room for improvement in this study, further research is warranted to develop more effective approaches in sex education for promoting desirable attitudes of sexual rights and gender equality. Also, evidence is needed about how those attitudes influence actual HPV prevention behavior. The intention to regularly use a condom for HPV prevention did not change after the education in either gender. Previous cohort studies verified that consistent condom use by male partners reduced the rate of HPV infection in female university students (Richardson et al., 2005; Vaccarella et al., 2006). Therefore, the effects and importance of regular condom use for HPV prevention need to be more emphasized considering the students' limited HPV prevention behavior. Noteworthy is that no favorable changes were observed in prevention intentions related to sexual behavior like abstinence from sex. People who are sexually active or change their partner are more likely to be infected with HPV than their sexually inactive or monogamous counterparts (Cha et al., 2007). With other demographic factors adjusted for, a definite relationship between husbands' extramarital sexual relationships and their wife's HPV infection is known (Oh et al., 2008). Although HPV prevention methods like limiting the number of sexual partners or practicing abstinence from sex in this study are effective, it is difficult to imagine that the adult university students will easily change their sexual attitudes and behavior. Proactive discussions on premarital sex may be in need for both male and female university students. HPV vaccination is recommend for both men and women as one of the most effective and conclusive HPV prevention methods (Center for Disease Control and Prevention, 2013). Giuliano et al. (2011) found men to have a consistent risk of HPV infection over their lives and thus suggested that it would be cost-effective to implement HPV vaccination for men. Unfortunately, the intention score to obtain HPV vaccination
was slightly higher but without a significant change in spite of the education. According to Oh et al.'s (2010) study, the most commonly cited barrier for having an HPV vaccination was high cost, followed by uncertain effectiveness and 3 dosages. A discussion of HPV vaccination costs needs to be initiated to learn whether the cost should be paid or supplemented by national health insurance or school health funds for adolescent and young adults. In conclusion, most intentions for HPV prevention did not improve after taking the education among both males and females. Sexual behavior or relevant intentions are unlikely to easily change with a short-term education. This study has limitations. Because of a convenient sampling method, the scores of education outcome measures including HPV knowledge and prevention intentions cannot be generalized to other populations and settings than Korean university students. Further research can replicate the study with other groups, for example, non-university young people. In addition, socially desirable responses were possible especially regarding sexual behavior, considering sexually conservative Korean culture, especially for unmarried young adults. It may be desirable that an education instructor and a researcher for data collection are not one and the same person to avoid socially desirable responses. Finally, this study measured only knowledge and motivation components and did not measure actual sexual behavior and practices regarding HPV prevention. This requires future research. Also, qualitative research is suggested to better understand sexual behavior of young adults and to facilitate a more effective behavior change. Conclusion The HPV education was effective in improving HPV knowledge, awareness of sexual rights, and perception of gender equality but had a small effect on intention to adopt HIV prevention methods among university students in Korea. Male students' low perception of gender equality and HPV prevention intention were mitigated through education. More research is needed to better understand students' perceived obstacles for practicing HPV prevention methods using qualitative data from interviews with Korean university students. In the future, HPV prevention education is recommended to include men as well as women but strategies to improve HPV prevention intention need to be employed. In addition to prevention intentions, knowledge and attitude need to be improved; four weeks in this study appear to be insufficient. In the future education periods need to be longer or an innovative teaching method needs to be tried. Acknowledgment This research was supported by Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Science, ICT 7 Future Planning (2012-R1-A1A3015525). References Ahn, S., Park, I., Han, J.S., Kim, T.I., Kwak, M.S., Chung, H.S., 2008. Health behaviors, reproductive health history, and sexual behaviors of college students. Korean J. Woman Health Nurs. 14 (3), 205–212. Center for Disease Control and Prevention, 2011. Human Papillomavirus Prevention. Retrieved May 10, 2012, from http://www.cdc.gov/hpv/Prevention.html. Center for Disease Control and Prevention, 2013. Human Papillomavirus (HPV): HPV Vaccines. Center for Disease Control and Prevention. Cha, E.S., Doswell, W.M., Kim, K.H., Charron-Prochownik, D., Patrick, T.E., 2007. Evaluating the Theory of Planned Behavior to explain intention to engage in premarital sex amongst Korean college students: a questionnaire survey. Int. J. Nurs. Stud. 44 (7), 1147–1157. Chaturvedi, A.K., Engels, E.A., Pfeiffer, R.M., Hernandez, B.Y., Xiao, W., Kim, E., Jiang, B., Goodman, M.T., Sibug-Saber, M., Cozen, W., Liu, L., Lynch, C.F., Wentzensen, N., Jordan, R.C., Altekruse, S., Anderson, W.F., Rosenberg, P.S., Gillison, M.L., 2011. Human papillomavirus and rising oropharyngeal cancer incidence in the United States. J. Clin. Oncol. 29 (32), 4294–4301.
