Journal of Genital System & DisordersISSN: 2325-9728

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Research Article, J Genit Syst Disor S Vol: 0 Issue: 1

Human Papillomavirus (HPV) Infection and Vaccines:Ottawa University Students’ Knowledge, Awareness and Vaccine Intentions

O Remes1, A Whitten1, KA Sabarre1 and KP Phillips1,2*
1Interdisciplinary School of Health Sciences, Faculty of Health Sciences, University of Ottawa, Ottawa, ON, Canada
2Institute of Population Health, University of Ottawa, Ottawa, ON, Canada
Corresponding author : Karen P. Phillips
Institute of Population Health, Interdisciplinary School of Health Sciences, Faculty of Health Sciences, University of Ottawa, 25 University Private, Room 21, Ottawa, Ontario K1N 6N5, Canada
Tel: (613) 562-5800 ext 8678
E-mail: [email protected]
Received: June 13, 2013 Accepted: September 15, 2013 Published: October 04, 2013
Citation: Remes O, Whitten A, Sabarre K-A and Phillips KP (2013) Human Papillomavirus (HPV) Infection and Vaccines: Ottawa University Students’ Knowledge, Awareness and Vaccine Intentions. J Genit Syst Disor S1. doi:10.4172/2325-9728.S1-006

 

Abstract

Human Papillomavirus (HPV) Infection and Vaccines:Ottawa University Students Knowledge, Awareness and Vaccine Intentions

Objective: The objective of this qualitative study was to assess young adults’ awareness of human papillomavirus (HPV) and associated health problems, mechanisms of HPV prevention, perceived personal risk of infection and awareness of HPV vaccines.

Method: Twenty undergraduate students, eleven women and nine men, were interviewed about HPV and HPV vaccine awareness in Ottawa, Canada, 2008. Interviews were transcribed and coded to identify major topical themes.

Keywords: Sexually transmitted infections; HPV; HPV vaccine; University students

Keywords

Sexually transmitted infections; HPV; HPV vaccine; University students

Introduction

Human papillomavirus (HPV) infections are the primary cause of both genital warts and cervical cancers, and are also implicated in the etiology of cancers of the skin, anus, penis and oral-pharyngeal cancers [1-3]. Although HPV infections are widespread, most immunologically-competent women will clear oncogenic types of HPV without progressing to cervical carcinoma [2]. Over 130 types of HPV have been classified with about 40 capable of infecting the anogenital epithelium [3]. Persistent infection with high-risk typesHPV-16 or 18 are responsible for 70% of global cervical cancer cases [1]. The quadrivalent Gardasil® vaccine, approved by in 2006 by Health Canada [2] and the US Food and Drug Administration [4], targets cervical cancer-associated HPV-16 and 18 and offers additional protection against HPV-6 and 11, associated with anogenital warts [2]. In 2007, Canadian priority groups for Gardasil® vaccination were initially identified as girls aged 9-13 years and young women aged 14- 26 years [2]. In 2012 these recommendations were expanded to include females aged 9-45 years [5]. A public school HPV vaccine-program, launched in September 2007, provided free vaccines to Ontario grade eight girls [6]. Older adolescents and young women, representing the highest risk group for all sexually transmitted infections (STI) by age [3], are not captured by this public health program and must seek HPV vaccine information, health-care providers and assume financial costs associated with HPV vaccination [7].
STI rates in Canada have increased since 1997 especially among young adults under the age of 24 years [3]. Reported STIs in Canada and the US include Chlamydia, gonorrhea and infectious syphilis but not HPV [3,4,8]. It is estimated that over 70% of the Canadian population will have at least one genital HPV infection during their lifetime; such that HPV is likely the most common STI [2,9]. As with Chlamydia and gonorrhea, HPV infections are most common among adolescents and young adults [2,9]. Other important determinants of HPV infection include ethnicity, place of residence and Aboriginal/ Inuit status [2,9]. The high prevalence of HPV infections may be explained by incomplete transmission protection provided by latex condom use and the omission of HPV in routine STI screening panels [9].
Although several US studies [10-14] have examined university students’ awareness of HPV and HPV vaccines, only a few Canadian studies [15-17] have addressed this topic. Most HPV awareness studies use a quantitative approach with Canadian studies emphasizing young adult women’s awareness and perceptions of HPV and HPV vaccines. Here we have used a qualitative approach to explore knowledge and awareness of HPV, associated health problems and methods of HPV prevention among both male and female university students. The perspectives of these participants uniquely captured the year following the initial launch of the HPV vaccine provide insight regarding young adults’ awareness of the vaccine, perceived personal risk of HPV infection and young women’s vaccine intentions.

