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Year : 2017 | Volume : 5 | Issue : 1 | Page : 36 - 40  


Original Articles
Secondary school girls knowledge and practice on human papillomavirus (HPV), cervical cancer and human papillomavirus (HPV) vaccination in Kuantan, Pahang, Malaysia

Khin Thandar Aung1, NurulSyafiqaBintiMdMerzuki2, Cho Cho Zaw Rahemma 3,

1: Lecturer/ Head, Critical Care Nursing Department Faculty of Nursing, International Islamic University, Malaysia 2: KPJ Specialist Hospital, Johor Baru, Malaysia 3: Lecturer/ Medical Surgical Nursing Department, Faculty of Nursing International Islamic University, Malaysia

Corresponding Author:

Khin Thandar Aung

Email ID: khin_ta@iium.edu.my

ABSTRACT:

Background: Cervical cancer becomes the second leading cancer in Malaysia and HPV infection is the main cause of this cancer. The availability of HPV vaccination can reduce down the risk of getting HPV infection thus will also reduce incidence of cervical cancer. However, due to little current information pertaining to the nature of HPV infection, cervical cancer and HPV vaccination themselves among the risky age, which is secondary school girls, therefore, a thorough understanding about knowledge on HPV, cervical cancer and HPV vaccination of secondary school girls and their practice on HPV vaccination is needed.

Objective: The aim of this study is to investigate the knowledge of secondary school girls about human papillomavirus (HPV), cervical cancer and human papillomavirus (HPV) vaccination and their practices on HPV vaccination.

Methods: A cross sectional study was conducted in two secondary schools; SMK TengkuPanglimaPerang and SMK (P) Methodist, Kuantan, Pahang, Malaysia. The total numbers of 295 secondary school girls were studied, and the data were collected through the distribution of structured questionnaires. Data analysis involved descriptive statistic and chi square test by using SPSS version 20.

Results: Results revealed that there was a high level of knowledge about HPV, cervical cancer, and HPV vaccination, however low/poor practice on HPV vaccination among secondary school girls.

Conclusion: Therefore, it is suggested that further study is required to focus the gap between knowledge, and practice, and examines the reasons of not receiving HPV vaccinations in the targeted group. Strategies for enhancing awareness to take HPV vaccination are also needed.

Key words: Knowledge, practice, human papillomavirus (HPV), cervical cancer, HPv

INTRODUCTION:

Cervical cancer is one of the most common cancers among women in the worldwide, and the second leading cancer in Malaysia. It is caused by a virus called human papillomavirus (HPV), which is one of the common causes of the sexually transmitted infections. Cervical cancer is strongly linked with human sexual behavior since the risk of getting HPV infection is usually increased in women with early sexual intercourse. Adolescence is a time of rapid change, and a period for experiencing challenges in all aspects of development. They start to examine their sexual orientation and who they are as people, though the sexual behaviors of adolescents are mostly influenced by their upbringings, culture, and laws of the society.

According to the National Network for Immunization Information (2008) [8], it has been estimated that more than 7% of high school students have their first sexual intercourse before the age of 13. Thus, the danger of early sexual intercourse needs to be precisely delivered especially to these secondary school students so that to prevent HPV infections, and reduce the risk for cervical cancer .Though cervical cancer is said to be one of the common types of cancer in the world, it is not so common in some countries where cervical screening is routine. It can be prevented by having regular screening, and Pap smear tests and HPV vaccination. Moreover, it can be successfully treated if detected in the early stage.

Policy on Human Papilloma Virus (HPV) vaccination was made by the Government of Malaysia started from the year 2012 targeting 13 years old Malaysian girls to have free injection of HPV vaccination. It was the effective initiative made by the government for its population to prevent the occurrence of cervical cancer.

However, there is little current information pertaining the nature of HPV infection, cervical cancer and HPV vaccination among the high risk age group such as secondary school girls. It is needed to explore their thorough understanding and knowledge of HPV, cervical cancer and HPV vaccination, and their practices on HPV vaccination. Thus, this study aimed to assess the knowledge level of secondary school girls about human papillomavirus (HPV), cervical cancer and human papillomavirus (HPV) vaccination and their practices on HPV vaccination.

MATERIAL & METHODS:

295 volunteered secondary school girls from form 1, 2 and 4 from SMK TengkuPanglimaPerang and SMK (P) Methodist, Kuantan Pahang were recruited by using the convenience sampling method. Malaysian, female, secondary school students of Form 1, 2 and 4 and able to read and understand Malay or English are chosen as inclusion criteria. Students who are visually impaired and use the Braille system were also excluded to participate in this study. The data were collected from April 2015 to May 2015.

