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A survey on human papillomavirus awareness and acceptance of vaccination among nursing students in a tertiary hospital in Ankara, Turkey

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A survey on human papillomavirus awareness and acceptance of vaccination among nursing students in a tertiary hospital in Ankara, Turkey
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  Vaccine 31 (2013) 2191–2195 ContentslistsavailableatSciVerseScienceDirect Vaccine  journalhomepage:www.elsevier.com/locate/vaccine A   survey   on   human   papillomavirus   awareness   and   acceptance   of    vaccinationamong   nursing   students   in   a   tertiary   hospital   in   Ankara,   Turkey Özlem   Uzunlar ∗ ,   S¸    ebnem   Özyer,   Eralp   Bas¸    er,   Cihan   To˘grul,   Müjdegül   Karaca,   Tayfun   Güngör  ZekaiTahirBurakWomen’sHealthEducationandResearchHospital,Ankara,Turkey a   r   t   i   c   l   e   i   n   f   o  Articlehistory: Received3September2012Receivedinrevisedform24December2012Accepted15January2013 Available online 30 January 2013 Keywords: HPVVaccinationTurkeyNursingstudentsKnowledgeAttitude a   b   s   t   r   a   c   t Objective:   The   purpose   of    this   study   was   to   assess   the   awareness   and   knowledge   regarding   human   papil-lomavirus   (HPV),   HPV   related   conditions   and   HPV   vaccine   among   nursing   students,   and   to   identify   theirattitudes   towards   HPV   vaccination. Materials   andmethods:   The   study   wascarried   out   at   atertiary   Women’s   Health   Care   Center   in   Ankara,Turkey.   Self-administered   questionnaires   were   filled   out   individually   by   the   nursing   students   and   bya   control   group   including   similar   aged   women.   Data   regarding   demographic   information,   knowledgeand   awareness   about   HPV   infection   and   HPV   vaccine,   attitudes   towards   vaccination,   acceptance   of    HPVvaccine   and   assessment   of    HPV   vaccination   attitudes   of    the   nurses   with   respect   to   the   gender   of    theirchildren   was   assessed   and   recorded. Results:   A   total   of    752   participants   was   included   in   the   analysis.   Five   hundred   and   twenty   (69.14%)   of    theparticipants   were   nursing   students   and   the   rest   ( n   =232;   30.8%)   were   control   group.   The   mean   ages   of    thenursing   students   and   the   control   group   were   19.4   (16–27)   and   19.4   (16–25)   years,   respectively.   Majorityof    the   nursing   students   knew   the   causal   relationship   between   HPV   and   cervical   cancer.   Seventy-eightpercent   of    the   nursing   students   and   22.4%   of    the   control   group   stated   that   they   hadheard   of    HPV   vaccine.While   the   rate   of    the   willingness   to   be   vaccinated   was   33.7%   in   the   nursing   student   group,   it   was   only13.4%   in   the   control   group. Conclusion:   The   awareness   and   knowledge   about   HPV,   itsrelation   with   cervical   cancer   and   prevention   of cervical   cancer   byHPV   vaccine   were   favorable   among   nursing   students   at   atertiary   hospital   in   Ankara,Turkey.   