Methods

Recruitment
Forty undergraduate males and females were invited to participate in a broad study examining knowledge and awareness of infertility, biological and environmental risk factors and treatment options in 2008 [18,19]. The emergence of HPV in the media as a topical sexual and reproductive health (SRH) issue led to the inclusion of HPV as a special subsection within our study. A subset of 20 participants was interviewed on the topics of HPV and HPV vaccines. Young adults were recruited from a university in Ottawa, Ontario using posters, snowball technique and FaceBook advertisements to participate in individual, semi-structured interviews. Participants were provided with a summary of the study, names of investigators and mechanisms of participation. This study was approved by the host institution ethics review board with study participation preceded by written consent.
Data collection
Drawing from our previous experience examining SRH education in Ottawa public secondary schools [20,21], it was anticipated that university students would have a good understanding of STIs, routes of transmission and prevention. We therefore designed interview questions explore young adults’ general knowledge awareness of HPV and HPV vaccines. At the time of the study, the introduction and promotion of HPV vaccines were topics of controversy. We expected young adults to be aware of HPV vaccines due to the widespread marketing campaign, but we were also interested in participants’ personal concerns of acquiring HPV and women’s choices regarding vaccine uptake. Individual, semi-structured interviews were both audiotaped and noted by a health sciences research student. Twenty participants were asked: What is HPV? How is it transmitted? How is it prevented? Where have you heard/learned about HPV? Is HPV related to any health problem other than an STI? Is HPV something you are/have been worried about? As HPV vaccines were not available for men at the time of the study, only female participants were asked: Have you thought about taking the vaccine against HPV? Why/why not? Demographic data, including sex, age and race/ethnicity were also collected (Table 1).
Table 1: Participant Characteristics.
Data analysis
Audio-recordings of the twenty interviews were transcribed and coded using NVIVO™ (QSR International, Cambridge, MA, USA) by health sciences research assistants and supervised by the research team leader. Grammatical errors, repetitive words, word breaks, hesitant pronunciations and pauses (…) were deliberately not corrected during transcription or for publication. Transcripts were evaluated by interview topic using qualitative content analysis [22] to identify emerging themes expressed by either male or female participants. Research team meetings were held regularly to confirm saturation, harmonize coding and discussion of major themes [23,24].