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Oh, J.K., Ju, Y.H., Franceschi, S., Quint, W., Shin, H.R., 2008. Acquisition of new infection and clearance of type-specific human papillomavirus infections in female students in Busan, South Korea: a follow-up study. BMC Infect. Dis. 8 (13), 1–6. Oh, J.K., Lim, M.K., Yun, E.H., Lee, E.H., Shin, H.R., 2010. Awareness of and attitude towards human papillomavirus infection and vaccination for cervical cancer prevention among adult males and females in Korea: a nationwide interview survey. Vaccine 28, 1854–1860. Park, S., Park, H., 2012. Knowledge regarding cervical cancer, human papillomavirus and acceptance of vaccination in Korean adult men. J. Korean Acad. Fundam. Nurs. 19 (2), 201–211. Pollack, A.E., Balkin, M., Edouard, L., Cutts, F., Broutet, N., 2007. The WHO/UNFPA working group on sexual and reproductive health and HPV vaccines. Ensuring Access to HPV Vaccines Through Integrated Services: A Reproductive Health PerspectiveBull. World Health Organ. 85 (1), 57–63. Pulerwitz, J., Barker, G., 2008. Measuring attitudes toward gender norms among young men in Brazil: development and psychometric evaluation of the GEM scale. Men Masculinities 10 (3), 322–338. Richardson, H., Abrahamowicz, M., Tellier, P.P., Kelsall, G., du Berger, R., Ferenczy, A., Coutlee, F., Franco, E.L., 2005. Modifiable risk factors associated with clearance of type-specific cervical human papillomavirus infections in a cohort of university students. Cancer Epidemiol. Biomark. Prev. 14 (5), 1149–1156. Robertson, A.A., Stein, J.A., Baird-Thomas, C., 2006. Gender differences in the prediction of condom use among incarcerated juvenile offenders: testing the Information–Motivation–Behavior Skills (IMB) model. J. Adolesc. Health 38 (1), 18–25. Rogow, D., Haberland, V., 2005. Sexuality and relationships education: toward a social studies approach. Sex Edu. 5 (4), 333–344. Schiffman, M., Castle, P.E., Jeronimo, J., Rodriguez, A.C., Wacholder, S., 2007. Human papillomavirus and cervical cancer. Lancet 370 (9590), 890–907. Shin, H.R., Lee, D.H., Herrero, R., Smith, J.S., Vaccarella, S., Hong, S.H., Jung, K.Y., Kim, H.H., Park, U.D., Cha, H.S., Park, S., Touze-, A., Mun-oz, N., Snijders, P.J., Meijer, C.J., Coursaget, P., Franceschi, S., 2003. Prevalence of human papillomavirus infection in women in Busam, South Korea. Int. J. Cancer 103, 413–421. The United Nations Development Programme, Human Development Report, 2014. Sustaining Human Progress: Reducing Vulnerability and Building Resilience, 2014. United Nations Development Programme, New York. Vaccarella, S., Franceschi, S., Herrero, R., Muñoz, N., Snijders, P.J., Clifford, G.M., Smith, J.S., Lazcano-Ponce, E., Sukvirach, S., Shin, H.R., de Sanjosé, S., Molano, M., Matos, E., Ferreccio, C., Anh, P.T., Thomas, J.O., Meijer, C.J., Group, I.H.P.S.S., 2006. Sexual behavior, condom use and human papillomavirus: pooled analysis of the IARC human papillomavirus prevalence surveys. Cancer Epidemiol. Biomark. Prev. 15 (2), 326–333. World Association for Sexual Health, 2008. Sexual health for the millennium: a declaration and technical document. Minneapolis, MN, USA. Yun, S.N., Kim, Y.I., Choi, J.M., Cho, H.S., Kim, Y.H., Park, Y.N., Oh, G.S., Lee, B.O., Cho, S.N., Cho, S.Y., Han, S.H., Ha, Y.M., 2005. Health education needs of students, parents and teachers and the status of health education in elementary, middle, and high schools. J. Korean Soc. Sch. Health 18 (1), 1–14.