However,   although   aware   of    the   theoretical   implications,   theydid   not   seem   to   apply   it   to   practice,suchas   not   having   regular   gynecologic   examinations   and   Pap   smears.   Thus,   further   studies   are   needed   toevaluate   the   factors   that   affect   practical   applications   of    health   care   professionals   responsible   for   providinghealth   education   to   the   public. © 2013 Elsevier Ltd. All rights reserved. 1.Introduction Althoughgenerallyconsideredapreventabledisease,cervicalcancer,afterbreastcancer,isthesecondmostcommoncauseofcancermortalityamongwomenworldwide.Globally,500,000womenarediagnosedwithcervicalcancerandeachyear,and270,000ofthemdieofthedisease,mostly(85%)indevelopingcountries[1].   Theincidencewasestimatedtobe4.3/100,000in2007inTurkey[2].   Themostrecentestimatedmortalityrateforcervicalcanceris14.9/100,000,thus560womendyingofcervicalcancerperyearinourcountry[2].   AccordingtoTurkishNationalCancerProgram,apopulationbasedorganizedcervicalscreeningprogramhasbeenplanned.However,theprogramcurrentlycov-ersonlyabout70%ofthepopulation.Althoughtheopportunistic ∗ Correspondingauthorat:ÜmitMah.MeksikaCad.ErasEvlerSitesiCBlokDaire19   Ümitköy,Ankara,Turkey.Tel.:+905327470999;fax:+903123104931. E-mailaddress: ozlemuzunlars@hotmail.com (Ö.Uzunlar). screeningstillexistsinsomeregionsofthecountry,anorganizedpopulationbasedcervicalscreeningprogramisnowongoing.InregionsofTurkey,wherethescreeningofcervicalcanceriscarriedoutonoccasionsofhospitaladmissions,healthcareprovidersbearanimportantroleforthewidespreaduseofscreeningprograms[2].Humanpapillomavirus(HPV)playsthemostimportantroleintheetiologyofcervicalcancer[3].   BecauseHPVtestingcurrentlyhasalimitedusebecauseofitshighcost,Papanicolaou(Pap)smearismorecommonlyusedincervicalcancerscreeningprograms.Socialvalues,beliefsandattitudesaboutcervicalcancerscreeningshowdisparitiesamongvariousnations.Limitationstohealthcareaccess,lackofrecommendationsforscreeningbyhealthcareproviders,fearofcancer,lackofregulargynecologicexaminations,stress,andpeople’shabitsandattitudestowardshealthallcontributetothesedifferences.AlthoughmostHPVinfectionsareasymptomatic,persistentinfectionwithcertainoncogenictypes(mainlytypes16and18)may   causecervicalcancerinwomen.Virtuallyallcervicalcancer 0264-410X/$–seefrontmatter © 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.vaccine.2013.01.033  2192  Ö.Uzunlaretal./Vaccine  31 (2013) 2191–2195  Table   1 Characteristicsoftheparticipants.CharacteristicNursingstudent( n =520)Control( n =232)Age(years,mean ± SD) 19.4 ± 2.4 19.4 ± 2.3(min–max)(16–27)(16–25)Maritalstatus( n ,%)Single491(94.4)222(95.7)Married17(3.3)10(4.3)Divorced12(2.3)0(0.0)Education( n ,%)Highschool 255(49.0) 104(44.8)University 265(51.0)128(55.2)Occupation( n ,%)Working40(7.7)29(12.5)Not   working480(92.3)203(87.5) casesarelinkedtogenitalinfectionwithHPV[4].Inordertopre- ventHPVinfectionsandreducetheriskofpre-invasiveandinvasiveneoplasiasofthecervix,theUnitedStatesFoodandDrugAdmin-istration(FDA)approvedaquadrivalentvaccineagainstHPVtypes6,11,16and18inJune,2006[5].   Also,theEuropeanCommissionapprovedabivalentvaccineagainsttypes16and18inSeptember2007.Bothproductsseemtobesafe,welltoleratedandeffective[6].Foraneffectiveprophylaxis,thevaccinehastobedeliveredbeforeexposuretothevirus,andpreferably,attheprepubertalstageinawoman’slife,astheantibodyresponsesarehighercomparedtothoseafterpuberty[7].   