Using knowledge interventions to determine stress and future preventative behaviour regarding cervical cancer and the human papilloma virus

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1 Using knowledge interventions to determine stress and future preventative behaviour regarding cervical cancer and the human papilloma virus Clare Austin (Psychology) Cervical cancer, the human papilloma virus (HPV) and cervical screening have recently become a target for mass media attention. Partially due to recent events, one example being the debate as to whether the National Health Service should lower the age that cervical screening begins (Department of Health 2009). Additionally, the human papilloma virus vaccine has recently been introduced in schools, which aims to target young girls before they start having sexual intercourse. Media attention, such as this, can have benefits, particularly in bringing awareness to a potentially life-threatening condition and emphasising the importance of taking preventative behaviours. However, when a sensitive subject matter receives mass media attention, great harm can also be caused, such as inducing fear (Clarke and Everest 2006). Cervical Screening and Cervical Cancer Cervical cancer is one of the less common cancers, it is very rare in young women, with the peak age being from ages years old (NHS Choices 2009). It is treated successfully in approximately two thirds of cases in the UK if detected in its early stages. It is also preventable, most women will have heard of cervical cancer, however, few know about the human papilloma virus and its links to cervical cancer (Denny-Smith, Bairan and Page 2006; Fernbach 2002; Mays, Zimet, Winston, Kee, Dickes and Su 2000; Walsh 2006). The human papilloma virus is an extremely common sexually transmitted disease causing genital warts, estimated to affect over half of all sexually-active women in the UK. Under twenty-five percent of cases of the human papilloma virus have been known to cause cervical cancer, however 99% of cervical cancers have been caused by the human papilloma virus strains 16 and 18 in 70% of women. In most cases, however, it is harmless and does not require treatment (NHS Immunisation 2010). Cervical screening has been described as secondary prevention, although extremely important and hugely effective in detecting abnormal cell changes, such as those caused by the human papilloma virus, before they become cancerous. Currently cervical screening is offered to women from ages 25 and over and is repeated every 3 years. This has been found to be extremely successful in saving many women s lives, preventing up to 75% potential cervical cancers, and seems adequate regarding the fact that cell changes can take up to 10 years to develop into cervical cancer. In addition to this, younger women s cervixes are still developing with cells under constant change, which may be 1

2 mistaken in screening for cell changes associated with the human papilloma virus, possibly leading to unnecessary treatment (NHS Choices 2009). Cervical screening tests are also sometimes misunderstood in terms of their purpose. It has been found that many women believe that this test is done to diagnose cervical cancer, hence leading to unnecessary anxiety when women get an abnormal result (Bekkers, van der Donck, Klaver, Minnen and Massuger 2002; Lagro-Janssen and Schijf 2004). Cervical screening tests merely detect abnormal cell changes in the cervix caused by the human papilloma virus, which, if left untreated, may develop into cervical cancer in the future. However, this process usually takes up to ten years (NHS Choices 2009). Many studies have looked at attendance for cervical screening (Bish, Sutton and Golombok 2000; Eiser and Cole 2002; Sheeran and Orbell 2000; Walsh 2006). Additionally to promoting cervical screening, studies aimed at reducing fear surrounding cervical cancer have been carried out. Holloway, Wilkinson, Peters, Russell, Cohen, Hale, Rogers and Lewis (2003) showed that the majority of women who had never had an abnormal cervical screening test result still perceived cervical cancer to be far more common than it was and wished to have their cervical screening test at unrealistically frequent intervals and found that a communication package left women feeling reassured and more comfortable with the standard 3 year interval. The Human Papilloma Virus (HPV) and Cervical Cancer Primary prevention also needs to be emphasised. This involves preventing the spread of the human papilloma virus by highlighting the association between the human papilloma virus and cervical cancer and promoting safe sex as a means of prevention. The human papilloma virus vaccination is also being offered to young girls in school, designed to reach girls before they start having sexual intercourse (Immunisation 2010). However, this vaccination only protects girls from the two most common strains of the human papilloma virus, strains 16 and 18. Therefore, safe sex and regular cervical screening tests are still required to prevent the spread of the human papilloma virus (NHS Choices 2009). The lack of knowledge about these potentially life-saving facts has led to many studies in this area (Denny-Smith et al. 2006; Fernbach 2002; Mays et al. 2000; Walsh 2006). A study by Denny-Smith et al. (2006) assessed female nursing students knowledge of perceived susceptibility, perceived seriousness and risk behaviours regarding the human papilloma virus and cervical cancer. Researchers were surprised at the nursing students lack of knowledge about 2

