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1 KNOWLEDGE OF HPV AND HPV VACCINATION AND THE ASSOCIATED FACTOR AMONG PRIMIGRAVIDAS IN A TERTIARY HOSPITAL Noor Sa adah Azmin 1, Kasmah Wati Pardi 2* 1 The National Heart Institute of Malaysia (IJN). 2 Nursing Programme, School of Health Sciences, Universiti Sains Malaysia. *Corresponding author: Kasmah Wati Pardi, PhD, School of Health Sciences, USM Health Campus, Kubang Kerian, Kota Bharu, Kelantan. kasmah_wati@usm.my ABSTRACT Background: Human papillomavirus (HPV) is the most common sexually transmitted infection which is linked to cervical cancer. Thus, there is a great need to prevent the cancer through HPV vaccination. However, knowledge about HPV and HPV vaccination among women is still lacking. The study aimed to assess the level of knowledge about HPV and HPV vaccination among primigravidas. It also examined the association between educational level and the level of knowledge about HPV and HPV vaccination. Materials and Methods: A self-administered questionnaire to assess knowledge on HPV and HPV vaccination was used in this cross-sectional study. The participants consisted of 161 primigravidas who attended an antenatal clinic of a tertiary hospital. Data were analysed in terms of frequencies and percentages using SPSS version Pearson Chi-square test was used to determine the association between educational level and level of knowledge about HPV and HPV vaccination. Result: Out of 161 respondents who completed the questionnaire, 72 (44.7%) of the respondents had good level of knowledge on HPV and HPV vaccination, whereas 89 (55.3%) of them had poor level of knowledge on HPV and HPV vaccination. Analysis of Pearson Chisquare test showed that there is no significant association between educational level and level of knowledge about HPV and HPV vaccination (p >.05). Conclusion: This study showed the primigravidas had poor knowledge on HPV and HPV vaccination. However, no significant association was found between educational level and level of knowledge about HPV and HPV vaccination. Therefore, a structured educational programme to improve the knowledge of the primigravidas is highly recommended. It is crucial for the primigravidas to have strong knowledge on HPV and HPV vaccination as they will be heavily involved in the HPV vaccination programme. Keywords: Human Papilloma Virus, Cervical Cancer, Primigravida, Knowledge, Nurses. Noor Sa adah Azmin, Kasmah Wati Pardi 57

2 1.0 Introduction Human papillomavirus (HPV) is the most common sexually transmitted infection linked to cancer of the cervix. In 2012, it was reported that new cases of cervical cancer in Malaysia was 2,145 and it was ranked as the second most common cancer among Malaysian women aged 15 to 44 years (Bruni et al., 2016). The death rate for cervical cancer in Malaysia was reported at 5.9% out of 10,300 deaths for women in 2014 (World Health Organisation, 2017). In 2016 in the United States, report showed that the number of new cases of women having cervical cancer was 12,990 cases and 4,120 of them died from the cancer (American Association for Cancer Research, 2017). This cancer is common among women and its development takes 10 to 20 years. Yet, women who contracted persistent infection of high risk type HPV are not being treated (National Cancer Institution, 2014). More important, cancer cervix has the potential to be prevented (American Association for Cancer Research, 2017; Zaridah, 2014). Thus, there is an urgent need to prevent cancer of the cervix from occurring. Evidence from the Centre for Disease Control and Prevention (2016) showed that among 30,700 cancer cases linked with HPV infection detected annually in the United States, about 28,000 could have been prevented from cancer with HPV vaccination. Increased risk of cervical cancer includes young age at first sexual debut. According to a report, 5.3% of adolescents between the age of 12 and 19 years in Malaysia have experienced sexual intercourse for the first time at the age of 15 years (Lee, Chen, Lee, & Kaur, 2006). Therefore in 2010, The Ministry of Health (MoH) Malaysia has started a national HPV vaccination programme to protect young women from HPV infection. The programme involved 13 year old children through a school vaccination programme. With the consent of their parents, the children would be given three doses of vaccination (Kementerian Pelajaran Malaysia, 2010). In this regard, the Malaysian Health Disease Control Director has urged all parents to take advantage of the National HPV Vaccination Programme and to give their consent for their daughters to be immunised with the vaccine (BERNAMA, 2015). Despite the positive health effect of the vaccine, there were some obstacles regarding parents acceptability of the vaccine. Haesebaert et al. (2012) and Holman et al. (2014) highlighted that parents need more information and knowledge about the vaccine before allowing their children to be vaccinated. It is true that poor knowledge about HPV might undermine the health benefits of HPV vaccination and HPV prevention (Lin, Fan, & Tu, 2016). To immunise children under the age of 18 years, the consent of parents is needed. Therefore, parents need to be given a good understanding of the benefits of HPV vaccination and HPV prevention. However, literatures on studies to determine knowledge of HPV and HPV vaccination among women consistently revealed that their level of knowledge has been a constant hindrance to their acceptance of HPV vaccination. A study conducted among adolescent women aged between 15 and 16 years revealed that they lack the understanding about cervical cancer prevention and that they were not aware of their susceptibility to the cancer (Lin et al., 2016). Knowledge on HPV infection was found low even among physicians and medical students, despite their education syllabus also includes information about vaccines and clinical diseases (Wen et al., 2014; Wong, Lee, Ngai, Chor, & Chan, 2013). Noor Sa adah Azmin, Kasmah Wati Pardi 58