This study used the questionnaire from the previous research by Kristen O Flarity. [9] An email request was sent to the researcher to get permission to use the questionnaire and approval has been received by the researcher. Regarding the validity of the questionnaires, a pilot study was conducted and the Cronbach alpha was 0.634. The questionnaire was distributed in English and Malay language, suitable with the respondents preferences to help them in better understanding and answering the questions. The questionnaire consists of 5 parts which are Part A (Socio-Demographic Data), Part B (Knowledge on Human Papillomavirus), and Part C (Knowledge about Cervical Cancer), Part D (Knowledge on Human Papillomavirus (HPV) Vaccination) and Part E (The Practice of HPV Vaccination). A questionnaire was distributed to the respondents by the researcher and 5-10 minutes time interval was given to answer the questions. The collected data were analyzed by using a computer statistical program, SPSS version 20 for Windows and statistical analysis was Chi-Square test. For all tests, the p- value was considered to be significant if it was less than 0.05 at a confidence interval 95%.

Before data collection started in this study, the ethical approvals were obtained from Kulliyyah of Nursing, Research Committee (KNRC), IIUM Research Ethics Committee (IREC), Ministry of Education Malaysia (MOE) and "JabatanPelajaranNegeri Pahang" (JPNP). The consent forms were distributed in the class to the students in the class so that they can bring it back home and asked for their parents consent. The participating students were also asked to sign a consent form for their participation, and making sure that their identity will be kept as anonymous.

RESULTS:

A total of 295 students responded to this study. The largest numbers of respondents were from form four students with 142 (48.1%) followed by form one students with 81(27.5%) and form two students with 72(24.4%).Mostly were Malay with 227 (76.9%).33(11.2%) were Chinese and 30 (10.2%) were Indians. Only 5% of respondents were from other ethnicity, which is Iban. In Malaysia education, form one is equal to grade 7 and students age was 12-13 years old. Form two is equal with grade 8 and form four is same as grade 10, normally students age are 15-16 years old. Table 1 illustrated the respondents background in detail.

Concerning on knowledge on HPV, cervical cancer and HPV vaccination, among the total respondents 261 (88.5%) had already heard about HPV before the survey was conducted. The majority of respondents reported learning about HPV through other health professional.

With the mean mark 9.57+3.428 for knowledge about HPV, 5.72+2.304 for knowledge about cervical cancer and 8.32+2.513 for knowledge on HPV vaccination, the level of knowledge about HPV with 45.4% (n=134) of respondents had a poor level of knowledge disregard from the form of study and ethnicity. Meanwhile, 54.6% (n=161) of the respondents achieved a good level of knowledge regarding HPV. Among 295 respondents, 121 (41%) from them had a poor level of knowledge about cervical cancer and 174 (59%) of the respondents had a good level of knowledge. The poor level of knowledge on HPV vaccination among respondents was only 48.8% (n=144) while 51.2% (n=151) from them had a good level of knowledge regarding HPV vaccination. The results were shown in Table 2.

Regarding practice on HPV vaccination, There were 166(56.3%) of the respondents had poor practice on HPV vaccination while 129(43.7%) from them had a good level of practice on HPV vaccination. The result showed in table 3 in detail.

The association between socio demographic data and level of knowledge about HPV, cervical cancer and HPV vaccination, the findings showed that there was a significant association between form of study and level of knowledge about HPV, cervical cancer and HPV vaccination (p<0. 001). However, no significant difference between ethnicity and level of knowledge about HPV, cervical cancer and HPV vaccination as (p-value>0.05) were found. The results were illustrated in Table 4.

Table 1: Socio demographic characteristics of secondary school girls (N=295)

Variables

Frequency (n)

Percent (%)

Form of Study

   

One

81

27.5

Two

72

24.4

Four

142

48.1

Ethnicity

   

Malay

227

76.9

Indian

30

10.2

Chinese

33

11.2

Others (Iban)

5

1.7

Table 2: Level of knowledge on HPV, cervical cancer and HPV vaccination among secondary school girls (N=295)

Variable

Frequency (n)

Percent (%)

Mean mark

Standard deviation

Level of knowledge about HPV

Poor

134

45.4

9.57

3.43

Good

161

54.6

   

Level of knowledge about cervical cancer

Poor

121

41

5.72

2.30

Good

174

59

   

Level of knowledge about HPV vaccination

Poor

144

48.8

8.32

2.51

Good

151

51.2

   

Table 3: Level of practice on HPV vaccination among secondary school girls (N=295)

Grade

Frequency (n)

Percent (%)

Mean Mark

Standard Deviation

Poor

166

56.3

22.82

4.34

Good

129

43.7

   

Table 4: Association between socio demographic data and level of knowledge on HPV, cervical cancer and HPV vaccination, and practice on HPV vaccination

Variable

n

Poor

N (%)

Good

N (%)

AX Statistics (df)

*p value

Association between form of study and knowledge about HPV

Form One

81

55 (67.9)

26 (32.1)

35.78 (2)

