Impact of psychosocial issues on cervical cancer prevention among Chinese women in Hong Kong

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1 Impact of psychosocial issues on cervical cancer prevention among Chinese women in Hong Kong Annie NY CHEUNG MBBS, MD, PhD, FRCPath, FHKAM(Path), FIAC, IFCAP Laurence L T Hou Professorship in Anatomical Molecular Pathology Department of Pathology, The University of Hong Kong Queen Mary Hospital, Hong Kong

2 Disclosures No financial relationships or conflict of interest to disclose

3 CHINA Hong Kong Area: 1,104 km 2 Population: 7,234,800

4 Trend of Age-standardised Incidence and Mortality Rates of Cervical Cancer in Hong Kong, new cases (2014), 131 death (2014) Rank 8 th in incidence and 9 th in mortality A successful example of opportunistic screening. Dept of Health, HKSAR 2017 Cancer Registry, HA, HKSAR

5 Impact of psychosocial issues on cervical cancer prevention among Chinese women in Hong Kong Barriers and facilitators to HPV vaccination among Chinese adolescent girls Acceptability of HPV vaccination among Chinese women Effect of de-stigmatising Effect of school-based cervical cancer education on perceptions towards HPV vaccination Psychological burden of positive high-risk HPV on women with atypical cervical cytology HPV vaccine: what are women most concerned about Assessment of knowledge and stigmatizing attitudes related to HPV among Hong Kong Chinese healthcare providers.

6 Barriers and facilitators to HPV vaccination among Chinese adolescent girls in Hong Kong Study to explore perceptions towards cervical cancer, HPV infection and HPV vaccination and to identify factors affecting the acceptability of HPV vaccination among Chinese adolescent girls in Hong Kong. Focus groups were conducted with Chinese adolescent girls in Hong Kong. Thematic analysis was employed to identify major themes related to cervical cancer and HPV vaccination. A supplementary questionnaire was administered to all participants before and after group discussion to assess their knowledge, attitudes and intention to be vaccinated and to collect demographic information. Kwan et al. Sex Transm Infect. 2008

7 Kwan et al. Sex Transm Infect. 2008

8 Kwan et al. Sex Transm Infect. 2008

9 Kwan et al. Sex Transm Infect. 2008

10 Barriers and facilitators to HPV vaccination among Chinese adolescent girls in Hong Kong Participants' knowledge on cervical cancer was limited and HPV was largely unheard of. They had difficulty understanding the mechanism linking cervical cancer with HPV infection. Participants held a favourable attitude towards HPV vaccination but the perceived timing of vaccination varied. The differences on knowledge, attitudes, intention to be vaccinated now and willingness to conform to significant others before and after the discussion were statistically significant, with an increased tendency towards favouring vaccination after the focus group. Kwan et al. Sex Transm Infect. 2008

11 Barriers and facilitators to HPV vaccination among Chinese adolescent girls in Hong Kong Barriers to vaccination high monetary cost uncertain length of vaccine effectiveness low perceived risk of HPV infection no immediate perceived need of vaccination anticipated family disapproval fear of the pain of injection. Facilitators to vaccination perceived family and peer support and medical reassurance on safety and efficacy of vaccine Kwan et al. Sex Transm Infect. 2008

12 Acceptability of HPV vaccination among Chinese women: concerns and implications Ethnic Chinese women 18 attended community women's health centres. 1/3 participants had heard of HPV and 1/2 had heard of vaccination against cervical cancer. HPV infection was perceived to be stigmatising and detrimental to intimate, family and social relationships. 88% of the participants indicated wish to be vaccinated. Majority of the participants believed that sexually experienced women should be vaccinated, while 27% opposed vaccinating sexually naive women. Younger age women who perceived a disruptive impact of HPV infection on intimate relationship and their partners' approval were significantly associated with a positive intention to be HPV vaccinated. Kwan et al. BJOG. 2009

13 Kwan et al. BJOG. 2009

14 Kwan et al. BJOG. 2009

15 Acceptability of HPV vaccination among Chinese women: concerns and implications There is a dire need for culturally sensitive and tailored education for the public, women of different ages and their partners about HPV and HPV vaccination. Emphasis must be placed on the prophylactic nature of the current vaccines, the uncertain effects when given to sexually experienced women, the importance of adolescent vaccination and the need for continued cervical screening whether vaccinated or not. Kwan et al. BJOG. 2009

16 De-stigmatising HPV in the context of cervical cancer Study to identify the components of a HPV message contributing to the stigma of HPV in cervical cancer. Chinese women attending a community-based clinic in Hong Kong were randomly allocated to read 1 of 3 written HPV messages: 1. Group 'lr+hrhpv': low-risk and high-risk HPVs facts 2. Group 'hrhpv': high-risk HPV facts only 3. Group 'ds+hrhpv': high-risk HPV facts and de-stigmatising components, namely being anti-stereotypical, motivational and low in complexity Main outcome measures were high-risk HPV-related sexual stigma, knowledge, attitude towards message, and intention to be HPV-tested measured by selfadministered questionnaires immediately before and after reading. Kwan et al. Psychooncology. 2010

17 De-stigmatising HPV in the context of cervical cancer Message allocation had a significant effect on sexual stigma. Kwan et al. Psychooncology Participants who read message ds+hrhpv showed the least stigma, and were significantly less likely to believe that high-risk HPV infection implicated promiscuity, non-monogamy or that monogamy offered complete protection against high-risk HPV. The genital HPV-focused message was more stigmatising than cervical cancerfocused messages. HPV message containing specific de-stigmatising components may reduce public stigma towards high-risk HPV. Focusing solely on high-risk HPV in the context of cervical cancer helps to avoid the stigmatising effect of genital warts from tainting perceptions about high-risk HPV infection.