3 cervical cancer and the human papilloma virus. These findings are consistent with a previous study (Ingledue et al. 2004, cited in Denny-Smith, Bairan and Page 2006) which found that women with increased knowledge of the human papilloma virus were more likely to attend cervical screening tests, emphasising the importance of education about the human papilloma virus and its links with cervical cancer. Anxiety Regarding Cervical Cancer and Cervical Screening As mentioned previously, cervical cancer, the human papilloma virus and cervical screening have received mass media attention recently and although this can help to promote awareness of cervical cancer and the human papilloma virus and encourage women to attend screening (Fernbach 2002), it can also cause fear. Clarke and Everest (2006) described and analysed the way in which cancer is portrayed in the mass media finding that cancer and fear were conflated through the use of fear stories. Studies have shown that cervical screening tests are sometimes misunderstood in terms of their purpose. In the study by Walsh (2006) found that 78% of women believed that the purpose of a cervical screening test was to diagnose cervical cancer, leading to unnecessary anxiety when women get abnormal results (Bekkers et al. 2002; Lagro-Janssen and Schijf 2004). Since the information materials do not specify the preventative nature of screening, women tend to think that abnormal test results mean that they have cancer (Lagro-Janssen and Schijf, 2004). Two studies have been conducted in The Netherlands (Bekkers et al. 2002; Lagro-Janssen and Schijf 2004) regarding cervical screening tests and anxiety. A study conducted by Lagro-Janssen and Schijf (2004) examined 27 women with abnormal cervical screening test results, revealing that cervical screening produces a great deal of anxiety in women, especially when receiving abnormal results. The present study recognises the need to promote cervical screening attendance, awareness of the human papilloma virus and resolve anxiety about cervical cancer in particular. This study aimed to investigate whether a knowledge intervention containing relevant facts about the human papilloma virus, cervical cancer and cervical screening could influence stress levels regarding cervical cancer and the human papilloma virus, as measured by the Impact of Events Scale (Horowitz et al. 1979) and behavioural intentions to attend cervical screening tests, as measured by the Theory of Planned Behaviour variables (Ajzen 1985, 1991). The theory of planned behaviour implies that people s attitudes are formed after careful consideration of the available information. According to the theory of planned behaviour, intentions are determined by attitudes, subjective norms and 3

4 perceived behavioural control. This is believed to provide a good prediction of behaviour (Connor and Norman 2005). It was predicted that the participants in the knowledge intervention, receiving correct information about the human papilloma virus, cervical cancer and cervical screening would differ on rates of subjective stress, measured by the Impact of Events Scale (Horowitz et al. 1979), by scoring lower due to the facts about cervical cancer and the human papilloma virus been gained, decreasing stress and score higher on intentions to attend cervical screening tests, as measured by the Theory of Planned Behaviour variables (Ajzen 1985, 1991) making participants more likely to attend cervical screening tests due to learning of their effectiveness in preventing cervical cancer than those in the non-intervention group receiving no knowledge. Method Design A between and within subjects design was used. All participants received a baseline questionnaire assessing their current lifestyle and knowledge about the human papilloma virus, cervical cancer and cervical screening. These measures were repeated after the knowledge intervention. Participants were randomly assigned to an intervention group or a non-intervention group, where they received the same knowledge questions about the human papilloma virus, cervical cancer and cervical screening via the knowledge intervention. However, those in the intervention group received the correct answers to each question after submitting their answer along with further information, whereas those in the non-intervention group did not until after the study was completed and they were debriefed. Participants Participants consisted of 100 female undergraduate students from the University of Central Lancashire in Preston aged from 18 to 25 (M=20.97). The study contained 100 participants at baseline, with a 62% response rate for the second questionnaire, giving a total sample of 62 women completing both stages of the study, 31 in the intervention group and 31 in the non-intervention group. The participants were selected on the university campus using opportunity sampling. Materials The study used a baseline questionnaire asking participants about their current lifestyle and preexisting knowledge about the human papilloma virus and cervical cancer. Participants subjective stress regarding cervical cancer and the human papilloma virus was measured using the questions selected from the Impact of Events Scale (Horowitz et al. 1979), tested for their reliability using 4