3 The findings are consistent with that of a systematic review which found many women lack the knowledge about HPV and cervical cancer (Chan, Chan, Ng, & Wong, 2012). In fact, even among mothers who have daughters between the ages of 14 and 18 years, 83.1% of them had low knowledge about HPV causing cervical cancer (Haesebaert et al., 2012). However, literature on primigravidas to explore their knowledge on HPV and HPV vaccination is limited. Thus, it is important to explore their knowledge on the subject as their knowledge level may influence them to give consent for their children to be vaccinated later. Meanwhile, the government s policy is to have those adolescents vaccinated with HPV vaccine (Kementerian Pelajaran Malaysia, 2010). Thus, it is critical for parents to have clear understanding about the disease and the benefits from vaccination to facilitate the government to implement the programme and later to educate their adolescent children on the danger of the disease. Without proper education or proper information provided, the Malaysian Government will have to face a great challenge to mandate the policy. Therefore, this study aimed to assess the level of knowledge about HPV and HPV vaccination among primigravidas. In addition, it aimed to examine whether educational level is associated with the level of knowledge about HPV and HPV vaccination. 2.0 Materials and Methods 2.1 Study design and setting The study was designed as a cross-sectional study conducted from 18 February 2016 to 30 April 2016 in the antenatal clinic of a tertiary hospital in the East Coast of Peninsular Malaysia. The antenatal clinic of the hospital was chosen to ensure that the target population can be reached. 2.2 Target population and sampling method The target population of the study included all primigravidas aged 18 years and above, who attended the antenatal clinic either for first time or for subsequent follow-ups regardless of their gestational age. Primigradiva women were chosen because they were not yet involved in considering to justify the HPV vaccine to be given to their children. The simple random sampling method was employed to recruit the samples based on list of names provided by the clinic. The estimated sample size, which included a 10% drop out rate was 187 (Raosoft Inc., 2004). 2.3 Instrument The questionnaire used to assess the level of knowledge on HPV and HPV vaccination among the primigravidas in this study was adopted from Sam et al. (2009). The questionnaire consisted of two parts as follows: Part A: Socio-demographic characteristics, including ethnicity, religion, educational level, and their knowledge about anyone who has had cancer. Noor Sa adah Azmin, Kasmah Wati Pardi 59

4 Part B: Pertaining to knowledge about HPV and HPV vaccination, consisting of 20 items with two domains. The first domain was about knowledge on how HPV might cause other health problems and how a person can be infected by HPV. The second domain was knowledge of HPV vaccination and the benefits of taking the vaccination. The primigravidas were asked to respond to the question by selecting Yes, No, or Don t Know. For each correct response the respondent was given 1 point, while for an incorrect response the respondent would receive a 0 score. For the multiple choice questions, the respondent would be awarded 1 point for each correct response. The maximum possible score totalled 20 points. Since the lowest score was 0 and the highest was 20, it is logical for a score of 10 points to be assumed as the neutral midpoint (Adibe et al., 2009). Hence, a score in the range of less and equal to than 10 ( 10) was considered as poor knowledge level, while a score of more than 10 (>10) would represent a good level of knowledge. 2.4 Validity and reliability The Malay version of the questionnaire from the original authors was validated (Sam et al., 2009). However, to ensure the questionnaire was reliable in the context of the present study, it was pretested to a sample of 10 primigravidas in the same institution and the Cronbach s alpha of the questionnaire used to assess the level of knowledge on HPV and HPV vaccination (Sam et al., 2009) showed a value of 0.896, which was indicative of good reliability. 2.5 Data collection Data were collected using a self-administered questionnaire as described earlier. A research information sheet was distributed on the spot by the researchers to the primigravidas while they were waiting for antenatal check-up at the clinic. The primigravidas who visited the clinic for the first time or for their subsequent follow-ups were approached to request them to participate in the study. The primigravida women were informed that their participation was entirely voluntary and they could refuse or withdraw freely from the study at any time, without any loss of benefits to which they were entitled. The primigravidas who did not wish to take part in the study were not asked to complete the questionnaire. Written informed consent was obtained from those primigravidas who agreed to participate in the study. The researchers distributed the questionnaires and then collected the completed questionnaires from primigravidas. The primigravidas were given approximately 15 to 20 minutes to complete the questionnaire. The reason was that the research team wished to assess their spontaneous responses without them referring to any source of information when they answered the questionnaire. However, this was not specifically mentioned to them before they answered the questionnaire, but it was expected that they would complete the questionnaire without access to any information resources. 2.6 Data analysis Data collected were entered, coded and analysed using Statistical Package for Social Sciences (SPSS) Version Frequencies and percentages were used to describe data on their socio- Noor Sa adah Azmin, Kasmah Wati Pardi 60

