Vaccination Status and Attitudes to Human Papilloma Virus in Millennial Medical Students Nelia Afonso MD Professor Biomedical Sciences Assistant Dean Community Integration and Outreach Oakland University William Beaumont School of Medicine Rochester, Michigan, USA afonso@oakland.edu
Number of cancers caused by HPV worldwide each year Photo credit: Courtesy: National Institutes of Health
Millennial Medical Students Our future healthcare providers - First in the target age group to have received the vaccine Aims of this study: Examine the HPV vaccination rate among medical students Determine medical student knowledge about HPV and attitudes toward vaccination.
HPV survey OUWB students Anonymous, 20-question online survey Email to all medical students (n=390) Vaccination status for HPV Reasons for personally accepting or rejecting the vaccine Knowledge about HPV Attitudes to HPV vaccine.
Participant Characteristics n=214 n (%) Age < 25 years 26-30 years > 31 years Gender Male Female Race/Ethnicity Asian Black/African American White Hispanic/Latino Other Year in Medical School M1 M2 M3 M4 Received Vaccination Yes No 141 (66.2) 64 (30.0) 8 ( 3.8) 101 (47.4) 112 (52.6) 53 (25.0) 8 ( 3.8) 128 (60.4) 6 ( 2.8) 17 ( 8.0) 71 (33.2) 60 (28.0) 45 (21.0) 38 (17.8) 95 (44.4) 119 (55.6)
HPV Coverage Rate Below 25 age group HPV vaccination rates: female medical students 72 % male medical students 21 %
Why did you receive the HPV vaccine?
Why did you not receive the HPV vaccine?
Knowledge and Attitudes Scores Gaps in knowledge: protective effect of HPV vaccine in cancers other than cervical 10% - vaccine only recommended for girls Vaccinated students scored better than unvaccinated students Attitudes 82% would recommend the vaccine to family and friends 40% felt they had adequate information 40% felt comfortable counseling patients. 7% felt vaccine would lead to risky sexual behavior
Knowledge Non-Vaccinated and Vaccinated Medical Students Knowledge Items Non-Vaccinated n=119 Mean (sd) 1 Vaccinated n=95 Mean (sd) 1 t-test p-value HPV is a sexually transmitted infection 4.3 (0.9) 4.7 (0.5) <0.001* Men and women can be carriers of HPV 4.4 (0.9) 4.7 (0.5) <0.001* HPV vaccine protects against genital warts 3.8 (1.1) 4.1 (1.0) 0.11 HPV vaccine protects against cervical cancer 4.3 (0.8) 4.5 (0.6) 0.01* HPV vaccine protects against other cancers 3.4 (1.3) 3.6 (1.3) 0.26 HPV vaccine is safe 4.3 (0.9) 4.6 (0.6) <0.001* HPV vaccine is effective 4.2 (0.8) 4.6 (0.6) <0.001* HPV vaccine has few side effects 3.9 (1.0) 4.3 (0.9) 0.003* HPV vaccination leads to lasting immunity 3.5 (0.9) 3.8 (0.9) 0.01* HPV vaccine is recommended for girls and boys 3.9 (1.1) 4.5 (0.8) <0.001*
Knowledge Non-Vaccinated and Vaccinated Medical Students Knowledge Items Non-Vaccinated n=119 Mean (sd) 1 Vaccinated n=95 Mean (sd) 1 t-test p-value HPV is a sexually transmitted infection 4.3 (0.9) 4.7 (0.5) <0.001 Men and women can be carriers of HPV 4.4 (0.9) 4.7 (0.5) <0.001 HPV vaccine protects against genital warts 3.8 (1.1) 4.1 (1.0) 0.11 HPV vaccine protects against cervical cancer 4.3 (0.8) 4.5 (0.6) 0.01 HPV vaccine protects against other other cancers cancers 3.4 (1.3) 3.6 (1.3) 0.26 HPV vaccine is safe 4.3 (0.9) 4.6 (0.6) <0.001 HPV vaccine is effective 4.2 (0.8) 4.6 (0.6) <0.001 HPV vaccine has few side effects 3.9 (1.0) 4.3 (0.9) 0.003 HPV vaccination leads to lasting immunity 3.5 (0.9) 3.8 (0.9) 0.01 HPV vaccine is recommended for girls and boys 3.9 (1.1) 4.5 (0.8) <0.001
Attitude Scores Non-Vaccinated and Vaccinated Medical Students Likert scale responses: 1= Strongly Disagree, 2=Disagree, 3=Neither Agree/Disagree, 4=Agree, 5=Strongly Agree Attitude Items HPV vaccination may lead to risky sexual behavior I have enough information to be able to counsel about HPV vaccine I feel comfortable counseling about HPV vaccination I would recommend the HPV vaccine to friends and family HPV vaccine should be mandatory Yes No Non-Vaccinated n=119 Mean (sd) 1 Vaccinated n=95 Mean (sd) 1 t-test p-value 1.9 (1.0) 1.6 (0.9) 0.02 2.7 (1.4) 3.3 (1.3) 0.001 2.8 (1.4) 3.3 (1.3) 0.01 3.9 (1.0) 4.6 (0.5) <0.001 n (%) n (%) Chi-square p-value 44 (38.3) 71 (61.7) 68 (73.1) 25 (26.9) <0.001
What are your views on HPV vaccination? Key themes identified from the textual data: Benefits of vaccination Emphasis on offering vaccine to boys and girls Moral implications associated with the HPV vaccine Need for counseling skills Need for education.