5 Cronbach s α. This measured participants subjective stress in regards to intrusion (α=.885) and avoidance (α=.827) regarding cervical cancer and the human papilloma virus. The questionnaire also used questions from the Theory of Planned Behaviour (Ajzen 1985, 1991) to measure participants current behavioural predictability towards attending cervical screening tests in terms of their attitude towards behaviour, (α=.554), belief composites (α=.286), subjective norm (α=.282) and perceived behavioural control (α=.326). The knowledge intervention was an online quiz, which participants completed in between the baseline questionnaire and the second questionnaire. This contained questions about the human papilloma virus, cervical cancer and cervical screening. To debrief, a leaflet was ed to participants containing all the relevant information about the human papilloma virus, cervical cancer and cervical screening and a debriefing statement with contact details if participants required any further information. Procedure The independent variables in this study were whether participants completed the intervention knowledge quiz, with access to the correct information, or the non-intervention knowledge quiz, without the correct information available. The dependent variables were therefore the participants rates of stress regarding the human papilloma virus and cervical cancer measured by the Impact of Events Scale (Horowitz et al. 1979) and their predictive variables regarding cervical screening attendance according to the Theory of Planned Behaviour (Ajzen 1985, 1991). Once ethical consent had been gained, participants were recruited by means of opportunity sampling. Consent was given by participants filling in their address on a consent form, they then filled in the baseline questionnaire. One week later participants were randomly allocated to the intervention or the nonintervention group, and were ed with a link to the either the intervention or the nonintervention online knowledge intervention and the second questionnaire. Participants then completed the knowledge intervention consisting of questions about the human papilloma virus, cervical cancer and cervical screening. After completion, participants were then measured using the same Impact of Events Scale (Horowitz et al. 1979) regarding the human papilloma virus and cervical cancer and the same Theory of Planned Behaviour (Ajzen 1985, 1991) measures regarding their intentions to attend cervical screening tests in the second questionnaire online. They were then thanked and instructed to download a leaflet containing all the relevant information about the human papilloma virus, cervical cancer and cervical screening. 5

6 Results The mean scores and standard deviations of intrusion and avoidance regarding the human papilloma virus and cervical cancer measures by the Impact of Events Scale pre- and post-knowledge intervention (Horowitz et al. 1979) are shown below (Tables 1-4). Table 1 Human Papilloma Virus Mean Standard Deviation Intrusion- Pre Intervention Intervention Non Intervention Total Intrusion- Post Intervention Intervention Non Intervention Total Table 2 Human Papilloma Virus Mean Standard Deviation Avoidance- Pre Intervention Intervention Non Intervention Total Avoidance- Post Intervention Intervention Non Intervention Total Table 3 Cervical Cancer Mean Standard Deviation Intrusion- Pre Intervention Intervention Non Intervention Total Intervention Intrusion- Post Intervention Non Intervention Total

7 Table 4 Cervical Cancer Mean Standard Deviation Avoidance- Pre Intervention Intervention Non Intervention Total Avoidance- Post Intervention Intervention Non Intervention Total Additionally, the mean scores and standard deviations of attitude towards behaviour (Table 5), belief composites (table 6), subjective norms (table 7) and perceived behavioural control (table 8) regarding cervical screening according to the Theory of Planned Behaviour (Ajzen 1985, 1991) are given. The scores are shown in terms of the pre and post intervention and the intervention group and the non-intervention group. Table 5 Cervical Screening Mean SD Attitude Towards Behaviour - Pre Intervention Attitude Towards Behaviour- Post Intervention Intervention Non-intervention Total Intervention Non-intervention Total Table 6 Cervical Screening Mean SD Belief Composites- Pre Intervention Belief Composites- Post Intervention Intervention Non-intervention Total Intervention Non-intervention Total