5 demographic characteristics and knowledge level. Pearson Chi-square test was used to determine the association between educational level and knowledge level. The significance level was set at p < Result The number of completed questionnaire collected from the respondents was 161. This means that the response rate was 86%. The findings of this study are presented under three headings: primigravidas socio-demographics; knowledge of primigravidas on HPV and HPV vaccination; and the associated factor influencing the knowledge level of the primigravidas towards HPV and HPV vaccination. 3.1 Socio-demographic characteristics Table 1 summarises the socio-demographic characteristics of the 161 respondents who participated in this study. Table 1: The socio-demographic data of the respondents Sociodemographic Mean SD Range Frequency Percentage data Age (years) Race Malay Chinese Religion Islam Buddhist Education Low education High education Knowing someone who has had cancer Yes No Notes. n = 161. As presented in Table 1, the mean age of the respondents was years old. In terms of ethnicity, Malays consisted of 158 (98.1%). Since Malays are also Muslims, therefore, in terms of religion Islam constituted 158 (98.1%). With respect to education, 103 (64.0%) of them were educated up to college/tertiary level, while 139 (86.3%) of them had not known someone who has had cancer. Noor Sa adah Azmin, Kasmah Wati Pardi 61

6 3.2 Knowledge of HPV and HPV vaccination Table 2 presents the knowledge level of the respondents on HPV and HPV vaccination. Table 2: Level of knowledge of HPV and HPV vaccination of the respondents Level of knowledge Frequency Percentage Good (score >10) Poor (score 10) Note. n = 161 Table 2 shows that 72 (44.7%) of the respondents had good level of knowledge on HPV and HPV vaccination, whereas 89 (55.3%) of them had poor level of knowledge on HPV and HPV vaccination. Subsequently, Table 3 presents knowledge level of the respondents on HPV and HPV vaccination. Table 3: Frequency and percentage pertaining to knowledge regarding HPV and HPV vaccine Question Frequency Percentage 1. Have you ever heard of genital warts? Yes No Have you heard of human papillomavirus (HPV)? Yes No What other problems might HPV infection/genital warts cause? a. No problem Yes No, Don t Know b. Vaginal discharge Yes No, Don t Know c. Infertility Yes No, Don t Know d. Abnormal Pap smear Yes No, Don t Know e. Cervical cancer Yes No, Don t Know Note. n = 161 Noor Sa adah Azmin, Kasmah Wati Pardi 62

7 Table 3 continued. Question Frequency Percentage 4. How can you get HPV from an infected person? a. By having sex Yes No, Don t Know b. By kissing Yes No, Don t Know c. By hugging or touching Yes No, Don t Know d. By sharing needles Yes No, Don t Know e. By blood transfusion Yes No, Don t Know f. Using the same toilet Yes No, Don t Know g. Sharing a meal Yes No, Don t Know Who can get HPV infection? a. Only men Yes No b. Only women Yes No c. Both men and women. Yes No d. Don t know Yes No Have you heard of the new human papillomavirus (HPV) vaccine? Yes No Note. n = 161 Noor Sa adah Azmin, Kasmah Wati Pardi 63