Contents lists available at ScienceDirect
Nurse Education Today journal homepage: www.elsevier.com/nedt
The effects of an HPV education program by gender among Korean university students Hae Won Kim a, Seungmi Park b,⁎, Hye Young Ahn c, Eun-Jun Park d a
The Research Institute of Nursing Science, College of Nursing, Seoul National University, Seoul, Republic of Korea Department of Nursing, Hoseo University, Asan-Si, Chungcheongnam-Do, Republic of Korea College of Nursing, Eulji University, Daejeon, Republic of Korea d Department of Nursing, Konkuk University, Chungju-si, Chungcheongbuk-do, Republic of Korea b c
a r t i c l e
i n f o
Article history: Accepted 16 December 2014 Keywords: Health education Sex education Sexual behavior Students Motivation Intention
s u m m a r y Purpose: This study compared the effects of an HPV education program by gender among Korean university students in terms of their knowledge of HPV, intention to prevent HPV, awareness of sexual rights, and perception of gender equality. Methods: A quasi-experimental pre–post design was employed. 31 male and 28 female university students participated in eight sessions of an HPV prevention program for four weeks and in a self-administrative survey. Results: At pre-test, the perception of gender equality and some of the intentions to prevent HPV, including the intention to make regular use of condoms, reduce the number of sexual partners, abstain from sex until marriage, and stop smoking or stay non-smoker, were lower among men than women. When these differences by gender at pre-test were taken into account using ANCOVA, education outcome measures at post-test did not differ by gender. After completing the HPV prevention program, both male and female students presented a significant increase in terms of HPV knowledge, awareness of sexual rights, and perception of gender equality. Among the intentions to prevent HPV, only male intention to recommend the Pap test to their partner and female intention to regularly seek the Pap test and pelvic examinations were significantly increased after the program. Conclusion: The HPV program was effective for both genders eliminating gender differences in attitudes and prevention intentions of HPV. However, the intentions to prevent HPV did not increase significantly, and future research is warranted to better understand students' perceived obstacles for practicing HPV prevention methods. © 2014 Elsevier Ltd. All rights reserved.
Introduction HPV-associated cancers, including cervical cancer, anal cancer, and oropharyngeal cancer, can be effectively prevented by avoiding HPV infection, which again can be avoided by practicing already known HPV prevention. As seen in the United States, the incidence of HPV-associated cervical cancer has decreased, but the incidence of the anal cancer or oropharyngeal cancer caused by HPV has increased and is likely to become higher than that of cervical cancers (Chaturvedi et al., 2011; Gillison et al., 2008), high-lighting the importance of continuous HPV prevention. In South Korea, HPV prevention is often left to individual women who want to avoid HPV-associated cervical cancer or to the pharmaceutical marketing of HPV vaccines. Although the vaccination is recommended for both females aged 9–26 and males aged 9–15 by the Korean Society of Obstetrics and Gynecology and Colposcopy (Kim et al., 2007), HPV vaccine has not been introduced ⁎ Corresponding author at: Department of Nursing, Hoseo University, 336-795, 20, Hoseo-ro, 79beon-gil, Baebang-Eup, Asan-Si, Chungcheongnam-Do, Republic of Korea. Tel.: +82 41 540 9533; fax: +82 41 540 9558. E-mail address: [email protected] (S. Park).
http://dx.doi.org/10.1016/j.nedt.2014.12.014 0260-6917/© 2014 Elsevier Ltd. All rights reserved.
to the school mandatory vaccination program yet. The HPV vaccination rate is less than 10% of Korean women (Kang and Moneyham, 2010) and unknown for Korean men. The high cost of the vaccination (about US $400), which is not covered by national health insurance, may have some relevance in explaining the low HPV vaccination rate. Nevertheless, one of the primary reasons for inadequate prevention measures is low awareness and attitudes regarding HPV (Oh et al., 2010) and greater education is needed. Although school health education is recommended from primary school to high school by the School Health Law of South Korea (http://www.law.go.kr/main.html), HPV relevant information is rarely included in school health education (Yun et al., 2005). Accordingly, Korean university students often have insufficient information or misconceptions about HPV infection and methods of prevention (Kim and Park, 2009; Oh et al., 2010). In light of the limited opportunity to learn about HPV among university students, a comprehensive education program is needed in Korea. In Korea, the overall seroprevalence of HPV was not significantly different between male and female university students (Clifford et al., 2007). Nyitray et al. (2011) found that the prevalence of anal HPV infection ranges from 12.2% to 47.2% with no age-group predilection. In previous studies, men consistently presented less knowledge than
H.W. Kim et al. / Nurse Education Today 35 (2015) 562–567
women about HPV although both genders are equally responsible for its transmission (Klug et al., 2008). However, research on male HPV prevention is hardly found in South Korea except for a few (Oh et al., 2010; Park and Park, 2012). There is even a misconception that HPV vaccination and prevention are necessary only for women because of the link with cervical cancer or that men are not at risk from HPV-associated cancers. To effectively prevent HPV transmission it is essential for men to have a clear understanding of the HPV infection and to participate in prevention such as condom use, limiting the number of sexual partners, or getting HPV vaccination (Giuliano et al., 2011). Issues of sexual rights and gender equality are often recommended in sex education to promote individual responsibility in interpersonal relationships (Ahn et al., 2008; Kim et al., 2010; Levesque, 2000). An egalitarian perspective in sexuality and sexual health is included in school health education in primary schools in South Korea (Han and Seo, 2014). However, men are less likely to think about or take preventive