8 Table 7 Cervical Screening Mean SD Subjective Norm- Pre Intervention Subjective Norm- Post Intervention Intervention Non-intervention Total Intervention Non-intervention Total Table 8 Cervical Screening Mean SD Perceived Behavioural Control- Pre Intervention Perceived Behavioural Screening- Post Intervention Intervention Non-intervention Total Intervention Non-intervention Total A series of mixed model 2 (group status) x2 (time) ANOVAs were conducted to examine whether the knowledge intervention had a significant effect on the impact of event scales measuring stress of the human papilloma virus and cervical cancer according to the Impact of Events Scale (Horowitz et al. 1979) and the Theory of Planned Behaviour (Ajzen 1985, 1991) to predict cervical screening test attendance. The mixed model ANOVAs tested whether there was a between-subjects effect to compare group status, i.e. intervention group versus the non-intervention group and also a withinsubjects effect of time, i.e. participant s pre- and post-intervention knowledge. The results showed that there was no significant main effect for intrusion stress in relation to the human papilloma virus for group status (F1,60=.23=0.63), however there was a significant main effect or for the time (F1,60=10.62, p=.00), showing that participants had significantly lower scores of intrusion stress regarding the human papilloma virus pre-intervention (M=0.50, SD=1.66) than post intervention (M=1.32, SD=2.65), no significant interactions were found for the group status and time (F1,60=.49, p=.49). In regards to avoidance stress regarding the human papilloma virus there was no significant main effect for group status (F1,60=1.52, p=.22), yet there was a significant main effect for time (F1,60=8.56, p=.00) showing had significantly less avoidance stress regarding the 8

9 human papilloma virus pre-intervention (M=0.89, SD=2.43) than they did post-intervention (M=1.74, SD=3.09) and there was no significant interactions (F1,60=.00, P=.96). There was no significant effect for intrusion stress regarding cervical cancer for group status (F1, 60= 1.52, P=.22), for time (F1, 60=.58, p=.54) or interaction effects (F1, 60=.06, p=.80). For avoidance stress regarding cervical cancer, there was no significant effect for group status (F1, 60=.28, p=.60), time (F1, 60=1.04, p=.21) or interactions (F1,60=1.04, p=.21). In regards to the theory of planned behaviour variables to predict cervical screening attendance, for attitudes towards behaviour there was no significant effect for group status (F1,60=.17, p=.68) yet there was for time (F1,60= 4.60, p=.04) with participants pre intervention scoring significantly lower (M=5.08, SD=1.8) than post intervention (M=5.58, SD=1.45) and there was no significant interactions (F1,60=.39, p=.54). There was no significant effect for belief composites for group status (F1,60= 1.22, p=.28), time (F1,60=.68, =.41) or interactions (F1,60=.01, p=.91). There was no significant effect for subjective norms for group status (F1, 60=1.32, p=.26) yet a significant interaction for time (F1,60= , p=.00) showing participants scored significantly lower pre intervention (M=1.52, SD=1.22) than post intervention (M=14.53, SD=2.02) and there was no significant interactions (F1,60=.41, p=.52). There was no significant effect for perceived behavioural control for group status (F1, 60=.28, p=.60), time (F1,60=.85, p=.36) and there was no significant interaction (F1,60=.85, P=.36). A correlation matrix was used to see whether there were significant correlations between intrusion according to Impact of Events Scale (Horowitz et al. 1979) for the human papilloma virus and cervical cancer at pre-intervention and post intervention and the sub scales of the theory of planned behaviour variables. There were no significant correlations between the intrusion scores for the human papilloma virus at pre-intervention and the subscales of the theory of planned behaviour variables. There were significant correlations between the predictor variables however. There was a negative correlation between attitude towards behaviour and subjective norm at pre-intervention (r=-.220, DF=100, p<0.05). Significant positive correlations between attitude towards behaviour pre-intervention and attitude towards behaviour at post-intervention (r=.392, DF=62, p=<0.01). Significant negative correlation between belief composites pre-intervention and subject norms pre-intervention (r=-.346, DF=100, p<0.01). Significant correlation for belief composites pre-intervention and attitude towards behaviour post intervention (r=.272, DF=62, P<0.05). Significant positive correlation between belief composites post-intervention and attitudes towards behaviour post-intervention (r=.428, DF=62, 9