What are your views on HPV vaccination? Benefits of vaccination From a public health stand point I feel everyone in the susceptible age range should get the HPV series because it really doesn't harm anything, but it can be an effective way to prevent the spread of a preventable disease. It is harder to change society behavior than to arm people against the disease.
What are your views on HPV vaccination? Emphasis on offering vaccine to boys and girls promoting vaccination of males is essential. Many people, even fellow medical students, were unaware that males could and should receive the vaccination. I believe its so important because there is no test for men to get to know if they have HPV, and could unknowingly pass it on to many partners without ever finding out.
What are your views on HPV vaccination? Moral implications associated with the HPV vaccine I really think HPV and all vaccinations should be strongly encouraged but I am on the fence about mandating them. I think mandates make people hostile and more likely to resist and feel forced into decisions that they aren't comfortable with. From a public health perspective I think getting folks on board with HPV vaccination is a big deal, especially since now we are seeing other cancers (not just cervical) related to it...
Limitations Small sample size Single medical school Self reported data - accuracy of respondents vaccination status could not be verified Response bias
It is now time to reframe our focus from STI Prevention to Cancer Prevention 69 of the NCI-designated Cancer Centers February 2016 joined together to warn about the severely low rate of HPV vaccination in the United States American Society of Clinical Oncology April 2016 endorsed dissemination of evidence-based information to increase awareness of the relationship between HPV and cancer at multiple sites affecting both men and women As educators.. begin this education at the undergraduate medical school level Millennial medical students are in the group that would have been eligible to receive this vaccine and would have the personal experience of vaccine that may facilitate provider-initiated conversation
New developments: CDC Recommends 2 HPV Vaccine Doses Instead of 3 Children under age 15 receive - 2 doses of the HPV vaccine, instead of 3 doses First dose - age 11 or 12 (boys and girls as young as 9 could receive it) Second dose - 6 to 12 months later Adolescents -15 and older when they first get vaccinated should still follow the three-dose schedule Dobson et al. Immunogenicity of 2 doses of HPV vaccine in younger adolescents vs 3 doses in young women: a randomized clinical trial. JAMA 2013
Gardasil-9 New HPV vaccine Potential to eradicate 90% of cervical, vulvar, vaginal and anal cancers HPV types 16, 18, 31, 33, 45, 52, and 58
In Summary Strong effect of physician recommendation on vaccination status Correct knowledge gaps Differences in knowledge and attitudes between vaccinated and non-vaccinated students Next Steps.. Curricular changes to address: knowledge misperceptions vaccine specific counseling Classroom to community Service learning - health education and outreach
Acknowledgements: Maurice J. Kavanagh M.Ed. Victoria C. Lucia, Ph.D. Stephanie M. Swanberg M.S.I. Jeanne M. Schulte M.Ed. Tracy Wunderlich M.A
Thank you! afonso@oakland.edu
Knowledge Non-Vaccinated and Fully Vaccinated Medical Students Knowledge Items Fully Vaccinated, Positive Responses n=75 n (%) Non-Vaccinated Positive Responses n=119 n (%) Fisher s Exact Test p-value HPV is a sexually transmitted 73 (97.3) 106 (89.8) 0.08 infection Men and women can be 74 (98.7) 108 (91.5) 0.053 carriers of HPV HPV vaccine protects against 58 (77.3) 86 (72.3) 0.50 genital warts HPV vaccine protects against 72 (96.0) 104 (87.4) 0.07 cervical cancer HPV vaccine protects against 36 (48.0) 56 (47.9) 1.00 other cancers HPV vaccine is safe 71 (95.9) 102 (85.7) 0.03 HPV vaccine is effective 71 (95.9) 104 (87.4) 0.07 HPV vaccine has few side effects HPV vaccination leads to lasting immunity HPV vaccine is recommended for girls and boys 64 (85.3) 83 (70.3) 0.02 49 (65.3) 58 (49.2) 0.04 68 (90.7) 83 (70.3) <0.001 Positive responses: Agree and Strongly Agree Likert scale responses were collapsed
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