<.001

Form Two

72

39 (54.2)

33 (45.8)

Form Four

142

40 (28.2)

102 (71.8)

Association between form of study and knowledge about cervical cancer

Form One

81

48 (59.3)

33 (40.7)

24.79 (2)

<.001

Form Two

72

35 (48.6)

37 (51.4)

Form Four

142

38 (26.8)

104 (73.2)

Association between form of study and knowledge about HPV vaccination

Form One

81

54 (66.7)

27 (33.3)

18.03 (2)

<.001

Form Two

72

37 ( 51.4)

35 (48.6)

Form Four

142

53 (37.3)

89 (62.7)

Association between ethnicity and level of knowledge about HPV

Malay

227

105 (46.3)

122 (53.7)

1.00 (1)

0.317

Indian

30

14 (46.7)

16 (53.3)

Chinese

33

15 (45.5)

18 (54.5)

Others (Iban)

5

0 (0.0)

5 (100.0)

Association between ethnicity and level of knowledge on cervical cancer

Malay

227

88 (38.8)

139 (61.2)

2.24(1)

0.135

Indian

30

11 (36.7)

19 (63.3)

Chinese

33

22 (66.7)

11 (33.3)

Others (Iban)

5

0 (0.0)

5 (100.0)

Association between ethnicity and level of knowledge about HPV vaccination

Malay

227

103 (45.4)

124 (54.6)

1.12 (1)

0.290

Indian

30

21 (70.0)

9 (30.0)

Chinese

33

20 (60.0)

13 (39.4)

Others (Iban)

5

0 (0.0)

5 (100.0)

Association between form of study and practice on HPV vaccination

Form One

81

49 (60.5)

32 (39.5)

0.97 (2)

0.616

Form Two

72

38 (52.8)

34 (47.2)

Form Four

142

79 (55.6)

63 (44.4)

Association between ethnicity and practice on HPV vaccination

Malay

227

125 (55.1)

102 (44.9)

0.31 (1)

0.580

Indian

30

16 (53.3)

14 (46.7)

Chinese

33

25 (75.8)

8 (24.2)

Others (Iban)

5

0 (0.0)

5 (100.0)

DISCUSSION:

The majority of participants had heard about HPV compared to a study by Al- Dubai, et al (2010) [1], in which study, just only 26% of the participants had heard about HPV. The present study illustrated that knowledge level regarding HPV has been increased since the HPV were well known advertised in social media and during this study was conducted; the HPV vaccination programme had started since three years ago at the Government level. When asking about the benefit what condom can do to reduce HPV infection, only small numbers choose that condom can reduce risk for HPV infection. In a report written by Waller (2010) [12], nearly half of the participants agreed that condom can prevent HPV infection. The most answered chosen by the participants in this study was by being vaccinated so HPV can be prevented. The reason in here was because the participants were secondary school girls and they were not exposed using condoms but more exposed to the vaccination program. In the study by Waller (2010) [12], the participants were young to adult women and the sexual intercourse was familiar to them, so do the use of condoms. Concerning the risk factors of cervical cancer small numbers among them answered smoking. It was rather low compared to one study conducted by Waller (2010) [12], half of the respondents answered that stopping smoking may reduce risk for cervical cancer.

The majority of the respondents heard about the HPV vaccine. In a previous study, 77.6 percentage was reported among secondary school girls in Melaka, Malaysia where only had heard of HPV vaccine Al-Naggar, et.al (2012) [2] and more critically low percentage was reported in a study conducted one year after the introduction of HPV vaccine in Malaysia by Wong and Sam [13] where only 10.3 percentage of the respondents had heard of the HPV vaccine. The number of respondents who had heard about HPV vaccine was impressively increased after six years HPV vaccine released in Malaysia. In this study, the more than half of respondents learnt about HPV vaccination through other health professional. Therefore the role of other health professional is vital in delivering the information. A study by Chow, et al (2010) [5] indicated that what would improve the mothers likelihood to get their daughters vaccinated was with doctors recommendation. It means that, health professional play important role in conveying information and convincing the parents to give consent for their daughters to receive the HPV vaccination. More than half of the respondents took three doses complete HPV vaccination. It can be also influenced by the increasing advertisement in social media on the importance of getting the HPV vaccine.

However, poor practice on present study were exposed due to their thoughts on taking HPV vaccination was time consuming .There is no previous study accessed that the practice on HPV vaccination by asking is it time consuming, so, no available data to support this statement. Further research needed to investigate more on this statement.