10 p<0.01). There was also a significant positive correlation between perceived behavioural control post-intervention and subjective norms post-intervention (r=1.00, DF=62, P<0.01). There was evidence of collinearity between the criterion variable, cervical cancer intrusion and belief composites pre-intervention (r=-.255, DF=100, p,0.05). A forward stepwise multiple regression was used. The first entered was belief composites at explaining 15% of variance (r=0.15) in cervical cancer intrusion at pre-intervention (F1, 61= , p<0.001). Belief composites post-intervention was entered second explaining a further 7.6% of variance (r=.076) in cervical cancer intrusion preintervention (F2, 61=8.417, p=<0.01). There was significant correlations between the criterion variable, human papilloma virus intrusion at post-intervention and belief composites at pre-intervention (r=-.275, DF=62, p=0.05). It explained belief composites pre-intervention entered first 7.6% of variance (r=0.076) in human papilloma virus intrusion at post-intervention (F1, 61=4.900, P=<0.05). Attitude towards behaviour at postintervention was entered second explaining a further 11.2% of variance (r=0.112) towards human papilloma virus intrusion at post-intervention (F2, 61=4.851, p=<0.05). Perceived behaviour control at pre-intervention was entered third explaining a further 16% of variance (r=0.16) towards human papilloma virus at post-intervention (F3, 61=4.866, p<0.01). There was a significant negative correlation between the criterion variable cervical cancer intrusion at post-intervention and belief composites pre-intervention (r=-.438, DF=62, p=<0.01). Significant correlations between cervical cancer intrusion at post-intervention and subjective norm at preintervention (r=.384, DF=62, p<0.01). Belief composites at pre-intervention was entered first showing 19.2% variance (r=0.192) towards cervical cancer intrusion at post-intervention (F1, 61=14.256, p<0.01). Belief composites at post-intervention was entered second explaining a further 23% of variance (r=0.23) towards cervical cancer intrusion at post-intervention (F2, 61=10.159,p< 0.01). Discussion Knowledge Regarding Cervical Screening In terms of the knowledge intervention, in regards to cervical screening, there was a lack of knowledge in terms of cervical screening s objective, consistent with the previous study by Walsh (2006). There was also a lack of knowledge about how often cervical screening tests should be attended consistent with Holloway et al. (2003) study. Additionally, most participants incorrectly 10

11 believed that all abnormal cell changes needed treatment. Cervical screenings effectiveness at preventing cervical cancer was also incorrectly estimated and what an abnormal cervical screening test result would mean, consistent with the findings by Walsh (2006). Knowledge Regarding the Human Papilloma Virus In answering questions about the human papilloma virus, most participants incorrectly estimated a woman s likelihood of contracting the human papilloma virus, consistent with previous findings (Ramirez et al. cited in Fernandez-Esquer, Ross and Torres 2000). Therefore the actual risk of the human papilloma virus was not associated with women s perception of risk. Most also failed to estimate how many cervical cancers are caused by the human papilloma virus or how many human papilloma viruses had been known to cause cervical cancer consistent with previous studies (Vail- Smith and White 1992, cited in Denny-Smith et al. 2006). However, most participants knew that the human papilloma virus was passed on through sexual intercourse, going against the previously mentioned study s findings (Ramirez et al. cited in Fernandez-Esquer, Ross and Torres 2000) reporting a lack of knowledge in regards to the human papilloma virus s modes of transmission, suggesting much more awareness in the present study. Most participants also correctly stated that not all human papilloma viruses will lead to cervical cancer, also contradicting earlier findings (Vail-Smith and White 1992, cited in Mays et al. 2000). Most correctly knew that the human papilloma virus vaccine does not give you complete protection from the human papilloma virus and most knew it was safe. Knowledge Regarding Cervical Cancer In terms of cervical cancer knowledge, most women failed to estimate the rate of cervical cancer among women in the UK per year, consistent with Holloway et al. (2003). Most also failed to recognise the risk factors associated with cervical cancer, consistent with Mays et al. (2000). However, most correctly knew that cervical cancer was uncommon among young women, this is unexpected as it was not correctly estimated in terms of rates of cervical cancer in women in the UK and the recent media controversies about bringing the screening age down would have been expected to influence women in terms of overestimating its prevalence. The majority correctly guessed cervical cancer s mortality rate, however as the rate of cervical cancer was not guessed correctly it suggests that it is thought that a much higher or lower percentage of those affected will 11