TheprimarytargetgroupofHPVvaccina-tionisyoungadolescentgirls.WithHPVvaccination,itisestimatedthattheriskofcervicalcancerfor12-year-oldgirlswillbereducedby61.8%[8].Thereasonwhywehavestudiedwithnursecandidatesisthattheyarethemostimportantstaffwhogiveeducationabouthealthtopatientsortothegeneralpublic.VariousinternationalstudieshavedemonstratedthattheawarenessofthecorrelationbetweenHPVandcervicalcanceramongthegeneralpublicandhealthcareprofessionalsislowtomoderate[3].   AscreeningprogrammayonlybeeffectiveafterprovidinganadequatelevelofconsciousnessaboutHPVinfectionandcervicalcarcinogenesistohealthcarepro-fessionals.TheaimofthisstudywastoassesstheawarenessaboutHPVinfection,theattitudetowardsHPVvaccinationandcervicalcancerpreventionamongnursingstudents,whoaregoingtobefuturehealthcareproviders. 2.Materialsandmethods ThisprospectivestudywascarriedoutbetweenFebruaryand June2012attheGynecologicOncologyDepartmentofZekaiTahirBurakWomen’sHealthEducationandResearchHospitalinAnkara,Turkey,whichisatertiarywomen’scarehospitalwith545bedsand20,000deliveriesperyear.AftertheInstitutionalReviewBoardapproval,aself-administeredquestionnairesurveywasconducted.AliteratureofpublishedsurveysaboutHPVandHPVvaccinationwasreviewed,andappropriatequestionswereselected,modifiedandadaptedtoTurkishpopulation.Thequestionnaireconsistedof 5sectionswithatotalof17items.Femalenursingstudentsthatarebeingtrainedatourhospi-talwithinthestudyperiodandacontrolgroupofnon-healthcareproviders(allagedbetween16and27)wereincludedinthestudy.Everyparticipantgavewritteninformedconsent.Theyfilledoutquestionnairesindividuallyunderthesupervisionofoneoftheresearchers.Thefirstsectioninvolvedquestionsregardingsociodemo-graphicvariables.Thequestionswereaboutage,maritalstatus,degreeofeducationandoccupation.Thequestionsinthesecondsectionwereaboutthepersonalapproachtothegynecologicexam-inationsandtheknowledgeabouttransmissionrouteoftheHPVinfection.ThethirdpartassessedtheinformationaboutHPV,HPVrelatedconditionsandthesourceoftheirinformation.Lastly,thefourthpartassessedtheawarenessandknowledgeaboutHPVvac-cines.Thissectionalsoinvestigatedintothecurrentvaccinationstatus,theiracceptanceofHPVvaccine,assessmentoftheirHPVvaccinationattitudesdependingonthegenderoftheirfuturechil-dren.Eachpartconsistedofmultiple-choiceandtrue/falsetypequestions.  2.1.Statisticalanalysis StatisticalanalyseswereperformedbySPSSforWindows18software(StatisticalPackageforSocialSciences,IL,USA).Chi-squaretestwasusedforunivariateanalysis.MultiplelogisticregressionanalysiswasusedtodeterminethefactorsaffectingHPVvaccination.Multivariateanalysiswas   performedbybinarylogisticregressiontest.Consideringalloftheparticipants,factorsaffectingwillingnesstobevaccinatedwereassessedbymultiplelogisticregressionanalysis.Thevariablesweretwoparticipantgroups(nursingstudentsandcontrolgroup),age,educationalsta-tus,beingawareofHPVvirus,andHPVvaccination,andknowledgeofthelinkbetweenHPVandcervicalcancer.Backwardlogisticregressiontechniquewasutilized.Oddsratioswerecalculatedforsignificantfactors.  p valueslessthan0.05wereconsideredstatisti-callysignificant. 