action with regard to STDs than women even though they have had the same education (Ahn et al., 2008; Kim et al., 2010; Levesque, 2000). Sexual health cannot be achieved or maintained without sexual rights for all humans (World Association for Sexual Health, 2008). In addition, gender equality, rights of men and women to nondiscrimination, influences sexual attitudes and practices of both genders and thus it should be dealt with in sex education (Rogow and Haberland, 2005). In fact, men who accept gender equality were more likely to have desirable attitudes toward sexual behavior and contraceptive use (Lee, 2005; Pulerwitz and Barker, 2008). Although understanding of sexual rights and gender equality is considered crucial components of STD prevention education (Kim et al., 2010), few HPV prevention programs are found to include those issues so far. HPV can be prevented through a comprehensive approach to sexual health (Pollack et al., 2007) and inclusion of the issues of sexual rights and gender equality is expected to promote university students' respect for not only their own sexual health but also that of their partners in terms of HPV prevention. To develop and evaluate HPV prevention education, the information– motivation–behavioral skill (IMB) model was adopted as a theoretical framework. Information and motivation, as independent factors, are influencing behavior change like HPV prevention behaviors directly or indirectly through behavioral skills (Robertson et al., 2006). When the IMB model is applied to the HPV education program in this study, the information component includes knowledge on HPV facts, prevention methods, sexual rights, and gender equality. Motivation to stop HPV-risky behaviors and adopt prevention methods was stimulated through small-group discussions in the program and measured through behavioral intention for HPV prevention as a proxy for real behavior. Behavioral skills in performing specific HPV prevention behavior, such as sexually assertive communication skills and condom use, were taught in the program but not measured in this study. The purpose of this study was to evaluate effects of HPV prevention education by gender, considering a previously known gender difference in HPV knowledge and general attitudes for sexual health. The following two hypotheses were proposed: 1) the HPV prevention education enhances both male and female university students' knowledge of
563
HPV, awareness of sexual rights, perception of gender equality, and intention to prevent HPV infection, and 2) the education reduces gender differences in terms of knowledge of HPV, awareness of sexual rights, perception of gender equality, and intention to prevent HPV infection. Methods Design and Participants The research protocol was approved by the Institutional Review Board. A pre–post test quasi-experimental design was employed. Using a convenience sampling method, university students were recruited through website and offline advertisements at the university from September 27 to October 8, 2010. Students were excluded if they 1) had been married with regular sexual activity, 2) majored health care fields such as nursing, medicine, or public health, and 3) were part of or completed an HPV vaccination program because they may be better informed about HPV and have more positive prevention attitudes than the other students (Kim and Park, 2009). To compare mean differences by gender, the number of subjects in each gender was estimated 26 for a statistical power of 0.80, significance of 0.05, and a large effect size of 0.79 based on a previous study (Kim, 2009) using G*Power 3.12. Assuming 20% withdrawal of subjects, a total of 59 students, 31 men and 28 women, participated in the study. Among the study applicants, 2 male students were not able to participate in the study because of their academic schedule, and 2 female students dropped out. Each participant was assured that their data would remain confidential and anonymous and signed an informed consent before the education. HPV Education Program The education program was based on the premise that HPV infection is common regardless of gender and that both men and women require equal perspective and responsibility for HPV prevention. The content was developed based on a previous HPV education program (Kim, 2009): a) the first four lectures about general HPV information, gender-specific HPV infection, genital warts, common approaches for HPV prevention, and sexual autonomy and sexual rights, and b) the following four small-group discussions about sexism and prejudice regarding sexuality, experiences and feeling of gender inequality, sexually assertive communication skills and condom use, and breaking prejudice about sexuality, STDs, and HPV (Table 1). Social factors like awareness of sexual rights and perception of gender equality are highly likely to influence interpersonal relations or negotiation in sexual behavior between men and women (De Meyer et al., 2014). Accordingly, the HPV program was designed to educate about gender equality and sexual rights in addition to HPV knowledge, expecting to improve gender-biased attitudes and strengthen HPV prevention intention for both males and females. The content and methodology of the education were validated by experts of women's health nursing, public health nursing, gynecology,
Table 1 Education contents of the HPV prevention program. Session
Contents
Instructional method
1 2
General HPV information: prevalence, pathology, types, and vaccines Gender-specific HPV infection: cervical, genital, and other types of cancers in males and females Genital warts as a common STDs among both males and females Common approaches for HPV prevention for both males and females: abstinence, regular condom use, fewer sexual partners, the cessation of smoking, HPV vaccination, and routine Pap smears Sexual autonomy and sexual rights for both males and females Sexism and prejudice regarding sexuality in Korean society Exploration of experiences and feelings of gender inequality in sexual health and interpersonal relationships Sexually assertive communication skills and condom use Breaking prejudices about sexuality, STDs, and HPV
Lecture with a handout Lecture with a handout
3 4 5 6 7 8
STDs = sexually transmitted diseases; HPV = human papilloma virus.