Results

Twenty participants were interviewed regarding their awareness of HPV and HPV vaccines. Eleven women and nine men, most 19 to 22 years of age, comprised this multiethnic sample (Table 1). Seven major themes emerged following qualitative data analysis of the interviews (Table 2).
Table 2: Interview Topics and Major Themes.
HPV and HPV vaccine awareness, knowledge
Two major themes emerged, reflecting a gender gap in the knowledge and awareness of HPV as an STI (Table 2).
Men exhibit poor awareness of HPV and HPV vaccines
Few male respondents (3/9) had ever heard of HPV or the HPV vaccine and therefore could not meaningfully discuss associated risk factors or routes of transmission.
“HPV? I don’t know the exact name. A virus. Something papillomavirus. Human? Presumably transmitted through humans. I don’t know. Prevented by not contacting humans, I don’t know. I don’t really know what it is.” - male, aged 19 years, Canadian (ID-8)
“I have no idea what is HPV. Gardasil, actually that does sound familiar. Gardasil? I’m just gonna say no.” – male, aged 19, Ethiopian (ID-19)
“I don’t know what HPV is. Gardasil? I don’t know. I’ve heard on the radio and stuff but I don’t think I ever knew what HPV was.” -male, aged 19, Kuwaiti (ID-5)
Women are aware of HPV as an STI and associate HPV with cancer
In contrast, most women were aware of HPV as an STI and could discuss risk factors and transmission. Most female respondents (10/11) were familiar with HPV as an STI and associated HPV with reproductive health problems such as genital warts, changes to cervical epithelium or some form of cancer.
“Human papillomavirus. Some strains of the virus cause genital warts, some of the strains can also end up causing cervical cancer. I know most cases of HPV are self-inoculated. Like you’ll touch something and then you won’t wash your hands when you go have fun with yourself or with other friends. Well if it’s, if I touch my hand..say I had HPV and I touched my friend’s shoulder, that won’t necessarily give my friend HPV.” -female, aged 20 years, born in Hong Kong (ID-1).
“Human papillomavirus, which is, it gives warts. There’s different strains, strains 16 and 18 I think are the ones that are thought to cause cancer. I think [it is transmitted] through contact with the warts or the virus being passed in a fluid. I think it can live outside of the body for a while as well. So it would be super less likely to pick it up, but possible to pick it up from surfaces.”-female, aged 21, Canadian (ID-14).
The HPV vaccine was mentioned as a mechanism of HPV prevention along with safer sex practices.
Women are aware of HPV vaccines emerged as a major theme. Women also associated routine medical examinations, Pap tests and minimizing numbers of sexual partners with HPV prevention. Women are aware of STI prevention, testing emerged as a subtheme for female respondents.
“Human papillomavirus. They say transmission is sometimes skin to skin contact but it would have to be a very specific way, like say you have a partner who has a genital wart on I guess their testicle and they have a condom on, but like it’s not covering their testicle and it comes in contact with you then you can contract genital warts. HPV prevention? If you don’t have sex with that person. I know someone who said that their boyfriend had like a genital wart on their nose and he gave them oral sex and then they got HPV. And just like, if you abstain, you can prevent it. And if you get tested I guess, you and your partner would both get tested.”- female, aged 22, Iranian (ID-18)
“HPV? humanpapill...virus....something virus. It can be [transmitted] through sexual intercourse, and exchange of bodily fluids which is usually associated with having sex..depending on the activities you’re doing. HPV is prevented by having protected sex, and getting routine checks, and definitely going to your doctor every year and getting a Pap for women. And for men, it’s always, getting routinely checked for sexual transmitted infection and overall, your sexual health. Having more sex with less partners is definitely a healthier thing to do. Cause the more partners you have, the more exposure you have to people and whatever they’re carrying or if they’re carrying anything.”- female, aged 21 years, Canadian (ID-6)