3.Results  3.1.Characteristicsoftheparticipants Atotalof812eligiblewomenwas   identifiedwithinthestudyperiod.Sixty(7.4%)ofthemwereexcludedbecauseofcodingerrorsandrefusaltojointhestudy.Theoverallresponseratewas92.6%.Atotalof752participantswasincludedinthefinalanalysis.Fivehundredandtwentyofthem(69.14%)werenursingstudentsand232(30.8%)werethecontrolgroup.Themeanagesofthenursingstudentsandthecontrolgroupwere19.4(16–27)and19.4(16–25)years,respectively.Majorityoftheparticipants(94.8%)weresingleandunemployed(90.8%)(Table1).  3.2.KnowledgeaboutHPV  DataregardingknowledgeofHPV,thecausalrelationshipbetweenHPVandcervicalcancerandrouteoftransmissionofHPVispresentedinTable2.Ofthe752participantsincludedinthe study,only7.4%( n =56)statedthattheyhadregulargynecologicexaminations.Therateofhavingregulargynecologicexaminationsamongnursingstudentswas   notanydifferentfromthecontrolgroup.Withregardtotheparticipants’own   perceptionsabouttheirlevelofknowledgeofSTD,72.5%ofthenursingstudentsand80.2%ofthecontrolgroupreportedthattheythoughttheyhadenoughinformationaboutSTD.70%oftheparticipantsknewthatvirusesmay   causecancer.Thelevelofawarenesswas   significantlyhigherinthenursinggroup(88.1%vs30.6%;  p <0.001).While76.9%ofthenursingstudentsknewthecausalrelationshipbetweenHPVandcervicalcancer,only22.9%ofthecontrolgroupseemedtoknowthatHPVcouldcausecervicalcancer.46%ofthenursingstudentsand22.4%ofthecontrolgroupknewthatHPVinfectionisasexuallytransmitteddisease.  3.3.KnowledgeaboutHPVvaccineandsourceofinformation Table3demonstratestheknowledgeofHPVvaccineamongthenursingstudentsandthecontrolgroup.78%ofthenursingstudentsand22.4%ofthecontrolgroupstatedthattheyhadheardofHPVvaccine.69%ofthenursingstudentsand17.7%ofthecontrolgroup  Ö.Uzunlaretal./Vaccine  31 (2013) 2191–2195  2193  Table   2 KnowledgeaboutSTD,HPVandHPVrelatedconditions.Nursingstudent( n =520)Control( n =232)  p * Havingregulargynecologicexams39(7.5)17(7.3)0.934ThoughtthathadenoughinformationaboutSTD 377(72.5)186(80.2)0.025Knew   thatvirusescancausecancer 458(88.1)71(30.6)<0.001HavingheardofHPV447(86.0)56(24.1)<0.001Knew   thatHPVistransmittedsexually239(46.0)52(22.4)<0.001Knew   thatcauseofcervicalcancerisHPV400(76.9)53(22.8)<0.001 * Chi-squaretest.  Table3 KnowledgeaboutHPVvaccine,sourceofinformationaboutHPVvaccine.Nursingstudent( n =520)Control( n =232)  p * HavingheardofHPVvaccine406(78.1)52(22.4)<0.001Knew   thatHPVvaccineisrecommendedforfemalesaged9–26363(69.8)41(17.7)<0.001SourceofinformationaboutHPVvaccineHealthprofessionals75(17.5)63(27.2)Media   93(22.0)33(14.2)Internet 115(27.2)25(10.8)<0.001Friends115(27.2)11(4.7)Other 25(5.9)100(43.1) * Chi-squaretest.  Table4 AttitudestowardsHPVvaccine.Nursingstudent( n =520)Control( n =232)  p * Vaccinationstatus 11(2.1)4(1.7)0.486Willingtobevaccinated345(66.3)31(13.4)<0.001Willingherdaughtertobevaccinated 394(75.8)111(47.8)<0.001Willinghersontobevaccinated373(71.7)48(20.7)<0.001 * Chi-squaretest. knewtherecommendedageforHPVvaccination.ThemajorsourceofinformationaboutHPVvaccinationforthenursingstudentswasthemedia,internetandtheirfriends,whileitwasfamily,schoolandteachersforthecontrolgroup(Table3)(  p <0.001).Interestingly,althoughtheparticipantsinthestudygroupwerefuturehealthcareproviders,thepercentageofthemreceivinginformationfromhealthcareproviderswasverylow(17.5%).Ontheotherhand,thisratiowassomewhathigherinthecontrolgroup(27.2%).  