Lecture with a handout Lecture with a handout Small-group discussion Small-group discussion Small-group discussion and practice Small-group discussion
564
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and teaching engineering. The education consisting of eight 50-min sessions was delivered in a multimedia classroom for four weeks by the first author and two assistants. In a small-group discussion, 9 ~ 10 students per group with a similar number of males and females participated and a team leader was selected. A small-group discussion was adopted to allow the students to speak their mind and communicate actively with one another about topics including sexual rights and gender equality. The discussion was guided so that the students could exchange their different perspectives and experiences regarding the education contents among men and women with respect to the opposite gender. Two meetings were held for a week prior to the education to take a pre-test and to increase the participants' emotional closeness while they introduced themselves and were oriented about the program. After completing the eight sessions, the post-test was conducted.
Data Collection and Measures Both a pre-test and a post-test were conducted using a selfadministered questionnaire in October and November 2010, respectively, assessing HPV knowledge, awareness of sexual rights, perception of gender equality, and intention to prevent HPV infection. The content of the structured questionnaire was validated by three HPV experts, and its applicability was verified by a pilot test with 10 female nursing students and 10 male engineering students. The participants' sociodemographic characteristics were asked in a pretest, which included age, grade, major, living conditions, sexual experience, the number of sexual partners, a history of STD examinations, previous condom use, smoking experience, alcohol consumption, and having heard of HPV and genital warts. Smoking and alcohol use were assessed because the regular use of cigarettes or alcohol is likely to increase the prevalence of HPV infection (National Cancer Institute, 2012; Shin et al., 2003). At both the pretest and posttest, knowledge of HPV, awareness of sexual rights, perception of gender equality, and intention to prevent HPV infection were measured as short-term education outcomes. Characteristics of these measures are summarized in Table 2 with the relevant references, the number of items, scales, and a reliability index. The HPV knowledge questionnaire was modified by eliminating three items after examining a reliability index in the pilot study, and the final five items were validated by two HPV experts: a) HPV can be asymptomatic, b) HPV can disappear without treatment, c) the HPV vaccine prevents HPV infection, d) condoms prevent HPV, and e) HPV can affect men. Perception of gender equality was measured with five items: a) control of sexuality is more difficult for males than for females, b) sex education is needed more by female students than by male students, c) an obscene portrayal of women's bodies in commercial advertising is not sexual discrimination but just marketing, d) sex outside of marriage is more morally serious for women than for men,
and e) sexual harassment is caused by body over-exposure. The answers to these items were reversely coded for scoring so that always the higher score refers to better outcomes in this study. Intention to prevent HPV infection was measured with six items: a) intention to make regular use of condoms, b) intention to reduce the number of sexual partners, c) intention to abstain from sex until marriage, d) intention to be vaccinated for HPV, e) intention to regularly undergo the Pap test or pelvic examinations even before marriage (females only) or to recommend seeking the Pap test or pelvic examinations regularly to sexual partners (males only), and f) intention to stop smoking or to stay a non-smoker.
Data Analysis SPSS Statistics version 20.0 was used. The homogeneity of sociodemographic factors and having heard of HPV was compared by gender using t-test, χ2, and Fisher's exact test. Gender comparison in the outcome variables, that is, HPV knowledge, awareness of sexual rights, perception of gender equality, and intention to prevent HPV, were analyzed using the Mann–Whitney U test in the pretest. In the posttest, the outcome measures were compared by gender using Wilcoxon signed-rank test after adjusting any gender differences found in the pretest with the ANCOVA.
