The Effect of Knowledge on Cervical Cancer toward HPV Vaccinations Attitude and Practice among the First Year

Female Students of Atma Jaya Catholic University School of Medicine Year 2011

Ernie Yantho* Sumanto Simon*** Elisabeth Rukmini Edhyana Sahiratmadja**;

*) Medical Student, Faculty of Medicine Atma Jaya Catholic University of Indonesia **) Department of Biology, Faculty of Medicine Atma Jaya Catholic University of Indonesia ***) Department of Clinical Pathology, Faculty of Medicine Atma Jaya Catholic University of Indonesia

Introduction: Cervical cancer is caused mainly by persistent infection of Human Papilloma Virus (HPV). The incidence of cervical cancer has been increasing widely. Therefore, HPV vaccination as an effective prevention is badly needed. However, knowledge on HPV vaccine among women are still insufficient, which leads to lesser interest and practice toward HPV vaccine. The aim of this study was to explore the relationship between knowledge of cervical cancer and attitude that may lead to HPV vaccination practice. Methods: This study was performed to assess knowledge, attitude, and practice (KAP) on cervical cancer and HPV vaccine. To assess knowledge of cervical cancer, a set of questionnaires was designed and asked before and after the seminar. The practice of HPV vaccination was followed up six months after seminar. A qualitative approach using in-depth interview was performed to explore their background reasons of either having or not having vaccination. The inclusion criteria was first year female students who participated in seminar and had not have HPV vaccination. Results: In total, there were 50 female students who met the inclusion criteria. At the end of the seminar, 31 of 50 (62%) female students have increasing rate of knowledge on cervical cancer. Moreover, 48 from 50 respondents showed positive interest to HPV vaccination after being given education on cervical cancer in seminar, however, after six months follow-up, only 3 of those 48 (6,25%) students have been vaccinated. There were several aspects, such as factors from the vaccine itself, role of the family that played role in the decision to get HPV vaccination. Conclusion: There are many other factors involved in decision making of having HPV vaccine, hence, education on cervical cancer may serve as a start point and plays an important role in encouraging womens attitude to have HPV vaccination.

Keywords: Cervical cancer, Human papillomavirus, Vaccination, Education, Knowledge, Attitude, Practice

Introduction Prevalence of cervical cancer has been increased recently in the world and 80 % of cases were found in developing countries. It has become the main cause of
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womens

mortality caused by cancer, in which there are 190.000 death every year. From Globocan Data in 2008, the incidence of cervical cancer in the world has reached 500.000 cases and mortality has more than 200.000 cases. In Indonesia, cervical cancer has become the most commonly found cancer in women, which is usually detected in advanced stage.2 One of the cause of invasive cervical cancer is human papillomavirus (HPV). More than 80 types of HPV have been identified and 40 among them infect reproduction system. HPV genital types are divided into three groups, low-risk types, probable high risk types, and high risk types which related to invasive cervical cancer.3 But, newest study showed that HPV infection has no direct relation with risks of cervical cancer as acute infection from HPV is self-limiting.4 Most acute HPV infections are self limiting. Persistent HPV infection is the cause of tumour promotor in cervix which induces cancer.5 The most effective prevention of HPV infection is HPV vaccine. From January 2008, there are two types of HPV vaccine which have been proven clinically safe and have been implemented to health program in some countries in the world. These vaccines are made with virus-like particles (VLP) recombinant technology and do not contain any biologic products or DNA, so they are not infectious. HPV vaccine has two types which are bivalent vaccine and quadrivalent vaccine. Bivalent vaccine contains VLP of HPV type 16 and 18, while quadrivalent vaccine contains four type HPVs, 6, 11, 16, and 18. 6 Even HPV vaccine has been introduced since 2008 but still less people know about HPV vaccine and have them vaccinated with HPV vaccine. Some studies have shown that knowledge of HPV vaccine among women are still insufficient eventhough they have shown positive attitude toward this vaccine.7 Unfortunately, until now there is not any study about rate of knowledge, attitude, and behaviour toward HPV vaccine in Indonesia from medical journal sites such as PubMed.