Additionally, secondary school girls should be told that all the doses of HPV vaccination will be given during school time, so no need to worry about the time consuming since it has been just three shots and short time each shot. It was important to address their concerned with rejecting the vaccine, so we can find the solution. A previous study related to education level and the level of knowledge on sexual transmitted disease was found significantly associated (p<.001) which was the same findings like this study Anwar, et.al (2010) [3]. Another study by Al- Dubai, et al (2010) [1] found that there is an association between age with the level of knowledge of HPV and HPV vaccination. There is no significant association between ethnicity and level of knowledge about HPV, cervical cancer and HPV vaccination since p>0.05. This result was contraindicated with a study by Cates, Brewer, Fazekas, Mitchell, & Smith (2009) [4], stated that whites had higher HPV knowledge than black respondents (42% versus 29%). A study supported the result which there is no association between ethnicity and level of knowledge about HPV and cervical cancer. Trio, et.al (2007) [11] Meanwhile, a study by Wong & Sam (2010) [13], there is a significant difference between ethnicity and knowledge HPV and cervical cancer (p<0.05).

The research findings revealed that there was no significant association between form of study and practice on HPV vaccination (p>0.05) as compared with a study by Donati, et al (2012) [6] educational level were significantly associated with cervical cancer prevention, which was HPV vaccination. The difference may be due to low respondent’s number for this study, so the possibility to achieved significant result was low.

In this study, ethnicity showed no significant influence on practice of HPV vaccination among secondary school girls (p>0.05). Different results were found in another study that showed race significantly associate with a practice on HPV vaccination Al-Naggar, et.al (2012) [2]. As cited by Allen et al., 2010; Pruitt and Schootman, 2010, in Al-Naggar, et.al (2012) [2] there were no significant differences in rates of vaccine practiced with ethnicity or race.

LIMITATIONS:

It is important to acknowledge the limitation of this study. This study was conducted in a small population of secondary school girl students in Kuantan, Pahang, Malaysia only. Ideally, a bigger sample would have enabled the researcher to examine the relationship between each variable

IMPLICATIONS OF PRACTICE:

Future studies should be conducted at various schools in Malaysia and all around the world to get generalizable results as a whole. Moreover, in school health nursing, the HPV vaccination programme should be implemented and continuously monitored whether successful or not.

CONCLUSION:

The national HPV vaccination program is extremely important, and is likely to significantly reduce the burden of cervical cancer and other HPV related cancers. Schools play a vital role in informing students, their parents and teachers about the vaccine, and positively influencing its uptake around the world. Nurses and other health professionals all influence the uptake of the HPV vaccine in Malaysia, both in the school-based National Immunization Program and in the primary care settings.

REFERENCES:

  1. Al- Dubai, S. A., Alshagga, M. A., Al-Naggar, R. A., Al-Jashamy, K., Baobaid, M. F., Tuang, C. P., et al. (2010). Knowledge, attitudes and barriers for Human Papilloma Virus (HPV) vaccines among Malaysian women. Asian Pac J Cancer Prev, 11(4):887-92. Retrieved from :http://www.ncbi.nlm.nih.gov/pubmed/21133596
  2. Al-Naggar, R. A., Bobryshev, Y. V., Al-Jashamy, K., & Al-Musli, M. (2012). Practice of HPV vaccine and associated factors among school girls in Melaka, Malaysia. Asian Pac J Cancer Prev 13: 3835-3840.Retrieved from http:// apocpcontrol.net/.../3835-40%205.7%20Redhwan%20Ahmed%20Al-Naggar%. doi: http://dx.doi.org/10.7314/APJCP.2012.13.8.3835
  3. Anwar, M., Sulaiman, S. A., Ahmadi, K., & Khan, T. M. (2010). Awareness of school students on sexually transmitted infections (STIs) and their sexual behaviour: A cross sectional study conducted in Pulau Pinang, Malaysia. BMC Public Health, 10:47. doi: 10.1186/1471-2458-10-47. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/20113511
  4. Cates, J. R., Brewer, N. T., Fazekas, K. I., Mitchell, C. E., & Smith, J. S. (2009). Racial differences in HPV knowledge, HPV vaccine acceptability, and related beliefs among rural, southern women. J Rural Health.; 25(1):93-7. doi: 10.1111/j.1748-0361.2009.00204.Retrieved from : http://www.ncbi.nlm.nih.gov/pubmed/19166567
  5. Chow, S.-N., Soon, R., Park, J. S., Pancharoen, C., Qiao, Y. L., Basu, P., et al. (2010). Knowledge, attitudes and communication around Human Papillomavirus (HPV) vaciination amongst urban asian mothers and physician. 2010 May 14; 28(22):3809-17. Doi: 10.1016/j.vaccine.2010.03.027. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/20347631
  6. Donati, S., Giambi, C., Declich, S., Salmaso, S., Filia, A., Atti, M. L., et al. (2012). Knowledge, attitude and practice in primary and secondary cervical cancer prevention among young adult Italian women. 30(12):2075-82.doi: 10.1016/j.vaccine.2012.01.057. Retrieved from: http://www.ncbi.nlm.nih.gov/pubmed/22300719
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