12 die from the disease. Most correctly identified preventative measures against cervical cancer, which is encouraging. Stress Regarding the Human Papilloma Virus When looking at the effectiveness of the knowledge intervention. Results showed that subjective stress subscales of intrusion and avoidance measured by the impact of events scale regarding the human papilloma virus and cervical cancer was no different for those in the intervention group or the non-intervention group. Therefore those that received the answers to the questions regarding cervical screening, the human papilloma virus and cervical cancer did not differ in stress levels regarding these issues. There were significant differences shown between the intrusion stress and avoidance stress in relation to the HPV for time. Levels of intrusion stress and avoidance stress were significantly higher post-intervention, suggesting that the knowledge intervention heightened participants stress. This could be due to a lack of knowledge previously to the human papilloma virus and an increased awareness due to the knowledge intervention. This is consistent with other previous studies reporting a lack of knowledge regarding the human papilloma virus (Mays et al. 2000; Denny-Smith et al. 2006). Stress Regarding Cervical Cancer There were no significant differences in intrusion and avoidance stress for time regarding cervical cancer suggesting that the intervention had no effect on participants stress pre- and postintervention. There was no interaction effect between the group and time, therefore indicating that participants did not differ in scores as a result of the intervention group and the pre- and postintervention times. This is possibly due to more pre existing knowledge regarding cervical cancer. However, it is not consistent with previous studies (Holloway et al. 2002) bringing more awareness of cervical cancer and lowering stress. Predictive Variables Regarding Cervical Screening Attendance Results from the knowledge intervention show that there were no significant differences in predictive variables according to the theory of planned behaviour in regards to cervical screening for attitudes towards behaviour, belief composites, subjective norm or perceived behavioural control for those in the intervention group or those in the non-intervention group. Hence, suggesting that the intervention did not affect those in the intervention group in terms of their predictive variables to screen any differently to those in the non-intervention group. There were no significant differences between belief composites and perceived behavioural control for time meaning that 12

13 participants did not alter in terms of their predictive variables pre and post intervention. However, there were significant differences regarding time for attitudes towards behaviour and subjective norms scoring higher post-intervention. Hence, suggesting that the knowledge intervention had an effect on these predictive variables in relation to attending cervical screening tests. There was no interaction effect between the group and time, therefore indicating that participants did not differ in scores as a result of the intervention group and the pre- and post-intervention times. These findings therefore indicate a promotion of cervical screening similar to previous findings (Fernbach 2002; Holloway et al. 2003, Sheeran and Orbell 2000). Limitations in this area of study include small sample sizes meaning that results cannot therefore be generalised. In regards to the participants themselves, studies such as this are of an intimate nature, possibly determining the selection of participants taking part in this study. Additionally to this, small time frames limit the effectiveness of the intervention, possibly not allowing the intervention to take full effect on participants attitudes. As this study is merely investigating intentions to attend cervical screening, unlike studies using measures of behaviour such as medical records and laboratory and health authority databases to measure screening attendance (Holloway 2003; Walsh 2006), these intentions may not be carried out. Distinctions have to therefore be made between inclined actors, those who intend to perform a particular behaviour and carry out the behaviour and inclined abstainers, those who intend to perform behaviour but do not (Bish et al. 2000). The subscales for the Theory of Planned Behaviour (Ajzen 1985, 1991) also reported to be unreliable therefore possibly affecting findings relating to intentions to attend cervical screening test. Implications taken from this study and previous studies include the need to increase knowledge about cervical screening tests and the human papilloma virus. There appears to be better awareness of cervical cancer but less about the human papilloma virus and its associations with cervical cancer and cervical screenings effectiveness in preventing cervical cancer. Due to the sensitive subject matter that is involved however, stress also needs to be taken into account and while increasing awareness of the human papilloma virus, women also need to be reassured of preventative measures. In regards to cervical cancer, there is an awareness, it would appear from the present study, therefore while maintaining that, the low prevalence rates and preventative measures must be emphasised to relieve stress and prevent behaviours such as over screening. Better communication from professionals must also be emphasised. 13

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