Method Study Design Design of this study is an experimental study which use quantitative study followed by qualitative study. For quantitative study, pre-test and post test is given to female students before and after seminar about benefits of HPV vaccine to see their rate of knowledge

(independent variable) and their attitude and behaviour toward HPV vaccination (dependent variable). After six months, follow up of this study is done for those who are interested to have HPV vaccination to see whether they have been vaccinated or not. Then, method of indepth interview is used to know about other background factors which influence the behaviour of HPV vaccination. Sample Respondents From 199 first year medical students in Atmajaya Catholic University of Indonesia in 2011, there were 87 students who attended seminar about cervical cancer. Those students includes 57 female students and 30 male students who has been excluded from this study. (Scheme 1) Before seminar, students were given pre-test to know their prior knowledge related to cervical cancer and HPV vaccine. After seminar, students had to do post-test to see inprovement in their knowledge about cervical cancer and HPV vaccine. From 57 female students, only 50 students who met the inclusion criteria as 7 students who were excluded from this study as 4 students had already vaccinated before seminar and 3 students dropped out from this study. After 6 months of follow up, samples of students who have in-depth interview were chosen randomly with purposive sampling. Data Collection Data collection of this study for quantitative study is taken from a set of questionnaires which are filled before and after seminar. Then, after 6 months, all students who have interest to be vaccinated are followed-up to see whether they have realization their interest in the form of being vaccinated. From respondents who have and have not been vaccinated, some of them are taken randomly to have in-depth interview.

Result From pre-test and post-test in quantitative study, the result shows that study showed that from 31 of 50 (62%) female students have increasing rate of knowledge on cervical cancer after given seminar which means a lot more respondents who have improvement in their knowledge then those who are not. With chi-square statistical test, it shows that there is relationship between education seminar and improvement of knowledge with value p = 0.087 (p<0.05). Moreover, 48 from 50 respondents showed positive attitude toward HPV vaccination after being given education on cervical cancer in seminar. However, after six months follow-up, only 3 of those 48 (6,25%) students have been vaccinated. Statistical test Fishers Exact Test to see whether there is relationship between improvement of knowledge

with attitude to have HPV vaccination. Result of this test is not significant as p value=0.620 (p>0.05) so that improvement of knowledge on cervical cancer does not affect behaviour to have HPV vaccine. From in depth interview, it is shown that a lot of background factors have played important role in the decision to have HPV vaccination. Those factors are aspects from the vaccine itself and from family background besides aspects of knowledge from seminar and other information medias. From the aspects of vaccine, reasons that were mostly brought up by respondents who did not have had vaccine were the cost and time period of the effectiveness of the vaccine. They complained that the cost of vaccine was too expensive for them so that they decided to postpone their decision to have HPV vaccine. The other reason that was brought up by them not to HPV vaccine now is effectiveness of HPV vaccine which only can be maintained for 10 years so that they decided to have HPV vaccine in their marriage age or when they were sexually active years later. Some of the respondents were also still questioned whether HPV vaccine really can protect them from HPV infection even they have already had enough knowledge about HPV vaccine. From family background, almost all of the respondents mother have known about HPV vaccine from their surroundingd even the knowlege is still superficial and they have given full support for those respondents to have vaccinated. But still, family background cannot really push them to have a real practice toward HPV vaccination.

Conclusion From quantitative study about knowledge, attitude, and behaviour toward HPV vaccination, it is found that giving education about cervical cancer in the form of seminar has been able to improve respondents knowledge toward cervical cancer and HPV vaccination greatly. This improvement has also led to positive attitude and interest to have HPV vaccination. But, in the process of follow-up after six months, it is found that respondents behaviour toward vaccination HPV are still low. Improvement in knowledge is still unable to promote the behaviour of having vaccination HPV eventhough interest toward HPV vaccination has appeared before. From qualitative study in-depth interview, it is found that respondents behaviour toward vaccination HPV is influenced by some external background factors which are aspects of vaccine itself and aspects from family besides knowledge which have been had before from a lot of information medias. Factors which have mainly caused great influence to

respondents behaviour are aspects from vaccine itself, which are effectivity of t he vaccine, duration of vaccines effectiveness, and cost of HPV vaccination. There are many other factors involved in decision making of having HPV vaccine, hence, education on cervical cancer may serve as a start point and plays an important role in encouraging womens attitude to have HPV vaccination

Scheme 1 Respondents in this study

College Students Year 2011 (n=199)

Students who attend cervical cancer seminar(n=87)

Students who do not attend cervical cancer seminar(n=112)

Pre-Test (Questionnaire)

Post-Test (Questionnaire)

Female college students (n=57)

Male college students (n=30) (EXCLUSION)

Students who have interest toward HPV vaccination (n=48)

Students who do not have interest toward HPV vaccination (n=2)

Students who have ever had HPV vaccination(n=4) Students who drop-out (n=3) (EXCLUSION)

Follow-up after 6 months

Students who have been vaccinated HPV (n=3)

Students who have not been vaccinated HPV (n=45)

In-depth interview all students

In-depth interview 6 among 45 students

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