Results Sociodemographic factors and having heard about HPV were not significantly different by gender except more males having sexual experience (χ2 = 7.55, p = .023) and smoking (χ2 = 18.82, p b .001) than females (Table 3). The average ages of male and female students were 20.57 ± 1.98 years and 19.70 ± 1.20 years, respectively. A majority of them were freshmen or sophomore, living in a university dormitory. A small number of the students had heard of HPV (7% of males, 14% of females) or genital warts (13% of males, 11% of females). At the pretest, the students' HPV knowledge was very low with a mean score of 0.80 ± 1.19 out of 5 for males and 1.46 ± 1.64 for females without a significant difference (Table 4). The awareness scores of sexual rights (score 17–68) were 53.67 ± 7.38 for males and 55.82 ± 6.67 for females without a significant difference. Gender differences were found from consistently low scores of males in terms of perception of gender equality (Z = − 2.40, p = .016) and four intentions of HPV prevention methods such as making regular use of condoms (Z = − 2.13, p = .033), reducing the number of sexual partners (Z = − 3.61, p b .001), practicing abstinence from sex until marriage (Z = − 3.55, p b .001), and stopping smoking or staying a non-smoker (Z = − 2.20, p = .028). An intention to get HPV vaccination was 3.52 ± 1.00 for males and 3.71 ± 0.90 for females, which was not high enough without a significant gender
Table 2 Measures and variables used to evaluate the HPV prevention education. Measures
Reference of original scales
Number of items
Scale
Cronbach's α
HPV knowledge
HPV knowledge scale Kim (2011) Kim et al. (2010)
5 out of original 8 items
1 (right) or 0 (wrong)
.82
17 items under 5 domains: sex education, free from prejudices and biases, sexual satisfaction, safe and equal sexuality, and sexual autonomy 5 items of sexuality subscale
1 (not at all important) to 4 (very important) Likert-type
.84
1 (very much agree) to 5 (never agree) Likert-type
.62
1 (not at all) to 5 (very much) Likert-type
.80
Awareness of sexual rights
Perception of gender equality Intention to prevent HPV infection
Korean gender egalitarianism scale Korean Women's Development Institute (1999) Kim (2009, 2012) Centers for Disease Prevention and Control for HPV prevention (CDCP, 2011)
6 items
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565
Table 3 Homogeneity of general sociodemographics between male and female students (N = 59). Characteristics
Categories
Male (n = 31)
1 2 3 4 With parents Alone, sublets Dormitory None Irregular Regular
20.57 ± 1.98 18 (58.1) 10 (32.2) 2 (6.5) 1 (3.2) 2 (6.5) 11 (35.5) 18 (58.1) 15 (50.0) 9 (30.0) 6 (20.0) 5.38 ± 7.71
19.70 ± 1.20 14 (50.0) 5 (17.9) 5 (17.9) 4 (14.3) 1 (4.6) 9 (32.1) 18 (64.3) 21 (80.8) 1 (3.8) 4 (15.4) 1.33 ± 0.51
27 (96.4) 1 (3.6) 15 (53.6) 7 (25.0) 6 (21.4) 12 (38.7) 19 (61.3) 1 (3.2) 14 (45.2) 8 (25.8) 8 (25.8) 29 (93.5) 2 (6.5) 27 (87.1) 4 (12.9)
24 (100.0) 0 (0.0) 18 (81.8) 2 (9.1) 2 (9.1) 26 (92.9) 2 (7.1) 6 (21.4) 12 (42.9) 5 (17.9) 5 (17.9) 23 (82.1) 5 (14.3) 25 (89.3) 3 (10.7)
χ2 or t (p)
Female (n = 28)
n (%) or M ± SD Age (years) Grade
Living condition
Sexual experience (n = 56)
Numbers of sexual partners (n: men = 13, women = 6) STDs examination (n = 52)
No Yes Never Rarely Often No Yes Never 1–2/month 1/week 2–3/week No Yes No Yes
Condom use (n = 50)
Smoking experience Frequency of alcohol consumption
Heard of HPV… Heard of genital warts…
3.86 (.055) 5.11 (.164)
0.38 (.826)
7.55 (.023)
1.85 (.191) (1.00)a 4.39 (.111)
18.82 (b.001) 4.97 (.174)
(.240)a (1.00)a
STDs = sexually transmitted diseases; HPV = human papilloma virus. a Fisher's exact test.