8 Table 3 continued. Question Frequency Percentage 7. What are the potential benefits of the vaccine? a. Protect against genital warts Yes No, Don t Know b. Protects against cervical cancer Yes No, Don t Know c. Treatment to recover from genital warts Yes No, Don t Know d. Treatment to recover from cervical cancer Yes No, Don t Know Note. n = 161 With regard to the knowledge on HPV, Table 3 shows that 143 (88.8%) of the respondents have heard of HPV. However, 153 (95.0%) of them said that HPV infection/genital warts would not cause any health problems; while 147 (91.3%) of the respondents agreed that HPV would infect other persons via sexual intercourse and only 88 (54.7%) of them agreed that only women can be infected with HPV. About HPV vaccination, 142 (88.2%) of the respondents have heard of the new HPV vaccine and 147 (91.3%) knew that the vaccine helps protect them against cervical cancer. 3.3 Association between educational level and knowledge about HPV and HPV vaccination The association between educational level and knowledge about HPV and HPV vaccination was analysed using the Pearson Chi-square test (Table 4). Table 4: Association between educational level and level of knowledge Variable Poor knowledge Knowledge level Good knowledge Education level Low 32 (55.2%) 26 (44.8%) High 57 (55.3%) 46 (44.7%) Note. n = 161. *Pearson Chi-square test, significant at p <.05 χ 2 (df) p value (1) 0.984* Noor Sa adah Azmin, Kasmah Wati Pardi 64

9 As presented in Table 4, the analysis of Pearson Chi-square test showed no significant association between educational level and the respondents level of knowledge about HPV and HPV vaccination (χ 2 (df) = 0.001(1), p >.05). 4.0 Discussion This study has successfully revealed the knowledge level of the respondents pertaining to HPV and HPV vaccination. The results showed that more than half of the respondents did not reach the anticipated level of knowledge about the topic. Findings of the present study are consistent with that of the studies conducted in Taiwan by Lin et al. (2016), in China by Wen et al. (2014), in Hong Kong by Wong et al. (2013) and a review by Chan et al. (2012). All these studies showed that knowledge levels of their study populations were low. Hence, this gap in knowledge may become a hindrance factor, which might influence the respondents motivation to later allow their daughters to be given HPV vaccination. In addition, this study also revealed that knowledge of HPV and HPV vaccination among the respondents has no association with educational level (p >.05) despite 64% of them were quite highly educated. It was anticipated that the higher the level of education the higher would be the association with knowledge on HPV. However, as has been indicated, in this study no association was found between the educational level of respondents and their knowledge of HPV. Earlier studies such as by Wen et al. (2014) and by Wong et al. (2013) have clearly indicated that even health professionals who are more qualified in health education were found to have low knowledge on HPV. Evidence provided by these studies means that it is critical to have an effective strategy to educate all mothers, targeting especially on those who are having their first pregnancy, to help the country achieve a higher rate of children inoculated with HPV vaccination. 5.0 Conclusion and recommendation In conclusion, the knowledge of HPV and HPV vaccination of the respondents in this study are still poor. This finding has an important implication on the effectiveness of the HPV vaccination programme, which aims to prevent HPV infection and to reduce the incidence of cervical cancer. This study has also shown that knowledge on the subject has no significant association with educational level of the respondents. In the case that the primigravidas, who are the key players in HPV vaccination, have low knowledge of the subject, the consequence is that more children they are currently conceiving might not get the permission to get HPV vaccination; while their mothers would be unable to give them and their family effective education on the topic. Recommendations for improvement should include a plan to have a structured educational programme, involving nurses of the antenatal clinic in particular, to teach the subject matter and to implement a regular teaching session during the clinic day to improve the primigravidas knowledge. It is important for the primigravidas to know the subject for the benefit of their children, as they will be the ones to give consent for their children to be Noor Sa adah Azmin, Kasmah Wati Pardi 65

10 immunised with the vaccination. Since this study only focuses on one setting and the findings could not be generalised to the whole primigravidas population, bigger scale studies are needed, including investigating the reason for the low level of knowledge despite them having higher level of education. Assessing knowledge of HPV among primigravidas could be useful to provide a baseline data for health professionals to tailor a health education strategy to prevent the disease. Acknowledgement The study protocol was approved by the Human Research Ethics Committee USM (HREC) with JEPeM Code USM/JEPeM/ A letter of permission was also obtained from the Director of the Hospital. The authors would like to thank all the participants involved in this study. The authors would also like to thank the original author, Dr. Jamal I-Ching Sam, for his permission to use the instrument he created. Declaration The authors declare that there are no competing interests in this study. Author contribution Author 1, Noor Saadah designed the concept of study, collected the data, conducted the analysis and drafted the manuscript with the help of Author 2, Kasmah Wati. Author 2, Kasmah Wati also supervised the study and prepared the final version of the paper. Both authors read and approved the manuscript prior to submission. References Adibe, M.O., Aguwa, C.N., Ukwe, C.V., Okonta, J.M., & Udeogaranya, O.P. (2009). Diabetes self-care knowledge among type 2 diabetic outpatients in south-eastern Nigeria. International Journal of Drug Development and Research, 1(1), American Association for Cancer Research. (2017). Reducing the burden of cervical cancer. Retrieved from cervical-cancerprevention-tool-underused.aspx Noor Sa adah Azmin, Kasmah Wati Pardi 66

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