18 The effect of school-based cervical cancer education on perceptions towards HPV vaccination among Hong Kong Chinese adolescent girls Study to evaluate the effects of school-based cervical cancer education on Hong Kong Chinese adolescent girls. Local secondary school students attended a tailored educational program on cervical cancer prevention. Self-administered questionnaires were used before and after the program. Kwan et al. Patient Educ Couns. 2011

19 Kwan et al. Patient Educ Couns. 2011

20 Before the program, HPV vaccine acceptance was favorable but relevant knowledge was low. After the program, participants had greater knowledge and a more positive attitude, with more girls anticipating family. There were more girls who indicated an intention to accept the vaccine afterward. Kwan et al. Patient Educ Couns. 2011

21 Kwan et al. Patient Educ Couns. 2011

22 The effect of school-based cervical cancer education on perceptions towards HPV vaccination among Hong Kong Chinese adolescent girls More knowledge, a more positive attitude and perceived support from significant others predicted a stronger intention to be HPV vaccinated. Educational program had a positive impact on participants perceptions towards HPV vaccination and their intention to be vaccinated. School-based cervical cancer education is a viable means to meet the substantial educational needs of adolescents. Promotion of HPV vaccination should include educating and influencing perceptions of families and peers. Kwan et al. Patient Educ Couns. 2011

23 HPV test for Triage of atypical squamous of undetermined significance (ASCUS) ASCUS was found in 3-4% of cervical cytology. ASCUS account for 60-80% of all abnormal cytology Women with ASCUS has higher risk of subsequent confirmation of LSIL or HSIL compared with general women population Cheung et al. Cancer Cytopathology 2004

24 HPV test for Triage of ASCUS anxiety of patients cost of repeat smears Earlier diagnosis of HSIL + cases HKCOG Guidelines 2002, 2008, 2016

25 Psychological burden of testing positive for high-risk HPV on women with ASC-US At result notification, the HPV +ve group had significantly higher state anxiety, cervical cancer worry and psychosocial burden than the HPV neg group. Irrespective of the HPV results, all outcome scores over time. At 6 months, no difference between the 2 in state anxiety, cervical cancer worry, perceived risk of cervical cancer and satisfaction with intimate relationship. Psychosocial burden remained higher in the HPV-positive group Kwan et al. Acta Obstet Gynecol Scand. 2011

26 Kwan et al. Acta Obstet Gynecol Scand. 2011

27 Knowledge and stigmatizing attitudes related to HPV among Hong Kong Chinese healthcare providers. Questionnaire to doctors, nurses, and smear-taking trainees providing cervical screening in Hong Kong. Most participants had basic knowledge about HPV infection and HPV vaccination. 1/3 knew that HPV infection is most common among young women, or infected individuals might not have any identifiable sexual risk factors. 1/3 agreed that individuals with HPV infection were sexually easy, responsible for their infection, or had more than 1 sexual partner. A lack of understanding of the indications for HPV testing and the implications of a positive result. Continued education on HPV and HPV testing is needed for frontline healthcare providers of screening in Hong Kong. More knowledge about HPV infection predicted less stigmatizing attitudes. Kwan et al. Int J Gynaecol Obstet. 2012

28 HPV vaccine: what are women most concerned about? Chan et al. J Obstet Gynaecol Res A cross-sectional questionnaire survey conducted in 1450 women attending outpatient family planning clinics in Hong Kong to investigate the areas of concerns that women have regarding HPV vaccination.

29 Top 3 factors that most women felt very important were: - vaccine effectiveness (45.4%) - effect duration (44.0%) - long-term side-effects(43.7%) Chan et al. J Obstet Gynaecol Res. 2012

30 - Education level significantly affected the degree of concerns in these areas - Income was significantly inversely associated with the importance of cost and effectiveness. Chan et al. J Obstet Gynaecol Res. 2012

31 Chan et al. J Obstet Gynaecol Res. 2012

32 HPV vaccine: what are women most concerned about? Chan et al. J Obstet Gynaecol Res A cross-sectional questionnaire survey conducted in 1450 women attending outpatient family planning clinics in Hong Kong to investigate the areas of concerns that women have regarding HPV vaccination. Such issues should be specifically addressed when vaccine information is given, bearing in mind the particular concerns in women with different socio-economic backgrounds.

33 Summary Continued education on cervical cancer, HPV vaccine and HPV testing is necessary for general public including females of different age groups and male population as well as frontline healthcare providers in Hong Kong. It is necessary to raise adolescents' perceived need to take preventive measures against HPV infection. De-stigmatising messages should be considered in education material to enhance compliance to HPV vaccinations and tests.

34 Thank you!!

HPV Knowledge Survey Healthcare Providers

HPV Knowledge Survey Healthcare Providers 1. What is your age? m 20-24 m 25-35 m 36-45 m 46-55 m 56-65 m 66-75 2. What is your gender? m Male m Female m Other 3. Which ethnic group do you identify with (please tick all that apply)? m New Zealand