difference. An intention to undergo or recommend the Pap test was 3.87 ± 0.92 for males and 4.14 ± 0.71 for females. By completing the HPV education, male students showed a significant increase in their HPV knowledge (Z = −3.80, p b .001), awareness of sexual rights (Z = − 2.78, p = .005), perception of gender equality (Z = − 2.53, p = .012), and an intention to recommend the Pap test to the partner (Z = − 2.49, p = 0.013, Table 4). Female students presented very similar findings with a significant increase in HPV knowledge (Z = − 3.16, p = 0.002), awareness of sexual rights (Z = − 2.83, p = 0.005), perception of gender equality (Z = − 2.13, p = 0.033), and an intention to undergo the Pap test and pelvic examinations regularly (Z = −2.36, p = 0.018). Therefore, the HPV education was found to be effective for both male and female university students. However, the education outcomes were not achieved at satisfying high level; for example, the HPV knowledge
score was lower than 3 out of 5 points, and perception of gender equality was lower than 18 out of 25 points. To compare the effects of the HPV education by gender at the posttest, the gender differences in perception of gender equality and some intentions of HPV prevention methods found at the pretest were taken into account using ANCOVA. As a result, there were no significant gender differences in HPV knowledge, awareness of sexual rights, perception of gender equality, and intentions to prevent HPV (Table 4), which demonstrates that comprehensive HPV education can eliminate gender differences in attitudes and prevention intentions of HPV. Discussion This study evaluated short-term effects of a four-week HPV education program in which both genders participated and attitudes toward sexual
Table 4 Knowledge and attitudes for HPV prevention by gender. Characteristics (min–max)
Pre-test Male
Post-test Female
Z (p)
M ± SD
Male
Pre–post difference Female
Z (p)
M ± SD
Male
Female
Z (p)
HPV knowledge (0–5) Awareness of sexual rights (17–68) Perception of gender equality (5–25)
0.80 ± 1.19 53.67 ± 7.38 13.76 ± 3.27
1.46 ± 1.64 55.82 ± 6.67 15.93 ± 3.22
−1.30 (.194) 1.35 (.250) −2.40 (.016)
2.68 ± 1.25 58.57 ± 6.25 14.93 ± 3.48
2.84 ± 1.03 60.50 ± 6.25 17.62 ± 3.66
−0.55 (.580) −1.17 (.241) 1.19 (.281)a
−3.80 (b.001) −2.78 (.005) −2.53 (.012)
−3.16 (.002) −2.83 (.005) −2.13 (.033)
Intention to prevent HPV (1–5) Make a regular use of condoms Reduce the number of sexual partners Practice abstinence from sex until marriage Get HPV vaccination Stop smoking or remain a non-smoker Regularly undergo the Pap test and pelvic exams Recommend the Pap test to the partner
4.00 ± 1.10 3.45 ± 1.36 2.52 ± 1.29 3.52 ± 1.00 4.20 ± 1.24 NA 3.87 ± 0.92
4.54 ± 0.79 4.64 ± 0.62 3.71 ± 0.90 3.71 ± 0.90 4.75 ± 0.75 4.14 ± 0.71 NA
−2.13 (.033) −3.61 (b.001) −3.55 (b.001) −0.78 (.438) −2.20 (0.28) – –
3.90 ± 1.12 4.00 ± 1.17 2.72 ± 1.31 3.69 ± 0.81 4.07 ± 1.19 NA 4.36 ± 0.49
4.42 ± 0.86 4.54 ± 0.81 4.00 ± 1.26 4.04 ± 0.72 4.54 ± 0.86 4.58 ± 0.50 NA
1.27 (.266)a 0.95 (.334)a 1.84 (.180)a −1.75 (.081) 0.61 (.440)a – –
−0.48 (.632) −1.86 (.063) −1.37 (.170) −0.69 (.488) −0.79 (.431) – −2.49 (0.013)
−0.58 (.564) −0.54 (.589) −1.19 (.235) −1.62 (.104) −0.84 (.399) −2.36 (.018) –
NA = not applicable; HPV = human papilloma virus. a Being adjusted for pretest differences using ANCOVA.
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rights and gender equality in addition to HPV-related content were dealt with. The education improved HPV knowledge, awareness of sexual rights, perception of gender equality for both genders but room for improvement remained, partially supporting hypothesis 1. Unfortunately many prevention intentions, except Pap smear testing, were not significantly improved in spite of completing the education in both genders. Significantly lower levels of gender equality perception and of most prevention intentions were found among men at the beginning, but these gender differences disappeared after taking the HPV education, supporting hypothesis 2. This study suggests that men should participate in efforts to prevent HPV infection considering their low perception of gender equality and low motivation for HPV prevention. Men showed consistently lower knowledge of HPV than females in previous studies (Kim, 2011; Klug et al., 2008; Oh et al., 2010). Though, often only women were targeted in HPV prevention programs because of the well-known fact that almost all cervical cancers are caused by HPV infection (Schiffman et al., 2007), in spite of that the inclusion of men in HPV programs was beneficial for both men and women. As seen in this study, male students who had taken part in the education program showed a strong intention to recommend the Pap test to their partner, which increases the likelihood of men playing an active role in preventing HPV infection and HPV-associated cancers. Unlike HPV education programs in general, the education content in this study taught awareness of sexual rights and perception of gender equality in HPV prevention. South Korea ranks 15th in the Human Development Index but 85th in the Gender Development Index, reflecting disparity in human development achievements between women and men in health, education and living standards, among the world nations (The United Nations Development Programme, 2014). This gender disparity issue in Korea was again found in a lower perception of gender equality of males in this study. Awareness of sexual rights and the gender equality perception scores were improved after the education but were not high enough. A small-group discussion in this study seems to contribute to reducing gender differences found at the pretest regarding knowledge and attitudes toward HPV and sexual health. Considering room for improvement in this study, further research is warranted to develop more effective