Although cancer was associated with HPV, knowledge gaps most often expressed by women included an inability to associate HPV with cancer of the cervix. This led to the emergence of a second subtheme: Women are unable to associate HPV with cervical cancer.
“They’re vaccinating for some reason, and I know it’s for some sort of cancer.” - female, aged 22 years, Canadian (ID-13)
“HPV- the human pap virus and it’s a strain of ovarian cancer, I think. I don’t think it’s sexually transmitted. Isn’t it naturally occurring? Everybody has it in their bodies but sometimes if it becomes active or something. I’m not too sure how it’s contracted. I don’t think it’s sexually transmitted.”-female, aged 22 years, Algeria (ID-3)
Generally, female participants identified HPV as an STI, affecting both men and women with sexual activity the major route of transmission. Several women were aware that multiple HPV strains can be associated with reproductive health problems. Although HPV was associated with cancer, few women could specify cervical cancer. In stark contrast, most men were not aware of HPV or HPV vaccines.
Sources of HPV information
At the time of our study there was significant North American media coverage and pharmaceutical marketing of the HPV (Gardasil®) vaccine [25]. All female respondents and a few males were aware of the vaccine media coverage with radio, television, newspapers, print advertisements on busses, campus posters and university planners/ agendas mentioned as venues for HPV vaccine promotion. To a lesser extent, some respondents identified course material/professors, peers or family members as sources of HPV vaccine information. Media coverage of HPV vaccine perceived as saturated emerged as a major theme among women and men familiar with HPV.
“Where have you not heard about HPV? Is more like the question. You hear it on the radio, you hear it on TV, definitely on the radio, the media because they’re trying to promote 12-year olds to get the vaccine in schools now. I took a course, sexology or whatever it’s called, human sexual behaviour, she spoke about it as well.” -female, aged 22, Canadian (ID-10)
“I read in the newspaper or I see it on television and it’s really important that people get the vaccine or that women get the vaccine. I always go to do the Pap test, one a year for so many years and no doctor ever explained me why they do it and what HPV is. And I just learned it from the articles I read or from the news. Newspaper. In fact the Ottawa Citizen. And then on CBC and CTV when I watch the news they always bring, like news concerning HPV.” –female, aged 32, German (ID-15)
“HPV- Human papillomavirus. I assume it’s transmitted through sexual activity in a similar way to herpes. They have a vaccine for it... on TV.”-male, aged 20, Canadian (ID-4)
“All the commercials for that vaccine, I looked it up, I started researching HPV and Gardasil when my mom mentioned it. It was on the back of the [university] agenda last year. They were also advertising it on some buses.”-female, aged 20 years, Hong Kong (ID-1)
“Yeah I’ve seen ads for that on TV. I’ve actually only seen it targeting for young girls. I’ve never really seen anything targeted for men in terms of STD prevention.”-male, aged 20 years, Canadian (ID-2)
Personal concerns about HPV infection
None of the participants expressed past or present concerns about personal susceptibility to HPV infection, reflected by the major theme: Low perceived personal risk associated with HPV. As only three of the nine male participants had any familiarity with the topic of HPV, most male respondents could not contemplate personal concern for transmission. Women identified sexual history as part of their personal HPV risk assessment which emerged as a subtheme (Table 2).
“I haven’t worried about HPV, but I’ve definitely been aware of it. I have [considered HPV vaccine], but I haven’t taken it. Depending.. it depends on how many partners I have in the lifestyle choice that will affect the decision to take the vaccine. Seeing that I have one consistent partner now, I don’t feel that I have the need to take the vaccine based on the fact that we’re both sexually healthy and don’t have any STI’s and never gotten any, never been exposed to it. So therefore I don’t feel that I’m going to contract it right now, based on my sexual history.”- female, aged 21 years, Canadian (ID-6)