3.4.AttitudestowardsHPVvaccination VaccinationstatusoftheparticipantsisshowninTable4.Only 2.1%ofthenursingstudentsand1.7%ofthecontrolgrouparecurrentlyvaccinated.Thepercentageofthewillingnesstobevacci-natedwas50%,66.3%and13.4%amongalltheparticipants,nursingstudentsandcontrolgroup,respectively.Theratioofthepartic-ipantswhowantedtheirfuturedaughterstobevaccinatedwas67.1%,75.8%and47.8%intheabovementionedgroups,respec-tively,whiletheratewas55.9%,71.7%and20.7%respectivelyaboutwillingnesstovaccinatetheirfuturesons.LogisticregressionanalysisrevealedthathavingpreviousknowledgeofHPVvaccineandbeingahealthcareprovidertobe(oddsratio(OR)=2.8;95%confidenceinterval(CI):1.8–4.3,OR=6.7,CI:3.8–11.7)weretheindependentfactorsrelatedtotheaccep-tanceoftheHPVvaccine.Thenursingstudentswere7.8timesmorewillingtobevaccinatedthanthecontrolgroup,andthosewho   hadalreadyheardofHPVvaccinewerethreetimesmorelikelytobevaccinatedthantheoneswhohadnot(Table5).Moreover,when thetwogroupsareconsidered,previousknowledgeaboutHPVvac-cineamongthenursingstudents,andageandknowledgeofcausalrelationbetweenHPVandcervicalcancerinthecontrolgroupareallrelatedtotheacceptanceoftheHPVvaccine.Thenursingstu-dents,whohadheardofHPVvaccinewere3.1times,whereasthemembersofthecontrolgroupwho   knewthecausalrelationbetweenHPVandcervicalcancerwerefivetimesmorelikelytobevaccinated(Table6). 4.Discussion Thepurposeofthisstudywas   toassesstheawarenessandknowledgeregardingHPV,HPVrelatedconditions,HPVvaccineandtoidentifytheattitudestowardsvaccinationamongTurk-ishnursingstudentsthatarebeingtrainedatatertiarycare  Table5 FactorseffectingHPVvaccineacceptance.Variables  p * OR95%CIforOR LowerUpperGroup<0.0017.7574.94912.159HavingheardofHPVvaccine <0.0012.9602.0324.311 * Multiplelogisticregression.  Table6 ThefactorsthatdeterminetherequestoftheHPVvaccinationaccordingtothegroups.Group  p * OR95%CIforOR LowerUpperNursingstudentsHavingheardHPVvaccine<0.0013.0922.0164.742ControlgroupAge0.0020.7320.5990.894KnowledgeofrelationbetweenHPVandcervicalcancer<0.0014.9882.13411.660 * Multiplelogisticregression.  Ö.Uzunlaretal./Vaccine  31 (2013) 2191–2195  2195 withourresults,Beyda˘g   etal.reportedthat78.1%ofthenursesincludedinthestudywantedtobevaccinated[11].IntheNigerian study,despitepoorknowledgeoftheHPVvaccinesamongnurses,mostofthemexpressedastrongdesiretobevaccinatedandhadtheintentiontorecommendittopreadolescentgirls[13].Nganwai etal.reportedthat66.2%ofthenurseswouldliketobevaccinated.However,onethirdoftherespondentsdidnotwanttobevacci-nated,becausetheywereunsureofitsefficacy(55.6%)andthoughttheyhadnoriskofHPVinfection(44.4%)andwereafraidofadverseeffectsofthevaccine(28.9%)[3].Inconclusion,ourstudyshowedthatawarenessandknowledgeaboutHPV,anditsrelationwithcervicalcancerandpreven-tionofcervicalcancerbyHPVvaccinationisquitesatisfactoryamongnursingstudentsinAnkara,Turkey.However,therearestillsomegapsintheuseofthisinformationinthepracticalapplicationsbythenurses,suchasnothavingregulargynecologicexamsandPapsmears.Healthcareprofessionalsarethemselvesresponsibletoeducatethegeneralpopulationaboutcervicalcan-cerscreening.People’sacceptanceofscreeningandvaccinationisstronglyassociatedwiththeirperceptionsoftheattitudesofhealthcareprofessionals.Thus,furtherstudiesareneededtoevaluatethefactorsthataffecttheapplicationsofcervicalcancerscreeningandHPVvaccinationamonghealthcareprofessionals.  Acknowledgments Wearegratefultoalltheparticipantswho   kindlyagreedtoparticipateinoursurvey.Nofundingwasreceivedforthestudy. 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