approaches in sex education for promoting desirable attitudes of sexual rights and gender equality. Also, evidence is needed about how those attitudes influence actual HPV prevention behavior. The intention to regularly use a condom for HPV prevention did not change after the education in either gender. Previous cohort studies verified that consistent condom use by male partners reduced the rate of HPV infection in female university students (Richardson et al., 2005; Vaccarella et al., 2006). Therefore, the effects and importance of regular condom use for HPV prevention need to be more emphasized considering the students' limited HPV prevention behavior. Noteworthy is that no favorable changes were observed in prevention intentions related to sexual behavior like abstinence from sex. People who are sexually active or change their partner are more likely to be infected with HPV than their sexually inactive or monogamous counterparts (Cha et al., 2007). With other demographic factors adjusted for, a definite relationship between husbands' extramarital sexual relationships and their wife's HPV infection is known (Oh et al., 2008). Although HPV prevention methods like limiting the number of sexual partners or practicing abstinence from sex in this study are effective, it is difficult to imagine that the adult university students will easily change their sexual attitudes and behavior. Proactive discussions on premarital sex may be in need for both male and female university students. HPV vaccination is recommend for both men and women as one of the most effective and conclusive HPV prevention methods (Center for Disease Control and Prevention, 2013). Giuliano et al. (2011) found men to have a consistent risk of HPV infection over their lives and thus suggested that it would be cost-effective to implement HPV vaccination for men. Unfortunately, the intention score to obtain HPV vaccination
was slightly higher but without a significant change in spite of the education. According to Oh et al.'s (2010) study, the most commonly cited barrier for having an HPV vaccination was high cost, followed by uncertain effectiveness and 3 dosages. A discussion of HPV vaccination costs needs to be initiated to learn whether the cost should be paid or supplemented by national health insurance or school health funds for adolescent and young adults. In conclusion, most intentions for HPV prevention did not improve after taking the education among both males and females. Sexual behavior or relevant intentions are unlikely to easily change with a short-term education. This study has limitations. Because of a convenient sampling method, the scores of education outcome measures including HPV knowledge and prevention intentions cannot be generalized to other populations and settings than Korean university students. Further research can replicate the study with other groups, for example, non-university young people. In addition, socially desirable responses were possible especially regarding sexual behavior, considering sexually conservative Korean culture, especially for unmarried young adults. It may be desirable that an education instructor and a researcher for data collection are not one and the same person to avoid socially desirable responses. Finally, this study measured only knowledge and motivation components and did not measure actual sexual behavior and practices regarding HPV prevention. This requires future research. Also, qualitative research is suggested to better understand sexual behavior of young adults and to facilitate a more effective behavior change. Conclusion The HPV education was effective in improving HPV knowledge, awareness of sexual rights, and perception of gender equality but had a small effect on intention to adopt HIV prevention methods among university students in Korea. Male students' low perception of gender equality and HPV prevention intention were mitigated through education. More research is needed to better understand students' perceived obstacles for practicing HPV prevention methods using qualitative data from interviews with Korean university students. In the future, HPV prevention education is recommended to include men as well as women but strategies to improve HPV prevention intention need to be employed. In addition to prevention intentions, knowledge and attitude need to be improved; four weeks in this study appear to be insufficient. In the future education periods need to be longer or an innovative teaching method needs to be tried. Acknowledgment This research was supported by Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Science, ICT 7 Future Planning (2012-R1-A1A3015525). References Ahn, S., Park, I., Han, J.S., Kim, T.I., Kwak, M.S., Chung, H.S., 2008. Health behaviors, reproductive health history, and sexual behaviors of college students. Korean J. Woman Health Nurs. 14 (3), 205–212. Center for Disease Control and Prevention, 2011. Human Papillomavirus Prevention. Retrieved May 10, 2012, from http://www.cdc.gov/hpv/Prevention.html. Center for Disease Control and Prevention, 2013. Human Papillomavirus (HPV): HPV Vaccines. Center for Disease Control and Prevention. Cha, E.S., Doswell, W.M., Kim, K.H., Charron-Prochownik, D., Patrick, T.E., 2007. Evaluating the Theory of Planned Behavior to explain intention to engage in premarital sex amongst Korean college students: a questionnaire survey. Int. J. Nurs. Stud. 44 (7), 1147–1157. Chaturvedi, A.K., Engels, E.A., Pfeiffer, R.M., Hernandez, B.Y., Xiao, W., Kim, E., Jiang, B., Goodman, M.T., Sibug-Saber, M., Cozen, W., Liu, L., Lynch, C.F., Wentzensen, N., Jordan, R.C., Altekruse, S., Anderson, W.F., Rosenberg, P.S., Gillison, M.L., 2011. Human papillomavirus and rising oropharyngeal cancer incidence in the United States. J. Clin. Oncol. 29 (32), 4294–4301.
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