“Worried about HPV? Not really. Cause I only got Gardasil when my mom insisted that I was gonna die from cervical cancer.” -female, aged 20 years, Hong Kong (ID-1)
Participants recognized that STI were something to avoid in general, but were not concerned specifically about HPV.
“I’m worried just about sexually transmitted disease in general, but not this one more particularly.”-female, aged 20 years, Canadian (ID-7)
“I don’t really worry about a lot of things, but I would prefer not to have it.”- male, aged 19 years, Canadian (ID-8)
HPV vaccine contemplations
We asked all female respondents whether they had been vaccinated against HPV or were planning to be vaccinated. Only two of eleven women had been vaccinated at the time of the study with one participant still contemplating the merits of HPV vaccination. Most women were uncertain or had personal concerns related to vaccine safety and the quality of the information delivered through the media. Women expressed a need to complete ‘their own research’ prior to vaccination suggesting safety concerns, lack of trust in vaccine promotion and a need to take personal responsibility for this decision. This was captured as the major theme: Women assert a personal responsibility to evaluate HPV vaccine safety.
“I haven’t been [concerned about HPV], no. I thought about [getting vaccinated], haven’t gone for it cause it’s not one of those that’s forced yet. If I had to, I would take it. But I wanna research it first. But as it’s a virus, and like any other virus and vaccine, I think it would be fine. It’d be safe.” - female, aged 22 years, Canadian (ID-13)
“No [not vaccinated] because it prevents only against certain types and it’s new so I’d like some more research on it before.” –female, aged 19, Canadian (ID-16)
“No [not vaccinated] cause I’ve heard, they have done studies but it’s not conclusive, they don’t really know if it does anything, if it is effective. So I’m skeptical, maybe I haven’t done enough research but I’m skeptical of it”-female, aged 22 years, Algeria (ID-3)
Women described multiple barriers to HPV vaccine uptake. Beyond the need to learn more about the HPV vaccine, nine of eleven women expressed concerns captured as subthemes (Table 2). These included: new vaccine, perhaps inadequately researched, safety concerns, expensive and vaccine eligibility restricted to young girls. Many women also expressed a lack of trust in the vaccine give its promotion by pharmaceutical companies.
“Yes [considered HPV vaccine], but has been only clinical testing for ten years. And for wider public in my opinion, you need 50 years to see if there’s other side effects before the first generation of people that get it, so like, the real result if you want. I am very skeptical.” - female, aged 20 years, Canadian (ID-7)
“Yes [considered HPV vaccination], but it’s too expensive and I don’t get it paid. Because I think it’s just, when you’re in a certain age group, and I am out of that age group. But I would have liked having it. But I went to the pharmacy and it’s around $500 I think. So I thought that was too expensive.” –female, aged 32, German (ID-15)
“No [not worried about HPV] and no I wouldn’t take the vaccine. Cause I learned about it in my human sexual behaviour class and I went to a conference with Dr. Abby Lippman who is a professor at McGill University for epidemiology and women’s studies and she did research on HPV which said that 90% of HPV infections get flushed out by itself. 90% within two years! And it got approved very quickly, five years, Gardasil. And it was funded by Merck’s..which is the manufacturer, so you don’t know how reliable it is.” - female, aged 22, Iranian (ID-18)
“I thought about asking my doctor about it. Haven’t gotten around to it but I’ve seen it on TV, like I think commercials, and I’ve heard it on the radio so I thought I should ask my doctor but I don’t know. I’ve heard it’s more for younger girls, I’m already 19, but I thought it’d just be a good idea to ask just in case.”-female, aged 19, Canadian (ID-20)

Discussion

At the time of our study HPV vaccine media coverage and pharmaceutical marketing were widespread [25], however most male participants were unfamiliar with HPV, did not recognize it as an STI and were not aware of the HPV vaccine. Several US studies of university students also report that young men are less aware of HPV and HPV vaccines compared to women [10,12]. HPV vaccine intentions of Floridian male university students [11] and adult men participating in an HPV clinical trial [26] are positively associated with knowledge and awareness of HPV/HPV vaccines [11]. In contrast, poor knowledge and awareness of HPV/HPV vaccines are associated with low vaccine intentions among US male university students [12,26,27]. Although the initial priority groups for HPV vaccination in Canada were girls and young women; consideration is now being given to the advantages of vaccinating boys and men [5,8,28,29]. It has been proposed that vaccination of young girls will provide sufficient herd immunity to protect their male partners [28], however these early models of HPV transmission did not consider homosexual transmission. Both the US (2009) and Canada (2012) have authorized use of Gardasil® for immunization of males 9-26 years of age and identified men-having-sex-with-men as a priority group for vaccination [5]. These changes in public policy will now require young men, a group with minimal HPV knowledge and awareness, to consider HPV vaccination.
It is evident that the North American launch and media coverage of the Gardasil® HPV vaccine was gendered in its approach [25]. The threat of cervical cancer to all adolescent girls was emphasized, negating differential risks to subpopulations, with minimal mention of sexual transmission of HPV [30,31]. Promotion of HPV vaccines to boys and men may prove challenging as incidence of penile/anal cancers is much lower than cervical cancer, with the development of these cancers in men over 50 years of age [32]. Sexual health of young men is generally presumed to be ‘normal’, such that most young men have less experience with routine health screening compared with women [33]. Developing male-focused, evidence-based sexual health promotion strategies should be an ongoing research priority.
Female participants demonstrated a general understanding of HPV and were able to associate HPV infection with cancer, however most were unable to specify HPV’s association with cervical cancer. This was surprising given the media’s strong emphasis of the association between cervical cancer and HPV during the launch of the HPV vaccine [25]. Previous studies report university women identify HPV as an STI, with most able to associate HPV infections with cervical cancer [10,12,14,16,17]. HPV knowledge gaps among our participants and other studies [13,15] may reflect regional differences in HPV vaccine marketing and sexual health education. We have previously established that Ottawa undergraduate students’ predominant source of SRH information is the compulsory Ontario secondary school health curriculum, which emphasizes STI awareness and STI/pregnancy risk reduction [20,21]. Last updated in 1999, the Ontario Health and Physical Education Curriculum, however, lack explicit mention of HPV or the HPV vaccine [34]. Incorporation of the long term consequences of STIs including infertility and cervical cancer would be invaluable additions to Ontario’s compulsory sexual health curriculum.
It was apparent that female participants but not males, perceived media saturation around the topic of the HPV vaccine. Several US studies of female university students also report media-driven HPV and HPV vaccine awareness [10,12,13]. The media messaging around HPV vaccine at the time of our study provides some insight into the perceptions of young women regarding vaccine safety and efficacy. The North American media discussed the introduction of the HPV vaccine as controversial, poorly understood by science, associated with death/illness (i.e. cervical cancer) and influenced by pharmaceutical companies [25]. These media themes were mirrored by our female participants when asked about their plans regarding immunization. Only two women had received the HPV vaccine while most of the other female respondents perceived that the Gardasil® vaccine was poorly researched, rushed to market, expensive and its introduction was unduly influenced by pharmaceutical companies. This is consistent with previous HPV vaccine intention studies from Saskatchewan [15], Quebec [35] and Pennsylvania [13]. HPV vaccine contemplation was influenced by family members, peers, professors and media promoting the HPV vaccine. Similarly, Quebec university students’ HPV vaccine intentions were related to physician recommendations and social influences [29]. Both male and female participants did not express specific concerns about contracting HPV and did not perceive themselves to be at risk, consistent with several US studies [10,26]. Relationship status and safe sexual practices were perceived as protective by female participants. Several studies have suggested HPV vaccine intentions are related to perceptions of HPV severity [7,11]. Risks and benefits associated with HPV vaccination need to be reinforced by family physicians, public health agencies and sexual health curricula. Interestingly, Ottawa female participants asserted it was necessary to perform their own research regarding vaccine safety/efficacy prior to being vaccinated. These assertions would seem to reflect the acquisition of personal health responsibility during the transition from adolescence to adulthood [36]. Further examination of the development of personal health responsibility may elucidate the interactions of determinants such as gender, race/ethnicity, socioeconomic status together with access to health education and promotion.

Limitations

This study provides valuable insight regarding the perceptions, attitudes and knowledge regarding HPV among Ontario undergraduate male and female students, however there were some limitations. The qualitative study design provides opportunities to explore our topic in depth but these findings are not generalizable to a larger population. Our study participants can be considered privileged socioeconomically with greater access to SRH information through on-campus peer education and health services. A cohort of young adults with no post-secondary education may be expected to have greater gaps in knowledge and understanding of HPV. Our multiethnic sample was heterogeneous with respect to race/ethnicity and religion; however gender seemed to be a more important determinant of HPV knowledge and awareness. A multiethnic sample best reflects the sociocultural environment of the university setting, and thus our heterogeneous sample is relevant.

Conclusions

Several recommendations emerge from our findings. Our interviews with young men were severely limited by participants’ lack of familiarity with HPV. This suggests a need for HPV health promotion targeted specifically to men. Although persistent HPV infection is linked with development of cancer in females, knowledge gaps exist regarding the specific types of cancer associated with HPV as well as the lack of routine serological HPV testing. The media saturation around HPV appeared to confound young women’s perceptions regarding vaccine safety and efficacy, such that future public health promotions should be developed and marketed by health agencies, rather than pharmaceutical companies.

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